Final Exam Student Questions Flashcards
Which of the following is true regarding the development of depression?
A. A family history of Major Depressive Disorder does not affect an individual’s risk for experiencing depression.
B. Most people who suffer from depression suffer from one single episode.
C. Depression develops as a result of a multifactorial interplay of genetics, environment, physiologic, social, and biochemical factors.
D. Depression appears the same in all individuals diagnosed.
Answer and rationale: C. The development of depression occurs as a result of the complex interactions between many different factors, including genes, environment, biochemical interactions, social factors and physiologic factors. A is incorrect because a family history does affect, and increase, and individual’s risk for experiencing depression. B is incorrect because most people who suffer from depression have repeated episodes. D is incorrect because depression presents differently with different signs, symptoms, and patterns in different individuals.
- Which hormone is most involved in the pathophysiology of Major Depressive Disorder?
A. Thyroid hormone B. Estrogen C. Growth hormone D. Dopamine
Answer and rationale: D. Dopamine is the hormone most involved in the pathophysiology of depression,
and it is targeted in many of the drug formulations used to manage symptoms in patients that are diagnosed. A, B, and C are incorrect because they are hormones not involved in the pathophysiology of MDD.
- During drug therapy for Major Depressive Disorder it is important to maintain regular contact with the patient during which of the following phases:
A. Acute treatment phase B. Continuation phase C. Maintenance phase D. All of the above
Answer and rationale: D. All of the above: Antidepressant therapy consists of 3 major phases: acute, continuation, and maintenance. Typically, patients should maintain contact with practitioners during all 3 phases of drug therapy. The practitioner should continue to monitor efficacy, side effects, and adherence.
- How long should practitioners recommend antidepressant therapy for a first episode of depression?
A. Only until symptoms resolve B. Indefinitely C. 4 to 6 months after symptom resolution D. PRN for symptoms
Answer: (C) Rationale: The practitioner should continue antidepressant therapy 4-6 months after symptom resolution. Failure to continue medication beyond symptom resolution confers an increased risk of relapse.
- MAOIs should not be prescribed with SSRIs or SNRIs because of what potential complication?
A- Hyperpyretic crisis B- Neuroleptic Malignant Syndrome C- Serotonin Syndrome D- Myocardial Infarction
Answer: (C) Rationale: The combination of MAOIs and SSRIs cause there to be to much serotonin
released or to remain in the central nervous systems, causing a adverse reaction. The most likely cause of serotonin syndrome is usually when two medications that affect the body’s level of serotonin are taken concurrently. A,B and D are all incorrect, as they are not potential complications associated with prescribing MAOIs with SSRIs or SNRIs
- Which one of these is not a type of depression?
A. Postpartum depression B. Seasonal affective disorder. C. Major depression with melancholic features. D. Insomnia
Answer: D. Insomnia. Rational: Insomnia is a problem falling asleep at anytime
A. Is a type of depression that usually happens after child birth
B. Associated with a pattern of depressed or manic episodes that occur with the onset of winter. C. It is characterized by profoundly depressed mood, nonractivity, and neurovegetative symptoms.
Patient has been receiving an antipsychotic medication called Haloperidol (haldol). On day 3 of treatment, the patient started having symptoms of shifting weight from foot to foot, walking in spot and inability to keep legs still. What acute condition is patient experiencing?
A. Agitation B. Tardive Dyskinesia C. Perioral MovementsD. Akathisia
D. Akathisa because this is an acute condition after receiving antipsychotic medication that can happen and can show signs of to much medication in patients system possibly related to an imbalance between the dopaminergic/cholinergic and dopaminergic/serotonergic system.B,C. Are Tardive responses from adverse effects that can happen with antipsychotic medications. A. Agitation can be commonly confused with Akathisia and increased doses of antipsychotics will make these symptoms worse.
A patient has been receiving antipsychotic’s for 5 days now. The patient started experiencing Acute dystonia. Signs/symptoms of this condition is?
A. chest tightness, tachycardia, sweating, worrying B. pin rolling of fingers, loss of swing in arms while ambulating
C. Difficulty swallowing, speakingD. painful movements, face, neck, back, tongue.
Ans Rationale
A. is s/s of anxiety. B. is s/s of parkinsonism C. is s/s of tardive dyskinesia
D. results lead to dominant mechanism resulting in acute dystonic reactions is thought to be nigrostriatal dopamine D2 receptor blockade, which leads to an
excess of striatal cholinergic output.
