Final Exam Student Questions Flashcards

Question

Before starting drug therapy for osteoarthritis, the practitioner should recommend appropriate nonpharmacologic therapies. These recommendations should include all the following EXCEPT: a. Moist heat to help diminish muscle spasms and relieve stiffness b. Weight loss, especially for patients with hip and knee osteoarthritis c. Avoid exercise which can deteriorate the joints that have osteoarthritis d. Use of assistive devices to help with ambulation and ADLs

Answer 1

Rationale: C is the answer. According to our text, A, B, and D are good recommendations for nonpharmacologic therapies. C is incorrect because exercise can strengthen muscles surrounding the involved joints and a fitness program can maintain flexibility of the involved joint through swimming, walking, cycling, or isometric exercises (p. 593 of the textbook)

Answer 2

Rationale: b. Acetaminophen is the correct answer. If the patient stays within the recommended dose there are very few side effects, and it is more cost effective. Corticosteroid injections are not the correct answer because they are restricted in use due to the potential for cartilage destruction and osteonecrosis from repeated injections. Analgesics are not the correct answer because you can only prescribe them for a limited time due to potential dependence and withdrawal symptoms. NSAIDS are not the correct answer because they have the possibility for many adverse events including visual changes, weight gain, headache, dizziness, nervousness, photosensitivity, weakness, tinnitus, easy bruising or bleeding, and fluid retention. (p. 593 - 599 in the text)

Answer 3

Rationale: A. 2 to 4 weeks is the correct answer, If the patient continuously uses capsaicin the maximal effect is seen in 2-4 weeks. B is wrong because Analgesics such as Tramadol a decrease in pain is seen in 1-2 hours. C is wrong because this is for acetaminophen, which if it is taken around the clock patients will experience pain relief in 1 week. D is how soon patients that receive corticosteroid injections would have symptom relief.

Answer 4

Rationale: Answer C is the correct answer. Pharmacologic treatment goals for osteoarthritis are to maintain function, prevent further joint damage, and to diminish associated pain (Per Pharmacotherapeutics for Advanced Practice textbook and its associated powerpoint slides). Answer C is therefore wrong in the pharmacologic treatment goals because there are no pharmacologics that actually reverse the effects of osteoarthritis to restore that joint to its original, pre osteoarthritic, functioning. Therefore, C would be the correct answer in this scenario.

Answer 5

Rationale: Answer D is the correct answer. This is because the recommendations for treatment of OA of the hand include 1st line of topical NSAIDs like capsaicin, 2nd line of APAP (acetaminophen), 3rd line of NSAIDs, and steroids for painful flare ups. All of these would be chosen before the practitioner considers opioids for the pain.

Answer 6

Rationale: Answer A is the correct answer. The key to acetaminophen dosing for OA is to schedule the dose regarding the patient’s pain. To be most effective, it must be taken regularly. The recommended dose is 650 mg every 4-6 hours or 1,000 mg every 6-8 hours. The patient should not wait until pain is present. It is most effective when taken around the clock to stay on top of the pain. If taken as scheduled, patients may have pain relief within 1 week of initiation.

Answer 7

D. Postmenopausal women using estrogen to manage the effects of menopause should be warned that estrogen use is linked to increased risk of heart disease, MI, stroke and breast cancer.

Answer 8

A. INCORRECT. The mirena does not cause an inflammatory reaction. This is an IUD but it is describing how the Paragard works. B. CORRECT. Mirena is a progestin only treatment that only partially inhibits ovulation but does prevent the sperm from moving into the reproductive system. C. INCORRECT. This is describing a cervical cap or diaphragm what are used with spermicide and create a physical barrier D. INCORRECT. The mirena is a progestin only treatment. This answer describes multiple other OC like pills, the patch or the nuva ring.

Answer 9

Answer: D Rationale: If a woman missed two doses and is in her first week of her medication cycle and has had intercourse, she should use emergency contraception a soon as possible, but could use it effectively up to 120 hours after intercourse. She should then resume her scheduled medications as before. A- This answer would be suitable for missing a single dose or if she had missed two doses of 30-35mg pills at any point into the cycle. B- This answer would be suitable if she missed more than two doses of any mg or two 20mg doses as a preventive measure while she begins taking the medication as originally planned. C- This answer is more suitable for someone who missed more than two pills or missed two pills of 20mg doses in their third week of medication cycle without intercourse.

Answer 10

Correct answer is : C; an NP should educate patient to avoid placing lotion/creams/powders on site and place patch on clean and dry skin. A is incorrect: Education should include to avoid placing patch on the same site two consecutive weeks. B is incorrect: Education should include that the location of patch should not be altered mid-week, but should be applied the same day each week. D is incorrect: Education should include that the patch should never be placed on the breast, cut or irritated skin.

Answer 11

Correct answer is: A; Progesterone-only mini-pill is appropriate for a lactating woman. B Is incorrect because monophasic continuous therapy is the recommended agent for a patient with endometriosis. C is incorrect because a combination pill with higher estrogen content in first half of cycle is recommended for a patient with breakthrough bleeding in the first half of the cycle. D is incorrect because depot medroxyprogesterone acetate is recommended for a noncompliant patient. ( Text Chapter 55 contraceptive notes power point, slides 16-18)

Answer 12

The correct Answer is (C). Oral contraceptives. Having given birth, a tubal ligation, ovary removal, hysterectomy, having used birth control for 5 years or more, and breastfeeding are associated with a lower chance of getting ovarian cancer. Answer A is incorrect because there is new research that might suggest a link between use of oral contraceptives and brain tumors and a brain cancer known as glioma. Answer B is incorrect because birth control increases the risk of breast cancer. Answer D is incorrect. Long-term use of oral contraceptives increases the risk of cervical cancer

