TEST BANK for Human Resources Management in Canada, 14th Edition by Gary Dessler, Chhinzer, Cole by ACADEMIAMILL

Pharmacotherapy A Pathophysiologic Approach 10th Edition Dipiro Talbert Yee Test Bank Chapter 1: Health Literacy and Medication Use 1. What time will the trough blood level need to be drawn if the nurse administers the intravenous medication dose at 9:00 AM? a. 6:30 AM b. 8:30 AM c. 9:30 AM d. 11:30 AM ANS: B Trough blood levels measure the lowest blood level of medicine and are obtained just before the dose is administered. In this case, 6:30 AM is too early to obtain the blood level. The other two times occur after the medication is administered. 2. What will the nurse expect the health care providers order to be when starting an older adult patient on thyroid hormone replacement therapy? a. Administering a loading dose of the drug b. Directions on how to taper the drug c. A dosage that is one third to one half of the regular dosage d. A dosage that is double the regular dosage ANS: C To prevent toxicity, dosages for new medications in older adults should be one third to one half the amount of a standard adult dosage. Loading doses of drugs could cause severe toxicity. Tapering off is characteristic of discontinuation of medications and is not appropriate for this situation. Older adults generally need a lower medication dosage than younger patients. DIF: Cognitive Level: Application REF: p. 29 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Which drugs cause birth defects? a. Teratogens b. Carcinogens c. Metabolites d. Placebos ANS: A Teratogens are drugs that cause birth defects. Carcinogens cause cancer. Metabolites are the end product of metabolism. Placebos are drugs that have no pharmacologic activity. 4. Which life threatening illness may occur as a result of aspirin (salicylate) administration during viral illness to patients younger than 20 years of age? a. Anaphylactic shock

b. c.

Reyes syndrome Chickenpox

d. Influenza A ANS: B Children are susceptible to Reyes syndrome if they ingest aspirin at the time of or shortly after a viral infection of chickenpox or influenza. Anaphylactic shock is caused by a hypersensitivity reaction. Chickenpox is the result of being infected with a virus. Influenza A is caused by a pathogen. 5. Which classification of medications commonly causes allergic reactions in children? a. Antacids b. Analgesics c. Antibiotics d. Anticonvulsants ANS: C Antibiotics, especially penicillins, commonly cause allergic reactions in children. Intravenous antibiotics can cause rapid reactions; therefore, the pediatric patients response to a medication should be assessed and monitored closely. Antacids rarely cause allergic reactions. Children are not particularly allergic to analgesics or anticonvulsants. 6. After giving instructions to an expectant mother about taking medications during pregnancy, which patient statement indicates the need for further teaching? a. I will not take herbal medicines during pregnancy. b. For morning sickness, I will try crackers instead of taking a drug. If I get a cold, I will avoid taking nonprescription medications until I check with my physician. I will limit my alcohol intake to only one glass of wine weekly.

c. d. ANS: D Alcohol needs to be eliminated during pregnancy and for 2 to 3 months prior to conception. Limited studies are available regarding the use of herbal medications in general, and thus they should be avoided during pregnancy. Alternative nonpharmacologic treatments are appropriate to use during morning sickness. The pregnant woman should also avoid using nonprescription drugs because few data are available about safe use in pregnancy. Because few medicines can be considered completely safe for use in pregnancy, the physician needs to approve and recommend the use of nonprescription drugs. 7. When is the ideal time for a nursing mother to take her own medications? a. Before the infant latches on to begin to breastfeed b. As soon as the mother wakes up in the morning c. Right before the mother goes to sleep at night d. As soon as the infant finishes breastfeeding ANS: D

