Final

Question 1

An 18 y/o male presents to clinic concerned he got ringworm from his goats. On exam he had a quarter sized ring-shaped lesion with a scaly border and central clearing. It is itchy, and the patient has been using a topical corticosteroid cream to help with symptoms. You decide he has tinea corporis. What should you do next?

a. ) Order him a prescription topical antifungal to add to his current regimen.
b. ) Tell him to stop using topical corticosteroids as they can often times make the ringworm worse or reoccur with long-term use.
c. ) Prescribe some nystatin powder.
d. ) Nothing, it will resolve on its own.

Answer 1

ANS B. Tell him to stop using topical corticosteroids as they can often times make the ringworm worse or reoccur with long-term use.

Question 2

An 80-year-old patient has a diagnosis of glaucoma, and the ophthalmologist has prescribed timolol (Timoptic) and pilocarpine eye drops. The primary care NP should counsel this patient:

a. That systemic side effects of these medications may be severe
b. That the combination of these two drugs may cause drowsiness
c. To begin an exercise program to improve cardiovascular health
d. That a higher dose of one or both of these medications may be needed

Answer 2

ANS A. that systemic side effects of these medications may be severe. Older patients are susceptible to systemic effects of topical eye drops. Timolol can cause cerebrovascular, central nervous system, and respiratory side effects, and pilocarpine can cause systemic β-blocker effects. The combination does not cause drowsiness. Although there is some correlation between cardiovascular health and glaucoma, beginning a new exercise program is not indicated. A higher dose of the medications would increase systemic side effects.

Question 3

An 18-month-old child who attends day care has head lice and has been treated with permethrin 1% (Nix). The parent brings the child to the clinic 1 week later, and the primary care NP notes live bugs on the child's scalp. The NP should order:
A.	Lindane
B.	Malathion
C.	Ivermectin
D.	Permethrin 5%

Answer 3

ANS D permethrin 5%. Permethrin is the first-line drug of choice for treating head lice and is usually effective in one application. Significant resistance to permethrin 1% has developed, and permethrin 5% is more effective. In pediculosis, if live lice can be found after 1 week, reapply treatment. This child may have been reinfected at day care and so should be treated again. Malathion is a second-line drug and is not recommended in children younger than age 2. Lindane is a third-line drug. Ivermectin is a fourth-line drug.

Question 4

An NP student asks her instructor about guidelines for using topical steroids. The Nurse Educator tell the student that:
A. evidence-based guidelines are available for each product.
B. standardized guidelines may be found for disease-specific conditions.
C. evidence-based studies support limited corticosteroid use in pregnancy.
D. standardized guidelines have been developed for use in children.

Answer 4

ANS B standardized guidelines may be found for disease-specific conditions.

Question 5

The advance practice registered nurse examines an adolescent who complains of severe right ear pain for the past 3 days. When retracting the pinna of the right ear to examine the ear, the APRN notes erythema, edema, and pain and a large amount of white exudate in the ear canal. The APRN should prescribe:
A. benzocaine otic drops tid.
B. ciprofloxacin otic drops qid.
C. glycerin oil drops weekly.
D. acetic acid, boric acid, and isopropyl alcohol solution.

Answer 5

ANS B ciprofloxacin otic drops qid. This patient has otitis externa. Ciprofloxacin otic drops instilled onto a wick in the ear canal are indicated to treat this condition. Benzocaine is a local anesthetic and would not treat the infection. Glycerin oil drops are used to soften cerumen. An acetic acid, boric acid, and isopropyl alcohol solution is used to prevent, not treat, otitis externa.

Question 6

A primary care NP is performing a well-child checkup on an adolescent patient and notes approximately 20 papules and comedones and 10 pustules on the patient’s face, chest, and back. The patient has not tried any over-the-counter products to treat these lesions. The NP should begin treatment with:
A. salicylic acid.
B. oral antibiotics.
C. topical tretinoin.
D. benzoyl peroxide and topical clindamycin.

Answer 6

AND D benzoyl peroxide and topical clindamycin.

Question 7

To anesthetize the thumb for sutures, the NP should use:

a. lidocaine hydrochloride
b. lidocaine w epinephrine
c. bupivacaine hydrochloride
d. bupivacaine w epinephrine

Answer 7

ANS A lidocaine hydrochloride

Question 8

A parent brings in a 2-month-old infant with a 5-day history of a white coating on the
tongue and decreased oral intake. The primary care NP should prescribe:
a. Clotrimazole, one troche tid
b. Chlorhexidine, 15 mL oral rinse bid
c. Carbamide peroxide, 2-3 drops tid
d. Nystatin oral suspension, 200,000 units qid

Answer 8

ANS D. Nystatin oral

Question 9

A patient who has scabies has been treated by the primary care NP with permethrin (Elimite). The patient returns to the clinic with mild pruritus and erythema. The NP does not observe new burrows on the skin. The NP should:
A. order malathion. 
B. order lindane. 
C. re-treat with permethrin. 
D. prescribe triamcinolone 0.1%.

Answer 9

ANS D prescribe triamcinolone 0.1%.

Question 10

The primary care NP teaches a patient how to instill eye drops for a prescription that requires two drops twice daily. Which statement by the patient indicates understanding of the teaching?
A. “I should put in one drop and wait 5 minutes before putting in the other one.”
B. “I should gently massage my eyes for 3 to 5 minutes after instilling the drops.”
C. “To make sure the medicine is evenly distributed, I should blink several times.”
D. “I may continue wearing my soft contact lenses while I am using this medication.”

Answer 10

ANS A “I should put in one drop and wait 5 minutes before putting in the other one.”

Question 11

A patient is seen by a primary care NP to evaluate a rash. The NP notes three ring-shaped lesions with elevated, erythematous borders and two smaller, scaly patches on the patient's abdomen. The patient has not used any over-the-counter medications on the rash. The NP diagnoses tinea corporis and should prescribe:
A. ketoconazole (Nizoral). 
B. miconazole (Lotrimin AF). 
C. oral terbinafine. 
D. oral itraconazole.

Answer 11

ANS B miconazole (Lotrimin AF).

Question 12

A primary care nurse practitioner (NP) prescribes a topical cream medication. Which statement by the patient indicates understanding of proper application of this medication?
A. “I should apply this medication after bathing.”
B. “I will apply this medication using circular strokes to ensure absorption.”
C. “I need to use a tongue blade to apply this medication.”
D. “I should apply this medication liberally to all affected areas.”

Answer 12

ANS A “I should apply this medication after bathing.”

Question 13

A primary care NP is considering using a topical immunosuppressive agent for a patient who has atopic dermatitis that is refractory to treatment with topical corticosteroids. The NP should:
A. tell the patient that these agents may be used long-term.
B. tell the patient that laboratory monitoring for hypothalamic-pituitary-adrenal (HPA) suppression will be necessary.
C. begin therapy with pimecrolimus (Elidel).
D. counsel the patient that these agents are more likely to cause skin atrophy.

Answer 13

ANS C begin therapy with pimecrolimus

Question 14

A patient has been treated for severe contact dermatitis on both arms with clobetasol propionate cream. At a follow-up visit, the primary care NP notes that the condition has cleared. The NP should:
A. prescribe triamcinolone cream for 2 weeks.
B. recommend continuing treatment for 2 more weeks.
C. discontinue the clobetasol and schedule a follow-up visit in 2 weeks.
D. discontinue the clobetasol and recommend prn use for occasional flare-ups.

Answer 14

ANS A prescribe triamcinolone cream for 2 weeks. treatment should be discontinued when the skin condition has resolved. Tapering the corticosteroid will prevent recurrence of the skin condition. Tapering is best done by gradually reducing the potency and dosing frequency at 2-week intervals. This patient was on a very high potency steroid, so changing to a medium frequency with follow-up in 2 weeks is an appropriate action. Discontinuing the steroid abruptly can lead to recurrence.

Question 15

A 5-year-old child has atopic dermatitis that is refractory to treatment with hydrocortisone acetone 2.5% cream. The prescriber should prescribe:
A. desonide cream 0.01%.
B. triamcinolone acetonide.
C. fluocinolone cream 0.2%.
D. betamethasone dipropionate ointment 0.05%.

Answer 15

ANS B triamcinolone acetonide. An over-the-counter steroid has failed to treat this child’s dermatitis, so the NP should prescribe something in a higher strength. Triamcinolone is a medium-strength steroid and should be used. The other three are in groups I and II, which are high-strength steroids and are not recommended in children.

Question 16

A FNP sees a child who has honey-crusted lesions with areas of erythema around the nose and mouth. The child's parent has been applying Polysporin ointment for 5 days and reports no improvement in the rash. The FNP should prescribe:
A. mupirocin.
B. neomycin.
C. a systemic antibiotic.
D. Polysporin with a corticosteroid.

Answer 16

ANS A. mupirocin. Treatment with a topical antiinfective agent should be reevaluated in 3 to 5 days if there is no improvement. Polysporin ointment is bacteriostatic, not bacteriocidal. Mupirocin is indicated for impetigo caused by Staphylococcus aureus, which is most common in children. Neomycin is an aminoglycoside and is not effective against S. aureus. A systemic antibiotic is not indicated unless the mupirocin fails to treat the infection. Adding a corticosteroid would increase the likelihood that the infection will worsen.

Question 17

A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory infections and asks about the best way to avoid getting sick. The NP should recommend which of the following?

a. Zinc gluconate supplements
b. Frequent hand washing
c. Echinacea
d. Normal saline nasal irrigation

Answer 17

B. Frequent hand washing.- Hand washing is the most effective way to prevent the spread of viral upper respiratory illness (VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun.

Question 18

A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patients condition worsens, and a chest radiograph obstained 2 days later shows bilateral infiltrates. The NP failed to:

a. Confirm the diagnosis
b. Prescribe an adequate dose of medications
c. Allow the drugs adequate time to work
d. Determine the aggressiveness of therapy

Answer 18

ANS A- the patient had symptoms that could occur with both asthma and aspiration pneumonia. The NP failed to confirm the diagnosis and prescribed the wrong treatment.

Question 19

A patient comes to the clinic with a 3-day history of fever and a severe cough that interferes with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The NP should:

a. suggest that the patient try a guaifenesin-only over-the-counter product.
b. prescribe an antibiotic to treat the underlying cause of the patient’s cough.
c. order a narcotic antitussive to suppress cough.
d. obtain a thorough history of the patient’s symptoms.

Answer 19

D. obtain a thorough history of the patient’s symptoms.- It is important to determine the underlying disorder that is causing the cough to rule out serious causes of cough. The NP should obtain a thorough history before prescribing any treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin may be used to make nonproductive coughs more productive. Antibiotics are indicated only for a proven bacterial infection.

Question 20

An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the patient that this drug:

a. will cause rebound congestion if withdrawn suddenly.
b. can cause many systemic side effects such as drowsiness.
c. will not provide maximum relief for a few weeks.
d. may cause a bitter aftertaste.

Answer 20

d. may cause a bitter aftertaste- Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may experience relief from symptoms within 30 minutes. Decongestants can cause rebound congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects.

Question 21

A parent asks an NP which over-the-counter medication would be best to give to a 5-year-old child who has a viral respiratory illness with nasal congestion and a cough. The NP should recommend which of the following?

a. Increased fluids with a teaspoon of honey
b. An antitussive/expectorant combination such as Robitussin DM
c. Diphenhydramine (Benadryl)
d. Over-the-counter pseudoephedrine with guaifenesin (Sudafed)

Answer 21

a. Increased fluids with a teaspoon of honey- Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has been shown to be effective in reducing cough in small children. Diphenhydramine is an antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and Robitussin are not recommended in children younger than 6 years.

Question 22

A child with chronic allergic symptoms uses an intranasal steroid for control of symptoms. At this child’s annual well-child checkup, the NP should carefully review this child’s:

a. height and weight.
b. blood pressure.
c. liver function tests.
d. urinalysis.

Answer 22

a. height and weight.- Intranasal corticosteroids can cause growth suppression in children. When using intranasal steroids in children, the lowest dosage should be used for the shortest period of time necessary, and growth should be routinely monitored. It is not necessary to evaluate urine, blood pressure, or liver function because of intranasal steroid use.

Question 23

An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing, and nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should prescribe:

a. triamcinolone (Nasacort AQ).
b. cromolyn sodium (Nasalcrom).
c. azelastine (Astelin).
d. phenylephrine (Neo-Synephrine)

Answer 23

a. triamcinolone (Nasacort AQ)- According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients. Intranasal corticosteroids are indicated for patients who do not respond to antihistamines. Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids.

Question 24

A patient asks an NP about using an oral over-the-counter decongestant medication for nasal congestion associated with a viral upper respiratory illness. The NP learns that this patient uses loratadine (Claritin), a b-adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects?

a. Rebound congestion
b. Liver toxicity
c. Excessive drowsiness
d. Tremor, restlessness, and insomnia

Answer 24

d. Tremor, restlessness, and insomnia- b-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive drowsiness, and rebound congestion are not known adverse effects of drug interactions

Question 25

A primary care NP sees an adolescent patient for a hospitalization follow-up after an asthma exacerbation. The patient reports having daily symptoms with nighttime awakening 4 or 5 nights per week and misses school several days each month. The patient currently uses a salmeterol/fluticasone LABA twice daily and albuterol as needed. The patient requires a refill of the albuterol prescription once a month. The patient does not have any known allergies. The NP should: a. order a high-dose ICS plus a LABA twice daily. b. consider adding theophylline to this patient's regimen. c. order a combination product with ipratropium and albuterol. d. continue the current regimen and add omalizumab daily.

Answer 25

a. order a high-dose ICS plus a LABA twice daily.- The patient has moderate persistent asthma not well controlled with the current regimen. The next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an asthma specialist. Theophylline is recommended in the 5- to 11-year age group. Omalizumab is indicated if the patient has allergies. Ipratropium is used during acute exacerbations.

Question 26

A 50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum. A chest x-ray is clear, and the patient's FEV1 is 80% of predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath sounds. The NP should: a. order a long-acting anticholinergic with albuterol twice daily. b. prescribe a moderate-dose ICS twice daily. c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. d. reassure the patient that these symptoms will subside.

Answer 26

c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.- For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended when FEV1 is less than 60%.

Question 27

A patient who was recently diagnosed with COPD comes to the clinic for a follow-up evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports occasional mild exertional dyspnea but is able to sleep well. The patient's FEV1 in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend: a. a combination LABA/ICS twice daily. b. home oxygen therapy as needed for dyspnea. c. influenza and pneumococcal vaccines. d. ipratropium bromide (Atrovent) twice daily.

Answer 27

c. influenza and pneumococcal vaccines. Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status. This patient is stable with the prescribed medications, so no additional medications are needed at this time. Home oxygen therapy is used for patients with severe resting hypoxemia.

Question 28

A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for exacerbation of symptoms. The patient reports using the SABA three or four times each week when short of breath. The patient reports feeling jittery and nauseated and having trouble sleeping. The primary care NP should: a. obtain a serum theophylline level. b. prescribe a leukotriene modifier instead of theophylline. c. order a creatinine clearance level. d. discontinue the SABA and change to ipratropium bromide.

Answer 28

a. obtain a serum theophylline level.- Nausea, vomiting, insomnia, jitteriness, and other symptoms may indicate theophylline toxicity. Serum concentration monitoring should be done whenever signs of toxicity are suspected. A serum creatinine clearance level is not indicated. Leukotriene modifiers are not used for COPD. Ipratropium is used as an adjunct to the SABA during acute exacerbations.

Question 29

A 75-year-old patient requires frequent use of corticosteroids to control COPD exacerbations. To monitor adverse drug effects in this patient, the primary care NP should: a. order an electrocardiogram to assess for arrhythmias. b. order routine chest radiographs to watch for pneumonia. c. order a bone density study. d. monitor the patient's renal function at every visit.

Answer 29

c. order a bone density study.- High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in an older adult. The NP should order a bone density study.

Question 30

A NP sees a patient who needs to be treated for the management of allergic rhinitis. Which of the following are preferred antihistamines that the NP can recommend? (SELECT ALL THAT APPLY): a. Loratadine b. Chlorpheniramine c. Cetirizine d. Fexofenadine

Answer 30

ANS: A & C & D

Question 31

A NP prescribes to a patient an antitussive syrup medication containing guaifenesin with codeine. Which common side effects may this patient experience? (SELECT ALL THAT APPLY): a. Drowsiness b. Diarrhea c. Dizziness d. Nausea/vomiting

Answer 31

ANS: A C D

Question 32

According to the CDC, National Center for Health Statistics, COPD is the third leading cause of death in the United States. True or False?

Answer 32

TRUE

Question 33

According to the CDC video, when using a metered-dose inhaler (in mouth), you should do the following (SELECT ALL THAT APPLY): a. Press down on inhaler one time, breathe in QUICKLY, and then hold breath for 5 - 10 seconds b. Put inhaler in your mouth, above your tongue, and between your teeth. c. Hold inhaler upright d. Shake inhaler 10 - 15 times

Answer 33

ANS: B C D

Question 34

``` Mr. Smith is a 53 year old patient that has been diagnosed with COPD using Spirometry. Further assessment results show his FEV1 is 28% of predicted, CAT score of 12, and he had 1 exacerbation in the past year leading to hospital admission. Based on your knowledge of the refined ABCD assessment tool (GOLD 2017), the NP should labelled this patient as follow: A. GOLD grade 4, group B B. GOLD grade 4, group D C. GOLD grade 2, group B D. GOLD grade 3, group D ```

Answer 34

B. GOLD grade 4, group D

Question 35

Mrs. Gomez is a 45 year old female diagnosed with COPD using Spirometry. She has been a smoker for over 20 years. Her FEV1 is 48% of predicted, she has a CAT score of 8, and she had more than 3 exacerbations in the past year. Based on the GOLD 2017 guidelines and Mrs. Gomez COPD assessment results, the NP should initiate treatment with: A. Spiriva (tiotropium bromide) B. Serevent Diskus (salmeterol xinafoate) C. Ventolin (albuterol) D. Flovent (fluticasone)

Answer 35

ANS: Spiriva

Question 36

According to GOLD 2017 guidelines, ICS-containing regimens are NOT recommended as initial maintenance treatment for COPD of any severity.

Answer 36

TRUE

Question 37

``` Based on the Gold 2017 guidelines and COPD assessment results, Mr. Scott was prescribed a LAMA medication to treat his COPD symptoms. However, a few months later, Mr. Scott's symptoms continue to be persistent and he has further exacerbations. Which of the following drugs is the next preferred treatment the NP should initiate: A. ANORO ELLIPTA B. FLOVENT DISKUS C. SYMBICORT AEROSOL D. BREO ELLIPTA ```

Answer 37

ANS: A Anoro ellipta

Question 38

Which of the following drugs is a LABA/ICS combination and would be most appropriate for a patient who is having compliance issues? a. Breo Ellipta b. Spiriva c. Anoro Ellipta d. Symbicort Aerosol

Answer 38

ANS A Breo Ellipta

Question 39

A MSN-prepared nurse is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the MSN-prepared nurse recommend for this patient? a. Loratadine (Claritin) b. Hydroxyzine (Vistaril) c. Diphenhydramine (Benadryl) d. Chlorpheniramine maleate (Chlorphen 12)

Answer 39

ANS A- Loratadine (Claritin)- Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible.

Question 40

A FNP is evaluating a patient who has COPD. The patient uses a LABA twice daily. The patient reports having increased exertional dyspnea, a frequent cough, and poor sleep. The patient also uses a short-acting β-adrenergic agonist (SABA) five or six times each day. Pulse oximetry reveals an oxygen saturation of 92%. The patient's FEV1/forced vital capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe a(n): a. combination ICS/LABA inhaler. b. oral corticosteroid. c. long-acting anticholinergic. d. long-acting oral theophylline.

Answer 40

ANS A combination ICS/LABA inhaler.- Providers should administer combination inhaled therapies for symptomatic patients with stable COPD and FEV1 less than 60%. Oral corticosteroids have not been shown to be effective, even in severe cases of COPD. Long-acting anticholinergic medications may be used as monotherapy in early stages of COPD. Long-acting theophylline is poorly tolerated because of side effects.

Question 41

A FNP sees a child with asthma to evaluate the child's response to the prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as needed. The child's symptoms are well controlled. The FNP notes slowing of the child's linear growth on a standardized growth chart. The FNP should change this child's medication regimen to a: a. SABA as needed plus a leukotriene modifier once daily. b. combination ICS/LABA inhaler twice daily. c. short-acting β2-agonist (SABA) with oral corticosteroids when symptomatic. d. combination ipratropium/albuterol inhaler twice daily.

Answer 41

ANS A - SABA as needed plus a leukotriene modifier once daily.- A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS. This child's symptoms are well controlled, so there is no need to step up therapy to include a LABA. Oral corticosteroids should be used only for severe exacerbations. Ipratropium and albuterol are used for severe exacerbations.

Question 42

A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which bile acid sequestrant should the primary care NP order? a. Colesevelam (Welchol) b. Colestipol (Colestid) c. Cholestyramine (Questran Light) d. Cholestyramine (Questran)

Answer 42

a. Colesevelam (Welchol) - All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient.

Question 43

A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient's baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient's LDL cholesterol. The NP should: a. reassure the patient that this side effect is common. b. order CK-MM tests. c. order LFTs. d. consider decreasing the dose of the medication.

Answer 43

a. reassure the patient that this side effect is common. - LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication.

Question 44

The primary care nurse practitioner (NP) sees a patient for a physical examination and orders laboratory tests that reveal low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous history of coronary heart disease. The NP should consider prescribing: a. ezetimibe (Zetia). b. simvastatin (Zocor). c. nicotinic acid (Niaspan). d. gemfibrozil (Lopid).

Answer 44

AND D. gemfibrozil (Lopid). Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels. This patient's LDL is within normal limits, so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor, used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy.

Question 45

A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The prescriber plans to change the patient's medication to dabigatran (Pradaxa). To do this safely, the prescriber should: A. initiate dabigatran when the patient's international normalized ratio (INR) is less than 2. B. start dabigatran 7 to 14 days after discontinuing warfarin. C. begin giving dabigatran 1 week before discontinuing warfarin. D. order frequent monitoring of the patient's INR after dabigatran therapy begins.

Answer 45

ANS A. initiate dabigatran when the patient's international normalized ratio (INR) is less than 2. There are no requirements for monitoring the INR or other measures for patients taking dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated when the INR is less than 2.

Question 46

A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant. The NP should expect that this patient will use which of the following anticoagulant medications? a. Warfarin b. Heparin c. Aspirin d. Dabigatran

Answer 46

b. Heparin Heparin does not cross the placental barrier and is the drug of choice for anticoagulation therapy during pregnancy, despite its category C classification. Aspirin is not recommended during the last 3 months of pregnancy. Dabigatran is not recommended. Warfarin crosses the placental barrier.

Question 47

An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider: a. rechecking the INR in 1 week. b. omitting a dose and administering 1 mg of vitamin K. c. omitting a dose and resuming at a lower dose. d. lowering the dose of warfarin.

Answer 47

a. rechecking the INR in 1 week. This patient's INR is only minimally prolonged, so no dose reduction is required. The NP should recheck the INR periodically. If the INR becomes more prolonged, lowering the dose of warfarin is recommended. If the INR approaches 5, omitting a dose and resuming at a lower dose is recommended. Vitamin K is used for an INR of 9 or greater.

Question 48

A patient who has had a new onset of AF the day prior will undergo cardioversion that day. The primary care NP will expect the cardiologist to: a. give low-dose aspirin before administering cardioversion. b. give clopidogrel after administering cardioversion. c. administer cardioversion without using anticoagulants. d. give warfarin and aspirin before attempting cardioversion

Answer 48

c. administer cardioversion without using anticoagulants. If the onset of AF has occurred within 48 hours, cardioversion can be done without anticoagulation. Clopidogrel is used in other cases for patients who cannot take aspirin. For patients with rheumatic mitral valve disease and AF or a history of systemic embolism, cardioversion plus aspirin is used. Warfarin is used in patients with one or more risk factors for stroke.

Question 49

A patient who has disabling intermittent claudication is not a candidate for surgery. Which of the following medications should the primary care NP prescribe to treat this patient? a. Warfarin (Coumadin) b. Cilostazol (Pletal) c. Pentoxifylline (Trental) d. Low-dose, short-term aspirin

Answer 49

b. Cilostazol (Pletal) - Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline. Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin therapy.

Question 50

A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to: a. take a double dose of the medication the next morning. b. avoid foods that are high in vitamin K for several days. c. skip today's dose and resume a regular dosing schedule in the morning. d. refill the prescription and take today's dose immediately.

Answer 50

c. skip today's dose and resume a regular dosing schedule in the morning. Consistency is the key to successful warfarin treatment, and the patient should take the medication at the same time every day. For missed doses, the patient should take the medication as soon as possible after the missed dose or not at all that day. Because it is late afternoon, the patient should skip the dose and resume normal scheduling the next day. It is not necessary to avoid foods high in vitamin K. Patients should not double up the next day.

Question 51

A patient who is obese is preparing to have surgery. To help prevent venous thromboembolism (VTE), the primary care NP should prescribe: a. low-dose aspirin once daily. b. clopidogrel (Plavix) 75 mg once daily c. warfarin (Coumadin) titrated to achieve an INR of 3.5. d. enoxaparin (Lovenox) 30 mg twice daily.

Answer 51

ANS D. enoxaparin (Lovenox) 30 mg twice daily. The American College of Clinical Pharmacy recommends against the use of aspirin alone for prophylaxis of VTE. Patients undergoing surgery who are at moderate to high risk for VTE should receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin. Aspirin may be part of the prophylaxis regimen. Clopidogrel and warfarin are not recommended.

Question 52

A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive: a. low-dose aspirin and warfarin b. intravenous alteplase. c. low-molecular-weight heparin (LMWH). d. unfractionated heparin (UFH) and warfarin

Answer 52

ANS D. Unfractionated heparin (UFH) and warfarin This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE.

Question 53

A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All of the patient's baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient's LDL cholesterol. The NP should: a. order LFTs. b. reassure the patient that this side effect is common. c. order CK-MM tests. d. consider decreasing the dose of the medication.

Answer 53

b. reassure the patient that this side effect is common. LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication.

Question 54

A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take: a. daily low-dose aspirin for 1 year. b. warfarin for 3 months postoperatively plus long-term aspirin. c. lifelong warfarin combined with enoxaparin as needed. d. heparin injections as needed based on activated partial thromboplastin time levels.

Answer 54

ANS b. warfarin for 3 months postoperatively plus long-term aspirin. Patients with biosynthetic valves should receive anticoagulation for 3 months with long-term aspirin prophylaxis. Patients with biosynthetic valves should receive anticoagulation for 3 months (INR goal, 2 to 3). Long-term prophylaxis for these patients should include aminosalicylic acid (75 to 100 mg daily), unless AF is present.

Question 55

A patient comes to the clinic with a complaint of gradual onset of left-sided weakness. The primary care NP notes slurring of the patient's speech. A family member accompanying the patient tells the NP that these symptoms began 4 or 5 hours ago. The NP will activate the emergency medical system and expect to administer: a. 325 mg of chewable aspirin. b. LMWH. c. warfarin (Coumadin) and aspirin. d. intravenous alteplase and aspirin.