Answer 13

D. Take the most recent missed active pill as soon as possible, discard other missed pills, and continue with the regular schedule, even if it means taking two pills in one day. Use back-up contraception or avoid intercourse for 7 days. A. is INCORRECT because the patient should continue taking her current pack and finish it before starting a new pack. B. is INCORRECT because the patient should take her missed pills as soon as she remembers it on the same day she should take it. C. is INCORRECT because pt should just take the recent pill that she missed and discard other missed pills and continue with the regular schedule. Rationale: Based on the US selected practice recommendations for contraceptive use, 2016 (CDC) Recommendations for providers for two missed pills for combined Progestin and Estrogen OCPs: -Missed oral contraceptive pills is a major cause of oral contraception failure. Guidelines have been established by the Centers for Disease Control and Prevention, which provide recommendations for missed oral contraception. Currently, if two or more pills are forgotten (more than 48 hours late) only the last 'forgotten' pill is taken, other missed pills are discarded and the next pill taken at the usual time - often this means taking two pills in one day. -A back-up method (condoms or avoid intercourse) is needed for the next 7 consecutive pill days. -If pills were missed in the last week of hormonal pills (days 15 to 21 for 28 pack days): omit the hormone free interval by finishing the hormonal pills and the current pack and starting a new pack the next day If unable to start a new pack immediately, use a back up contraception until hormonal pills for my new pack of been taken for seven consecutive days -Considered emergency contraception if hormonal pills were missing during the first week and unprotected sexual intercourse occurred in the previous five days or at other times as appropriate -If the patient missed the inactive pills, the pack should be finished in a new pack started the next day missing out the break Source: the American College of Obstetricians and Gynecologists and CDC

Answer 14

C (Diabetes Mellitus) Rationale: Uncontrolled Hypertension, known or suspected pregnancy, and acute liver disease are all absolute contraindications to hormone therapy (Found in textbook Box 56.1 on page 976). Diabetes Mellitus is not contraindicated in hormone therapy.

Answer 15

Answer: D (Cold intolerance) Rationale: Vaginal dryness, insomnia, and mood changes are all very common symptoms for women who are perimenopausal or postmenopausal. Cold intolerance is not a common symptom, as many women experience hot flashes. Any of these symptoms may indicate a need for hormone replacement therapy for symptom control, but not for prolonged use. (Found in textbook on page 972.)

Answer 16

Answer: D Rationale: D is correct because an increased dose of estrogen may be needed in smokers because only half of the serum level achieved in nonsmokers is reached (Textbook pg. 976, Interactions paragraph) A is incorrect because alcohol increases the circulating levels of estrogen due to the liver’s preoccupation with metabolizing the alcohol at the expense of estrogen (Textbook pg. 976, Interactions paragraph) B is incorrect because patients taking phenytoin metabolize estrogen at a faster rate (Textbook pg. 976, Interactions paragraph) C is incorrect because the use of hormone therapy containing estrogen plus a progestogen in linked to a lowered risk of colon cancer (Textbook pg. 977)

Answer 17

Answer: B (Management of menopause is achieved on the highest dose possible for as long as the patient wants) Rationale: Patients should be advised that management is achieved on the lowest dose and for the shortest duration possible due to increased risk of breast cancer, CHD, and VTE associated with long term use. Patients are encouraged to reach out to their provider when they feel discontinuation is appropriate (Found in textbook pgs 975 & 981).

Answer 18

Answer: A (Family history of breast cancer) Rationale: Absolute contraindications for combination oral contraceptive pills include thombophlebitis, thromoembolic disorder, cerebral vascular disease, coronary occlusion, impaired liver function, breast cancer, abnormal vaginal bleeding in the absence of a diagnosed cause, pregnancy, and smokers older than 35 years old. (Found in textbook pg. 967 box 55.2 ).

Answer 19

Answer: A (height) Rationale: When selecting the most appropriate contraceptive agent for a patient the practitioner should consider body mass index because the obese patient may require higher doses of estrogen and progesterone. Additionally, baseline blood pressure, lipid panel measurements and liver and renal function panels should be taken into consideration to determine if the patient is an appropriate candidate for oral contraception. Height is not a determining factor of the appropriate agent. (Found on textbook page 966).

Answer 20

D Rationale: According to the text and lecture, metformin (p. 793), glimepiride (p. 792) and nateglinide (lecture) are contraindicated or use with caution in patients with CKD. Repaglinide is excreted by the liver, not the kidneys, so it is safer to use.

Answer 21

Rationale: According to the text and lecture, thiazolidinediones are contraindicated for patients with heart failure (793-794). These medications also have adverse side effects of weight gain, risk of fracture, and fluid retention. Alpha-glucose inhibitors (794), amylinomimetics (797), and sulfonylureas (788, 792) make no mention of heart failure. According to the lecture, there is a Black Box warning for thiazolidinediones and heart failure

Answer 22

Rationale: According to the lecture (Insulin Precautions/Interactions slide) and text (Page 266), Beta blockers (except for metoprolol) may mask the symptoms of hypoglycemia. Hypoglycemia triggers the release of catecholamines which bind to Beta 1 receptors in the heart causing an increase in heart rate. Beta blockers decrease this effect.

Answer 23

C Rationale: According to the text (pg 793), metformin-induced lactic acidosis is a potentially fatal complication of metformin therapy. Risk of lactic acidosis increases with age and renal dysfunction, so with Mrs. S’s recent infection most likely contributing to her renal dysfunction and probable poor tissue perfusion, metformin should not be restarted at this time. In addition, metformin is contraindicated with CHF. (Mackenzie)

Answer 24

B Rationale: According to the text and lecture, Rosiglitazone is contraindicated in patients already taking insulin. Taking these medications together may pose increased risk of heart issues, such as decreased blood flow to the heart and angina.

Answer 25

B Rationale: According to the lecture, the most important components of an effective treatment program for DM is to create a drug therapy regimen individualized for each patient, to include oral glucose-lowering agents for some type 2 patients, and to prevent and treat both acute and chronic complications of DM such as hypoglycemia.

Answer 26

C Rational: C.) is the right answer because it has both routes that Regular insulin can be administered. B.) is right as well but isn’t best because IV is also an optional route. A.) is incorrect because it can not be administered orally and D.) is wrong as well because C.) is right. See Diabetes lecture per L. Cordell specifically the slide titled “Short Acting Insulin”.

Answer 27

Rational: A.) is the correct answer based on the recommended treatment for long-acting insulin administration for a Type 1 diabetic. B, C,and D are wrong because this would be too much long acting insulin for a Type 1. See Diabetes lecture per L. Cordell specifically the slide titled “Recommended order of treatment for Type 1 DM”.

Answer 28

Rational: D) is the correct answer because rapid acting insulin peaks 45-75 minutes after administration. This is the time when the patient will be at highest risk for hypoglycemia. A, B, and C are outside of the peak time. See Table 46.4, pg. 799 and Professor Cordell’s lecture, slide 34.

