NURS 6560 mind term exam questions and answers

Question 1

1. S. is a 59-year-old female who has been followed for several years for aortic regurgitation. Serial echocardiography has demonstrated normal ventricular function, but the patient was lost to follow-up for the last 16 months and now presents complaining of activity intolerance and weight gain. Physical examination reveals a grade IV/VI diastolic aortic murmur and 2+ lower extremity edema to the midcalf. The AGACNP considers which of the following as the most appropriate management strategy?

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Question 2

An ascending thoracic aneurysm of > 5.5 cm is universally considered an indication for surgical repair, given the poor outcomes with sudden rupture. Regardless of the aneurysm’s size, all of the following are additional indications for immediate operation except:

Question 3

Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders:NURS 6560 mind term exam questions and answers

Question 3

Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders: NURS 6560 mind term exam questions and answers

Question 4

Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As a result of a serious motor vehicle accident, he has had repair of a small bowel perforation, splenectomy, and repair of a hepatic laceration. He will be on total parenteral nutrition postoperatively. The AGACNP recognizes that the most common complications of parenteral nutrition are a consequence of: NURS 6560 mind term exam questions and answers

Question 5

Mr. Mettenberger is being discharged following his hospitalization for reexpansion of his second spontaneous pneumothorax this year. He has stopped smoking and does not appear to have any overt risk factors. While doing his discharge teaching, the AGACNP advises Mr. Mettenberger that his current risk for another pneumothorax is:

Question 6

One of the earliest findings for a patient in hypovolemic shock is:

Question 7

Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with a more chronic form are most likely to be present with:

Question 8

The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable, awake, alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift, the oncoming staff nurse appreciates a profound change in the patient’s mental status from the day before. Vital signs and hemodynamic parameters are as follows: NURS 6560 mind term exam questions and answers

BP 88/54 mm Hg
Pulse 110 bpm
Respiratory rate 22 breaths per minute
SaO2 93% on a 50% mask
Systemic vascular resistance (SVR) 1600 dynes ∙ sec/cm⁵
Cardiac index 1.3 L/min. NURS 6560 mind term exam questions and answers
Pulmonary capillary wedge pressure (PCWP) 8 mm Hg

This clinical picture is most consistent with which shock state?

Question 9

When counseling patients to prevent postoperative pulmonary complications, the AGACNP knows that with respect to smoking cessation, the American College of Surgeons and National Surgical Quality Improvement Program guidelines are clear that patients who stop smoking _____ weeks before surgery have no increased risk of smoking-related pulmonary complications. NURS 6560 mind term exam questions and answers

Question 10

Mitch C. is a 39-year-old male who is brought to the ED by paramedics. According to the report of a neighbor, Mitch was distraught over a breakup with his fiancée and attempted to commit suicide by mixing some chemicals from under his kitchen sink and drinking them; afterward he changed his mind and knocked on his neighbor’s door asking for help. Mitch is awake but stuporous, and the neighbor has no idea what he drank. Visual inspection of his mouth and oropharynx reveals some edema and erythema. He is coughing and has large amounts of pooling saliva. Mitch is not capable of answering questions but he appears in pain. Endoscopy reveals full thickness mucosal injury with mucosal sloughing, ulceration, and exudate. The AGACNP knows that the appropriate course of treatment must include:

Question 11

Jared V. is a 35-year-old male who presents for evaluation of a dry cough. He reports feeling well overall but notices that he gets out of breath more easily than he used to when playing soccer. A review of systems yields results that are essentially benign, although the patient does admit to an unusual rash on his legs. Physical examination reveals scattered erythematous nodules on both shins. There is no drainage, discomfort, or itch. Additionally, diffuse, mildly enlarged lymph nodes are appreciated bilaterally. Results of a comprehensive metabolic panel and complete blood count are within normal limits. Twelve-lead ECG reveals sinus bradycardia at 58 bpm. Chest radiography reveals bilateral hilar and mediastinal lymphadenopathy. The AGACNP suspects: NURS 6560 mind term exam questions and answers

NURS 6560 mind term exam questions and answers

Question 12

Mrs. Miller is a 44-year-old female who is on postoperative day 1 following a total abdominal hysterectomy. Her urine output overnight was approximately 200 mL. The appropriate response for the AGACNP would be to order:

A.A urinalysis and culture     B. 1 liter of NSS over 8 hours     C. Encourage increased mobility D.Liberalize salt in the diet

Question 13

All of the following are risk factors for spontaneous pneumothorax except:

A.Connective tissue disease     B. Scuba diving     C. Chronic obstructive pulmonary disease (COPD) D.Central line insertion

Question 14

The AGACNP is going over preoperative information and instructions with a patient who is having a major transverse abdominal procedure tomorrow morning. The patient is very nervous and is asking a lot of questions. The AGACNP prescribes a sleeping agent because he knows that anxiety and sleeplessness may:

A.Lead to hypoxia due to hyperventilation     B. Increase the physiologic stress response postoperatively     C. Contribute to risk of delirium and prolonged length of stay                  D.Decrease p.o. intake and produce nutritional risk

Question 15

In a patient with thyroid nodules, which of the following is the diagnostic study of choice to rule out thyroid cancer?

A.Radioiodine scanning     B. Percutaneous needle biopsy     C. CT scan     D.Ultrasound

Question 16

When counseling a patient about treatment modalities for achalasia, the AGACNP advised that which of the following is the treatment of choice?

A.Calcium channel antagonists     B. Intrasphincter botulinum injection     C. Pneumatic dilation D.Myotomy and partial fundoplication

Question 17

Mr. Liu is a 52-year-old male who has a history of thyroidectomy. He presents complaining of numbness and tingling in his legs and feet and generalized fatigue. Physical examination reveals a positive Chvostek’s sign. Which of the following laboratory studies should be ordered first?

A.Renal function tests     B. Parathyroid hormone     C. Calcium     D.Magnesium

Question 18

1. is a 75-year-old male patient who, during a recent wellness evaluation, was found to have a new onset grade II/VI crescendo-decrescendo cardiac murmur at the 2nd intercostal space, right sternal border. He is symptom free and reports no limitations to his usual daily activity. He specifically denies activity intolerance or near syncope, and he is very active physically. Echocardiography reveals a mild aortic calcification. The AGACNP knows that ongoing management for R. V. must include:

A.Annual or biannual serial echocardiography     B. Modification of activity level                                 C. Baseline cardiac catheterization     D. Statin therapy

Question 19

The lower esophageal sphincter is characterized by periods of intermittent relaxation called transient lower esophageal sphincter relaxations. These relaxations are independent of the relaxation triggered by swallowing and are the most common cause of:

1. Physiologic reflux B. Symptomatic esophagitis C. Barrett’s metaplasia                    D.Esophageal carcinoma

Question 20

While reviewing morning labs on a postoperative patient, the AGACNP notes that the patient’s basic metabolic panel is as follows: Na+ 132 mEq/L K+ 4.6 mEq/L Cl- 87 mEq/L CO2 25 mEq/L A normal saline infusion is ordered in an attempt to avoid:

A.Hyperkalemia     B. Hypernatremia     C. Metabolic alkalosis     D.Metabolic acidosis

Question 21

1. is a 49-year-old man who presents for evaluation. He has a long history of alcohol and tobacco use, with a 65-year pack history and an admitted 14-drink-per-week alcohol habit. He is getting worried because he can no longer swallow his bourbon. He is not a good historian but he does admit to a 1+ year history of bloating, heartburn, and progressive difficulty swallowing food. He didn’t worry too much about his symptoms until he stopped being able to swallow bourbon. He thinks he has lost approximately 15 lbs in the last year. He denies any blood in his stool and has not had any vomiting. The AGACNP knows that the most likely diagnosis is:

A.Zenker’s diverticulum     B. Achalasia     C. Esophageal carcinoma     D.Hiatal hernia

Question 22

Which of the following treatment modalities has no role in the treatment of shock?

