NR 509 APEA 3P EXAM WEEK 4 2024
UPDATEQUESTIONS AND VERIFIED
ANSWERS WITH RATIONALES ALREADY
GRADED A+
A 59-year-old unemployed man complains of almost always feeling tired and hungry, despite getting
sufficient rest and having a good appetite and access to sufficient food. The client is obese and,
despitethe warm weather outside, wearing thermal socks with his sandals. He says this is because his
feet are always cold and "feel funny." With which body system should the clinician begin the
examination?
• b. Head and neck
• Rationale: The physical examination should proceed "head to toe" to optimize client
comfort; minimize the number of changes in client position; and, because it is always done
in the same way, to ensure that nothing is missed. Even though symptoms are reported in
thelower extremities, the examination will attend to this region at the appropriate time.
The same argument applies to the posterior thorax, abdomen, and nervous system.
A 65-year-old retired pilot visits the clinic because of recurrent headache. The client reports
dizzinessof recent onset (previous 2 weeks) and occasional numbness on the left side. Which of the
following systems or regions should be examined in the clinician's focused assessment?
Nervous
Rationale: The nervous system examination covers mental status, cranial nerves, motor
andsensory systems, and reflexes. The presence of headache, dizziness, and numbness
suggest nervous system involvement. Symptoms of cardiovascular involvement include
palpitations,chest pain, edema, or heart murmurs, none of which are noted in the case
description. Musculoskeletal problems are usually associated with muscle or joint pain or
stiffness. The respiratory system should be examined when clients have a cough,
difficulty breathing, or hemoptysis. The gastrointestinal system should be examined
when clients complain of heartburn, irregular or bloody stools, or food intolerance
(among other symptoms).
A 54-year-old diplomat working at the United Nations reports occasional chest pain and a sense of
tightness in his chest when particularly stressed over work deadlines. The client is 6 feet 4 inches tall.
,He has a temperature of 98.6ºF and blood pressure of 140/78. He has a cut over one eye that he says
is"from shaving." Which of the following represents subjective information about this client?
d. Cut over eye from shaving
Rationale: Subjective information is any information that the client reports but that is not
directly observable or measurable. In this case, the cut is observable but the manner in
which the cut was sustained is not. Shaving injuries are not usually seen above an eye, so
this part ofthe client's report could be explored further. Temperature, blood pressure, and
height are incorrect because these were measured by the clinician. Employment at the
United Nations isincorrect because, although this was not measured by the clinician, it is a
fact that can be verified objectively.
A 32-year-old office worker reports excessive stress at work and pain in the right lower quadrant.
She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The
clientlooks pale and is sweating lightly. Which of the following is an objective finding?
e. Accelerated heart rate
Rationale: Objective findings are those detected on physical examination by the clinician. A
resting heart rate of 93 bpm is higher than normal. Pain in the right lower quadrant, history
ofvomiting, and the client's high stress level are all subjective findings because they rely on
theclient's report. A pale appearance is not necessarily an objective finding, because what
appears pale to one clinician might not appear pale to another.
A 29-year-old electrician complains of persistent cough and wheezing, particularly when he exercises.
Hesays he smokes "occasionally" but rarely so much that he needs to purchase cigarettes: "Mostly, I
bum them," he says, chuckling. Upon hearing this information, what is the best next step on the part
of the clinician?
b. Determine the number of pack-years the client smokes.
Rationale: An accurate determination of a client's tobacco use is important for assessing
theoverall health risk due to smoking. Although the client minimizes his smoking, it is
possible that the number of cigarettes smoked per day and the length of time he has
smoked would result in a high pack-year value. Although determining the client's exercise
regimen could beof value later on, it is not necessarily relevant to his presenting problem,
which is coughing. Exercise simply precipitates this symptom. There are no signs such as
memory loss or anxiety suggesting that a mental status examination would be helpful. At
some point, it may become important to explain the relationship between smoking and
cancer, but this would not be the best "next step" in fact-finding. Similarly, determining a
, client's immunization history is important for health maintenance, but is not necessary for
the initial diagnosis of the causes of his problem.
A 47-year-old fitness trainer visits the physician assistant (PA) because of skin dryness, night sweats,
andirregular menstrual periods. It is the PA's first contact with this client. The client notes that "My
sex life has really gone downhill lately" and says that she is considering divorcing her husband of 20
years, stating that "He's not a bad guy. I just think that I can do better." In which of the following ways
should the clinician proceed?
