Midterm Flashcards
A parent brings a 6-year-old child to the clinic for evaluation of a rash. The primary care NP notes three annular lesions with elevated borders and central clearing on the child’s face and a similar lesion on the back of the neck that extends above the hairline. The NP should prescribe:
a. griseofulvin.
b. topical ketoconazole.
c. oral ketoconazole.
d. fluconazole
A. Griseofulvin.
Griseofulvin is used for tinea infections of the skin, hair, and nails that are not responsive to topical therapy. Topical treatment of tinea capitis is usually ineffective because the fungus invades the hair shaft. Fluconazole is not indicated for tinea infections.
A patient comes to the clinic to have a Mantoux tuberculin skin test read after 48 hours. The primary care NP notes a 6-mm area of induration. The patient is a young adult with no known contacts and has never traveled abroad. The NP should:
a. repeat the test.
b. refer to an infectious disease specialist.
c. tell the patient the test is negative.
d. order a chest radiograph.
D. Order a chest radiograph.
A chest x-ray should be obtained on all patients who have a positive purified protein derivative tuberculin test (PPD). The test was read in the appropriate time frame, so repeating the test is not necessary. This patient has a positive PPD. Referral to an infectious disease specialist should be made when the diagnosis is confirmed.
A patient is taking isoniazid, pyrazinamide, rifampin, and streptomycin to treat TB. The primary care NP should routinely perform:
a. serum glucose and liver function tests (LFTs)
b. bone marrow density and ophthalmologic tests
c. ophthalmologic, hearing, and serum glucose tests
d. color vision, serum glucose, and LFTs
C. ophthalmologic, hearing, and serum glucose tests- For patients taking isoniazis, obtain periodic ophthalmologic examinations; for patients taking pyrazinamide, perform blood glucose tests.
A primary care NP sees a 5-year-old child for a tuberculin skin test. The child lives in a high-risk community, and a grandparent who babysits has active TB. The PPD shows a 6-mm area of induration. A chest radiograph is normal. The NP will refer this patient to an infectious disease specialist and should expect the patient to be on \_\_\_\_\_ for \_\_\_\_\_ months. A. Isoniazid; 6 B. Thambutol; 3 C. Isoniazid and rifapentine; 3 D. Ethambutol and amikacon; 6
C. Isoniazid and rifapentine; 3- This child has a positive PPD with no pulmonary signs, so a 3-month course of isoniazid and rifapentine is indicated. Ethambutol is not recommended in children younger than 13 years.
A patient was prescribed isoniazid and rifampin by the NP for the treatment of latent TB. A few days later the patient calls the NP very concerned and reports that his urine turned red/orange in color. The NP should
a. order renal function tests
b. Reassure the patient that this is a known side effect and to continue with the treatment
c. tell the patient to stop taking the medications immediately
d. refer the patient to a specialist
B. reassure the patient that this is a known side effect and to continue with the treatment
A NP will start treating a patient for TB. Which of the following drugs are considered first-line anti-TB agents approved by the FDA? (SELECT ALL THAT APPLY):
a) Isoniazid
b) Capreomycin
c) Levofloxacin
d) Pyrazinamide
A and D. Isoniazid and pyrazinamide
A patient is diagnosed with onychomycosis. The primary care NP notes that the patient takes quinidine. The NP should prescribe:
a. Terbinafine (Lamisil)
b. Fluconazole (Diflucan)
c. Itraconazole (sporanox)
d. Griseofulvin (Gris-PEG)
A. Terbinafine (Lamisil)- Sporanox and terbinafine are both indicated to treat onychomycosis. Sporanox is not indicated in patients taking quinidine because of the risk of cardiac arrhythmias. Fluconazole and griseofulvin are not indicated to treat onychomycosis.
A woman who takes oral contraceptive pills develops vaginal candidiasis. The primary care NP prescribes a single dose of fluconazole. When counseling the patient about this drug, the NP should tell her:
a. That the drug is safe if she were to become pregnant
b. That she may consume alcohol while taking this medication
c. To use a backup contraceptive method for the next two months
d. That she may need a lower dose of fluconazole because she takes oral contraceptives
C. to use a backup contraceptive method for the next two months- Women using oral contraception who take antifungals should be advised to use supplemental contraception during and for 2 months after antifungal therapy. Antifungals have teratogenic effects and are not safe during pregnancy. Patients should not consume alcohol while taking antifungal medications. It is not necessary to lower the antifungal dose in women taking oral contraceptive pills.
A patient has been diagnosed with a systemic mycoses infection and will start treatment with intravenous Amphotericin B. Which of the following is true about Amphotericin B? (SELECT ALL THAT APPLY):
a. May cause renal insufficiency
b. Works by disrupting DNA synthesis in fungal cells
c. Can be either fungicidal or fungistatic
d. Dose adjustment is not required in patients with hepatic dysfunction
A, C, D
A patient with CHF will receive oral treatment for a tinea pedis infection. The NP may use any of the following antifungal agents, except:
a. Terbinafine
b. Itraconazole
c. Griseofulcin
d. Flucanzole
B. itraconazole
A patient is taking amantadine to treat a viral infection. The patient calls the primary care NP to report having blurred vision. The NP should:
a. Question the patient about suicidal ideation
b. Tell the patient to stop the medication immediately
c. Counsel the patient to avoid driving until this subsides
d. Tell the patient to come to the clinic for electroencephalogram
C. Blurred vision or impaired mental acuity may result from the use of amantadine. Patients with a history of psychiatric illness may develop suicidal ideation, but this is not associated with blurred vision. It is not necessary to stop the medication. Patients with a history of seizures may have seizures with this drug, but this is not associated with blurred vision.
A patient refuses an influenza vaccine and asks the primary care nurse practitioner (NP) if the influenza medications will prevent him from getting influenza. The NP should tell the patient that although the influenza vaccine remains the best protection against influenza:
A. Amantadine may be given prophylactically
B. Rimantadine is curative if given early after exposure
C. Zanamivir can be used before or after exposure to influenza A or B
D. The influenza vaccine is unnecessary because antiviral medications are so effective
C- Zanamivir has been shown to be 70% to 90% effective for prophylaxis before or after exposure to influenza A or B. Amantadine and rimantadine are not recommended for prophylaxis of seasonal influenza, and many strains have developed resistance to both of these drugs.
