Midterm Flashcards
1
Q
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
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.
2
Q
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.
A
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.
3
Q
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
A
C. ophthalmologic, hearing, and serum glucose tests- For patients taking isoniazis, obtain periodic ophthalmologic examinations; for patients taking pyrazinamide, perform blood glucose tests.
4
Q
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
A
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.
5
Q
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
A
B. reassure the patient that this is a known side effect and to continue with the treatment
6
Q
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
A and D. Isoniazid and pyrazinamide
7
Q
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
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.
8
Q
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
A
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.
9
Q
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
A, C, D
10
Q
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
A
B. itraconazole
11
Q
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
A
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.
12
Q
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
A
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.
13
Q
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
A
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.
14
Q
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.
A
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.
15
Q
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
A
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.
16
Q
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
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.
17
Q
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
A
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
18
Q
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.
A
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.
19
Q
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.
A
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
20
Q
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
A
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.
21
Q
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
A
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
22
Q
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
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
23
Q
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).
A
B- Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs
24
Q
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
A
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
25
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
26
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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.
27
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.
28
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.
29
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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
30
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.
31
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
32
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.
33
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
34
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
35
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
36
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.
37
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
38
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.
39
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
40
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
41
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
42
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.
43
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.
44
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
45
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
46
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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.
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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
47
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.
48
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
49
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
50
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
51
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
52
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
53
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
54
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.
55
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.
56
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.
57
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.
58
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.
59
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
60
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.
61
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.
62
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
63
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
64
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.
65
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
66
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
67
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
68
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.
69
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.
70
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
71
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
72
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.
73
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
74
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.
75
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
76
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
77
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.
78
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.
79
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.
80
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.
81
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
82
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.
83
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
84
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
85
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
86
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.
87
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.
88
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.
89
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.
90
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
91
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.
92
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.
93
The primary care NP is performing a medication reconciliation on a patient who takes digoxin for congestive heart failure and learns that the patient uses ibuprofen as needed for joint pain. The NP should counsel this patient to:
a. use naproxen (Naprosyn) instead of ibuprofen.
b. increase the dose of digoxin while taking the ibuprofen.
c. use an increased dose of ibuprofen while taking the digoxin.
d. take potassium supplements to minimize the effects of the ibuprofen.
A. Ibuprofen and indomethacin increase the effects of digoxin, so the NP should recommend another NSAID, such as naproxen, that does not have this effect. Increasing the dose of digoxin or the ibuprofen would increase the likelihood of digoxin toxicity further. Potassium should be monitored while taking NSAIDs long-term, but supplements should not be given unless there is a potassium deficiency.
94
A primary care NP prescribes a nonselective NSAID for a patient who has osteoarthritis. The patient expresses concerns about possible side effects of this medication. When counseling the patient about the medication, the NP should tell this patient:
a. to avoid taking antacids while taking the NSAID.
b. to take each dose of the NSAID with a full glass of water.
c. that a few glasses of wine each day are allowed while taking the NSAID.
d. to decrease the dose of the NSAID if GI symptoms occur
B. To avoid GI distress associated with NSAIDs, a full glass of water is recommended. Patients may take NSAIDs with antacids. Patients should avoid alcohol while taking NSAIDs. Patients should report GI symptoms to their provider.
95
A patient who has osteoarthritis is scheduled to have knee surgery. The patient takes aspirin for MI prophylaxis and naproxen (Naprosyn) for pain and inflammation. Which statement by the patient to the primary care NP indicates a need for further teaching?
a. "I should stop taking aspirin at least 5 days before surgery."
b. "I will check with the surgeon to see if I need to stop taking the naproxen."
c. "I will need to stop taking both medications 1 week before I have surgery."
d. "Both of these medications interfere with platelet production and may cause blood clots.
C. Although both medications interfere with platelet formation, some NSAIDs may continue to be taken before surgery, depending on the procedure and the surgeon preference. The patient should stop taking aspirin 5 days before surgery.
96
A patient who has hypertension is taking a thiazide diuretic. The patient has a serum uric acid level of 8 mg/dL. The primary care nurse practitioner (NP) caring for this patient should:
a. prescribe colchicine.
b. discontinue the thiazide diuretic.
c. order a 24-hour urine collection.
d. refer the patient to a rheumatologist.
C. Patients who have hypertension or who take thiazide diuretics are at increased risk for gout. An elevated uric acid level alone is not diagnostic, and a 24-hour urine collection should be ordered. Colchicine should not be prescribed until the diagnosis is confirmed. It is not necessary to discontinue the thiazide diuretic. A referral to a specialist is not indicated.
97
A patient comes to the clinic reporting sudden pain and swelling of one knee joint. The primary care NP suspects gout. When preparing to order diagnostic tests, the most important initial test the primary care NP should order is:
a. renal function tests.
b. serum uric acid levels.
c. 24-hour urine collection.
d. synovial fluid aspirate for Gram stain and culture
D. Although the other tests are part of the diagnostic process, the most important differential diagnosis to be made in a patient with gout is the exclusion of a septic joint.
98
Gout is diagnosed in a patient, and tests show the cause to be an underexcretion of uric acid. The primary care NP should prescribe:
a. febuxostat (Uloric).
b. colchicine (Colcrys).
c. allopurinol (Zyloprim).
d. probenecid (Benemid).
D. A uricosuric agent is indicated to increase the excretion of uric acid. Probenecid is a uricosuric medication. Febuxostat and allopurinol are xanthine oxidase inhibitors. Colchicine is not a uricosuric agent
99
A primary care NP prescribes probenecid to treat a patient who has gout. The patient comes to the clinic 2 weeks later with severe flank pain. The NP should:
a. ask the patient about fluid intake.
b. order a urinalysis and urine culture.
c. change the medication to allopurinol.
d. recommend nonsteroidal anti-inflammatory drugs (NSAIDs) to treat flank pain
A. Uricosuric agents are tubular blocking agents and decrease serum uric acid levels by increasing urinary excretion of uric acid. During this process, high concentrations of uric acid develop in the proximal renal tubules and may predispose the patient to the development of urinary stones. Patients should be encouraged to drink plenty of fluids. The patient who presents with flank pain should be questioned about fluid intake. If fluid intake is sufficient and renal stones are ruled out, a urinary tract infection may be considered. Allopurinol is not indicated. NSAIDs are not indicated.
100
A patient who is obese and has hypertension is taking a thiazide diuretic and develops gouty arthritis, which is treated with probenecid. At a follow-up visit, the patient's serum uric acid level is 7 mg/dL, and the patient denies any current symptoms. The primary care NP should discontinue the probenecid and:
a. prescribe colchicine.
b. prescribe febuxostat.
c. tell the patient to use an NSAID if symptoms recur.
d. counsel the patient to report recurrence of symptoms.
A. Colchicine is a first-line drug for preventing acute attacks. Because this patient has three risk factors, a preventive medication should be used. Febuxostat is a second-line preventive medication. The patient should not be treated on an as-needed basis.
101
A patient with a history of gouty arthritis comes to the clinic with acute pain and swellingof the great toe. The patient is not currently taking any medications. The primary care NP should prescribe:
a. naproxen.
b. colchicine.
c. probenecid.
d. allopurinol
A. Naproxen is the first medication given for an attack of acute gouty arthritis to stop the inflammatory response. Pharmacologic treatment for hyperuricemia must be started after the acute attack has subsided.
102
A patient who is taking colchicine for gout is in the clinic 1 week after beginning the medication. The patient reports decreased appetite and nausea. The primary care NP should:
a. suspect worsening of gouty arthritis.
b. order vitamin B12 levels to assess for vitamin deficiency.
c. discontinue the colchicine for 48 hours until symptoms subside.
d. reassure the patient that these are common, temporary side effects
C. Colchicine toxicity causes nausea, vomiting, and anorexia. When toxicity is suspected, the medication should be temporarily discontinued and restarted after symptoms subside.
103
A patient who has a previous history of renal stones will begin taking probenecid for gout. The primary care NP should:
a. add colchicine to the patient's drug regimen.
b. counsel the patient to use high-dose aspirin for pain.
c. teach the patient to drink plenty of acidic fluids such as juice.
d. tell the patient to stop taking the medication when symptoms subside.
A. Patients at risk for urinary stones may take colchicine along with probenecid to reduce the risk caused by probenecid. Salicylates and acidic urine increase the risk. The medication must be tapered 6 months after the last acute attack.