Answer 55

ANS a. 325 mg of chewable aspirin. Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred 3 hours previously. The administration of anticoagulation or antiplatelet agents during the first 24 hours is not recommended. The oral administration of aspirin within 24 to 48 hours after stroke onset is recommended.

Question 56

A patient who has diabetes is taking simvastatin (Zocor) 80 mg daily to treat LDL cholesterol level of 170 mg/dL. The patient has a body mass index of 29. At a follow-up visit, the patient's LDL level is 120 mg/dL. The primary care NP should consider: a. referring the patient to a dietitian for assistance with weight reduction. b. increasing the simvastatin to 80 mg twice daily. c. changing the medication to ezetimibe/simvastatin (Vytorin). d. adding nicotinic acid to the patient's drug regimen.

Answer 56

ANS c. changing the medication to ezetimibe/simvastatin (Vytorin). Patients with diabetes have a goal LDL of less than 100 mg/dL. If maximum-dose statin is unable to achieve the goal LDL, a combination product such as a statin plus ezetimibe is recommended. The maximum recommended dose is 80 mg daily, so increasing the dose to 80 mg twice daily is incorrect.

Question 57

A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: a. recommend supplements of omega-3 along with the atorvastatin. b. change the patient's medication to cholestyramine (Questran). c. change the atorvastatin dose to 15 mg twice daily. d. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.

Answer 57

d. add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated.

Question 58

A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient's initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: a. order liver function tests (LFTs). b. add gemfibrozil (Lopid) to the patient's medication regimen. c. change atorvastatin to twice-daily dosing. d. order a creatine kinase-MM (CK-MM) level.

Answer 58

d. order a creatine kinase-MM (CK-MM) level. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated.

Question 59

Which of the following statements is true regarding unfractioned heparin (UFH) and low molecular weight heparin (LMWH): (SELECT ALL THAT APPLY) a. LMWH may be administered IV or SC b. LMWH has a longer half-life and increased bioavailability compared to UFH c. No effect on existing clots d. The anticoagulant effect of heparin starts with its binding to antithrombin III

Answer 59

ANS: BCD

Question 60

TRUE/FALSE: The mechanism of action of clopidogrel is by inhibiting the binding of ADP to its receptors on platelets and subsequent ADP-mediated activation of IIb/IIIa complex.

Answer 60

TRUE

Question 61

Which of the following statements is true regarding the Rx product Vascepa (icosapent ethyl)? SELECT ALL THAT APPLY a. It is used for lowering triglyceride levels b. It contains only EPA c. It increases LDL levels d. It contains both EPA and DHA

Answer 61

Ans: A,B

Question 62

TRUE/FALSE: There is a boxed warning about stopping DOAC agents in AF patients because DOAC agents are short-acting, and if stopped can quickly return patients to their risk of stroke before starting therapy.

Answer 62

True

Question 63

A male patient was released from the hospital after the placing of a coronary stent. The patient needs to be treated with an antiplatelet medication. After reviewing the drugs available with the NP, the patient shares with the NP that he has no insurance and that he recently lost his job. Based on the patients needs and current drugs available, which medication with the NP most likely prescribe? a. Warfarin (coumadin) b. Clopidogrel (Plavix) c. Prasugrel (effient) d. Dabigatran (Pradaxa)

Answer 63

ANS: B. clopidogrel (Plavix)

Question 64

Which of the following statements are true regarding the new oral anticoagulants Eliquis, Pradaxa, and Xarelto? (SELECT ALL THAT APPLY) a. Pradaxa is the only one given once per day b. Eliquis leads to MORE bleeds when compared to warfarin c. Xarelto is the only one given once per day d. Eliquis leads to FEWER bleeds when compared to warfarin.

Answer 64

ANS: CD

Question 65

A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals LDL of 130 mg/dL, HDL of 35 mg/dL, and triglycerides 150 mg/dL. The woman is sedentary with a body mass index of 26. The woman asks the prescriber about using a statin medication. The prescriber should: A. recommend dietary and lifestyle changes first. B. begin therapy with atorvastatin 10 mg per day. C. discuss quality-of-life issues as part of the decision to begin medication. D. tell her there is no clinical evidence regarding efficacy of statin medication in her case.

Answer 65

B. begin therapy with atorvastatin 10 mg per day. This woman would be using a statin medication for secondary prevention because she already has a history of MI, so a statin should be prescribed. Dietary and lifestyle changes should be a part of therapy, but not the only therapy. She is relatively young, and quality-of-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women.

Question 66

Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the family care nurse practitioner (FNP) why the procedure is necessary. The FNP should tell the patient: A. this medication prevents clots but does not alter rhythm. B. if the medication proves effective, the procedure may be canceled. C. there are no medications that alter the arrhythmia causing AF. D. to ask the cardiologist if verapamil may be ordered instead of cardioversion.

Answer 66

ANS A. this medication prevents clots but does not alter rhythm. Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. β-Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF.

Question 67

A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient's father developed coronary heart disease at age 55 years. The NP should prescribe: a. cholestyramine (Questran). b. lovastatin/niacin (Advicor). c. gemfibrozil (Lopid). d. atorvastatin (Lipitor).

Answer 67

AND D. atorvastatin (Lipitor). HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male first-degree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy.

Question 68

A primary care NP is preparing to order digoxin for an 80-year-old patient who has systolic heart failure. The NP obtains renal function tests, which are normal. The NP should: a. administer a digoxin 0.6 mg capsule once and then 0.3 mg every 8 hours x3. b. prescribe a digoxin 0.125 mg tablet once daily. c. administer a loading dose of intravenous digoxin in the clinic and then give 0.125 mg once daily. d. give an initial dose of 0.5 mg digoxin tablet and then 0.125 mg every 6 hours x4.

Answer 68

ANS b. prescribe a digoxin 0.125 mg tablet once daily. In primary care settings, slow digitalization rather than a loading dose is generally recommended because of the risk of toxicity. Digitalization may be achieved within 1 week with the use of small daily maintenance doses.

Question 69

A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not working as well as it did initially. The primary care NP should: a. contact the patient's pharmacy to ask if generic digoxin was dispensed. b. recommend a reduced potassium intake. c. hold the next dose of digoxin and obtain a serum digoxin level. d. increase the dose of digoxin to 0.5 mg daily.

Answer 69

ANS A. contact the patient's pharmacy to ask if generic digoxin was dispensed Clinicians should be aware that generic digoxin marketed by different companies may not be bioequivalent to the branded digoxin (Lanoxin). Patients with hyperkalemia would show intensified effects, not diminished effects of digoxin. Patients with diminished effects may have received a generic brand. It is not correct to increase the dose of digoxin without first obtaining a digoxin level. Because this patient is reporting decreased effects, it is unnecessary to suspect toxicity.

Question 70

A patient undergoes a routine electrocardiogram (ECG), which reveals occasional premature ventricular contractions that are present when the patient is resting and disappear with exercise. The patient has no previous history of cardiovascular disease, and the cardiovascular examination is normal. The primary care NP should: a. prescribe quinidine (Quinidex Extentabs). b. consider using amiodarone if the patient develops other symptoms. c. refer the patient to a cardiologist for further evaluation. d. tell the patient that treatment is not indicated

Answer 70

ANS d. tell the patient that treatment is not indicated. The most important factor in determining whether to treat premature ventricular contractions is the presence of underlying heart disease, such as myocardial ischemia, previous myocardial infarction, cardiac scarring or hypertrophy, or left ventricular dysfunction. Because of the risks associated with antiarrhythmic therapy, patients should not be treated unless clear indications are present. Premature ventricular contractions are not treated if the patient is asymptomatic, if the patient has a normal heart, if the premature ventricular contractions are simple, and if they disappear with exercise. Amiodarone is not used to treat acute premature ventricular contractions but is used for long-term prophylaxis.

Question 71

A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The primary care NP notes thready, rapid pulses and 3-second capillary refill. An ECG reveals a heart rate of 198 beats per minute with a regular rhythm. The NP should: a. order digoxin and verapamil and ask the patient to return for a follow-up examination in 1 week. b. administer intravenous fluids and obtain serum electrolytes. c. send the patient to an emergency department for evaluation and treatment. d. administer amiodarone in the clinic and observe closely for response.

Answer 71

ANS c. send the patient to an emergency department for evaluation and treatment. Paroxysmal supraventricular tachycardia (PSVT) is a very fast regular rate and rhythm. This patient is becoming decompensated and should be referred to the emergency department for evaluation and treatment. The primary care NP should not treat this in the clinic or as an outpatient until the patient is stable.

Question 72

A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a. consider prescribing a b-blocker. b. obtain renal function tests. c. order serum electrolytes. d. call the patient's cardiologist to discuss adding digoxin to the patient's regimen.

Answer 72

ANS c. order serum electrolytes. Patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are not indicated. b-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure.

Question 73

A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest, determined to be from long QT syndrome. The NP should: a. order genetic testing for this patient. b. refer the patient to a cardiologist for further evaluation. c. schedule a treadmill stress test. d. discontinue the trimethoprim-sulfamethoxazole

Answer 73

ANS a. order genetic testing for this patient. When a family member's death is found to be from long QT syndrome, the entire family must undergo testing. Treadmill testing may be normal in many cases. Trimethoprim-sulfamethoxazole can prolong the QT interval and should not be used in patients at risk, but genetic testing should be performed to determine this.

Question 74

The primary care NP is seeing a patient for a hospital follow up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that "no one explained anything about them". The NP's initial response should be to: A. ask the patient to describe the medication regimen B. ask the patient to make a list of questions about the medications C. determine what the patient understands about coronary artery disease D. give the patient information about drug effects and any adverse reactions

Answer 74

ANS C. determine what the patient understands about coronary artery disease

Question 75

A 55-year-old African American patient has three consecutive blood pressure readings of 140/95 mm Hg. The patients body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: a. An angiotensin-converting enzyme inhibitor. b. A thiazide diuretic c. Dietary and lifestyle changes only d. A beta-blocker

Answer 75

ANS B thiazide diuretic. the patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails.

Question 76

The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient's laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: a. counsel the patient about dietary and lifestyle changes. b. prescribe a thiazide diuretic. c. consider treatment with an angiotensin-converting enzyme inhibitor. d. reassure the patient that these findings are normal.

Answer 76

ANS a. counsel the patient about dietary and lifestyle changes. The patient's blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise.

Question 77

A 55-year-old patient with no prior history of hypertension has a blood pressure greater than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should: a. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. b. order a urinalysis and creatinine clearance and begin therapy with a b-blocker. c. counsel the patient about dietary and lifestyle changes. d. perform a careful cardiovascular physical assessment.

Answer 77

d. perform a careful cardiovascular physical assessment. if the patient is younger than 20 or older than 50 years old at the onset of elevated blood pressure, the NP should look for causes of secondary hypertension. The physical examination should include a careful cardiovascular assessment. This patient will need pharmacologic treatment, but not until the underlying cause of hypertension is determined.

Question 78

The primary care NP sees a new patient who has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. The patient's blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should: a. continue the current drug regimen. b. add an angiotensin-converting enzyme inhibitor. c. order a b-blocker. d. change to an aldosterone antagonist medication.

Answer 78

b. add an angiotensin-converting enzyme inhibitor.- evidence-based guidelines suggest that optimal control of hypertension to less than 130/80 mm Hg could prevent 37% of cardiovascular disease in men and 56% in women, so this patient, although showing improvement, could benefit from the addition of another medication. An angiotensin-converting enzyme inhibitor is an appropriate drug for patients who also have diabetes. b-Blockers and aldosterone antagonist medications are not recommended for patients with diabetes.

Question 79

A patient who has had a previous myocardial infarction has a blood pressure of 135/82 mm Hg. The patient's body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe: a. a calcium-channel blocker. b. an angiotensin-converting enzyme inhibitor. c. lifestyle modifications. d. a thiazide diuretic.

Answer 79

b. an angiotensin-converting enzyme inhibitor. this patient has prehypertension but has a compelling reason for treatment. Patients who have had a myocardial infarction should be treated with a b-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ARB).

Question 80

The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: a. initiate monotherapy with a thiazide diuretic. b. begin combination therapy with an ARB and a calcium-channel blocker. c. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. d. discuss dietary and lifestyle modifications with the patient.

Answer 80

a. initiate monotherapy with a thiazide diuretic. african Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans.

Question 81

An 80-year-old male patient will begin taking an a-antiadrenergic medication. The primary care NP should teach this patient to: a. be aware that priapism is a common side effect. b. ask for assistance while bathing. c. take the medication in the morning with food. d. restrict fluids to aid with diuresis.

Answer 81

b. ask for assistance while bathing. all antihypertensives can cause orthostatic hypotension, so patients should be cautioned to avoid sudden changes in position and to use caution when bathing because a hot bath or shower may aggravate dizziness. Older patients are at increased risk for falls and should be cautioned to ask for assistance. Patients taking a-antiadrenergics should consume extra fluids because dehydration can increase the risk of orthostatic hypotension. Patients should take the medication at bedtime because drowsiness is a common side effect. Priapism is not a side effect of these drugs.

Question 82

A patient is in the clinic for an annual physical examination. The primary care NP obtains a medication history and learns that the patient is taking a b-blocker and nitroglycerin. The NP orders laboratory tests, performs a physical examination, and performs a review of systems. Which finding may warrant discontinuation of the b-blocker in this patient? a. Wheezing, dyspnea, and cough b. Decreased exercise tolerance c. Increased triglycerides d. Nausea, vomiting, and anorexia

Answer 82

a. Wheezing, dyspnea, and cough. b-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the b-blocker may be required. b-Blockers may cause an insignificant increase in serum triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common.

Question 83

An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of the time. The primary care NP should: a. contact the patient's cardiologist to discuss decreasing the dose of propranolol. b. tell the patient to stop taking the medication immediately. c. recommend that the patient take the medication at bedtime. d. tell the patient that tolerance to this side effect will occur over time.

Answer 83

a. contact the patient's cardiologist to discuss decreasing the dose of propranolol. elderly patients have described sedation and sleep disturbances with b-blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly.

Question 84

A patient will begin treatment with a beta-blocker. The patient wants to know about the most common side effects. The NP should educate the patient and discuss the following: (SELECT ALL THAT APPLY) a. Sexual dysfunction b. Fatigue c. Insomnia d. Tachycardia

Answer 84

ANS: ABC sexual dysfunction, fatigue, insomnia

Question 85

A patient who has stable angina pectoris and a history of previous myocardial infarction takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil: a. increases the rate of contraction of the cardiac muscle. b. has a positive inotropic effect to increase cardiac output. c. increases the force of contraction of the cardiac muscle. d. improves blood flow and oxygen delivery to the heart.

Answer 85

d. improves blood flow and oxygen delivery to the heart. Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary resistance and improves blood flow through collateral vessels as well as oxygen delivery to ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of contraction of the heart.

Question 86

A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient's cardiologist to discuss: a. increasing the dose of nifedipine. b. ordering renal function tests. c. evaluation of left ventricular function. d. changing to amlodipine

Answer 86

d. changing to amlodipine. mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms

Question 87

Which of the following adverse effects are associated with calcium channel blockers? (SELECT ALL THAT APPLY) a. Dizziness b. Headache c. Hyperlipidemia d. Sedation

Answer 87

ANS: AB dizziness, headache

Question 88

Clinical studies have found that ACEIs are clinically proven to reduce total mortality by preventing deaths from progressive heart failure. ACEIs should be given to all patients with symptomatic or asymptomatic heart failure because ACEIs: (SELECT ALL THAT APPLY) a. Restore the heart to its normal elliptical shape b. Reverse ventricular remodeling c. Decrease renal blood flow d. Reduce ventricular dilation

Answer 88

ANS: A, B, D (increases renal blood flow)

Question 89

A patient who is taking an ACE inhibitor sees the primary care NP for a follow-up visit. The patient reports having a persistent cough. The NP should: a. ask whether the patient has had any associated facial swelling with this cough. b. reassure the patient that tolerance to this adverse effect will develop over time. c. consider changing the medication to an ARB. d. order a bronchodilator to counter the bronchospasm caused by this drug.

Answer 89

c. consider changing the medication to an ARB. A persistent cough may occur with ACE inhibitors and may warrant discontinuation of the drug. An ARB would be the next drug of choice because it does not have this side effect. The cough is not related to bronchospasm. Angioedema is not related to ACE inhibitor-induced cough. Patients do not develop tolerance to this side effect.

Question 90

A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary care NP should counsel the patient to: a. take care when getting out of bed or a chair after the first dose of the ACE inhibitor. b. minimize fluid intake for several days when beginning therapy with the ACE inhibitor. c. discuss taking an increased dose of the thiazide diuretic with the cardiologist. d. report wheezing and shortness of breath, which may occur with these drugs.

Answer 90

a. take care when getting out of bed or a chair after the first dose of the ACE inhibitor. ACE inhibitors have a first-dose effect that may cause a precipitous symptomatic fall in blood pressure, particularly in patients receiving diuretics. The patient should be counseled about rising quickly from sitting or lying down. Wheezing and shortness of breath are unlikely. An increased dose of diuretic and a reduction in fluid intake are not indicated and may add to hypotension.

Question 91

Which of the following statements is true regarding the use of loop diuretics? (SELECT ALL THAT APPLY) a. Loop diuretics relieve the congestive symptoms of pulmonary and peripheral edema b. It is a potent diuretic that, if given in excessive amounts, may lead to profound losses of water and electrolyte depletion c. May cause hyperkalemia d. May cause ototoxicity

Answer 91

ANS ABD

Question 92

``` The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure. The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim (Bactrim) previously. The NP should prescribe: A. ethacrynic acid. B. furosemide (Lasix). C. acetazolamide (Diamox). D. hydrochlorothiazide (HydroDIURIL). ```

Answer 92

ANS A ethacrynic acid (a different kind of loop diuretic). Patients who are allergic to sulfa drugs should avoid diuretics that are sulfonamide derivatives. Ethacrynic acid is the only choice that is not a sulfonamide derivative.

Question 93

``` A patient with congestive heart failure will begin therapy with a diuretic medication. The primary care NP orders lab tests, which reveal a GFR of 25ml/min. The initial drug the NP should prescribe is: A. metolazone B. furosemide (Lasix) C. spironolactonce (Aldactone) D. hydrochlorothiazine (hydrodiuril ```

Answer 93

ANS: A metolazone. In patients with GFR less than 30, thiazides are relatively ineffective with the exception of metolazone. Potassium-sparing diuretics should be used with great caution or acoided altogether in patients with renal insufficiency

Question 94

Mrs. Smith is a 43-year-old Caucasian female patient who presents to the clinic for a follow up appointment. She has diabetes and hypertension and has been taking a thiazide diuretic for 6 months. Her blood pressure at the beginning of treatment was 155/95 mmHg. the blood pressure today is 144/90 mmHg. The NP should: a. Change to an aldosterone antagonist medication b. Order a beta blocker c. Continue the current drug regimen d. Add an angiotensin-converting enzyme inhibitor

Answer 94

ANS D Add an angiotensin-converting enzyme inhibitor

Question 95

A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking: a. carvedilol (Coreg). b. propranolol (Inderal). c. nadolol (Corgard). d. timolol (Blocadren).

Answer 95

a. carvedilol (Coreg). The 2012 guides for prevention of cardiovascular disease recommend that b-blocker therapy should be used in all patients with left ventricular systolic dysfunction with heart failure or prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol.

Question 96

A patient who takes a calcium channel blocker is in the clinic for an annual physical examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate: a. complete blood count and electrolytes. b. liver function tests (LFTs) and renal function. c. thyroid and insulin levels. d. serum calcium channel blocker level.

Answer 96

b. liver function tests (LFTs) and renal function. Patients who take calcium channel blockers should have periodic renal and LFTs.

Question 97

A patient who has stable angina is taking nitroglycerin and a b-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: a. verapamil HCl (Calan). b. isradipine (DynaCirc). c. nicardipine (Cardene). d. nifedipine (Procardia XL).

Answer 97

a. verapamil HCl (Calan). Nitrates and b-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose.

Question 98

A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-up visit. The primary care NP notes a blood pressure of 100/60 mmHg. The patients lungs are clear, and there is no peripheral edema. The patients seeum potassium is 3.4 mEq/L. The NP should: a. continue furosemide at the current dose. b. decrease furosemide to 60 mg once daily. c. increase furosemide to 80 mg twice daily. d. change furosemide dose the 40 mg twice daily.

Answer 98

ANS: B The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This patient has a low potassium level just under the lower limit, so a reduction in dose is indicated.

Question 99

A patient is taking spironolactone and comes to the clinic complaining of weakness and tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute and a blood pressure of 100/58 mm Hg. The NP should: a. obtain a serum drug level. b. order an electrocardiogram (ECG) and serum electrolytes. c. change the medication to a thiazide diuretic. d. question the patient about potassium intake.

Answer 99

ANS: B The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum electrolytes. This should be done before changing the medication. Because hyperkalemia can cause fatal arrhythmias, an ECG is necessary.

Question 100

A patient who has congestive heart failure and arthritis has been taking chlorthalidone(Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure of 145/90 mm Hg. The NP should: a. ask the patient which medications are used for pain. b. add furosemide (Lasix) to the patient's drug regimen. c. increase the dose of chlorthalidone to 100 mg daily d. recommend that the patient use salt substitutes to season

Answer 100

Answer A. for diuretic resistance, the NP should evaluate factors such as patient nonadherence, physiologic causes, and drugs that may increase resistance, including nonsteroidal antiinflammatory drugs (NSAIDs). This patient has arthritis, and it is likely that NSAID use may be causing diuretic resistance. A second drug, such as furosemide, should be added after the cause of diuretic resistance is determined. The maximum daily dose of chlorthalidone is100 mg per day, but increasing the dose is not recommended to treat diuretic resistance. Recommending salt substitutes is not indicated.

Question 101

The primary care NP sees a patient several months after a myocardial infarction (MI). The patient has been taking furosemide to treat heart failure. The NP notes that the patient has edema of the hands, feet, and ankles. The NP should add which drug to this patient's regimen? a. Ethacrynic acid b. Chlorothiazide (Lozol) c. Triamterene (Dyrenium) d. Spironolactone (Aldactone)

Answer 101

ANS: B. The addition of a thiazide to a loop diuretic along with sodium restriction may be useful in the treatment of refractory edema in patients with congestive heart failure. Ethacrynic acid is a loop diuretic. The other two options are potassium-sparing diuretics.

Question 102

The primary care NP sees a patient who has a history of hypertension and alcoholism. The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe: a. albuterol metered-dose inhaler. b. furosemide (Lasix). c. spironolactone (Aldactone). d. chlorthalidone (Zaroxolyn).

Answer 102

ANS: B furosemide (Lasix). In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary and congestive edema. Loop diuretics are also useful to treat states of volume excess in cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an enlarged liver on examination, furosemide is a good first choice to relieve this patient's congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol might be used for symptomatic treatment only.

Question 103

The primary care NP sees a patient who has heart failure following an MI 6 months before this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of both feet. The NP should prescribe: a. mannitol. b. metolazone. c. acetazolamide (Diamox). d. spironolactone (Aldactone).

Answer 103

ANS: D Spironolactone has been shown to be of particular benefit in the treatment of severe congestive heart failure when added to an ACE inhibitor and a loop diuretic.

Question 104

A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend: a. 30 minutes of aerobic exercise daily. b. beginning therapy with a statin medication. c. taking 81 to 325 mg of aspirin daily. d. starting a thiazide diuretic to treat hypertension.

Answer 104

a. 30 minutes of aerobic exercise daily. this patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated.

Question 105

A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The primary care nurse practitioner (NP) auscultates S3 heart sounds but does not palpate hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should consult a cardiologist to discuss prescribing a(n): a. loop diuretic. b. angiotensin-converting enzyme (ACE) inhibitor. c. b-blocker. d. angiotensin receptor blocker (ARB).

Answer 105

a. loop diuretic. This patient shows signs of systolic heart failure. Treatment for heart failure should begin with a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. b-Blockers are used in patients with minimal fluid retention and would be added later. ARBs are used if ACE inhibitors are not tolerated or are ineffective

Question 106

A patient who has heart failure has been treated with furosemide and an ACE inhibitor. The patient's cardiologist has added digoxin to the patient's medication regimen. The primary care NP who cares for this patient should expect to monitor: a. serum electrolytes. b. blood glucose levels. c. complete blood counts (CBCs). d. serum thyroid levels

Answer 106

a. serum electrolytes. hypokalemia makes the myocardium more sensitive to digoxin. These levels should be monitored closely in patients taking furosemide, which can deplete potassium. Serum glucose, thyroid levels, and a CBC should be monitored if indicated by other conditions.

Question 107

A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching? a. "I should eat foods high in potassium." b. "I should use a salt substitute while taking these medications." c. "I need to take a calcium supplement every day." d. "I should avoid high-sodium foods."

Answer 107

d. "I should avoid high-sodium foods." patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium.

Question 108

A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a. consider prescribing a b-blocker. b. obtain renal function tests. c. order serum electrolytes. d. call the patient's cardiologist to discuss adding digoxin to the patient's regimen.

Answer 108

c. order serum electrolytes. patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are not indicated. b-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure.

Question 109

A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a. obtain a serum potassium level to assess for hyperkalemia. b. decrease the dose of the diuretic to prevent further dehydration. c. obtain a digoxin level before the patient takes the next dose of digoxin. d. hold the ACE inhibitor until the patient's blood pressure stabilizes.

Answer 109

c. obtain a digoxin level before the patient takes the next dose of digoxin. to monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity.

Question 110

An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20 mg once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should change the dose of nadolol to _____ mg _____ daily. a. 20; twice b. 40; twice c. 40; once d. 80; once

Answer 110

c. 40; once. b-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily.

Question 111

A patient with a history of coronary heart disease develops atrial fibrillation. The primary care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which b-blocker medication? a. Sotalol (Betapace) b. Nadolol (Corgard) c. Timolol (Blocadren) d. Propranolol (Inderal)

Answer 111

a. Sotalol (Betapace). Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease.

Question 112

A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient's current dose is 30 mg once daily. The primary care NP should: a. obtain serum drug levels to see if the dose is therapeutic. b. tell the patient to continue taking the timolol and return in 1 month. c. change the medication to propranolol. d. increase the dose to 40 mg once daily.

Answer 112

b. tell the patient to continue taking the timolol and return in 1 month. When giving timolol for migraine prophylaxis, the provider should inform the patient that it may take several weeks for therapy to be effective. The dose should be titrated and maintained for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not serum drug levels.

Question 113

A patient who has been taking propranolol for 6 months reports having nocturnal cough and shortness of breath. The primary care NP should: a. obtain serum drug levels to monitor for toxicity of this medication. b. contact the patient's cardiologist to discuss changing to a selective b-blocker. c. instruct the patient to increase activity and exercise to counter these side effects. d. tell the patient to stop taking the medication.

Answer 113

b. contact the patient's cardiologist to discuss changing to a selective b-blocker. nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective b-blocker with the patient's cardiologist. â-Blockers should never be stopped abruptly. Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these side effects if bronchospasm is the cause.