Taking medications after breastfeeding reduces the amount of the medication that will reach the baby. Medications taken directly before breastfeeding may have a high concentration in the milk and possibly pass on to the baby. The mother must take into consideration when her medications are ordered to be taken, and schedule them around breastfeeding. 8. Which age-related change would affect transdermal drug absorption in geriatric patients the most? a. Difficulty swallowing b. Diminished kidney function c. Changes in pigmentation d. Altered circulatory status ANS: D The decreased circulation that occurs with aging will affect transdermal drug absorption. Difficulty swallowing would not affect transdermal drugs being absorbed. Kidney function affects drug excretion. Changes in pigmentation would not affect transdermal drug absorption. 9. Which intervention would be considered to reduce accumulation of a drug in a patient who has decreased liver function? a. Decreasing the time interval between dosages b. Reducing the dosage c. Administering the medication intravenously d. Changing the drug to one that has a longer half life ANS: B Dosages must be reduced to prevent accumulation. Decreasing the time interval between dosages would increase the accumulation of the drug. The intravenous route has the fastest absorption and with liver dysfunction would increase the accumulation of the drug. A similar drug with a longer half life would stay in the system longer; with impaired liver function, the result would be increased accumulation. 10. The nurse is teaching an elderly patient with difficulty swallowing about his medications. Which explanation by the nurse is most helpful? a. Enteric coated tablets can be crushed and taken with applesauce. b. Tablets that are scored can be broken in half. c. Medications labeled SR can be crushed. d. Avoid taking medications in liquid form. ANS: B It is acceptable to break scored tablets in half to facilitate swallowing of the medication. Enteric coated tables should never be crushed because of the effect on the absorption rate and potential for toxicity. Medications labeled SR indicate sustained release and should not be crushed because of the effect on the absorption rate. Medication in liquid form may be easier to swallow. 11. The nurse is administering an antibiotic intravenously. Which blood level determines the lowest amount of medication present in the patient? a. Peak

b. c.

Serum Therapeutic

d. Trough ANS: D The lowest amount of a medication in the blood is the trough. The peak is the highest amount of medication in the blood. Serum level identifies the amount of medication present. Therapeutic levels identify the range in which a medication is effective. 12. Which patient would the nurse identify as having the lowest rate of absorption of enteral medications? a. A 5-year-old boy b. An 18-year-old woman c. A 55-year-old man d. An 85-year-old woman ANS: A Males stomachs empty more rapidly; children have increased motility, resulting in decreased absorption time. As one gets older, gastrointestinal (GI) motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption. Males stomachs empty more rapidly; however, as one gets older, GI motility is decreased, resulting in an increase in absorption time. As one gets older, GI motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption. 13. What is the definition of cumulative effect of a drug? a. Drug toxicity related to overmedication b. Drug buildup related to decreased metabolism c. The inability to control the ingestion of drugs d. The need for higher dosage to produce the same effect as previous lower dosages ANS: B Cumulative effects are related to diminished metabolism or excretion of a drug that causes it to accumulate. Cumulative effects can lead to drug toxicity. Toxicity occurs when adverse effects are severe. Inability to control the ingestion of drugs is drug dependence. The need for higher dosage to produce the same effect as previous lower dosages is the definition of tolerance. 14. Which patient, when compared with the general population, would require a larger dose or more frequent administration of a drug to attain a therapeutic response? a. A 29 year old who has been diagnosed with kidney failure b. A 35 year old obese male who is being evaluated for an exercise program c. A 52 year old diagnosed with hypothyroidism and decreased metabolic rate d. A 72 year old with decreased circulatory status ANS: B An obese individual would require a larger dose of a drug to attain a therapeutic response. An individual with kidney failure would require less medication because of decreased excretory

ability. Individuals with decreased metabolic rate would metabolize drugs more slowly and require smaller doses or less frequent administration. Individuals with decreased circulation would require less medication. 15. A resident in a long term care facility reports difficulty swallowing enteric coated aspirin and asks the nurse to crush it prior to administration. The most appropriate action for the nurse to take is to: a. crush the tablet and mix with applesauce. b. encourage the resident to swallow the tablet with a full glass of water. c. hold the medication and notify the physician. d. substitute a regular aspirin for the enteric coated tablet. ANS: C The medication should be held and the physician notified. The physician has the authority to determine how to proceed in this situation. Enteric coated tablets should not be crushed because this will increase the absorption rate and the potential for toxicity. Geriatric patients may have difficulty swallowing and are at risk for choking and aspiration. They should not be encouraged to swallow medications if they report difficulty swallowing. The physician must determine if a substitution can be ordered. Prescribing is not in the nurses scope of practice. Chapter 2: Cultural Competency 1. What are compelling reasons for needing cultural competency in healthcare? A. Health disparities are declining and are no longer relevant B. The diversity of patients encountered in the U.S. has plateaued C. Health professional shortages are no longer present improving provider-patient concordance D. Medication errors can be reduced by improving linguistic competency in an organization 2. Based on the cultural competency models addressed in the chapter, which of the following is true? A. The LEARN model describes providers as going through distinct stages of change ranging from cultural destructiveness to cultural proficiency B. Cultural competency is achieved through experience, skills, knowledge, and a positive attitude C. The Purnell model describes providers as progressing through a continuum of cultural consciousness ranging from the unconsciously incompetent to the unconsciously competent D. Cultural humility plays a minor role in connecting the skills, encounters, and desire to work across cultures

