Competency Appraisal 2

Diabetes Mellitus Questions

1. Short-acting insulin secretagogues (repaglinide,
nateglinide) are faster acting than sulfonylureas.
They may be especially effective for which of the
following?
a. Preventing overnight hypoglycemia
b. Promoting weight loss in obese patients
c. Reducing postprandial hyperglycemia
d. Improving peripheral insulin sensitivity
The answer is C. These drugs stimulate insulin secretion in a
manner similar to sulfonylureas, but they are faster acting and may
stimulate insulin secretion more during meals than at other times.
Thus, they may be especially effective for reducing postprandial
hyperglycemia. Choice B: There may be some weight gain,
although apparently less than with sulfonylureas. Choice D:
Biguanides are considered peripheral insulin sensitizers.
2. In many patients with type 2 DM, glucose levels are
adequately controlled with lifestyle changes or oral
drugs, and insulin is added when glucose remains
inadequately controlled by ≥ 2 oral drugs. The
addition of insulin is the most effective with which of
the following oral drugs?
reflect glucose levels over the preceding 3 mo. However, HbA1c
values may be falsely high or low, and tests must be done in a
certified clinical laboratory. Point-of-care HbA 1c tests should not
be used for diagnosis, but they can be used for monitoring DM
control. Choice D: Urine glucose measurement, once commonly
used, is no longer used for diagnosis or monitoring because it is
neither sensitive nor specific.
4. Knowing that gluconeogenesis helps to maintain
blood glucose levels, a nurse should:
a. Document weight changes because of fatty
acid mobilization.
b. Evaluate the patient’s sensitivity to low room
temperatures because of decreased adipose
tissue insulation.
c. Protect the patient from sources of infection
because of decreased cellular protein
deposits.
d. Do all of the above.
The answer is D. All measures ensure gluconeogenesis in
maintaining glucose homeostasis. The purpose of gluconeogenesis
is to maintain blood glucose levels during a fast. In the human
body, some tissues rely almost exclusively on glucose as a
metabolic fuel source.

a. Alpha-glucosidase inhibitors (AGIs)

b. Insulin secretagogues (sulfonylureas, 5. The nurse is admitting a patient diagnosed with type
repaglinide, nateglinide) 2 diabetes mellitus. The nurse should expect the
c. Oral biguanides (metformin) following symptoms during an assessment, except:
d. Sodium-glucose co-transporter 2 (SGLT2) a. Hypoglycemia
inhibitors (canagliflozin and dapagliflozin) b. Frequent bruising
c. Ketonuria
The answer is C. The rationale for combination therapy is strongest
for use of insulin with oral biguanides and insulin sensitizers. d. Dry mouth

The answer is A. Hypoglycemia does not occur in type 2 diabetes

3. Diagnosis of DM is suggested by typical symptoms
and signs and is usually best confirmed by which of
the following tests?
a. Fasting plasma glucose
b. Measurement of insulin levels
c. Fasting HbA1c test
d. Urine glucose
The answer is A. DM is indicated by typical symptoms and signs
and confirmed by measurement of plasma glucose. Measurement
after an 8- to 12-h fast or 2 h after ingestion of a concentrated
glucose solution (oral glucose tolerance testing [OGTT]) is best.
OGTT is more sensitive for diagnosing DM and impaired glucose
tolerance but is less convenient and reproducible than FPG. It is
therefore rarely used routinely, except for diagnosing gestational
DM and for research purposes. Choice B: Measurement of insulin
levels is useful in the evaluation of hypoglycemia. Because they
are typically elevated in patients with type 2 diabetes and absent in
those with type 1 and vary in response to oral intake and treatment,
they are not useful for diagnosis. Choice C: HbA1c measurements
unless the patient is on insulin therapy or taking other diabetes
medication. In T2DM, the response to insulin is diminished, and
this is defined as insulin resistance. During this state, insulin is
ineffective and is initially countered by an increase in insulin
production to maintain glucose homeostasis, but over time, insulin
production decreases, resulting in T2DM.
6. Glycosylated hemoglobin (HbA1C) test measures the
average blood glucose control of an individual over
the previous three months. Which of the following
values is considered a diagnosis of pre-diabetes?
a. 6.5-7%
b. 5.7-6.4%
c. 5-5.6%
d. >5.6%
The answer is B. Glycosylated hemoglobin levels between
5.7%-6.4% are considered as pre-diabetes. The hemoglobin A1c
(glycated hemoglobin, glycosylated hemoglobin, HbA1c, or A1c)
Competency Appraisal 2

test is used to evaluate a person’s level of glucose control. The test

shows an average of the blood sugar level over the past 90 days
and represents a percentage. Anyone with an HbA1c value of 5.7 %
to 6.4 % is considered to be prediabetic