You are the nurse practitioner caring for a patient with major depressive disorder. Your patient’s symptoms have improved on the 20 mg daily dose of Celexa (SSRI) but when you are conducting your 6 month follow up visit, you learn the patient had seen an additional provider and been prescribed Nardil (MAO inhibitor) and the patient has been taking this medication in addition to the SSRI. The patient is now complaining of symptoms consistent with Serotonin Syndrome. All of the following are present in Serotonin Syndrome EXCEPT:
A. Heat stroke B. Fever
C. Increased creatinine
D. Tachycardia
A, B, and D are signs and symptoms of the life threatening syndrome in which interactions of
SSRIs and MAO inhibitors leads to sudden increase in systemic serotonin.
- The NP recognizes that the patient is experiencing Neuroleptic Malignant Syndrome if
A. The patient has involuntary buccolingual movements B. The patient has a temperature of 98.6 degrees Fahrenheit, bradycardia and warm, dry skin C. The patient has a temperature of 105 degrees Fahrenheit, muscular rigidity, altered mental status, and autonomic dysfunction D. The patient has a shuffling gait and exhibits pill rolling and cog wheeling motions
C is correct, a patient with Neuroleptic Malignant Syndrome exhibits fever up to 107 degrees Fahrenheit, muscle rigidity, altered mental status, and autonomic dysfunction. A is incorrect, the patient has tardive dyskinesia. B is incorrect, the patient with Neuroleptic Malignant Syndrome is expected to have high fever, tachycardia and diaphoresis. D is incorrect, the patient is exhibiting parkinsonism.
In a teenage patient diagnosed with ADHD with no significant medical history (unremarkable pulmonary and cardiac history and no other mental health diagnoses). In addition to referral to CBT, in which order would you try medication therapy if the patient was not responding to the treatment?
A. First try a stimulant therapy, if no response, try a non-stimulant therapy B. First try a non-stimulant therapy, if no response, try a stimulant and immediately
refer to a mental health specialist
C. First try a stimulant therapy, if no response, try dose increase, if no response, try a
different stimulant therapy, if no response, refer to a mental health specialist
D. First try a non-stimulant therapy, if no response, try dose increase, if no response, try a
stimulant therapy, if no response, refer to a mental health specialist
A. Incorrect. A dose increase of the first stimulant should be trialed if the patient does
not experience symptoms with the first intervention. B. Incorrect. A stimulant medication should be tried as first line therapy. Correct answer: C. According to video by Professor Alice Teall the correct order of
treatment for ADHD in the primary care setting is stimulant therapy→ dose increase of first stimulant therapy→ different stimulant therapy→ refer to mental health specialist.
D. Incorrect. A stimulant medication should be tried as first line therapy.
Which of the following drug classes would be considered a first line therapy for generalized
anxiety disorder?
A. SNRI B. MAOI C. Benzodiazepine D. Atypical antipsychotic
A. SSRI or SNRI are considered first line treatments for GAD in adults
according to Uptodate.
B. MAOI have been found to be effective in the treatment of panic disorders; their effectiveness in treatment of GAD has not been explored. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017) C. According to Uptodate, Benzodiazepines should only be used in treatment resistant or partial treatment resistant GAD. D. Atypical antipsychotics are not indicated in the treatment of GAD
Which of the following is not part of the clinical features of the movement pattern in tardive
dyskinesia?
A. Repetitive movementsB. Stereotyped movementsC. Abnormal movementD. Painful movements
Answer is D. Painful movements
Rationale: Tardive dyskinesia is a neurological syndrome characterized by repetitive, involuntary, purposeless movements caused by the long-term use of certain drugs. Features may include grimacing; tongue protrusion; lip smacking, puckering, and pursing; and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also
occur. Painful movement is not its feature. Ref: medicinenet.com
Antipsychotics are FDA approved for the use of treating behavioral and neuropsychiatric symptoms with the following conditions EXCEPT
A. SchizophreniaB. Alzheimer’s diseaseC. Major depressive disorderD. Bipolar disorder
B. Alzheimer’s disease
Rationale: Antipsychotics are not specifically FDA approved for Alzheimer’s and dementia, but they are often widely used for treating patient’s behavioral and
neuropsychiatric symptoms in long term care facilities. Antipsychotics are approved for use with schizophrenia, MDD, and bipolar disorder.