A.Lactated Ringer’s     B. Fresh frozen plasma (FFP)     C. Vasopressors     D.Colloid solutions

Question 23

The development of coronary artery disease (CAD) and, ultimately, plaque formation is a multifactorial process that includes endothelial injury from hypertension, cigarette smoking, and dyslipidemia. These events lead to endothelial cell dysfunction, which is theorized to result in:

A.Decreased nitric oxide production     B. Smooth muscle cell atrophy     C. Collagen degradation D.Enlarged arterial lumen

Question 24

Mr. Comstock is a 71-year-old male who presents with a general sense of feeling weak and unwell; he thinks he has the flu even though he received a flu vaccination this year. He describes a vague collection of symptoms, including weakness, nausea, dizziness, and “getting out of breath” very easily. He says he can barely climb the steps anymore without stopping to rest. Of the possible differential diagnoses, coronary artery disease (CAD) is high among the probabilities because of his age and gender. His physical examination is unremarkable except that he appears weak. His vital signs are as follows: temperature 98.0°F, pulse 100 bpm, respiratory rate 16 b.p.m., and BP 178/100 mm Hg. A chest radiograph is within normal limits with no acute pulmonary infection. A 12-lead ECG reveals inverted T waves in leads V1 to V5. The AGACNP is suspicious that most of his symptoms are:

1. Psychosomatic B. Early congestive heart failure (CHF) C. Anginal equivalents             D.Normal age-related changes

Question 25

Mrs. Carpenter is a 59-year-old female who presents with an acute myocardial infarction. She is acutely short of breath and has coarse rales on auscultation. Physical examination reveals a grade V/VI systolic murmur, loudest at the point of maximal impulse with radiation to the midaxillary line. The AGACP recognizes:

1. Acute mitral valve regurgitation B. Acute aortic valve regurgitation C. Acute cardiac tamponade     D. Acute pulmonary embolus

Question 26

Mr. Nelson is a 65-year-old male who has been advised that he is a candidate for coronary artery bypass grafting. He has been doing some internet research and is asking about whether or not he should have a “beating heart” bypass. Regarding off-pump coronary bypass grafting, the AGACNP advises Mr. Nelson that:

A.There is a slightly higher risk of neurologic complications     B. Long-term results suggest that the grafts do not stay open as long as those in traditional bypass grafting      C. The incidence of off-pump bypass grafting has increased significantly in the last 10 years      D.The off-pump procedure is considerably more expensive but is correlated with better long-term outcomes

Question 27

Mrs. McCallum is a 48-year-old female who presents for evaluation of a vague set of gastrointestinal symptoms. She feels generally well and has always been healthy, but lately she has had a lot of heartburn and a sense of reflux in her throat. Most recently she has had a recurring sense of food getting stuck in her throat. The AGACNP knows that which diagnostic study should be performed first?

A.Barium swallow     B. Upper endoscopy     C. Esophageal manometry                                  D.Ambulatory pH monitoring

Question 28

Mr. Key is a 53-year-old male patient who developed empyema following a serious bout of bacterial pneumonia. He presented as septic and was started immediately on intravenous antibiotics and drainage of the sinus cavity. Forty-eight hours later, he is much improved clinically and drainage has receded. The next step in his care would be:

A.A CT scan      B. Eloesser’s procedure     C. Decortication     D.Reexpansion

Question 29

Mrs. Bowers is a 41-year-old patient who requires surgical management of osteomyelitis. She has a long history of methamphetamine use and has a BMI of 17.9 kg/m2 . She clearly is nutritionally depleted and volume contracted, but she has no clear chronic medical history except for unmedicated hypertension, which may be due to her chronic stimulant use. She denies alcohol use but admits to a 1½ pack a day cigarette habit. A primary postoperative concern for Mrs. Bowers is:

A.Excess bleeding     B. Thromboemboli development     C. Poor wound healing      D.Renal failure

Question 30

The congenital diaphragmatic hernia that occurs more often in women and does not usually produce symptoms until midlife is known as:

A.Zenker’s hernia     B. Bochdalek’s hernia     C. Morgagni’s hernia     D.Atraumatic hernia

Question 31

1. is a 67-year-old male who is being discharged following inpatient management for unstable angina. S. B. did not know that he had coronary artery disease (CAD) and in fact had not seen a health care provider for many years. While reviewing his lifestyle habits, he admits that he is obese, has poor eating habits, does not engage in any purposeful physical activity, and smokes two packs of cigarettes daily. He verbalizes that he is grateful that this was not a “real” heart attack and does not seem receptive to lifestyle management strategies. The AGACNP advises him that it is important to take this “warning” attack seriously because:
2. 10% of patients with unstable angina will die of cardiovascular disease within 6 months B. 25% of patients with unstable angina will develop congestive heart failure within 6 months C. 65% of patients with unstable angina will have an ST elevation MI within 1 year                             D. 90% of patients with unstable angina will have cerebrovascular symptoms within 1 year

Question 32

According to the American College of Surgeons (ACS), who among the following patients should have a chest radiograph as part of preoperative assessment?

A.All patients > 40 years of age     B. All patients who smoke cigarettes     C. All patients having thoracic procedures     D.All patients with cardiac disease

Question 33

According to the Carpentier classification scheme of mitral valve regurgitation, a type I regurgitation is most likely due to:

A.Cardiomyopathy     B. Excessive leaflet motion     C. Ruptured papillary muscles                     D.Rheumatic heart disease

Question 34

101. is a 37-year-old female who is admitted via the emergency room after her roommate called emergency medical services (EMS). She has no significant medical history and does not know what is wrong with her. She has been feeling generally unwell for the last few days, and today she had an episode of confusion that scared her roommate to the extent that the roommate called EMS. Her physical examination reveals a temperature of 101.9°F, pulse of 110 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 92/58 mm Hg. A comprehensive metabolic panel reveals a slightly elevated blood urea nitrogen (BUN)/creatinine but otherwise is normal. A white blood cell differential reveals a leukocyte count of 14,000 cells/µL with neutrophils of 83%. The AGACNP knows that these values are consistent with:
102. Systemic inflammatory response syndrome (SIRS) B. High-output septic shock                    C. Neurogenic shock      D.Multiple organ dysfunction syndrome (MODS)

Question 35

Which shock state is worsened in the setting of mechanical ventilation?

1. Septic B. Cardiac compressive C. Neurogenic     D.Cardiogenic

Question 36

98. is a 41-year-old male being admitted for surgical reduction of an open femur fracture sustained in a multiple vehicle collision. Preoperative assessment reveals that he is on beta-adrenergic antagonists after having been diagnosed with coronary artery disease approximately 1 month ago. He admits that he feels a little better but says he still gets pain in his chest when he exerts himself. He is pain free now. Vital signs are as follows: temperature 98.1°F, pulse 88 bpm, respiratory rate 18 breaths per minute, and blood pressure 142/86 mm Hg. The AGACNP knows that which of the following is the most important action before R. B. goes to the operating room?

A.A cardiology consultation     B. Blood pressure control     C. Resuming beta-adrenergic antagonists D. Pain control

Question 37

Cholesteatoma is a condition characterized by a collection of desquamated keratin leading to bony erosion in the ossicular chain and inner ear. The goal of surgery in cholesteatoma is:

1. Production of a dry ear B. Preservation of sensorineural hearing C. Debridement of infection D.Restoration of the tympanic membrane

Question 38

The AGACNP knows that when managing a patient with acute cardiogenic shock after myocardial infarction, all of the following pharmacologic agents may be used except:

A.Opioids     B. Diuretics     C. Beta-adrenergic antagonists     D.Anticholinergics

Question 39

Mr. Baer is a 79-year-old man who is being admitted for a carotid endarterectomy. While performing his preoperative evaluation, the AGACNP appreciates two positive answers to the CAGE screening questionnaire. This is an indication for:

1. Perioperative benzodiazepines for withdrawal syndrome B. Daily multivitamin and 100 mg of thiamine perioperatively C. Further diagnostic evaluation for alcoholism                                D.Delay of operation until completion of detoxification

Question 40

According to the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA), the recommendation regarding antiplatelet therapy in patients with cardiovascular disease preoperatively is that:

A.Antiplatelet therapy should be held for 10 days preoperatively                                                          B. Cardiac consultation is required before an operation in patients who are on antiplatelet therapy   C. Medications should be continued unless concerns about hemostasis are significant         D.Antiplatelet therapy should be initiated in all high-risk cardiac procedures

Question 41

Mr. Austin is a 64-year-old male who has a long history of mitral valve stenosis. His condition has developed to the extent that he has symptomatic congestive heart failure, and due to a variety of comorbidities he is not a candidate for surgery. Ongoing medical therapy for Mr. Austin should include:

A.Anticoagulants      B. Diuretics       C. Antibiotics       D.Inotropes

Question 42

The progression of coronary artery plaque formation can lead to a variety of pathologic conditions. When subtotal plaque disruption occurs resulting in vasoconstriction, platelet activation, and embolization, it most commonly causes which clinical phenomenon?