Question 114

A primary care NP provides teaching for a patient who will begin taking propranolol (Inderal). Which statement by the patient indicates understanding of the teaching? a. "I should take this medication on an empty stomach." b. "I should use caution while driving while taking this medication." c. "I should not take the medication if my pulse is less than 60 beats per minute." d. "If I have shortness of breath, I should discontinue the medication immediately."

Answer 114

b. "I should use caution while driving while taking this medication." because the medication can cause fatigue and drowsiness, patients should be advised to use caution when driving. The medication should be taken with food. Patients should not take a dose if the heart rate is less than 50 beats per minute. Patients should be advised to report shortness of breath but should not abruptly stop taking the medication.

Question 115

A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient's cardiologist to discuss adding: a. verapamil HCl (Calan). b. diltiazem (Cardizem). c. nifedipine (Procardia XL). d. amlodipine (Norvasc).

Answer 115

c. nifedipine (Procardia XL). Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug.

Question 116

A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient's cardiologist about changing the medication to: a. amlodipine (Norvasc). b. verapamil HCl (Calan). c. short-acting nifedipine (Procardia). d. isradipine (DynaCirc).

Answer 116

b. verapamil HCl (Calan). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine.

Question 117

An African-American patient who is obese has persistent blood pressure readings greater than 150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should consider prescribing a(n): a. b-blocker. b. ACE inhibitor. c. calcium channel blocker. d. angiotensin receptor blocker.

Answer 117

c. calcium channel blocker. African-American patients are considered good candidates for calcium channel blockers to treat hypertension. Treatment with calcium channel blockers as monotherapy in African-American patients has proved to be more effective than some other classes of antihypertensive agents.

Question 118

Which of the following agents used in class II and class III heart failures is known to have alpha as well as non-selective beta blocking action? a. Carvedilol (coreg) b. Amlodipine (Norvasc) c. Lisinopril (Zestril) d. Captopril (capoten)

Answer 118

ANS. A. Carvedilol

Question 119

A patient takes hydrochlorothiazide to treat hypertension and asks the primary care NP why it is necessary to reduce sodium intake while taking this medication. The NP should explain that decreasing sodium is necessary to: a. prevent renal insufficiency b. minimize the incidence of hypokalemia c. decrease the length of time the patient needs to be on the diuretic d. prevent post diuretic sodium retention

Answer 119

ANS D. If dietary salt intake is high, the amount of sodium lost in response to the diuretic may be partially or completely offset by postdiuretic sodium retention. Sodium restriction does not prevent renal insufficiency or minimize the incidence of hypokalemia. Sodium restriction is necessary to maintain the drugs effectiveness but does not increase the chance of discontinuing the medication.

Question 120

A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no peripheral edema. The patient's serum electrolytes are normal. The NP should prescribe: a. furosemide (Lasix) b. triamterene (Dyrenium) c. acetazolamide (Diamox) d. hydrochlorothiazide (hydrodiuril)

Answer 120

ANS D. Hydrochlorothiazide. Thiazide diuretics are first line drugs for treating hypertension. The other three drugs are not thiazide diuretics.

Question 121

An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: a. recommend a low-sodium diet in addition to the medication. b. increase the captopril dose to 50 mg twice daily. c. change the drug to losartan (Cozaar) 50 mg once daily. d. add a thiazide diuretic to this patient's regimen

Answer 121

d. add a thiazide diuretic to this patient's regimen. some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case.

Question 122

A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin for angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor. Preliminary laboratory tests reveal decreased renal function. The NP should: a. order a renal perfusion study before starting treatment. b. choose an ARB instead. c. add a low-dose thiazide diuretic to the drug regimen. d. begin therapy with a low-dose ACE inhibitor.

Answer 122

a. order a renal perfusion study before starting treatment. ACE inhibitors are contraindicated in patients with bilateral renal stenosis. Because this patient has decreased renal function, perfusion studies are indicated. If the patient does not have bilateral renal stenosis, a low-dose ACE inhibitor may be used. An ARB is indicated if perfusion studies show bilateral renal stenosis. A thiazide diuretic is not indicated

Question 123

A patient who has type 2 diabetes is seen by a primary care NP for a physical examination. The NP notes a blood pressure of 140/95 mm Hg on three occasions. A urinalysis reveals macroalbuminuria. The patient's serum creatinine is 1.9 mg/dL. Adhering to evidence-based practice, the NP should prescribe: a. fosinopril sodium (Monopril). b. losartan (Cozaar). c. captopril (Capoten). d. enalapril maleate (Vasotec

Answer 123

b. losartan (Cozaar). In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dL), ARBs have been shown to delay the progression of nephropathy. Losartan is an ARB. The other medications are ACE inhibitors.

Question 124

A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin taking spironolactone. The primary care NP should counsel this patient to: a. avoid foods that are high in potassium. b. discuss changing the ACE inhibitor to an ARB with the cardiologist. c. avoid taking antacids containing magnesium while taking these drugs. d. use a salt substitute when seasoning foods

Answer 124

a. avoid foods that are high in potassium. Use of potassium-sparing diuretics or salt substitutes can induce hyperkalemia when taking ACE inhibitors, so this patient should be counseled to restrict potassium. Salt substitutes are high in potassium and are contraindicated. It is not necessary to change to an ARB. Antacids are not contraindicated.

Question 125

The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP learns that the patient has decreased renal function and has renal artery stenosis in the right kidney. The NP should: a. initiate ACE inhibitor therapy at a low dose. b. give the captopril with a thiazide diuretic to improve renal function. c. order lisinopril (Zestril) instead of captopril to avoid increased nephropathy. d. consider a different drug class to treat this patient's symptoms.

Answer 125

a. initiate ACE inhibitor therapy at a low dose. patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary to avoid ACE inhibitors with unilateral renal stenosis.

Question 126

A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes. The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain. The NP should: a. change from a sublingual to a transdermal patch nitroglycerin. b. contact the patient's cardiologist to discuss admission to the hospital. c. discontinue the nitroglycerin and order ranolazine (Ranexa ER). d. increase the nitroglycerin dose to 0.6 mg per dose.

Answer 126

ANS b. contact the patient's cardiologist to discuss admission to the hospital. Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or duration of pain and fewer precipitating factors. Patients with unstable angina should be admitted to a coronary care unit. The primary care NP should not change any medications without consultation with the patient's cardiologist.

Question 127

A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP's next action should be to: a. give 325 mg of chewable aspirin. b. administer oxygen at 2 L/minute. c. call EMS. d. obtain an electrocardiogram.

Answer 127

ANS b. administer oxygen at 2 L/minute. When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin.

Question 128

A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed. The primary care nurse practitioner (NP) reviews this medication with the patient at the patient's annual physical examination. Which statement by the patient indicates understanding of the medication? a. "I should take aspirin along with the nitroglycerin when I have chest pain." b. "I should take nitroglycerin and then rest for 15 minutes before taking the next dose." c. "I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1." d. "I should call 9-1-1 if chest pain persists 5 minutes after the first dose."

Answer 128

ANS d. "I should call 9-1-1 if chest pain persists 5 minutes after the first dose." Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS), more recent guidelines suggest an alternative strategy to reduce delays in emergency care. These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses of nitroglycerin are given 5 minutes apart over 15 minutes.

Question 129

A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to: a. use the patch as needed for angina pain. b. change the patch four times daily. c. apply one patch daily in the morning and remove in 12 hours. d. use two patches daily and change them every 12 hours.

Answer 129

ANS c. apply one patch daily in the morning and remove in 12 hours. To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily.

Question 130

A patient who has been taking quinidine for several years reports lightheadedness, fatigue, and weakness. The primary care NP notes a heart rate of 110 beats per minute. The serum quinidine level is 6 mg/mL. The NP should: a. reassure the patient that this is a therapeutic drug level. b. admit the patient to the hospital and obtain a cardiology consultation. c. discontinue the medication immediately. d. order an ECG, CBC, liver function tests (LFTs), and renal function tests.

Answer 130

ANS d. order an ECG, CBC, liver function tests (LFTs), and renal function tests. The therapeutic level for quinidine is 2 to 5 ìg/mL. Some patients have therapeutic responses at up to 6 mg/mL. The NP should order ECG, CBC, LFT, and renal function tests.

Question 131

The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome. The cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not obese. The patient asks the NP what else can be done to minimize risk of sudden cardiac arrest. The NP should counsel the patient to: a. drink extra fluids when exercising. b. reduce stress with yoga and hot baths. c. ask the cardiologist about an implantable defibrillator. d. ask the cardiologist about adding procainamide to the drug regimen.

Answer 131

a. drink extra fluids when exercising. patients with long QT syndrome should avoid situations in which they might overheat or get dehydrated. This patient should be encouraged to drink plenty of fluids while exercising and should avoid activities such as yoga and hot baths. Implantable cardioverter-defibrillators are used for high-risk patients. Procainamide can cause long QT syndrome.

Question 132

Which of the following statements is true regarding the mechanism of action of digoxin in the treatment of HF? (SELECT ALL THAT APPLY) a. has an inotropic effect on cardiac cells b. produces a decreased force of contraction of the cardiac muscle c. increases CO and produces mild diuresis, helping to relieve symptoms d. it is most effective in HF causes by decreased left ventricular function and other low-output syndromes

Answer 132

ANS ACD

Question 133

Which of the following drugs can exacerbate HF and should be avoided, when possible? (SELECT ALL THAT APPLY) a. ibuprofen b. lisinopril c. pioglitazone d. furosemide

Answer 133

ANS AC

Question 134

Which of the following statements is true regarding the use of organic nitrates? a. Ensure a nitrate-free interval to prevent tolerance b. Produce vascular smooth muscle relaxation c. Are contraindicated with PDE5 inhibitors (sildenafil and others) d. Only first and second statements are correct e. All of the above statements are correct

