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Quiz Session - Attempts With Random Questions

AANPCB FNP Exam Questions

Page 4 of 50

61.

The postpartum primipara you are rounding on at the hospital the day after she delivered tells you she has decided not to breastfeed her new son because she is concerned about becoming pregnant again soon after his birth. She reports that her own mother became pregnant again within a few weeks of giving birth to her older sister "since she was breastfeeding and couldn't use any birth control pills" and added "my husband doesn't want to use condoms."

You explain to her that:

  • She can begin taking progestin-only pills (POPs) before she is discharged from the hospital without jeopardizing breastfeeding.

  • She can request to have an intrauterine device (IUD) placed before she is discharged from the hospital and begin breastfeeding now.

  • She should avoid any sexual activity/vaginal penetration until her six-week postpartum visit and can start any variety of hormonal contraception at that time, so her breastfeeding will not be impacted by hormonal contraception in the early weeks.

  • You would be happy to discuss with her and her partner why barrier methods such as condoms are a good option for the breastfeeding dyad.

Correct answer: She can begin taking progestin-only pills (POPs) before she is discharged from the hospital without jeopardizing breastfeeding.

Women may be concerned that if they make the choice to breastfeed they will be unable to have access to quality, effective contraception. They fear their milk supply will decrease or "dry up" if they choose to use hormonal contraception and hence feel they must choose between breastfeeding their newborn (and risking closely spaced pregnancies) and effective contraception.

The POP is a safe and highly effective hormonal contraceptive for breastfeeding women that can be started before they are even discharged from the hospital. The POP is most effective if the woman is exclusively breastfeeding. It does not confer risk of decreasing breast milk production nor does it impact the quality of the milk. One disadvantage of POP use is the menstrual bleeding irregularity associated with its use.

IUD usage is acceptable in breastfeeding women and can be inserted immediately following delivery in most cases. However, this is still an uncommon practice in the United States and may not be a possibility in all facilities.

Discussing barrier methods with this couple is not appropriate in this situation, as the couple has already decided they do not prefer to use condoms.

Reminding the patient she should be avoiding any sexual activity/vaginal penetration until her six-week postpartum check is appropriate. However, the patient may still engage in sexual activity prior to this time and unintended pregnancy may result.

62.

A 35-year-old woman who completed urinary tract infection (UTI) prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim) 6 to 7 months ago called your office today complaining of UTI symptoms of dysuria and urinary frequency and urgency.

You know that after completing UTI prophylaxis, most women: 

  • Re-establish their pattern and frequency of UTIs within 6 months of discontinuation of prophylaxis

  • Are unlikely to resume the same frequency or chronicity of UTI as they experienced prior to UTI prophylaxis

  • Develop chronic, persistent vulvovaginal candidiasis that causes urogenital symptoms easily mistaken for recurrence of UTI

  • Remain free from recurrent UTI and go on to establish a UTI frequency similar to that of women who have never experienced chronic, recurrent UTI

Correct answer: Re-establish their pattern and frequency of UTIs within six months of discontinuation of prophylaxis

UTI prophylaxis should be considered for women of reproductive age who experience two or more symptomatic UTIs within six months or three or more UTIs over 12 months. Women who have had fewer UTIs but have more severe discomfort and symptoms during their UTIs should also be considered for UTI prophylaxis. Methods of UTI prophylaxis prescribed depend on the frequency and pattern of recurrences and on patient preference. They may vary between continuous daily dosing, single-dose therapy with the onset of symptoms, or a single dose self-administered postcoitus.

It is important to note that antimicrobial prophylaxis does not appear to change the natural history of recurrences. Unfortunately, most women re-establish their pattern and frequency of UTIs within 6 months of discontinuation of prophylaxis.

63.

When performing a wellness check-up for a seven-year-old female, you note the enlargement of both breasts with no other signs of pubertal development. The child's growth chart reveals a normal rate of growth. Which of the following is the most likely diagnosis?

  • Premature thelarche

  • Premature adrenarche

  • Precocious puberty

  • Turner syndrome

Correct answer: Premature thelarche

Premature thelarche is a relatively common, benign normal variant in which the isolated appearance of breast development is noted in females between the ages of 6 and 8 years. The common finding is the enlargement of one or both breasts. There are no other signs of pubertal development, and the child is growing at a normal rate.