A.Endothelial cell dysfunction       B. Prinzmetal’s angina      C. Transmural myocardial infarction D.Non-ST elevation myocardial infarction

Question 43

1. is a 29-year-old male who presents with a chief complaint of profound dizziness for the past 2 to 3 days. Further clarification reveals that he is having brief but intense episodes of a sense of the room spinning. He denies any history of head injury or discharge from the ear. The vertigo is reproduced easily with cervical rotation. The AGACNP knows that the most likely cause is:

A.Cerebral tumor         B. Ménière’s disease           C. Adverse drug effect                                 D.Benign paroxysmal positional vertigo (BPPV)

Question 44

P.T. is a 61-year-old male who is seen in follow-up. He was initially seen for evaluation of dysphagia. An endoscopy was negative for malignancy and subsequent esophageal manometry supported a diagnosis of esophageal achalasia. While discussing implications and treatment options with P.T., the AGACNP tells him that the primary complication of achalasia is:

1. Progressive esophageal discomfort B. Aspiration pneumonia C. Squamous cell carcinoma D.Long-term malabsorption problems

Question 45

97. is a 51-year-old female who presents in shock following a penetrating injury to the spinal cord—her boyfriend reportedly stabbed her in the back with an unidentified kitchen utensil. The patient’s mental status is deteriorating, and her vital signs are as follows: temperature 97.2°F, heart rate 131 bpm, respirations 14 breaths per minute, and blood pressure 79/49 mm Hg. The AGACNP presumes neurogenic shock, with the injury likely:

A.Not fully transecting the spinal cord      B. At the level of T10       C. Precipitating sepsis                  D. Producing cardiovascular decompensation

Question 46

Janet is a 34-year-old female with no significant medical history who is being evaluated for a planned uterine ablation. She has significant history of menorrhagia and has been unresponsive to a variety of medical therapies to try to stop the bleeding. Her history and physical examination are within normal limits. The AGACNP knows that Janet will require which one of the following preoperative diagnostic studies?

1. Urinalysis B. Complete blood count C. 12-lead electrocardiogram      D.Chest radiography

Question 47

Best practices for assessing diseases of the thyroid gland include a thorough but targeted history, systematic physical examination, and selective use of appropriate diagnostic evaluation. The AGACNP knows that although serum T3 and T4 are not indicated routinely, a free T4 test is most useful in evaluating patients:

A.With profound symptoms of hypothyroidism      B. Following treatment for Graves’ disease            C. To rule out autonomous toxic nodule      D. At risk for thyroid cancer

Question 48

Evaluation of cardiac valve disease must include:

A.Chest radiography      B. 12-lead ECG      C. Echocardiography      D.Chemical stress test

Question 49

Jolene L. is a 36-year-old female who presents for an emergent cholecystectomy; she has had progressive acute pain for almost 1 week and now there is concern about gangrenous tissue. Of particular concern is the fact that she has Graves’ disease and has not been adherent to treatment. On admission, her temperature is 102.7°F, pulse is 158 bpm, and blood pressure is 180/114 mm Hg. She is tremulous and anxious. A 12-lead ECG reveals uncontrolled atrial fibrillation. Before cholecystectomy, Jolene must be treated with:

A.Digitalis for heart rate control      B. Radioactive ablation      C. Beta-adrenergic antagonists D.Reserpine

Question 50

1. is discussing his postoperative hip replacement expectations. He is advised that although he will have some discomfort, he should be vocal about asking for pain medication, because it is essential that he get out of bed and begin ambulating as soon as possible after his surgery. He expresses some fear and is concerned that his hip won’t heal properly if he walks on it. The AGACNP reassures him that he must begin ambulating quickly in order to decrease risk for:

A.Decubitus ulcers      B. Scar tissue formation      C. Pneumonia      D.Anxiety

Question 51

1. is a 71-year-old male with small cell lung cancer; he has been treated with chemotherapy. Initially he had symptom improvement but now appears to have had a recurrence. On examination today, he is quite edematous and has gained 12 lbs since his office visit 1 week ago. A metabolic panel reveals a serum Na+ of 119 mEq/dL. The AGACNP knows that J. H. likely has:

A.Brain metastasis      B. Congestive heart failure (CHF)      C. Syndrome of inappropriate antidiuretic hormone (SIADH)      D.Metabolic alkalosis

Question 52

According to the American College of Surgeons (ACS) and the National Surgical Quality Improvement Program (NSQIP) guidelines for preoperative evaluation of the geriatric patient, the preoperative evaluation should include all of the following except:

A.Cognitive ability      B. Functional status      C. Competency assessment      D. Frailty score

Question 53

Improvements in both equipment and technique have led to the evolution of video-assisted thoracoscopic surgery (VATS) as being used most commonly for:

A.Mediastinal lymph node dissection      B. Resection of malignant tumor      C. Metastasectomy D.Thoracic vertebral discectomy

Question 54

Which of the following is a normal finding on postoperative day 8 of a carotid endarterectomy?

A.A temperature of 100.5°F         B. Serosanguinous drainage with some tenderness                           C. A flesh-colored induration along the entire length of the incision                                                  D.A fluctuant collection of milky fluid

Question 55

Mrs. Evans is an 82-year-old female who is on postoperative day 3 following resection of a small bowel tumor. She is alert today and her nasogastric tube is removed. The AGACNP knows that if the recovery proceeds normally, Mrs. Evans may begin clear liquids:

A.Immediately      B. In 24 hours      C. When bowel sounds return     D.After a negative swallow study

Question 56

When writing the initial postoperative progress note, the AGACNP should be sure to include all of the following except:

A.A summary of the procedure and any significant deviations from normal                                         B. An outline of the plan for postoperative management and follow-up                                               C. The plan for ongoing monitoring                        D.Mechanism of DVT prophylaxis

Question 57

101. is a 39-year-old male who presents to the hospital emergency room with a chief complaint of profound substernal chest pain. Results of the 12-lead ECG and cardiac enzymes test are normal. Vital signs are as follows: temperature 101.9°F, pulse 129 bpm, respirations 26 breaths per minute, and blood pressure 90/60 mm Hg. The patient is pale and clearly unwell, and physical examination reveals a systolic pericardial crunching sound. Which of the following additional pieces of history would make the AGACNP suspect acute mediastinitis?

A.A 48 pack year smoke history      B. A 2-day history of vomiting       C. Aortic valve regurgitation D.Cardiac tamponade

Question 58

Mrs. Van Doern is being examined on postop day 3 following surgical resection following a bowel obstruction. The postoperative course been unremarkable. Upon removal of the dressing, the incision is dry with staples intact. There is an approximately 0.5 cm erythema around the incision. There is no exudate. The patient demonstrates some discomfort on palpation of the site. The most appropriate approach to this patient includes:

A.Leaving the wound open to air and medicating for pain        B. Ordering a topical antibiotic, replacing the dressing with a nonadherent dressing, and following up in 2 days                                 C. Beginning systemic antibiotics to cover skin flora                                                              D.Obtaining a white blood cell differential, redress the wound and reassess in the a.m.