Answer 134

ANS. E all of the above

Question 135

``` Match the following antiarrhythmic class of drugs with their corresponding mechanism of action: Class I ------------------- Class II ------------------ Class III ---------------- Class IV ---------------- ```

Answer 135

Sodium Channel Blockers Beta-adrenergic blockers Potassium channel blockers Calcium channel blockers

Question 136

A patient will begin treatment with amiodarone. To monitor for toxicity the NP should do the following (SELECT ALL THAT APPLY): a. Perform baseline chest radiographs and pulmonary function tests b. Thyroid function test at baseline and periodically during therapy c. Obtain annual ophthalmic examination d. Obtain ECG, serum creatinine, magnesium, and potassium levels every 3 months

Answer 136

ANS ABC

Question 137

A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a. decrease the dose of the diuretic to prevent further dehydration. b. obtain a serum potassium level to assess for hyperkalemia. c. obtain a digoxin level before the patient takes the next dose of digoxin. d. hold the ACE inhibitor until the patient's blood pressure stabilizes.

Answer 137

ANS c. obtain a digoxin level before the patient takes the next dose of digoxin. To monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity

Question 138

TRUE/FALSE: The most common cause of death from digoxin toxicity is ventricular fibrillation.

Answer 138

True

Question 139

The primary care NP sees a new patient for a routine physical examination. When auscultating the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed by a pause. History reveals no past cardiovascular disease, but the patient reports occasional syncope and shortness of breath. The NP should: a. order a complete blood count (CBC) and electrolytes and consider a trial of procainamide. b. prescribe a b-blocker and anticoagulant and order 24-hour Holter monitoring. c. schedule a cardiac stress test and a graded exercise test. d. order an ECG and refer to a cardiologist.

Answer 139

ANS d. order an ECG and refer to a cardiologist. Premature ventricular contractions are premature ventricular beats with a compensatory pause. This patient has no prior history, but does have syncope and shortness of breath. The NP should order an ECG and refer the patient to a cardiologist for further evaluation. If there were no other symptoms, the NP could order stress testing. Medications are not indicated without further testing and without consultation with a cardiologist.

Question 140

The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: a. 60 mg on awakening and 40 mg 7 hours later. b. 40 mg twice daily 30 minutes before meals. c. 60 mg four times daily at 6-hour intervals. d. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM.

Answer 140

ANS b. 40 mg twice daily 30 minutes before meals. Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point.

Question 141

A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend: a. changes in diet to avoid acidic foods. b. daily treatment with a PPI. c. antacid therapy as needed. d. consultation with a gastroenterologist for endoscopy

Answer 141

ANS: B daily treatment with PPI. This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications. Changes in diet are not recommended as treatment but may help with symptoms. Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy.

Question 142

Which of the following statements is true regarding the use of antacids? (SELECT ALL THAT APPLY) a. Antacids are weak bases that neutralize gastric hydrochloric acid b. Antacids also have a number of cytoprotective effects c. Antacids protect the stomach by coating the mucosal lining d. Antacids with high ANC usually are more effective than others

Answer 142

ANS: ABD

Question 143

An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend: a. magnesium hydroxide (Milk of Magnesia). b. aluminum hydroxide (Amphojel). c. sodium bicarbonate (Alka-Seltzer). d. calcium carbonate (Tums).

Answer 143

d. calcium carbonate (Tums). Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients. Aluminum hydroxide is not as effective as calcium carbonate.

Question 144

A patient has NSAID-induced ulcer and has started taking ranitidine (Zantac). At a follow-up appointment 3 days later, the patient reports no alleviation of symptoms. The primary care NP should: a. change from ranitidine to omeprazole (Prilosec). b. reassure the patient that drug effects take several weeks. c. order cimetidine (Tagamet). d. add metronidazole to the drug regimen.

Answer 144

a. change from ranitidine to omeprazole (Prilosec). If the patient does not start to see improvement within a few days after initiation of treatment with a histamine-2 blocker, the provider either should increase the dose of the medication or should change to a PPI. Cimetidine is a histamine-2 blocker and has many serious side effects. Metronidazole is used only when H. pylori is known to be present. Patients should start to get relief within a few days.

Question 145

A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe: a. pantoprazole (Protonix). b. omeprazole (Prilosec). c. esomeprazole (Nexium). d. ranitidine (Zantac).

Answer 145

d. ranitidine (Zantac). PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine.

Question 146

A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should: a. change the NSAID to a corticosteroid. b. prescribe omeprazole (Prilosec). c. teach the patient about a bland diet. d. prescribe cimetidine (Tagamet)

Answer 146

b. prescribe omeprazole (Prilosec). Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated.

Question 147

Which of the following statements is true regarding the use of proton pump inhibitors (PPIs)? (SELECT ALL THAT APPLY) a. PPIs are the most potent available inhibitors of gastric secretion b. Some adverse effects include: nausea, headache, diarrhea, GI disturbance, and bone fractures with long-term use c. A dose adjustment is necessary when using PPIs to treat geriatric patients d. PPIs and H2-blockers should not be used concurrently

Answer 147

ANS: ABD (no dose adjustment necessary)

Question 148

A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend _____ g of fiber per day. a. 20 b. 15 c. 10 d. 25

Answer 148

c. 10. Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age.

Question 149

A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend: a. adding docusate sodium (Colace). b. polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax). c. adding nonpharmacologic measures such as biofeedback. d. lactulose (Chronulac) and polyethylene glycol (MiraLAX).

Answer 149

a. adding docusate sodium (Colace). Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category.

Question 150

A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each month for constipation. The primary care NP should counsel this patient to: a. change the laxative to docusate sodium (Colace). b. take the digoxin 2 hours before taking the psyllium. c. ask the cardiologist about taking an increased dose of digoxin. d. decrease fluid intake to avoid cardiac overload.

Answer 150

b. take the digoxin 2 hours before taking the psyllium. Laxatives can affect the absorption of drugs in the intestine by decreasing transit time. Digoxin is a drug that is affected by decreased transit time. Patients should be counseled to take the drugs 2 hours apart.

Question 151

A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family members have had similar symptoms, which have resolved. The primary care NP should recommend: a. attapulgite (Kaopectate). b. bismuth subsalicylate (Pepto-Bismol). c. an electrolyte solution (Pedialyte). d. diphenoxylate (Lomotil).

Answer 151

c. an electrolyte solution (Pedialyte). Antidiarrheals are not generally recommended in children. Bismuth is not recommended in children younger than 16 years of age with viral illnesses because it can mask symptoms of Reye's syndrome. Oral rehydration with electrolyte solution is safe.

Question 152

A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea. Her husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60 mm Hg. The NP should: a. prescribe attapulgite to treat her diarrhea. b. obtain a stool culture and start antibiotic therapy. c. refer her to an emergency department for intravenous (IV) fluids. d. instruct her to replace lost fluids by drinking Pedialyte.

Answer 152

c. refer her to an emergency department for intravenous (IV) fluids. Diarrhea in pregnant women can have serious consequences, and the patient may need to be referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is usually viral, and antibiotics are not given unless a stool culture is performed and is positive. Because the patient is pregnant and has nausea, oral rehydration would not be effective.

Question 153

A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the clinic after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP should: a. order testing for Clostridium difficile and consider metronidazole therapy. b. obtain a stool specimen and order vancomycin. c. prescribe diphenoxylate (Lomotil) to provide symptomatic relief. d. reassure the patient that diarrhea is a common side effect of antibiotic therapy.

Answer 153

a. order testing for Clostridium difficile and consider metronidazole therapy. The guidelines for treatment of diarrhea emphasize comprehensive evaluation before treatment begins. Antibiotic use points to C. difficile as a possible cause, and metronidazole is often used to treat mild to moderate infection. Vancomycin is used when C. difficile is severe. Diphenoxylate can worsen the infection because it slows transit time of the bacteria in the gut. Prolonged diarrhea during antibiotic therapy should be investigated.

Question 154

A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe: a. prochlorperazine (Compazine). b. scopolamine transdermal. c. aprepitant (Emend). d. ondansetron (Zofran).

Answer 154

d. ondansetron (Zofran). No antiemetic drugs should be used for nausea and vomiting during pregnancy unless approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label) for hyperemesis gravidum.

Question 155

A primary care NP sees a patient who is about to take a cruise and reports having had motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch: a. every 3 days. b. daily. c. 1 hour before embarking. d. as needed for nausea.

Answer 155

a. every 3 days. The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed.

Question 156

A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe: a. ondansetron. b. scopolamine. c. meclizine. d. dimenhydrinate

Answer 156

c. meclizine. Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo.

Question 157

A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe: a. dicyclomine (Bentyl). b. simethicone (Phazyme). c. metoclopramide (Reglan). d. mesalamine (Asacol).

Answer 157

a. dicyclomine (Bentyl). Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas. Metoclopramide is used to increase motility.

Question 158

A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea but is now having occasional constipation. The primary care NP should recommend: a. beginning therapy with a TCA. b. beginning treatment with an SSRI. c. increasing the amounts of raw fruits and vegetables in the diet. d. over-the-counter (OTC) laxatives as needed when constipated.

Answer 158

d. over-the-counter (OTC) laxatives as needed when constipated. Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can increase the likelihood of bloating.

Question 159

A woman with IBS has been taking antispasmodic medications and reports some relief, but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing: a. alosetron (Lotronex). b. misoprostol (Cytotec). c. simethicone (Phazyme). d. tricyclic antidepressants (TCAs).

Answer 159

d. tricyclic antidepressants (TCAs). TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms and are useful for long-term treatment. Alosetron is ordered by a GI specialist if symptoms are resistant to all other interventions and has been shown to be effective in women with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers. Simethicone acts locally to treat symptoms of trapped air and gas.

Question 160

TRUE/FALSE: A diet with adequate fiber is the cornerstone of treatment for IBS, and 25 grams per day is recommended

Answer 160

True

Question 161

A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that: a. a fundoplication will be necessary to correct the cause of GERD. b. a combination of lifestyle changes, medications, and surgery may be necessary. c. elevation of the head of the bed at night can relieve most symptoms. d. over-the-counter (OTC) antacids can be effective and should be tried first.

Answer 161

b. a combination of lifestyle changes, medications, and surgery may be necessary. People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids are sometimes used but are rarely used as first-line treatment.

Question 162

A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums: a. neutralize stomach acid as well as proton pump inhibitors (PPIs) b. do not help reduce symptoms of erosive esophagitis. c. can help to heal erosions in esophageal tissue. d. help reduce symptoms in conjunction with PPIs.

Answer 162

d. help reduce symptoms in conjunction with PPIs. Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI.

Question 163

A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and reports a decrease in symptoms. The patient asks the primary care NP if the medication may be discontinued. The NP should tell the patient that: a. the condition may eventually be cured, but therapy must continue for years. b. antireflux surgery must be done before the PPI can be discontinued. c. the dose may be decreased for long-term therapy. d. once the symptoms have cleared completely, the medication may be discontinued.

Answer 163

c. the dose may be decreased for long-term therapy. Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy should be continued long-term and titrated down to the lowest effective dose based on symptom control. PPI therapy is considered safer than surgery and should be tried first before surgery is performed. GERD is a lifelong syndrome and is not curable

Question 164

A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in symptoms. The next response of the primary care NP is to: a. refer the patient to an endocrinologist for endoscopy and further management. b. increase the dose of the PPI. c. add a histamine-2-receptor agonist. d. change to long-term, low-dose PPI therapy.

Answer 164

c. add a histamine-2-receptor agonist. If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis. When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist.

Question 165

A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to: a. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). b. change to aluminum hydroxide (Amphojel). c. use magnesium hydroxide (Milk of Magnesia) instead. d. continue using sodium bicarbonate (Alka-Seltzer) as needed.

Answer 165

a. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances.

Question 166

A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is still present. The NP should order: a. a PPI, amoxicillin, and metronidazole for 14 days. b. continuation of the PPI for 4 to 8 weeks. c. a PPI, bismuth subsalicylate, tetracycline, and metronidazole. d. a PPI, clarithromycin, and amoxicillin for 14 more days.

Answer 166

a. a PPI, amoxicillin, and metronidazole for 14 days. A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolide-allergic patients and for re-treatment for 14 days if first-line treatment of choice failed because of occasional resistance to clarithromycin.

Question 167

A patient with a diagnosis of peptic ulcer disease asks the primary care NP about nonpharmacologic treatment. Which statement by the NP is correct? a. "Lifestyle changes and proper diet may eliminate the need for medication." b. "You should consume a diet that is high in fiber." c. "One or two cups of coffee each day won't hurt you." d. "Alcoholic beverages are strictly prohibited when you have an ulcer."

Answer 167

b. "You should consume a diet that is high in fiber." Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine increases acid secretion and should be avoided. Patients may consume alcohol in moderation. Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer disease, they do not eliminate the need for medications.

Question 168

An 80-year-old patient has a history of renal disease and develops a duodenal ulcer. The primary care NP should order a: a. decreased dose of a PPI. b. normal dose of a PPI. c. decreased dose of a histamine-2 blocker. d. normal dose of a histamine-2 blocker.

Answer 168

b. normal dose of a PPI. No adjustment of dosage is necessary for older patients taking PPIs. Patients with a history of renal disease may have decreased elimination of histamine-2 blockers, so the NP should avoid these if possible.

Question 169

A patient with peptic ulcer disease is taking a histamine-2 blocker and tells the primary care NP that over-the-counter antacid tablets help with the discomfort. The NP should tell this patient to: a. take the antacid and the histamine-2 blocker at the same time b. take the histamine-2 blocker 2 hours before taking the antacid. c. discontinue the histamine-2 blocker. d. discontinue the antacid.

Answer 169

b. take the histamine-2 blocker 2 hours before taking the antacid. Histamine-2 blockers should not be taken within 2 hours of antacid ingestion because antacids decrease the action of histamine-2 blockers.

Question 170

A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP performs a medication history and learns that the patient also takes digoxin. The NP should recommend: a. decreasing the dose of digoxin. b. obtaining a serum digoxin level. c. changing the PPI to omeprazole. d. increasing the dose of lansoprazole

Answer 170

b. obtaining a serum digoxin level. Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that require absorption in an acid stomach, including digoxin. It may be necessary to increase the dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so changing to another PPI would not solve the problem. Increasing the dose of lansoprazole would decrease the absorption of digoxin.

Question 171

A primary care nurse practitioner (NP) sees a patient who is concerned about constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend: a. increased intake of fluids and fiber. b. docusate sodium (Colace) as needed. c. psyllium (Metamucil) on a daily basis. d. polyethylene glycol (MiraLAX) as needed.

Answer 171

a. increased intake of fluids and fiber. The objective definition of constipation is two or fewer bowel movements per week or excessive straining. This patient does not meet these criteria, so the NP should recommend increasing fluids and fiber to help soften stools. Laxatives should not be used unless constipation is present or is chronic to avoid laxative dependence.

Question 172

A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend: a. a daily bulk laxative. b. glycerin suppositories as needed. c. a saline laxative as needed. d. long-term docusate sodium.

Answer 172

c. a saline laxative as needed. Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use.

Question 173

A patient who has cerebral palsy is wheelchair dependent and receives enteral nutrition via a gastrostomy tube. The patient has infrequent, hard bowel movements despite using a high-fiber formula and receiving 1500 mL of fluid per day. The NP should order: a. docusate sodium (Colace). b. sodium phosphate (Fleets) enema. c. polyethylene glycol (MiraLAX). d. bisacodyl (Dulcolax).

Answer 173

c. polyethylene glycol (MiraLAX). Fluids, fiber, and exercise, which help most people, are not applicable to people who are wheelchair bound. Other individuals with congestive heart failure are unable to tolerate these mechanisms. Osmotic laxatives, such as polyethylene glycol are used to manage long-term constipation. It is essential for clinicians to know their patients and assess what is reasonable for them to do.

Question 174

A primary care NP sees a patient who reports having decreased frequency of stools over the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should: a. recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily. b. start daily methylcellulose (Citrucel) and increased fluids. c. order a sodium phosphate enema and psyllium (Metamucil). d. give magnesium hydroxide (Milk of Magnesia).

Answer 174

c. order a sodium phosphate enema and psyllium (Metamucil). If a patient is severely constipated, an enema is indicated. When there is underlying chronic constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are first-line treatments for long-term constipation.

Question 175

A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should: a. counsel the patient to discontinue the laxative and increase fluid and fiber intake. b. tell her that long-term use of suppositories is safer than long-term laxative use. c. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually.

Answer 175

d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer long-term laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation.

Question 176

A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are: a. useful in cases of acute infection with elevated temperature. b. useful when other symptoms, such as hematochezia, develop. c. not curative and may prolong the illness. d. most beneficial when symptoms persist longer than 2 weeks.

Answer 176

c. not curative and may prolong the illness. Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases.

Question 177

A patient who has experienced five to seven liquid stools for 3 days is seen in the clinic by the primary care NP. The patient reports having had fever, mucoid stools, and nausea without vomiting. The patient has been drinking Gatorade to stay hydrated. The NP obtains a stool specimen for culture and should prescribe: a. attapulgite (Kaopectate). b. loperamide hydrochloride (Imodium). c. bismuth subsalicylate (Pepto-Bismol). d. diphenoxylate (Lomotil).

Answer 177

c. bismuth subsalicylate (Pepto-Bismol). Bismuth reduces symptoms through antidiarrheal and antibacterial properties and can decrease nausea and vomiting. Opioid antidiarrheals should be given after the cause of infectious diarrhea is treated; these can actually prolong symptoms because they slow transit of the causative organisms through the gut. Attapulgite can be used because it binds bacteria and toxins in the gastrointestinal tract, but bismuth is a better choice in this case because it helps to treat nausea. The patient is drinking Gatorade and is getting electrolyte replacement.

Question 178

A 2-year-old child has chronic "toddler's" diarrhea, which has an unknown but benign etiology. The child's parent asks the primary care NP if a medication can be used to treat the child's symptoms. The NP should recommend giving: a. diphenoxylate (Lomotil). b. bismuth subsalicylate (Pepto-Bismol). c. attapulgite (Kaopectate). d. an electrolyte solution (Pedialyte).

Answer 178

d. an electrolyte solution (Pedialyte). Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children.

Question 179

A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP's priority should be to: a. administer opioid antidiarrheal medications. b. obtain stool cultures. c. consider prescribing metronidazole. d. begin rehydration therapy.

Answer 179

d. begin rehydration therapy. Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms.

Question 180

A primary care NP sees a patient 2 days after an outpatient surgical procedure. The patient reports using ondansetron for nausea. The NP notes a blood pressure of 88/56 mm Hg, and the patient reports feeling faint. The NP should suspect: a. hemorrhage b. drug toxicity. c. drug interaction. d. dehydration.

Answer 180

b. drug toxicity Hypotension and faintness are signs of overdose of ondansetron, and drug toxicity is the more likely cause of this patient's decrease in blood pressure.

Question 181

A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days. The patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of greater than 3 seconds. The NP should: a. prescribe a rectal antiemetic medication. b. encourage the patient to take small, frequent sips of Gatorade. c. admit to the hospital for intravenous (IV) rehydration. d. obtain a complete blood count and serum electrolytes.

Answer 181

c. admit to the hospital for intravenous (IV) rehydration. If vomiting is not controlled, dehydration may occur. Patients who are dehydrated, as this patient is, must be treated with IV fluids in a hospital or emergency department setting.

Question 182

A patient who is about to begin chemotherapy expresses concern to the primary care NP about gastrointestinal side effects of the treatments. The NP should reassure the patient that: a. taking ondansetron before chemotherapy decreases nausea and vomiting. b. most newer chemotherapeutic agents do not cause nausea and vomiting. c. antiemetics will be administered as needed if nausea and vomiting occur. d. a scopolamine patch is an effective way to prevent nausea and vomiting

Answer 182

a. taking ondansetron before chemotherapy decreases nausea and vomiting. In many situations, nausea and vomiting may be anticipated. These situations may involve motion sickness or chemotherapy. Premedicating the patient with an antiemetic may be necessary in order for the patient to receive full therapy; this is the current standard of care. Although most chemotherapeutic agents have emetogenic potential, the use of premedication with 5-HT3 receptor antagonists significantly decreases the nausea and vomiting experienced during and after administration The most common agent in this class, ondansetron, is now available as a generic.

Question 183

A primary care NP sees a 3-year-old patient who has been vomiting for several days. The child has had fewer episodes of vomiting the past day and is now able to take sips of fluids without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and pale but warm skin. The child's blood pressure is 88/46 mm Hg, the heart rate is 110 beats per minute, and the temperature is 37.2° C. The NP should: a. prescribe a scopolamine patch. b. send the child to the hospital for IV fluids. c. prescribe promethazine. d. begin oral rehydration therapy.

Answer 183

d. begin oral rehydration therapy. The use of antiemetics in children is discouraged for cases of uncomplicated vomiting. The child has compensated, mild dehydration and is now able to tolerate fluids, so oral rehydration is indicated.

Question 184

A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is: a. whether the pain is sharp or diffuse. b. the age of the patient when the pain began. c. the relation of the pain to stools. d. what time of day the pain occurs

Answer 184

c. the relation of the pain to stools. The new Rome II guidelines maintain that irritable bowel syndrome (IBS) of any subtype is characterized by a strong relationship between abdominal pain and defecation because of visceral hypersensitivity to gut-related events. The other characteristics of pain may be assessed to help guide management of IBS, but the first is necessary for a correct diagnosis.

Question 185

A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend: a. avoiding gluten and lactose in the diet. b. beginning aerobic exercise, such as running, every day. c. increasing water intake to eight to ten glasses per day. d. 25 g of fiber each day

Answer 185

d. 25 g of fiber each day. A diet with adequate fiber is the cornerstone of treatment, and 25 g per day is recommended. Unless the patient has a documented gluten or lactose malabsorption, avoiding these substances is not recommended. Water intake should be six to eight glasses per day. Regular walking is usually the best exercise.

Question 186

A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP should: a. discontinue the antidiarrheal medication. b. encourage the patient to increase water intake. c. lower the dose of the antispasmodic medication. d. prescribe a TCA.

Answer 186

c. lower the dose of the antispasmodic medication. Patients taking antispasmodic medications should be monitored for anticholinergic side effects, such as increased heart rate, dry mouth, difficulty urinating, and constipation. The NP should lower the dose if needed. TCAs are used to treat pain long-term. Because the antidiarrheal medication is used as needed, there is no reason to discontinue it. Increasing water intake may improve symptoms associated with side effects but would not treat the underlying cause of these symptoms.

Question 187

A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone (Phazyme), and a TCA. She reports having continued severe diarrhea. The primary care NP should: a. refer her to a gastroenterologist for endoscopy. b. increase the fiber in her diet to 30 g per day. c. order diphenoxylate (Lomotil). d. prescribe alosetron after ruling out pregnancy.

Answer 187

a. refer her to a gastroenterologist for endoscopy. Alosetron is given only to women with severe chronic diarrhea-predominant IBS and only after anatomic or biochemical abnormalities of the GI tract have been excluded. Because this woman's symptoms are persistent and severe, diphenoxylate and increased dietary fiber are not indicated.

Question 188

A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe: a. an SSRI antidepressant. b. benztropine (Cogentin). c. a TCA. d. cimetidine

Answer 188

b. benztropine (Cogentin). Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg

Question 189

A man who has benign prostatic hypertrophy (BPH), in whom prostate carcinoma has been ruled out, asks the primary care nurse practitioner (NP) about beginning drug therapy to treat his symptoms. The NP notes that he consistently has blood pressure readings around 145/90 mm Hg. The NP should prescribe: a. tadalafil (Cialis). b. doxazosin (Cardura). c. tamsulosin (Flomax). d. finasteride (Proscar)

Answer 189

ANS: B- Doxazosin is a nonspecific -blocker, which also lowers blood pressure and should be considered to treat BPH in patients who also have hypertension. Tadalafil is used to treat erectile dysfunction. Tamsulosin is a specific á-blocker and is first-line treatment for patients with BPH who do not have hypertension. Finasteride is a 5-reductase inhibitor, which is not a first-line medication

Question 190

A patient who has BPH is taking tamsulosin and dutasteride and asks the primary care NP why he needs to take both medications. The NP should tell him: a. the combination helps reduce the risk of prostate carcinoma. b. two-drug therapy is required before corrective prostatectomy surgery. c. both drugs are given so that smaller doses of each drug may be administered. d. one gives faster symptom relief, whereas the other shrinks the size of the prostate.

Answer 190

ANS: D- A 5α-reductase inhibitor is given to shrink the size of the prostate, but maximum benefit is not achieved until 6 months of therapy. The α-blocker is given to provide more rapid relief. The combination does not decrease the risk of carcinoma. The drug therapy is not a prerequisite to surgery, although it may be used before surgical intervention. The combination therapy does not affect the dose of either drug

Question 191

A patient who has BPH is taking alfuzosin (Uroxatral) and finasteride (Proscar). The patient has had two urinary tract infections (UTIs) in the past 2 months. A urinalysis in the clinic is negative for leukocyte esterase but positive for hematuria. The primary care NP should: a. discontinue finasteride. b. refer the patient to a urologist. c. change alfuzosin to tamsulosin. d. add doxazosin to the drug regimen

Answer 191

ANS: B- Surgery is indicated for patients who are refractory to treatment with medications or who have recurrent UTIs or hematuria. The NP should refer the patient to a urologist. All -blockers are considered equally efficacious, so changing the drug regimen is not indicated

Question 192

A patient who has BPH is taking doxazosin and finasteride. The patient asks the primary care NP whether he has an increased risk of prostate cancer. The NP should tell him: a. his overall cancer risk is increased. b. he has an increased risk of a certain type of cancer. c. his cancer risk is the same as any other man his age. d. doxazosin will increase his cancer risk, but only slightly.

Answer 192

ANS: B- There is an overall reduction in prostate cancer risk for patients taking 5-reductase inhibitors, such as finasteride, but there is an increased risk of high-grade prostate cancer. His overall cancer risk is less. Doxazosin does not affect cancer risk

Question 193

A patient tells the primary care NP that he has difficulty getting and maintaining an erection. The NP's initial response should be to: a. prescribe sildenafil (Viagra). b. perform a medication history. c. evaluate his cardiovascular status. d. order a papaverine injection test to screen for erectile dysfunction

Answer 193

ANS: B- Because the use of multiple medications is associated with a higher prevalence of erectile dysfunction, a medication history should be performed first to see if any medications have sexual side effects. A cardiovascular evaluation may be assessed next. Papaverine injection tests are useful screening tools after a thorough history has been performed. Medications are prescribed only after a diagnosis is determined and other causes have been ruled out

Question 194

The primary care NP is preparing to prescribe sildenafil for a man who has erectile dysfunction. The NP should remember to tell this patient: a. to avoid oral nitrates while taking this medication. b. that the drug may cause penile aching. c. to use a condom if his sexual partner is pregnant. d. dyspepsia may occur and may warrant discontinuation of the drug

Answer 194

ANS: A- Deaths have been reported in men on concomitant treatment with oral nitrates who are taking sildenafil. Patients taking alprostadil may experience penile ache. Finasteride, not sildenafil, isteratogenic, and a man taking finasteride should use condoms if his partner is pregnant

Question 195

A man who has cardiovascular disease and takes nitroglycerin for angina pain develops erectile dysfunction. The primary care NP who cares for this patient should recommend: a. sildenafil (Viagra). b. testosterone injections. c. vascular reconstruction surgery. d. use of a vacuum constriction device.

Answer 195

ANS: D- Deaths have been reported in men on concomitant treatment with oral nitrates who are taking sildenafil. Patients with erectile dysfunction should be advised to try nonpharmacologic treatment, such as a vacuum constriction device. Testosterone injections are used for men withdocumented androgen deficiency. Vascular reconstruction surgery may be used for men with decreased blood flow and should be considered if other treatments are ineffective.

Question 196

A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: a. relax vascular smooth muscle. b. dissolve atheromatous lesions. c. reduce C-reactive protein levels. d. prevent catecholamine release

Answer 196

ANS a. relax vascular smooth muscle. Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand. Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce C-reactive protein levels.

Question 197

A patient who has erectile dysfunction wants a medication to use as needed. The primary care NP should recommend: a. tadalafil (Cialis). b. sildenafil (Viagra). c. avanafil (Stendra). d. vardenafil (Levitra)

Answer 197

ANS: C- Avanafil is the newest drug on the market and can be used on an as-needed basis because it has a shorter half-life and shorter onset of action. It may be taken 30 minutes before sexual activity. The other agents have an onset of action of several hours.

Question 198

The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also reports having an increased urge to void even when her bladder is not full. She is not taking any medications. The NP should: a. perform a dipstick urinalysis. b. prescribe desmopressin (DDAVP). c. prescribe oxybutynin chloride (Ditropan XL). d. teach exercises to strengthen the pelvic muscles

Answer 198

ANS: A- A focused history with a careful physical examination is essential for determining the cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can cause incontinence. Medications are prescribed after determining the cause, if any, and treating underlying conditions. Exercises to strengthen the pelvic muscles are part of treatment.

Question 199

A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is normal. To treat this, the primary care NP should consider prescribing: a. flavoxate (Urispas). b. bethanechol (Urecholine). c. phenazopyridine (Pyridium). d. oxybutynin chloride (Ditropan XL).

Answer 199

ANS: D- This patient is describing urge incontinence, or overactive bladder, which occurs when the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full. Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria.

Question 200

A patient reports having urinary frequency and discomfort associated with urination. After a careful physical examination and history to determine the cause, the NP should prescribe a medication from which drug class? a. Cholinergics b. Antispasmodics c. Anticholinergics d. Urinary tract analgesics

Answer 200

ANS B:- Antispasmodics are smooth muscle relaxants. Use of these drugs can produce increased bladder capacity and exhibit local anesthetic and analgesic actions. Cholinergic agents increase detrusor muscle tone to improve initiation of voiding and bladder emptying. Anticholinergics decrease detrusor tone to treat urge incontinence. Urinary tract analgesics areused to treat pain via a local analgesic effect on urinary tract mucosa and are used in conjunction with antibiotics to treat UTI.

Question 201

A parent brings an 8-year-old child to the clinic because the child continues to wet the bed despite using cognitive-behavioral measures and a bed alarm system. The NP should prescribe: a. solifenacin (VESIcare). b. tolterodine (Detrol LA). c. desmopressin (DDAVP). d. phenazopyridine (Pyridium).

Answer 201

ANS: C- Desmopressin is used as an antidiuretic and decreases urine output for approximately 6 hours and is often used to treat nocturia in children. Solifenacin and tolterodine are anticholinergics. Phenazopyridine is a urinary tract analgesic

Question 202

A patient has a UTI and will begin treatment with an antibiotic. The patient reports moderate to severe suprapubic pain. The primary care NP should prescribe: a. ibuprofen as needed. b. bethanechol (Urecholine). c. phenazopyridine (Pyridium). d. increased oral fluid intake to dilute urine

Answer 202

ANS: C- Phenazopyridine is a urinary tract analgesic used to treat pain via a local analgesic effect on urinary tract mucosa in conjunction with antibiotics to treat UTI. Ibuprofen may be used but does not have direct effects on the urinary tract mucosa. Bethanechol is used to treat voiding dysfunction and not pain. Increasing fluid intake should be used as adjunct therapy

Question 203

A primary care NP prescribes oxybutynin chloride for an 80-year-old patient to treat urinary incontinence. When teaching this patient about this medication, the NP should tell the patient: a. to increase intake of fluids and fiber. b. that alcohol may be consumed in moderation. c. that drowsiness may be a transient adverse effect. d. that hypertension may occur and to report headaches

Answer 203

ANS: A- Oxybutynin chloride is an anticholinergic drug and can cause dry mouth and constipation. Patients should be taught to increase fluids and fiber. Patients should be cautioned to avoid alcoholic beverages. Drowsiness occurs but does not subside, and elderly patients are at increased risk for this side effect. Anticholinergics cause hypotension

Question 204

A patient reports dribbling small amounts of urine but also has difficulty initiating a urine stream. The primary care NP should prescribe: a. solifenacin (VESIcare). b. bethanechol (Urecholine). c. phenazopyridine (Pyridium). d. oxybutynin chloride (Ditropan XL).

Answer 204

ANS: B- Bethanechol is a cholinergic agonist and is used to treat voiding dysfunction by increasing the activity of the detrusor muscle. Solifenacin and oxybutynin chloride are anticholinergics. Phenazopyridine is a urinary tract analgesic.

Question 205

A serious side effect associated with desmopressin is: a. dehydration. b. hypotension. c. hyponatremia. d. urinary retention.

Answer 205

ANS: C- Patients taking desmopressin should be cautioned to limit fluid intake because hyponatremia and water intoxication may occur.

Question 206

A man who has benign prostatic hypertrophy (BPH), in whom prostate carcinoma has been ruled out, asks the primary care nurse practitioner (NP) about beginning drug therapy to treat his symptoms. The NP notes that he consistently has blood pressure readings around 115/75 mm Hg. The NP should prescribe: a. tadalafil (Cialis). b. doxazosin (Cardura). c. tamsulosin (Flomax). d. finasteride (Proscar)

Answer 206

ANS; C Flomax

Question 207

A patient who has BPH is taking finasteride to shrink the size of the prostate is asking the NP “what is the expected time to achieve the maximum benefit of taking 5-alpha reductase inhibitors for the prostate reduction?” The primary NP should advise the client that: a. 6 months of therapy is required to achieve maximum benefit b. It is impossible to estimate the amount of time c. There is no evidence supporting the use of this drug d. 3 months of therapy is required to achieve maximum benefits

Answer 207

ANS: A 6 months

Question 208

An adult patient who has a viral upper respiratory infection asks the primary care nurse practitioner (NP) about taking acetaminophen for fever and muscle aches. To help ensure against possible drug toxicity, the NP should first: a. determine the patient's height and weight. b. ask the patient how high the temperature has been. c. tell the patient to take 325 mg initially and increase as needed. d. ask the patient about any other over-the-counter (OTC) cold medications being used.

Answer 208

ANS: D- Acetaminophen is present in many other OTC products, so patients should be cautioned about taking these with acetaminophen to avoid overdose. The adult dose is not based on height and weight and is not determined by the degree of temperature elevation

Question 209

A parent asks a primary care NP how much acetaminophen to give a 2-year-old child who has a temperature of 37.5° C. The NP should tell the parent that: a. acetaminophen is not safe in children younger than 6 years. b. acetaminophen may mask a fever and prevent treatment of other symptoms c. antipyretics are usually not necessary for temperatures less than 37.7° C. d. antipyretics should be given to prevent seizures, but nonsteroidal antiinflammatory drugs are a better choice

Answer 209

ANS: C- Acetaminophen is the drug of choice for treating fever but is generally not indicated for fever less than 37.7° C. Acetaminophen is safe for children and infants. Treating the fever may prolong the illness and mask symptoms, but these are not contraindications for giving antipyretics.

Question 210

An 80-year-old patient with congestive heart failure has a viral upper respiratory infection. The patient asks the primary care NP about treating the fever, which is 38.5° C. The NP should: a. recommend acetaminophen. b. recommend high-dose acetaminophen. c. tell the patient that antibiotics are needed with a fever that high. d. tell the patient a fever less than 40° C does not need to be treated

Answer 210

ANS: A- Patients with congestive heart failure may have tachycardia from fever that aggravates their symptoms, so fever should be treated. High doses should be given with caution in elderly patients because of possible decreased hepatic function. Antibiotics should not be given without evidence of bacterial infection

Question 211

A patient comes to the clinic and reports breaking out in an urticarial rash 1 hour after taking acetaminophen for osteoarthritis symptoms. The primary care NP should: a. order a complete blood count with differential. b. order liver and renal function tests. c. suspect Reye's syndrome and arrange for hospitalization. d. tell the patient not to take products containing acetaminophen again

Answer 211

ANS: D- Urticaria is indicative of a hypersensitivity reaction to acetaminophen. Patients who are hypersensitive should not take the drug again. Laboratory tests are not indicated. An urticarial rash does not indicate Reye's syndrome

Question 212

A patient in the clinic reports taking a handful of acetaminophen extra-strength tablets about 12 hours prior. The patient has nausea, vomiting, malaise, and drowsiness. The patient's aspartate aminotransferase and alanine aminotransferase are mildly elevated. The primary care NP should: a. expect the patient to sustain permanent liver damage. b. reassure the patient that these symptoms are reversible. c. tell the patient that acetylcysteine cannot be given this late. d. administer activated charcoal to remove acetaminophen from the body.

Answer 212

ANS: A - After acetaminophen overdose, if liver enzymes are elevated within 24 hours, irreversible liver damage is likely. Acetylcysteine may still be given to mitigate the effects. Activated charcoal is effective only when given immediately

Question 213

A patient reports having persistent mild to moderate pain in both knees usually associated with standing. The patient reports knee stiffness for 15 to 20 minutes each morning. The primary care nurse practitioner (NP) learns that the patient has used heating pads and acetaminophen, which no longer relieve the pain. The NP orders an erythrocyte sedimentation rate, which is normal. The NP should consider prescribing: a. aspirin. b. a cyclooxygenase-2 (COX-2) inhibitor. c. glucosamine and chondroitin. d. a topical nonsteroidal antiinflammatory drug (NSAID)

Answer 213

ANS: D- Topical NSAIDs, acupuncture, and tramadol are effective for pain relief in knee osteoarthritis. Treatment for osteoarthritis should begin with nonpharmacologic treatment, and acetaminophen should be first-line pharmacologic treatment. NSAIDs should be used when these two measures are no longer effective. COX-2 inhibitors are more expensive and should be used in the presence of gastrointestinal (GI) side effects or for moderate to severe pain. Glucosamine and chondroitin do not relieve most osteoarthritis pain.

Question 214

A 70-year-old patient describes moderate to severe pain associated with osteoarthritis in fingers, thumbs, hips, and knees. The patient is currently taking high-dose acetaminophen. The patient has a strong family history of cardiovascular disease and has been diagnosed with hypertension. To help alleviate this patient's pain, the primary care NP should consider prescribing: a. a COX-2 inhibitor and low-dose aspirin. b. ketorolac (Toradol) and 325 mg of aspirin. c. naproxen (Naprosyn) and low-dose aspirin. d. indomethacin (Indocin) and 325 mg of aspirin.

Answer 214

ANS: C- Aspirin at the dosage of 325 mg every other day or 81 mg daily is effective inreducing the incidence of myocardial infarction (MI) and stroke. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.

Question 215

A patient with mild to moderate osteoarthritis pain has been taking acetaminophen for pain. The primary care NP prescribes a nonselective NSAID. At a follow-up visit, the patient reports mild GI side effects. The NP should: a. order misoprostol to take with the NSAID. b. discontinue the NSAID and order tramadol. c. change the medication to a COX-2 inhibitor. d. change the medication to naproxen (Naprosyn)

Answer 215

ANS: A- HAIf the patient experiences GI distress, coadministration of histamine-2 blockers, proton pump inhibitors, or misoprostol may be considered. Tramadol is used for severe pain. A COX-2 inhibitor is generally used for long-term therapy. Naproxen is another nonselective NSAID and would likely have similar GI side effects. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.

Question 216

A patient is taking 81 mg of aspirin daily to decrease MI risk and uses acetaminophen for mild osteoarthritis symptoms. For flare-ups of osteoarthritis pain, the primary care NP should prescribe: a. ibuprofen (Motrin). b. celecoxib (Celebrex). c. naproxen (Naprosyn). d. increasing the dose of aspirin

Answer 216

ANS: C- Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.

Question 217

An 80-year-old patient has been taking naproxen (Naprosyn) for osteoarthritis for 6 months. The patient reports adequate pain relief but complains of feeling tired. The primary care NP will order: a. liver function tests. b. a serum potassium level. c. a complete blood count (CBC). d. a creatinine clearance and urinalysis

Answer 217

ANS: C- Elderly patients are more susceptible to the adverse effects of NSAIDs, especially slow GI bleeds leading to anemia (manifested as fatigue, lethargy). Patients complaining of fatigue should have a CBC to evaluate for anemia

Question 218

A patient who has rheumatoid arthritis begins taking naproxen (Naprosyn) 500 mg once daily for pain. After 1 week, the patient calls the primary care NP to report no change in inflammation. The NP should: a. change the medication to tramadol. b. change the medication to ketorolac (Toradol). c. increase the dose of naproxen to 1000 mg daily. d. counsel the patient that pain relief may not occur for another week

Answer 218

ANS: D- The analgesic effect of NSAIDs should be noticed within 1 to 4 hours of administration. However, the full antiinflammatory effect will not be apparent until after a few weeks. Tramadol and ketorolac are used for severe pain. It is not necessary to increase the dose of naproxen.

Question 219

The primary care NP sees an adolescent who reports moderate to severe dysmenorrhea. The NP recommends an NSAID and counsels the patient about its use. Which statement by the patient indicates a need for further teaching? a. "I should not take this if I think I might be pregnant." b. "I should take this medication on a schedule for 2 to 3 days." c. "I will begin taking this 1 to 3 days before my period begins." d. "I will take this medicine every 4 to 6 hours as needed for pain."

Answer 219

ANS: C- When treating primary dysmenorrhea, NSAIDs should be started 24 to 72 hours before the patient starts menstrual bleeding. The medication should be taken on a routine basis for 2 to 3 days. It should not be taken during pregnancy.

Question 220

The primary care NP is performing a medication reconciliation on a patient who takes digoxin for congestive heart failure and learns that the patient uses ibuprofen as needed for joint pain. The NP should counsel this patient to: a. use naproxen (Naprosyn) instead of ibuprofen. b. increase the dose of digoxin while taking the ibuprofen. c. use an increased dose of ibuprofen while taking the digoxin. d. take potassium supplements to minimize the effects of the ibuprofen.

Answer 220

ANS: A- Ibuprofen and indomethacin increase the effects of digoxin, so the NP should recommend another NSAID, such as naproxen, that does not have this effect. Increasing the dose of digoxin or the ibuprofen would increase the likelihood of digoxin toxicity further. Potassium should be monitored while taking NSAIDs long-term, but supplements should not be given unless there is a potassium deficiency.

Question 221

A primary care NP prescribes a nonselective NSAID for a patient who has osteoarthritis. The patient expresses concerns about possible side effects of this medication. When counseling the patient about the medication, the NP should tell this patient: a. to avoid taking antacids while taking the NSAID. b. to take each dose of the NSAID with a full glass of water. c. that a few glasses of wine each day are allowed while taking the NSAID. d. to decrease the dose of the NSAID if GI symptoms occur

Answer 221

ANS: B- To avoid GI distress associated with NSAIDs, a full glass of water is recommended. Patients may take NSAIDs with antacids. Patients should avoid alcohol while taking NSAIDs. Patients should report GI symptoms to their provider.

Question 222

A patient who has osteoarthritis is scheduled to have knee surgery. The patient takes aspirin for MI prophylaxis and naproxen (Naprosyn) for pain and inflammation. Which statement by the patient to the primary care NP indicates a need for further teaching? a. "I should stop taking aspirin at least 5 days before surgery." b. "I will check with the surgeon to see if I need to stop taking the naproxen." c. "I will need to stop taking both medications 1 week before I have surgery." d. "Both of these medications interfere with platelet production and may cause blood clots.

Answer 222

ANS: C- Although both medications interfere with platelet formation, some NSAIDs may continue to be taken before surgery, depending on the procedure and the surgeon preference. The patient should stop taking aspirin 5 days before surgery.

Question 223

A patient who has hypertension is taking a thiazide diuretic. The patient has a serum uric acid level of 8 mg/dL. The primary care nurse practitioner (NP) caring for this patient should: a. prescribe colchicine. b. discontinue the thiazide diuretic. c. order a 24-hour urine collection. d. refer the patient to a rheumatologist.

Answer 223

ANS: C- Patients who have hypertension or who take thiazide diuretics are at increased risk for gout. An elevated uric acid level alone is not diagnostic, and a 24-hour urine collection should be ordered. Colchicine should not be prescribed until the diagnosis is confirmed. It is not necessary to discontinue the thiazide diuretic. A referral to a specialist is not indicated.

Question 224

A patient comes to the clinic reporting sudden pain and swelling of one knee joint. The primary care NP suspects gout. When preparing to order diagnostic tests, the most important initial test the primary care NP should order is: a. renal function tests. b. serum uric acid levels. c. 24-hour urine collection. d. synovial fluid aspirate for Gram stain and culture

Answer 224

ANS: D- Although the other tests are part of the diagnostic process, the most important differential diagnosis to be made in a patient with gout is the exclusion of a septic joint.

Question 225

A primary care NP prescribes probenecid to treat a patient who has gout. The patient comes to the clinic 2 weeks later with severe flank pain. The NP should: a. ask the patient about fluid intake. b. order a urinalysis and urine culture. c. change the medication to allopurinol. d. recommend nonsteroidal antiinflammatory drugs (NSAIDs) to treat flank pain

Answer 225

ANS: A-Uricosuric agents are tubular blocking agents and decrease serum uric acid levels by increasing urinaryexcretion of uric acid. During this process, high concentrations of uric acid develop in the proximal renaltubules and may predispose the patient to the development of urinary stones. Patients should beencouraged to drink plenty of fluids. The patient who presents with flank pain should be questioned aboutfluid intake. If fluid intake is sufficient and renal stones are ruled out, a urinary tract infection may beconsidered. Allopurinol is not indicated. NSAIDs are not indicated.

Question 226

Gout is diagnosed in a patient, and tests show the cause to be an underexcretion of uric acid. The primary care NP should prescribe: a. febuxostat (Uloric). b. colchicine (Colcrys). c. allopurinol (Zyloprim). d. probenecid (Benemid).

Answer 226

ANS: D- A uricosuric agent is indicated to increase the excretion of uric acid. Probenecid is a uricosuricmedication. Febuxostat and allopurinol are xanthine oxidase inhibitors. Colchicine is not a uricosuric agent

Question 227

A patient who is obese and has hypertension is taking a thiazide diuretic and develops gouty arthritis, which is treated with probenecid. At a follow-up visit, the patient's serum uric acid level is 7 mg/dL, and the patient denies any current symptoms. The primary care NP should discontinue the probenecid and: a. prescribe colchicine. b. prescribe febuxostat. c. tell the patient to use an NSAID if symptoms recur. d. counsel the patient to report recurrence of symptoms

Answer 227

ANS: A- Colchicine is a first-line drug for preventing acute attacks. Because this patient has three risk factors, a preventive medication should be used. Febuxostat is a second-line preventive medication. The patient should not be treated on an as-needed basis.

Question 228

A patient with a history of gouty arthritis comes to the clinic with acute pain and swellingof the great toe. The patient is not currently taking any medications. The primary care NP should prescribe: a. naproxen. b. colchicine. c. probenecid. d. allopurinol.

Answer 228

ANS: A-Naproxen is the first medication given for an attack of acute gouty arthritis to stop the inflammatory response. Pharmacologic treatment for hyperuricemia must be started after the acute attack has subsided.

Question 229

A patient who is taking colchicine for gout is in the clinic 1 week after beginning the medication. The patient reports decreased appetite and nausea. The primary care NP should: a. suspect worsening of gouty arthritis. b. order vitamin B12levels to assess for vitamin deficiency. c. discontinue the colchicine for 48 hours until symptoms subside. d. reassure the patient that these are common, temporary side effects

Answer 229

ANS: C- Colchicine toxicity causes nausea, vomiting, and anorexia. When toxicity is suspected, the medication should be temporarily discontinued and restarted after symptoms subside.

Question 230

A patient who has a previous history of renal stones will begin taking probenecid for gout. The primary care NP should: a. add colchicine to the patient's drug regimen. b. counsel the patient to use high-dose aspirin for pain. c. teach the patient to drink plenty of acidic fluids such as juice. d. tell the patient to stop taking the medication when symptoms subside.

Answer 230

ANS: A- Patients at risk for urinary stones may take colchicine along with probenecid to reduce the risk caused by probenecid. Salicylates and acidic urine increase the risk. The medication must be tapered 6 months after the last acute attack

Question 231

A 55-year-old woman who experienced menopause at age 50 years undergoes central dual-energy x-ray absorptiometry and has a T-score greater than 2.5. The patient weighs 130 lb and has a body mass index of 22. She sits at a computer all day at work. The primary care nurse practitioner (NP) caring for this patient should: a. prescribe a bisphosphonate. b. prescribe hormone replacement therapy. c. counsel the patient about diet and exercise. d. prescribe a selective estrogen receptor modulator

Answer 231

ANS: C. The NP should counsel the patient about diet and exercise. Women who are at least 5 years postmenopausal or who have several risk factors should have bone density testing. Osteoporosis is defined as a T-score of less than 2.5, and treatment is indicated for women with T-scores that are 2 or more standard deviations below the normal premenopausal level. It is not necessary to initiate treatment at this time

Question 232

A 50-year-old white woman who is experiencing menopause asks the primary care NP what she can do to prevent osteoporosis. She has a negative family history and no risk factors. The NP should counsel her to: A. consider bisphosphonate therapy in 5 years. B. undergo bone density testing every 2 years. C. avoid high-impact sports that can lead to fractures. D. take supplemental calcium and vitamin D every day

Answer 232

ANS: D. Postmenopausal women should consume 1200 mg of calcium and at least 1000 U of vitamin D each day. Bisphosphonate therapy should be considered for persons with known risk factors. Bone density testing is indicated for women with risk factors and then routinely after age 65. Patients should be encouraged to engage in high-impact sports if possible to improve bone density.

Question 233

A 60-year-old woman has a central dual-energy x-ray absorptiometry with a T-score of 1.9. A health history reveals no risk factors for osteoporosis. The primary care NP should: a. prescribe alendronate sodium (Fosamax). b. counsel her to increase her physical activity. c. prescribe calcitonin (Miacalcin nasal spray). d. prescribe supplemental calcium and vitamin D

Answer 233

ANS: A. This woman's T-score is less than 2.5 and indicates osteoporosis. She should begin treatment with a bisphosphonate. Increasing physical activity and taking supplemental calcium and vitamin D are indicated as well but only as part of a medication regimen. Calcitonin is not a first-line medication

Question 234

