ANCC Psychiatric-Mental Health Nurse Practitioner (PMHNP-BC)

Correct: In cases of acute bacterial sialadenitis that progress to abscess formation (indicated by fluctuance and systemic toxicity), the standard of care involves admission for intravenous hydration to address stasis, parenteral antibiotics targeting Staphylococcus aureus, and surgical drainage. Drainage must be performed carefully using blunt dissection (Hilton’s method) parallel to the branches of the facial nerve to prevent iatrogenic injury.

Correct: The Sommerlad intracvelar veloplasty is characterized by the use of an operating microscope to perform a radical dissection of the levator veli palatini muscle. In a cleft palate, this muscle is abnormally attached to the posterior border of the hard palate (the palatal aponeurosis). The primary objective is to release these abnormal attachments and retroposition the muscle fibers, suturing them across the midline to create a functional transverse muscle sling, which is critical for velopharyngeal competence and speech development.

Incorrect: The V-Y pushback (Wardill-Kilner) focuses on lengthening the palate through flap design rather than radical muscle dissection. Primary pharyngoplasty is not a standard component of a primary palatoplasty and is usually reserved for secondary speech surgery. Gingivoperiosteoplasty is a procedure used to manage the alveolar cleft, not the soft palate muscle reconstruction required for velopharyngeal function.

Takeaway: The hallmark of the Sommerlad palatoplasty is the radical mobilization and retropositioning of the levator veli palatini to reconstruct the functional velar muscle sling.

Correct: For large (typically >5-7mm) stones located in the hilum of the submandibular gland that are palpable, a transoral surgical approach (hilar incision) is the gold standard for gland preservation. This technique allows for direct access to the stone while avoiding the morbidity associated with a transcervical submandibular gland excision, such as scarring or risk to the marginal mandibular nerve.

Incorrect: Extracorporeal shockwave lithotripsy is generally less effective for large submandibular stones than for parotid stones and often requires multiple sessions with a lower success rate for complete clearance. Conservative management is inappropriate for a 9mm stone as it is highly unlikely to pass spontaneously and increases the risk of chronic sialadenitis. Blind basket retrieval is dangerous for stones of this size, as it can lead to ductal avulsion, scarring, or the stone becoming wedged in the ductal system.

Takeaway: Gland-preserving transoral surgery is the preferred management for large, palpable hilar submandibular stones over radical excision or conservative measures.

Correct: Modified Radical Neck Dissection (MRND) is categorized into three types based on the preservation of non-lymphatic structures (spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle) while removing lymph node levels I through V. Type II MRND is specifically defined by the preservation of two of these structures, which in standard surgical nomenclature are the spinal accessory nerve and the internal jugular vein, while the sternocleidomastoid muscle is removed.

Incorrect: Modified Radical Neck Dissection Type I involves the preservation of only one non-lymphatic structure, typically the spinal accessory nerve. Modified Radical Neck Dissection Type III, also known as functional neck dissection, involves the preservation of all three non-lymphatic structures (SAN, IJV, and SCM). Selective Neck Dissection refers to a procedure where one or more lymph node levels are preserved (e.g., levels IV or V), which contradicts the scenario where levels I-V were cleared.

Takeaway: Modified Radical Neck Dissection Type II is distinguished by the preservation of the spinal accessory nerve and internal jugular vein with the sacrifice of the sternocleidomastoid muscle.

Correct: Under the AJCC 8th edition guidelines for oral cavity squamous cell carcinoma, the T-category is determined by both the maximum surface diameter and the depth of invasion (DOI). A tumor that measures between 2 cm and 4 cm in diameter with a DOI of 10 mm or less is classified as T2. Since the lesion in this scenario is 3.5 cm with an 8 mm DOI, it fits the T2 criteria perfectly.

Incorrect: T1 is incorrect because the tumor diameter exceeds 2 cm. T3 is incorrect because the tumor diameter does not exceed 4 cm and the depth of invasion is not greater than 10 mm (a DOI > 10 mm would automatically trigger T3 regardless of diameter). T4a is incorrect because it requires invasion into specific structures such as the cortical bone of the mandible or maxilla, the maxillary sinus, or the skin of the face, none of which are present in this case.

Takeaway: The AJCC 8th edition for oral cavity cancer incorporates depth of invasion (DOI) as a critical component alongside tumor diameter to define the T-category.

Correct: Arthroscopic lysis and lavage is considered the gold standard for Wilkes Stage II and III internal derangement when conservative measures fail. This minimally invasive procedure allows for the release of adhesions in the superior joint space, removal of inflammatory mediators, and can be combined with disc repositioning (plication) to restore normal biomechanics and joint volume with significantly less morbidity than open joint procedures.