Question 59

K.T. is a 38-year-old female with a BMI of 39 kg/m2 who needs surgical reduction of a hiatal hernia. She is asking about the recovery process and says that she has read about something called the obesity paradox. She wants to know what that means with respect to her healing. The AGACNP explains that the paradox refers to the fact that:

1. Obesity correlates with poor outcomes for some surgical procedures but not others. B. There is an inverse relationship between weight and surgical outcomes. C. Underweight patients have more surgical complications than obese patients.                                 D. Planned weight loss preoperatively is indicated only when the BMI is > 40 kg/m2 .

Question 60

Esophageal motility disorders are sometimes a consequence of systemic diseases such as scleroderma, Raynaud’s disease, and systemic lupus erythematosus. When patients with these diseases have gastroparesis, which medication should be added to the regimen?

1. A proton pump inhibitor B. A histamine 2 receptor antagonist C. A calcium channel antagonist        D. A promotility agent

Question 61

1. is a 46-year-old female with metastatic breast cancer. She is currently off cycle for chemotherapy and generally is feeling well. Today, however, she presents feeling acutely unwell. She says that she has had coldlike symptoms over the last few days, including cough, nasal congestion, headache, and a hoarse voice in the mornings. Today she became acutely concerned because she feels as though her face and even shoulders look swollen and a bit discolored—bluish. She denies any nausea or vomiting but admits to feeling generally fatigued; she attribute it to her cancer. Recognizing the likely diagnosis, the AGACNP knows that treatment will likely include:

A.Radiation      B. Surgery      C. Fibrinolytics      D. Expansile stents

Question 62

1. is a 61-year-old female patient who complaints of pleuritic chest pain and cough. During the history, she indicates that she occasionally has seen a little bit of blood in her sputum, but she thought it was from coughing so hard. What finally prompted her to come in was that she coughed up a “stone.” Recognizing that the patient might have broncholithiasis, the AGACNP asks about exposure to:

A.Cigarettes      B. Asbestos      C. Bird excrement      D. Swimming pools

Question 63

Heart transplant is the surgical option for patients with congestive heart failure for whom medical therapies have failed. All of the following are contraindications to transplant except:

A.New York Heart Association (NYHA) class IV status      B. Obesity        C. Elevated pulmonary vascular resistance       D.Recent malignancy

Question 64

Kelly T. is a 49-year-old female who is being admitted for aortic valve replacement. Her preoperative evaluation revealed an ascending thoracic aneurysm of 4.8 cm in diameter. Kelly has not had any aneurysm symptoms and is generally considered a very strong surgical candidate. The AGACNP knows that the standard of care dictates:

1. Postponing her valve surgery due to the aneurysm B. Annual imaging of the aneurysm after her valve replacement C. Surgical repair of the aneurysm at the same time as valve replacement D. Surgical repair of the aneurysm after successful recovery from valve replacement

Question 65

1. is a 39-year-old female who was admitted for evaluation of progressive activity intolerance, and chest radiography revealed a large right lower lobe pleural effusion. A pleural fluid tap was performed, but fluid analysis results were inconclusive and the cause of the effusion could not be identified. The AGACNP knows that which diagnostic study is most appropriate to identify the cause of pleural effusion when fluid analysis is inadequate?
2. Scalene biopsy B. Video-assisted thoracoscopic surgery (VATS) C. Pleural needle biopsy D.Open surgical biopsy

Question 66

While on call, the AGACNP is asked to evaluate a deteriorating patient. The patient was admitted for exacerbation of pneumonia and congestive heart failure (CHF). The systolic blood pressure is < 90 mm Hg, and the urine output is < 10 mL/hr. A 12-lead ECG reveals no acute processes but reveals previously noted changes that are consistent with bilateral atrial and ventricular enlargement and a marked left axis deviation. You insert a pulmonary artery (PA) line and anticipate which of the following pressures? (CI, cardiac index; PAOP, pulmonary artery occlusion pressure ; RAP, right atrial pressure)

A.CI 1.3 L/min, PAOP 27 mm Hg, RAP 18 mm Hg      B. CI 1.9 L/min, PAOP 12 mm Hg, RAP 6 mm Hg C. CI 2.4 L/min, PAOP 18 mm Hg, RAP 8 mm Hg       D.CI 1.4 L/min, PAOP 7 mm Hg, RAP 4 mm Hg

Question 67

A critically ill patient with multiple traumatic injuries sustained during a motor vehicle accident has had a pulmonary artery line inserted to follow cardiac pressures. Which of the following sets of pressures would be consistent with hypovolemic shock? (CI, cardiac index; CVP, central venous pressure; PCWP, pulmonary capillary wedge pressure)

A.CI 1.3 L/min, PCWP 27 mm Hg, CVP 18 mm Hg      B. CI 1.3 L/min, PCWP 6 mm Hg, CVP 4 mm Hg C. CI 2.3 L/min, PCWP 12 mm Hg, CVP 8 mm Hg      D.CI 2.9 L/min, PCWP 16 mm Hg, CVP 6 mm Hg

Question 68

Aggressive fluid resuscitation is indicated in all of the following shock states except:

A.Hypovolemic      B. Cardiogenic      C. Obstructive      D.Distributive

Question 69

The risk-benefit ratio always is considered when evaluating patients with mitral valve disease as surgical candidates for valve correction. Who among the following patients is not considered a good operative candidate?

1. A patient with severe mitral regurgitation and endocarditis with systemic embolization B. A patient with severe mitral regurgitation and left ventricular dysfunction C. A patient with severe mitral regurgitation and normal ventricular function                                      D. A patient with severe mitral regurgitation and pulmonary hypertension

Question 70

1. is a 29-year-old male who is recovering from an open fixation of a femur fracture sustained in a diving accident. He has an order for Dilaudid 1 mg IV q2h p.r.n. for pain. He is still having pain and requests more medication. The AGACNP considers that:

A.This is the maximum dose for Dilaudid and nonpharmacologic measures should be maximized      B. The dose may be increased to 2 mg and response assessed                                                             C. He may be opiate addicted, and this should be explored before the dose is increased                D.An adjunct medication such as ibuprofen should be added to his regimen

Question 71

Mrs. Saraceno is a 71-year-old female who had an episode of acute pulmonary edema following an endovascular aneurysm repair. She was managed successfully with a loop diuretic and is ultimately discharged on furosemide 60 mg daily and instructed to follow up with cardiology. She is seen in the office postoperatively 2 weeks after discharge. She has not yet seen a cardiologist but has continued all discharge medications. Her metabolic panel is as follows: Na+ 126 mEq/L K+ 4.0 mEq/L Cl- 93 mEq/L CO2 28 mEq/L BUN 40 mg/dL Cr 1.3 mg/dL The AGACNP recognizes that the patient likely has which abnormality as a consequence of diuretic overuse?

A.Hyponatremia      B. Hypokalemia      C. Metabolic acidosis      D.Intrarenal failure

Question 72

Mrs. Hoffman is an 82-year-old female who is on postoperative day 4 following mastectomy for breast cancer. This morning her vital signs include a temperature of 101.2°F, pulse of 110 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 100/70 mm Hg. The incisions look good and there is no physical finding or symptom of incision infection. The only abnormal physical finding is a significant tender edema on the right cheek and neck. In addition to ordering increased intravenous hydration and parenteral antibiotics to target Staphylococcus aureus, the AGACNP orders:

1. Loop diuretics B. Chewing gum C. Ambulation      D.Incentive spirometry

Question 73

Kelly is a 50-year-old female who had chest radiography as part of a preoperative history and physical examination before an elective cosmetic procedure. She has no significant medical history and takes no daily medications except hormone therapy for menopausal symptoms. The radiology report of her chest film includes a 4-mm coin lesion in the right middle lobe. Kelly reports her health as excellent and has no clear risk factors for malignancy. The AGACNP knows that the next step in her management should be:

A.Repeat radiography in 6 months      B. CT scan of the chest      C. Needle biopsy of the lesion      D.A pulmonology consult

Question 74

Which of the following esophageal foreign objects should not have endoscopic removal attempted? A.Impacted meat      B. Pointed nail      C. Button battery      D.Cocaine packet

Question 75

Mrs. Glasgow is a 55-year-old female who is day 4 post open cholecystectomy. She has had some unanticipated postoperative ectopy and remains hospitalized. This morning her temperature is 100.9°F. While assessing her for infection, the AGACNP knows that which finding would be most consistent with an infectious process?