``` A 70-year-old patient who has a high fracture risk has been taking alendronate (Fosamax) and calcium for 6 months. The primary care NP orders a urine NTx level, which is 42. The NP should discontinue the alendronate and prescribe A. raloxifene (Evista). b. teriparatide (Forteo). c. calcitonin (Miacalcin nasal spray). d. ibandronate sodium (Boniva) ```

Answer 234

ANS: B. Teriparatide is used in patients with a high fracture risk or in whom bisphosphonate therapy has failed. Raloxifene and ibandronate are second-line treatments for patients with usual fracture risks. Calcitonin is a last-line treatment.

Question 235

A 60-year-old female patient has begun taking a daily bisphosphonate to prevent osteoporosis and complains of gastrointestinal (GI) upset and dyspepsia. The primary care NP's initial response should be to: a. prescribe a proton pump inhibitor (PPI). b. order intravenous (IV) bisphosphonates. c. suggest that she take the drug with food. d. review the instructions for taking the drug with the patient

Answer 235

ANS: D. Oral bisphosphonates must be taken on an empty stomach, and the patient must remain upright and not eat or drink anything for 30 to 60 minutes. GI upset and dyspepsia are frequent and can be minimized with correct administration. A PPI is not indicated. IV bisphosphonates may be indicated if the patient is unable to tolerate the oral drug after correct administration is confirmed. Bisphosphonates should not be taken with food

Question 236

A 50-year-old woman with osteopenia will begin taking raloxifene (Evista). When counseling this patient about this drug regimen, the primary care NP should tell her to: A. go for walks daily. b. take the medication 1 hour before meals. c. sit upright for 30 minutes after taking the drug. d. avoid using diuretics while taking this medication

Answer 236

ANS: A. Raloxifene is a selective estrogen receptor modulator, and it carries a risk of venous thromboembolism. Patients should be encouraged to avoid immobilization. The other instructions are part of medication teaching about bisphosphonates

Question 237

A 60-year-old woman is in the clinic for an annual well-woman examination. She has been taking alendronate (Fosamax) 10 mg daily for 4 years. Her last bone density test yielded a T-score of 2.0. Her urine NTx level today is 22. She walks daily. Her fracture risk is low. The primary care NP should recommend that she: a. take a 1- to 2-year drug holiday. b. change to 70 mg of alendronate weekly. c. decrease the alendronate dose to 5 mg daily. d. change to ibandronate (Boniva) 3 mg IV every 3 month

Answer 237

ANS: A. The American Association of Clinical Endocrinologists recommends patients have a "drug holiday" after 4 to 5 years of bisphosphonate treatment if osteoporosis is mild and the fracture risk is low. The other options are all viable treatment regimens but are not appropriate in this case

Question 238

A patient who has several risk factors for osteoporosis has a bone density test that indicates osteopenia. The primary care NP plans to prescribe a bisphosphonate. Before initiating treatment, the NP should: a. order an upper GI x-ray. b. initiate PPI therapy. c. order serum calcium and vitamin D levels. d. prescribe a calcium and vitamin D supplement

Answer 238

ANS: C. Patients must have adequate nutrition, calcium, and vitamin D. Hypocalcemia and vitamin D deficiency must be corrected before therapy is initiated. An upper GI x-ray is indicated only if the patient is symptomatic. Patients at risk for fracture should not take PPIs. Calcium and vitamin D supplements should be given with bisphosphonate therapy; however, the first action is to evaluate current serum levels

Question 239

The primary care nurse practitioner (NP) is seeing a patient who reports chronic lower back pain. The patient reports having difficulty sleeping despite taking ibuprofen at bedtime each night. The NP should prescribe: a. diazepam (Valium). b. metaxalone (Skelaxin). c. methocarbamol (Robaxin). d. cyclobenzaprine (Flexeril).

Answer 239

ANS: D- Cyclobenzaprine (Flexeril) is indicated for chronic low back pain and provides an added benefit of aiding sleep, which is a common problem among patients with back pain. The other medications are used for acute lower back pain.

Question 240

A patient reports having an acute onset of low back pain associated with lifting a heavy object the day before. Besides advising the patient to rest and apply ice, the primary care NP should prescribe: a. an opioid analgesic. b. metaxalone (Skelaxin) c. cyclobenzaprine (Flexeril). d. a nonsteroidal antiinflammatory drug (NSAID).

Answer 240

ANS: D- NSAIDs and acetaminophen are first-line analgesic treatments for low back pain. Opioidsare used for severe low back pain. The other two medications are not first-line treatments.

Question 241

A patient who was in a motor vehicle accident has been treated for lower back muscle spasms with metaxalone (Skelaxin) for 1 week and reports decreased but persistent pain. A computed tomography scan is normal. The primary care NP should: a. suggest ice and rest. b. order physical therapy. c. prescribe diazepam (Valium). d. add an opioid analgesic medication.

Answer 241

ANS: B- Physical therapy may be used as an injury begins to heal. This patient is experiencing improvement of symptoms, so physical therapy may now be helpful. Ice and rest are useful in the first 24 to 48 hours after injury. Diazepam is used on a short-term basis only.Opioid analgesics are used for severe pain.

Question 242

A patient with lower back pain and right-sided sciatica has taken an NSAID and a TCA for 1 week. The patient reports some decrease in pain but is experiencing increased tingling and numbness of the right leg. The primary care NP should: a. order a magnetic resonance imaging (MRI) study. b. order physical therapy. c. refer the patient to a neurologist. d. continue the TCA for 1 more week.

Answer 242

ANS: A- acute episodes of low back pain should be treated with an analgesic for 1 to 2 weeks. A muscle relaxant is used to treat spasms. Patients with sciatica should be treated for 6 weeks. If a neurologic deficit progresses, MRI should be ordered. Physical therapy is not indicated until serious injury is ruled out. A neurology consultation is necessary in urgent conditions and conditions with bilateral neurologic findings. The TCA may be continued, but the progression of symptoms necessitates radiologic evaluation.

Question 243

A 70-year-old patient has low back pain and will begin taking metaxalone (Skelaxin). The primary care NP should counsel this patient to: a. drink extra fluids. b. avoid taking NSAIDs. c. get up from a chair slowly. d. take care to avoid slips and falls.

Answer 243

ANS: D- Use of any muscle relaxant puts elderly patients at risk for falls, so patients should be advised to take precautions. It is not necessary to increase fluids or avoid NSAIDs. This drug does not have hypotensive effects, so it is not necessary to provide the caution to rise out of chairs slowly

Question 244

A patient comes to the clinic complaining of low back pain unrelieved by NSAIDs. The patient has a history of angle-closure glaucoma and renal disease. The primary care NP shouldprescribe: a. tizanidine (Zanaflex). b. metaxalone (Skelaxin). c. acetaminophen (Tylenol). d. cyclobenzaprine (Flexeril).

Answer 244

ANS: B- Metaxalone may be taken by patients with angle-closure glaucoma and is metabolized by the liver, so it is safe for this patient. Tizanidine should not be given to patients with renal disease because clearance may be reduced by more than 50%. After using NSAIDs with no relief, recommendations are to change to a muscle relaxant. Cyclobenzaprine is not recommended inpatients with glaucoma.

Question 245

A patient has acute low back pain caused by lifting a heavy object. The patient reports having one or two drinks with meals each day. The primary care NP should prescribe: a. an NSAID. b. diazepam (Valium). c. metaxalone (Skelaxin). d. acetaminophen (Tylenol)

Answer 245

ANS: A- Skeletal muscle relaxants should not be taken with alcohol because effects are additive. Acetaminophen has toxic effects on the liver, and patients who consume alcohol regularly should avoid acetaminophen and diazepam.

Question 246

A patient is identified as having stage 2 Alzheimer's disease and elects to take donepezil (Aricept). The patient asks the primary care nurse practitioner (NP) how long the medication will be needed. The NP should tell the patient that donepezil must be taken: a. until symptoms improve. b. indefinitely because it is not curative. c. for 24 weeks, which is when cognitive function improves in most patients. d. until symptoms worsen, when a switch to memantine (Namenda) will be needed

Answer 246

ANS: B. Cholinesterase (ChE) inhibitor drugs such as donepezil diminish symptoms; when the drug is stopped, the symptoms return. Cognitive function will show improvement at about 24 weeks, but the drug must be continued indefinitely

Question 247

A patient who has Alzheimer's disease has been taking donepezil for 1 year. The patient's spouse reports a worsening of symptoms. The primary care NP should consider: a. switching to ginkgo biloba. b. adding an antidepressant medication. c. changing to galantamine (Razadyne). d. adding memantine hydrochloride (Namenda)

Answer 247

ANS: D. Memantine hydrochloride can be added to therapy when symptoms worsen. Ginkgo biloba may be useful but is not recommended as adjunct therapy. Antidepressants given to patients with Alzheimer's disease who have depression appear not to be effective and often cause adverse effects or produce unwanted drug interactions. Galantamine is part offirst-line therapy but should not be given with donepezil because both are ChE inhibitors.

Question 248

Early-stage Alzheimer's disease is diagnosed in a patient, and the primary care NP recommends therapy with a ChE inhibitor. The patient asks why drug treatment is necessary because most functioning is intact. The NP should explain that medication may: a. delay progression of symptoms. b. produce temporary disease remission. c. prevent depressive effects of the disease. d. reduce the need for adjunct medications later on

Answer 248

ANS: A. Pharmacologic treatment should begin as soon as Alzheimer's disease is suspected because early treatment can slow disease progression. Medication does not produce disease remission or prevent depression. The disease eventually progresses despite medication, and adjunct therapies are often required

Question 249

A patient has a diagnosis of depression and Alzheimer's disease with mild, intermittent symptoms. The primary care NP should prescribe a(n): a. antidepressant. b. ChE inhibitor. c. antidepressant and ginkgo biloba. d. antidepressant and a ChE inhibitor.

Answer 249

ANS: B. Antidepressants given to patients with Alzheimer's disease do not appear to be effective and cause adverse effects and unwanted drug interactions.

Question 250

A patient is newly diagnosed with Alzheimer's disease stage 6 on the Global Deterioration Scale. The primary care NP should prescribe: a. donepezil (Aricept). b. rivastigmine (Exelon). c. memantine (Namenda). d. galantamine (Razadyne)

Answer 250

ANS: C. Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine.

Question 251

A patient has been taking donepezil (Aricept) for several months after being diagnosed with Alzheimer's disease. The patient's spouse brings the patient to the clinic and reports that the patient seems to be having visual hallucinations. The primary care NP should: a. increase the dose. b. decrease the dose. c. switch to memantine (Namenda). d. switch to galantamine (Razadyne).

Answer 251

ANS: B. Hallucinations may be a sign of drug toxicity. The NP should decrease the dose

Question 252

A patient who has Alzheimer's disease is taking 10 mg of donepezil daily and reports difficulty sleeping. The primary care NP should recommend: a. decreasing the dose to 5 mg. b. increasing the dose to 15 mg. c. taking the drug in the morning. d. taking the drug in the evening

Answer 252

ANS: C. Donepezil is typically taken in the evening just before going to bed; however, in patients experiencing sleep disturbance, daytime administration is preferred. The dose should not be increased or decreased

Question 253

A patient who is diagnosed with Alzheimer's disease experiences visual hallucinations. The primary care NP should initially prescribe: a. donepezil (Aricept). b. rivastigmine (Exelon). c. memantine (Namenda). d. galantamine (Razadyne).

Answer 253

ANS: B. Patients with dementia with Lewy bodies may show benefit with rivastigmine. Visual hallucinations are a hallmark feature of Lewy body dementia

Question 254

A patient has been taking an opioid analgesic for chronic pain and tells the primary care nurse practitioner (NP) that the medication doesn't work as well anymore. The NP should suspect drug: a. addiction. b. tolerance. c. modulation. d. dependence.

Answer 254

ANS: B- Tolerance is characterized by decreasing drug effect over time, meaning that more drug is needed to achieve the same effect. Addiction is an overwhelming obsession with obtaining and using a drug for non-medically approved purposes. Dependence is the development of abstinence syndrome or withdrawal symptoms.

Question 255

A patient has pain caused by a chronic condition. The patient is reluctant to take opioids because of a fear of addiction. The primary care NP should tell the patient that opioids: a. carry a high risk of psychological dependence when used long-term. b. will help to improve the patient's functional outcomes and quality of life. c. will eventually become ineffective for treating pain when used over a long period. d. may require switching from one type of opioid to another to prevent tolerance over time.

Answer 255

ANS B:- Chronic pain requires routine administration of drugs, and addiction is generally not a concern, especially for patients with chronic pain or terminal illness. Opioid analgesics will help the patient improve function and quality of life. Tolerance may develop, and higher dosesmay be required to maintain effectiveness. Randomized, controlled trials are lacking to support switching opioids to manage tolerance and side effects

Question 256

A patient is diagnosed with a condition that causes chronic pain. The primary care NP prescribes an opioid analgesic and should instruct the patient to: a. wait until the pain is at a moderate level before taking the medication. b. take the medication at regular intervals and not just when pain is present. c. start the medication at higher doses initially and taper down gradually. d. take the minimum amount needed even when pain is severe to avoid dependency.

Answer 256

ANS: B- Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain.

Question 257

A patient who is a recovering alcoholic is preparing for surgery and expresses fears about using opioid analgesics postoperatively for pain. The primary care NP should tell the patient: a. that opioids should not be used. b. to take a very low dose of the opioid. c. that nonsteroidal antiinflammatory drugs will be the only safe option. d. that opioids are safe when taken as directed

Answer 257

ANS:D- Fear of drug dependency or addiction does not justify withholding of opiates or inadequate management of pain. As long as the medication is taken as directed, it is safe

Question 258

A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days after surgery. When the patient is discharged from the hospital, the primary care NP should expect the patient to receive a prescription for _____ mg orally every _____ hours. a. hydrocodone 30; 6 b. hydrocodone 75; 6 c. meperidine 300;12 d. meperidine 75; 6

Answer 258

ANS: A- When patients are switched from one opiate to another, an equianalgesic table should be used to convert the dosage of the current drug to the equivalent dosage of the new drug. An oral dose of 30 mg of hydrocodone is equivalent to an IM dose of 75 mg of meperidine

Question 259

A patient has been taking an opioid analgesic for 2 weeks after a minor outpatient procedure. At a follow-up clinic visit, the patient tells the primary care NP that he took extra doses for the past 2 days because of increased pain and wants an early refill of the medication. The NP should suspect: a. dependence. b. drug addiction. c. possible misuse. d. increasing pain

Answer 259

ANS: C- Unsanctioned dose increases are a sign of possible drug misuse. Dependence refers to an abstinence or withdrawal syndrome. Drug addiction is an obsession with obtaining and using the drug for nonmedical purposes. The patient should not have increased pain at 2 weeks

Question 260

A patient who is taking an antibiotic to treat bronchitis reports moderate rib pain associated with frequent coughing. The primary care NP should consider prescribing: a. morphine. b. hydrocodone c. hydromorphone. d. oxycodone CR.

Answer 260

ANS: B- Hydrocodone is used for cough suppression as well as pain. Morphine can cause profound respiratory depression.

Question 261

A patient who has migraine headaches takes sumatriptan as abortive therapy. The patient tells the primary care nurse practitioner (NP) that the sumatriptan is effective for stopping symptoms but that the episodes are occurring three to four times per month. The NP should consider the addition of: a. aspirin. b. topiramate. c. ergotamine. d. opioid analgesics

Answer 261

ANS: B- Topiramate is an anticonvulsant agent that is approved as a preventive medication for migraines. The other medications are indicated for abortive therapy.

Question 262

A patient comes to the clinic and reports recurrent headaches. The patient has a headache diary, which reveals irritability and food cravings followed the next day by visual disturbances and unilateral right-sided headache, nausea, and photophobia lasting 2 to 3 days. The NP should recognize these symptoms as _____ migraine. a. classic b. hemiplegic c. basilar-type d. ophthalmoplegic

Answer 262

ANS: A - These are symptoms of classic migraine. Hemiplegic migraine is characterized by motor and sensory symptoms. Basilar-type migraine includes vertigo, diplopia, dysarthria, tinnitus, and decreased hearing. Ophthalmoplegic migraine affects the third, fourth, or fifth cranial nerve, causing permanent damage

Question 263

A patient comes to the clinic concerned about possible migraine headaches. The primary care NP conducts a history and physical examination, and the patient describes vise-like pressure in the back of the head that occurs almost daily during the work week. The NP should recommend: a. acetaminophen. b. topiramate. c. sumatriptan. d. ergotamine

Answer 263

ANS:A - This patient is describing symptoms typical of tension headaches. The NP should recommend acetaminophen, not migraine medications

Question 264

A patient who has migraine headaches tells the primary care NP that drinking coffee and taking nonsteroidal antiinflammatory drugs (NSAIDs) seems to help with discomfort. The NP should tell the patient that: a. this combination can lead to longer lasting headache pain. b. these substances are not indicated for migraine headaches. c. doing this can increase the risk of more chronic migraines. d. an opioid analgesic would be a better choice for migraine pain

Answer 264

ANS: A - Overuse of pain or migraine medications can cause a transformed migraine, which is a long-lasting headache. Following a migraine episode, the patient has rebound headache daily or nearly daily. NSAIDs, caffeine, opiates, and triptans can cause these rebound headaches. NSAIDs and caffeine are often used to treat migraines. Narcotics and barbiturates increase the risk for development of chronic migraine headaches and should not be first-line drugs.

Question 265

A patient takes rizatriptan (Maxalt) to abort migraine headaches but tells the primary care NP that the headaches have become more frequent since a promotion at work. The NP's initial response should be to: a. prescribe topiramate (Topamax). b. stress the importance of establishing new routines. c. help the patient identify stressors associated with the new role. d. add a combination NSAID, aspirin, and caffeine product to the regimen.

Answer 265

ANS B:- Prevention or reduction of episodes of migraine requires healthy regular daily habits. Regularity of habits, rather than just searching for triggers, is essential for enhancing the effectiveness of nonpharmacologic approaches. If the increase in migraine episodes remains chronic after nonpharmacologic measures are taken, topiramate may be used

Question 266

A primary care NP prescribes sumatriptan for abortive treatment of migraine headaches. The patient returns to the clinic 1 month later to report increased frequency of the headaches. The NP should: a. add an opioid analgesic. b. consider changing to dihydroergotamine (D.H.E. 45). c. suggest that the patient take sumatriptan with a NSAID. d. ask the patient how often the sumatriptan is used each week

Answer 266

ANS: D- It is important that any abortive agent be administered no more often than 2 days per week to avoid the possibility of rebound headache. Patients should be encouraged to try products for at least two or three episodes of migraine before they decide they are ineffective, so changing the drug regimen may not be indicated at this time.

Question 267

A patient who has migraine headaches without an aura reports difficulty treating the migraines in time because they come on so suddenly. The patient has been using over-the-counter NSAIDs. The primary care NP should prescribe: a. frovatriptan (Frova). b. sumatriptan (Imitrex). c. cyproheptadine (Periactin). d. dihydroergotamine (D.H.E. 45).

Answer 267

ANS: B- If the patient is able to take medication at the earliest onset of migraine, ergots are usually effective. Triptans are more effective when patients have difficulty "catching the headache in time." Sumatriptan begins to work in 15 minutes and so would be indicated for this patient. Frovatriptan has a longer half-life. Cyproheptadine is not a first-line

Question 268

A patient who has mild to moderate migraine headaches has severe nausea and vomiting with each episode. For the best treatment of this patient, the primary care NP should prescribe: a. triptan nasal spray. b. metoclopramide and aspirin. c. an NSAID and prochlorperazine. d. sumatriptan and metoclopramide.

Answer 268

ANS: A- Administer triptan migraine medication in nasal spray or injection for patients with severenausea and vomiting who have trouble taking oral medications. An antiemetic, such asprochlorperazine or metoclopramide, may be used, although the latter has serious side effects

Question 269

A patient who has migraine headaches usually has two to three severe migraines each month. The patient has been using a triptan nasal spray but reports little relief and is concerned about missing so many days of work. The primary care NP should consider: a. an oral triptan plus an opioid analgesic. b. an injectable triptan plus an oral corticosteroid. c. an intramuscular steroid plus an opioid analgesic. d. dihydroergotamine hydrochloride plus an opioid analgesic.

Answer 269

ANS: B- For severe migraines, an injectable triptan should be considered along with corticosteroids or opioids as rescue medications. Oral triptans are not as effective for severe migraines. Ergotamines may be tried as second-line therapy.

Question 270

A patient who experiences migraines characterized by unilateral motor and sensory symptoms tells the primary care NP that despite abortive therapy with a triptan, the frequency of episodes has increased to three or four times each month. The NP should: a. add a selective serotonin reuptake inhibitor (SSRI) antidepressant. b. change to dihydroergotamine hydrochloride c. prescribe a â-blocker such as propranolol. d. prescribe an anticonvulsant such as topiramate

Answer 270

ANS: D- Topiramate is useful for migraine prophylaxis. SSRI antidepressants are considered second-line treatment for prophylaxis and are less effective than tricyclic antidepressants. Ergotamines are not used as prophylaxis. -Blockers are commonly used but may aggravate neurologic symptoms associated with hemiplegic or basilar migraine, which is what this patient has.

Question 271

A patient who is diagnosed with migraine headaches has a history of cardiovascular disease and hypertension. The NP should prescribe: a. triptan nasal spray. b. rizatriptan (Maxalt). c. cyproheptadine (Periactin). d. dihydroergotamine (D.H.E. 45)

Answer 271

ANS: C- Triptans and ergotamines are contraindicated in patients with cardiovascular disease or hypertension. Cyproheptadine is safe for these patients.