Answer 29

Answer choice D is the correct answer because regular insulin therapy is used for patients who are not having prandial spikes throughout the day, and patients on continuous tube feeding and NPO patients will not have prandial spikes. Answer choices B and C are correct for the same reason, but D is a more inclusive answer. Answer choice A is incorrect because every time a patient receives a bolus tube feeding, they will have a prandial spike and rapid acting insulin would be more appropriate in this situation. See Diabetes lecture per L. Cordell specifically the slide titled “Short Acting Insulin”.

Answer 30

D Rationale: In patients with DMII, progression of the illness causes worsening insulin resistance and decreased insulin secretion. Because of this, intensification of treatment to include exogenous insulin is often indicated. “Insulin is the preferred second-line medication for patients with A1C >8.5 percent or with symptoms of hyperglycemia despite initial therapy with metformin and lifestyle intervention. Avoiding insulin, the most potent of all hypoglycemic medications, at the expense of poorer glucose control and greater side effects and cost, is not likely to benefit the patient in the long term.” (McCulloch, 2017)

Answer 31

Answer: C. Rationale: Following the initiation of intermediate/long acting insulin therapy, the ADA recommends checking fasting glucose daily and increasing insulin dose by 2 units every 3 days until fasting glucose is within target range (80-130mg/dl).

Answer 32

Correct response: E. Rationale: Amylin affects glucose control through several mechanisms, including slowed gastric emptying, regulation of postprandial glucagon, and reduction of food intake (table 1). Glucagon-like peptide 1 (GLP-1) exhibits similar properties as amylin, with the exception of insulin secretory effects. Amylin, unlike GLP-1, does not have insulin secretory effects, but both regulate hyperglycemia in part through amelioration of inappropriate glucagon secretion and gastric emptying. GLP-1 and amylin appear to have differing magnitudes of physiologic effects and bind to different receptors in the area postrema, the part of the brain that may be key for their effects on satiety Pramlintide is a stable, soluble, non aggregating, equipotent amylin analog that is administered by mealtime subcutaneous injection. It is available for use for both type 1 and insulin-treated type 2 diabetes. Pramlintide reproduces the actions of amylin and controls glucose without causing weight gain.

Answer 33

Best answer- a. Chlamydia Rationale- Patients who are infected with N. gonorrhea are often coinfected with C. trachomatis (the bacteria that causes chlamydia). In order to prevent spread, serious comorbidities and antimicrobial resistance, patients with gonorrhea are also treated for chlamydia. b. Syphilis, c. HPV and d. Genital herpes are incorrect because they do not as commonly coexist with gonorrhea and are not automatically treated without a confirmation of infection.

Answer 34

Best answer- b. Ceftriaxone 250 mg IM once PLUS azithromycin 1 g PO once Rationale- This course of treatment is effective at treating both N. gonorrhea and C. trachomatisand can be given in the office during the same visit. This is ideal for the patient because she stated that she does not take her birth control pill daily as indicated, and therefore may not be reliable in continuing to take an ATB bid for 7 days.a.Ceftriaxone 250 mg IM once is incorrect because this alone will not treat for C. trachomatis c. Ceftriaxone 250 mg IM once PLUS doxycycline 100 mg PO bid for 7 days is incorrect because the patient has stated that she does not take her birth control pill daily and therefore may not be reliable in continuing to take the doxycycline bid for 7 days. d.None of these because she might be pregnant is incorrect because ceftriaxone and azithromycin are pregnancy category B and can be taken even if she is pregnant.

Answer 35

Best answer: C. The preferred treatment for Chlamydia is Azithromycin, Erythromycin, Doxycycline, and Ofloxacin.

Answer 36

Best answer: E. People exposed in any stage of Syphilis should be evaluated.

Answer 37

Except for B, all the above statements are true regarding genital herpes. Asymptomatic viral shedding is actually more frequent in genital HSV-2 infections and the most during the first 12 months of acquiring HSV-1

Answer 38

Best answer: D. Protease inhibitors can cause a syndrome of lipodystrophy, hyperlipidemia, diabetes mellitus type 2, and kidney stones.

Answer 39

Answer: A Rationale: While A,B,C are all appropriate treatments for Jane’s chlamydial infection, due to her history of non-compliance the best treatment for her is the single dose of azithromycin. Ceftriaxone is not an antibiotic indicated for chlamydia, this is generally indicated for PID (UpToDate, 2017).

Answer 40

Answer: C Rationale: It has been determined therapy with azithromycin or doxycycline is highly effective therefore these patients don’t need retested after treatment unless they are pregnant. It is recommended that Jessica’s partners within the last 60 days should be treated for chlamydia. It is also recommended patients should abstain from sexual intercourse for 7 days after a single dose or until the 7-day regimen is completed. The abstinence should continue until the patient’s sex partner has been treated to prevent reinfection. Chlamydial infections and gonococcal infections often accompany one another so a patient positive for one gets treated for both (UpToDate, 2017).

Answer 41

Answer: B Rationale: Doxycycline is contraindicated in pregnancy in the second and third trimester so this medication should not be prescribed for Whitney. Erythromycin estolate is contraindicated during pregnancy because of drug related hepatotoxicity, however erythromycin base is an acceptable regimen to give. Azithromycin and amoxicillin are the recommended regimens for pregnant women being treated for chlamydial infections (UpToDate, 2017).