Premature adrenarche is a benign condition in which a child 5 to 6 years old develops body odor, pubic hair, and rarely, axillary hair. Precocious puberty is defined as the (early) onset of secondary sexual characteristics before the child's eighth birthday. Turner syndrome occurs in girls and is a chromosomal anomaly that can result in hypogonadism.

64.

The mother of the 15-month-old African American female you are examining appears embarrassed when you ask her if her daughter drinks whole milk during the day as part of her dietary intake. She states her daughter is still breastfeeding, and while she is at work she expresses her milk to provide her with pumped milk. Her daughter typically drinks approximately 12 oz. of the pumped milk per day in addition to solid foods.

You know that consuming breast milk after 12 months of age:

  • is recommended and provides the ideal form of nutrition.

  • is not recommended as it does not provide adequate calories for a toddler and may prevent the rapidly growing toddler from taking in enough solids during the day.

  • should be limited to a total intake of 16 to 24 oz. per day.

  • should gradually be substituted with whole milk, replacing it ounce for ounce over a period of 4-6 weeks.

Correct answer: is recommended and provides the ideal form of nutrition.

Breastfeeding provides the ideal form of nutrition during infancy, and consuming breast milk either directly from the breast or via pumped milk in a cup or other drinking implement should be recommended from 12 to 24 months. Breast milk contains immunoactive factors that help protect against infectious disease and may reduce the incidence of allergic disorders. Human milk transfers maternal antibodies to the child, and the macrophages, which make up approximately 80% of the cells in breast milk, kill bacteria, fungi, and viruses. The breastfed child's digestive tract contains large amounts of Lactobacillus bifidus, in contrast to that of the formula-fed child, preventing the growth of harmful organisms.

Consumption of cow's milk should be limited to 16 to 24 oz. per day in toddlers older than 12 months who are not breastfeeding.

65.

When performing an examination of a patient reporting pain over the medial epicondyle and inner aspect of the lower humerus, which of the following findings would you expect to observe as well?

  • Pain that is aggravated with flexion of the wrist or pronation of the forearm

  • Restricted range of motion of the elbow

  • Pain that increases with wrist extension against resistance, especially in the elbow

  • Visible redness and swelling over the elbow

Correct answer: Pain that is aggravated with flexion of the wrist or pronation of the forearm

Medial epicondylitis, or "golfer's elbow," is characterized by increased pain with wrist flexion against resistance and with forearm pronation against resistance. There is palpable tenderness over the medial epicondyle. Decreased grip strength also occurs.

There is normal range of motion with both medial and lateral epicondylitis, so if the range of motion is restricted, other diagnoses should be considered. An increase of pain with wrist extension, especially against resistance, is associated with lateral epicondylitis. Visible redness and swelling are rarely seen.

66.

Nail removal may be required for all the following conditions except:

  • Acute paronychia

  • Onychogryphosis

  • Onychocryptosis

  • Onychomycosis

Correct answer: Acute paronychia

The nurse practitioner may be faced with needing to remove a patient's nail for a variety of different reasons. Chronic conditions such as chronic recurrent paronychia, onychogryphosis (curved deformed nails), onychocryptosis (ingrown nail), and onychomycosis (fungal infection of the nail) may require treatment by removing the nail.

Acute paronychia is not an indication for removal of the nail.

67.

A patient who was concerned they were experiencing symptoms of COVID-19 called the primary care office to request an appointment for an evaluation. All of the following patients are at higher risk of experiencing severe disease associated with COVID-19, except:

  • A patient with a history of asthma

  • A male patient

  • A patient with Native American ethnicity

  • An obese patient

Correct answer: A patient with a history of asthma

Several groups of patients are at greater risk of experiencing severe COVID-19. Institutionalized individuals or individuals living in long-term care facilities and individuals who are older than 65 years are at the greatest risk of dying from COVID-19 infection, with over 80% of deaths attributed to COVID-19 affecting this demographic. Individuals with comorbidities such as hypertension, pulmonary disease, diabetes, cardiovascular disease, malignancy, obesity, liver disease, immune system disorders, and cerebral infarction of a non-traumatic source are much more likely to die from COVID-19 than individuals without comorbidities. Hypertension is most highly correlated with death from COVID-19, as is having more than one comorbidity, while having an asthma diagnosis is not correlated with a higher risk of experiencing severe disease. Males are significantly more likely to experience severe disease or death due to COVID-19 than females, although this correlation is not yet fully understood. Certain ethnicities appear to be at risk of experiencing more severe disease when infected with COVID-19—Native Americans, African Americans, and Latinos.  