104
A man who has benign prostatic hypertrophy (BPH), in whom prostate carcinoma has been ruled out, asks the primary care nurse practitioner (NP) about beginning drug therapy to treat his symptoms. The NP notes that he consistently has blood pressure readings around 145/90 mm Hg. The NP should prescribe:
a. tadalafil (Cialis).
b. doxazosin (Cardura).
c. tamsulosin (Flomax).
d. finasteride (Proscar)
B. Doxazosin is a nonspecific blocker, which also lowers blood pressure and should be considered to treat BPH in patients who also have hypertension. Tadalafil is used to treat erectile dysfunction. Tamsulosin is a specific á-blocker and is first-line treatment for patients with BPH who do not have hypertension. Finasteride is a 5-reductase inhibitor, which is not a first-line medication
105
A patient who has BPH is taking tamsulosin and dutasteride and asks the primary care NP why he needs to take both medications. The NP should tell him:
a. the combination helps reduce the risk of prostate carcinoma.
b. two-drug therapy is required before corrective prostatectomy surgery.
c. both drugs are given so that smaller doses of each drug may be administered.
d. one gives faster symptom relief, whereas the other shrinks the size of the prostate.
D. A 5α-reductase inhibitor is given to shrink the size of the prostate, but maximum benefit is not achieved until 6 months of therapy. The α-blocker is given to provide more rapid relief. The combination does not decrease the risk of carcinoma. The drug therapy is not a prerequisite to surgery, although it may be used before surgical intervention. The combination therapy does not affect the dose of either drug
106
A patient who has BPH is taking alfuzosin (Uroxatral) and finasteride (Proscar). The patient has had two urinary tract infections (UTIs) in the past 2 months. A urinalysis in the clinic is negative for leukocyte esterase but positive for hematuria. The primary care NP should:
a. discontinue finasteride.
b. refer the patient to a urologist.
c. change alfuzosin to tamsulosin.
d. add doxazosin to the drug regimen
B. Surgery is indicated for patients who are refractory to treatment with medications or who have recurrent UTIs or hematuria. The NP should refer the patient to a urologist. All -blockers are considered equally efficacious, so changing the drug regimen is not indicated
107
A patient who has BPH is taking doxazosin and finasteride. The patient asks the primary care NP whether he has an increased risk of prostate cancer. The NP should tell him:
a. his overall cancer risk is increased.
b. he has an increased risk of a certain type of cancer.
c. his cancer risk is the same as any other man his age.
d. doxazosin will increase his cancer risk, but only slightly.
B. There is an overall reduction in prostate cancer risk for patients taking 5-reductase inhibitors, such as finasteride, but there is an increased risk of high-grade prostate cancer. His overall cancer risk is less. Doxazosin does not affect cancer risk
108
A patient tells the primary care NP that he has difficulty getting and maintaining an erection. The NP's initial response should be to:
a. prescribe sildenafil (Viagra).
b. perform a medication history.
c. evaluate his cardiovascular status.
d. order a papaverine injection test to screen for erectile dysfunction
B. Because the use of multiple medications is associated with a higher prevalence of erectile dysfunction, a medication history should be performed first to see if any medications have sexual side effects. A cardiovascular evaluation may be assessed next. Papaverine injection tests are useful screening tools after a thorough history has been performed. Medications are prescribed only after a diagnosis is determined and other causes have been ruled out
109
The primary care NP is preparing to prescribe sildenafil for a man who has erectile dysfunction. The NP should remember to tell this patient:
a. to avoid oral nitrates while taking this medication.
b. that the drug may cause penile aching.
c. to use a condom if his sexual partner is pregnant.
d. dyspepsia may occur and may warrant discontinuation of the drug
A. Deaths have been reported in men on concomitant treatment with oral nitrates who are taking sildenafil. Patients taking alprostadil may experience penile ache. Finasteride, not sildenafil, isteratogenic, and a man taking finasteride should use condoms if his partner is pregnant
110
A man who has cardiovascular disease and takes nitroglycerin for angina pain develops erectile dysfunction. The primary care NP who cares for this patient should recommend:
a. sildenafil (Viagra).
b. testosterone injections.
c. vascular reconstruction surgery.
d. use of a vacuum constriction device.
D. Deaths have been reported in men on concomitant treatment with oral nitrates who are taking sildenafil. Patients with erectile dysfunction should be advised to try nonpharmacologic treatment, such as a vacuum constriction device. Testosterone injections are used for men with documented androgen deficiency. Vascular reconstruction surgery may be used for men with decreased blood flow and should be considered if other treatments are ineffective.
111
A patient who has erectile dysfunction wants a medication to use as needed. The primary care NP should recommend:
a. tadalafil (Cialis).
b. sildenafil (Viagra).
c. avanafil (Stendra).
d. vardenafil (Levitra)
C. Avanafil is the newest drug on the market and can be used on an as-needed basis because it has a shorter half-life and shorter onset of action. It may be taken 30 minutes before sexual activity. The other agents have an onset of action of several hours.
112
The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also reports having an increased urge to void even when her bladder is not full. She is not taking any medications. The NP should:
a. performs a dipstick urinalysis.
b. prescribe desmopressin (DDAVP).
c. prescribe oxybutynin chloride (Ditropan XL).
d. teach exercises to strengthen the pelvic muscles
A. A focused history with a careful physical examination is essential for determining the cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can cause incontinence. Medications are prescribed after determining the cause, if any, and treating underlying conditions. Exercises to strengthen the pelvic muscles are part of treatment.
113
A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is normal. To treat this, the primary care NP should consider prescribing:
a. flavoxate (Urispas).
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. oxybutynin chloride (Ditropan XL).
D. This patient is describing urge incontinence, or overactive bladder, which occurs when the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full. Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria.
114
A patient reports having urinary frequency and discomfort associated with urination. After a careful physical examination and history to determine the cause, the NP should prescribe a medication from which drug class?
a. Cholinergics
b. Antispasmodics
c. Anticholinergics
d. Urinary tract analgesics
B. Antispasmodics are smooth muscle relaxants. Use of these drugs can produce increased bladder capacity and exhibit local anesthetic and analgesic actions. Cholinergic agents increase detrusor muscle tone to improve initiation of voiding and bladder emptying. Anticholinergics decrease detrusor tone to treat urge incontinence. Urinary tract analgesics areused to treat pain via a local analgesic effect on urinary tract mucosa and are used in conjunction with antibiotics to treat UTI.
115
A parent brings an 8-year-old child to the clinic because the child continues to wet the bed despite using cognitive-behavioral measures and a bed alarm system. The NP should prescribe:
a. solifenacin (VESIcare).
b. tolterodine (Detrol LA).
c. desmopressin (DDAVP).
d. phenazopyridine (Pyridium).
C. Desmopressin is used as an antidiuretic and decreases urine output for approximately 6 hours and is often used to treat nocturia in children. Solifenacin and tolterodine are anticholinergics. Phenazopyridine is a urinary tract analgesic
116
A patient has a UTI and will begin treatment with an antibiotic. The patient reports moderate to severe suprapubic pain. The primary care NP should prescribe:
a. ibuprofen as needed.
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. increased oral fluid intake to dilute urine
C. Phenazopyridine is a urinary tract analgesic used to treat pain via a local analgesic effect on urinary tract mucosa in conjunction with antibiotics to treat UTI. Ibuprofen may be used but does not have direct effects on the urinary tract mucosa. Bethanechol is used to treat voiding dysfunction and not pain. Increasing fluid intake should be used as adjunct therapy
117
A primary care NP prescribes oxybutynin chloride for an 80-year-old patient to treat urinary incontinence. When teaching this patient about this medication, the NP should tell the patient:
a. to increase intake of fluids and fiber.
b. that alcohol may be consumed in moderation.
c. that drowsiness may be a transient adverse effect.
d. that hypertension may occur and to report headaches
A. Oxybutynin chloride is an anticholinergic drug and can cause dry mouth and constipation. Patients should be taught to increase fluids and fiber. Patients should be cautioned to avoid alcoholic beverages. Drowsiness occurs but does not subside, and elderly patients are at increased risk for this side effect. Anticholinergics cause hypotension
118
A patient reports dribbling small amounts of urine but also has difficulty initiating a urine stream. The primary care NP should prescribe:
a. solifenacin (VESIcare).
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. oxybutynin chloride (Ditropan XL).