Use of antipsychotics increase risks for falls due to
A. Extrapyramidal side effectsB. Orthostatic hypotensionC. SedationD. All of the above
Answer: D
Rationale: Antipsychotics increase risks for falls due to sedation, cardiovascular effects that cause orthostatic hypotension, and extrapyramidal side effects, such as tardive
dyskinesia, dystonia and tremors.Ref: Textbook, page 80
Due to the increased risk for agranulocytosis, which antipsychotic is considered a last resort
in treatment resistant schizophrenia?
A. Risperidone B. Quietiapine C. Clozapine D. Aripiprazole
Answer: C
Rationale: Clozapine is often considered to be the most effective atypical antipsychotic, but is reserved for resistant cases only due to this potentially fatal ADE. Close blood monitoring is required when a patient is on this drug.
A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should
provide which instruction to the client?
A) Take the medication 1 hour before a meal.B) Decrease the dosage if signs of illness decrease C) Apply a sunscreen before being exposed to the sun.D) Increase the dosage up to 50 mg twice per day if signs of illness don’t decrease.
C) Apply a sunscreen before being exposed to the sun.
Because haloperidol can cause photosensitivity and precipitate severe sunburn, the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse also should teach the client to take haloperidol with meals — not 1 hour before — and should instruct the client not to decrease or increase the dosage unless the physician orders it.Ref: Medscape
Choose the option that covers the clinical signs and symptoms of neuroleptic malignant
syndrome:
A. Hypothermia, dystonia, mental status changes, acute renal failureB. Hyperthermia, rigidity, mental status changes, acute renal failureC. Hypothermia, akathesia, elevated pulse, diaphoresis, renal failureD. Hyperthermia, tardive dyskinesia, diaphoresis, mental status changes
Answer is B. Hyperthermia, rigidity, mental status changes, acute renal failure
Rationale: Cardinal features of NMS are severe muscular rigidity; hyperthermia (temperature >38°C); autonomic instability and changes in the level of consciousness. It also includes elevated pulse, diaphoresis and acute renal failure. Akathesia, Dystonia, or tardive dyskinesia
are features of EPS.
Which is NOT a mechanism of action of antidepressant agents?
a. Inhibits the breakdown of catecholamine’s which increases catecholamines in
synapse. b. Stimulates the post-synaptic receptors. c. Inhibits the re-uptake of catecholamine’s by the pre-synaptic neurons.
d. Potentiate the action of GABA and depress CNS functioning.
Explanation: “A” is a MOA of antidepressants because MOAIs inhibit the breakdown of catecholamine. “B” is a MOA of antidepressants because some novel drugs stimulate the post-synaptic receptors. “C” is a MOA of antidepressants because
SSRIs, SNRIs and other anti-depressant agents inhibit the re-uptake of
catecholamines. “D” is the “correct” answer (NOT a MOA) because benzodiazepines
potentiate the action of GABA and are NOT used to treat depression.
Nancy is a 19 year old being treated with SSRI for major depressive disorder. What is a
sign that require immediate intervention by the clinician?
a. Nancy reports an improved mood. b. Nancy reports that the medication is making her restless and she is having trouble
sleeping.
c. Nancy reports that she has started giving away her possessions.
d. Nancy reports nausea and GI disturbances.
Explanation: “A” is a positive therapeutic effect of SSRIs. “B” and “D” are negative side effects of SSRI and medication may need to be re-evaluated. “C” is a warning sign of suicidal ideation the “best” answer for this question because it requires immediate intervention.
Brittany is a 30 year old woman diagnosed with major depressive disorder and is started on an SSRI. Which of the following is not an important fact for the clinician to teach the
patient:
a. With the SSRI’s there is a possibility of sexual dysfunction. b. If you begin experiencing signs of serotonin syndrome (fever, tachycardia, profuse sweating, tremors) you should seek medical help right away.
c. You should expect to feel less depressed within a day or two.
d. You should return to the office in 2-4 weeks so we can discuss effectiveness of treatment.