3. According to the 2000 Executive Order 13166 of Title VI of the Civil Rights Act, which of the following services should a healthcare organization meet to receive federal funding (eg, Medicare)? A. Recruit, retain, and promote a diverse staff and leadership representative of the service area demographics B. Offer and provide meaningful access to language services at a nominal cost to patients with limited English proficiency C. Make easy-to-understand printed materials available in languages used frequently in the population served D. Using family or minors as interpreters may be used if requested by the patient 4. The Patient Explanatory model includes: A. Explaining the pathophysiologic process of diseases B. Identifying potential causes of illness C. Involving the family and community in deciding the treatment for a patient D. Navigating between spiritual and family leaders to help the patient improve 5. The "4 Cs" method to elicit patients' understanding of their health and illnesses includes asking patients… A. What they think will cure their condition B. When they completed their last course of medication C. What will the problem cost the patient D. What concerns they have about their health situation 6. Healthcare providers must be more knowledgeable about CAM therapies, cultural practices, and their choice to use traditional medicine. When inquiring about CAM, the provider should A. recognize that nearly 75% of the US population document CAM use B. consider that herbal products from the US must follow current Good Manufacturing Practices C. ask targeted questions of patients such as "Do you use herbs?" to get a straight-forward answers

D. understand that patients often have low disclosure rates of use of CAM 7. When striving toward cultural competency, which of the following statements about stereotypes, generalizations, and patient care is true? A. Generalizations can help to provide a framework for understanding how patients may respond to a health-related situation B. Stereotypes can help to form reasonable assumptions about how patients from different cultures will behave in the healthcare setting C. Stereotypes and generalizations can be helpful to creating a positive healthcare environment D. Stereotypes and generalizations are not useful in understanding how a patient may react in a healthcare setting 8. Which of the following is an example of healthcare beliefs or practices that have been found in various racial and ethnic groups in the United States? A. "Culture-bound syndromes" or folk-illnesses can be found in Western cultures B. Trust in the U.S. healthcare system exists because of previous efforts for equality (eg, Tuskegee syphilis study) C. Illness and disease are synonymous D. Physical signs of bruises or welts on the skin are often signs of physical abuse, particularly in cultures of Asian descent 9. To better understand individual patient health behaviors in the healthcare setting, a healthcare provider can… A. Rely on chart documentation to learn about the family and cultural health traditions of the patient B. Understand socioeconomic status and immigration issues faced in the community C. Explore the social and cultural networks of the community D. All of the above E. B and C only 10. Examples of communication styles that work across cultures include:

A. Shaking hands as a form of respect B. Providing ample distance to show respect of interpersonal space C. Using the first name to address a patient D. Observing patient behaviors and trying to follow them 11. Of the following choices, the most appropriate way to determine how to communicate with a patient from a different culture and language than your own is to: A. Provide as much information as possible to demonstrate professional competency B. Use a variety of written resources about the culture of the patient before the visit and use only this information to conclude your treatment approach C. Talk to the bilingual staff members and ask how they would want to be treated D. Treat the patient as they would want to be treated and use a trained interpreter 12. If you do not speak the same language as your patients, what would be the optimal way to conduct the patient visit? A. Use a family member to interpret B. Ask a bilingual staff person to interpret for you C. Use a trained interpreter D. All of the above 13. Which of the following best describes social determinants of health and their relationship to cultural competency? A. Socioeconomic status, age, race, ethnicity, and communities are factors that influence health B. Training in cultural competency has helped to decrease health disparities in healthcare C. Communities have little effect on the healthcare outcomes of individuals and families D. All of the above 14. Assessment of organizational values and beliefs about diversity and culture are important to providing a positive and open environment for patient care and should be conducted:

A. When an organization is expecting an accreditation or licensure survey B. On an as-needed basis for performance improvement C. If patient satisfaction surveys reveal poor outcomes D. Periodically, as needed, and with long-term considerations for the organization 15. Steps for organizational self-assessment include: A. Involving community collaborations and partnerships after decisions are made at an organizational level B. Disseminating positive results to demonstrate the high competency of the organization C. Getting "buy-in" from only the organizational personnel D. Including personnel and fiscal resources to promote cultural competency in the annual budget ANSWERS 1. D. 2.

10.

11.

12.

13.

14.

15.