Answer 42

``` Answer: C Rationale: A and D are both treatment options for Trichomoniasis; however, given Sara’s medication history of GI upset with certain medications and subsequent non-compliance, tinidazole is the best choice of treatment for her as it causes fewer gastrointestinal side effects than metronidazole (UpToDate, 2017). Answer B is incorrect because the 5-nitroimidazole drugs (metronidazole or tinidazole) are the only class of drugs that provide curative therapy of trichomoniasis, thus azithromycin (an antibiotic), would not be indicated (UpToDate, 2017). ```

Answer 43

Answer: A Rationale: Per the CDC 2015 guidelines for the management of syphilis, parental administration of penicillin G (by IM route) is the recommended treatment for syphilis. Doxycycline can be used if the patient has a penicillin allergy but is not recommended in the absence of an allergy or other contraindication. Azithromycin should only be used if both penicillin and doxycycline cannot be used and should be used with caution and not as a first-line medication. Zosyn is not a recommended therapy for syphilis.

Answer 44

Answer: D Rationale: While doxycycline and tetracycline are both acceptable alternative treatments for syphilis in case of a penicillin allergy, they are both contraindicated in pregnancy as they are category D medications. Erythromycin is also a category D medication and is not utilized in the treatment of syphilis. The only safe medication to treat syphilis in the pregnant patient is penicillin, and desensitization and careful monitoring of the patient is necessary to treat syphilis in the pregnant patient with a PCN allergy.

Answer 45

Answer: C (Diabetes Mellitus) Rationale: Uncontrolled Hypertension, known or suspected pregnancy, and acute liver disease are all absolute contraindications to hormone therapy (Found in textbook Box 56.1 on page 976). Diabetes Mellitus is not contraindicated in hormone therapy.

Answer 46

Answer: D (Cold intolerance) Rationale: Vaginal dryness, insomnia, and mood changes are all very common symptoms for women who are perimenopausal or postmenopausal. Cold intolerance is not a common symptom, as many women experience hot flashes. Any of these symptoms may indicate a need for hormone replacement therapy for symptom control, but not for prolonged use. (Found in textbook on page 972.)

Answer 47

Answer: D Rationale: D is correct because an increased dose of estrogen may be needed in smokers because only half of the serum level achieved in nonsmokers is reached (Textbook pg. 976, Interactions paragraph) A is incorrect because alcohol increases the circulating levels of estrogen due to the liver’s preoccupation with metabolizing the alcohol at the expense of estrogen (Textbook pg. 976, Interactions paragraph) B is incorrect because patients taking phenytoin metabolize estrogen at a faster rate (Textbook pg. 976, Interactions paragraph) C is incorrect because the use of hormone therapy containing estrogen plus a progestogen in linked to a lowered risk of colon cancer (Textbook pg. 977)

Answer 48

Answer: B (Management of menopause is achieved on the highest dose possible for as long as the patient wants) Rationale: Patients should be advised that management is achieved on the lowest dose and for the shortest duration possible due to increased risk of breast cancer, CHD, and VTE associated with long term use. Patients are encouraged to reach out to their provider when they feel discontinuation is appropriate (Found in textbook pgs 975 & 981).

Answer 49

Answer: A (Family history of breast cancer) Rationale: Absolute contraindications for combination oral contraceptive pills include thombophlebitis, thromoembolic disorder, cerebral vascular disease, coronary occlusion, impaired liver function, breast cancer, abnormal vaginal bleeding in the absence of a diagnosed cause, pregnancy, and smokers older than 35 years old. (Found in textbook pg. 967 box 55.2 ).

Answer 50

Answer: A (height) Rationale: When selecting the most appropriate contraceptive agent for a patient the practitioner should consider body mass index because the obese patient may require higher doses of estrogen and progesterone. Additionally, baseline blood pressure, lipid panel measurements and liver and renal function panels should be taken into consideration to determine if the patient is an appropriate candidate for oral contraception. Height is not a determining factor of the appropriate agent. (Found on textbook page 966).

Answer 51

The answer is C, because you would never increase the frequency of an opioid drug that is already prescribed to work for a set duration of time. The drug will build up in the system due to the half-life overlap if it is scheduled too frequently. a. Is not correct, because this is an acceptable next step in prescribing opioids when the pain increases to the moderate category. b. is not correct, because increasing the dose of a drug would be an acceptable next step in prescribing opioids. d. is not correct, because this step is always necessary before changing a drug prescription. Assessing the pain using the OLDCARTS acronym will help you as the provider to know what your next step should be.

Answer 52

The correct answer is B, Loperaminde (Imodium). According to slide 7 of the “Therapeutic Use of Opioids” powerpoint, both morphine and hydromophone (Dilaudid) are strong opiod agonists. Slide 16 of the same powerpoint states that loperamide (Imodium) is a weak opioid agonist, and slide 18 states that Nalmafene (Revex) is an opioid antagonist used to reverse the effects of opioids.

Answer 53

Correct answer is B, because it appears Tracy is having an overdose reaction from the large dose of oxycodone. Since this is Tracy’s first surgical procedure, it is assumed she is naive when it comes to opioid pain medications, and 80mg was a large starting dose for such an individual. According to slide 18 of the opioid powerpoint, naloxone (Narcan) is an opioid antagonist, so you would want to administer this drug ASAP to reverse the effects of the oxycodone. You would not administer diphenoxylate (lomotil) because this medication is for GI upset and would not be helpful in this situation.

Answer 54

Answer: A & C According to the CDC Guidelines for Prescribing Opioids for Chronic Pain, it is most appropriate to start patients on the lowest effective dose of a short-acting opioid to control pain and the prescriber should always start low and go slow if prescribing an opioid for pain control. It would not be appropriate to start the patient on both a short and long-acting opioid or to only initiate them on a long-acting opioid.

Answer 55

Correct Answer: D) Fentanyl transdermal patch should be used in opioid-tolerant patients with a chronic pain process. The patient should have required oral morphine 60 mg or another equivalent opioid every day for the last 7 days to be considered tolerant. Incorrect answers: A) Fentanyl transdermal patch should not be used for acute pain or in someone who has not consistently taken opioids. B) Heat may increase the absorption of a transdermal fentanyl patch, which may result in increased delivery of the medication/potentially lethal overdose. The patch should not be applied to skin that is wet. C) Fentanyl patch should not be used for acute pain and also has a delayed onset of 12-16 hours after placement. Graham needs faster pain relief than the patch can provide. Resources: Chapter 7 of Pharmacotherapeutics for Advanced Practice, page 105. Therapeutic Use of Opioids Drug Characteristics lecture, slide 12.

Answer 56

Correct Answer: C) Havara should supplement her opioid medication with senna, bowel stimulants, and laxatives as needed. Because her pain is being well-controlled by the medication dosage, frequency and drug being taken, an adjunctive therapy to combat the side effect of constipation should be added. Resource: Opioid Class Characteristics powerpoint slide 18 Incorrect Answers: A. Havara has had adequate pain relief from her medication so the dosage should not be adjusted unless the pain management is being affected. B. Havara has had adequate pain relief from her medication so the frequency should not be adjusted unless the pain management is being affected. C. Havara has had adequate pain relief from her medication so switching to a non-opioid medication should not be considered unless pain management is being affected.

Answer 57

Answer: C - rationale: realizing that pain is a common symptom and cannot always be eliminated completely, a realistic goal of opioid therapy is to have the pain be manageable by the patient with the least amount of side effects possible, since opioids can cause significant side effects reference: slide 8 & 9 of “Pain Management Into” lecture, audio content Wrong answer rationale: a) it is not practical & sometimes not even possible to completely eliminate a patient’s pain. b) weaning off opioid use is not a primary goal of pain management d) the goal of opioid therapy isn’t always to reduce pain - but to make it manageable for the patient & using non-opioid meds is not a goal of opioid therapy

Answer 58

Answer: B & C - rationale: morphine decreases anxiety associated with shortness of breath caused by acute pulmonary edema, thus reducing cardiac preload & afterload reference: slide 14 of “Opioid Therapy” lecture, audio content Wrong answer rationale: a. Pain/pressure from peripheral edema would more likely be relieved by a diuretic & not morphine d. morphine reduces preload, not increases it

Answer 59

Correct Answer: A - rationale: Opioids typically outlast naloxone as Naloxone’s duration of action is approximately 45 minutes, shorter than opioids. (Textbook: pg. 106) Wrong answer rationale:(b) Naloxone in activated when given orally. (Textbook: pg. 106) (c) Side effects of naloxone are rare, but occur due to release of neurotransmitters when the antagonist is administered. (Textbook, pg. 106) (d) Side effects of opioids are sedation, confusion, respiratory depression, itching, nausea/vomiting, constipation. Opioid antagonists work to by reversing respiratory depression. (Textbook, pg. 106, & lecture on opioid drug characteristics)

Answer 60

Correct Answer: B - rationale: opioids are contraindicated in conditions associated with decreased respiratory reserve because of their risk of respiratory depression (Lecture: Opioid Therapy Class Characteristics) Wrong answer rationale:(a) Opioids are appropriate treatment for cancer-related pain (Ch. 7 of textbook) (c) Tramadol, a weak opioid, is effective in treating fibromyalgia (Lecture: Therapeutic Use of Opioids Drug Characteristics) (d) Postoperative pain is often treated with opioid medications because the pain can be severe (Ch. 7 of textbook)