A patient who has genital herpes has frequent outbreaks. The patient asks the primary care NP why it is necessary to take oral acyclovir all the time and not just for acute outbreaks. The NP should explain that oral acyclovir may:
a. prevent the virus from developing resistance.
b. cause episodes to be shorter and less frequent.
c. Actually eradicate the virus and cure the disease
d. reduce the chance of transmitting the virus to others
B. cause episodes to be shorter and less frequent- Oral acyclovir has prevented or reduced the frequency of severity of recurrences in more than 95% of patients and so should be given to patients with recurrent episodes. It does not affect resistance. The antiviral medication does not eradicate the virus; it prevents replication. The disease is transmitted even without symptoms.
A patient who is taking metronidazole calls the primary care NP to report severe nausea and vomiting along with heart palpitations. The NP should:
a. counsel the patient to take the medication with food.
b. ask the patient about any recent alcohol consumption.
c. reassure the patient that these symptoms will subside.
d. instruct the patient to go to an emergency department for intravenous fluids.
B. ask the patient about any recent alcohol consumption- Metronidazole can cause a disulfiram-like reaction if taken with alcohol. Mild gastrointestinal upset may be prevented by taking the medication with food. The patient needs to be told not to drink alcohol with this drug to prevent this severe reaction. If the symptoms persist, it may be recommended that the patient go to the emergency department.
The primary care NP sees a female patient and makes a diagnosis of Trichomonas vaginalis. The patient does not want to tell her partner she has it because she thinks she may have contracted it from someone else. The NP will tell her:
a. as long as she takes the antibiotic for 7 days, the infection will be cured.
b. she and all of her partners must be treated, or the infection will not be cured.
c. she can be treated, but if the infection recurs, she will have to tell both partners.
d. she and the person who infected her will need one-time doses of metronidazole
B. she and all of her partners must be treated, or the infection will not be cured- because this is a sexually transmitted disease, both partners have to be treated for a cure to be achieved.
A patient has been taking oral prednisone 60 mg daily for 3 days for an asthma exacerbation, which has resolved. The patient reports having gastrointestinal (GI) upset. The primary care nurse practitioner (NP) should:
a. discontinue the prednisone.
b. begin tapering the dose of the prednisone.
c. order a proton pump inhibitor (PPI) to counter the effects of the steroid.
d. change the prednisone dosing to every other day.
A- The patient’s asthma symptoms have resolved, so the prednisone may be discontinued. If the patient has been on the medication for a few days, it is not necessary to taper the dose before the patient stops taking it. If the patient required long-term dosing of the steroid, a PPI could be used. Every-other-day dosing is used. Alternate-day dosing is sometimes used for long-term therapy to minimize suppression of the hypothalamic-pituitary-adrenal(HPA) axis.
A patient will require a long course of steroids to treat a chronic inflammatory condition. The primary care NP expects the specialist to order:
a. prednisone daily.
b. triamcinolone daily.
c. hydrocortisone every other day.
d. dexamethasone every other day
C- Hydrocortisone is a short-acting glucocorticoid. The use of a short-acting agent and an alternate-day dosage regimen should be considered for long-term therapy. Prednisone and triamcinolone are medium-acting glucocorticoids. Dexamethasone is a long-acting glucocorticoid
A 70-year-old patient with COPD who is new to the clinic reports taking 10 mg of prednisone daily for several years. The primary care NP should:
A. begin a gradual taper of the prednisone to wean the patient off the medication.
B. tell the patient to take the drug every other day before 9:00 AM.
C. order a serum glucose, potassium level, and bone density testing.
D. perform pulmonary function tests to see if the medication is still needed.
C- Order a serum glucose, potassium level, and bone density testing. Serum glucose and potassium levels are part of monitoring for side effects of steroids. Because elderly patients are more prone to certain potential catabolic adverse effects of steroid therapy, caution is required. Osteoporosis is often seen with elderly patients, so bone density testing should be performed. The medication dosing regimen should not be changed unless there is an indication of adverse effects.
A primary care NP prescribes an oral steroid to a patient and provides teaching about the medication. Which statement by the patient indicates a need for further teaching?
a. “I should take this medication with food.”
b. “I will take the medication at 8:00 AM each day.”
c. “I can expect a decreased appetite while I am taking this medication.”
d. “I should not stop taking the medication without consulting my provider.
C- Therapeutic administration is least likely to interfere with natural hormone production when the drug is given at the time of natural peak activity. It is generally recommended to administer the full daily dose before 9 AM. Oral glucocorticoids usually are given with meals to limit GI irritation. Common side effects include changes in mood, insomnia, and increased appetite
A patient with ulcerative colitis takes 30 mg of methylprednisolone (Medrol)daily. The primary care NP sees this patient for bronchitis and orders azithromycin (Zithromax). The NP should:
A. stop the methylprednisolone while the patient is taking azithromycin.
B. temporarily decrease the dose of methylprednisolone.
C. change the dosing of methylprednisolone to 15 mg twice a day.
D. order intramuscular (IM) methylprednisolone
B- Temporarily decrease the dose of methylprednisolone. When given concurrently with macrolide antibiotics, methylprednisolone clearance is reduced, so a smaller dose of methylprednisolone is needed. IM administration does not affect clearance of the drug. Changing the dose to twice-daily dosing is not recommended. Stopping the drug abruptly is not recommended.
A patient is being tapered from long-term therapy with prednisolone and reports weight loss and fatigue. The primary care NP should counsel this patient to:
a. consume foods high in vitamin D and calcium.
b. begin taking dexamethasone because it has longer effects.
c. expect these side effects to occur as the medication is tapered.
d. increase the dose of prednisolone to the most recent amount take
D- Sudden discontinuation or rapid tapering of glucocorticoids in patients who have developed adrenal suppression can precipitate symptoms of adrenal insufficiency, including nausea, weakness, depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected
A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should:
a. order a fasting plasma glucose level.
b. consider prescribing metformin (Glucophage).
c. suggest dietary changes and increased exercise.
d. obtain serum insulin and hemoglobin A1clevels
A- Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Seruminsulin level is not indicated
A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this patient's laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe: A. colesevelam (Welchol) B. metformin (Glucophage). C. glyburide (Micronase). D. nateglinide (Starlix).
B- Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs
A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should:
a. order metformin (Glucophage).
b. order a lipid profile, complete blood count, and liver function tests (LFTs).
c. order an oral glucose tolerance test.
d. set a weight loss goal of 10 to 15 lb
D- To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated
A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend:
a. taking the metformin dose as usual the morning of surgery.
b. using insulin during the perioperative and postoperative periods.
c. that the patient stop taking metformin several days before surgery.
d. adding a sulfonylurea medication until recovery from surgery is complete
B- Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery
A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? A. Metformin/glyburide (Glucovance) B. Insulin and metformin(Glucophage) C. Saxagliptin/metformin(Kombiglyze) D. Metformin/pioglitazone (ACTOplus met)
A- Metformin/glyburide (Glucovance)- obese patients with normal renal function and elevated fasting plasma glucose may be started on a combination of metformin and a second-generation sulfonylurea.
A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe:
a. pramlintide (Symlin).
b. repaglinide (Prandin).
c. glyburide (Micronase).
d. metformin (Glucophage).
A- pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated.
A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1cis 7.3%. The NP should:
A. begin insulin therapy.
B. change to therapy with colesevelam (Welchol).
C. add a third oral antidiabetic agent to this patient’s drug regimen.
D. enroll the patient in a weight loss program to achieve better glycemic control.
A- The target hemoglobin A1cgoal for adults is less than 7%. Insulin therapy is indicated if maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the maximum recommended doses of metformin and glyburide. Colesevelam does not decrease hemoglobin A1c. Adding a third oral antidiabetic agent is not recommended. A weight loss program may be a part of this patient’s treatment, but insulin is necessary to maintain glycemic control.
A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP should order: A. nateglinide (Starlix). B. glyburide (Micronase). C. colesevelam (Welchol). D. metformin (Glucophage)
D- Metformin is the only drug listed that is recommended for children
A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the patient reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats per minute. The NP should:
a. obtain LFTs.
b. decrease the dose of metformin.
c. change metformin to glyburide.
d. order electrolytes/BMP, ketones, and serum glucose.
D- Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should include electrolytes, ketones, and serum glucose.
A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe:
a. condoms.
b. tubal ligation.
c. monophasic combined oral contraceptive pill (COCP).
d. low-estrogen COCP.
D- low-estrogen COCPs are recommended for women older than 40 with or without cardiovascular risk. Monophasic COCPs are recommended for women with migraine headaches. Condoms are more useful for preventing sexually transmitted diseases and not as reliable as contraception. Tubal ligation has surgical risks
A primary care NP prescribes a COCP for a woman who has never taken oral contraceptives before. The woman is in a monogamous relationship, and she and her partner have been using condoms and wish to stop using them. Her last period was 1 week ago. The NP should:
a. perform an in-office pregnancy test before starting a COCP.
b. tell the patient to begin the first pill today and to continue using condoms for 7 days.
c. tell the patient to begin the first pill on the Sunday of or following her next menstrual period.
d. tell the patient to begin the first pill today and to return in 2 weeks for a pregnancy test
B- to start COCPs using the quick start method, the woman takes the first pill on the day of her office visit and uses a barrier method such as condoms for the first 7 days. The patient should be reasonably sure she is not pregnant; she can take a pregnancy test in 2 to 3 weeks if pregnancy is suspected later. If she is pregnant, taking the COCPs would not negatively affect early pregnancy.
A woman who began taking a COCP 2 months ago calls the primary care NP to report having nausea every day. She takes a pill at the same time each morning. The NP should tell her to:
a. try taking the pill in the evening each day.
b. come to the clinic for a urine pregnancy test.
c. take the pill on an empty stomach with water.
d. stop taking the pill for 7 days and then restart
A- if nausea occurs when taking the pill, patients should be instructed to switch to the opposite time of day or to take with food. A urine pregnancy test is not indicated. If nausea occurs, patients should take the pill with food. Patients stop taking pills for 7 days at the end of each 21-day pack
The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen?
a. “I have to take a pill only every 3 months.”
b. “I should expect to have only four periods each year.”
c. “I will need to use condoms for only 7 more days.”
d. “This type of pill has fewer side effects than other types.”
B- the extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types
A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and:
a. take one cycle of COCPs.
b. take a home pregnancy test.
c. use condoms for the next 7 days.
d. contact the clinic if she misses a period
C- if a transdermal patch has been discovered to be loose or has come off, patients should use a backup method of contraception. It is not necessary to use oral contraceptives. A home pregnancy test is not indicated
A woman who has been taking a COCP tells the primary care NP that, because of frequent changes in her work schedule, she has difficulty remembering to take her pills. The woman and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring:
a. within 7 days after her last active pill.
b. and use a backup contraceptive for 7 days.
c. and continue the COCP for one more cycle.
d. on the same day she stops taking her COCP
A. Patients should be switched from a COCP to a vaginal ring by insertion within 7 days after the last active pill. No backup method is needed. Patients do not need to continue one more cycle of COCPs. Women taking progestin-only pills insert the ring on the last day of the pill pack.
A postpartum woman will begin taking the minipill while she is nursing her infant. The primary care NP should instruct the patient:
a. to use backup contraception while taking the minipill.
b. to continue using the minipill for 6 months after she stops nursing.
c. that irregular periods while taking the minipill may indicate she is pregnant.
d. that this method does not increase her risk of thromboembolic events
D- minipills are used primarily in breastfeeding women. There is no increased risk for thromboembolic events for women taking these pills. It is not necessary to use a backup method of contraception. Women should be advised to contact the provider when they stop nursing so that a COCP can be prescribed. The more disrupted the bleeding pattern, the more likely it is that ovulation is inhibited
A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant and tells the primary care NP that she would like to space her children about 2 years apart. The NP should:
a. discontinue the progestin-only pill.
b. prescribe a COCP and a folic acid supplement.
c. prescribe a progestin-only pill for another 6 months.
d. suggest that she use a barrier method of contraception.