Question 272

A patient reports frequent headaches to the primary NP. The patient describes the headaches as unilateral and moderate in intensity, accompanied by nausea, vomiting, and photophobia. There is no aura, and the headaches generally last 24 to 48 hours. The NP should: a. prescribe dihydroergotamine (D.H.E. 45). b. prescribe topiramate (Topamax) as migraine prophylaxis. c. recognize these as classic migraines and order sumatriptan (Imitrex). d. suggest treatment with acetaminophen because these are probably tension headaches.

Answer 272

ANS: C- This patient has symptoms of classic migraine with repeated episodes. Sumatriptan is a first-line medication. Ergotamines are second-line medications. Topiramate is used as migraine prophylaxis in patients who have increasingly frequent migraine episodes. These symptoms are not characteristic of tension headaches.

Question 273

A patient who has partial seizures has been taking phenytoin (Dilantin). The patient has recently developed thrombocytopenia. The primary care nurse practitioner (NP) should contact the patient's neurologist to discuss changing the patient's medication to: a. topiramate (Topamax). b. levetiracetam (Keppra). c. zonisamide (Zonegran). d. carbamazepine (Tegretol

Answer 273

ANS: D. Evidence-based recommendations exist showing carbamazepine to be effective as monotherapy for partial seizures. Because this patient has developed a serious side effect of phenytoin, changing to carbamazepine may be a good option. The other three drugs may be added to phenytoin or another first-line drug when drug-resistant seizures occur, but are not recommended as monotherapy

Question 274

A patient is newly diagnosed with generalized epilepsy. The primary care NP will refer this patient to a neurologist and should expect this patient to begin taking: a. phenytoin (Dilantin). b. topiramate (Topamax). c. lamotrigine (Lamictal). d. levetiracetam (Keppra)

Answer 274

ANS: A . There is little good-quality evidence to support the use of newer monotherapy over older drugs. Phenytoin is the prototype of many seizure medications and is usually tried first. Other drugs may be used if seizures are resistant to phenytoin or if side effects occur.

Question 275

A patient who takes carbamazepine (Tegretol) has been seizure-free for 2 years and asks the primary care NP about stopping the medication. The NP should: a. order an electroencephalogram (EEG). b. prescribe a tapering regimen of the drug. c. inform the patient that antiepileptic drug (AED) therapy is lifelong. d. tell the patient to stop the drug and use only as needed

Answer 275

ANS A: Discontinuation of AEDs may be considered in patients who have been seizure-free for longerthan 2 years. An EEG should be obtained before the medication is withdrawn. The drug should be tapered to prevent status epilepticus, but only after a normal EEG is obtained. AED therapy is not lifelong in all patients. Patients should not stop AED medications abruptly, and these drugs are not used on an as-needed basis

Question 276

A 12-month-old child with severe developmental delays was recently treated in an emergency department for a febrile seizure and is seen by the primary care NP for a follow-up visit. The child's parent asks if it is necessary to continue giving the child phenobarbital. The NP should tell the parent that: a. the phenobarbital may be used on an as-needed basis. b. the phenobarbital may be stopped when an EEG is normal. c. once the febrile illness is past, the phenobarbital may be stopped. d. their child is at increased risk for seizures and should continue the phenobarbital

Answer 276

ANS D: Although the American Academy of Pediatrics has concluded that the risks of long-term treatment with phenobarbital outweigh the potential benefits in most cases, continued treatment with this drug is used in children at greatest risk for future neurologic problems, including children with febrile seizures before 18 months of age and children with neurologic dysfunction or severe developmental delays

Question 277

A patient who is taking phenytoin (Dilantin) for a newly diagnosed seizure disorder calls the primary care NP to report a rash. The NP should: a. order a phenytoin level. b. reassure the patient that this is a self-limiting adverse effect. c. recommend that the patient take diphenhydramine to treat this side effect. d. tell the patient to stop taking the phenytoin and contact the neurologist immediately

Answer 277

ANS: D. Phenytoin should be discontinued if skin rash appears because some rashes can be life-threatening. Rashes are not related to serum drug levels, so a phenytoin level is not indicated. Although some rashes are self-limiting, the patient should stop taking the drug until serious rashes are ruled out. Suggesting diphenhydramine is not correct until the severity of the rash is known.

Question 278

A patient who takes valproic acid for a seizure disorder is preparing to have surgery. The primary care NP should order: a. coagulation studies. b. a complete blood count. c. an EEG. d. a creatinine clearance test.

Answer 278

ANS: A. Valproic acid may cause thrombocytopenia and inhibition of platelet aggregation. Platelet counts and coagulation studies should be done before therapy is initiated, at regular intervals, and before any surgical procedure is performed.

Question 279

A 20-kg child takes valproic acid (Depakote) for seizures and has had regular dose increases with a current dose of 250 mg twice daily. The child continues to have one to two seizures each week along with significant drowsiness that interferes with school participation. The primary care NP should contact the child's neurologist to discuss: a. obtaining a serum valproic acid level. b. changing the medication to gabapentin (Neurontin). c. increasing the valproic acid by 5 mg per kg of weight. d. adding lamotrigine (Lamictal) to this child's drug regimen.

Answer 279

ANS: D. Research suggests a combination of lamotrigine and valproate to be the most effective regimen in patients with refractory epilepsy. Valproic acid dosing may be increased to a maximum of 60 mg/kg/day unless side effects prevent further increase in dosage. The other drugs are not recommended

Question 280

A patient who takes carbamazepine (Tegretol) for a seizure disorder is seen by a primary care NP for a routine physical examination. A complete blood count (CBC) reveals a low white blood cell (WBC) count. The NP should: a. order a WBC differential. b. discontinue the carbamazepine. c. reassure the patient that this effect is temporary. d. decrease the carbamazepine dose and recheck the CBC in 2 weeks

Answer 280

ANS: A. A benign leukopenia associated with carbamazepine is common and is reversible and dose-related. A WBC differential should be performed before changing the drug regimen.

Question 281

A patient who has Parkinson's disease takes levodopa and carbidopa. The patient asks the primary care nurse practitioner (NP) why two drugs are necessary. The NP should explain that both drugs are needed to: a. prolong effects of the levodopa. b. delay progression of the disease. c. decrease adverse peripheral side effects. d. enhance passage of both drugs across the blood-brain barrier.

Answer 281

ANS: C. Combining carbidopa with levodopa results in increased concentrations of levodopa in the central nervous system and decreased conversion of levodopa to dopamine in the periphery, where it causes adverse effects. Carbidopa does not prolong the effects of levodopa. The combination does not cause delay in disease progression and does not enhance passage across the blood-brain barrier.

Question 282

A patient who has Parkinson's disease and who takes levodopa reports that the drug effects wear off more quickly than before. The primary care NP should: a. add carbidopa. b. add amantadine. c. increase the dose of levodopa. d. add a monoamine oxidase B inhibitor (MAO-B).

Answer 282

ANS: D . When an MAO-B is given, it appears to enhance and prolong the response to levodopa, reducing the wearing-off effect. Carbidopa does not alter this effect. Amantadine is not indicated. Increasing the dose of levodopa is not indicated.

Question 283

A patient who has Parkinson's disease takes levodopa and carbidopa. The patient reports experiencing tremors between doses. The primary care NP should: a. add entacapone. b. add amantadine. c. discontinue the carbidopa. d. increase the dose of levodopa.

Answer 283

ANS: A. Catecholamine O-methyl transferase inhibitors, such as entacapone, are used to prolong the effects of levodopa and help prevent breakthrough tremors that occur before the next dose of levodopa. Amantadine is not indicated. Increasing carbidopa does not have this effect. Increasing the dose of levodopa does not prolong its effects.

Question 284

A patient who takes levodopa and carbidopa for Parkinson's disease reports experiencing freezing episodes between doses. The primary care NP should consider using: a. selegiline. b. amantadine. c. apomorphine. d. modified-release levodopa

Answer 284

ANS: C. Apomorphine injection is used for acute treatment of immobility known as "freezing.

Question 285

A patient who has Parkinson's disease who takes levodopa and carbidopa reports having drooling episodes that are increasing in frequency. The primary care NP should order: a. benztropine. b. amantadine. c. apomorphine. d. modified-release levodopa

Answer 285

ANS: A. Anticholinergics, such as benztropine, are used to control drooling

Question 286

A patient who is diagnosed with Parkinson's disease will begin taking levodopa and carbidopa. The patient asks the primary care NP what dietary interventions may be helpful in improving symptoms. The NP should recommend: a. consuming a high-calorie diet. b. consuming a low-carbohydrate diet. c. avoiding extra fluids during meal times. d. minimizing intake of high-protein foods during the day.

Answer 286

ANS:D Some people find that avoiding high-protein foods during the day and "hoarding" them until the evening improves mobility during the day. Because of decreased activity associated with the disease, patients should not eat a diet high in calories. A low-carbohydrate diet is not indicated. Patients should consume plenty of water with food to aid in chewing and swallowing

Question 287

A 55-year-old patient develops Parkinson's disease characterized by unilateral tremors only. The primary care NP will refer the patient to a neurologist and should expect initial treatment to be: a. levodopa. b. carbidopa. c. pramipexole. d. carbidopa/levodopa

Answer 287

ANS: C. Pramipexole. Patients younger than 65 years of age should be started with a dopamine agonist

Question 288

A 65-year-old patient is diagnosed with Parkinson's disease. The patient has emphysema and narrow-angle glaucoma. The primary care NP should consider beginning therapy with: a. selegiline. b. benztropine. c. carbidopa/levodopa. d. ropinirole hydrochloride

Answer 288

ANS: A. Selegiline is safe for patients with glaucoma and emphysema. Benztropine is contraindicated in patients with glaucoma and emphysema. Dopamine precursors, such as carbidopa/levodopa, are contraindicated in patients with narrow-angle glaucoma and cautioned in patients with emphysema.

Question 289

A patient reports feelings of sadness and hopelessness along with difficulty sleeping and weight loss. The primary care NP learns that the patient's mother died 6 months earlier. The NP should: a. offer a referral to a bereavement counselor. b. begin pharmacologic treatment with fluoxetine. c. determine whether medications are causing these symptoms. d. tell the patient that these symptoms will go away in a few months

Answer 289

ANS: A. Bereavement over the loss of a loved one may be associated with symptoms of major depression. Although only 17% of these patients receive pharmacologic treatment, 94% of symptoms have been found to resolve in 13 months or less. Bereavement counseling should be the first step. Pharmacologic treatment may be warranted if symptoms do not improve. This patient has a clear cause for depression. It is not enough to reassure the patient that the symptoms will resolve because this belittles their concern

Question 290

A patient reports having feelings of hopelessness and anxiety for the past few months. The primary care nurse practitioner (NP) performs a history and learns that these feelings occur almost daily. The patient also reports having headaches and difficulty concentrating at work along with wanting to sleep all the time. The patient has gained 5 lb in the past 6 months. The NP should: a. tell the patient that these symptoms should resolve on their own. b. reassure the patient that these are symptoms of minor depression. c. tell the patient that an exercise regimen alone should be effective. d. assess the patient for alcohol and drug use and for suicidal ideation.

Answer 290

ANS: D. The patient is having symptoms of major depression, but other factors such as drug or alcohol abuse that may be contributing to the diagnosis must be ruled out first. Patients should be asked about suicidal ideation so that measures can be taken to prevent a suicide attempt. Symptoms of major depression require treatment. Exercise should be a part of any plan but should not be the only intervention.

Question 291

A patient has been taking paroxetine (Paxil) for major depressive symptoms for 8 months. The patient tells the primary care NP that these symptoms improved after 2 months of therapy. The patient is experiencing weight gain and sexual dysfunction and wants to know if the medication can be discontinued. The NP should: a. change to a tricyclic antidepressant medication. b. begin to taper the paroxetine and instruct the patient to call if symptoms increase. c. tell the patient to stop taking the medication and to call if symptoms get worse. d. continue the medication for several months and consider adding bupropion

Answer 291

ANS: D. Once a patient achieves remission, a continuation phase of 16 to 20 weeks followed by a maintenance phase of 4 to 9 months should be carried out. Some responders, called apathetic responders, may have a decrease in most symptoms but continue to have lack of pleasure, decreased libido, and lack of energy. Bupropion can be added to therapy to treat these symptoms. Patients should not change medications during this phase, should not begin a drug taper, and should never stop the medication abruptly

Question 292

The primary care NP has prescribed sertraline (Zoloft) for a patient who initially reported daily symptoms of hopelessness, sadness, insomnia, and weight loss. After several months of therapy, the patient no longer feels hopeless or sad but continues to have difficulty eating and sleeping. The NP should contact the patient's psychiatrist to discuss a. adding mirtazapine (Remeron). b. changing to duloxetine (Cymbalta). c. adding another selective serotonin reuptake inhibitor (SSRI) antidepressant. d. an inpatient admission to the hospital

Answer 292

ANS: A. Mirtazapine may be added to the drug regimen for partial responders who continue to feel anxious. Changing medications is not recommended. Adding another SSRI is contraindicated

Question 293

A patient has been taking fluoxetine (Prozac) for depression and comes to the clinic to report nausea and jitteriness. The primary care NP notes tremors and sees that the patient is confused. The patient has a heart rate of 95 beats per minute. The NP should: a. change to bupropion (Wellbutrin). b. ask the patient about other medications. c. discontinue the fluoxetine immediately. d. add mirtazapine (Remeron) to treat anxiety

Answer 293

ANS: B. Serotonin syndrome is a potentially lethal set of symptoms such as these. The NP should evaluate whether the patient is taking other SSRIs, monoamine oxidase inhibitors, bupropion, serotonin-norepinephrine reuptake inhibitors, or other medications that can precipitate this. Changing medication is not indicated. Patients should never abruptly discontinue an SSRI. Adding mirtazapine is not indicated.

Question 294

``` A patient who has symptoms of depression also reports chronic pain. The primary care NP should begin therapy with A. Fluoxetine (Prozac) B. Bupropion (Wellbutrin) C. Nortriptyline (Pamelor) D. Duloxetine (Cymbalta) ```

Answer 294

ANS: D. Duloxetine is an antidepressant that also has uses for pain syndromes associated with depression

Question 295

An 80-year-old patient experiences prolonged sadness after the death of a spouse. The patient reports being unable to sleep or eat. The primary care NP should prescribe _____ mg _____ daily. a. trazodone 50; three times b. trazodone 100; three times c. mirtazapine 15; at bedtime d. mirtazapine 30; at bedtime

Answer 295

ANS: C. Mirtazapine side effects include sedation and increased appetite, and sedation is more likely with a lower dose. Mirtazapine is often used in nursing homes to stimulate appetite in older adults

Question 296

``` The primary care NP sees a 16-year-old patient who reports feeling hopeless and sad. The child's parent reports increased aggression and a decline in school performance. The NP should consider prescribing: A. fluoxetine (Prozac) b. nortriptyline (Pamelor). c. tranylcypromine (Parnate). d. venlafaxine hydrochloride (Effexor). ```

Answer 296

ANS: A. Fluoxetine may be used in children 8 years of age and older. Nortriptyline may be used in children 12 years of age and older but is not a first-line drug. The other drugs are not indicated in adolescents younger than 18 years

Question 297

A 15-year-old patient who is seeing a psychiatrist began taking an antidepressant 1 week before a clinic visit with the primary care NP. The NP should: a. schedule weekly clinic visits to evaluate response to the medication. b. encourage the child to report feelings of self-harm to a school counselor. c. contact the patient by phone every 2 weeks to see how the medication is working. d. instruct the child's parents to report changes in behavior to the child's psychiatrist

Answer 297

ANS: A. Pediatric patients should have face-to-face contact with a provider at least weekly during the first 4 weeks of treatment to evaluate for clinical worsening, suicidality, or unusual changes in behavior.

Question 298

A patient has been taking fluoxetine 20 mg every morning for 5 days and calls the primary care NP to report decreased appetite, nausea, and insomnia. The NP should: a. suggest taking a sedative at bedtime. b. change the medication to bupropion. c. add trazodone to the patient's regimen. d. reassure the patient that these effects will subside

Answer 298

ANS: D. Side effects are seen with the first few doses but resolve in approximately 7 days. Patients should avoid taking sedatives while taking antidepressants

Question 299

A patient comes to the clinic and reports having insomnia that began within the last year. The primary care nurse practitioner (NP) learns that the patient often lies awake worrying about problems at work. The patient feels fatigued during the day and experiences frequent stomach discomfort. The NP should prescribe: a. buspirone. b. melatonin. c. alprazolam. d. diphenhydramine

Answer 299

ANS: A. This patient is having insomnia because of anxiety. Alprazolam has a high abuse potential, so starting therapy with an antianxiety medication is a good choice. Melatonin and diphenhydramine are given for insomnia

Question 300

A patient tells the primary care NP about having difficulty giving presentations at work. The patient experiences anxiety and often feels faint or vomits. The NP should: a. prescribe buspirone. b. prescribe alprazolam. c. order a selective serotonin reuptake inhibitor (SSRI) antidepressant. d. recommend cognitive-behavioral therapy

Answer 300

ANS: D. The patient is describing a phobic disorder. Cognitive-behavioral therapy is recommended as first-line treatment, with SSRI medications as adjunct therapy

Question 301

An adolescent patient comes to the clinic and reports anxiety and poor sleep that have persisted since experiencing a hurricane 8 months prior. The patient has been receiving cognitive-behavioral therapy, which has helped a little. The primary care NP should order: a. doxepin. b. fluoxetine. c. alprazolam. d. clonazepam

Answer 301

ANS: B. This patient has posttraumatic stress disorder. If cognitive-behavioral therapy has not been effective, the patient should be given an SSRI as second-line treatment. Doxepin is atricyclic antidepressant. The other two choices are benzodiazepines

Question 302

A patient reports difficulty falling asleep and staying asleep every night and has difficulty staying awake during the commute to work every day. The NP should: a. suggest the patient try diphenhydramine first. b. perform a thorough history and physical examination. c. teach about avoiding caffeine and good sleep hygiene. d. suggest melatonin and consider prescribing Ambien if this is not effective

Answer 302

ANS: B. Before treating insomnia with drug therapy, it is important first to rule out any physiologic causes of a sleep disorder. The other interventions may be tried if no serious cause of the disorder is found

Question 303

A patient is in the clinic with acute symptoms of anxiety. The patient is restless and has not slept in 3 days. The primary care NP observes that the patient is irritable and has moderate muscle tension. The patient's spouse reports that similar symptoms have occurred before in varying degrees for several years. The NP should refer the patient to a psychologist and should prescribe which drug for short-term use? a. Alprazolam b. Buspirone c. Melatonin d. Zolpidem

Answer 303

ANS: A. For acute anxiety, a benzodiazepine should be prescribed. SSRIs or buspirone should be used for long-term treatment. Melatonin and zolpidem are anti-insomnia agent

Question 304

A patient reports going to bed at 10:00 pm every night but often lays awake until midnight. The primary care NP instructs the patient to practice good sleep hygiene and to avoid caffeine in the evening. After 1 week of this regimen, the patient reports still lying awake until 11:00 PM. The NP should: a. order a sleep study. b. consider short-term zolpidem. c. order ramelteon for several weeks. d. reassure the patient and re-evaluate in 1 week.

Answer 304

ANS: D. Treatment of patients with insomnia begins with sleep hygiene. It is important that the patient have reasonable expectations and understand that the time of onset of sleep can be moved up only by 15 minutes every 3 or 4 days. This patient is showing improvement, which means the measures are working. When these measures are ineffective, medications may be considered.

Question 305

A patient reports difficulty returning to sleep after getting up to go to the bathroom every night. A physical examination and a sleep hygiene history are noncontributory. The primary care NP should prescribe: a. zaleplon. b. ZolpiMist. c. ramelteon. d. chloral hydrate

Answer 305

ANS: B. ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle ofthe night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep onset. Chloral hydrate is not typically used as outpatient therapy.

Question 306

The primary care nurse practitioner (NP) is performing a physical examination on a patient who has been taking mesoridazine (Serentil) for several weeks to treat schizophrenia. The patient is exhibiting rhythmic movements of the face and jaw. The NP should be concerned that the patient may: a. need a higher dose of mesoridazine. b. need to change to thioridazine (Mellaril). c. have developed neuroleptic malignant syndrome. d. be exhibiting signs of an irreversible adverse effect

Answer 306

ANS: D. Tardive dyskinesia, or abnormal involuntary movements characterized by rhythmic involuntary movements of the tongue, face, mouth, or jaw, may be progressive and irreversible. This condition can occur with all antipsychotics, especially the first-generation antipsychotics. Increasing the dose may increase the symptoms. Thioridazine is another first-generation antipsychotic with a similar adverse-effect profile. Neuroleptic malignant syndrome occurs weeks after initiation and is characterized by fever, catatonia, muscle rigidity, and autonomic instability.

Question 307

A patient with a recent diagnosis of schizophrenia is taking thioridazine (Mellaril) to treat psychotic symptoms. The patient's family member is concerned that the patient continues to have little interest in activities and has difficulty beginning even simple tasks. The primary care NP should contact the patient's psychiatrist to discuss changing to: a. fluphenazine (Prolixin). b. risperidone (Risperdal). c. chlorpromazine (Thorazine). d. prochlorperazine (Compazine)

Answer 307

ANS: B. First-generation antipsychotics treat positive but not negative symptoms associated with psychotic states. This patient exhibits negative symptoms and should be treated with a second-generation antipsychotic, such as risperidone. The other three drugs are first-generation antipsychotics.

Question 308

A 22-year-old male patient who has dropped out of college has increasingly disorganized behavior and delusional thinking. His parents report that he lives at home and has no desire to find a job or help around the house. The primary care NP has ruled out organic causes and has referred the patient to a psychiatrist for treatment. To prepare for the referral visit, the NP should: a. begin therapy with a low-potency antipsychotic. b. begin therapy with a high-potency antipsychotic. c. obtain a complete blood count (CBC), serum lipids, and hemoglobin A1c. d. order liver function tests (LFTs), a CBC, an electrocardiogram (ECG), and a urinalysis

Answer 308

ANS: D. Before antipsychotic drugs are initiated, baseline laboratory tests, including LFTs, CBC, ECG,and urinalysis, should be performed. Serum lipids and hemoglobin A1cmay be ordered if the patient has risk factors for diabetes or metabolic syndrome

Question 309

``` A patient who is newly diagnosed with schizophrenia is overweight and has a positive family history for type 2 diabetes mellitus. The primary care NP should consider initiating antipsychotic therapy with: A. ziprasidone (Geodon). B. olanzapine (Zyprexa). C. risperidone (Risperdal). D. chlorpromazine (Thorazine) ```

Answer 309

ANS: A. Many antipsychotics increase the risk of metabolic syndrome in patients. Ziprasidone does not have effects on weight. The other agents all increase the risk of weight gain and metabolic syndrome

Question 310

A patient has been taking olanzapine (Zyprexa) for 3 weeks to treat schizophrenia. The primary care NP notes that the patient has more coherent speech and improved initiative and attentiveness but continues to have delusional ideation. The NP should: a. increase the dose of olanzapine. b. decrease the dose of olanzapine. c. maintain the same dose of olanzapine d. change from olanzapine to chlorpromazine

Answer 310

ANS: A. Clinicians should gradually increase the dose of antipsychotic medication to achieve therapeutic effects, while minimizing side effects. It may take weeks to achieve full therapeutic effects

Question 311

An elderly patient with dementia exhibits hostility and uncooperativeness. The primary care NP prescribes clozapine (Clozaril) and should counsel the family about: A. a decreased risk of extrapyramidal symptoms. B. improved cognitive function. C. the need for long-term use of the medication. D. a possible increased risk of heart disease and stroke

Answer 311

ANS: D. Antipsychotics are useful in treating some psychiatric symptoms of dementia and help to improve quality of life in many patients. They do not improve cognitive function, however. They increase the risk of extrapyramidal symptoms and should be used only on a short-term basis. They increase the risk of heart disease and stroke.

Question 312

A patient who takes 150 mg of clozapine (Clozaril) twice daily calls the primary care NP at 10:00 AM one day to report forgetting to take the 8:00 AM dose. The NP should counsel the patient to: a. take the missed dose now. b. take 75 mg of clozapine now. c. wait and take the evening dose at the usual time. d. take the evening dose 2 hours earlier than usual.

Answer 312

ANS: C. Advise patients to take missed doses only if remembered within 1 hour after the time the dose was due

Question 313

A patient comes to the clinic for a physical examination 2 weeks after the last dose of clozapine (Clozaril). The primary care NP should: a. order a CBC with differential. b. obtain serum lipids and LFTs. c. obtain a serum clozapine level. d. assess for orthostatic hypotension.

Answer 313

ANS: A. Clozapine presents a significant risk for agranulocytosis, and leukocytes should be monitored before starting treatment, weekly during treatment, and weekly for at least 4 weeks after discontinuing treatment

Question 314

A patient who is overweight is diagnosed with schizophrenia. The primary care NP should consider prescribing: a. olanzapine (Zyprexa). b. ziprasidone (Geodon). c. quetiapine (Seroquel). d. aripiprazole (Abilify)

Answer 314

ANS: B. Of the four drugs listed, ziprasidone causes the least metabolic side-effect burden of second-generation antipsychotics

Question 315

A patient has been taking oral prednisone 60 mg daily for 3 days for an asthma exacerbation, which has resolved. The patient reports having gastrointestinal (GI) upset. The primary care nurse practitioner (NP) should: a. discontinue the prednisone. b. begin tapering the dose of the prednisone. c. order a proton pump inhibitor (PPI) to counter the effects of the steroid. d. change the prednisone dosing to every other day.

Answer 315

ANS: A- The patient's asthma symptoms have resolved, so the prednisone may be discontinued. If the patient has been on the medication for a few days, it is not necessary to taper the dose before the patient stops taking it. If the patient required long-term dosing of the steroid, a PPI could be used. Every-other-day dosing is used. Alternate-day dosing is sometimes used for long-term therapy to minimize suppression of the hypothalamic-pituitary-adrenal(HPA) axis.

Question 316

A patient will require a long course of steroids to treat a chronic inflammatory condition. The primary care NP expects the specialist to order: a. prednisone daily. b. triamcinolone daily. c. hydrocortisone every other day. d. dexamethasone every other day

Answer 316

ANS: C- Hydrocortisone is a short-acting glucocorticoid. The use of a short-acting agent and an alternate-day dosage regimen should be considered for long-term therapy. Prednisone andtriamcinolone are medium-acting glucocorticoids. Dexamethasone is a long-acting glucocorticoid

Question 317

A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child examination, the family nurse practitioner (FNP) notes a decrease in the child's linear growth rate. The FNP should consult the child's asthma specialist about: a. gradually tapering the child off the prednisone. b. a referral for possible growth hormone therapy. c. giving a double dose of prednisone every other day. d. dividing the prednisone dose into twice-daily dosing.

Answer 317

ANS C- giving a double dose of prednisone every other day.- Administration of a double dose of a glucocorticoid every other morning has been found to cause less suppression of the HPA axis and less growth suppression in children. Because the child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indicated. Twice-daily dosing would not change the HPA axis suppression.

Question 318

A 70-year-old patient with COPD who is new to the clinic reports taking 10 mg of prednisone daily for several years. The primary care NP should: A. begin a gradual taper of the prednisone to wean the patient off the medication. B. tell the patient to take the drug every other day before 9:00 AM. C. order a serum glucose, potassium level, and bone density testing. D. perform pulmonary function tests to see if the medication is still needed.

Answer 318

ANS: C- Order a serum glucose, potassium level, and bone density testing. Serum glucose and potassium levels are part of monitoring for side effects of steroids. Because elderly patients are more prone to certain potential catabolic adverse effects of steroid therapy, caution is required. Osteoporosis is often seen with elderly patients, so bone density testing should be performed. The medication dosing regimen should not be changed unless there is an indication of adverse effects.

Question 319

A primary care NP prescribes an oral steroid to a patient and provides teaching about the medication. Which statement by the patient indicates a need for further teaching? a. "I should take this medication with food." b. "I will take the medication at 8:00 AM each day." c. "I can expect a decreased appetite while I am taking this medication." d. "I should not stop taking the medication without consulting my provider.

Answer 319

ANS: C- Therapeutic administration is least likely to interfere with natural hormone production when the drug is given at the time of natural peak activity. It is generally recommended to administer the full daily dose before 9 AM. Oral glucocorticoids usually are given with meals to limit GI irritation. Common side effects include changes in mood, insomnia, and increased appetite.

Question 320

A patient with ulcerative colitis takes 30 mg of methylprednisolone (Medrol)daily. The primary care NP sees this patient for bronchitis and orders azithromycin (Zithromax). The NP should: A. stop the methylprednisolone while the patient is taking azithromycin. B. temporarily decrease the dose of methylprednisolone. C. change the dosing of methylprednisolone to 15 mg twice a day. D. order intramuscular (IM) methylprednisolone

Answer 320

ANS: B- Temporarily decrease the dose of methylprednisolone. When given concurrently with macrolide antibiotics, methylprednisolone clearance is reduced, so a smaller dose of methylprednisolone is needed. IM administration does not affect clearance of the drug. Changing the dose to twice-daily dosing is not recommended. Stopping the drug abruptly is not recommended.

Question 321

A patient is being tapered from long-term therapy with prednisolone and reports weight loss and fatigue. The primary care NP should counsel this patient to: a. consume foods high in vitamin D and calcium. b. begin taking dexamethasone because it has longer effects. c. expect these side effects to occur as the medication is tapered. d. increase the dose of prednisolone to the most recent amount take

Answer 321

ANS: D- Sudden discontinuation or rapid tapering of glucocorticoids in patients who have developed adrenal suppression can precipitate symptoms of adrenal insufficiency, including nausea, weakness, depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected

Question 322

A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should: a. order a fasting plasma glucose level. b. consider prescribing metformin (Glucophage). c. suggest dietary changes and increased exercise. d. obtain serum insulin and hemoglobin A1clevels

Answer 322

ANS: A. order a fasting glucose level. Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Seruminsulin level is not indicated

Question 323

``` A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this patient's laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe: A. colesevelam (Welchol) B. metformin (Glucophage). C. glyburide (Micronase). D. nateglinide (Starlix). ```

Answer 323

ANS: B- Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs

Question 324

A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical examination, the patient's fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should: a. order metformin (Glucophage). b. order a lipid profile, complete blood count, and liver function tests (LFTs). c. order an oral glucose tolerance test. d. set a weight loss goal of 10 to 15 lb

Answer 324

ANS: D- To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated

Question 325

A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: a. taking the metformin dose as usual the morning of surgery. b. using insulin during the perioperative and postoperative periods. c. that the patient stop taking metformin several days before surgery. d. adding a sulfonylurea medication until recovery from surgery is complete

Answer 325

ANS: B- Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery.