Incorrect: Open joint discectomy is typically reserved for cases where the disc is severely damaged, perforated, or non-salvageable, which is more characteristic of Wilkes Stage IV or V. High condylar ostectomy is not a standard primary treatment for disc displacement without reduction and may lead to occlusal instability. Total joint replacement is a terminal salvage procedure indicated for end-stage joint disease with significant osseous destruction or ankylosis, and is far too aggressive for a patient with a salvageable disc and no osseous remodeling.

Takeaway: For Wilkes Stage III internal derangement failing conservative therapy, minimally invasive arthroscopic surgery is the preferred initial surgical intervention to restore function and manage pain.

Correct: Effective translation of adjuvant therapy impact into surgical action requires proactive management of the future radiation field. Pre-radiation dental clearance (ideally 14-21 days prior) is essential to allow mucosal healing and reduce the risk of osteoradionecrosis (ORN). Furthermore, because radiotherapy causes endarteritis obliterans and tissue hypoxia, vascularized free tissue transfer (such as a fibula free flap) is the gold standard for reconstruction as it provides its own independent blood supply, which is more resilient to the effects of radiation compared to non-vascularized grafts or local flaps.

Incorrect: Delaying extractions until after radiotherapy (Option C) significantly increases the risk of ORN because the bone’s healing capacity is permanently compromised. Operating during the chemotherapy nadir (Option B) is contraindicated due to the high risk of sepsis and hemorrhage associated with neutropenia and thrombocytopenia; additionally, non-vascularized bone grafts frequently fail in irradiated beds. Hyperbaric oxygen therapy (Option D) is not indicated as a routine prophylactic measure for primary resection and does not address the fundamental need for vascularized tissue in complex reconstructions.

Takeaway: Surgical planning for head and neck oncology must prioritize pre-radiotherapy dental optimization and the use of vascularized tissue to mitigate the long-term risks of hypoxia and osteoradionecrosis.

Correct: In cases of peri-implantitis where non-surgical therapy (debridement and oral hygiene instruction) fails to resolve inflammation and deep pockets (>= 6mm), surgical intervention is indicated. Open flap debridement allows for direct visualization and mechanical/chemical decontamination of the implant surface. If the defect morphology is contained (e.g., a 3-wall defect), regenerative procedures using bone substitutes and membranes can be employed to regain bone support.

Incorrect: Non-surgical adjuncts like photodynamic therapy or systemic antibiotics are generally insufficient as monotherapies for advanced lesions with significant bone loss, as they do not allow for adequate decontamination of the complex implant surface. Immediate explantation is usually reserved for mobile implants or those with extreme bone loss (typically >50%) where the prognosis is hopeless, which is not necessarily the case with a 3mm defect.

Takeaway: Surgical access via open flap debridement is necessary for effective surface decontamination and potential regeneration when peri-implantitis persists after non-surgical treatment.

Correct: In pediatric patients, the management of mandibular fractures must account for rapid bone healing and the presence of growth centers. For a displaced symphysis fracture, open reduction and internal fixation with resorbable plates provide stability without interfering with future mandibular growth or requiring a second surgery for hardware removal. For the non-displaced condylar fracture, early mobilization is critical to prevent temporomandibular joint ankylosis and to promote functional remodeling of the condyle, which is highly active in children.

Incorrect: Using rigid titanium fixation for both fractures is inappropriate because it can restrict the transverse growth of the mandible and often necessitates a second surgery for removal. Prolonged maxillomandibular fixation for six weeks is contraindicated in children as it significantly increases the risk of permanent joint stiffness or ankylosis. Extracting developing tooth buds is an aggressive approach that causes unnecessary morbidity and complicates future dental development and alveolar ridge maintenance.

Takeaway: The management of pediatric jaw fractures prioritizes stable fixation of displaced segments using growth-accommodating materials and early mobilization of condylar injuries to prevent ankylosis.

Correct: House-Brackmann Grade II (Slight Dysfunction) is characterized by a gross slight weakness noticeable only on close inspection. Anatomically, it is defined by moderate to good forehead function, complete eye closure with minimal effort, and slight asymmetry of the mouth. This grade represents the mildest form of functional deficit on the scale, excluding a normal Grade I.

Incorrect: House-Brackmann Grade III (Moderate Dysfunction) is incorrect because it involves an obvious but not disfiguring difference between the two sides, and eye closure requires effort rather than being minimal. Grade IV (Moderately Severe Dysfunction) is incorrect as it is characterized by obvious, disfiguring weakness, an inability to move the forehead, and incomplete eye closure. Grade V (Severe Dysfunction) is incorrect because it involves barely perceptible motion and a complete lack of forehead movement.

Takeaway: The House-Brackmann scale is the clinical standard for grading facial nerve function, where Grade II is distinguished by preserved forehead motion and complete eye closure with minimal effort.