B- serum folate levels may be decreased by oral contraceptives. Women who become pregnant shortly after stopping oral contraceptive use may have a greater chance of birth defects. This woman should become pregnant in about 6 months if she wants to space her children 2 years apart, so she needs an oral contraceptive. Progestin-only pills are used only during lactation.
A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she:
a. is having nausea/vomiting or diarrhea.
b. delays taking a pill by 5 or 6 hours.
c. takes nonsteroidal antiinflammatory drugs several days in a row.
d. has recurrent headaches or insomnia
A- vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to use backup contraception if they experience these. The other conditions do not lead to oral contraceptive failure
A woman who has been taking a COCP for 2 months tells the primary care NP that she has had several headaches, breakthrough bleeding, and nausea. The NP should counsel the woman:
a. to change to a progestin-only pill.
b. to stop taking the COCP immediately.
c. to use a backup form of contraception.
d. that these effects will likely decrease in another month.
D- breakthrough bleeding, nausea, and headaches are common during the first 3 months of therapy and should improve without intervention. Progestin-only pills are used for lactating women only. Prolonged bleeding and severe headache would warrant discontinuation of the COCP. Backup contraception is not indicated
An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary care NP that she likes the fact that she won’t have to deal with pills or periods. The primary care NP should tell her that she:
a. should consider another form of contraception after 1 year.
b. may have irregular bleeding, especially in the first month or so.
c. will need to take calcium and vitamin D every day while using this method.
d. will have to take oral contraceptive pills in addition to Depo-Provera when she takes antibiotics
B- because of strong progestational effects on the endometrium, irregular bleeding or spotting is common in the early months of use. Because of concerns about the effect of depot medroxyprogesterone acetate on bone density, it is recommended that woman change to another birth control method after 2 years, not 1 year. Calcium and vitamin D supplements have not been shown to prevent bone density loss. It is not necessary to take oral contraceptive pills when taking antibiotics
A sexually active patient tells the primary care NP that she has been unable to get her new COCP pill pack until today and has missed 3 days of pills. The NP should tell her to:
a. use backup contraception and take 2 pills each day for the next 2 days.
b. begin a new pack of pills today and use backup contraception for 7 days.
c. begin a new pack of pills today, take a Plan B pill, and use backup contraception for 7 days.
d. Take a pregnancy test, begin a new pack of pills today, and use backup contraception for 7 days.
C- patients who miss 2 or more pills at the beginning or end of a pack should use emergency contraceptive pills, such as the Plan B pill, restart a new pill pack, and use backup contraception for 7 days.
A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should:
a. tell her that starting HT now may reduce her risk of breast cancer.
b. advise a short course of HT now that may decrease her risk for CHD.
c. tell her that HT will not help control her symptoms during postmenopause.
d. recommend herbal supplements for her symptoms to avoid HT side effects.
A- the current gap hypothesis regarding breast cancer supports initiating HT 5 years or more after menopause. To decrease risk for CHD, HT should begin at the time of menopause. HT will relieve vasomotor symptoms at all stages of menopause. Herbal supplements have estrogenizing effects and carry the same risks as estrogen therapy.
The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3 years. The NP decreases the dosage, and several weeks later, the woman calls to report having several hot flashes each day. The NP should:
a. increase the HT dose.
b. Discontinue HT.
c. recommend black cohosh to alleviate symptoms.
d. reassure her that these symptoms will diminish over time.
A. Increase the HT dose- The Women’s Health Initiative results indicate that HT use for 3 to 5 years is safe and recommend slow weaning after women review HT with their providers at annual visits. If symptoms recur, the dose should be increased until symptoms improve
A 52-year-old woman reports having hot flashes and intense mood swings. After a year of having irregular menstrual periods, she has not had a period for 6 months. The primary care NP should diagnose:
a. menopause.
b. dysmenorrhea.
c. perimenopause.
d. postmenopause.
C- perimenopause usually occurs between ages 42 and 55 and is characterized by erratic ovulation and irregular periods, hot flashes, and intensified PMS symptoms. Menopause begins when periods have been absent for 12 months. Postmenopause describes the 5-year period after menopause. Dysmenorrhea is painful periods
A woman with a family history of breast cancer had her last menstrual period 12 months ago and is experiencing hot flashes. She has not had a hysterectomy. The primary care NP should recommend: A. black cohosh. B. estrogen-only therapy. C. progesterone-only therapy. D. limiting alcohol and caffeine intake.
D. limiting alcohol and caffeine intake. -Hot flashes can be triggered by environmental conditions such as stress, excitement, anxiety, and alcohol and caffeine consumption. Black cohosh carries the same risks as estrogen. Estrogen-only therapy is not recommended for women with an intact uterus. Progesterone therapy is not recommended
A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should:
a) prescribe estrogen-only therapy.
b) initiate oral contraceptive pills now.
c) discuss using bioidentical HT.
d) plan to use estrogen-progesterone therapy when menopause begins.
D. Plan to use estrogen-progesterone therapy when menopause begins- HORMONE THERAPY- The timing hypothesis suggests that initiating HT at or very near to the time of menopause, which begins when a woman has not had a period for 12 months, reduces CHD in postmenopausal women. Estrogen-only therapy is indicated only for women who do not have a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated.