Question 326

``` A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? A. Metformin/glyburide (Glucovance) B. Insulin and metformin(Glucophage) C. Saxagliptin/metformin(Kombiglyze) D. Metformin/pioglitazone (ACTOplus met) ```

Answer 326

ANS: A- Metformin/glyburide (Glucovance)- obese patients with normal renal function and elevated fasting plasma glucose may be started on a combination of metformin and a second-generation sulfonylurea.

Question 327

A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe: a. pramlintide (Symlin). b. repaglinide (Prandin). c. glyburide (Micronase). d. metformin (Glucophage).

Answer 327

ANS: A- pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated.

Question 328

A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1cis 7.3%. The NP should: A. begin insulin therapy. B. change to therapy with colesevelam (Welchol). C. add a third oral antidiabetic agent to this patient's drug regimen. D. enroll the patient in a weight loss program to achieve better glycemic control.

Answer 328

ANS: A- The target hemoglobin A1cgoal for adults is less than 7%. Insulin therapy is indicated if maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the maximum recommended doses of metformin and glyburide. Colesevelam does not decrease hemoglobin A1c. Adding a third oral antidiabetic agent is not recommended. A weight loss program may be a part of this patient's treatment, but insulin is necessary to maintain glycemic control.

Question 329

``` A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP should order: A. nateglinide (Starlix). B. glyburide (Micronase). C. colesevelam (Welchol). D. metformin (Glucophage) ```

Answer 329

ANS: D- Metformin is the only drug listed that is recommended for children

Question 330

A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the patient reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats per minute. The NP should: a. obtain LFTs. b. decrease the dose of metformin. c. c hange metformin to glyburide. d. order electrolytes/BMP, ketones, and serum glucose.

Answer 330

ANS: D- Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should include electrolytes, ketones, and serum glucose.

Question 331

A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should: a. tell her that starting HT now may reduce her risk of breast cancer. b. advise a short course of HT now that may decrease her risk for CHD. c. tell her that HT will not help control her symptoms during postmenopause. d. recommend herbal supplements for her symptoms to avoid HT side effects.

Answer 331

ANS: A- the current gap hypothesis regarding breast cancer supports initiating HT 5 years or more after menopause. To decrease risk for CHD, HT should begin at the time of menopause. HT will relieve vasomotor symptoms at all stages of menopause. Herbal supplements have estrogenizing effects and carry the same risks as estrogen therapy

Question 332

The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3 years. The NP decreases the dosage, and several weeks later, the woman calls to report having several hot flashes each day. The NP should:

Answer 332

Increase the HT dose- The Women's Health Initiative results indicate that HT use for 3 to 5 years is safe and recommend slow weaning after women review HT with their providers at annual visits. If symptoms recur, the dose should be increased until symptoms improve.

Question 333

A 52-year-old woman reports having hot flashes and intense mood swings. After a year of having irregular menstrual periods, she has not had a period for 6 months. The primary care NP should diagnose: a. menopause. b. dysmenorrhea. c. perimenopause. d. postmenopause.

Answer 333

ANS: C- perimenopause usually occurs between ages 42 and 55 and is characterized by erratic ovulation and irregular periods, hot flashes, and intensified PMS symptoms. Menopause begins when periods have been absent for 12 months. Postmenopause describes the 5-year period after menopause. Dysmenorrhea is painful periods

Question 334

A woman with a family history of breast cancer had her last menstrual period 12 months ago and is experiencing hot flashes. She has not had a hysterectomy. The primary care NP should recommend:

Answer 334

limiting alcohol and caffeine intake. -Hot flashes can be triggered by environmental conditions such as stress, excitement, anxiety, and alcohol and caffeine consumption. Black cohosh carries the same risks as estrogen. Estrogen-only therapy is not recommended for women with an intact uterus. Progesterone therapy is not recommended

Question 335

A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should

Answer 335

Plan to use estrogen-progesterone therapy when menopause begins- HORMONE THERAPY- The timing hypothesis suggests that initiating HT at or very near to the time of menopause, which begins when a woman has not had a period for 12 months, reduces CHD in postmenopausal women. Estrogen-only therapy is indicated only for women who do not have a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated.

Question 336

A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman's mother had CHD. She has no family history of breast cancer. The NP should prescribe: a. estrogen-only HT now. b. estrogen-only HT in 5 years. c. estrogen-progesterone HT now. d. estrogen-progesterone HT in 5 years

Answer 336

ANS: A- HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated

Question 337

Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend: a. testosterone therapy. b. estrogen-only therapy. c. nonhormonal drugs for osteoporosis. d. estrogen-progesterone therapy for 1 to 2 years

Answer 337

ANS: C- Although estrogen slows the progression of osteoporosis, it also increases the risk of breast cancer when initiated early in menopause. This woman should receive a nonhormonal treatment for osteoporosis and may receive HT in 5 years if menopausal symptoms persist. Testosterone therapy, estrogen-only therapy, and estrogen-progesterone therapy are not indicated

Question 338

A 50-year-old woman reports severe, frequent hot flashes and vaginal dryness. She is having irregular periods. She has no family history of CHD or breast cancer and has no personal risk factors. The primary care NP should recommend:

Answer 338

Low-dose oral contraceptive therapy- Oral contraceptive pills are not approved by the U.S. Food and Drug Administration for management of perimenopausal symptoms except to treat irregular menstrual bleeding. This patient has a low risk for CHD and breast cancer, so oral contraceptive pills are relatively safe. She is also at risk for pregnancy, so oral contraceptive pills can help to prevent that

Question 339

A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe: a. estrogen-only HT. b. low-dose oral contraceptive therapy. c. selective serotonin reuptake inhibitor therapy until menopause begins. d. estrogen-progesterone HT.

Answer 339

ANS: A- Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women

Question 340

A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP's next action should be to: A. order LH and FSH levels. B. order a serum prolactin level. C. prescribe testosterone replacement. D. obtain a morning serum testosterone level

Answer 340

ANS: D- To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive

Question 341

A man who has secondary hypogonadism associated with pituitary dysfunction will begin exogenous testosterone therapy. The patient asks the primary care NP about future chances of fathering children. The NP should tell him that A. Fertility may improve with testosterone therapy. B. exogenous testosterone therapy will shut down sperm production. C.he should store sperm ahead of the initiation of testosterone therapy. D. fertility can be restored when testosterone therapy is discontinued

Answer 341

ANS: A- Men with secondary hypogonadism may become fertile with exogenous testosterone

Question 342

A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend: A. increasing the dose of warfarin. B, more frequent blood glucose monitoring. C. a higher than usual dose of testosterone. D. increasing insulin doses to prevent hypoglycemia

Answer 342

ANS: B- Patients with diabetes may require a decrease in insulin dose because of the metabolic effects of androgens. More frequent blood glucose monitoring should be performed. Warfarin doses may need to be decreased because androgens increase sensitivity to anticoagulants.

Question 343

``` Match the following terms with their corresponding definitions: Antibiotic------ Antimicrobial----- Bacteriostatic----- Bactericidal---- ```

Answer 343

Product of a living organism that kills or inhibits growth of microorganisms Any naturally occurring or synthetic substance that kills or inhibits growth of microorganisms Ability to inhibit growth and replication of bacteria Ability to kill bacteria independent of immune system

Question 344

Match the following class of antibiotics with their corresponding site of antimicrobial action: Macrolides, tetracyclines, aminoglycosides, clindamycin --- Fluoroquinolones, rifampin --- Beta-lactams, vancomycin, daptomycin --- Sulfonamides, trimethoprim --- Isoniazid, Amphotericin B, Polymyxins ---

Answer 344

``` inhibitors of protein synthesis inhibitors of nucleic acid function or synthesis inhibitors of cell wall synthesis inhibitors of metabolism inhibitors of cell membrane function ```

Question 345

When choosing to prescribe an antibiotic a NP should select one that meets the following criteria (SELECT ALL THAT APPLY): a. Most effective b. Lowest toxicity c. Broadest spectrum d. Most cost-effective

Answer 345

ANS ABD (not broad spectrum)

Question 346

A patient that had been traveling abroad presented to the clinic with a MILD case of traveler’s diarrhea. The patient tells the NP that he is allergic to fluoroquinolones. Which of the following would be the most appropriate treatment for this patient? a. Cipro (ciprofloxacin_ 750 mg x 1 dose b. Azithromycin 1000 mg x 1 dose c. Flagyl (metronidazole) 500 mg tid x 10-14 days d. Bactrim D5 (TMP/SMX) bid x 7-10 days

Answer 346

ANS B azithromycin

Question 347

A patient with otitis media is treated for 10 days with amoxicillin. At the follow-up visit, the primary care NP notes bilateral erythematous, bulging tympanic membranes. The NP should prescribe: a. amoxicillin for 10 more days. b. oral amoxicillin-clavulanate (Augmentin) for 10 days. c. oral dicloxacillin (Dynapen) for 10 days. d. intramuscular injection of penicillin G (Bicillin).

Answer 347

b. oral amoxicillin-clavulanate (Augmentin) for 10 days. Antibiotic resistance to penicillins occurs through three mechanisms, the most important being bacteria producing b-lactamase, which breaks down the b-lactam ring and renders the penicillin inactive. Clavulanic acid, used in combination with penicillins, prevents this inactivation. The NP should prescribe amoxicillin-clavulanate. Giving 10 more days of amoxicillin would not be effective. Dicloxacillin is used when resistance is caused by penicillinase-resistant staphylococcal infection. Penicillin G is not used to treat otitis media.

Question 348

A 70-year-old patient will begin taking cefdinir (Omnicef) for an acute exacerbation of COPD. Before initiating therapy, the primary care NP should order: a. an electrocardiogram (ECG). b. a creatinine clearance test. c. coagulation studies. d. liver function tests (LFTs).

Answer 348

b. a creatinine clearance test. Geriatric patients may need adjusted doses based on creatinine clearance testing, so obtaining a creatinine clearance test before initiating therapy is indicated. LFTs, coagulation studies, and an ECG are not indicated.

Question 349

A woman has a Chlamydia infection. Before initiating treatment with a tetracycline antibiotic, the primary care nurse practitioner (NP) should: a. obtain baseline liver function and renal function tests. b. tell her she must stop using oral contraceptive pills. c. perform a pregnancy test. d. check her bilirubin and serum amylase levels.

Answer 349

c. perform a pregnancy test. Tetracycline antibiotics can permanently stain teeth in children and in pregnant women. Before using a tetracycline in a woman who may be pregnant, the NP should perform a pregnancy test. Other laboratory tests are not indicated for short-term use. Women taking oral contraceptive pills should continue to take them.

Question 350

A primary care NP sees a 6-month-old patient who has a persistent staccato cough. The NP is aware that there is a pertussis outbreak in the community. The NP should obtain appropriate cultures and treat empirically with: a. telithromycin. b. azithromycin. c. clarithromycin. d. erythromycin.

Answer 350

d. erythromycin. Erythromycin is a first-choice drug for the treatment of pertussis.

Question 351

While a patient is receiving an aminoglycoside medication by intramuscular injection, the provider should instruct the patient to expect: A. discomfort to the injection site, which can be treated with warm moist heat. B. development of localized infection, which can be treated with an occlusive dressing. C. discomfort to the injection site, which can best be relieved with narcotic analgesics. D. development of localized bleeding, which may require the application of an occlusive dressing.

Answer 351

A. discomfort to the injection site, which can be treated with warm moist heat. The administration of aminoglycosides by intramuscular injection may cause discomfort to the injection site, which can be treated with warm moist heat and mild analgesics.

Question 352

A patient is seen in the clinic with a 1-week history of frequent watery stools. The primary care NP learns that a family member had gastroenteritis a week prior. The patient was treated for a UTI with a sulfonamide antibiotic 2 months prior. The NP should suspect: A. Clostridium difficile-associated disease (CDAD). B. viral gastroenteritis. C. serum sickness reaction. D. recurrence of the UTI.

Answer 352

A. Clostridium difficile-associated disease (CDAD). Cases of CDAD have been reported 2 months after a course of antibiotics, and CDAD should be suspected in all patients who present with diarrhea after antibiotic use. Viral gastroenteritis is possible, but the possibility of CDAD must be investigated. Serum sickness reaction is not usually associated with diarrhea and generally occurs within weeks of drug administration.

Question 353

A primary care NP prescribes TMP/SMX for a patient who is experiencing an exacerbation of COPD. The patient calls the NP 2 days later to report increased fever, cough, and shortness of breath. The NP should tell the patient: a. To stop taking the medication b. That symptoms such as sore throat and arthralgia are more worrisome c. To continue the medication because these are signs of the disease process d. That sulfisoxazole (Gantrisin) will be prescribed instead to minimize side effects

Answer 353

ANS; A, stop taking the medication. These are symptoms that may be early signs of serious reactions. Sore throat and arthralgia should also be reported byt are not more worrisome than the symptoms the patient is experiencing. Do not change to another sulfonamide because similar symptoms would occur.

Question 354

``` Match the following drugs with the most appropriate adverse effect: Sulfamethoxazole --- Levofloxacin --- Tetracycline --- Gentamicin --- ```

Answer 354

- hemolytic anemia - tendon rupture - deposition of drug in bones and teeth - ototoxicity

Question 355

Which of the following is correct regarding the monitoring of aminoglycosides? (SELECT ALL THAT APPLY): a. Serum peak (drawn approximately 30 to 45 minutes after IV dosing; 60 minutes after IM dosing) b. Trough (drawn immediately BEFORE dosing); levels should be monitored every second or third dose and every 7 to 10 days thereafter for the duration of therapy c. Test eight cranial nerve function by serial audiometric testing d. Monitor creatinine and BUN

Answer 355

ANS ACD (not trough- would be correct if monitored after 2-3 days and every 3-4 days thereafter for duration of therapy)

Question 356

A patient with aids is under the care of a NP. Which of the following drug treatments is the NP most likely using for MAC prophylaxis? a. Once-weekly doxycycline b. Once-weekly azithromycin c. Once-weekly penicillin d. Once-weekly ciprofloxacin

Answer 356

ANS B once-weekly azithromycin

Question 357

Which of the following cephalosporins has the longest half-life (6-8 hours), is effective in the treatment of gonorrhea, and is only available in IM or IV forms? a. Ceftriaxone (Rocephin) b. Cefuroxime (ceftin) c. Cephalexin (keflex) d. Cefixime (suprax)

Answer 357

ANS A Ceftriazone (rocephin)

Question 358

A patient was seen in a local emergency department and was treated empirically for pharyngitis with ampicillin and comes to the clinic 2 days later with an urticarial rash. The patient has no previous history of atopy and does not have respiratory symptoms. The primary care NP should suspect: a. penicillin allergy. b. serum sickness. c. mononucleosis. d. scarlatina.

Answer 358

c. mononucleosis. A nonallergic urticarial rash occasionally occurs with ampicillin and is common in patients with mononucleosis. This patient has pharyngitis, which was not diagnosed by throat culture. The NP should suspect mononucleosis and a nonallergic rash. Serum sickness and penicillin allergy are possible but less likely. A scarlatiniform rash is not urticarial.

Question 359

A primary care NP sees a patient who has dysuria, fever, and urinary frequency. The NP orders a urine dipstick, which is positive for nitrates and leukocyte esterase, and sends the urine to the laboratory for a culture. The patient is allergic to sulfa drugs. The NP should: a. order cefaclor (Ceclor). b. administer intramuscular ceftriaxone (Rocephin). c. wait for culture results before ordering an antibiotic. d. prescribe cefixime (Suprax).

Answer 359

d. prescribe cefixime (Suprax). Cephalosporins are useful for empirical treatment of many of the most common infections seen in primary care. Cefixime is a third-generation cephalosporin, which has greater activity against Escherichia coli and excellent penetration into body fluids, making it a good choice for empirical treatment of urinary tract infection.

Question 360

A patient is taking sulfisoxazole. The patient calls the primary care NP to report abdominal pain, nausea, and insomnia. The NP should: a. reassure the patient that these are minor adverse effects of this drug. b. order a CBC with differential, platelets, and a stool culture. c. change to TMP/SMX. d. tell the patient to stop taking the drug immediately.

Answer 360

a. reassure the patient that these are minor adverse effects of this drug. These side effects are considered common minor side effects of sulfonamide medications. They occur with all drugs in this class, so changing to TMP/SMX is not indicated. The patient should continue taking the medication. It is not necessary to perform laboratory tests.

Question 361

A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: a. prescribe amoxicillin-clavulanate twice daily for 10 days. b. prescribe amoxicillin twice daily for 10 days. c. initiate antibiotic therapy if the child's condition worsens. d. prescribe azithromycin once daily for 5 days.

Answer 361

c. initiate antibiotic therapy if the child's condition worsens. Signs and symptoms of otitis media that indicate a need for antibiotic treatment include otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of choice.

Question 362

A primary care nurse practitioner (NP) is prescribing once-daily azithromycin to a 25-year-old woman. When teaching her about the drug, the NP should tell her to: A. take the medication on an empty stomach. B. use a backup contraception method other than oral contraceptive pills. C. expect severe gastrointestinal side effects while taking this drug. D. cut the pill in half and take twice daily if side effects are severe.

Answer 362

B. use a backup contraception method other than oral contraceptive pills. Patients who use oral contraceptive pills for birth control should be advised that macrolides can reduce their efficacy and that they should consider using a backup method of contraception. Azithromycin can be taken without regard to food. Severe gastrointestinal side effects are uncommon. The tablets should not be chewed, crushed, or cut.

Question 363

When prescribing TMP/SMX to children, the primary care NP should recall that: a. Dosing is based on the trimethoprim component of the drug b. TMP/SMX should not be prescribed for children younger than 2 years. c. Folic acid supplements must be given to children who take this medication. d. The medication should be given three or four times per day because of rapid metabolism.

Answer 363

ANS A. When determined the dose of TMP/SMX, the dose is based on the trimethoprim component of the drug. Children older than 2 months of age may take this medication. Folic acid supplements are not indicated. The medication is given twice daily in all age groups.

Question 364

A 60-year-old patient comes to the clinic reporting a sudden onset of a painful rash that began the day before. The primary care NP notes a vesicular rash along a dermatome on one side of the patient's back. The patient has a low-grade fever. The NP will prescribe: a. varicella vaccine. b. metronidazole (Flagyl). c. acyclovir (Zovirax). d. amantadine (Symmetrel).

Answer 364

c. acyclovir (Zovirax). Acyclovir is effective against herpes viruses including the varicella-zoster virus that causes shingles. Varicella vaccine is given to prevent shingles in older patients. Metronidazole is an antiprotozoal. Amantadine is given to treat influenza.

Question 365

A child with a febrile illness is taking a cephalosporin. While in the clinic for a follow-up visit, the child has a tonic-clonic seizure. The primary care NP should: a. suspect the development of a secondary central nervous system infection. b. reassure the parent that seizures can occur while taking cephalosporins. c. ask the child's parent how much of the cephalosporin the child has taken. d. administer acetaminophen because this is likely a febrile seizure.

Answer 365

c. ask the child's parent how much of the cephalosporin the child has taken. Seizures can occur with an overdose of cephalosporins, so the NP should determine whether this has occurred. It is not correct to assume that the seizure is fever-related or that it is a normal side effect of the cephalosporin.

Question 366

A new patient comes to see the primary care NP with fever, mild dehydration, and dysuria with flank pain. The patient tells the NP that a previous provider always prescribed trimethoprim-sulfamethoxazole and wonders why a urine culture is necessary because this antibiotic has worked in the past. The NP should tell this patient that a culture is necessary to help determine: a. the correct dose of the antibiotic. b. whether antibiotic resistance is occurring. c. whether multiple organisms are causing infection. d. the length of antibiotic therapy needed to treat the infection.

Answer 366

b. whether antibiotic resistance is occurring. Antibiotic resistance can occur when bacteria are repeatedly exposed to antibiotic agents. Even though a particular antibiotic is effective for a certain type of infection, resistance can occur, and another antibiotic may be necessary. A culture and sensitivity test is essential for choosing the right antibiotic. The culture and sensitivity test does not help determine the dose or the length of therapy.

Question 367

``` A patient comes to the clinic before a trip to an area where malaria is endemic. The primary care NP will prescribe: A. tinidazole (Tindamax). B. metronidazole (Flagyl). C. chloroquine (Plaquenil). D. amantadine (Symmetrel). ```

Answer 367

C. chloroquine (Plaquenil). Chloroquine is used as malaria prophylaxis.

Question 368

The primary care NP sees a child in the clinic who has a 5-day history of cough, poor fluid intake, and fever of 103° F. A chest radiograph shows areas of consolidation in the child's lungs. The child's cough is nonproductive, and the NP is unable to get a sputum specimen. The NP should: A. Give the child's parents a specimen cup and ask that they try to bring in a sputum specimen for cx B. Prescribe a broad-spectrum antibiotic to cover any possible causative organism C. Refer the child to a pulmonologist or ID D. Ask colleagues in the clinic about children they have treated and what they have prescribed

Answer 368

ANS D: ask colleagues. The child shows signs of a bacterial infection, but getting a sputum culture is not likely. The NP should ask colleagues about similar cases and treat according to those patterns. Broad-spectrum antibiotics increase the incidence of resistance. If this child's symptoms do not respond to empiric therapy, referral may be warranted.

Question 369

A parent brings a 6-year-old child to the clinic for evaluation of a rash. The primary care NP notes three annular lesions with elevated borders and central clearing on the child's face and a similar lesion on the back of the neck that extends above the hairline. The NP should prescribe: a. griseofulvin. b. topical ketoconazole. c. oral ketoconazole. d. fluconazole.

Answer 369

a. griseofulvin. Griseofulvin is used for tinea infections of the skin, hair, and nails that are not responsive to topical therapy. Topical treatment of tinea capitis is usually ineffective because the fungus invades the hair shaft. Fluconazole is not indicated for tinea infections.

Question 370

A female patient presents with grayish, odorous vaginal discharge. The primary care NP performs a gynecologic examination and notes vulvar and vaginal erythema. Testing of the discharge reveals a pH of 5.2 and a fishy odor when mixed with a solution of 10% potassium hydroxide. The NP should: a. order metronidazole 500 mg twice daily for 7 days. b. order topical fluconazole. c. withhold treatment until culture results are available. d. prescribe a clotrimazole vaginal suppository for 7 days.

Answer 370

a. order metronidazole 500 mg twice daily for 7 days. This patient has classic symptoms of bacterial vaginosis. The treatment of choice is metronidazole. Fluconazole is used to treat fungal infections. Cultures are generally not helpful in the diagnosis of bacterial vaginosis. Clotrimazole is used to treat Candida infections.

Question 371

A patient comes to the clinic several days after an outpatient surgical procedure complaining of swelling and pain at the surgical site. The primary care NP notes a small area of erythema but no abscess or induration. The NP should: a. refer the patient to the surgeon for further evaluation. b. prescribe topical mupirocin four times daily. c. suggest that the patient apply warm soaks three times daily. d. prescribe TMP-SMX

Answer 371

d. prescribe TMP-SMX. This patient has cellulitis, so empirical treatment with TMP-SMX is indicated. Topical mupirocin is used for superficial skin infections, not cellulitis. Warm soaks may be used as an adjunct to antimicrobial treatment. Unless the cellulitis becomes worse, it is not necessary to refer the patient to the surgeon.

Question 372

A patient comes to the clinic with a history of fever of 102° F for several days, poor appetite, and cough. A sputum culture is pending, but Gram stain indicates a bacterial infection. The primary care nurse practitioner (NP) should: a. use a broad-spectrum antibiotic for initial treatment. b. offer symptomatic treatment only unless the patient's condition worsens. c. begin empirical antibiotic therapy. d. prescribe an antibiotic when culture and sensitivity results are known.