Obtain a menstrual history for the previous 6 months.
Rationale: It is important to review the seven attributes of a client's principal symptom(s),
which in this case are skin dryness, night sweats, reduced interest in sex, and irregular
menstrual periods. Helping the client review the pros and cons of divorce would not
addressher physical symptoms. Informing the client that menopause is a normal part of
aging, although perhaps appropriate in the longer term, is premature since it has not been
determined that she is perimenopausal. There are no symptoms that would prompt the
clinician to conduct a breast examination. Symptoms that might lead one to determine the
client's out-of-country travel historyinclude a rash, fever, or other signs of infection, which
are absent here.
A 26-year-old homeless male presents for a new-client evaluation at a community health center. He
has a history of intravenous drug use, from which he contracted hepatitis C. He also suffers from
uncontrolled asthma that he has had since childhood, with treatment including frequent doses of oral
steroids when he cannot keep inhalers in his possession. Two years ago, he was diagnosed with
bipolar disorder. On today's visit, his main concern is a small abscess in his right antecubital fossa at a
heroin injection site. Which of the following is the best approach to the health history for this client at
his firstvisit?
Good!
e. A comprehensive health history
Rationale: Almost all new clients should undergo a comprehensive health history including
the history of present illness (HPI), past medical history, family history, personal and social
history, and ROS. This client, in particular, has a complex past with a number of current
issues; becoming acquainted with the whole picture of his health and health care at the
first visit can make future visits more streamlined and fruitful. In this client's case, he has
one very acute issue that must be addressed that day (the abscess), but his other chronic
conditions can wait until future visits for more thorough treatment. A clinician-centered
health history is incorrect because it is structured toward discrete data items desired by
the clinician, such as ticking boxes for billing reasons. This approach may not best serve the
needsof a client with such a complex medical and social history. A health history with only
yes-no options is incorrect because this may be helpful in the ROS portion of a history, such
an approach is unlikely to elicit this client's full range of conditions and needs. An ROS only
, is incorrect because it is a very limited portion of the examination that often covers areas
not mentioned in the HPI. Performing this portion alone is inadequate for any client or
conditions. A problem-focused health history is incorrect because this client's abscess may
require a brief problem-focused assessment (when did it start? how painful it is? any
associated symptoms?), his overall care demands a more thorough subjective history
toestablish appropriate care.
A 39-year-old nurse who is a well-established client complains of irregular menstrual periods and
pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a
"sleepingpill." The client also says she is thinking of leaving her job. What is the best "next step" in
caring for this client?
c. Obtain a more complete description of problems.
Rationale: It is critical to thoroughly understand the client's problem in order to narrow the
focus of the examination. This is particularly true when symptoms are reported in multiple
body systems, as in this case. To the extent possible, the seven attributes of each symptom
should be explored. Although it may be necessary to perform a pelvic examination, the
exam will yield more information if the clinician has determined, for example, the client's
pregnancy history. The clinician may need to obtain a urine sample for testing later but
shouldhave a possible diagnosis in mind when doing so. A similar argument applies
regarding obtaining blood for testing—testing for what? Recent travel destinations should
be elicited if there is a suspicion that an infectious agent was acquired somewhere else, but
more information is needed to determine whether this would be a realistic suspicion.
A 29-year-old female professional athlete presents to a new primary care provider with chronic
menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a
dismissalof her complaints because of her high level of physical fitness and conditioning. She is
seeking a care provider who will explore the issue in more detail and work with her particular
concerns. Which of the following is the description of the client-centered care this individual seeks?
b. Validating and empathetic with open-ended questions
Rationale: client-centered care is loosely structured, supportive, aimed at meeting the
client where they are in their disease process, and characterized by open-ended questions.
Structured and clinician-centered with open-ended questions is incorrect because open-
endedquestions are consistent with client-centered care, and the description specifically
endorses clinician-centered care. Dismissive and concrete with open-ended questions is
incorrect because open-ended questions are consistent with client-centered care, whereas
concrete questions are left out in favor of unstructured discussion. A dismissive attitude is
never appropriate in client care. Affirming and reassuring with close-ended questions is
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