A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe:
a. estrogen-only HT now.
b. estrogen-only HT in 5 years.
c. estrogen-progesterone HT now.
d. estrogen-progesterone HT in 5 years
A- HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated
Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend:
a. testosterone therapy.
b. estrogen-only therapy.
c. nonhormonal drugs for osteoporosis.
d. estrogen-progesterone therapy for 1 to 2 years
C- Although estrogen slows the progression of osteoporosis, it also increases the risk of breast cancer when initiated early in menopause. This woman should receive a nonhormonal treatment for osteoporosis and may receive HT in 5 years if menopausal symptoms persist. Testosterone therapy, estrogen-only therapy, and estrogen-progesterone therapy are not indicated
A 50-year-old woman reports severe, frequent hot flashes and vaginal dryness. She is having irregular periods. She has no family history of CHD or breast cancer and has no personal risk factors. The primary care NP should recommend:
a) estrogen-only HT.
b) low-dose oral contraceptive therapy.
c) selective serotonin reuptake inhibitor therapy until menopause begins.
d) estrogen-progesterone HT
B. Low-dose oral contraceptive therapy- Oral contraceptive pills are not approved by the U.S. Food and Drug Administration for management of perimenopausal symptoms except to treat irregular menstrual bleeding. This patient has a low risk for CHD and breast cancer, so oral contraceptive pills are relatively safe. She is also at risk for pregnancy, so oral contraceptive pills can help to prevent that
A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe:
a. estrogen-only HT.
b. low-dose oral contraceptive therapy.
c. selective serotonin reuptake inhibitor therapy until menopause begins.
d. estrogen-progesterone HT.
A- Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women
A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to:
A. order LH and FSH levels.
B. order a serum prolactin level.
C. prescribe testosterone replacement.
D. obtain a morning serum testosterone level
D- To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive
A man who has secondary hypogonadism associated with pituitary dysfunction will begin exogenous testosterone therapy. The patient asks the primary care NP about future chances of fathering children. The NP should tell him that
A. Fertility may improve with testosterone therapy.
B. exogenous testosterone therapy will shut down sperm production.
C. he should store sperm ahead of the initiation of testosterone therapy.
D. fertility can be restored when testosterone therapy is discontinued
A- Men with secondary hypogonadism may become fertile with exogenous testosterone
A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin. The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The primary care NP should recommend:
A. increasing the dose of warfarin.
B, more frequent blood glucose monitoring.
C. a higher than usual dose of testosterone.
D. increasing insulin doses to prevent hypoglycemia
B- Patients with diabetes may require a decrease in insulin dose because of the metabolic effects of androgens. More frequent blood glucose monitoring should be performed. Warfarin doses may need to be decreased because androgens increase sensitivity to anticoagulants.
The primary care nurse practitioner (NP) is seeing a patient who reports chronic lower back pain. The patient reports having difficulty sleeping despite taking ibuprofen at bedtime each night. The NP should prescribe:
a. diazepam (Valium).
b. metaxalone (Skelaxin).
c. methocarbamol (Robaxin).
d. cyclobenzaprine (Flexeril).
D- Cyclobenzaprine (Flexeril) is indicated for chronic low back pain and provides an added benefit of aiding sleep, which is a common problem among patients with back pain. The other medications are used for acute lower back pain.
A patient reports having an acute onset of low back pain associated with lifting a heavy object the day before. Besides advising the patient to rest and apply ice, the primary care NP should prescribe:
a. an opioid analgesic.
b. metaxalone (Skelaxin)
c. cyclobenzaprine (Flexeril).
d. a nonsteroidal anti-inflammatory drug (NSAID).
D- NSAIDs and acetaminophen are first-line analgesic treatments for low back pain. Opioids are used for severe low back pain. The other two medications are not first-line treatments.
A patient who was in a motor vehicle accident has been treated for lower back muscle spasms with metaxalone (Skelaxin) for 1 week and reports decreased but persistent pain. A computed tomography scan is normal. The primary care NP should:
a. suggest ice and rest.
b. order physical therapy.
c. prescribe diazepam (Valium).
d. add an opioid analgesic medication.
B- Physical therapy may be used as an injury begins to heal. This patient is experiencing improvement of symptoms, so physical therapy may now be helpful. Ice and rest are useful in the first 24 to 48 hours after injury. Diazepam is used on a short-term basis only. Opioid analgesics are used for severe pain.
A patient with lower back pain and right-sided sciatica has taken an NSAID and a TCA for 1 week. The patient reports some decrease in pain but is experiencing increased tingling and numbness of the right leg. The primary care NP should:
a. order a magnetic resonance imaging (MRI) study.
b. order physical therapy.
c. refer the patient to a neurologist.
d. continue the TCA for 1 more week.
A- acute episodes of low back pain should be treated with an analgesic for 1 to 2 weeks. A muscle relaxant is used to treat spasms. Patients with sciatica should be treated for 6 weeks. If a neurologic deficit progresses, MRI should be ordered. Physical therapy is not indicated until serious injury is ruled out. A neurology consultation is necessary in urgent conditions and conditions with bilateral neurologic findings. The TCA may be continued, but the progression of symptoms necessitates radiologic evaluation.
A 70-year-old patient has low back pain and will begin taking metaxalone (Skelaxin). The primary care NP should counsel this patient to:
a. drink extra fluids.
b. avoid taking NSAIDs.
c. get up from a chair slowly.
d. take care to avoid slips and falls.
D- Use of any muscle relaxant puts elderly patients at risk for falls, so patients should be advised to take precautions. It is not necessary to increase fluids or avoid NSAIDs. This drug does not have hypotensive effects, so it is not necessary to provide the caution to rise out of chairs slowly
A patient comes to the clinic complaining of low back pain unrelieved by NSAIDs. The patient has a history of angle-closure glaucoma and renal disease. The primary care NP should prescribe:
a. tizanidine (Zanaflex).
b. metaxalone (Skelaxin).
c. acetaminophen (Tylenol).
d. cyclobenzaprine (Flexeril).
B- Metaxalone may be taken by patients with angle-closure glaucoma and is metabolized by the liver, so it is safe for this patient. Tizanidine should not be given to patients with renal disease because clearance may be reduced by more than 50%. After using NSAIDs with no relief, recommendations are to change to a muscle relaxant. Cyclobenzaprine is not recommended inpatients with glaucoma.
A patient has acute low back pain caused by lifting a heavy object. The patient reports having one or two drinks with meals each day. The primary care NP should prescribe:
a. an NSAID.
b. diazepam (Valium).
c. metaxalone (Skelaxin).
d. acetaminophen (Tylenol)
A- Skeletal muscle relaxants should not be taken with alcohol because effects are additive. Acetaminophen has toxic effects on the liver, and patients who consume alcohol regularly should avoid acetaminophen and diazepam.