7.
8.
Competency Appraisal 2

Hypertension and Hpertensive Emergencies Questions

1. In patients with hypertensive encephalopathy, at

which of the following mean arterial pressures (MAP)
do the cerebral vessels begin to dilate rather than
remain constricted?
a. 120 mm Hg
b. 140 mm Hg
c. 160 mm Hg
d. 180 mm Hg

The answer is C. Cerebral vessels begin to dilate rather than

remain constricted above a mean arterial pressure of about 160
mm Hg (lower for normotensive people whose BP suddenly
increases). As a result, the very high BP is transmitted directly to
the capillary bed with transduction and exudation of plasma into
the brain, causing cerebral edema, including papilledema. Choices
A, B, and D are incorrect.

2. Which of the following symptoms and signs is most

likely present to some degree in many hypertensive
emergencies?
a. Chest pain
b. Global cerebral deficits
c. Lethargy
d. Retinopathy

The answer is D. Severe retinopathy is usually present with

hypertensive encephalopathy, and some degree of retinopathy is
present in many other hypertensive emergencies. Choices A, B,
and C are not typically present in hypertensive emergencies; chest
pain (choice A) is a common cardiovascular finding, global cerebral
deficits (choice B) suggest encephalopathy, and lethargy (choice C)
is a sign of renal failure.

3. Which of the following treatments for hypertensive

emergencies has been shown to increase patient
mortality and should not be used when alternative
medications are available?
a. Clevidipine
b. Nicardipine
c. Nitroglycerin
d. Nitroprusside

The answer is D. Recent data has shown increased patient

mortality for nitroprusside compared to choices A, B, and C when
used to treat hypertensive emergencies.

4. S
Competency Appraisal 2
Angina Pectoris
(Stable and Unstable Angina) Questions
1. When evaluating a patient with suspected unstable
angina, which of the following is the most important
test that should be done within 10 minutes of
presentation?
a. Serum cardiac troponin
b. Coronary angiography
c. Serum creatine kinase
d. ECG
The answer is D. This test is the most important test and should be
done within 10 minutes of the patient presenting with symptoms.
Choices A and C: Measurement of these cardiac markers should be
done on presentation as well. Serum cardiac troponin will be
slightly elevated, but serum creatine kinase will not be elevated in
patients with unstable angina. However, these tests are not as
immediately important as ECG. Choice B: Coronary angiography is
usually done within the first 24 to 48 hours of hospitalization to
detect lesions that may require treatment.
2. Which of the following medications is the preferred
treatment for chest pain associated with unstable
angina?
a. Aspirin
b. Heparin
c. Morphine
d. Nitroglycerin
The answer is D. Nitroglycerine is an antianginal therapy that is the
preferred treatment for chest pain and should be administered
sublingually at first and then by continuous IV drip if needed.
Choice A: Aspirin should be given to all patients with unstable
angina, but it does not treat the chest pain associated with this
disorder. It is a blood thinner or antiplatelet agent. Choice B:
Heparin is an anticoagulant and will not treat chest pain. Choice C:
Morphine is also an antianginal therapy, but due to its adverse
effects, it should be used only if a patient has a contraindication to
nitroglycerin or is in pain despite nitroglycerin therapy.
3. A 60-year-old man who is obese comes to the
emergency department because he had sudden
onset of intense chest pain while at rest, 30 minutes
ago. He says the pain has been worsening since that
time. Testing is done, and unstable angina is
diagnosed. The patient receives the appropriate
immediate treatment and is admitted to the hospital
for further management, including coronary
angiography, pharmacotherapy, and monitoring. The
patient responds well to treatment, and after a few
days he is ready to be discharged to home. After
discharge, which of the following next steps is most
appropriate to improve prognosis in this patient?
a. Begin taking fibrinolytic medications
b. Gradually taper all prescribed medications,
especially antiplatelet agents
c. Make lifestyle changes such as diet
modification and weight loss
d. Undergo stress testing shortly after discharge
The answer is C. In order to improve prognosis, it is important for
this patient to make changes in lifestyle and to aggressively
manage his risk factor of obesity. Choice A: Fibrinolytic
medications are not indicated in patients with unstable angina.
Choice B: This patient should continue to take all prescribed
medications. No prescribed medications, especially the
antiplatelets, should be tapered. Choice D: Because this patient
underwent coronary angiography while in the hospital, it is not
necessary for him to undergo stress testing once discharged.
4. Angina pectoris is usually described as chest
discomfort rather than as chest “pain.” The
symptoms of angina pectoris may be a vague, barely
troublesome ache or may rapidly become a severe,
intense precordial crushing sensation. Although the
location of the discomfort varies, it is most
commonly felt at which of the following locations?
a. Beneath the sternum
b. Down the inside of the right arm
c. In the throat, jaws, and teeth
d. In the upper abdomen
The answer is A. This is the most common location of the
discomfort of angina pectoris. Choices B, C, and D: These are other
locations where the discomfort of angina pectoris may be felt, but
they are not as common as beneath the sternum.
5. When a patient presents with typical exertional
symptoms of angina pectoris, ECG is indicated.
Because angina resolves with rest, ECG can rarely be
done during an attack. An abnormal resting ECG
alone does not establish or refute the diagnosis of
angina pectoris. In order to confirm the diagnosis,
which of the following is the most appropriate next
step?
a. Coronary angiography
b. Electron beam CT scan
c. Intravascular ultrasonography
d. Stress testing
The answer is D. Exercise stress testing with ECG is done if a
patient has a normal resting ECG and can exercise, and stress
testing with myocardial imaging is done when the resting ECG is
abnormal because false-positive ST-segment shifts are common
on stress ECG. Choice A: Coronary angiography is the standard for
diagnosing coronary artery disease but is not necessary to confirm
the diagnosis. Choices B and C: These are imaging studies that are
Competency Appraisal 2