Explanation: “C” is the correct answer, as it is not true and should not be taught to patients. SSRIs may take 4 weeks, even up to 12 weeks to take full therapeutic effect. “A” is true, as sexual dysfunction is a commonly reported side effect of SSRIs. “B” is also an important teaching point. Serotonin syndrome is a rare, but life threatening reaction to SSRIs, and the patient should know to seek help right away with these symptoms. “D” is true, as the patient should expect to follow up to make sure therapy is effective and to discuss any side effects that may cause the patient to want to stop treatment. Adjustments to treatment should be made instead.
According to the Texas Mediation Algorithm what is stage 2 therapy for the treatment of depression?
a. ECT b. Alternate monotherapy SSRI, bupropion, nefazodone, TCA, venlafaxine, MAOI drug,
or combination antidepressant: TCA+ SSRI.
c. Alternate monotherapy SSRI, bupropion, nefazodone, TCA, or venlafaxine.
d. Other
Explanation: The correct answer is (C). The recommended treatment for depression according to the Texas Medication algorithm states that stage 2 therapy should be an alternate to the initial monotherapy if the initial treatment does not warrant a beneficial response. Answer (A) is stage 4 treatment if other options have been exhausted with no positive results. Answer (B) is stage 3 treatment per the algorithm and answer (D) is the final stage (stage 5) when all other options have been exhausted with no benefit to the patient.
Matthew is a 17-year-old high school student who was recently seen in the clinic for feelings of depression. He was brought in by his mother, who noted recent changes in his mood, insomnia, weight loss, difficulty concentrating in school with slipping grades, and overall anhedonia. Matthew told his mom two weeks ago he wanted to quit basketball, a sport he has play his he was five. During his visit, Matthew told the PCP he had been having thoughts of suicide. To ensure Matthew’s safety, his mother was made aware and referrals were made to psychiatry. Matthew has been getting counseling for 2 weeks, and was started on an SSRI 7 days ago. Which finding below is most concerning and requires immediate intervention from Matthew’s mom?
a. Matthew states his mood is “not really better” and still has difficulty concentrating
and intervals of irritability. b. Matthew complains of feeling drowsy at school the first few days after taking the medication. c. Matthew becomes agitated easily, especially when friends or family ask him why he wants to quit basketball.
d. Matthew’s mother notes around day 7 of his medication therapy that Matthew
has more energy, seems less fatigued, and is cleaning his room, even though his mood and depressed affect do not seem improved.
Explanation: Answer (A) is incorrect because the typical onset of SSRIs is between 1-4 weeks, so effects of the medication are not likely to be seen on day 7 of the medication therapy. Answer (B) is incorrect because drowsiness is an expected and common side effect associated with SSRIs; for Matthew, the PCP could suggest he take his dose at bedtime, allowing for the drowsiness to take effect during the HS period and hopefully, improving his previous complaints of insomnia. Answer (C) is incorrect because although agitated behavior can be a warning sign of suicide,
agitation can also be a side effect associated with SSRIs. In Matthew’s case, he
becomes agitated specifically when asked about quitting the basketball team, a sport he used to find pleasure playing. With his previous thoughts of suicide, he may be
quitting basketball to end ties with outstanding groups. Answer (D) is the “correct”
answer. With both SSRIs and SNRIs, patients may see an early improvement in symptoms of fatigue and find more energy to get up and act without an improvement in mood or depression due to the 1-4-week onset/full medication effect. With someone who is or has had suicidal thoughts of may have a plan, he or she is at high risk of acting on suicidal thoughts due to a depressive mood but an increase in energy to act.
Sally was recently started on an MOAI for major depressive disorder. Which of the following is an important teaching point to include with this class of drugs?
a. MAOIs often cause a benign rash b. Sally should come back to the office is she does not experience relief of symptoms within 7 days c. foods such as aged cheese, tap beer, and yogurt should be avoided when taking MAOI’s
d. MAOIs can be discontinued at any time without risk for side effects
Explanation: Correct answer is C–when taken in combination with foods that contain high levels of tyramine, MAOIs can cause hypertensive crisis. Choice A is incorrect because a benign rash is not a common side effect of MAOIs. Choice B is incorrect because it may take up to 4 weeks before Sally experiences relief of symptoms. Choice D is incorrect; Sally should be counseled on the risk of withdrawal symptoms when abruptly discontinuing anti-depressants such as MAOIs.