Answer 61

Answer: B Rationale-- Indicated for chronic pain who cannot take oral meds. The patch is designed to provide analgesia for 72 hours, altho some may experience breakthrough after 48 .Unique formulation. Each patch carries a relatively large amount of medication, and starting a patient on a fentanyl patch could result in over medication, sedation and respiratory depression. As such, the fentanyl patch should only be used for opioid tolerant patients. * per Therapeutic Use of Opioids PP

Answer 62

Answer: C - rationale: tolerance usually develops within a few days to most of the adverse reactions associated with opioids except for constipation. Constipation prevention is needed in patients receiving opioids. (per pg 106 of our text book) Wrong answer rationale: (safety of opioids, pg 106/chapter 7 principles of pharmacology in pain management) a. although considered the most dangerous side effect, chronic pain patients on opioids usually develop tolerance to respiratory depression (exceptions are elderly, head injury, closed head trauma, hemodynamic issues, obstructive sleep apnea, and patients with liver/kidney failure) b. Nausea and vomiting usually subside after a few days for most patients using opioids c. Patients who use opioids for chronic pain will experience less sedation over time and increase their tolerance for this side effect

Answer 63

Answer: B - According to the text (page 520), there are three pathophysiological aspects in the development of a UTI that are to be considered - A, C, and D are all included. B is not. Leukocytes in the urine do not automatically indicate a UTI. Rather it could be a sign of an infection or something more serious.

Answer 64

Answer: D - According to the text (page 519), patients presenting with any two of the following symptoms meet the clinical diagnostic criteria for symptomatic UTI.

Answer 65

Answer: B - According to the text (page 520), a UTI is considered complicated if symptoms have persisted for more than 7 days. Answer A is too soon to be considered complicated. Answers C and D are both several days past the 7 day mark, which is a significant diagnostic criteria for complicated UTI’s.

Answer 66

Answer: C - According to the text (page 526), cranberry juice can be used as an alternative to antibiotics or for the prevention of UTIs. Answers A and B are foods that do irritate the bladder and should be avoided. Answer D is incorrect, because C does not irritate the bladder.

Answer 67

Answer: D- According to the text (page 520), answers A, B and C all meet the criteria for diagnosis of complicated UTI. Answer D meets the criteria for diagnosis of an uncomplicated UTI.

Answer 68

Answer: B, C and D - According to the text (Figure 32.1), flank pain, nausea, vomiting, CVA tenderness, and temperature > 38°C (100.4°F) are s/s of pyelonephritis; dysuria, urinary urgency, and urinary frequency are s/s of both cystitis and pyelonephritis.

Answer 69

A. Recommendations are based on the level of emetic potential, day of treatment, and in some circumstances the drugs as well. NK1R antagonist, a 5-HT3 receptor antagonist, dexamethasone and olanzapine are recommended for high emetic potential chemotherapies. Dosing for dexamethasone is 4-12 mg IV or PO, however IV medications are always preferred. Additionally, medication given before and during the chemotherapy to prevent nausea and emesis have been proven the most effective.

Answer 70

Answer : B Triple therapy that includes two antibiotics and bismuth subsalicylate is the most effective regimen. It eliminates the bacteria and prevents recurrence of ulcers in 90% of people who receive this treatment. Bismuth monotherapy is successful in eradicating H. pylori at 0-32% successful rate.

Answer 71

Answer: C. The medications are most effective in prophylaxis than treatment Rational: N/V medications are most effective in prophylaxis than treatment. The other answers are all correct, N/V medications do act on the vomiting center of the brain, their mechanisms of action include D2 receptor antagonist and H1 receptor antagonists, and their effects include anticholinergic, antidopaminergic and antihistaminic.

Answer 72

Correct answer = C Rationale: “First-line therapy is selected based on the presenting symptoms… Antidiarrheal agents are recommended in patients with IBS-D. Loperamide is the preferred agent because it causes the least CNS activity and has the added benefit of improving anal sphincter tone. With the additional problems of pain, gas and abdominal bloating, a trial of antispasmodic may relieve symptoms. Dicyclomine is the agent of first choice because of its shorter half-life, which may minimize anticholinergic side effects of the class.” A is incorrect as magnesium citrate is an osmotic laxative, an agent used to treat constipation. B is incorrect as the patient also has symptoms of abdominal bloating/gas. See rationale above. D is incorrect as Lomotil is not a first line antidiarrheal choice due to its increased anticholinergic side effects. “Unresolved complaints of IBS-D can be treated with lomotil, which has a longer duration of action but can be addictive because of its opioid properties and should be reserved for short-term use.”

Answer 73

Answer: B: discontinue metoclopramide therapy until further notice. Rationale: Metoclopramide is a prokinetic drug that treats nausea and vomiting by increasing the gastric emptying and peristalsis. Metoclopramide would further increase the already rapid gastric emptying that occurs with dumping syndrome thus making the nausea and vomiting worse. It would be best to discontinue the metoclopramide until the dumping syndrome is resolved.

Answer 74

Correct Answer: D Rationale: Lifestyle and dietary modification — Although several lifestyle and dietary modifications have been used in clinical practice, a systematic review of 16 randomized trials that evaluated the impact of these measures on GERD concluded that only weight loss and elevation of the head end of the bed improved esophageal pH-metry and/or GERD symptoms. We suggest the following lifestyle and dietary measures: ●Weight loss for patients with GERD who are overweight or have had recent weight gain. ●Elevation of the head of the bed in individuals with nocturnal or laryngeal symptoms (eg, cough, hoarseness, throat clearing). This can be achieved either by putting six- to eight-inch blocks under the legs at the head of the bed or a Styrofoam wedge under the mattress. We also suggest a corollary to this recommendation: refraining from assuming a supine position after meals and avoidance of meals two to three hours before bedtime. ●Dietary modification should not be routinely recommended in all patients with GERD. However, we suggest selective elimination of dietary triggers (fatty foods, caffeine, chocolate, spicy foods, food with high fat content, carbonated beverages, and peppermint) in patients who note correlation with GERD symptoms and an improvement in symptoms with elimination. Other measures that have a physiologic basis but have not consistently been demonstrated to improve reflux symptoms include: ●Avoidance of tight-fitting garments to prevent increasing intragastric pressure and the gastroesophageal pressure gradient. ●Promotion of salivation through oral lozenges/chewing gum to neutralize refluxed acid and increase the rate of esophageal acid clearance. ●Avoidance of tobacco and alcohol as both reduce lower esophageal sphincter pressure and smoking also diminishes salivation. ●Abdominal breathing exercise to strengthen the antireflux barrier of the lower esophageal sphincter.

Answer 75

Rationale: Metronidazole (Flagyl) is not used in the treatment of cystitis. TMP/SMX (Bactrim) is considered first-line treatment for uncomplicated cystitis in adults.(Nitrofurontin (Macrobid) is also a first-line treatment option, but it was not listed.) Piperacillin-Tazobactam (Zosyn) is administered parenterally in the treatment of complicated cystitis.

Answer 76

Rationale: Metronidazole (Flagyl) is not used in the treatment of cystitis. TMP/SMX (Bactrim) is not the best choice in a patient who may be or may become pregnant, as this drug works by inhibiting folic acid synthesis and therefore may increase the risk of fetal neural tube defects. Amoxicillin-clavulanate (Augmentin) is an empiric option for the treatment of UTIs and is generally considered safe in pregnancy (Category B). Ciprofloxacin is used in the treatment of UTIs, but Augmentin is a better choice, as fluoroquinolones are generally avoided during pregnancy.

Answer 77

D. Rationale: A fluoroquinolone is an appropriate antibiotic to prescribe in this situation. However, because this is a case of complicated cystitis (the patient is a 65-year old female with the comorbidity of MS and has an indwelling Foley catheter), in which the patient is both symptomatic and has a positive culture, you would want to prescribe this antibiotic at this strength for 7-14 days. The other answers are all appropriate in your approach to her care. First, you always want to be re-assessing the patient’s need for an indwelling Foley catheter. Second, it is necessary to obtain a urinalysis because the patient presents with urinary symptom. Finally, as already discussed, prescribing an antibiotic is the correct action to take.

Answer 78

D. Rationale: Because the patient is complaining of pain in the lower abdomen and perineum area, it is important to determine whether the cause of symptoms is an infection of the prostate or infection of the bladder to determine appropriate treatment. To confirm the diagnosis of prostatitis, a prostate exam, blood PSA level, and urinalysis must be completed. Pain and tenderness will be elicited during the prostate exam, the PSA level will be increased, and the urinalysis will be positive for bacteria.

Answer 79

C. Rationale: Severe nausea/vomiting is common in pyelonephritis, and may be so severe that the patient is not able to tolerate PO antibiotics. In this case, hospitalization would be required for IV antibiotics and IV fluids for hydration. Dysuria, fever, and headache are also common in pyelonephritis but do not potentiate hospitalization.

Answer 80

C. Rationale: Risk factors for recurrent cystitis include DM, functional disability, recent sexual intercourse, a prior hx of urogynecologic surgery, urinary retention, and urinary incontinence.

Answer 81