A patient has been taking an opioid analgesic for chronic pain and tells the primary care nurse practitioner (NP) that the medication doesn’t work as well anymore. The NP should suspect drug:
a. addiction.
b. tolerance.
c. modulation.
d. dependence.
B- Tolerance is characterized by decreasing drug effect over time, meaning that more drug is needed to achieve the same effect. Addiction is an overwhelming obsession with obtaining and using a drug for non-medically approved purposes. Dependence is the development of abstinence syndrome or withdrawal symptoms
A patient has pain caused by a chronic condition. The patient is reluctant to take opioids because of a fear of addiction. The primary care NP should tell the patient that opioids:
a. carry a high risk of psychological dependence when used long-term.
b. will help to improve the patient’s functional outcomes and quality of life.
c. will eventually become ineffective for treating pain when used over a long period.
d. may require switching from one type of opioid to another to prevent tolerance over time.
B. Chronic pain requires routine administration of drugs, and addiction is generally not a concern, especially for patients with chronic pain or terminal illness. Opioid analgesics will help the patient improve function and quality of life. Tolerance may develop, and higher doses may be required to maintain effectiveness. Randomized, controlled trials are lacking to support switching opioids to manage tolerance and side effects
A patient is diagnosed with a condition that causes chronic pain. The primary care NP prescribes an opioid analgesic and should instruct the patient to:
a. wait until the pain is at a moderate level before taking the medication.
b. take the medication at regular intervals and not just when pain is present.
c. start the medication at higher doses initially and taper down gradually.
d. take the minimum amount needed even when pain is severe to avoid dependency.
B- Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain.
A patient who is a recovering alcoholic is preparing for surgery and expresses fears about using opioid analgesics postoperatively for pain. The primary care NP should tell the patient:
a. that opioids should not be used.
b. to take a very low dose of the opioid.
c. that nonsteroidal anti-inflammatory drugs will be the only safe option.
d. that opioids are safe when taken as directed
D- Fear of drug dependency or addiction does not justify withholding of opiates or inadequate management of pain. As long as the medication is taken as directed, it is safe
A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days after surgery. When the patient is discharged from the hospital, the primary care NP should expect the patient to receive a prescription for _____ mg orally every _____ hours.
a. hydrocodone 30; 6
b. hydrocodone 75; 6
c. meperidine 300;12
d. meperidine 75; 6
A- When patients are switched from one opiate to another, an equianalgesic table should be used to convert the dosage of the current drug to the equivalent dosage of the new drug. An oral dose of 30 mg of hydrocodone is equivalent to an IM dose of 75 mg of meperidine
A patient has been taking an opioid analgesic for 2 weeks after a minor outpatient procedure. At a follow-up clinic visit, the patient tells the primary care NP that he took extra doses for the past 2 days because of increased pain and wants an early refill of the medication. The NP should suspect:
a. dependence.
b. drug addiction.
c. possible misuse.
d. increasing pain
C- Unsanctioned dose increases are a sign of possible drug misuse. Dependence refers to an abstinence or withdrawal syndrome. Drug addiction is an obsession with obtaining and using the drug for nonmedical purposes. The patient should not have increased pain at 2 weeks
A patient who is taking an antibiotic to treat bronchitis reports moderate rib pain associated with frequent coughing. The primary care NP should consider prescribing:
a. morphine.
b. hydrocodone
c. hydromorphone.
d. oxycodone CR.
B- Hydrocodone is used for cough suppression as well as pain. Morphine can cause profound respiratory depression.
A patient who has migraine headaches takes sumatriptan as abortive therapy. The patient tells the primary care nurse practitioner (NP) that the sumatriptan is effective for stopping symptoms but that the episodes are occurring three to four times per month. The NP should consider the addition of:
a. aspirin.
b. topiramate.
c. ergotamine.
d. opioid analgesics
B- Topiramate is an anticonvulsant agent that is approved as a preventive medication for migraines. The other medications are indicated for abortive therapy.
A patient comes to the clinic concerned about possible migraine headaches. The primary care NP conducts a history and physical examination, and the patient describes vise-like pressure in the back of the head that occurs almost daily during the work week. The NP should recommend:
a. acetaminophen.
b. topiramate.
c. sumatriptan.
d. ergotamine
A - This patient is describing symptoms typical of tension headaches. The NP should recommend acetaminophen, not migraine medications
A patient comes to the clinic and reports recurrent headaches. The patient has a headache diary, which reveals irritability and food cravings followed the next day by visual disturbances and unilateral right-sided headache, nausea, and photophobia lasting 2 to 3 days. The NP should recognize these symptoms as _____ migraine.
a. classic
b. hemiplegic
c. basilar-type
d. ophthalmoplegic
A - These are symptoms of classic migraine. Hemiplegic migraine is characterized by motor and sensory symptoms. Basilar-type migraine includes vertigo, diplopia, dysarthria, tinnitus, and decreased hearing. Ophthalmoplegic migraine affects the third, fourth, or fifth cranial nerve, causing permanent damage
A patient who has migraine headaches tells the primary care NP that drinking coffee and taking nonsteroidal anti-inflammatory drugs (NSAIDs) seems to help with discomfort. The NP should tell the patient that:
a. this combination can lead to longer lasting headache pain.
b. these substances are not indicated for migraine headaches.
c. doing this can increase the risk of more chronic migraines.
d. an opioid analgesic would be a better choice for migraine pain.
A - Overuse of pain or migraine medications can cause a transformed migraine, which is a long-lasting headache. Following a migraine episode, the patient has rebound headache daily or nearly daily. NSAIDs, caffeine, opiates, and triptans can cause these rebound headaches. NSAIDs and caffeine are often used to treat migraines. Narcotics and barbiturates increase the risk for development of chronic migraine headaches and should not be first-line drugs.
A patient takes rizatriptan (Maxalt) to abort migraine headaches but tells the primary care NP that the headaches have become more frequent since a promotion at work. The NP’s initial response should be to:
a. prescribe topiramate (Topamax).
b. stress the importance of establishing new routines.
c. help the patient identify stressors associated with the new role.
d. add a combination NSAID, aspirin, and caffeine product to the regimen.