A.Neutrophilia of 82% of the white blood cell differential       B. A blood urea nitrogen (BUN)/creatinine ratio of > 20      C. Pain to palpation at the incision site                                          D.A significant decrease in appetite

Question 76

1. is a 48-year-old female who has suffered with profound GERD symptoms for several years. She has had aggressive trials of medical therapies and has been adherent to nonpharmacologic interventions. She is now in the aggressive diagnostic phase of evaluation and is preparing for 24-hour ambulatory pH monitoring. The AGACNP advises that in preparation for this test, M. L. should:

A.Continue her current proton pump inhibitor (PPI) therapy consistent with the way she has been taking it         B. Eat consistently with her normal eating habits up until the procedure                        C. Avoid straining for a bowel movement while the monitor is in place                                          D.Not do anything differently as compared with her normal daily life

Question 77

Mr. Rowley is a 79-year-old male patient who is having a surgical repair of a thoracic aneurysm. He has significant underlying chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD), and his early postoperative course will require ventilator support, nutritional support, and a variety of drains and other apparatuses. His wife has asked that he not be told about the ventilator because he is afraid of it—he watched his brother struggle with ventilator therapy. The best approach would be to tell Mrs. Rowley that:

A.The patient will be sedated and will not remember the ventilator after he recovers                          B. Her wishes will be respected and the ventilator specifically will not be discussed                             C. Being prepared for his postoperative treatment will lessen his anxiety and fear                       D.Every effort will be made to avoid ventilator support

Question 78

Ludwig’s angina is a potentially fatal condition characterized by neck pain, neck edema, edema of the base of the mouth, and tongue displacement. The AGACNP knows that the underlying cause is a consequence of:

A.Arteriolar constriction      B. Hypersensitivity       C. Infection         D.Adverse drug effect

Question 79

When counseling a 41-year-old female patient who requires mitral valve surgery for severe mitral stenosis, the AGACNP helps differentiate among options. She advises the patient that in most circumstances, given her age, she is likely to do best with which type of procedure?

A.Bioprosthetic valve replacement        B. Mechanical valve replacement                                             C. Native valve debridement         D.Catheter-based balloon valvotomy

Question 80

Alan is a 14-year-old male who has been referred for evaluation of a previously undiagnosed cardiac murmur. According to his parents, Alan has no significant medical history and has always been a healthy child. His growth and development have been within normal limits and his well-child checks have been normal. His cardiac murmur was identified during a soccer preparticipation physical examination. During today’s exam, he denies any cardiopulmonary symptoms. He admits that he gets out of breath when he is running during soccer but assumed it was just because he was running. Physical examination reveals a grade III/VI systolic murmur at the 2nd intercostal space, left sternal border, and a clearly fixed split S2 heart sound. The AGACNP knows that this murmur is probably:

A.Mitral regurgitation            B. Aortic stenosis           C. Atrial septal defect            D. Still’s murmur

Question 81

The AGACNP is evaluating a patient who he believes has fungal pneumonia. The patient says she has just relocated to Pennsylvania from Scottsdale, Arizona. When considering specific types of fungal etiology, the AGACNP knows that which type is endemic to the Arizona desert?

A.Histoplasmosis           B. Blastomycosis                C. Coccidioidomycosis              D.Aspergillosis P

Question 82

With respect to management of chronic illness on the morning of surgery, which of the following is a true statement? A. Patient with diabetes should be started on an insulin gtt to maintain serum glucose < 150 mg/dL B. Patients with coronary artery disease should have antiplatelet agents held C. Patients on beta adrenergic antagonists should continue therapy D. Patients with Hgb < 9 mg/dL should be transfused with packed red blood cells Question 82 With respect to management of chronic illness on the morning of surgery, which of the following is a true statement?

1. Patient with diabetes should be started on an insulin gtt to maintain serum glucose < 150 mg/dL B. Patients with coronary artery disease should have antiplatelet agents held C. Patients on beta adrenergic antagonists should continue therapy                       D. Patients with Hgb < 9 mg/dL should be transfused with packed red blood cells

Question 83

Mr. Mireya is a 66-year-old male who is admitted for palliative surgery for a glioblastoma. He has borderline stage III-IV chronic kidney disease. The AGACNP realizes that he is at increased risk in the perioperative period for:

A.Hypercalcemia             B. Hypokalemia             C. Thrombocytopenia             D.Eosinophilia

Question 84

Barrett’s esophagus is best described as:

A.A symptomatic condition of gastric reflux           B. A condition that occurs more commonly in women of childbearing age           C. A metaplastic adaptation to repeated irritation                        D.A secondary motility disorder

Question 85

Ms. Carson is a 71-year-old female who presents with significant pleuritic-type chest pain. She has no known cardiopulmonary history and does not smoke cigarettes. Her history is significant only for an upper endoscopy this morning for evaluation of severe gastroesophageal reflux disease (GERD). She tolerated the procedure well and was discharged home. Over the afternoon she developed worsening pain on the left side of her chest and finally had to come to the emergency department. Her vital signs are as follows: temperature 100.0°F, pulse 116 bpm, respiratory rate 22 breaths per minute, and blood pressure 96/60 mm Hg. The AGACNP orders which of the following diagnostic studies to confirm the suspected diagnosis?

A.Chest radiograph          B. 12-lead ECG          C. Upper endoscopy          D.Esophagram

Question 86

Lilly M. is a 44-year-old female who is transferred to the emergency department following a severe fall. She had been standing on the balcony of a four-story building and tried to balance on the railing. She fell and sustained numerous internal and external injuries. In the emergency room she was in profound hypovolemic shock. Bleeding appears to have been stopped, and rapid infusion of 2 L of normal saline has just been completed. The AGACNP knows that the next step in fluid resuscitation includes:

A.Transfusion of packed red blood cells (PRBCs) based on hematocrit               B. Infusion of 1 L of lactated Ringer’s             C. 1 more liter of normal saline solution (NSS) over 10 minutes               D.No additional fluid unless the systolic blood pressure (SBP) is < 90 mm Hg

Question 87

1. is a 67-year-old male with a history of significant coronary artery disease, who now presents in acute cardiogenic shock. His blood pressure is 82/50 mm Hg, and the pulse is in sinus bradycardia at 44 bpm. He is awake and oriented but lethargic and says he feels lightheaded. The treatment of choice for this patient is: A.Transvenous pacing B. Aggressive fluid resuscitation C. Atropine 0.5 mg q2min × 4 D.Epinephrine 1 mg IV Question 88 Jeff Z. is a 49-year-old male who is on the heart transplant list due to myocarditis-related end stage congestive heart failure. While counseling Jeff about bridge devices that allow him to be discharged from the hospital, the AGACNP tells Jeff that the most frequently used device is:

A.Ideal for smaller-framed patients        B. Implanted below the diaphragm                                         C. Independent of external power for up to 24 hours            D.Good for up to 2 years

Question 89

Mrs. Brownlee is a 63-year-old female who is admitted for surgical replacement of her aortic valve. She has a history of symptomatic aortic stenosis, osteoarthritis, and hypothyroidism. She has always been very thin, and her admitting height and weight are 5’4” and 110 lbs. In considering her postoperative nutritional needs, the AGACNP recognizes that:

1. Postoperative calorie requirements are higher than baseline because of the hypermetabolic response to physiologic stress B. The parasympathetic response to thoracic surgery requires a proportionally greater increase in protein calories C. Calorie requirements will not change postoperatively, as the increased stress response is balanced by bedrest and decreased activity calorie use.                    D.Nutritional requirements are individualized postoperatively, and it is not possible to predict postoperative needs in

Question 90

Mr. Cortez is a 41-year-old male with a long history of chronic allergic rhinitis. He has not had health insurance for most of his adult life, so he has self-treated his nasal symptoms with a combination of over-the-counter agents including antihistamines, decongestants, and nasal sprays. He recently obtained coverage under the Affordable Care Act and presents more regularly for care of his chronic nasal symptoms; he cannot go longer than a few hours without using his nasal spray. The nasal mucosa is edematous and hyperemic on inspection. The AGACNP know that this patient suffers from:

A.Chronic sinusitis          B. Rhinitis medicamentosa            C. Adverse drug effect                               D. Psychological dependence

Question 91

Mrs. Knickerson is an 89-year-old female who lives alone at home. She is generally in good health, and her functional status is reasonably strong. Her son and daughter-in-law stop by once or twice a week and help her with some household chores. Mrs. Knickerson’s only medical diagnosis is hypertension, for which she has taken HCTZ 12.5 mg for as long as she can remember. Today when her son went into the home, he found her in bed, clearly unwell and a bit disoriented. Upon hospital admission, she is found to have vital signs as follows: temperature 100.9°F, pulse 122 bpm, respirations 22 breaths per minute, and blood pressure 82/53 mm Hg. Her saO2 on 2 L of nasal oxygen is 89%. Chest radiograph is clear, and 12-lead ECG demonstrates sinus tachycardia. Urinalysis reveals +++ white blood cells, + nitrites, + red blood cells, and ++ bacteriuria. The AGACNP suspects which of the following shock states?

A.Hypovolemic                  B. Cardiogenic                C. Obstructive                  D.Neurogenic

Question 92

Which of the following is a true statement with respect to needle lung biopsy?

A.It is the preferred method of biopsy in patients with comorbid pulmonary hypertension                  B. It is highly sensitive, yielding diagnostic data in > 90% of patients               C. Serious complications are very rare                D.There is concern about spreading a tumor in patients with localized disease

Question 93

29. is a 55-year-old male patient with obstructive sleep apnea. He is motivated to control his condition and has been adherent to conservative therapeutic options. He has lost almost 65 lbs and now has a body mass index of 29. He drinks alcohol < 1 x monthly and does not smoke cigarettes. He had difficulty adjusting to bilevel positive airway pressure (BiPAP) but has used it for several months, with only marginal improvement. He presents today to talk about surgical options. The AGACNP counsels J. S. that:

A.He is not a strong candidate for surgical success            B. Before the operation, he needs to reduce his BMI to 25            C. The first step would be tonsillectomy and adenoidectomy                        D.The best out outcomes occur with multilevel surgery

Question 94

The process by which an assessment of the patient is performed, before an operation, to evaluate overall health and identify risk factors for intra- and postoperative complications is known as:

1. Preoperative evaluation B. Diagnostic evaluation C. Preoperative preparation D.Diagnostic preparation

Question 95

Mrs. Carroll is an 81-year-old female who is going to have a surgical procedure for removal of an obstructing large-bowel tumor. While assessing her nutritional status, the AGACNP knows that which of the following is a severe risk factor for poor surgical outcome?

A.Admitting body mass index of 18.1 kg/m2               B. 3 day dietary history of < 1200 calories daily C. A serum albumin of 3.2 g/dL                   D.Unplanned weight loss of 8 lbs. in the last 6 months.

Question 96

Carolyn is a 25-year-old injection drug user who has had a long history of health problems since her early teenage years. She has preexisting mitral valve regurgitation and has had endocarditis in the past. She is now being treated for lung abscess that presumably occurred with aspiration in an intoxicated state. She was admitted and started on intravenous antibiotic therapy, IV fluids, and nutritional support. She is now on day 5 of antibiotic therapy and remains septic and febrile. The AGACNP knows that the indicated course of treatment includes:

A.Continued antibiotic therapy with evaluation on day 7                B. Change to a different extended spectrum antibiotic                 C. Percutaneous drainage of the abscess                           D.Thoracotomy with open drainage

Question 97

Mr. Zuckerman is a 62-year-old man who presents for evaluation of a sense of difficulty swallowing and food getting stuck. He also reports that sometimes he can hear or “feel” a gurgling sound in his throat. He had a barium swallow study that demonstrated a large pharyngoesophageal (Zenker’s) diverticulum. The AGACNP knows that which of the following additional diagnostic studies is not indicated?

A.Esophageal manometry      B. Chest radiograph       C. Endoscopy      D.Ambulatory pH monitoring

Question 98

Which of the following foreign bodies in the ear canal is considered a surgical emergency that requires immediate intervention by otolaryngology (ENT) without any attempt to remove by a non-ENT provider?

A.A popcorn kernel       B. A cockroach       C. A button battery       D.A piece of cotton

Question 99

When a patient has suspected postoperative bleeding, the immediate priority of care is to:

A.Identify the bleeding site                B. Ensure hemodynamic stability                                                        C. Transfuse packed red blood cells                D.Obtain a stat surgical consult

Question 100

Mr. Quigley is a 56-year-old male patient who presents for evaluation of difficulty swallowing. Physical examination of the oropharynx reveals a pink irregular mass of approximately 4 cm in the posterior pharynx. The patient is advised that he appears to have an abnormal growth and will need to be referred to otolaryngology. He asks how he got a tumor in his throat. The AGACNP replies that the greatest risk factor(s) for oropharyngeal tumors is(are):

A.Tobacco and alcohol use                   B. Human papillomavirus (HPV)                                                 C. Family history of a first degree relative                     D. Female gender