Chapter 3: Medication Safety Principles and Practices 1. Where would the procedures and treatments directed by the health care provider be found? a. Summary sheet b. Physicians order form c. Physicians progress notes d. History and physical examination form ANS: B The physicians order form contains all procedures and treatments ordered by the health care provider. A summary sheet provides a brief overview of the hospital course at discharge. Physicians progress notes provide regular observations on the patients course of treatment and response. A history and physical examination form provides information about baseline information from the patient. 2. Which action will the nurse take when it is determined that the narcotic count is incorrect while obtaining a medication from the narcotic area? a. Determine the cause of the discrepancy at the end of the shift. b. Notify the health care provider stat. c. Call the nurse from the previous shift to determine if there was a discrepancy earlier. d. Report the discrepancy to the charge nurse immediately. ANS: D Reporting the discrepancy to the charge nurse immediately enables the supervisory staff to narrow the time frame during which a medication was taken and not documented. The discrepancy needs to be addressed immediately, and therefore determining the cause of the discrepancy at the end of the shift is not the most appropriate action for the nurse to take. It is not appropriate to contact the health care provider for an incorrect narcotic count. The count would have been verified at shift change; calling the nurse from the previous shift is not an appropriate action for the nurse to take. 3. Which action will the nurse take if a dosage is unclear on a health care providers order? a. Ask the patient what dosage was given in the past. b. Ask another physician to determine the correct dosage. c. Tell the patient that the medication will not be given. d. Contact the health care provider to verify the correct dosage. ANS: D Any questionable orders should be verified by the health care provider who wrote the orders. The patient is not a reliable source of verification. The physician who wrote the order should verify it. It would be a medication error to withhold the dose instead of verifying it. 4. What is the most reliable method to calculate a pediatric patients medication dosage?

a. b.

Age Height

c. Body surface area (BSA) d. Placement on a growth scale ANS: C The most reliable method is by proportional amount of BSA or body weight. Because of the differences in weight among children, age is not a reliable method. Because of the differences in height among children, this is not a reliable method. Placement on a growth scale identifies how the child corresponds to other children on a percentile. Although it is determined by a specific measurement, the percentile identified would not be a specific measurement; therefore, this is not a reliable method. 5. Which medication route provides the most rapid onset of a medication, but also poses the greatest risk of adverse effects? a. Intradermal b. Subcutaneous (subcut) c. Intramuscular (IM) d. Intravenous (IV) ANS: D IV medications are delivered directly into the bloodstream and avoid the first pass effect of the liver. Intradermal, subcut, and IM administration have a slower absorption rate. 6. Which is known as the fifth vital sign? a. Temperature b. Respirations c. Pain d. Pulse ANS: C Pain is known as the fifth vital sign. 7. Which is true regarding the unit dose drug distribution system? a. The inventory is delivered to each nursing unit on a regular and recurring basis. The system delivers one dose of each medication to be administered until the subsequent b. delivery of inventory. The use of single dose packages of drugs dispensed to fill each dose requirement as it is c. ordered. d. The amount of inventory needed to dose all patients on the unit for a 24 hour interval. ANS: C The unit dose drug distribution system uses single unit packages of drugs dispensed to fill each dose requirement as it is ordered. 8. The nursing assessment identifies that the client is nauseated and cannot take acetaminophen (Tylenol) orally. Which is true regarding the substitution of this medication to suppository form? a. It is standard practice when the patient is unable to take the ordered medication.

b. c.

It is acceptable if the patient agrees to the altered route form. It is preferable to having the patient miss a dose of the medication.

d. It is contraindicated without an order from the health care provider. ANS: D One dosage form of medication should never be substituted for another unless the prescriber is consulted; there can be a great variation in the absorption rate of the medication through different routes of administration. The substitution of one form for another is not standard practice, and is not acceptable or preferable without the prescribers order. 9. Which medication order requires nursing judgment and means administer if needed? a. Morphine 4 mg IV stat b. Morphine 4 mg IV prior to procedure c. Morphine 4 mg IV four times a day d. Morphine 4 mg IV every 4 hours PRN ANS: D PRN indicates for the nurse to administer morphine every 4 hours if needed and requires nursing judgment. Stat means the dose of morphine would be given immediately, not as needed. The orders for the dose of morphine to be given prior to the patients scheduled procedure and four times a day, do not indicate to give the dose as needed. 10. What is medication reconciliation? Comparing the patients current medication orders to all of the medications actually being a. taken b.