68.

Which of the following age ranges is most common for the development of new-onset rheumatoid arthritis (RA)? 

  • 20 to 40 years 

  • 30 to 50 years 

  • 40 to 60 years 

  • 50 to 50 years 

Correct answer: 20 to 40 years 

RA is a systemic autoimmune disorder that is more common in women than in men (as with most autoimmune diseases) and causes chronic systemic inflammation, including the synovial membranes of multiple joints. RA is now known to potentially shorten the lifespan while producing considerable disability, particularly without optimal treatment. 

Although new-onset RA can occur at any age, peak age at onset is 20 to 40 years. Initial RA often presents with acute polyarticular inflammation. The patient experiences slowly progressive malaise, weight loss, and stiffness that is symmetrical, is typically worse on arising, lasts about 1 hour, involves at least three joints, and can recur after a period of inactivity or exercise. 

69.

A 25-year-old male patient seen at the urgent care clinic describes sudden pain that began around the navel and has shifted to the lower right abdomen. The pain increases with walking or if he coughs. In the course of your assessment, you discover the presence of rebound tenderness, especially at a point 2 inches from the superior anterior point of the ileum along a line drawn to the umbilicus.

Which diagnostic sign have you revealed?

  • Blumberg's sign

  • Psoas sign

  • Obturator sign

  • Homans' sign

Correct answer: Blumberg's sign

Rebound tenderness, which is abdominal pain that worsens with the release of deep palpation, indicates the likelihood of peritoneal irritation and helps with the diagnosis of acute appendicitis. The presence of rebound tenderness is known as a positive Blumberg's sign.

The psoas test checks for tenderness of the psoas muscle by passively extending the thigh of a patient lying on his side with knees extended or asking the patient to actively flex his thigh at the hip. The obturator sign is done through flexion and internal rotation of the hip. Homans' sign was used as a sign for deep vein thrombosis, not for appendicitis; however, it should be noted that evidence indicates that the Homans' sign has not proven to be a clinically significant physical assessment tool.

70.

Your patient is undergoing treatment for cancer. You have completed instructing her about the use of a topical medication for relief of symptoms related to her treatments. Which statement by the patient indicates that further instruction is needed to be effective?

  • "The thicker the skin where I rub in the medicine, the better the medication will work."

  • "More of the medicine in an ointment will absorb than the medicine that is in a lotion."

  • "I won't benefit very much if I only rub the medicine into the palms of my hands."

  • "Even though this isn't an oral medication, I will still benefit from it."

Correct answer: "The thicker the skin where I rub in the medicine, the better the medication will work."

Cutaneous drug absorption is typically inversely proportional to the thickness of the stratum corneum.

In general, the less viscous the vehicle containing a topical medication, the less of the medication is absorbed. As a result, medication contained in a gel or lotion is absorbed in smaller amounts than medication contained in a cream or ointment. The thickness of the palms of the hands and the soles of the feet creates a barrier so that relatively little topical medication is absorbed when applied to these sites. Topical medications provide a viable alternative for patients who are unable, for various reasons, to take oral medications.

71.

Your 55-year-old female patient has come to the clinic due to severe head pain in the temple area, jaw pain when chewing food, and double vision. While you plan to refer the patient for an arterial biopsy, which laboratory test would you also include in your plan of care?

  • C-reactive protein (CRP)

  • Complete metabolic profile (CMP)

  • Partial thromboplastin time (PTT)

  • International normalized ratio (INR)

Correct answer: C-reactive protein (CRP)

The patient's symptoms are consistent with giant cell or temporal arteritis. Laboratory tests related to this condition include C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

Clotting studies such as partial thromboplastin time (PTT) and international normalized ratio (INR) are not indicated, nor is a complete metabolic profile (CMP).

72.