B. Bethanechol is a cholinergic agonist and is used to treat voiding dysfunction by increasing the activity of the detrusor muscle. Solifenacin and oxybutynin chloride are anticholinergics. Phenazopyridine is a urinary tract analgesic.
119
A serious side effect associated with desmopressin is:
a. dehydration.
b. hypotension.
c. hyponatremia.
d. urinary retention.
C. Patients taking desmopressin should be cautioned to limit fluid intake because hyponatremia and water intoxication may occur.
120
In every state, prescriptive authority for NPs includes the ability to write prescriptions:
A. for controlled substances.
B. for specified classifications of medications.
C. without physician-mandated involvement.
D. with full, independent prescriptive authority.
B. for specified classifications of medications
121
A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose?
a. Rectal
b. Topical
c. Sublingual
d. Intramuscular
C. Sublingual
122
The primary care nurse practitioner (NP) writes a prescription for an antibiotic using an electronic drug prescription system. The pharmacist will fill this prescription when:
a. the electronic prescription is received.
b. the patient brings a written copy of the prescription.
c. a copy of the written prescription is faxed to the pharmacy.
d. the pharmacist accesses the patient's electronic record to verify.
A. the electronic prescription is received. Some scheduled drugs still require written copies. Faxed copies would be allowed but are not necessary for the pharmacist to fill the prescription.
123
A patient receives an inhaled corticosteroid to treat asthma. The patient asks the nurse why the drug is given by this route instead of orally. The nurse should explain that the inhaled form:
a. is absorbed less quickly.
b. has reduced bioavailability.
c. has fewer systemic side effects.
d. provides dosing that is easier to regulate.
C. has fewer systemic side effects.
124
A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that:
a. CYP450 enzyme reactions will not interfere with this drug's metabolism.
b. substrates such as alcohol cannot interfere with the drug when the patient is abstaining.
c. food-drug interactions are limited to those where food enhances or inhibits drug absorption.
d. a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required.
D. A thorough history of diet, alcohol use, smoking, and over the counter and herbal products is required.
125
The neighbor of a primary care NP asks the NP to write a prescription for an antibiotic. The NP should tell the neighbor:
a. a prescription will be written one time only.
b. she will ask a colleague to write the prescription.
c. that it is illegal to write prescriptions for friends.
d. that it is best if the neighbor sees a health care provider before obtaining a prescription.
D. that it is best if the neighbor sees a health care provider before obtaining a prescription.
126
A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African-American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of:
a. bioavailability.
b. pharmacokinetics.
c. pharmacodynamics.
d. anatomy and physiology.
B. pharmacokinetics.
127
The family nurse practitioner sees a 6-month-old infant for a routine physical examination and notes that the infant has a runny nose and a cough. The parents report a 2-day history of a temperature of 99° F to 100° F and two to three loose stools per day. Other family members have similar symptoms. The infant has had two sets of immunizations at 2 and 4 months of age. The FNP should:
A. administer the 6-month immunizations at this visit today.
B. schedule an appointment in 2 weeks for 6-month immunizations.
C. administer DTaP, Hib, IPV, hepatitis B, and PCV13 today and RV in 2 weeks.
D. withhold all immunizations until the infant's temperature returns to normal and the cough is gone.
A. administer the 6-month immunizations at this visit today. - Minor upper respiratory infection or gastroenteritis, with or without fever, is not an indication for withholding a scheduled vaccine dose.
128
A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6-year-old child. The parent explains that the medication label does not give instructions about how much to give a child. The best action is to:
A. order a prescription antitussive medication for the child.
B. ask the parent to identify all of the ingredients listed on the medication label.
C. calculate the dose for the active ingredient in the over-the-counter preparation.
D. tell the parent to approximate the dose at about one third to one half the adult dose.
B. ask the parent to identify all of the ingredients listed on the medication label. - Over-the-counter cough medications often contain dextromethorphan, which can be toxic to young children. It is important to identify ingredients of an over-the-counter medication before deciding if it is safe for children. A prescription antitussive is probably not warranted until the cough is evaluated to determine the cause. Until the ingredients are known, it is not safe to approximate the child's dose based on only the active ingredient
129
A previsit health history on a new patient is obtained. The patient reports taking vitamins every day. The best response is to:
A. ask the patient to bring all vitamin bottles to the clinic appointment.
B. recommend natural vitamin products over synthetic vitamin products.
C. reassure the patient that vitamins that are high in folic acid are safe to take.
D. tell the patient that some vitamins, such as vitamin C, are safe in large doses.
A. ask the patient to bring all vitamin bottles to the clinic appointment. - It is important to determine exactly what the patient is taking, so asking patients to bring vitamin bottles to the clinic is appropriate. There is no evidence that natural products are better than synthetic products. High doses of folic acid may mask signs of vitamin B12 deficiency. Vitamin C in high doses can cause dependency.
130
A woman who is breastfeeding her infant asks what she can use for headaches while she is nursing. The appropriate response is to tell her:
A. most medications enter breast milk and are not safe.
B. most over-the-counter medications are safe for the breastfed infant.
C. she may need to interrupt breastfeeding when taking headache medications.
D. she should consider weaning her infant to formula if her headaches are frequent.
B. most over-the-counter medications are safe for the breastfed infant. - Most over-the-counter medications are considered safe for the breastfed infant and do not necessitate a disruption of breastfeeding, even though most medications cross easily into breast milk. Any interruption of breastfeeding carries a risk of premature weaning and so is indicated only when the mother must take medications known to cause serious harm to the baby. It is not recommended that she wean her infant to formula when she needs medications for her headaches.
131
The mother of a 3-year-old child who weighs 15 kg tells the advance practice nurse that she has liquid acetaminophen at home but does not know what dose to give her child. The advance practice nurse should tell the mother:
a. to give 1 teaspoon every 4 to 6 hours as needed.
b. to throw away the old medication and get a new bottle.
c. that she may give 5 to 7.5 mL per dose every 4 to 6 hours.
d. to find out whether she has a preparation made for infants or children.
D. to find out whether she has a preparation made for infants or children. - Acetaminophen drops for infants are three times as concentrated as the oral liquid for children. The drops have been pulled from the market, but many parents may still have old preparations on hand. The NP should first determine which preparation this mother has before giving dosage recommendations. If the mother has the oral liquid for children, answers A and C would both be acceptable because the concentration is 160 mg per 5 mL. The mother should not be counseled to throw away the medication until the NP has more information.
132
An MSN-prepared nurse is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the MSN-prepared nurse recommend for this patient?
a. Loratadine (Claritin)
b. Hydroxyzine (Vistaril)
c. Diphenhydramine (Benadryl)
d. Chlorpheniramine maleate (Chlorphen 12)
A. Loratadine (Claritin)- Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible.
133
An FNP is evaluating a patient who has COPD. The patient uses a LABA twice daily. The patient reports having increased exertional dyspnea, a frequent cough, and poor sleep. The patient also uses a short-acting β-adrenergic agonist (SABA) five or six times each day. Pulse oximetry reveals an oxygen saturation of 92%. The patient's FEV1/forced vital capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe a(n):
a. combination ICS/LABA inhaler.
b. oral corticosteroid.
c. long-acting anticholinergic.
d. long-acting oral theophylline
A. combination ICS/LABA inhaler. - Providers should administer combination inhaled therapies for symptomatic patients with stable COPD and FEV1 less than 60%. Oral corticosteroids have not been shown to be effective, even in severe cases of COPD. Long-acting anticholinergic medications may be used as monotherapy in early stages of COPD. Long-acting theophylline is poorly tolerated because of side effects.
134
A parent brings in a 2-month-old infant with a 5-day history of a white coating on the tongue and decreased oral intake. The primary care NP should prescribe:
a. nystatin oral suspension, 200,000 units qid.
b. clotrimazole, one troche tid.
c. chlorhexidine, 15 mL oral rinse bid.
d. carbamide peroxide, 2 to 3 drops tid.
A. nystatin oral suspension, 200,000 units qid.- Nystatin is an antifungal medication and is indicated for treatment of oral candidiasis, or thrush. Clotrimazole is an antifungal but is not indicated for oral candidiasis in infants because the patient must be able to allow the troche to dissolve. Chlorhexidine is used to treat gingivitis. Carbamide peroxide is used to treat minor oral inflammation.