The administration of high alert medications that have been ordered on admission to an acute care facility

The completion of an incident report following a variance that resulted in a serious complication

A printout of computerized patient data that identifies the times that all of the ordered d. medications are to be administered ANS: A Medication reconciliation is the process of comparing a patients current medication orders to all of the medications that the patient is actually taking. Administering high alert medications and completing an incident report are not the same as medication reconciliation. A printout of computerized patient data that identifies the times that all of the ordered medications are to be administered is a description of the medication administration record (MAR), not a description of medication reconciliation. 11. Which example best demonstrates safe drug administration by the nurse? a. Administering an oral medication with the patient sitting upright b. Asking children to say their name before administering the medication c. Leaving the medications on the bedside stand after verifying patient identification d. Returning the unused portion of a medication to a stock supply bottle ANS: A

itting the patient upright for oral medications is safe medication practice. Children should never be asked their names as a means of positive identification. Remaining with a patient until the drug is swallowed is safe practice. Returning an unused portion of medication to the stock supply bottle is not safe medication practice. 12. The nurse determines that a prescribed medication has not been administered as ordered on the previous shift. What action will the nurse take? a. Administer the medication immediately. b. Complete an incident report. c. Notify the nurse responsible for the error. d. Record the occurrence in the nurses notes. ANS: B An incident report is completed when a medication error occurs. Depending on the medication and frequency of administration, the medication may not be given immediately. It is not the nurses responsibility to notify another nurse of the error. Medication errors are not recorded in the nurses notes. DIF: Cognitive Level: Application REF: p. 100 OBJ: 6 | 11 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 13. A patients liquid cough medicine has been discontinued with one half of the bottle remaining. The home health nurse is aware that according to the U.S. Food and Drug Administration (FDA) guidelines on prescription medication disposal, the next step should be to: a. save the remainder for another patient with the same prescription. b. flush the remainder down the toilet. c. read the drug label for specific disposal instructions. d. pour remaining medication into a hazardous waste container. ANS: C The nurse must follow specific disposal instructions on the drug label or in the patient information leaflet that accompanies the medication. Prescription medications should not be shared among patients. Prescription drugs should not be flushed down the toilet unless specifically instructed to do so by the manufacturer. The first action to be taken is to follow disposal instructions on the label. If the drug label indicates it should be emptied into a hazardous waste container, measures should be taken to prevent leaking and/or accidental ingestion. 14. Who defines the standards of care for the practice of nursing? (Select all that apply.) a. State boards of nursing b. Hospital policy and procedures c. d.

Federal laws regulating health care facilities The Joint Commission

e. Professional nursing associations ANS: A, C, D, E

Standards of care are defined by state boards of nursing, federal laws regulating health care facilities, The Joint Commission, and professional nursing associations such as the American Nurses Association. Individual hospital policies and procedures incorporate federal and state guidelines into their respective policies and procedures and are often more stringent than state and federal regulations. 15. What must the nurse have before administering any medication? (Select all that apply.) a. A current license to practice b. A medication order signed by a practitioner licensed with prescription privileges c. d.

Knowledge of the medication Consultation with a pharmacist

e. Knowledge of the clients diagnosis ANS: A, B, C, E Physicians must be licensed to prescribe medications; nurses must be licensed to administer medications. Safe medication administration includes knowledge of the medication, pathophysiology of patient diagnoses, and pharmacodynamics of the ordered medication on the pathophysiology. It is not necessary for the nurse to consult with a pharmacist each time medication is to be administered to a patient. 16. Which advantage(s) does the unit dose drug distribution system include? (Select all that apply.) a. There is decreased participation by the pharmacy. The pharmacist is able to analyze prescribed medications for each client for drug b. interactions and contraindications. c. There is less waste of medications. d. The time spent by nursing personnel preparing these medications is increased. e. Credit is given to the patient for unused medications. ANS: B, C, E Because the pharmacist has a profile of all medications for each patient, he or she is able to analyze prescribed medications for each patient for drug interactions and contraindications. This is an advantage of the unit dose drug distribution system. Less waste of medications is an advantage of the unit dose drug distribution system. Because each dose is individually packaged, credit can be given to the patient for unused medications. There is increased pharmacist involvement and better use of his or her extensive drug knowledge and nursing personnel time is decreased with this method. 17. Which statement(s) is/are true regarding the types of medication orders? (Select all that apply.) a. Stat orders are the same as single dose orders. b. Standing orders indicate the number of specified doses of a medication to be given. c. d.