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Sometimes I dream a dream

1. 500-600 words; 5-paragraph structure (can have more than five).
2. Your idea about the story itself—the value of the story (at least a paragraph)
3. How it applies to life in general (at least a paragraph)
4. How it applies to you.  Write about an item that is important to you, one that has been passed down to you or one that you hope will be or an item that you have that you will plan to pass down to someone (at least a paragraph). .
5. Be sure to supply
a. A parenthetical reference
b. A Works Cited
I will wait for her in the yard that Maggie and I made so clean and wavy yesterday afternoon. A yard like this is more comfortable than most people know. It is not just a yard. It is like an extended living room. When the hard clay is swept clean as a floor and the fine sand around the edges lined with tiny, irregular grooves, anyone can come and sit and look up into the elm tree and wait for the breezes that never come inside the house.
Maggie will be nervous until after her sister goes: she will stand hopelessly in corners, homely and ashamed of the burn scars down her arms and legs, eying her sister with a mixture of envy and awe. She thinks her sister has held life always in the palm of one hand, that “no” is a word the world never learned to say to her.
You’ve no doubt seen those TV shows where the child who has “made it” is confronted, as a surprise, by her own mother and father, tottering in weakly from backstage. (A pleasant surprise, of course: What would they do if parent and child came on the show only to curse out and insult each other?) On TV mother and child embrace and smile into each other’s faces. Sometimes the mother and father weep, the child wraps them in her arms and leans across the table to tell how she would not have made it without their help. I have seen these programs.
Sometimes I dream a dream in which Dee and I are suddenly brought together on a TV program of this sort. Out of a dark and soft.seated limousine I am ushered into a bright room filled with many people. There I meet a smiling, gray, sporty man like Johnny Carson who shakes my hand and tells me what a fine girl I have. Then we are on the stage and Dee is embracing me with tears in her eyes. She pins on my dress a large orchid, even though she has told me once that she thinks orchids are tacky flowers.
In real life I am a large, big.boned woman with rough, man.working hands. In the winter I wear flannel nightgowns to bed and overalls dur.ing the day. I can kill and clean a hog as mercilessly as a man. My fat keeps me hot in zero weather. I can work outside all day, breaking ice to get water for washing; I can eat pork liver cooked over the open fire minutes after it comes steaming from the hog. One winter I knocked a bull calf straight in the brain between the eyes with a sledge hammer and had the meat hung up to chill before nightfall. But of course all this does not show on television. I am the way my daughter would want me to be: a hundred pounds lighter, my skin like an uncooked barley pancake. My hair glistens in the hot bright lights. Johnny Carson has much to do to keep up with my quick and witty tongue.
But that is a mistake. I know even before I wake up. Who ever knew a Johnson with a quick tongue? Who can even imagine me looking a strange white man in the eye? It seems to me I have talked to them always with one foot raised in flight, with my head fumed in whichever way is farthest from them. Dee, though. She would always look anyone in the eye. Hesitation was no part of her nature.
“How do I look, Mama?” Maggie says, showing just enough of her thin body enveloped in pink skirt and red blouse for me to know she’s there, almost hidden by the door.
“Come out into the yard,” I say.
Have you ever seen a lame animal, perhaps a dog run over by some careless person rich enough to own a car, sidle up to someone who is ignorant enough to be kind to him? That is the way my Maggie walks. She has been like this, chin on chest, eyes on ground, feet in shuffle, ever since the fire that burned the other house to the ground.
Dee is lighter than Maggie, with nicer hair and a fuller figure. She’s a woman now, though sometimes I forget. How long ago was it that the other house burned? Ten, twelve years? Sometimes I can still hear the flames and feel Maggie’s arms sticking to me, her hair smoking and her dress falling off her in little black papery flakes. Her eyes seemed stretched open, blazed open by the flames reflected in them. And Dee. I see her standing off under the sweet gum tree she used to dig gum out of; a look of concentration on her face as she watched the last dingy gray board of the house fall in toward the red.hot brick chimney. Why don’t you do a dance around the ashes? I’d wanted to ask her. She had hated the house that much.
I used to think she hated Maggie, too. But that was before we raised money, the church and me, to send her to Augusta to school. She used to read to us without pity; forcing words, lies, other folks’ habits, whole lives upon us two, sitting trapped and ignorant underneath her voice. She washed us in a river of make.believe, burned us with a lot of knowl edge we didn’t necessarily need to know. Pressed us to her with the serf’ ous way she read, to shove us away at just the moment, like dimwits, we seemed about to understand.
Dee wanted nice things. A yellow organdy dress to wear to her grad.uation from high school; black pumps to match a green suit she’d made from an old suit somebody gave me. She was determined to stare down any disaster in her efforts. Her eyelids would not flicker for minutes at a time. Often I fought off the temptation to shake her. At sixteen she had a style of her own: and knew what style was.
I never had an education myself. After second grade the school was closed down. Don’t ask my why: in 1927 colored asked fewer questions than they do now. Sometimes Maggie reads to me. She stumbles along good.naturedly but can’t see well. She knows she is not bright. Like good looks and money, quickness passes her by. She will marry John Thomas (who has mossy teeth in an earnest face) and then I’ll be free to sit here and I guess just sing church songs to myself. Although I never was a good singer. Never could carry a tune. I was always better at a man’s job. I used to love to milk till I was hooked in the side in ’49. Cows are soothing and slow and don’t bother you, unless you try to milk them the wrong way.
I have deliberately turned my back on the house. It is three rooms, just like the one that burned, except the roof is tin; they don’t make shingle roofs any more. There are no real windows, just some holes cut in the sides, like the portholes in a ship, but not round and not square, with rawhide holding the shutters up on the outside. This house is in a pasture, too, like the other one. No doubt when Dee sees it she will want to tear it down. She wrote me once that no matter where we “choose” to live, she will manage to come see us. But she will never bring her friends. Maggie and I thought about this and Maggie asked me, “Mama, when did Dee ever have any friends?”
She had a few. Furtive boys in pink shirts hanging about on washday after school. Nervous girls who never laughed. Impressed with her they worshiped the well.turned phrase, the cute shape, the scalding humor that erupted like bubbles in Iye. She read to them.
When she was courting Jimmy T she didn’t have much time to pay to us, but turned all her faultfinding power on him. He flew to marry a cheap city girl from a family of ignorant flashy people. She hardly had time to recompose herself.
When she comes I will meet—but there they are!
Maggie attempts to make a dash for the house, in her shuffling way, but I stay her with my hand. “Come back here, ” I say. And she stops and tries to dig a well in the sand with her toe.
It is hard to see them clearly through the strong sun. But even the first glimpse of leg out of the car tells me it is Dee. Her feet were always neat.looking, as if God himself had shaped them with a certain style. From the other side of the car comes a short, stocky man. Hair is all over his head a foot long and hanging from his chin like a kinky mule tail. I hear Maggie suck in her breath. “Uhnnnh, ” is what it sounds like. Like when you see the wriggling end of a snake just in front of your foot on the road. “Uhnnnh.”
Dee next. A dress down to the ground, in this hot weather. A dress so loud it hurts my eyes. There are yellows and oranges enough to throw back the light of the sun. I feel my whole face warming from the heat waves it throws out. Earrings gold, too, and hanging down to her shoul.ders. Bracelets dangling and making noises when she moves her arm up to shake the folds of the dress out of her armpits. The dress is loose and flows, and as she walks closer, I like it. I hear Maggie go “Uhnnnh” again. It is her sister’s hair. It stands straight up like the wool on a sheep. It is black as night and around the edges are two long pigtails that rope about like small lizards disappearing behind her ears.
“Wa.su.zo.Tean.o!” she says, coming on in that gliding way the dress makes her move. The short stocky fellow with the hair to his navel is all grinning and he follows up with “Asalamalakim, my mother and sister!” He moves to hug Maggie but she falls back, right up against the back of my chair. I feel her trembling there and when I look up I see the perspiration falling off her chin.
“Don’t get up,” says Dee. Since I am stout it takes something of a push. You can see me trying to move a second or two before I make it. She turns, showing white heels through her sandals, and goes back to the car. Out she peeks next with a Polaroid. She stoops down quickly and lines up picture after picture of me sitting there in front of the house with Maggie cowering behind me. She never takes a shot without mak’ ing sure the house is included. When a cow comes nibbling around the edge of the yard she snaps it and me and Maggie and the house. Then she puts the Polaroid in the back seat of the car, and comes up and kisses me on the forehead.
Meanwhile Asalamalakim is going through motions with Maggie’s hand. Maggie’s hand is as limp as a fish, and probably as cold, despite the sweat, and she keeps trying to pull it back. It looks like Asalamalakim wants to shake hands but wants to do it fancy. Or maybe he don’t know how people shake hands. Anyhow, he soon gives up on Maggie.
“Well,” I say. “Dee.”
“No, Mama,” she says. “Not ‘Dee,’ Wangero Leewanika Kemanjo!”
“What happened to ‘Dee’?” I wanted to know.
“She’s dead,” Wangero said. “I couldn’t bear it any longer, being named after the people who oppress me.”
“You know as well as me you was named after your aunt Dicie,” I said. Dicie is my sister. She named Dee. We called her “Big Dee” after Dee was born.
“But who was she named after?” asked Wangero.
“I guess after Grandma Dee,” I said.
“And who was she named after?” asked Wangero.
“Her mother,” I said, and saw Wangero was getting tired. “That’s about as far back as I can trace it,” I said. Though, in fact, I probably could have carried it back beyond the Civil War through the branches.
“Well,” said Asalamalakim, “there you are.”
“Uhnnnh,” I heard Maggie say.
“There I was not,” I said, “before ‘Dicie’ cropped up in our family, so why should I try to trace it that far back?”
He just stood there grinning, looking down on me like somebody inspecting a Model A car. Every once in a while he and Wangero sent eye signals over my head.
“How do you pronounce this name?” I asked.
“You don’t have to call me by it if you don’t want to,” said Wangero.
“Why shouldn’t 1?” I asked. “If that’s what you want us to call you, we’ll call you.”
.
“I know it might sound awkward at first,” said Wangero.
“I’ll get used to it,” I said. “Ream it out again.”
Well, soon we got the name out of the way. Asalamalakim had a name twice as long and three times as hard. After I tripped over it two or three times he told me to just call him Hakim.a.barber. I wanted to ask him was he a barber, but I didn’t really think he was, so I didn’t ask.
“You must belong to those beef.cattle peoples down the road,” I said. They said “Asalamalakim” when they met you, too, but they didn’t shake hands. Always too busy: feeding the cattle, fixing the fences, putting up salt.lick shelters, throwing down hay. When the white folks poisoned some of the herd the men stayed up all night with rifles in their hands. I walked a mile and a half just to see the sight.
Hakim.a.barber said, “I accept some of their doctrines, but farming and raising cattle is not my style.” (They didn’t tell me, and I didn’t ask, whether Wangero (Dee) had really gone and married him.)
We sat down to eat and right away he said he didn’t eat collards and pork was unclean. Wangero, though, went on through the chitlins and com bread, the greens and everything else. She talked a blue streak over the sweet potatoes. Everything delighted her. Even the fact that we still used the benches her daddy made for the table when we couldn’t effort to buy chairs.
“Oh, Mama!” she cried. Then turned to Hakim.a.barber. “I never knew how lovely these benches are. You can feel the rump prints,” she said, running her hands underneath her and along the bench. Then she gave a sigh and her hand closed over Grandma Dee’s butter dish. “That’s it!” she said. “I knew there was something I wanted to ask you if I could have.” She jumped up from the table and went over in the corner where the churn stood, the milk in it crabber by now. She looked at the churn and looked at it.
“This churn top is what I need,” she said. “Didn’t Uncle Buddy whittle it out of a tree you all used to have?”
“Yes,” I said.
“Un huh,” she said happily. “And I want the dasher, too.”
“Uncle Buddy whittle that, too?” asked the barber.
Dee (Wangero) looked up at me.
“Aunt Dee’s first husband whittled the dash,” said Maggie so low you almost couldn’t hear her. “His name was Henry, but they called him Stash.”
 