135
A family nurse practitioner (FNP) is evaluating a patient with asthma who reports having wheezing and coughing 1 or 2 days each week and awakening from sleep three or four times each month with asthma symptoms. The patient's forced expiratory volume in 1 second (FEV1) is 80% of the predicted value. The patient's current medication regimen is an albuterol metered-dose inhaler, 2 puffs every 4 hours as needed. The FNP should prescribe:
a. montelukast (Singulair) po daily.
b. ipratropium bromide bid with albuterol.
c. a low-dose inhaled corticosteroid (ICS), 2 puffs bid.
d. a long-acting β-adrenergic agonist (LABA), 1 puff bid.
C. a low-dose inhaled corticosteroid (ICS), 2 puffs bid. - This patient has symptoms of mild, persistent asthma. The preferred controller medication in adults and children with persistent asthma is a low-dose ICS. Montelukast is a leukotriene modifier, which may be considered as an alternative to a low-dose ICS but is not the first option to try. Ipratropium is often used during an acute exacerbation but not for long-term control. LABA medications are used in patients with moderate persistent symptoms.
136
A patient has been treated for severe contact dermatitis on both arms with clobetasol propionate cream. At a follow-up visit, the primary care NP notes that the condition has cleared. The NP should:
a. prescribe triamcinolone cream for 2 weeks.
b. recommend continuing treatment for 2 more weeks.
c. discontinue the clobetasol and schedule a follow-up visit in 2 weeks.
d. discontinue the clobetasol and recommend prn use for occasional flare-ups.
A. prescribe triamcinolone cream for 2 weeks.- Treatment should be discontinued when the skin condition has resolved. Tapering the corticosteroid will prevent recurrence of the skin condition. Tapering is best done by gradually reducing the potency and dosing frequency at 2-week intervals. This patient was on a very high potency steroid, so changing to a medium frequency with follow-up in 2 weeks is an appropriate action. Discontinuing the steroid abruptly can lead to recurrence.
137
A 5-year-old child has atopic dermatitis that is refractory to treatment with hydrocortisone acetone 2.5% cream. The prescriber should prescribe:
a. desonide cream 0.01%.
b. triamcinolone acetonide.
c. fluocinolone cream 0.2%.
d. betamethasone dipropionate ointment 0.05%.
B. triamcinolone acetonide. - An over-the-counter steroid has failed to treat this child's dermatitis, so the NP should prescribe something in a higher strength. Triamcinolone is a medium-strength steroid and should be used. The other three are in groups I and II, which are high-strength steroids and are not recommended in children.
138
A 70-year-old patient asks an NP about using diphenhydramine (Benadryl) to control intermittent allergic symptoms that include runny nose and sneezing. The NP should counsel this patient to:
a. take the lowest recommended dose initially.
b. monitor for hypertension while taking the drug.
c. take the antihistamine with a decongestant for best effect.
d. watch for symptoms of paradoxical excitation with this medication.
A. take the lowest recommended dose initially. - Antihistamines are more likely to cause excessive sedation, syncope, dizziness, confusion, and hypotension in elderly patients; a decrease in dose is usually necessary. Hypotension is likely; there is no need to monitor for hypertension. This patient does not have symptoms of congestion. Paradoxical excitation occurs in some young children but is not an identified risk in elderly patients.
139
A patient with asthma is given an asthma action plan and returns to the clinic in 2 weeks to follow up on symptoms. Which statement by the patient indicates a need for further teaching?
a. "I use the ICS as needed when I am wheezing."
b. "A side effect of albuterol may be shortness of breath."
c. "I should rinse my mouth thoroughly after using an ICS."
d. "I put the albuterol metered-dose inhaler in my mouth with my lips sealed around it."
A- "I use the ICS as needed when I am wheezing."- ICSs are controller medications and are not used as needed for symptoms, so this statement by the patient indicates a need for further teaching. The other statements are true.
140
An FNP sees a child with asthma to evaluate the child's response to the prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as needed. The child's symptoms are well controlled. The FNP notes slowing of the child's linear growth on a standardized growth chart. The FNP should change this child's medication regimen to a:
a. SABA as needed plus a leukotriene modifier once daily.
b. combination ICS/LABA inhaler twice daily.
c. short-acting β2-agonist (SABA) with oral corticosteroids when symptomatic.
d. combination ipratropium/albuterol inhaler twice daily.
A - SABA as needed plus a leukotriene modifier once daily. - A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS. This child's symptoms are well controlled, so there is no need to step up therapy to include a LABA. Oral corticosteroids should be used only for severe exacerbations. Ipratropium and albuterol are used for severe exacerbations.
141
A 75-year-old patient who has cardiovascular disease reports insomnia and vomiting for several weeks. The advance practice registered nurse orders thyroid function tests. The tests show TSH is decreased and FT4 is increased. The APRN should consult with an endocrinologist and order:
a. thyrotropin.
b. methimazole.
c. levothyroxine.
d. propylthiouracil
B. methimazole. - Patients with hyperthyroidism, or Graves' disease, will require radioactive iodine. Elderly patients and patients with cardiovascular disease should be pretreated with an antithyroid medication such as methimazole. Thyrotropin is used to diagnose thyroid cancer. Levothyroxine is used to treat hypothyroidism. Propylthiouracil is also a thyroid suppressant, but methimazole is preferred.
142
A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child weighs 15 kg. The family NP sees the child for a 3-year-old check-up. The FNP should consult with a pediatric endocrinologist to discuss:
a. increasing the dose to 90 mcg/day.
b. decreasing the dose to 30 mcg/day.
c. stopping the medication and checking TSH and T4 in 4 weeks.
d. discussing the need for lifetime replacement therapy with the child's parents.
C. stopping the medication and checking TSH and T4 in 4 weeks. - In congenital hypothyroidism, therapy may be stopped for 2 to 8 weeks after the patient reaches 3 years of age. If TSH levels remain normal, thyroid supplementation may be discontinued permanently.
143
A 70-year-old patient with COPD who is new to the clinic reports taking 10 mg of prednisone daily for several years. The prescriber should:
a. tell the patient to take the drug every other day before 9:00 AM.
b. order a serum glucose, potassium level, and bone density testing.
c. perform pulmonary function tests to see if the medication is still needed.
d. begin a gradual taper of the prednisone to wean the patient off the medication.
B. 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.
144
An 80-year-old female patient with a history of angina has increased TSH and decreased Free T4. The nurse practitioner should prescribe _____ mcg of _____.
a. 25; liothyronine
b. 75; liothyronine
c. 25; levothyroxine
d. 75; levothyroxine
C. 25; levothyroxine- Elderly individuals may experience exacerbation of cardiovascular disease and angina with thyroid hormone replacement. It is advisable to start low at 25 mcg and work up as tolerated. Liothyronine is a synthetic T3.
145
A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child examination, the family nurse practitioner (FNP) notes a decrease in the child's linear growth rate. The FNP should consult the child's asthma specialist about:
a. gradually tapering the child off the prednisone.
b. a referral for possible growth hormone therapy.
c. giving a double dose of prednisone every other day.
d. dividing the prednisone dose into twice-daily dosing.
C. giving a double dose of prednisone every other day. - Administration of a double dose of a glucocorticoid every other morning has been found to cause less suppression of the HPA axis and less growth suppression in children. Because the child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indicated. Twice-daily dosing would not change the HPA axis suppression.
146
What drugs should be avoided at all costs during pregnancy (Catagory X)?
finasteride (Proscar, Propecia) (Should not handle crushed or broken tabs); isotretinoin (Accutane) (Child-bearing aged women must be prescribed 2 types Contraception, neg pregnancy test 1 month before, during and 1 month after); High Dose Vit A; warfarin (Coumadin); misoprostol (Cytotec); androgenic hormones (Testosterone, OCPs, HRT); Live virus vaccines; Thalidomide, DES, methimazole (D), methotrexate, chemotherapeutic agents, radiation
147
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A patient reports fatigue, weight gain, and dry skin. The primary care APN orders thyroid function tests. The patient's thyroid stimulating hormone (TSH) is 40 microunits/mL, and T4 is 0.1 ng/mL. The APN should refer the patient to an endocrinologist and prescribe:
A. methimazole
B. liothyronine
C. levothyroxine
D. propylthiouracil
```
C. Levothyroxine- This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a thyroid suppressant. Liothyronine is synthetic T3. Propylthiouracil is a thyroid suppressant.
148
A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care APN should:
a) order a T4 level today.
b) increase the dose to 100 mcg.
c) check the TSH level in 1 week.
d) reassure the patient that this will improve in several weeks.