Answer 372

c. begin empirical antibiotic therapy. Patients with signs and symptoms of a bacterial infection may be treated empirically, especially if Gram stain is positive. The antibiotic may need to be changed when culture and sensitivity results become available. It is best to use an antibiotic that is specific to the suspected organism and not a broad-spectrum antibiotic.

Question 373

A patient has a sore throat with fever. The primary care NP observes erythematous 4+ tonsils with white exudate. A rapid antigen strep test is negative, and a culture is pending. The NP orders amoxicillin as empiric treatment. The patient calls the next day to report a rash. The NP should suspect: a. scarlatiniform rash from the streptococcal infection. b. a serum sickness reaction to the penicillin. c. penicillin drug allergy. d. a viral cause for the patient's symptoms.

Answer 373

d. a viral cause for the patient's symptoms. Certain viral infections, such as mononucleosis, increase the frequency of rash in response to penicillin and is commonly attributed to penicillin allergy.

Question 374

A patient has been taking ciprofloxacin for 3 days and calls the primary care nurse practitioner (NP) to report having headaches and dizziness. The NP should: a. reassure the patient that these are common side effects. b. decrease the dose of ciprofloxacin. c. change to levofloxacin. d. change to an antibiotic in another drug class.

Answer 374

a. reassure the patient that these are common side effects. Headaches and dizziness are common side effects of fluoroquinolones. It is not necessary to change to another fluoroquinolone, decrease the dose, or change to another antibiotic class.

Question 375

A patient has begun treatment for HIV. The primary care NP should monitor the patient's complete blood count (CBC) at least every _____ months. a. 6 to 9 b. 9 to 12 c. 1 to 3 d. 3 to 6

Answer 375

d. 3 to 6. The patient's CBC should be monitored at least every 3 to 6 months and more frequently if values are low and bone marrow toxicity is present.

Question 376

A patient has confirmed Rocky Mountain spotted fever, and the infectious disease specialist is treating the patient with doxycycline 100 mg orally for 7 days. The patient comes to the clinic for follow-up care with the primary care NP at the end of therapy and reports continued fever, headache, and myalgia. The NP will consult with the infectious disease specialist and order: a. 7 more days of doxycycline. b. erythromycin 250 mg four times daily for 7 days. c. hospital admission for intravenous chloramphenicol. d. amoxicillin 500 mg three times daily for 10 to 14 days.

Answer 376

c. hospital admission for intravenous chloramphenicol. With treatment, the patient's condition should start to improve in 2 to 3 days. Continued elevation of the temperature may indicate lack of efficacy or drug fever. Chloramphenicol is used to treat Rocky Mountain spotted fever. It is not correct to continue therapy with doxycycline because treatment failure is likely. Erythromycin is used to treat Lyme disease. Amoxicillin is not indicated.

Question 377

A patient has had severe diarrhea for 2 weeks. Laboratory testing reveals Clostridium difficile. The primary care NP should prescribe: a. clarithromycin. b. fidaxomicin. c. erythromycin. d. azithromycin.

Answer 377

b. fidaxomicin.. Fidaxomicin is indicated only for treatment of C. difficile-associated diarrhea. The other macrolides are not used for this purpose.

Question 378

A patient has recently returned from travel in Central America and reports having seven to eight liquid stools each day with severe tenesmus. The primary care NP notes a temperature of 102° F. A stool specimen is Hemoccult positive with leukocytes present. The NP will: a. order tests for Clostridium difficile. b. prescribe tinidazole 2000 mg for 3 days. c. give 750 mg of ciprofloxacin one time only. d. order a stool culture and begin therapy with a fluoroquinolone.

Answer 378

d. order a stool culture and begin therapy with a fluoroquinolone. By history, this patient likely has traveler's diarrhea. The NP should obtain a culture and should start a fluoroquinolones antibiotic empirically. C. difficile is suspected in patients who have been taking antibiotics, which is not true in this case. Tinidazole is used for amebiasis or giardiasis. Ciprofloxacin may be given as a single dose for mild traveler's diarrhea.

Question 379

A patient has urethritis. The primary care NP should prescribe: a. tetracycline. b. demeclocycline. c. doxycycline. d. minocycline.

Answer 379

d. minocycline. Minocycline is indicated to treat urethritis

Question 380

A patient is taking cefadroxil (Duricef) and comes to the clinic complaining of loose stools for several days. The primary care NP notes normal vital signs; warm, pink skin with elastic turgor; and moist mucous membranes. The NP should: a. reassure the patient that loose stools are common with antibiotics. b. recommend consuming lactobacillus-containing foods to minimize diarrhea. c. discontinue the cefadroxil. d. order tests for Clostridium difficile-associated disease (CDAD).

Answer 380

d. order tests for Clostridium difficile-associated disease (CDAD). The U.S. Food and Drug Administration (FDA) advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. This patient's symptoms are mild, so discontinuation of the drug is not warranted unless CDAD is present.

Question 381

A patient is taking an aminoglycoside and a cephalosporin. The primary care NP should consider _____ the dose of _____. a. increasing; aminoglycoside b. decreasing; aminoglycoside c. decreasing; cephalosporin d. increasing; cephalosporin

Answer 381

b. decreasing; aminoglycoside. Cephalosporins can heighten aminoglycoside toxicity, so a decrease in the dose of the aminoglycoside should be considered.

Question 382

A patient is taking amantadine to treat a viral infection. The patient calls the primary care NP to report having blurred vision. The NP should: a. counsel the patient to avoid driving until this subsides. b. question the patient about suicidal ideation. c. tell the patient to stop the medication immediately. d. tell the patient to come to the clinic for an electroencephalogram.

Answer 382

a. counsel the patient to avoid driving until this subsides. Blurred vision or impaired mental acuity may result from the use of amantadine. Patients with a history of psychiatric illness may develop suicidal ideation, but this is not associated with blurred vision. It is not necessary to stop the medication. Patients with a history of seizures may have seizures with this drug, but this is not associated with blurred vision.

Question 383

A patient is diagnosed with onychomycosis. The primary care NP notes that the patient takes quinidine. The NP should prescribe: a. terbinafine (Lamisil). b. griseofulvin (Gris-PEG). c. itraconazole (Sporanox). d. fluconazole (Diflucan).

Answer 383

a. terbinafine (Lamisil). Sporanox and terbinafine are both indicated to treat onychomycosis. Sporanox is not indicated in patients taking quinidine because of the risk of cardiac arrhythmias. Fluconazole and griseofulvin are not indicated to treat onychomycosis.

Question 384

A patient is taking isoniazid, pyrazinamide, rifampin, and streptomycin to treat TB. The primary care NP should routinely perform: a. color vision, serum glucose, and LFTs. b. ophthalmologic, hearing, and serum glucose tests. c. bone marrow density and ophthalmologic tests. d. serum glucose and liver function tests (LFTs).

Answer 384

b. ophthalmologic, hearing, and serum glucose tests. For patients taking isoniazid, obtain periodic ophthalmologic examinations; for patients taking pyrazinamide, perform blood glucose tests.

Question 385

A patient who has been taking ciprofloxacin for 14 days for treatment of a UTI is seen in the clinic for a follow-up urinalysis. The urinalysis reveals crystalluria. The primary care NP should: a. counsel the patient to increase fluid intake. b. decrease the dose of ciprofloxacin. c. change the antibiotic to norfloxacin. d. discontinue the ciprofloxacin.

Answer 385

a. counsel the patient to increase fluid intake. Fluoroquinolones can cause renal irritation and urine crystals. Patients should be advised to maintain proper hydration to avoid this. It is not necessary to discontinue the ciprofloxacin or to decrease the dose.

Question 386

A patient who has been taking medications to treat TB tells the primary care NP that the infectious disease specialist has added ethambutol to the drug regimen. The patient asks the NP for information about this drug. The NP should explain that this drug: a. requires more frequent monitoring of LFTs. b. should be taken 1 hour before or 2 hours after a meal. c. means the patient will need regular vision examinations and evaluation of color vision. d. should not be taken by patients who have renal impairment.

Answer 386

c. means the patient will need regular vision examinations and evaluation of color vision. Ethambutol can cause changes in vision, including red-green color blindness. It should be taken with food. It may be taken by patients with renal impairment with adjustment of doses.

Question 387

A patient who has had two recent urinary tract infections is in the clinic with dysuria and fever. The primary care NP reviews the patient's chart and notes that in both previous cases the causative organism and sensitivity were the same. The NP should: a. order a urine culture and treat empirically pending culture results. b. order a microscopic evaluation of the urine and an antibiotic. c. treat the patient empirically without a culture. d. order a urine culture and sensitivity and wait for results before treating.

Answer 387

a. order a urine culture and treat empirically pending culture results. Because this patient has had similar infections in the past, treating empirically is acceptable. The NP must still obtain a culture and sensitivity so that appropriate antibiotic therapy can be provided, even though it is likely that this is a recurrence of the same organism. A culture should always be obtained when possible. A microscopic evaluation is used to determine whether or not a culture should be performed and is not diagnostic.

Question 388

A patient is taking tetracycline for a rickettsial infection and reports having heartburn. The primary care NP should: a. recommend drinking milk when taking the medication. b. tell the patient to use antacids when heartburn occurs. c. ask the patient how the medication is taken. d. tell the patient to take the medication with food.

Answer 388

c. ask the patient how the medication is taken. Patients should sit up for at least 30 minutes after taking tetracycline to avoid the risk of esophageal ulceration. Tetracycline should not be taken with food, antacids, or milk.

Question 389

A patient who is taking a fluoroquinolone antibiotic for pyelonephritis develops Clostridium difficile-associated disease (CDAD). The primary care NP should treat for C. difficile and _____ fluoroquinolone. a. increase the dose of b. continue the c. decrease the dose of d. discontinue the

Answer 389

d. discontinue the. Patients who develop CDAD while taking fluoroquinolones should stop taking the drug immediately

Question 390

A patient who takes isoniazid and rifampin for latent TB comes to the clinic with a new-onset cough and night sweats. The primary care NP should evaluate these findings by ordering: a. a sputum culture. b. renal function tests. c. tuberculin skin test. d. LFTs

Answer 390

a. a sputum culture. Patients with latent TB who develop symptoms while being treated should have a sputum culture.

Question 391

A patient with group A b-hemolytic streptococcal pharyngitis is treated with penicillin V. At a follow-up visit 2 weeks later, the patient presents with edema of the hands and feet, blood pressure of 140/85 mm Hg, and cola-colored urine. A urine dipstick shows proteinuria. The primary care NP should: a. order oral amoxicillin-clavulanate for 14 days. b. prescribe 10 more days of penicillin V. c. obtain an ASO titer and creatinine clearance. d. perform a repeat throat culture.

Answer 391

c. obtain an ASO titer and creatinine clearance. A minimum of 10 days of treatment is recommended for any infection caused by group A b-hemolytic streptococcus to prevent the occurrence of rheumatic fever or acute glomerulonephritis. This patient shows signs of acute glomerulonephritis, so the NP should obtain an ASO titer and creatinine clearance to help confirm the diagnosis. It is not necessary to repeat the throat culture. Treatment involves controlling blood pressure and maintaining renal function, not giving antibiotics.

Question 392

A patient who was recently hospitalized and treated with gentamicin tells the primary care NP, "My kidney function test was abnormal and they stopped the medication." The patient is worried about long-term effects. The NP should: a. reassure the patient that complete recovery should occur. b. monitor renal function for several months. c. refer the patient to a nephrologist for follow-up evaluation. d. monitor serum electrolytes and serum creatinine and BUN.

Answer 392

a. reassure the patient that complete recovery should occur. Recovery of renal function occurs if the drug is stopped at the first sign of renal impairment. It is necessary to monitor blood values during therapy to ensure effectiveness and prevent toxicity.

Question 393

A patient who was hospitalized for an infection was treated with an aminoglycoside antibiotic. The patient asks the primary care nurse practitioner (NP) why outpatient treatment wasn't an option. The NP should tell the patient that aminoglycoside antibiotics: a. cause serious adverse effects. b. are more likely to be toxic. c. carry more risk for serious allergic reactions. d. must be given intramuscularly or intravenously.

Answer 393

d. must be given intramuscularly or intravenously. Aminoglycoside antibiotics must be given intramuscularly or intravenously when treating infection. Their side effects may be serious, which is an indication for hospitalization.

Question 394

A primary care NP is planning to order a macrolide antibiotic for a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease. The patient is taking a cytochrome (CYP) 3A medication. The NP should order: a. clarithromycin. b. erythromycin base. c. azithromycin. d. erythromycin estolate.

Answer 394

ANS c. azithromycin.

Question 395

A primary care NP is preparing to prescribe a fluoroquinolone for a patient who has a history of alcohol abuse that has caused liver damage. The NP should choose: a. ciprofloxacin. b. gemifloxacin. c. norfloxacin. d. levofloxacin

Answer 395

d. levofloxacin. Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones.

Question 396

A primary care NP is preparing to prescribe a macrolide antibiotic for a patient who has a history of a prolonged QT interval on electrocardiogram. Which macrolide antibiotic should the NP prescribe? a. Clarithromycin b. Azithromycin c. Telithromycin d. Erythromycin

Answer 396

b. Azithromycin. Azithromycin does not cause a prolonged QT interval , unlike the other macrolides, so it would be safe for this patient. Visual disturbances have been found to occur with the use of telithromycin. Erythromycin has a wider range of adverse effects and can cause cardiac effects in patients who have a prolonged QT interval. The Ilosone, E-Mycin, and Erythrocin are all erythromycins.

Question 397

A primary care NP provides teaching for a patient who is about to begin taking levofloxacin tablets to treat an infection. Which statement by the patient indicates a need for further teaching? a. "I should take the tablet 2 hours before taking vitamins or an antacid." b. "I should use caution while driving when taking this medication." c. "I should use sunscreen while taking this medication." d. "I should take this medication on an empty stomach."

Answer 397

d. "I should take this medication on an empty stomach." Levofloxacin tablets may be taken without regard to food, although levofloxacin solution must be taken on an empty stomach. Patients should be cautioned to use sunscreen and to avoid situations where drowsiness may impair function. Levofloxacin should not be taken with antacids or vitamins.

Question 398

A primary care NP provides teaching to a patient who will begin taking cefadroxil (Duricef). Which statement by the patient indicates a need for further teaching? a. "I should take this medication with food." b. "I will take this medication twice daily." c. "I should report any rash that occurs." d. "Gastrointestinal (GI) symptoms are common but not worrisome."

Answer 398

d. "Gastrointestinal (GI) symptoms are common but not worrisome." The FDA advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. Patients should be taught to report all GI symptoms

Question 399

A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprim-sulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase. The NP sends the urine for culture and should treat this patient empirically with: a. ciprofloxacin. b. azithromycin. c. gemifloxacin. d. TMP/SMX.

Answer 399

a. ciprofloxacin. Fluoroquinolones are effective in treatment of UTIs that are resistant to other antibiotics. Because this patient recently completed a course of TMP/SMX, the NP can assume that the bacterium causing the infection is resistant to TMP/SMX. Gemifloxacin is not indicated for UTI, but ciprofloxacin is. Azithromycin is not a fluoroquinolone.

Question 400

A primary care NP sees a patient who reports a 2-week history of nasal congestion and runny nose. The NP performs a history and learns that the nasal discharge has changed from yellow to green in the past few days, accompanied by a fever of 102° F and unilateral facial pain. To treat this patient, the NP should: a. order azithromycin daily for 5 days. b. prescribe cefdinir twice daily for 10 days. c. recommend symptomatic treatment because this is probably a viral infection. d. prescribe amoxicillin-clavulanate twice daily for 10 days.

Answer 400

d. prescribe amoxicillin-clavulanate twice daily for 10 days. Evidence of a bacterial sinus infection includes prolonged symptoms without improvement for 10 to 14 days, fever greater than 102° F, and unilateral pain. A bacterial infection should be suspected if nasal discharge turns from yellow to green. Amoxicillin-clavulanate is a recommended first-line drug to treat sinusitis.

Question 401

A primary care NP sees a patient who was recently hospitalized for infection and treated with gentamicin for 10 days. The patient tells the NP that the drug was discontinued early because "my blood level was too high." The NP should order: a. a serial audiometric test. b. a urinalysis and complete blood count. c. a serum blood urea nitrogen (BUN) and creatinine. d. serum calcium, magnesium, and sodium.

Answer 401

a. a serial audiometric test. Aminoglycosides are associated with ototoxicity and nephrotoxicity. Recovery of renal function occurs if the drug is stopped at the first sign of renal impairment. The NP should evaluate the possibility of ototoxicity with a serial audiometric test.

Question 402

A primary care nurse practitioner (NP) sees a child who has several honey-colored crusted lesions around the nose and mouth. The NP notes that no other lesions are present. The NP should prescribe: a. dicloxacillin. b. trimethoprim-sulfamethoxazole (TMP-SMX). c. mupirocin topical. d. clarithromycin.

Answer 402

c. mupirocin topical. Although systemic antibiotics are often required to treat impetigo, mupirocin can be used for topical treatment of mild impetigo. Because this is a localized infection, mupirocin can be ordered empirically. Dicloxacillin and clarithromycin are used when systemic empirical treatment is indicated. TMP-SMX is used to treat cellulitis.

Question 403

A school-age child comes to the clinic with a 5-day history of cough and low-grade fever. The primary care NP auscultates crackles and diminished breath sounds bilaterally. The NP should: a. recommend symptomatic treatment. b. obtain a sputum culture. c. order azithromycin. d. prescribe doxycycline.

Answer 403

ANS c. order azithromycin. Community-acquired pneumonia in school-age children is commonly caused by Mycoplasma. Azithromycin is a first-line drug of choice to treat this type of pneumonia.

Question 404

A woman has a urinary tract infection (UTI) and has been taking TMP-SMX for 3 days along with increased fluids. She reports continued dysuria and urinary frequency and has a consistent, low-grade fever. The primary care NP should: a. prescribe amoxicillin-clavulanate twice daily for 7 days. b. prescribe ciprofloxacin twice daily for 3 days. c. order doxycycline twice daily for 7 to 14 days. d. order TMP-SMX DS twice daily for 7 days.

Answer 404

b. prescribe ciprofloxacin twice daily for 3 days. Initial treatment of uncomplicated UTI is a 3-day course of TMP-SMX. Ciprofloxacin is used if the patient is still symptomatic. Doxycycline is a second-line treatment. Amoxicillin-clavulanate is used to treat pyelonephritis.

Question 405

A woman is in the 36th week of pregnancy. The nurse practitioner (NP) providing prenatal care learns that the woman has a history of two previous urinary tract infections during this pregnancy. A dipstick urinalysis in the office today is negative for leukocyte esterase and nitrites. The NP should: a. prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis. b. order a voiding cystourethrogram to rule out structural anomalies that may cause urinary tract infection. c. encourage the patient to increase daily water intake and to wear only cotton underwear. d. order nitrofurantoin daily to minimize the patient's risk of urinary tract infection late in her pregnancy.

Answer 405

c. encourage the patient to increase daily water intake and to wear only cotton underwear. For women at risk for recurrent urinary tract infection while pregnant, prevention and treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton underpants. Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract infection during pregnancy, but not after the 36th week of gestation. A voiding cystourethrogram is not indicated and would expose the fetus to radiation

Question 406

During a gynecologic examination of a sexually active adolescent girl, the primary care NP notes mucopurulent cervicitis. A culture is positive for Neisseria gonorrhoeae. The NP should: a. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin. b. give a single dose of 2 g of oral azithromycin. c. administer benzathine penicillin G 2.4 million units intramuscularly. d. prescribe oral doxycycline 100 mg daily for 7 days.

Answer 406

a. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin. Many patients who present with one sexually transmitted disease (STD) have other concomitant STDs. When gonorrhea or urethritis/cervicitis is diagnosed, the NP should treat for both N. gonorrhoeae and Chlamydia. A single-dose treatment ensures compliance. A single, 2-g dose of azithromycin is indicated to treat chancroid. Benzathine penicillin G is indicated to treat syphilis. A 7-day regimen of doxycycline is used to treat Chlamydia, but not gonorrhea.

Question 407

An adult patient has cellulitis. The patient is a single parent with health insurance who works and is attending classes at a local university. To treat this infection, the primary care nurse practitioner (NP) should prescribe: a. cefadroxil (Duricef). b. cefdinir (Omnicef). c. ceftriaxone (Rocephin). d. cephalexin (Keflex).

Answer 407

a. cefadroxil (Duricef). First-generation cephalosporins, such as cephalexin and cefadroxil, are used for skin and soft tissue infections. Cefadroxil is preferred in this case because it can be given twice daily instead of four times daily, and this patient will be more likely to comply with the drug regimen. Cefdinir and ceftriaxone are both third-generation cephalosporins.

Question 408

An 80-year-old patient who has COPD takes TMP/SMX for acute exacerbations, which occur three or four times each year. To monitor this patient for adverse drug reactions, the primary care NP should order: a. blood urea nitrogen and creatinine. b. a complete blood count (CBC) with differential. c. serum bilirubin levels. d. liver function tests.

Answer 408

b. a complete blood count (CBC) with differential. The most frequently reported severe adverse reactions in elderly patients include bone marrow depression and decreased platelets. A CBC with differential is indicated to monitor for this. Evaluation of liver and renal function should be performed before beginning treatment because adverse effects are more common in patients with decreased renal and liver function.

Question 409

A young woman will begin taking minocycline. The primary care NP should tell this patient to: a. expect headaches while taking this medication. b. always take the medication on an empty stomach. c. use a backup form of contraception if currently taking oral contraceptive pills. d. avoid taking antacids while taking this drug.

Answer 409

c. use a backup form of contraception if currently taking oral contraceptive pills. Tetracyclines may decrease the effects of oral contraceptive pills, so patients should use a backup form of contraception. Headaches are uncommon. Minocycline may be taken with food and is not affected by antacids.

Question 410

``` A sexually active woman is being treated for streptococcal pharyngitis. The patient takes oral contraceptive pills (OCPs). Which penicillin should the primary care NP prescribe for this patient? A. Ampicillin B. Penicillin V C. Penicillin G D. Dicloxacillin ```

Answer 410

C. Penicillin G . Although penicillin V is the drug of choice, ampicillin and penicillin G can be used to treat streptococcal pharyngitis. Penicillin G is the only penicillin that does not interfere with OCPs. Dicloxacillin is not recommended to treat streptococcal pharyngitis.

Question 411

A patient is taking dicloxacillin (Dynapen) 500 mg every 6 hours to treat a severe penicillinase-resistant infection. At a 1-week follow-up appointment, the patient reports nausea, vomiting, and epigastric discomfort. The primary care NP should: A. Change the medication to cephalosporin B. Decrease the dose to 250 mg every 6 hours C. Reassure the patient that these are normal adverse effects of this drug D. Order blood cultures, a white blood cell count, and LFTs

Answer 411

ANS D: order blood cultures, a white blood cell (WBC) count with differential, and liver function tests (LFTs). When giving penicillinase-resistant penicillins, it is important to monitor therapy with blood cultures, WBC with differential cell counts, and LFTs before treatment and weekly during treatment. This patient may have typical gastrointestinal side effects, but the symptoms may also indicate hepatic damage. Changing the medication is not indicated, unless serious side effects are present. Decreasing the dose is not indicated.

Question 412

A primary care nurse practitioner (NP) sees a 3-year-old child who has a history of recurrent otitis media. The child's parent tells the NP that the child is allergic to penicillin. The NP learns that the child developed an all-over rash 2 days after starting amoxicillin at age 2 years. The NP should: A. order a penicillin skin test. B. use cephalosporins when treating otitis media. C. order penicillin desensitization so the child can take penicillin when needed. D. use amoxicillin when needed because actual allergy correlates poorly with patient report.

Answer 412

A. order a penicillin skin test. Although it is true that patient report correlates poorly with actual allergy, there is a risk of life-threatening anaphylaxis with a true penicillin allergy. The NP should order a penicillin skin test to verify allergy. If the skin test is positive, the patient should avoid b-lactam antimicrobials. Penicillin desensitization can be used for penicillin-allergic patients who need penicillins.

Question 413

``` Which antibiotic requires administration of a loading dose? A. Ilosone B. E-Mycin C. Erythrocin D. Zithromax ```

Answer 413

D. Zithromax . It is important to give a loading dose, without which minimum plasma concentrations may take 5 to 7 days to reach steady state.

Question 414

A patient has been taking griseofulvin for 4 weeks to treat a tineal capitis infection. The primary care NP notes improvement but not complete cure. The NP should: A. renew the rx after obtaining renal, liver, and hematopoietic tests B. prescribe griseofulvin for 4 more weeks and the re-evaluate the infection C. Add a topical antifungal cream and refill the griseofulvin rx for 2 weeks D. obtain a cx and change to ketoconazole

Answer 414

ANS A, renew the rx … Tineal infections may take 6 weeks to respond to griseofulvin. Patients taking griseofulvin longer than 4 weeks should have renal, hepatic, and hematopoietic functions monitored periodically. Topical antifungals typically are not effective for tinea capitis. Ketoconazole is usually not effective for tinea capitis.

Question 415

The primary care NP teaches a patient about TMP/SMX before prescribing it to treat a urinary tract infection (UTI). Which statement by the patient indicates a need for further teaching? a. “I will take this medication with food.” b. “I should drink a full glass of water with each dose.” c. “I should stay out of direct sunlight and use sunscreen.” d. “I should report any ringing in my ears or a sore throat.”

Answer 415

ANS: A TMP/SMX should be taken on an empty stomach, so this statement is incorrect and indicates the need for further teaching. The other statements all are correct.

Question 416

A patient has been taking trimethoprim-sulfamethoxazole (TMP/SMX) for 14 days. The patient calls the primary care nurse practitioner (NP) to report fever, rash, and enlarged lymph nodes. The NP should suspect: a. serum sickness reaction. b. immediate sensitivity reaction. c. cytotoxic hypersensitivity reaction. d. cell-mediated hypersensitivity reaction.

Answer 416

A Serum sickness reaction can occur days to weeks after administration of the drug and is characterized by fever, rash, and lymphadenopathy. Immediate sensitivity reaction includes anaphylaxis, urticaria, and angioedema and occurs within 30 minutes of drug administration. Cytotoxic hypersensitivity reaction causes hemolytic anemia, neutropenia, and thrombocytopenia and develops 7 to 14 days after drug administration. Cell-mediated hypersensitivity reaction causes maculopapular rash, Stevens-Johnson syndrome, and toxic epidermal necrolysis and takes 48 to 72 hours to develop.

Question 417

A patient is taking levofloxacin to treat sinusitis. The patient calls the primary care NP to report pain just above the heel of the right foot. The NP should: a. change to ofloxacin. b. change to ciprofloxacin. c. discontinue the levofloxacin. d. reassure the patient that this is a common side effect.

Answer 417

C Warnings have been issued for the fluoroquinolone antibiotics for the increased risk of tendon ruptures. Ruptures have occurred unilaterally and bilaterally, and have involved the Achilles tendon; however, ruptures in the shoulder joint, hand, biceps, thumb, and other tendon sites have been reported. The risk of tendon rupture is further increased in those over age 60, those receiving concomitant steroid therapy, and in kidney, heart, and lung transplant recipients. Reasons for tendon ruptures also include physical activity or exercise, kidney failure, and tendon problems in the past. These ruptures may occur during therapy or up to several months after discontinuation of drugs.