You are providing care for an adult patient with acute otitis media (AOM) that has recurred following an episode of AOM the month before, which was treated with oral amoxicillin.

What modification will you make to the previous plan of care for this patient?

  • Prescribe oral high-dose amoxicillin-clavulanate

  • Add polymyxin B with neomycin otic drops

  • Prescribe oral ciprofloxacin

  • Add ofloxacin with hydrocortisone otic drops

Correct answer: Prescribe oral high-dose amoxicillin-clavulanate

Treatment for the patient with Acute Otitis Media (AOM), typically caused by S. pneumoniae (Streptococcus pneumoniae), who had been treated with antibiotics in the prior month, includes high-dose oral amoxicillin-clavulanate as well as high-dose amoxicillin and certain oral cephalosporins.

Topical otic drops are not an effective treatment for AOM. Ciprofloxacin is indicated for the treatment of malignant otitis externa, typically caused by Pseudomonas aeruginosa.

73.

You are providing care for a 45-year-old man who has a high risk of heart failure and has previously been assigned as having Class I heart disease. He complains today of experiencing fatigue, weakness, and waking at night feeling anxious and breathless the previous week. You note marked edema of his lower extremities as well as crackles over the lung bases and wheezing during the exam.

Which intervention would you include in your plan of care to evaluate his worsening heart failure?

  • Evaluation of patient's heart failure using the New York Heart Association Functional Classification system (NYHA I-IV)

  • Auscultation of heart tones to assess for a physiologic murmur

  • Referral for MRI

  • Ordering an exercise stress test

Correct answer: Evaluation of patient's heart failure using the New York Heart Association Functional Classification system (NYHA I-IV)

The NYHA I-IV is recognized as an effective tool for evaluating heart failure and can be quickly and easily implemented in the office setting. Class I heart disease is defined by the NYHA as having no limitations on physical activity and no heart failure symptoms during ordinary activities. The NYHA classes are based on reports of patient symptoms and exercise capacity. During an acute heart failure event, the patient's classification category is typically higher and should be expected to return to a lower level once the acute episode has resolved.

NYHA Functional Classification:

  • I. No limitation of physical activity. Ordinary physical activity does not cause symptoms of heart failure.
  • II. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of heart failure.
  • III. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of heart failure.
  • IV. Unable to carry on any physical activity without symptoms of heart failure or symptoms of heart failure at rest.

While assessing heart tones is necessary for a patient presenting with symptoms of heart failure, a physiologic murmur is only found in the absence of cardiac pathology.

An MRI would only be ordered if the results of an echocardiogram required clarification.

While an exercise stress test is useful in evaluating patients with heart failure, it would not be used in evaluating an acute heart failure event.

74.

According to the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III, LDL-C level is the primary target in use of statins for both primary and secondary prevention of cardiovascular disease (CVD). 

Which of the following correctly describes the NCEP ATP III  LDL-C level goals of statin usage?

  • < 100 mg/dL for high-risk patients, < 130 mg/dL for moderate-risk patients, and < 160 mg/dL for low-risk patients

  • < 90 mg/dL for high-risk patients, < 120 mg/dL for moderate-risk patients, and < 150 mg/dL for low-risk patients

  • < 100 mg/dL for high-risk patients, < 150 mg/dL for moderate-risk patients, and < 180 mg/dL for low-risk patients

  • < 75 mg/dL for high-risk patients, < 100 mg/dL for moderate-risk patients, and < 125 mg/dL for low-risk patients

Correct answer: < 100 mg/dL for high-risk patients, < 130 mg/dL for moderate-risk patients, and < 160 mg/dL for low-risk patients

The NCEP has drafted the most widely recognized treatment guidelines for hyperlipidemia; these guidelines include the use of statins to lower LDL-C. 

ATP III recommends the following LDL-C target goals:

  • < 100 mg/dL for high-risk patients
  • < 130 mg/dL for moderate-risk patients
  • < 160 mg/dL for low-risk patients

75.