C. Check the TSH level in 1 week
149
A primary care APN orders thyroid function tests. The patient's TSH is 1.2 microunits/mL, and T4 is 1.7 ng/mL. The APN should:
a. assess the patient for symptoms of hyperthyroidism.
b. ask the patient about the use of medications such as lithium.
c. tell the patient that the results most likely indicate hypothyroidism.
d. ask an endocrinologist to evaluate for possible Hashimoto's thyroiditis.
C. Tell the patient that the results most likely indicate hypothyroidism- Primary hypothyroidism is the most common form of hypothyroidism. Use of certain drugs, such as lithium, and diseases such as Hashimoto's thyroiditis can cause hypothyroidism but are less likely. The patient does not have signs of hyperthyroidism.
150
A patient has been taking levothyroxine 100 mcg daily for several months. The patient comes to the clinic with complaints of insomnia and irritability. The primary care APN notes a heart rate of 92 beats per minute. The APN should:
a. change to liothyronine 75 mcg/day.
b. discontinue levothyroxine indefinitely.
c. order propylthiouracil to counter the increased thyroid levels.
d. order TSH and T4 levels and decrease the dose to 75 mcg/day.
D. Order TSH and T4 levels and decrease the dose to 75 mcg per day - When signs of thyrotoxicosis occur, the drug should be decreased or temporarily discontinued for 5 to 7 days. Liothyronine is not indicated. Propylthiouracil is not indicated.
151
A patient with Graves' disease is taking methimazole. After 6 months of therapy, the primary care APN notes normal T3 and T4 and elevated TSH. The APN should:
a. order a complete blood count (CBC) with differential.
b. order aspartate aminotransferase, AGT, and LDH tests.
c. decrease the dose of the medication.
d. add levothyroxine to the patient's regimen.
C. Decrease the methimazole dose- Once clinical levels of thyrotoxicosis have been resolved, elevated TSH indicates a need to reduce the dosage. A CBC with differential is performed at the beginning of treatment and when signs of infection are present. Liver function tests may be monitored periodically but are not indicated by the current laboratory results. Levothyroxine is not indicated.
152
A female patient presents with grayish, odorous vaginal discharge. The primary care APN performs a gynecologic examination and notes vulvar and vaginal erythema. Testing of the discharge reveals a pH of 5.2 and a fishy odor when mixed with a solution of 10% potassium hydroxide. The APN should:
a) order topical fluconazole.
b) order metronidazole 500 mg twice daily for 7 days.
c) withhold treatment until culture results are available.
d) prescribe a clotrimazole vaginal suppository for 7 days.
B. Order metronidazole 500 mg twice daily for 7 days- indicates treatment for bacterial vaginosis.
153
A young woman will begin taking minocycline. The primary care APN should tell this patient to:
a) avoid taking antacids while taking this drug.
b) expect headaches while taking this medication.
c) always take the medication on an empty stomach.
d) use a backup form of contraception if currently taking oral contraceptive pills.
D. Use a backup form of contraception if currently taking oral contraceptive pills
154
A patient comes to the clinic to have a Mantoux tuberculin skin test read after 48 hours. The primary care APN notes a 6-mm area of induration. The patient is a young adult with no known contacts and has never traveled abroad. The APN should:
a) repeat the test.
b) order a chest radiograph.
c) tell the patient the test is negative.
d) refer to an infectious disease specialist.
B. Order a chest xray
155
A primary care APN 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 APN will refer this patient to an infectious disease specialist and should expect the patient to be on _____ for _____ months.
a) isoniazid; 6
b) ethambutol; 3
c) isoniazid and rifapentine; 3
d) ethambutol and amikacin; 6
C. Isoniazid and rifapentine; 3
156
A patient has a Mantoux tuberculin skin test with a 12-mm area of induration. The patient has a cough, and a chest radiograph is positive. The primary care APN should refer this patient to an infectious disease specialist and should plan to monitor a regimen of:
a) isoniazid for 6 months.
b) isoniazid and rifapentine.
c) isoniazid, rifapentine, and ethambutol.
d) isoniazid, rifampin, pyrazinamide, and ethambutol.
D. Isoniazid, rifampin, pyrazinamide, and ethambutol
157
A patient was diagnosed with tinea corporis and given topical ketoconazole. The patient tells the primary care APN that the infection is not getting better. The APN should:
a) prescribe griseofulvin.
b) prescribe oral ketoconazole.
c) obtain a culture of the infection site.
d) recommend 3 more weeks of treatment with the topical medication.
C. Obtain a culture of the infection site
158
A woman who takes oral contraceptive pills develops vaginal candidiasis. The primary care APN prescribes a single dose of fluconazole. When counseling the patient about this drug, the APN 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 2 months.
d) that she may need a lower dose of fluconazole because she takes oral contraceptive pills.
C. To use a backup contraceptive method for the next 2 months
159
A patient who is taking metronidazole calls the primary care APN to report severe nausea and vomiting along with heart palpitations. The APN 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
160
Unless contraindicated, the pharmacological management of mild osteoarthritis pain is to begin with:
a. flexeril
b. ibuprofen
c. acetaminophen
d. aspirin
C. Acetaminophen
161
Several agents are effective in reducing the frequency and severity of migraine attacks. The NP is educating a client on the different choices available to provide prophylactic treatment and identifies the following drug classes as FIRST LINE treatment agents (SELECT ALL THAT APPLY):
A. Beta Blockers (BBs; i.e. propranolol)
B. Selective Serotonin Reuptake Inhibitors (SSRIs; i.e. paroxetine)
C. Tricyclic Antidepressents (TCAs; i.e. amitriptylline)
D. Anticonvulsants (i.e. gabapentin)
A and C (per PPT- Beta blockers, calcium channel blockers, and tricyclic antidepressants are all first line prophylactic. SSRI and anticonvulsants are second line)
162
The 12 recommendations provided by the CDC on the Opioid Prescribing Guidelines (2016) are grouped into the following conceptual areas, EXCEPT:
a. Assessing risk and addressing harms of opioid use
b. Opioid selection, dosage, duration, follow-up, and discontinuation
c. Determining when to initiate or continue opioids for chronic pain
d. Reducing the increasing number of opioid dependency in America
D- Reducing the increasing number of opioid dependency in America
163
Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain management. (T/F)
True
164
The NP understands that when opioids are needed to manage acute pain, the following principles should give the prescription of opioids (SELECT ALL THAT APPLY):
a. Prescribe at least 2 additional days than expected just in case the patient does not get a prompt follow up appointment
b. Prescribe ER/LA opioids for best treatment of acute pain
c. Re-evaluate patients with severe acute pain that continues longer than the expected duration to confirm initial diagnosis
d. Prescribe the lowest effective dose
C and D
165
Clinicians should continue opioid therapy for at least 2 additional weeks when there is no clinically meaningful improvement in pain and function that outweighs risks to patient safety during the first 30 days of treatment. (T/F)
False
166
For its potential for abuse, the drug Tramadol (Ultram) was changed to a Schedule II drug by the DEA in recent years. (T/F)
FALSE; Schedule IV
167
A patient experiencing an acute overdose with a narcotic such a morphine may display the following signs and symptoms: (SELECT ALL THAT APPLY)
a. Hypothermia
b. Profound respiratory depression
c. Stupor or coma
d. Respiratory rate less than 60 breaths/min
ANS: A B C
168
Clonazepam is the only benzodiazepine indicated for muscle relaxation because of its direct muscle relaxant effects. (T/F)
FALSE- diazepam
169
Rizatriptan (Maxalt) should not be given to patients with cardiac risk factors unless a cardiovascular evaluation shows no underlying disease. (T/F)
TRUE
170
A patient with type 2 diabetes and CV disease has been treated with Metformin for several months. After re-evaluating the patient, the NP adds Jardiance (empagliflozin) to the patient's drug regime. The patient inquires about Jardiance. Which of the following statements is true regarding Jardiance? (SELECT ALL THAT APPLY):
a. It is the first diabetes med approved to reduce risk of CV death in patients with type 2 diabetes and CV disease.
b. It is a dipeptidyl peptidase-4 (DPP4) inhibitor
c. It is a selective sodium-glucose transporter-2 (SGLT2) inhibitor
d. It works by reducing glucose reabsorption in the kidneys, thereby increasing urinary glucose excretion.