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
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)
Due to the cost effectiveness, safety, and few adverse events (dizziness and rash) if taken within recommended dosage, this is the first line pharmacotherapy for osteoarthritic pain:
a. Corticosteroid Injections b. Acetaminophen c. Analgesics like tramadol d. NSAIDs like aspirin or naproxen
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)
A 60-year-old woman comes into the office and is diagnosed with osteoarthritis in her hand along with nonpharmacological you prescribe capsaicin, a topical agent, you tell her to expect the topical agent to take effect in what amount of time?
a. 2 to 4 weeks b. 1-2 hours c. 1 week d. 3-4 days
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.
The 60-year-old woman who is newly diagnosed with osteoarthritis in her knee ask what her goals of treatment are with this condition. You accurately tell her that the pharmacologic goals in the treatment of osteoarthritis are all the following except:
a. To maintain function b. To prevent further joint damage c. To completely reverse the effects of damage to her affected joint d. To diminish associated pain
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.
A 51-year-old male, David, comes into your office and after a history and physical, you diagnose him with osteoarthritis of his hand. Out of these treatment options, which is not a 1st, 2nd, or 3rd line treatment for OA of the hand?
a. Acetaminophen b. Topical NSAIDs, like capsaicin c. NSAIDs, like ibuprofen d. Opioids
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.
When educating a patient on taking acetaminophen for Osteoarthritis, all the following are important
EXCEPT:
a. Acetaminophen should only be taken when pain is present with osteoarthritis. b. Patients should be aware of other products that may contain acetaminophen so that they are not exceeding the daily limit. c. Alcohol should be minimized or avoided. d. Patients with a history of liver disease or who are chronic alcohol drinkers should not take more than 1,800 mg a day.
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.
The Food and Drug Administration (FDA) issued a “black box warning” forestrogen to alert postmenopausal consumers of the increased risk of:
a. Myocardial Infarction b. Stroke c. Breast Cancer d. All of the above -
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.
All of the following are reasons to implement evidence-based guidance for contraceptive use except :
a. To base family planning practices on the best available evidence - This is a reason to implement evidence-based guidance for contraceptive use.
b. To create medical barriers to contraceptive use - Incorrect; evidence-based guidance for contraceptive use works to remove medical barriers. c. To address misconceptions regarding who can safely use contraception - This is a reason to implement evidence-based guidance for contraceptive use. d. To improve access and quality of care in family planning - This is a reason to implement evidence-based guidance for contraceptive use.
B
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 - defined as the absence of menstrual periods for 12 months b. Dysmenorrhea - refers to the symptom of painful menstruation c. Perimenopause - “menopause transition”, correct because she has not been without a period for over a year but is beginning to experience signs
and symptoms of menopause d. Postmenopause - stage following menopause and generally starts between 24 and 36 months after a woman’s last period.
C
A 38-year-old woman visits her gynecologist for birth control. She tells her gynecologist she typically uses condoms but would like something that her and her partner do not have to deal with at the time of intercourse. She notes that she smokes 3 cigarettes/day and has a history of a deep vein thrombosis. All of the following are appropriate choices for the gynecologist to offer the patient except :
a. Depo-Provera - This form of birth control is safe for women older than 35 years of age who smoke and have a history of an embolic event. b. Implanon - This form of birth control is safe for women older than 35 years
of age who smoke and have a history of an embolic event. c. IUD - This form of birth control is safe for women older than 35 years of age who smoke and have a history of an embolic event. d. Combined oral contraceptive - Combined oral contraceptives are contraindicated in patients who are over 35 years old and smoke and who have a history of an embolic event.
D
Sara is a 37 year old woman with a history of diabetes mellitus and hypertension. Which contraceptive would be the first choice for her?
a. Seasonale - This is an estrogen-containing contraceptive; this would put Sara at a high risk for VTE. b. Ortho-cyclen - This is an estrogen-containing contraceptive; this would put Sara at a high risk for VTE. c. Plan B - This should be used as emergency contraception only. d. Nexplanon - Progestin-only hormonal contraceptives are the best choice for women at increased risk of VTE (ex: hypertension, smoking, migraine headaches, diabetes, over age 35.