Renewal orders facilitate physician review before continuance of high risk medications. PRN medications will designate a mandatory number of times the medication is to be administered.

e. Verbal orders should be used as much as possible. ANS: B, C Standing orders state the frequency of medication dosages to be administered or indicate the time frame of administration. Renewal orders require the physician to review medications that have expired orders, as determined by facility policy. Renewal policies facilitate physician verification of the necessity to continue a medication beyond a usual time frame and help ensure patient safety. Single dose and stat orders are not the same. PRN medications are not ordered a mandatory number of times, although a maximum number might be specified. Verbal orders should be avoided whenever possible. 18. Which statement(s) is/are true regarding computerized prescriber order entry (CPOE)? (Select all that apply.) a. Integrates the ordering system with the pharmacy, laboratory, and nurses stations b. Provides instant access to online information to facilitate patient care needs c. d.

Facilitates review of ordered medications for potential drug interactions Facilitates review of drugs for appropriateness of dosages

e. Alleviates the need to perform mathematical computations ANS: A, B, C, D CPOE systems integrate patient information, provide instant access, facilitate review of ordered medications for potential drug interactions, and facilitate review of drugs for appropriateness of dosages. Alleviation of the need to perform mathematical computations is not a component of the CPOE system. Chapter 4: Clinical Pharmacokinetics and Pharmacodynamics 1. Clearance determines A. the time to reach steady-state B. the loading dose required to achieve the desired steady-state concentration C. the maintenance dose required to achieve the desired steady state concentration D. the dosage interval E. a and d 2. Volume of distribution determines A. the time to reach steady-state B. the loading dose required to achieve the desired steady-state concentration C. the maintenance dose required to achieve the desired steady state concentration D. the dosage interval

E. a and d 3. Half-life determines A. the time to reach steady-state B. the loading dose required to achieve the desired steady-state concentration C. the maintenance dose required to achieve the desired steady state concentration D. the dosage interval E. a and d 4. The clearance is A. dependent upon the value of volume of distribution B. dependent upon the value of half-life C. a function of the blood flow to clearing organs and the efficiency of the organ in extracting the drug D. a function of the physiologic volume of blood and tissues and how the drug binds in blood and tissues E. a and b 5. The volume of distribution is A. dependent upon the value of clearance B. dependent upon the value of half-life C. a function of the blood flow to clearing organs and the efficiency of the organ in extracting the drug D. a function of the physiologic volume of blood and tissues and how the drug binds in blood and tissues E. a and b 6. The half-life is A. dependent upon the value of volume of distribution

B. dependent upon the value of clearance C. a function of the blood flow to clearing organs and the efficiency of the organ in extracting the drug D. a function of the physiologic volume of blood and tissues and how the drug binds in blood and tissues E. a and b 7. Linear pharmacokinetics means A. drug serum concentrations decrease in a straight line when plotted on a concentration-time graph B. drug serum concentrations decrease in a straight line when plotted on a log concentrationtime graph C. steady-state drug serum concentrations change proportionally to dose D. steady-state drug serum concentrations change non-proportionally to dose 8. Nonlinear pharmacokinetics means A. drug serum concentrations decrease in a straight line when plotted on a concentration-time graph B. drug serum concentrations decrease in a straight line when plotted on a log concentrationtime graph C. steady-state drug serum concentrations change proportionally to dose D. steady-state drug serum concentrations change non-proportionally to dose 9. Most drugs follow nonlinear pharmacokinetics A. true B. false 10. Pharmacokinetic models are useful to A. describe concentration-time data sets

B. redict drug serum concentrations after several doses or after different routes of administration C. calculate pharmacokinetic constants (clearance , volume of distribution, half-life) D. a & c E. a, b & c 11. Factors to be considered when prescribing the best drug dose of a patient include A. age B. gender C. weight D. other concurrent disease states and drug therapies E. all of the above 12. Clinicians should begin considering dosage adjustment of renally eliminated drugs at what creatinine clearance value: A. 90 mL/min (1.5 mL/s) B. 60 mL/min (1 mL/s) C. 30 mL/min (0.5 mL/s) D. 15 mL/min (0.25 mL/s) 13. Clinicians should begin considering dosage adjustment of heaptically eliminated drugs at what Child-Pugh score value: A. 1 B. 3 C. 5 D. 8 E. 10 14. The enzyme system responsible for the metabolism of most drugs is

A. P-glycoprotein B. alkaline phosphatase C. creatine kinase D. cytochrome P450 E. HMG-CoA 15. If pharmacologic effect is plotted versus drug concentration for most agents, the shape of the graph is A. linear B. hyperbolic C. parabolic D. trapezoidal ANSWERS 1. C. 2.