``` Which drug class is considered first line therapy for acute anxiety related to a time- limited stressor? a. SSRIs [INCORRECT; considered the drug of choice for GAD; 2-4 week onset of action, not for acute anxiety attacks] b. Benzodiazepines [CORRECT; Benzos should be used for short-term management of acute phases of anxiety, as well as any subsequent exacerbations] c. SNRIs [INCORRECT; considered the drug of choice for GAD and those with comorbid depression] d. TCAs [INCORRECT; effective in treating GAD and controlling panic attacks in patients with PD and GAD] ```

Answer 82

All of the following contribute to increased severity of benzodiazepine withdrawal syndrome except for: a. Abrupt discontinuation of drug [INCORRECT; A is a true statement. Abrupt discontinuation is associated with withdrawal symptoms of greater severity. Tapering should be gradual, over at least 4 weeks with 10 percent decrease every 3 to 4 days] b. Short half life of drug [INCORRECT; B is a true statement. Drugs with shorter half lives are more associated with withdrawal phenomena, as longer half life drugs are removed at a slower and more steady state] c. Long half life of drug [CORRECT; C is not true] d. Increased duration of use [INCORRECT; D is a true statement. Withdrawal is relatively infrequent with short term use. The longer the duration and the higher the dosage use, the greater the severity of withdrawal]