When examining a patient with symptoms consistent with a potential diagnosis of adrenal insufficiency, you recognize that all the following are potential causes of primary adrenal insufficiency EXCEPT: 

  • Abrupt cessation of chronic use of systemic corticosteroids

  • Infections

  • An autoimmune response that attacks the adrenal gland(s)

  • Anticoagulant use 

Correct answer: Abrupt cessation of chronic use of systemic corticosteroids

Secondary adrenal insufficiency, not primary, can occur in those who have been taking systemic corticosteroids for a chronic condition (such as asthma or arthritis) for a protracted time, usually > 2 weeks and at a higher dose, then abruptly stop taking the corticosteroids. 

Primary adrenal insufficiency (Addison's disease) refers to the condition in which damage to the adrenal gland hinders its production of hormones. This can result for a number of reasons, including an autoimmune response that attacks the glands, infections, hemorrhage or blood loss, tumors, or the use of anticoagulants. 

76.

In evaluating patients for weight surgery, you know the ideal candidate for a bariatric surgical procedure has which of the following characteristics?

  • A BMI ≥ 35 kg/m2 with underlying diabetes, hypertension, dyslipidemia, or cardiovascular disease

  • A BMI ≥ 40 kg/m2 and without any underlying or associated comorbidities

  • A BMI ≥ 40 kg/m2 and current drug or alcohol abuse

  • A BMI ≥ 35 kg/m2 and without any associated comorbidities

Correct answer: A BMI ≥ 35 kg/m2 with underlying diabetes, hypertension, dyslipidemia, or cardiovascular disease

The ideal candidate for bariatric surgery is a person with BMI ≥ to 40 kg/m2 or a person with BMI ≥ 35 kg/m2 with associated comorbidities. Comorbidities may include diabetes, hypertension, dyslipidemia, sleep apnea, cardiovascular disease, gastroesophageal reflux, degenerative joint disease, steatohepatitis, or other obesity-related conditions that have failed treatment with behavioral or pharmacologic therapies.

Contradictions to bariatric surgery include current drug or alcohol abuse, mental health conditions that have either not been treated or are not currently stable, inability to be compliant with a treatment plan, or other underlying health conditions that would preclude surgery.

77.

"The pain is so bad it makes me want to kill myself," says a 50-year-old female who is describing her headaches to you. She states the headaches occur only a "few times a year, always in the spring" and feels like "a hot poker in my eye." She states they typically wake her up after she has been asleep for approximately one hour and last for about 30 minutes, then reoccur several hours later. She states this pattern persists for several weeks before spontaneously resolving.

You diagnose the patient with:

  • Cluster headache

  • Tension-type headache

  • Migraine without aura

  • Secondary headache

Correct answer: Cluster headache

Cluster headaches are also referred to as migrainous neuralgia and are most common in middle-aged men who have heavy alcohol and tobacco usage. Recent studies suggest the condition is likely underdiagnosed in women. Cluster headaches are often referred to as "suicide headache" due to the severity of the associated pain. They tend to occur in clusters over several weeks' time and are often associated with the vernal or autumnal equinox. Cluster headaches often wake the affected individual from their sleep after approximately one hour and pain is often located behind one eye.

Tension-type headaches are usually bilaterally located with pressing, nonpulsatile pain that is mild to moderate in intensity. Either nausea, photophobia, or phonophobia can be present, but greater than one of these symptoms suggests migraine.

Migraine headaches without aura are usually laterally located although occasionally bilateral. They have a pulsating quality, which is moderate to severe in intensity and are aggravated by or cause avoidance of normal daily activities. Nausea/vomiting, photophobia, and phonophobia may occur.

Secondary headaches are associated with or caused by other conditions, such as a brain tumor, increased intracranial pressure, or viremia, which need to be addressed for the headache to resolve. Signs and symptoms of secondary headache include systemic symptoms, such as fever or weight loss, altered mental status, sudden onset, change in headache quality with a change in position, and visual deficits.

78.

A family nurse practitioner (FNP) who works at a hospital-based obstetric clinic has been providing routine prenatal care for a patient who is just entering the second trimester of pregnancy. The patient appears flushed and anxious and complains of experiencing frequent palpitations and feeling nervous and hot all the time. Urgent lab work reveals an undetectable TSH level and significantly elevated T3 and T4 levels. The FNP calls the endocrinology department within the hospital and requests a same-day consultation for the patient. 

Which of the following medications will the endocrinologist most likely use to treat this patient's hyperthyroidism?