used to evaluate the coronary arteries and not to confirm the

diagnosis of angina pectoris.

6. The main goals of using pharmacotherapy to treat

angina pectoris are to relieve acute symptoms,
prevent or reduce ischemia, and prevent future
ischemic attacks. Which of the following drugs is
usually reserved for patients in whom symptoms
persist despite optimal treatment with other
antianginal drugs?
a. Aspirin
b. Nifedipine
c. Nitroglycerine
d. Ranolazine

The answer is D. This is a sodium channel blocker that can be used

to treat chronic angina pectoris that is not responsive to other
antianginal drugs. Choice A: This is an antiplatelet drug that
inhibits platelet aggregation and can reduce the risk of ischemic
events. Choice B: This is a calcium channel blocker that can be
used if symptoms persist despite use of nitrates. Choice C: This is
the most effective drug for an acute attack if used sublingually.
Nitroglycerine is a potent smooth-muscle relaxant and vasodilator.

7. N
Competency Appraisal 2

Urinary Tract Infection Questions

1. Renal candidiasis commonly originates from the GI

tract. Patients with diabetes or those who are
immunocompromised are at high risk for renal
candidiasis. If these high-risk patients are
hospitalized, which of the following is most likely the
major source of candidemia?
a. Antibiotic therapy
b. Immunosuppressive therapy
c. Indwelling intravascular catheter
d. Urinary catheter

The answer is C. Patients who are immunocompromised and

hospitalized are at increased risk of renal candidiasis if they have
an indwelling intravascular catheter. A and D: these are typical
causes of lower UTI with Candida. Immunosuppressive therapy
(choice B), in combination with catheters, stents, anastomotic
leaks, obstruction, and antibiotics, places a patient with renal
transplantation at risk for candidemia.

2. A diagnosis of Candida UTI is usually confirmed via

urine culture. However, it is difficult to determine
whether the candiduria indicates true Candida UTI,
colonization, or contamination. Differentiating
Candida colonization from infection requires
evidence of tissue reaction, such as which of the
following?
a. Fever
b. Hypertension
c. Pneumaturia
d. Pyuria

The answer is D. Evidence of pyuria indicates a tissue reaction

such as bladder inflammation or irritation. A, B, and C are
symptoms that may indicate infection, but they are not considered
tissue reactions.