B. - Prevention or reduction of episodes of migraine requires healthy regular daily habits. Regularity of habits, rather than just searching for triggers, is essential for enhancing the effectiveness of nonpharmacologic approaches. If the increase in migraine episodes remains chronic after nonpharmacologic measures are taken, topiramate may be used
A primary care NP prescribes sumatriptan for abortive treatment of migraine headaches. The patient returns to the clinic 1 month later to report increased frequency of the headaches. The NP should:
a. add an opioid analgesic.
b. consider changing to dihydroergotamine (D.H.E. 45).
c. suggest that the patient take sumatriptan with a NSAID.
d. ask the patient how often the sumatriptan is used each week
D. It is important that any abortive agent be administered no more often than 2 days per week to avoid the possibility of rebound headache. Patients should be encouraged to try products for at least two or three episodes of migraine before they decide they are ineffective, so changing the drug regimen may not be indicated at this time.
A patient who has migraine headaches without an aura reports difficulty treating the migraines in time because they come on so suddenly. The patient has been using over the counter NSAIDs. The primary care NP should prescribe:
a. frovatriptan (Frova).
b. sumatriptan (Imitrex).
c. cyproheptadine (Periactin).
d. dihydroergotamine (D.H.E. 45).
B. If the patient is able to take medication at the earliest onset of migraine, ergots are usually effective. Triptans are more effective when patients have difficulty “catching the headache in time.” Sumatriptan begins to work in 15 minutes and so would be indicated for this patient. Frovatriptan has a longer half-life. Cyproheptadine is not a first line
A patient who has mild to moderate migraine headaches has severe nausea and vomiting with each episode. For the best treatment of this patient, the primary care NP should prescribe:
a. triptan nasal spray.
b. metoclopramide and aspirin.
c. an NSAID and prochlorperazine.
d. sumatriptan and metoclopramide.
A. Administer triptan migraine medication in nasal spray or injection for patients with severe nausea and vomiting who have trouble taking oral medications. An antiemetic, such as prochlorperazine or metoclopramide, may be used, although the latter has serious side effects
A patient who has migraine headaches usually has two to three severe migraines each month. The patient has been using a triptan nasal spray but reports little relief and is concerned about missing so many days of work. The primary care NP should consider:
a. an oral triptan plus an opioid analgesic.
b. an injectable triptan plus an oral corticosteroid.
c. an intramuscular steroid plus an opioid analgesic.
d. dihydroergotamine hydrochloride plus an opioid analgesic.
B. For severe migraines, an injectable triptan should be considered along with corticosteroids or opioids as rescue medications. Oral triptans are not as effective for severe migraines. Ergotamines may be tried as second-line therapy.
A patient who experiences migraines characterized by unilateral motor and sensory symptoms tells the primary care NP that despite abortive therapy with a triptan, the frequency of episodes has increased to three or four times each month. The NP should:
a. add a selective serotonin reuptake inhibitor (SSRI) antidepressant.
b. change to dihydroergotamine hydrochloride
c. prescribe a â-blocker such as propranolol.
d. prescribe an anticonvulsant such as topiramate
D. Topiramate is useful for migraine prophylaxis. SSRI antidepressants are considered second-line treatment for prophylaxis and are less effective than tricyclic antidepressants. Ergotamines are not used as prophylaxis. -Blockers are commonly used but may aggravate neurologic symptoms associated with hemiplegic or basilar migraine, which is what this patient has.
A patient who is diagnosed with migraine headaches has a history of cardiovascular disease and hypertension. The NP should prescribe:
a. triptan nasal spray.
b. rizatriptan (Maxalt).
c. cyproheptadine (Periactin).
d. dihydroergotamine (D.H.E. 45)
C. Triptans and ergotamines are contraindicated in patients with cardiovascular disease or hypertension. Cyproheptadine is safe for these patients.
A patient reports frequent headache to the primary NP. The patient describes the headaches as unilateral and moderate in intensity, accompanied by nausea, vomiting, and photophobia. There is no aura, and the headaches generally last 24 to 48 hours. The NP should:
a. prescribe dihydroergotamine (D.H.E. 45).
b. prescribe topiramate (Topamax) as migraine prophylaxis.
c. recognize these as classic migraines and order sumatriptan (Imitrex).
d. suggest treatment with acetaminophen because these are probably tension headaches.
C. This patient has symptoms of classic migraine with repeated episodes. Sumatriptan is a first-line medication. Ergotamines are second-line medications. Topiramate is used as migraine prophylaxis in patients who have increasingly frequent migraine episodes. These symptoms are not characteristic of tension headaches.
An adult patient who has a viral upper respiratory infection asks the primary care nurse practitioner (NP) about taking acetaminophen for fever and muscle aches. To help ensure against possible drug toxicity, the NP should first:
a. determine the patient’s height and weight.
b. ask the patient how high the temperature has been.
c. tell the patient to take 325 mg initially and increase as needed.
d. ask the patient about any other over-the-counter (OTC) cold medications being used.
D. Acetaminophen is present in many other OTC products, so patients should be cautioned about taking these with acetaminophen to avoid overdose. The adult dose is not based on height and weight and is not determined by the degree of temperature elevation
A parent asks a primary care NP how much acetaminophen to give a 2-year-old child who has a temperature of 37.5° C. The NP should tell the parent that:
a. acetaminophen is not safe in children younger than 6 years.
b. acetaminophen may mask a fever and prevent treatment of other symptoms
c. antipyretics are usually not necessary for temperatures less than 37.7° C.
d. antipyretics should be given to prevent seizures, but nonsteroidal antiinflammatory drugs are a better choice
C. Acetaminophen is the drug of choice for treating fever but is generally not indicated for fever less than 37.7° C. Acetaminophen is safe for children and infants. Treating the fever may prolong the illness and mask symptoms, but these are not contraindications for giving antipyretics.
