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C. Listen to the conversation, and answer the following questions (Q1-Q5). 1) 소피아는 방학 때 어디 갔다 왔어요?  __________ (3pts)

B. Listen to the conversation, and answer the following questions (Q1-Q5).  1) What does 천천히 골라 보세요 mean? __________ (3pts)

A. Listen to the conversation, and answer the following questions (Q1-Q5). 5) 야구장에 갈 때 왜 두꺼운 옷을 입고 가야 돼요? __________ (4pts)

A. Listen to the conversation, and answer the following questions (Q1-Q5). 4) “이번 주엔 날씨가 따뜻했으면 좋겠어요.” 은 무슨 뜻(mean)이에요? __________ (4pts)

C. Listen to the conversation, and answer the following questions (Q1-Q5). 2) 소피아의 한국 여행은 어땠어요? __________ (4pts)

Please log into the following website and complete the assessment titled “ATI RN Pharmacology Online Practice 2023 A” www.atitesting.com I have completed the ATI RN Pharmacology Practice 2023 A by accessing this “quiz” through HonorLock.  RN Pharmacology Online Practice 2023 A – is open & available for completion.  ***Handwritten remediation & Individual Performance Profile submission due by Monday November 24th at 11:59pm. (See ATI Module for submission details.)

Please log into the following website and complete the assessment titled “ATI RN Pharmacology Online Practice 2023 B” www.atitesting.com I have completed the ATI RN Pharmacology Practice 2023 B by accessing this “quiz” through HonorLock.  RN Pharmacology Online Practice 2023 B – is open & available for completion.  ***Handwritten remediation & Individual Performance Profile submission due by Monday November 24th at 11:59pm. (See ATI Module for submission details.)

Describe the relationship between preload, afterload, and contractility. Include discussion of the Frank-Starling law as it relates to these relationships.

Cirrhosis 1. Background Definition: End-stage fibrosis and nodular regeneration of the liver resulting from chronic liver injury, leading to distortion of hepatic architecture, portal hypertension, and hepatic insufficiency. Pathophysiology: Chronic hepatocellular injury (inflammation, necrosis) → fibrosis → nodular regeneration → disruption of hepatic blood flow and function. Portal hypertension develops from increased intrahepatic resistance. Etiologies: Chronic viral hepatitis: HBV, HCV (most common worldwide). Alcohol-associated liver disease. Nonalcoholic steatohepatitis (NASH). Autoimmune hepatitis, hemochromatosis, Wilson disease, α1-antitrypsin deficiency, biliary disease. Epidemiology: A leading cause of death worldwide. Increasing prevalence due to metabolic syndrome and NAFLD/NASH. 2. History Early (compensated): Often asymptomatic or mild nonspecific fatigue, weakness, or anorexia. Decompensated (advanced): Jaundice Ascites Peripheral edema Hepatic encephalopathy (confusion, asterixis) Gastrointestinal bleeding from esophageal or gastric varices Easy bruising or prolonged bleeding (coagulopathy) Other features: Pruritus (especially in cholestatic causes) Dark urine / pale stools Sexual dysfunction, gynecomastia, menstrual irregularities (endocrine effects). 3. Exam Findings General: Jaundice, muscle wasting, fatigue. Skin: Spider angiomas, palmar erythema, bruising, jaundice. Abdomen: Hepatomegaly (early) → small, shrunken liver (late). Ascites, shifting dullness. Splenomegaly (portal hypertension). Caput medusae (distended abdominal veins). Neurologic: Asterixis, confusion (hepatic encephalopathy). Endocrine: Gynecomastia, testicular atrophy. 4. Making the Diagnosis A. Laboratory Findings LFT pattern: AST > ALT (esp. alcoholic), elevated bilirubin, low albumin, prolonged PT/INR. Other labs: Thrombocytopenia (splenic sequestration), hyponatremia. Confirmatory: Elevated serum fibrosis markers or biopsy (definitive but not always required). B. Imaging Ultrasound: First-line; shows nodular liver, splenomegaly, ascites. Elastography: Noninvasive measurement of liver stiffness. CT/MRI: Evaluate for nodularity, portal hypertension, HCC. C. Assessing Severity Child-Pugh score: Grades liver function (bilirubin, albumin, INR, ascites, encephalopathy). MELD score: Predicts mortality and determines liver transplant priority. D. Complications to Screen For Hepatocellular carcinoma (HCC): Ultrasound ± AFP every 6 months. Varices: Screening endoscopy. Hepatorenal syndrome spontaneous bacterial peritonitis (SBP) (ascites with >250 PMNs/µL, fever, abdominal pain) 5. Management A. General Management Treat underlying cause: Abstain from alcohol. Antivirals for HBV/HCV. Weight loss for NASH. Chelation (Wilson disease) or phlebotomy (hemochromatosis). Avoid hepatotoxins (NSAIDs, acetaminophen >2g/day). Vaccinations: HAV, HBV, influenza, pneumococcal. B. Management of Complications Complication Management Ascites Sodium restriction, diuretics (spironolactone ± furosemide), paracentesis, avoid NSAIDs Spontaneous Bacterial Peritonitis (SBP) Empiric cefotaxime; prophylaxis with norfloxacin or TMP-SMX Variceal Bleeding Octreotide, endoscopic band ligation, nonselective beta-blockers (propranolol/nadolol) for prevention Hepatic Encephalopathy Lactulose ± rifaximin, avoid sedatives Hepatorenal Syndrome Albumin, vasoconstrictors (midodrine/octreotide), treat precipitating factors C. Definitive Therapy Liver transplantation: Only curative option for end-stage disease. Indicated by MELD score ≥15 or recurrent decompensation.   Question A 58-year-old man with a history of alcohol-associated cirrhosis presents with increasing abdominal distension and confusion over the past week. His temperature is 100.6°F (38.1°C), blood pressure 102/64 mm Hg, and pulse 96/min. On examination, he has jaundice, ascites with shifting dullness, and mild asterixis. Paracentesis reveals: WBC count: 420 cells/µL (80% neutrophils) Protein: 0.8 g/dL Culture: Escherichia coli Which of the following is the most likely complication responsible for this presentation?