ANS: A, C, D
171
A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory infections and asks about the best way to avoid getting sick. The NP should recommend which of the following?
a. Zinc gluconate supplements
b. Frequent hand washing
c. Echinacea
d. Normal saline nasal irrigation
B. Frequent hand washing. - Hand washing is the most effective way to prevent the spread of viral upper respiratory illness (VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun.
172
A patient comes to the clinic with a 3-day history of fever and a severe cough that interferes with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The NP should:
a. suggest that the patient try a guaifenesin-only over-the-counter product.
b. prescribe an antibiotic to treat the underlying cause of the patient's cough.
c. order a narcotic antitussive to suppress cough.
d. obtain a thorough history of the patient's symptoms.
D. obtain a thorough history of the patient's symptoms. - It is important to determine the underlying disorder that is causing the cough to rule out serious causes of cough. The NP should obtain a thorough history before prescribing any treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin may be used to make nonproductive coughs more productive. Antibiotics are indicated only for a proven bacterial infection.
173
An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the patient that this drug:
a. will cause rebound congestion if withdrawn suddenly.
b. can cause many systemic side effects such as drowsiness.
c. will not provide maximum relief for a few weeks.
d. may cause a bitter aftertaste.
D. may cause a bitter aftertaste- Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may experience relief from symptoms within 30 minutes. Decongestants can cause rebound congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects.
174
A parent asks an NP which over-the-counter medication would be best to give to a 5-year-old child who has a viral respiratory illness with nasal congestion and a cough. The NP should recommend which of the following?
a. Increased fluids with a teaspoon of honey
b. An antitussive/expectorant combination such as Robitussin DM
c. Diphenhydramine (Benadryl)
d. Over-the-counter pseudoephedrine with guaifenesin (Sudafed)
A. Increased fluids with a teaspoon of honey- Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has been shown to be effective in reducing cough in small children. Diphenhydramine is an antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and Robitussin are not recommended in children younger than 6 years.
175
A child with chronic allergic symptoms uses an intranasal steroid for control of symptoms. At this child's annual well-child checkup, the NP should carefully review this child's:
a. height and weight.
b. blood pressure.
c. liver function tests.
d. urinalysis.
A. height and weight. - Intranasal corticosteroids can cause growth suppression in children. When using intranasal steroids in children, the lowest dosage should be used for the shortest period of time necessary, and growth should be routinely monitored. It is not necessary to evaluate urine, blood pressure, or liver function because of intranasal steroid use.
176
An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing, and nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should prescribe:
a. triamcinolone (Nasacort AQ).
b. cromolyn sodium (Nasalcrom).
c. azelastine (Astelin).
d. phenylephrine (Neo-Synephrine)
A. triamcinolone (Nasacort AQ)- According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients. Intranasal corticosteroids are indicated for patients who do not respond to antihistamines. Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids.
177
A patient asks an NP about using an oral over-the-counter decongestant medication for nasal congestion associated with a viral upper respiratory illness. The NP learns that this patient uses loratadine (Claritin), a b-adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects?
a. Rebound congestion
b. Liver toxicity
c. Excessive drowsiness
d. Tremor, restlessness, and insomnia
D. Tremor, restlessness, and insomnia- b-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive drowsiness, and rebound congestion are not known adverse effects of drug interactions.
178
A primary care NP sees an adolescent patient for a hospitalization follow-up after an asthma exacerbation. The patient reports having daily symptoms with nighttime awakening 4 or 5 nights per week and misses school several days each month. The patient currently uses a salmeterol/fluticasone LABA twice daily and albuterol as needed. The patient requires a refill of the albuterol prescription once a month. The patient does not have any known allergies. The NP should:
a. order a high-dose ICS plus a LABA twice daily.
b. consider adding theophylline to this patient's regimen.
c. order a combination product with ipratropium and albuterol.
d. continue the current regimen and add omalizumab daily.
A. order a high-dose ICS plus a LABA twice daily. - The patient has moderate persistent asthma not well controlled with the current regimen. The next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an asthma specialist. Theophylline is recommended in the 5- to 11-year age group. Omalizumab is indicated if the patient has allergies. Ipratropium is used during acute exacerbations
179
50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum. A chest x-ray is clear, and the patient's FEV1 is 80% of predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath sounds. The NP should:
a. order a long-acting anticholinergic with albuterol twice daily.
b. prescribes a moderate-dose ICS twice daily.
c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.
d. reassure the patient that these symptoms will subside.
C. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. - For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended when FEV1 is less than 60%.
180
A patient who was recently diagnosed with COPD comes to the clinic for a follow-up evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports occasional mild exertional dyspnea but is able to sleep well. The patient's FEV1 in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend:
a. a combination LABA/ICS twice daily.
b. home oxygen therapy as needed for dyspnea.
c. influenza and pneumococcal vaccines.
d. ipratropium bromide (Atrovent) twice daily.
C. influenza and pneumococcal vaccines. Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status. This patient is stable with the prescribed medications, so no additional medications are needed at this time. Home oxygen therapy is used for patients with severe resting hypoxemia.
181
A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for exacerbation of symptoms. The patient reports using the SABA three or four times each week when short of breath. The patient reports feeling jittery and nauseated and having trouble sleeping. The primary care NP should:
a. obtains a serum theophylline level.
b. prescribes a leukotriene modifier instead of theophylline.
c. order a creatinine clearance level.
d. discontinue the SABA and change to ipratropium bromide.
A. obtains a serum theophylline level. - Nausea, vomiting, insomnia, jitteriness, and other symptoms may indicate theophylline toxicity. Serum concentration monitoring should be done whenever signs of toxicity are suspected. A serum creatinine clearance level is not indicated. Leukotriene modifiers are not used for COPD. Ipratropium is used as an adjunct to the SABA during acute exacerbations.
182
A 75-year-old patient requires frequent use of corticosteroids to control COPD exacerbations. To monitor adverse drug effects in this patient, the primary care NP should:
a. order an electrocardiogram to assess for arrhythmias.
b. order routine chest radiographs to watch for pneumonia.
c. order a bone density study.
d. monitor the patient's renal function at every visit.
C. order a bone density study. - High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in an older adult. The NP should order a bone density study.
183
A NP sees a patient who needs to be treated for the management of allergic rhinitis. Which of the following are preferred antihistamines that the NP can recommend? (SELECT ALL THAT APPLY):
a. Loratadine
b. Chlorpheniramine
c. Cetirizine
d. Fexofenadine
ANS: A & C & D
184
A NP prescribes to a patient an antitussive syrup medication containing guaifenesin with codeine. Which common side effects may this patient experience? (SELECT ALL THAT APPLY):
a. Drowsiness
b. Diarrhea
c. Dizziness
d. Nausea/vomiting
ANS: A C D
185
According to the CDC, National Center for Health Statistics, COPD is the third leading cause of death in the United States. True or False?
TRUE
186
According to the CDC video, when using a metered-dose inhaler (in mouth), you should do the following (SELECT ALL THAT APPLY):
a. Press down on inhaler one time, breathe in QUICKLY, and then hold breath for 5 - 10 seconds
b. Put inhaler in your mouth, above your tongue, and between your teeth.
c. Hold inhaler upright
d. Shake inhaler 10 - 15 times
ANS: B, C, D
187
MATCH THE CLASS
- Xopenex (levalbuterol)
- Serevent (salmeterol xinafoate)
- Dulera (mometasone/formoterol)
- Spiriva (tiotropium bromide)
- Short-Acting B2-adrenergic Agonists
- Long-Acting B2-adrenergic agonist
- Long-Acting B2-adrenergic agonist/Corticosteroid Combination
- long acting anticholinergic
188
```
Mr. Smith is a 53-year-old patient that has been diagnosed with COPD using Spirometry. Further assessment results show his FEV1 is 28% of predicted, CAT score of 12, and he had 1 exacerbation in the past year leading to hospital admission. Based on your knowledge of the refined ABCD assessment tool (GOLD 2017), the NP should label this patient as follow:
A. GOLD grade 4, group B
B. GOLD grade 4, group D
C. GOLD grade 2, group B
D. GOLD grade 3, group D
```
B. GOLD grade 4, group D
189
Mrs. Gomez is a 45-year-old female diagnosed with COPD using Spirometry. She has been a smoker for over 20 years. Her FEV1 is 48% of predicted, she has a CAT score of 8, and she had more than 3 exacerbations in the past year. Based on the GOLD 2017 guidelines and Mrs. Gomez COPD assessment results, the NP should initiate treatment with:
A. Spiriva (tiotropium bromide)
B. Serevent Diskus (salmeterol xinafoate)
C. Ventolin (albuterol)
D. Flovent (fluticasone)
A. Spiriva
190
According to GOLD 2017 guidelines, ICS-containing regimens are NOT recommended as initial maintenance treatment for COPD of any severity.t/f
TRUE
191
```
Based on the Gold 2017 guidelines and COPD assessment results, Mr. Scott was prescribed a LAMA medication to treat his COPD symptoms. However, a few months later, Mr. Scott's symptoms continue to be persistent and he has further exacerbations. Which of the following drugs is the next preferred treatment the NP should initiate:
A. ANORO ELLIPTA
B. FLOVENT DISKUS
C. SYMBICORT AEROSOL
D. BREO ELLIPTA
```
A. Anoro ellipta
192
Which of the following drugs is a LABA/ICS combination and would be most appropriate for a patient who is having compliance issues?