“Maggie’s brain is like an elephant’s,” Wangero said, laughing. “I can use the chute top as a centerpiece for the alcove table,” she said, sliding a plate over the chute, “and I’ll think of something artistic to do with the dasher.”
When she finished wrapping the dasher the handle stuck out. I took it for a moment in my hands. You didn’t even have to look close to see where hands pushing the dasher up and down to make butter had left a kind of sink in the wood. In fact, there were a lot of small sinks; you could see where thumbs and fingers had sunk into the wood. It was beautiful light yellow wood, from a tree that grew in the yard where Big Dee and Stash had lived.
After dinner Dee (Wangero) went to the trunk at the foot of my bed and started rifling through it. Maggie hung back in the kitchen over the dishpan. Out came Wangero with two quilts. They had been pieced by Grandma Dee and then Big Dee and me had hung them on the quilt ftames on the ftont porch and quilted them. One was in the Lone Stat pattetn. The other was Walk Around the Mountain. In both of them were scraps of dresses Grandma Dee had wotn fifty and more years ago. Bits and pieces of Grandpa Jattell’s Paisley shirts. And one teeny faded blue piece, about the size of a penny matchbox, that was from Great Grandpa Ezra’s unifotm that he wore in the Civil War.
“Mama,” Wangro said sweet as a bird. “Can I have these old quilts?”
I heard something fall in the kitchen, and a minute later the kitchen door slammed.
“Why don’t you take one or two of the others?” I asked. “These old things was just done by me and Big Dee from some tops your grandma pieced before she died.”
“No,” said Wangero. “I don’t want those. They are stitched around the borders by machine.”
“That’ll make them last better,” I said.
“That’s not the point,” said Wangero. “These are all pieces of dresses Grandma used to wear. She did all this stitching by hand. Imag’ ine!” She held the quilts securely in her atms, stroking them.
“Some of the pieces, like those lavender ones, come ftom old clothes her mother handed down to her,” I said, moving up to touch the quilts. Dee (Wangero) moved back just enough so that I couldn’t reach the quilts. They already belonged to her.
“Imagine!” she breathed again, clutching them closely to her bosom.
“The ttuth is,” I said, “I promised to give them quilts to Maggie, for when she matties John Thomas.”
She gasped like a bee had stung her.
“Maggie can’t appreciate these quilts!” she said. “She’d probably be backward enough to put them to everyday use.”
 
“I reckon she would,” I said. “God knows I been saving ’em for long enough with nobody using ’em. I hope she will!” I didn’t want to bring up how I had offered Dee (Wangero) a quilt when she went away to college. Then she had told they were old~fashioned, out of style.
“But they’re priceless!” she was saying now, furiously; for she has a temper. “Maggie would put them on the bed and in five years they’d be in rags. Less than that!”
“She can always make some more,” I said. “Maggie knows how to quilt.”
Dee (Wangero) looked at me with hatred. “You just will not under.stand. The point is these quilts, these quilts!”
“Well,” I said, stumped. “What would you do with them7”
“Hang them,” she said. As if that was the only thing you could do with quilts.
Maggie by now was standing in the door. I could almost hear the sound her feet made as they scraped over each other.
“She can have them, Mama,” she said, like somebody used to never winning anything, or having anything reserved for her. “I can ‘member Grandma Dee without the quilts.”
I looked at her hard. She had filled her bottom lip with checkerberry snuff and gave her face a kind of dopey, hangdog look. It was Grandma Dee and Big Dee who taught her how to quilt herself. She stood there with her scarred hands hidden in the folds of her skirt. She looked at her sister with something like fear but she wasn’t mad at her. This was Maggie’s portion. This was the way she knew God to work.
When I looked at her like that something hit me in the top of my head and ran down to the soles of my feet. Just like when I’m in church and the spirit of God touches me and I get happy and shout. I did some.thing I never done before: hugged Maggie to me, then dragged her on into the room, snatched the quilts out of Miss Wangero’s hands and dumped them into Maggie’s lap. Maggie just sat there on my bed with her mouth open.
“Take one or two of the others,” I said to Dee.
But she turned without a word and went out to Hakim~a~barber.
“You just don’t understand,” she said, as Maggie and I came out to the car.
“What don’t I understand?” I wanted to know.
“Your heritage,” she said, And then she turned to Maggie, kissed her, and said, “You ought to try to make something of yourself, too, Maggie. It’s really a new day for us. But from the way you and Mama still live you’d never know it.”
She put on some sunglasses that hid everything above the tip of her nose and chin.
Maggie smiled; maybe at the sunglasses. But a real smile, not scared. After we watched the car dust settle I asked Maggie to bring me a dip of snuff. And then the two of us sat there just enjoying, until it was time to go in the house and go to bed.

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Community AssessmentIn this weeks media presentations.

ApplicationCommunity AssessmentIn this weeks media presentations, Ms. Marren and Dr. Fernando Guerra discussed the importance of community assessment when determining the needs of the community and health promotion or intervention programs. In addition, Dr. Sattler examined the influence of the environment on the health of a community, along with occupational health concerns.Community assessment is one of the three core functions of public health nursing and is the process of thinking critically about the community. It involves a logical, systematic approach to identify a communitys needs, problems (including environmental and occupational problems), and strengths and resources. Assessment of the health of a community can begin with a simple windshield assessment: a drive through the community noting strengths and problems. Community assessment also includes data gathering through examining vital statistics, and the demographics of the community.To prepare for this Application, review the media presentations for this week and Chapter 18 in the textbook on community assessment. In addition, use Table 185 on page 410 in the course textbook to guide your windshield assessment. Incorporate your windshield assessment with your Application.Conduct an assessment of the community in which you live, including a windshield assessment. Then, write a 3- to 4-page paper that includes the following: DemographicsVital statisticsEnvironmental issuesOccupational health hazardsVulnerable populationsResources available in the communityOther pertinent information about the community (Incorporate information from the windshield assessment into the paper.)

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