An 80-year-old patient with congestive heart failure has a viral upper respiratory infection. The patient asks the primary care NP about treating the fever, which is 38.5° C. The NP should:
a. recommend acetaminophen.
b. recommend high-dose acetaminophen.
c. tell the patient that antibiotics are needed with a fever that high.
d. tell the patient a fever less than 40° C does not need to be treated
A. Patients with congestive heart failure may have tachycardia from fever that aggravates their symptoms, so fever should be treated. High doses should be given with caution in elderly patients because of possible decreased hepatic function. Antibiotics should not be given without evidence of bacterial infection
A patient comes to the clinic and reports breaking out in an urticarial rash 1 hour after taking acetaminophen for osteoarthritis symptoms. The primary care NP should:
a. order a complete blood count with differential.
b. order liver and renal function tests.
c. suspect Reye’s syndrome and arrange for hospitalization.
d. tell the patient not to take products containing acetaminophen again
D. Urticaria is indicative of a hypersensitivity reaction to acetaminophen. Patients who are hypersensitive should not take the drug again. Laboratory tests are not indicated. An urticarial rash does not indicate Reye’s syndrome
A patient in the clinic reports taking a handful of acetaminophen extra-strength tablets about 12 hours prior. The patient has nausea, vomiting, malaise, and drowsiness. The patient’s aspartate aminotransferase and alanine aminotransferase are mildly elevated. The primary care NP should:
a. expect the patient to sustain permanent liver damage.
b. reassure the patient that these symptoms are reversible.
c. tell the patient that acetylcysteine cannot be given this late.
d. administer activated charcoal to remove acetaminophen from the body.
A. After acetaminophen overdose, if liver enzymes are elevated within 24 hours, irreversible liver damage is likely. Acetylcysteine may still be given to mitigate the effects. Activated charcoal is effective only when given immediately
A patient reports having persistent mild to moderate pain in both knees usually associated with standing. The patient reports knee stiffness for 15 to 20 minutes each morning. The primary care nurse practitioner (NP) learns that the patient has used heating pads and acetaminophen, which no longer relieve the pain. The NP orders an erythrocyte sedimentation rate, which is normal. The NP should consider prescribing:
a. aspirin.
b. a cyclooxygenase-2 (COX-2) inhibitor.
c. glucosamine and chondroitin.
d. a topical nonsteroidal antiinflammatory drug (NSAID)
D. Topical NSAIDs, acupuncture, and tramadol are effective for pain relief in knee osteoarthritis. Treatment for osteoarthritis should begin with nonpharmacologic treatment, and acetaminophen should be first-line pharmacologic treatment. NSAIDs should be used when these two measures are no longer effective. COX-2 inhibitors are more expensive and should be used in the presence of gastrointestinal (GI) side effects or for moderate to severe pain. Glucosamine and chondroitin do not relieve most osteoarthritis pain.
A 70-year-old patient describes moderate to severe pain associated with osteoarthritis in fingers, thumbs, hips, and knees. The patient is currently taking high-dose acetaminophen. The patient has a strong family history of cardiovascular disease and has been diagnosed with hypertension. To help alleviate this patient’s pain, the primary care NP should consider prescribing:
a. a COX-2 inhibitor and low-dose aspirin.
b. ketorolac (Toradol) and 325 mg of aspirin.
c. naproxen (Naprosyn) and low-dose aspirin.
d. indomethacin (Indocin) and 325 mg of aspirin.
C. Aspirin at the dosage of 325 mg every other day or 81 mg daily is effective in reducing the incidence of myocardial infarction (MI) and stroke. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.
A patient with mild to moderate osteoarthritis pain has been taking acetaminophen for pain. The primary care NP prescribes a nonselective NSAID. At a follow-up visit, the patient reports mild GI side effects. The NP should:
a. order misoprostol to take with the NSAID.
b. discontinue the NSAID and order tramadol.
c. change the medication to a COX-2 inhibitor.
d. change the medication to naproxen (Naprosyn)
A. HaIf the patient experiences GI distress, coadministration of histamine-2 blockers, proton pump inhibitors, or misoprostol may be considered. Tramadol is used for severe pain. A COX-2 inhibitor is generally used for long-term therapy. Naproxen is another nonselective NSAID and would likely have similar GI side effects. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.
A patient is taking 81 mg of aspirin daily to decrease MI risk and uses acetaminophen for mild osteoarthritis symptoms. For flare-ups of osteoarthritis pain, the primary care NP should prescribe:
a. ibuprofen (Motrin).
b. celecoxib (Celebrex).
c. naproxen (Naprosyn).
d. increasing the dose of aspirin
C. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk.
An 80-year-old patient has been taking naproxen (Naprosyn) for osteoarthritis for 6 months. The patient reports adequate pain relief but complains of feeling tired. The primary care NP will order:
a. liver function tests.
b. a serum potassium level.
c. a complete blood count (CBC).
d. a creatinine clearance and urinalysis
C. Elderly patients are more susceptible to the adverse effects of NSAIDs, especially slow GI bleeds leading to anemia (manifested as fatigue, lethargy). Patients complaining of fatigue should have a CBC to evaluate for anemia
A patient who has rheumatoid arthritis begins taking naproxen (Naprosyn) 500 mg once daily for pain. After 1 week, the patient calls the primary care NP to report no change in inflammation. The NP should:
a. change the medication to tramadol.
b. change the medication to ketorolac (Toradol).
c. increase the dose of naproxen to 1000 mg daily.
d. counsel the patient that pain relief may not occur for another week.
D. The analgesic effect of NSAIDs should be noticed within 1 to 4 hours of administration. However, the full antiinflammatory effect will not be apparent until after a few weeks. Tramadol and ketorolac are used for severe pain. It is not necessary to increase the dose of naproxen.
The primary care NP sees an adolescent who reports moderate to severe dysmenorrhea. The NP recommends an NSAID and counsels the patient about its use. Which statement by the patient indicates a need for further teaching?
a. “I should not take this if I think I might be pregnant.”
b. “I should take this medication on a schedule for 2 to 3 days.”
c. “I will begin taking these 1 to 3 days before my period begins.”
d. “I will take this medicine every 4 to 6 hours as needed for pain.”
D. When treating primary dysmenorrhea, NSAIDs should be started 24 to 72 hours before the patient starts menstrual bleeding. The medication should be taken on a routine basis for 2 to 3 days. It should not be taken during pregnancy.