3. A 65-yr-old man with recently confirmed

symptomatic fungal cystitis comes to the office to
discuss treatment options. Which of the following is
the most appropriate treatment for the next 2 wk?
a. Amphotericin B 0.6 mg/kg IV once/day
b. Fluconazole 200 mg po once/day
c. Flucytosine 25 mg/kg IV qid
d. Voriconazole 6 mg po bid

The answer is B. This is the appropriate 2-wk therapy for patients

with symptomatic fungal cystitis. Choice A is appropriate for fungi
resistant to fluconazole. Choice C, in the oral form instead of the IV
form, is appropriate for resistant fungal pyelonephritis and is
typically added to the regimen if patients have adequate renal
function. Clinical experience with using voriconazole (choice D) for
treatment of symptomatic fungal cystitis is scant.
Competency Appraisal 2

Pneumonia (CAP and Nosocomial) Questions

1. Which of the following conditions commonly

misdiagnosed as pneumonia has the most serious
outcomes?
a. Acute bronchitis
b. Airway obstruction
c. Heart failure
d. Pulmonary embolism

The answer is D. This is the most serious common misdiagnosis. A

and C: These are part of the differential diagnosis.

2. Mortality rates in patients with pneumonia are

highest in which of the following scenarios?
a. Pathogen is atypical bacteria
b. Pathogen is gram-negative bacteria
c. Pathogen is gram-positive bacteria
d. Patient is < 50 years of age

The answer is B. Mortality rates are highest with gram-negative

bacteria and CA-MRSA, though these are relatively infrequent
causes of community-acquired pneumonia. Choices A, C, and D are
incorrect.

3. Mortality rates in patients with pneumonia are

highest in which of the following scenarios?
a. Pathogen is atypical bacteria
b. Pathogen is gram-negative bacteria
c. Pathogen is gram-positive bacteria
d. Patient is < 50 years of age

The answer is B. Mortality rates are highest with gram-negative

bacteria and CA-MRSA, though these are relatively infrequent
causes of community-acquired pneumonia. Choices A, C, and D are
incorrect.
Competency Appraisal 2

Pertussis Questions

1. Which of the following causes of cough is more

common in children than in adults?
a. Asthma
b. Pneumonia
c. Postnasal drip
d. Psychogenic causes

The answer is A. The causes of cough in children are similar to

those in adults, but asthma and foreign body aspiration are more
common in children. Choices B, C, and D: These causes of cough
are not more common in children than in adults.

2. Which of the following findings on physical

examination of a patient with cough is most
concerning?
a. Foreign body in the ear
b. Hemoptysis
c. Intermittent fever
d. Weight gain

The answer is B. Large amounts of hemoptysis are concerning for

bronchitis, TB, or primary lung cancer. Choice A: Foreign body in
the ear is not an immediate concern. Choice C: Persistent fever,
and not intermittent fever, is of concern. Choice D: Weight loss,
and not gain, is concerning in a patient with cough.

3. Which of the following findings on physical

examination of a patient with cough is most
concerning?
a. Antitussives
b. Demulcents
c. Expectorants
d. Protussives

The answer is D. Protussives, which stimulate cough, are indicated

for the treatment of cystic fibrosis and bronchiectasis, in which a
productive cough is an important method of airway clearance.
Choice A: Antitussives depress cough, which is not appropriate.
Choice B: Use of demulcents such as cough drops is not supported
by scientific evidence. Choice C: Expectorants are thought to
facilitate coughing up of secretions but are of limited, if any,
benefit in most circumstances.
Competency Appraisal 2
Competency Appraisal 2

Myofascial Pain Syndrome Questions

1. Which of the following causes of cough is more

common in children than in adults?
a. Asthma
b. Pneumonia
c. Postnasal drip
d. Psychogenic causes

The answer is
Competency Appraisal 2

Osteoarthritis Questions

1. Which of the following causes of cough is more

common in children than in adults?
a. Asthma
b. Pneumonia
c. Postnasal drip
d. Psychogenic causes

The answer is
Competency Appraisal 2

Septic Shock Questions

1. Which of the following causes of cough is more

common in children than in adults?
a. Asthma
b. Pneumonia
c. Postnasal drip
d. Psychogenic causes

The answer is