Answer 83

Which of the following is a reason to prescribe a benzodiazepine? a. They have the least likelihood to cause dependence and are normally used long term. [INCORRECT; Long-term benzodiazepine medication should be avoided. All benzodiazepines are associated with a risk of dependence. Benzodiazepines have a sedative effect, they predispose the patient to accidents, cause disturbances of the cognitive function and may lead to confusion and agitation] b. Some have a quick response and can be used with psychotherapy or cognitive behavior therapy. [CORRECT; Benzos such as clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax) are useful for panic attacks. They are safe when used as directed and often bring quick relief from panic symptoms. Cognitive psychotherapy is useful in many cases of anxiety] c. They should be used as a first-choice drug with a patient experiencing withdrawal from substance abuse. [INCORRECT; Benzodiazepines should be avoided with withdrawal. Anxiety, sleep disorders and adverse effects of the abused drugs have made many drug addicts additionally dependent on benzodiazepines. If deemed necessary, the risk of developing dependence may be reduced if the stopping time is already planned at the time of prescription. Not suitable in alcohol abuse. Should not be used as first choice drugs] d. The side effects are limited to increase heart rate and breathing. [INCORRECT; The most common adverse effects of benzodiazepines are sedation, worsening of psychomotor functions and transient memory disorders. In addition, typically a low heart rate and breathing can occur]

Answer 84

A. Start initial loading dose at 100mg/day for the first week. [INCORRECT; Could lead to adverse effects like serotonin syndrome] B. Start at 5mg/day for the first two weeks then titrate up by 2.5mg/day in the following weeks until symptoms are relieved or maximum dose is achieved. [ INCORRECT; Would take way too long for the patient to reach therapeutic levels and runs the risk of the patient becoming noncompliant] C. Initiate Sertraline at 25mg/day, after a week increase to a therapeutic dose of 50mg/day and continue for four to six weeks. If patient does not experience a robust clinical outcome, Sertraline can be titrated up every week/bi-weekly in 50 mg increments to a maximum dose of 150 mg/day. [CORRECT; this is a safe taper for this type of medication and would typically avoid adverse effects like serotonin syndrome depending on the patient’s dosing weight/extraneous metabolic processes] D. Start at the max allowable dose (150mg/day) and decrease if patient experiences moderate to severe adverse effects. [INCORRECT; Could lead to serotonin syndrome]

Answer 85

a. Administer Naloxone IV and monitor until the patient recovers then admit to the psychiatric unit. [INCORRECT; Naloxone is an opioid antagonist used to treat opioid overdose not Benzodiazepine overdose] b. Administer a single dose of Flumazenil IV and monitor the patient's vitals until they are stable patient recovers then discharge the patient. [INCORRECT; while Flumazenil is the correct drug of choice for Benzodiazepine overdose, it has a short half-life and repeated doses may be needed as re-sedation can occur so discharging the patient after first stabilizing is incorrect. c. Administer a single dose of activated charcoal and monitor the patient's vitals until they are stable and discharge. [INCORRECT; Single-dose activated charcoal is not routinely recommended, as the risks far outweigh the benefit. BZD are very rarely fatal in overdoses, and the altered mental status from BZD overdose greatly increases the risk of aspiration following oral charcoal dosing] d. Administer Flumazenil IV and monitor the patient's vitals. Delay discharge when the patient's vitals are stable as a repeated dose of Flumazenil may be necessary. [CORRECT; Flumazenil is the only Benzodiazepine receptor antagonist available for clinical use. But because it has a short half life of 0.7-1.3 hours, re-sedation commonly occurs and repeated doses of flumazenil may be needed]

Answer 86

a. Begin the patient on a single antidepressant drug, preferably an SSRI or SNRI, at a low dose, and re-evaluate clinical presentation in three weeks. [INCORRECT; The practitioner should allow 4-8 weeks to pass before re-evaluating or titrating the dose] b. Begin the patient on a single antidepressant drug, preferably an SSRI or SNRI, at a low dose, and re-evaluate clinical presentation in five weeks. [CORRECT; A low dose SSRI/SNRI (first line treatment) should be used, and the practitioner should allow 4-8 weeks to pass before re-evaluating or titrating the dose] c. Begin the patient on a single antidepressant drug, preferably an SSRI or SNRI, at a high dose, and re-evaluate clinical presentation in three weeks. [INCORRECT; A patient should never be started on a high dose of antidepressants. The practitioner also only allowed three week’s time to pass before re-evaluating or titrating the dose] d. Begin the patient on a single antidepressant drug, preferably an SSRI or SNRI, at a high dose, and re-evaluate clinical presentation in five weeks. [INCORRECT; A patient should never be started on a high dose of antidepressants]

Answer 87

Correct answer: C - Benzodiazepines cause GABA-A receptors to increase the opening of chloride channels along the cell membrane, leading to an inhibitory effect on cell firing (Pharmacotherapeutics for Advanced Practice- A Practical Approach- Chapter 41 page 707) A-resembles a short-acting beta agonist, which are not associated with Benzodiazepines. B- is a long acting beta agonist with is not related to benzodiazepines. D- Is a made-up answer.

Answer 88

Correct answer: C - Benzodiazepine receptor antagonists block the action of benzodiazepines and reverses sedative effects. (Pharmacotherapeutics for Advanced Practice- A Practical Approach- Chapter 41 page 709). A- a SNRI would not reverse the effects of Benzos. B- a beta blocker would not reverse the effects of Benzos. D- an opioid agonist would not reverse the effects of a benzo, and perhaps make it worse

Answer 89

Correct answer: A- All these are symptoms per our textbook box 41.5 (Pharmacotherapeutics for Advanced practice 2015, p. 717). B- High temperatures and vomiting not associated with withdraw. C- symptoms of depression. D- A is the right answer

Answer 90

Correct answer: A - Anxiety disorders often occur with many other psychiatric disorders B - Inaccurate as anxiety disorders tend to occur with other disorders. C - Features of anxiety disorders include autonomic hyperactivity, not hypo D - First line treatment of anxiety disorders are SSRIs or TCAs; Buspirone is a second line treatment (References: Anxiety-A case presentation lecture, slide 7 and 25).