D
When taking a daily oral contraceptive, a patient should be told to contact the provider for all the following reasons EXCEPT ?
a. Experiencing ear pain - A patient is advised to contact the provider immediately if they experience chest pain, eye pain/problems, severe leg pain, severe abdominal pain, and headaches. These could be symptoms of other life threatening problems occurring in the patient such as DVT,
stroke, HTN, MI, PE, or gallbladder disease b. Experiencing chest pain c. Experiencing severe leg pain d. Experience abdominal pain
A
J. N., 23-year-old graduate student at a business college, presents to the family practice clinic for seeking a hormonal oral contraceptive (OC) since she is dating her boyfriend for 3 months. But like many women, she is unaware of the health risks and side effects of OC. As a healthcare practitioner, what the potential side effects that need to be explained to J.N. that she must seek immediate medical care except
A. Headache B. Severe leg pain C. Chest pain
D. Depression
D
A.B. is a 26-year-old woman who identifies as a lesbian and has sex with women. She returns to your clinic for a follow-up appointment following a diagnostic laparoscopy that revealed endometriosis. After recommending a
contraceptive, A.B. asks “why do I need to take birth control if my partners are
women?” You respond by saying:
A. “The copper ions of a nonhormonal IUD will alter the uterine pH, creating an
environment that will limit endometrial proliferation and inflammation. This will
ease your endometriosis symptoms.”B. “A triphasic oral contraceptive will mimic your body’s natural hormone
fluctuations throughout the menstrual cycle. Taking this medication will ensure your endometriosis symptoms are more predictable and manageable through other pharmacotherapies.”
C. “Monophasic continuous hormone therapy through oral contraceptives will regulate the hormone levels that otherwise cause negative symptoms of your endometriosis. Taking one pill per day every day will reduce your symptoms.”
D. “We suggest folks with a new diagnosis of endometriosis take a contraceptive in the time leading up to surgical treatment to prevent an unintended pregnancy. You may not need this medication if your partners don’t have sperm.”
C
H.M. is an 18 year old female presenting to your clinic. She informs you that she is sexually active with men and will be attending college next year, which is why she wanted to begin taking an oral contraceptive. As her provider, you also inform H.M. of other contraceptive methods in addition to providing information regarding oral contraceptives. What information is important to include?
A. She may want to consider using a different method, because oral contraceptives can have high failure rates in teens and young adults
B. She may want to consider using the Ortho Erva patch for contraception because
it also protects against STIs C. She may not want to consider using the Nuva Ring since it must be inserted into the vagina every two weeks D. She may want to consider using the Depo Provera shot because she would only need to receive the injection once a year while on summer break
A
A 25 year old female is interested in starting Depo Provera injections as a form of contraception. She asks, “What do I need know about it?” You replied the
following statements except:
A. “Depo Provera is injected intra-muscularly every 11 to 13 weeks.”B. “Depo Provera can cause possible weight gain and particularly bone loss; so
exercise regularly and increase taking calcium and Vitamin D.”
C. “If you come later than 13 weeks, I will give you Depo Provera injection right away.”
D. “Return to fertility is around 10 months from the last injection.”
C
K.L. a 21 year old college student has come to your clinic in need of
contraception and would like to know what the benefits of oral contraceptives are. You inform her that the benefits are:
A. She will be protected from STI’s, including HIV with oral contraceptive
use. B. Weight gain is not a factor to consider with oral contraceptive use and this method also alleviates breast tenderness. C. Oral contraceptives help regulate menses and decrease the risk of ovarian and endometrial cancer.D. Oral contraceptive dosing is convenient and easy to remember. You only need to take it once a week.
C
M.L. is a 30 year old female and is an established client at your clinic. Today she presents to refill her oral contraception prescription. When reviewing her medication history she informs you that she is has been taking an antibiotic for the last 3 days, and still has 7 days left of the regimen for a recent infection. Is this of any concern to you as a provider when refilling her prescription?
A. No, oral contraceptives have low drug-drug interactions B. No, she is an established client who you know has been healthy during past visits C. Yes, she cannot take her contraceptive during the antibiotic regimen because it will further increase her risk for thromboembolic disease D. Yes, she should continue to take her oral contraceptive, but it is important to educate her that the antibiotics can decrease the contraceptive effectiveness
D
You are an NP counseling your 22 year old patient about contraceptive options. She is interested in using Mirena but wanted to know how it works. You respond:
a. It inhibits sperm motility by creating an inflammatory reaction in the uterus to prevent sperm from reaching the tube b. It uses progestin only to causes cervical mucus to thicken, preventing sperm from reaching an egg, and it occasionally prevents an egg from being released c. It kills sperm and is a physical barrier to sperm entering the cervix d. It uses both estrogen and progestin to suppress ovulation
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.