Achalasia 1. Background Definition: Primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the distal esophagus. Pathophysiology: Degeneration of inhibitory ganglion cells in the myenteric (Auerbach’s) plexus leads to unopposed excitatory stimulation, causing LES hypertonicity and functional obstruction. Epidemiology: Rare (~1 in 100,000 annually); usually presents between ages 25–60; affects men and women equally. Etiology: Mostly idiopathic; secondary (pseudoachalasia) may result from malignancy (e.g., gastric cardia adenocarcinoma) or Chagas disease. 2. History Symptoms: Progressive dysphagia to both solids and liquids (unlike mechanical obstruction). Regurgitation of undigested food, especially at night. Chest pain or pressure after eating. Weight loss from poor intake. Possible heartburn-like symptoms unresponsive to PPIs. Duration: Typically develops gradually over months to years. Risk factors: None established; may have association with autoimmune or viral mechanisms. 3. Exam Findings Often unremarkable; may note mild weight loss or signs of malnutrition. Pulmonary findings (e.g., wheezing, cough) may occur from aspiration of regurgitated food. 4. Making the Diagnosis Gold standard: Esophageal manometry — shows absent peristalsis and incomplete LES relaxation (definitive diagnostic test). Commonly used/initial tests: Barium swallow (esophagram): “Bird’s beak” tapering at LES with proximal esophageal dilation (often first clue). Endoscopy (EGD): Performed to rule out malignancy (pseudoachalasia) or secondary causes; may show retained food or saliva. Note: All three tests are often used sequentially — barium swallow suggests diagnosis, manometry confirms, and endoscopy excludes malignancy. 5. Management A. Lifestyle / Supportive Eat slowly, chew thoroughly, and elevate head of bed. Avoid eating close to bedtime. B. Medications (temporary or bridge therapy) Nitrates or calcium channel blockers (e.g., nifedipine) lower LES pressure but have limited long-term benefit. Botulinum toxin injection into LES provides short-term relief (useful for nonsurgical candidates). C. Definitive Procedures Pneumatic dilation: Endoscopic balloon disruption of LES fibers; effective but may require repeat treatments. Heller myotomy (laparoscopic): Surgical division of LES muscles; often combined with partial fundoplication to prevent reflux. Peroral endoscopic myotomy (POEM): Minimally invasive endoscopic alternative to Heller myotomy with similar outcomes. Question A 38-year-old woman reports a 6-month history of progressive difficulty swallowing both solids and liquids. She also notes occasional regurgitation of undigested food and mild, unintentional weight loss. She has no heartburn relief with proton pump inhibitors. A barium swallow shows a dilated esophagus tapering to a narrow “bird’s beak” at the gastroesophageal junction. Which of the following is the most appropriate next diagnostic step to confirm the diagnosis?