Answer 91

Correct answer: B - 2-3 weeks. (Anxiety-A case presentation lecture, slide 29.) Our text states that there is a 2-4-week delay until onset of therapeutic effect when starting SSRIs therefore the nurse should follow up within this time period to see how the patient is responding to the current treatment (Pharmacotherapeutics for Advanced practice, page 706). A - incorrect as 7-10 days would not allow enough time for the drug to start taking effect and show symptom improvement. C and D - incorrect as the drug begins to show reduction in anxiety within 2-4 weeks, thus the patient should be reassessed sooner to see if any changes in the current regimen should be made.

Answer 92

Correct answer: C. SSRI or SNRI Our text states that SSRIs and SNRIs are considered first line therapy for GAD (Pharmacothereapeutics for Advance practice, page 712). A - is incorrect as buspirone is indicated after confirmed failure or intolerance to multiple members of the SSRIs or SNRI classes has occured (Pharmacotherapeutics for Advance Practice, page 712). B - is incorrect as benzodiazepines are not considered first line therapy however they may be added as adjunct treatment when SSRIs or SNRIs have failed. Benzos are sometimes used when first starting SSRI or SNRI treatment to help support patients while they are waiting the weeks it takes for the SSRI/SNRI to start improving symptoms (Pharmacotherapeutics for advance practice, page 712). D - is incorrect as their effectiveness in GAD has not been proven, these drugs are not considered first line because of it's dietary restrictions and potential for serious drug interactions (Pharmacotherapeutics for Advance Practice, page 711).

Answer 93

Correct answer is A, acetaminophen, based on her history of GI issues and her level of pain. NSAID’s are inappropriate as they have a higher risk of GI problems and anticoagulation properties. An opioid is not appropriate for her condition and level of pain. Reference: Pharmacotherapeutics for Advanced Practice textbook, pages 100-104. (Alexa)

Answer 94

Correct answer is C (Reye’s Syndrome). As discussed in lecture, Reye’s Syndrome can cause fatty liver and encephalopathy when using Aspirin in children under the age of 18 who are symptomatic with varicella or flu-like illness. Although the other listed answers are known adverse reactions when using Aspirin, c is the best answer. Referenced from Analgesic Lecture (3/31/17) Slide 10. (Sarah)

Answer 95

Correct answer: C Ibuprofen: ALL NSAID medications carry a Black Box Warning, due to the increased risk of CV adverse events and are contraindicated in perioperative pain treatment for patients undergoing coronary artery bypass surgery. While Lisinopril may increase the risk for hypotension during anesthesia, it is not the best answer. Albuterol is an acceptable PRN treatment for asthma, and should be used cautiously with CV disease, but it is not the best answer. (Pharmacotherapies for Advanced Practice, Chapter 36, pg. 598). (Steffanie)

Answer 96

Correct answer: D Patients with OA should take acetaminophen around the clock, as prescribed, regardless of pain level to achieve the best outcome for pain management, NOT as needed for pain. Minimization of alcohol consumption, awareness of medications that also contain acetaminophen, and no more than 1 gram of acetaminophen per day are all important elements of patient education. (Pharmacotherapies for Advanced Practice, Chapter 36, pg. 601).(Steffanie)

Answer 97

Correct answer: C- Rest. Before initiating drug therapy, the practitioner should recommend appropriate physical active or PT to reduce pain, improve motion, strengthen the surrounding muscles and maintain functional ability. Fitness programs that incorporate swimming, walking, cycling, isometric exercise help promote flexibility. Moist heat helps diminish muscle spasms and relieves stiffness. Additionally, overweight patients should be counseled on the need for weight loss to reduce further joint damage and associated pain. (Pharmacotherapies for Advanced Practice, Chapter 36, pg. 593).(Amanda)

Answer 98

Correct Answer with Rationale: D: The patient should be prescribed an NSAID with a shorter half-life and a lower dose because of her age. Additionally, any individual over the age of 65 should be considered high-risk for a GI bleed and should be treated with either a COX-2 inhibitor or a combination of a nonselective NSAID and a gastric protective agent such as a proton pump inhibitor. Although A is correct it is nonspecific and therefore is not the best answer to the question. Elderly patients have decreased metabolism and therefore should not be prescribed higher dose NSAIDS. Finally, NSAIDs with longer half-lifes should also be avoided due to the decreased metabolism associated with the elderly.

Answer 99

The answer is B. A. Mary will still need drug therapy even though she is 45 C. The goal for drug therapy is to PREVENT not reduce fractures D. Bisphosphonates are contraindicated in patients with a history of esophageal problems, gastritis, or peptic ulcer disease due to the adverse events including GI disturbance,esohpagitis, diarrhea, and abdominal pain.

Answer 100

The answer is B. A. Calcium Carbonate needs to be taken with food because acid is needed for maximal absorption. It will not be absorbed as well due to Lynn’s PPI use decreasing her gastric acid production. B. Calcium Citrate is better absorbed and may be preferred by patients with reduced gastric acid production or high gastric pH because it does not require acid for absorption. C. Calcitonin balances parathyroid hormone, but is not a first choice drug for the PREVENTION of osteoporosis. D. Cautious Bisphosphonate use is recommended for patients with GI disorders.

Answer 101

The correct answer is d. a. Lactation and pregnancy are both contraindications for SERM therapy b. SERMs are contraindicated in women who have a history of thromboembolic events c. A patient needs to discontinue SERM use 72 hours before prolonged immobility d. Hyperlipidemia is not a contraindication. SERMs have the potential to decrease total cholesterol and LDL levels.

Answer 102

``` The answer is A. According to the Pharmacotherapeutics for Advanced Practice class text pg. 986, table “Risk Factors” B. is incorrect because sedentary lifestyle is a risk factor C is incorrect because risk factors include Race:white, asian, native american/indian D. is incorrect because low calcium intake is a risk factor ```

Answer 103

The answer is B According to the Pharmacotherapeutics for Advanced Practice class text pg. 991, figure 57.1 “Treatment algorithm for osteoporosis” A. Discontinuing all treatment is not an option per the algorithm. C. The patient should only add hormone modifiers if the DEXA scan is worsened D. Calcitonin is a hormone modifier- see rationale for option C.

Answer 104

The answer is C. Pharmacotherapeutics for Advanced Practice: A Practical Approach A. Raloxifene is a first-line therapy for prevention B. Bisphosphonates are a first-line therapy for prevention and treatment C. Calcitonin is a second-line therapy for osteoporosis D. During first-line therapy, patients should have calcium and vitamin D supplementation