JY, a 25 year-old female, was on vacation and forgot to take two doses worth of her daily oral contraceptive medication. Her oral pills were 20mg doses and this was first week of her scheduled doses. Her and her boyfriend had intercourse the previous night. According to oral contraceptive guidelines, what should be her next action regarding the missed
doses? Please select one answer.
a. She should take missed pill as soon as possible and resume schedule; a back-up plan of contraception is not necessary. b. Use condom or abstain from sex for 7 days c. Finish the active pills in the pack and start a new pack the next week d. Use Levonorgestrel and resume taking the pills the next day after using Levonorgestrel
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.
After discussing different contraception options, your patient decides to try The Patch (Ortho Evra). The education on The Patch includes all of the following except:
a. Avoid placing the patch on exactly the same site two consecutive weeks b. Location of patch should not be altered mid-week c. Placing lotion/creams/powders on site will not interfere with the patch
d. Never place patch on the breast
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.
A 28 year old patient sees an NP in clinic. She is 3 months postpartum and is breastfeeding. She is interested in oral contraception. NP understands that the recommended oral contraceptive agent for breastfeeding postpartum patient is which of the following?
a. Progesterone only mini pill b. monophasic continuous therapy c. Combination pill with higher estrogen content in first half of cycle d. Depot medroxyprogesterone acetate
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)
An 18 y/o patient comes to see you at the clinic. She is interested in oral contraception. This patient describes herself as being anxious and very worried about cancer since there is a history of different cancers in her family. You are able to tell this patient that an advantage of oral contraception is that it may reduce the risk of which cancer:
A.) Brain cancer B.) Breast cancer C.) Ovarian cancer D.) Cervical cancer
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
The NP receives a phone call from an 18-year old female patient on combined oral contraceptive pills, stating that she missed the previous two days of her birth control pill. She is inquiring as to what she should do now, as these are the “active pills”. The NP
advices her to:
A. Discard the current pack begin with the new one the following day. B. Resume taking the pills that are scheduled the following day. C. Take two active pills today and two active pills tomorrow, then resume the regular schedule. 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.
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
Absolute contraindications in hormone therapy include all of the following EXCEPT:
a. Uncontrolled hypertension b. Known or suspected pregnancy c. Diabetes Mellitus d. Acute liver disease
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.
Women with low estrogen levels, after menopause, are more likely to report any of the following symptoms EXCEPT:
A. Mood changes B. Vaginal dryness C. Insomnia D. Cold intolerance
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.)
Which of the following statements about the use of Hormone therapy is TRUE?
A. Alcohol decreases the circulating levels of estrogenB. Patients on phenytoin metabolize estrogen at a slower rate
C. Use of hormone therapy containing estrogen plus a progestogen is linked to an increased risk of colon cancerD. An increased dose of estrogen may be needed in smokers
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)
When providing patient education for individuals starting hormone therapy, which of the following information SHOULD NOT be included:
A. It may take up to 4 weeks for the patient to experience a decrease in symptoms B. Management of menopause is achieved on the highest dose possible for as long as the patient wants C. Patients should be encouraged to talk to their provider about any adverse events D. In the event of a missed dose the patient should not double the next dose
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).
Clara is a 42 year old female patient who has come to you for her yearly physical exam. She expresses that she is finished having children and is curious about her options for birth control. When choosing birth control option that would work for her, absolute contraindications for combination oral contraceptive pills would include all of the following EXCEPT:
A. Family history of breast cancer B. Liver disease C. Current pregnancy D. Personal history of embolic event
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 ).
When deciding which contraceptive agent is most appropriate the practitioner should consider all of the following measurements EXCEPT:
A. Height B. Blood pressure C. Lipid panel D. Body mass
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).
A patient is diabetic and has CKD. Which of the following oral medication is the best for
this patient?
a. Starlix/Nateglinide (a meglitinide analog) b. Metformin (a biguanide) c. Glimepiride (a 2nd generation sulfonylurea) d. Prandin/Repaglinide (a meglitinide analog
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.