  • Propylthiouracil (PTU)

  • Methimazole

  • Propranolol

  • Radioactive iodine

Correct answer: Propylthiouracil (PTU)

Primary hyperthyroidism affects females 8-to-1 over males and is most often caused by Graves disease (60% to 80% of cases). Patients diagnosed with hyperthyroidism often also have associated autoimmune disorders, including pernicious anemia, myasthenia gravis, rheumatoid arthritis, and type 1 diabetes. While the rate of true hyperthyroidism in pregnancy is low (0.2%), approximately 2% of pregnant women will experience gestational transient thyrotoxicosis, which does not require treatment. Pregnant women who are diagnosed with hyperthyroidism during pregnancy require immediate treatment to prevent the development of thyroid storm (thyrotoxicosis), a potentially deadly complication of hyperthyroidism. 

Treatment of hyperthyroidism typically includes the use of propylthiouracil (PTU), methimazole, or radioactive iodine. Radioactive iodine is contraindicated with pregnancy, and methimazole is known to cause goiter and cretinism in a developing fetus, especially when administered during the first trimester. PTU is most likely to be used to treat hyperthyroidism during pregnancy; PTU may cause hypothyroidism in newborns.

Propranolol, metoprolol, or atenolol may be administered to help alleviate the symptoms associated with hyperthyroidism.

79.

The 52-year-old female you have diagnosed with rosacea has responded well to metronidazole gel 1% applied to her rash but feels her rash does worsen occasionally. She is unsure what triggers the worsening of the rash.

After reviewing the patient's general diet and lifestyle activities, you recommend avoidance of which of the following?

  • The glass of wine she has before bed each night

  • The tuna fish and gluten-containing crackers she eats for lunch at work

  • The humidifier she uses at home

  • The detergent she uses when washing her laundry

Correct answer: The glass of wine she has before bed each night

Rosacea is a chronic and relapsing inflammatory skin condition of unclear origin that is more common in people with light-colored skin. It is characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and papulopustular eruptions resembling acne. Flares of the disease may be triggered by many factors and can be different for individual patients.

Some rosacea flares include:

  • UV/sunlight exposure
  • hot/cold exposure
  • exercise
  • stress
  • coffee and caffeine
  • chocolate
  • alcohol
  • spicy foods
  • cosmetic products
  • certain medications

In addition to the metronidazole gel the patient is already using, avoidance of triggers that cause exacerbation should be implemented. This includes alcohol intake. The other answer choices are not factors that could trigger rosacea flare-ups. 

80.

A 63-year-old female presents to your office with a complaint of yellow-green vaginal discharge and bothersome vulvovaginal irritation. She states that her husband passed away three years ago, and she has not engaged in any sexual activity since that time. She denies any recent treatment with antibiotics and use of any new chemical products, including laundry detergents, bath soaps, and feminine hygiene products.

You know that infection with what sexually transmitted infection (STI) is possible based on the patient's symptoms?

  • Trichomoniasis

  • Chlamydia

  • Genital herpes

  • Bacterial vaginosis

Correct answer: Trichomoniasis

Trichomoniasis is one of the most common STIs in the United States and is caused by a motile parasitic protozoa (Trichomonas vaginalis) that can be spread from person to person during sexual intercourse. The motile organism typically causes symptoms of thin, green-yellow vaginal discharge with associated perivaginal irritation in females. Trichomonal infection in females may also present with symptoms consistent with urinary tract infection (dysuria) or atrophic vaginitis (vulvovaginal irritation or dyspareunia) and may be incorrectly diagnosed and treated, leaving the actual infection untreated. Cervical exam reveals petechial hemorrhage, referred to as "strawberry spots," in 30% of cases of trichomoniasis.

Infection with chlamydia typically presents as irritative voiding symptoms, mucopurulent vaginal discharge, and cervicitis but is often asymptomatic in females.

Genital herpes presents as painful ulcerated lesions and lymphadenopathy, particularly with the first outbreak. Subsequent outbreaks may be less severe.

Bacterial vaginosis is not a sexually transmitted infection but is instead an overgrowth of anaerobes and typically presents as an increase in vaginal secretions that may be thin, gray, and homogeneous and have a foul odor, and women may complain of burning and pruritus.

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