a. Breo Ellipta
b. Spiriva
c. Anoro Ellipta
d. Symbicort Aerosol
A. Breo Ellipta
193
A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, "Dispense as Written." The NP should explain that a different brand of this drug:
a. may cause different adverse effects.
b. does not necessarily have the same therapeutic effect.
c. is likely to be less safe than the brand specified in the prescription.
d. may vary in the amount of drug that reaches the site of action in the body.
ANS: D- Different formulations of the same drug may have varying degrees of bioavailability, and it may be important to stick to a particular brand for drugs with narrow therapeutic ranges. All drugs with similar active ingredients should have the same therapeutic actions and side effects and should be equally safe.
194
A patient takes an oral medication that causes gastrointestinal upset. The patient asks the primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may:
a. alters drug absorption.
b. alter drug distribution.
c. lead to drug toxicity.
d. increase stomach upset.
A- alter drug absorption - Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset.
195
A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of:
a. bioavailability.
b. pharmacokinetics.
c. pharmacodynamics.
d. anatomy and physiology.
B- Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions.
196
The primary care NP should understand that a drug is at a therapeutic level when it is:
a. at peak plasma level.
b. past 4 or 5 half-lives.
c. at its steady plasma state.
d. between minimal effective concentration and toxic levels.
D- The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives.
197
A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To help ensure patient safety, the NP prescribing the medication should:
a. Assess the patients sleeping patterns
b. Ask the patient about problems with constipation
c. Obtain a baseline creatinine clearance before the first dose
d. Perform a thorough evaluation of cognitive and motor abilities
D. perform a thorough evaluation of cognitive and motor abilities
198
which of the following correctly describes an age-related physiologic alteration that affects the pharmacokinetics of medications in geriatric patients?
a. Increased acid output leading to decreased drug absorption
b. Decrease in the body fat compartment
c. Decline in creatinine clearance with an increase in age
d. Increase in water compartment
C. Decline in creatinine clearance with an increase in age
199
The NP is getting ready to start a 75-year-old client on a highly protein bound drug (phenytoin). Review of the client’s record reveals a recently obtained laboratory report with albumin 2.5 g/dL, as the only out of range value. With this in mind, the NP will prescribe the needed highly protein-bound drug in:
a. The same amount that would be given in a client with normal albumin
b. Reduced doses for the patients with low serum albumin levels
c. Increased doses for the patient with high serum albumin values
d. Reduce dose for patients with high serum albumin values
B. reduced doses for the patients with low serum albumin levels
200
A NP is prescribing an antibiotic for a child who will need to take a total of 750 mg per day. What dosing regimen should the NP prescribe to promote compliance?
a. 250mg/5ml-375 mg PO bid
b. 250mg/5ml-250 mg PO tid
c. 500mg/5 ml-375 mg PO bid
d. 500mg/5ml-250 mg PO tid
ANS C- 500mg/5ml-375 mg PO bid (achieves dose in least volume and doses)
201
Pharmacokinetics of drug therapy in the pediatric population is dynamic and is known to change for each of the age groups that comprise the pediatric category. In safelu prescribing medications to the pediatric population, the NP must clearly remember the ages of each group. All of the age groups listed below are correct, EXCEPT:
a. Infants 30 days to 12 months
b. Toddlers 2 YO- 5 YO
c. Children 5 YO to 12 YO
d. Adolescents 13 YO to 17 YO
B. toddlers
202
A woman has just learned she is pregnant and is in her 10th gestational week. The woman reports that she takes valproic sodium (Depakote) for a seizure disorder and has been seizure-free for several years. The NP should:
a. prescribes folic acid supplements.
b. changes her antiepileptic drug to lamotrigine (Lamictal).
c. order prophylactic vitamin K to be given in the second trimester.
d. recommend that she discontinue taking the valproic sodium by 12 weeks.
A. prescribe folic acid supplements. - Maternal folic acid deficiency is induced by anticonvulsants, especially valproic acid, so folic acid supplements must be given. Although antiepileptic drugs can have consequences for the developing fetus, once a woman is pregnant, the benefit-risk ratio favors continued use of the woman's current antiepileptic medication, so she should not discontinue the medication or change to lamotrigine. Vitamin K is recommended beginning at 36 weeks of gestation and for the newborn at birth to counter the possibility of hemorrhagic disease of the newborn.
203
As it relates to the determinants of teratogenicity, the NP explains to the client who just received news of being pregnant that the most critical period in which drug exposure should be avoided is the:
a. Fetal period
b. Embryonic period
c. Pre-conception period
d. Ovulation period
ANS: B. Embryonic period, week 3-8
204
A man who has benign prostatic hypertrophy (BPH), in whom prostate carcinoma has been ruled out, asks the primary care nurse practitioner (NP) about beginning drug therapy to treat his symptoms. The NP notes that he consistently has blood pressure readings around 115/75 mm Hg. The NP should prescribe:
a. tadalafil (Cialis).
b. doxazosin (Cardura).
c. tamsulosin (Flomax).
d. finasteride (Proscar)
C. Flomax
205
A patient who has BPH is taking finasteride to shrink the size of the prostate is asking the NP “what is the expected time to achieve the maximum benefit of taking 5-alpha reductase inhibitors for the prostate reduction?” The primary NP should advise the client that:
a. 6 months of therapy is required to achieve maximum benefit
b. It is impossible to estimate the amount of time
c. There is no evidence supporting the use of this drug
d. 3 months of therapy is required to achieve maximum benefits
A. 6 months
206
A patient asks a primary care NP whether over-the-counter drugs are safer than prescription drugs. The NP should explain that over-the-counter drugs are:
A. generally safe when label information is understood and followed.
B. safer because over-the-counter doses are lower than prescription doses of the same drug.
C. less safe because they are not well regulated by the Food and Drug Administration (FDA).
D. not extensively tested, so claims made by manufacturers cannot be substantiated.
A. generally safe when label information is understood and followed
207
Which of the following statements is true about the prescribing practices of physicians?
A. Older physicians tend to prescribe more appropriate medications than younger physicians.
B. Antibiotic medications remain in the top five classifications of medications prescribed.
C. Most physicians rely on a "therapeutic armamentarium" that consists of less than 100 drug preparations per physician.
D. The dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies.
D. the dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies
208
A primary care NP is aware that many patients in the community use herbal remedies to treat various conditions. The NP understands the importance of:
A. learning about the actions, uses, doses, and toxicities of these agents.
B. prescribing these agents when possible to ensure safe dosing.
C. counseling patients to stop using herbal products to avoid toxic side effects.
D. teaching patients that these products are unregulated and unsafe to use.
A. learning about the actions, uses, doses, and toxicities of these agents
209
As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to:
A. attain the same level of expertise as physicians who currently prescribe medications.
B. learn from the experiences of physicians and develop expertise based on evidence-based practice.
C. maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices.
D. develop relationships with pharmaceutical representatives to learn about new medications as they are developed.
B. learn from the experiences of physicians and develop expertise based on evidenced-based practice
210
A patient who has migraine headaches has begun taking timolol and 2 months after beginning this therapy reports no change in frequency of migraines. The patient's current dose is 30 mg once daily. The primary care NP should:
A. change the medication to propranolol.
B. increase the dose to 40 mg once daily.
C. obtain serum drug levels to see if the dose is therapeutic.
D. tell the patient to continue taking the timolol and return in 1 month.
D. tell the patient to continue taking the timolol and return in 1 month
211
A patient who has asthma and who is known to the primary care NP calls the NP after hours and asks for refill of an albuterol metered dose inhaler. The patient has not been seen in the clinic for more than a year. The NP should:
A. call the pharmacy to order the medication w/ several refills
B. send an electronic prescription to the pharmacy for one time only
C. send the patient to the ER for evaluation of symptoms
D. refill the drug and tell the patient that an office visit is necessary for further refills
D. refill the drug and tell the patient that an office visit is necessary for further refills
212
A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient's medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should:
A. contact the insurance provider to explain why this particular formulation is necessary
B. change the patient's medication to a different drug class that doesn't have these bioavailability variations
C. accept the situation and monitor the patient closely for drug effects with each prescription refill
D. ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of- pocket expense
A. contact the insurance provider to explain why this particular formulation is necessary- changing the drug could have life changing consequences so the NP must advocate for the desired drug
213
A 50 year old woman who is postmenopausal is taking an aromatase inhibitor as part of a breast cancer treatment regimen. She calls her primary care NP to report that she has had hot flashes and increased vaginal discharge but no bleeding. The NP should:
A. schedule her for a gynecologic exam
B. recommend that she use a barrier method of contraception
C. tell her to stop taking the medication and call her oncologist
D. reassure her that these are normal side effects of the medication
A. schedule her for a gynecologic exam
214
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A patient who has an upper respiratory infection reports using OTC cold preparations. The primary care NP should counsel this patient to use caution when taking additional OTC meds such as:
A. antipyretics
B. calcium supplements
C. acid reflux meds
D. antioxidant supplements
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A. antipyretics
215
A patient has been using an herbal supplement for 2 years that the primary NP knows may have toxic side effects. The NP should:
A. Tell the patient to stop taking the supplement immediately
B. inform the patient of the risks of toxic side effects with this supplement
C. refer the patient to a CAM provider who can manage the patient's therapy
D. prescribe another herbal drug that has fever adverse effects than the one the patient is taking
B. inform the patient of the risks of toxic side effects with this supplement
216
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A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme:
A. inhibitor
B. substrate
C. inducer
D. metabolizer
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A. inhibitor
217
The primary care NP is prescribing a medication for an off-label use. To help prevent a medication error, the NP should:
A. write "off label use" on the prescription and provide a rationale
B. call the pharmacist to explain why the instructions deviate from common use
C. write the alternative drug regimen on the prescription and send it to the pharmacy
D. tell the patient to ignore the label directions and follow the verbal instructions given in the clinic
A. write "off label use" on the prescription and provide a rationale
218
A CNM:
A. May administer only drugs used during labor and delivery
B. May treat only women
C. May practice only in birthing centers and home birth settings
D. Has prescriptive authority in all 50 states
D. Has prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings.
219
The current trend toward transitioning NP programs to the doctoral level will mean that:
a. NPs will be better prepared to meet emerging health care needs of patients
b. NPs licenses in one state may practice in other states
c. Requirements for physician supervision of NPs will be removed in all states
d. Full prescriptive authority will be granted to all NPs with doctoral degrees
A- NPs will be better prepared to meet emerging health care needs of patients. The AACN has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will be required to meet licensure requirements of each state.
220
A primary care NP prepared to teach a patient about the management of a chronic condition. the patient says "I don’t want to know all of that. Just tell me what to take and when." The NP should initially:
a. Ask the patient to describe the disease process and the medications to evaluate understanding.
b. Give the patient basic written instructions about medications, follow-up visits, and symptoms
c. Ask the patient to explore feelings and fears about having a chronic disease and taking medications.
d. Explain to the patient that without mutual cooperation, the treatment regimen will not be effective.
B: give the patient basic written instructions about medications, follow-up visits, and symptoms. As the therapeutic relationship grows, the NP may elicit more active participation and understanding.
221
To increase the likelihood pharmacotherapy, when teaching a patient about using a medication, the primary care nurse practitioner (NP) should:
a. Provide educations about the medication actions and adverse effects
b. Give the patient copies of medication packages inserts describing the drug use
c. Stress the importance of taking the medication exactly as it is prescribed
d. Encourage the patient to participate in the choice of medication
D. Encourage the patient to participate in the choice of medication. It is important that the patient owns the problem and has a part in the solution.
222
A patient who has chronic pain and who takes oxycodone calls the clinic to ask for a refill of the medication. The NP notes that’s the medication refill is not due for 2 weeks. The patient tells the NP that the refill is needed because he is going out of town. An initial action by the NP should be for:
a. Confront the patient about misuse of narcotics and refuse to fill the prescription.
b. Review the patient’s chart to see if this is a one-time occurrence.
c. Fill the prescription and document the patient’s explanation of the reason.
d. Call the patients pharmacist and report suspicion of drug-seeking behaviors.
B. Review the patient’s chart to see if this is a one-time occurrence. If this is a pattern, the pharmacist should be notified. Patients should be confronted if the problem is apparent, and practitioners should not refill the prescriptions.
223
The primary care NP sees a patient covered by Medicaid, writes a prescription for a medication, and is informed by the pharmacist that the medication is “off-formulary.” The NP should:
a. inform the patient that an out-of-pocket expense will be necessary.
b. write the prescription for a generic drug if it meets the patient’s needs.
c. call the patient’s insurance provider to advocate for this particular drug.
d. contact the pharmaceutical company to see if medication samples are available.
B. write the prescription for a generic drug if it meets the patient’s needs. Insisting the pt pay out of pocket may mean the prescription won’t get filled, asking for a drug sample does not solve the long-term problem.
224
A patient has recurrent symptoms and tells the primary care NP that she can’t remember to take her medication all the time. The NP should:
a. give her shortened regimens of the drug to facilitate compliance.
b. provide written information about her condition and the medication.
c. administer the medication in the clinic to ensure that she takes the drug.
d. ask her about her lifestyle, her schedule, and her understanding of her condition.
D. ask about her lifestyle, schedule, condition
225
A primary care NP will begin practicing in a state in which the governor has opted out of the federal facility reimbursement requirement. The NP should be aware that this defines how NPs may write prescriptions:
a. without physician supervision in private practice.
b. as CRNAs without physician supervision in a hospital setting.
c. in any situation but will not be reimbursed for this by government insurers.
d. only with physician supervision in both private practice and a hospital setting
B. as CRNAs without physician supervision in hospital setting
226
When prescribing a medication for a chronic condition, the primary care NP should tell the patient:
a. to contact the pharmacy whenever refills are needed
b. that it is necessary to return to the clinic for each monthly refill of the medication
c. about the frequency of clinic visits necessary for the number of refills authorized
d. to ask the pharmacist to supply several months’ worth of the medication at a time.
C. about the frequency of clinic visits necessary for the number of refills authorized. It is important to determine how closely a patient should be monitored while taking a drug for a chronic condition and let the patient know how often he needs to be seen.
227
The primary care NP is reviewing evidence-based recommendations about the off-label use of a particular drug. Which recommendation should influence the NP's decision about prescribing the medication?
a. Pharmaceutical company reports using anecdotal evidence
b. Data from randomized, experimental studies
c. Patient reports about the effectiveness of the drugs for this purpose
d. Endorsement of this use by a leading practitioner in the field
B- Randomized, experimental studies yield the best data about use of medications. Patient reports carry the least weight because bias can occur, and other factors can influence outcomes. Pharmaceutical company reports are biased.
228
Provision of Primary Health Care by the NP include the following functions (select all that apply)
a. Prevention
b. Treatment
c. Prescription
d. Diagnosis
ANS: A B C D
229
Which of the following are common components found on a prescription for a controlled substance? (select all that apply)
a. Strength or concentration
b. DEA number
c. Directions for use
d. Full name of drug
ANS: A B C D
230
When discussing new drugs with pharmaceutical representatives, the ARNP should ask about direct comparison head-to-head studies with older, standard drugs in comparable doses. (T/F)
TRUE
231
A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patient’s condition worsens, and a chest radiograph obtained 2 days later shows bilateral infiltrates. The NP failed to:
a. Confirm the diagnosis
b. Prescribe an adequate dose of medications
c. Allow the drugs adequate time to work
d. Determine the aggressiveness of therapy
A- the patient had symptoms that could occur with both asthma and aspiration pneumonia. The NP failed to confirm the diagnosis and prescribed the wrong treatment
232
In comparing the effect of acetaminophen vs. NSAIDS, acetaminophen is known to have: (SATA)
Strong antipyretic effect
Weak anti-inflammatory effect
Strong analgesic affect