10.

11.

12.

13.

14.

15. B. Chapter 5: Pharmacogenetics 1. The site(s) for genetic variations that may affect drug pharmacodynamics include: A. drug metabolizing enzymes B. drug target proteins C. drug transporter proteins D. a and b E. a and c 2. The most commonly occurring variant in the human genome is: A. single nucleotide polymorphism B. tandem repeat polymorphism C. nucleotide base deletion D. nucleotide base insertion E. frameshift mutation 3. CYP2D6 polymorphism can affect: A. drug toxicity B. drug interaction potential C. drug delivery D. a and b E. b and c 4. Which CYP2D6 phenotype is associated with reduced analgesic response to codeine? A. Ultra-rapid metabolizer

B. Extensive metabolizer C. Poor metabolizer D. Intermediate metabolizer E. None of the above 5. Which of the following is an example of a drug target gene? A. TPMT B. CYP1A2 C. SLCO1B1 D. UGT1A1 E. VKORC1 6. Which gene is predictive of clopidogrel effectiveness? A. CYP2C9 B. CYP2C19 C. CYP2D6 D. CYP3A4 E. CYP4F2 7. A patient with newly diagnosed atrial fibrillation will be starting warfarin. A rapid SNP test is done and reveals the CYP2C9*2/*3 and VKORC1 AA genotypes. Which of the following responses to warfarin would be predicted based on this genotype? A. Increased metabolism; use lower dose B. Decreased metabolism; use higher dose C. Decreased metabolism and increased sensitivity; use lower dose D. Increased metabolism and decreased sensitivity; use higher dose E. Increased metabolism and increased sensitivity; avoid warfarin

8. Genetic variations in drug targets may contribute to which drug property: A. bioavailability B. half-life C. peak dose area under the curve D. ethnic differences in response E. entry into the central nervous system 9. Screening for which of the following polymorphisms is indicated prior to carbamazepine use in a person of Southeast Asian descent? A. CYP2D6*2 B. HLA-B*15:02 C. CYP2C9*2 D. TPMT*2 E. UGT1A1*28 10. Which gene predicts risk for muscle toxicity with simvastatin use? A. SLCO1B1 B. HLA-B C. HMG-CoA D. LDLR E. ABCB1 11. Mutations in which of the following genes increases the risk for thrombosis with oral contraceptives? A. Prothrombin B. CYP2C9 C. ADRB1

D. SCN5A E. ABCB1 12. Which drug is recommended to reduce tumor progression in a patient with breast cancer who overexpresses the HER2 gene? A. Mercaptopurine B. Tamoxifen C. Trastuzumab D. Voriconazole E. Irinotecan 13. An obstacle to successful gene therapy is: A. an inability to identify genetic defects B. inefficient gene delivery C. difficulty identifying eligible patients D. lack of research efforts E. all of the above 14. Which of the following gene therapy techniques has prompted the most ethical concern? A. Naked DNA transfer B. Adeno-associated viral gene delivery C. Retroviral-mediated gene therapy D. Electroporation E. Germ line manipulation ANSWERS 1. B. 2.

10.

11.

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14.

Chapter 6: Pediatrics 1. Which should the nurse use to prepare liquid medication in volumes less than 5 milliliters? a. Calibrated syringe b. Paper measuring cup c. Plastic measuring cup d. Household teaspoon ANS: A To ensure accuracy, a calibrated syringe without a needle should be used to prepare a liquid dosage less than 5 milliliters. Paper and plastic measuring cups are not calibrated for liquid volumes less than 5 milliliters. A household teaspoon is not accurate enough to measure small amounts of medication. 2. Which food choice is appropriate to mix with medication? a. Formula or milk b. Applesauce c. Syrup d. Orange juice ANS: B

To prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications. Formula and milk are essential foods in a childs diet. Medications may alter their flavor and cause the child to avoid them in the future. Syrup is not used to mix with medications because of its high sugar content. Orange juice is considered an essential food; therefore, the nurse should not mix medications with it. 3. Which physiological difference would affect the absorption of oral medications administered to a 3-month-old infant? a. More rapid peristaltic activity b. More acidic gastric secretions c. Usually more rapid gastric emptying d. Variable pancreatic enzyme activity ANS: D Pancreatic enzyme activity is variable in infants for the first 3 months of life as the gastrointestinal system matures. Medications that require specific enzymes for dissolution and absorption might not be digested to a form suitable for intestinal action. Infants up to 8 months of age tend to have prolonged motility. The longer the intestinal transit time, the more medication is absorbed. The gastric secretions of infants are less acidic than in older children or adults. Gastric emptying is usually slower in infants. 4. Which factor should the nurse remember when administering topical medication to an infant? a. Infants require a larger dosage because of a greater body surface area. b. Infants have a thinner stratum corneum that absorbs more medication. c. Infants have a smaller percentage of muscle mass compared with adults. d. The skin of infants is less sensitive to allergic reactions. ANS: B Infants and young children have a thinner outer skin layer (stratum corneum), which increases the absorption of topical medication. A similar dose of a topical medication administered to an infant compared with an adult is approximately three times greater in the infant because of the greater body surface area. The smaller muscle mass in infants affects site selection for injected medications. The young childs skin is more prone to irritation, making contact dermatitis and other allergic reactions more common. 5. What is the appropriate nursing response to a parent who asks, What should I do if my child cannot take a tablet? a. You can crush the tablet and put it in some food. b. Find out if the medication is available in a liquid form. c. If the child cant swallow the tablet, tell the child to chew it. d. Let me show you how to get your child to swallow tablets. ANS: B A tablet should not be crushed without knowing whether it will alter the absorption, effectiveness, release time, or taste. Therefore telling the parent to find out whether the medication is available in liquid form is the most appropriate response. A chewed tablet may

ave an offensive taste, and chewing it may alter its absorption, effectiveness, or release time. Forcing a child, or anyone, to swallow a tablet is not acceptable and may be dangerous. 6. What is the maximum safe volume that an infant (aged 1 to 12 months) can receive in an intramuscular injection? a. 0.25 milliliter b. 0.5 milliliter c. 1 milliliter d. 1.5 milliliters ANS: C The maximum volume of medication for an intramuscular injection to an infant is 1 mL. The neonate should receive no more than 0.5 mL per intramuscular injection. 1.5 milliliters is not appropriate for an infant. It is appropriate for an intramuscular injection to a child 3 to 14 years of age. 7. Which muscle would the nurse select to give a 6-month-old infant an intramuscular injection? a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis ANS: D The vastus lateralis is not located near any vital nerves or blood vessels. It is the best choice for intramuscular injections for children younger than 3 years of age. The deltoid muscle is not used for intramuscular injections in young children. The ventrogluteal muscle is safe for intramuscular injections for children older than 18 months. The dorsogluteal muscle does not develop until a child has been walking for at least 1 year. 8. The nurse is planning to administer an intramuscular injection to a 13-year-old child. What is the maximum volume of medication that can be injected into the ventrogluteal site? a. 0.5 to 1 milliliter b. 1 to 1.5 milliliters c. 1.5 to 2 milliliters d. 2 to 2.5 milliliters ANS: C The maximum volume of medication for an intramuscular injection to an older child (6 to 14 years) is 1.5 to 2.0 milliliters. 0.5 to 1.4 milliliters are acceptable volumes to inject, but they are not the maximum. 2 to 2.5 milliliters exceeds the amount that can be safely injected into one site for a 13-year-old child. 9. Which parameter should guide the nurse when administering a subcutaneous injection? a. Do not give injections in edematous areas. b. Attach a clean 1-inch needle to the syringe. c. d.

The maximum volume injected into one site is 2 milliliters. Do not pinch up tissue before inserting the needle.

ANS: A Subcutaneous injections should never be given in areas of edema because absorption is unreliable. A short (no more than 5/8inch) needle should be used to deposit medication into subcutaneous tissue. Volumes for subcutaneous injections are small, usually averaging 0.5 milliliters. The skin is pinched up for a subcutaneous injection to raise the fatty tissue away from the muscle. 10. Which action is correct when administering ear drops to a 2-year-old child? a. Administer the ear drops straight from the refrigerator. b. Pull the pinna of the ear back and down. c. Massage the pinna after administering the medication. d. Pull the pinna of the ear back and up. ANS: B For children younger than 3 years, the pinna, or lower lobe, of the ear should be pulled back and down to straighten the ear canal. Medication should be at room temperature because cold solutions in the ear will cause pain. The tragus of the ear should be massaged to ensure the drops reach the tympanic membrane. For a child 3 years or older, the pinna is pulled up and back. 11. A nurse is preparing to start a continuous IV infusion on a child. The nurse selects a Buretrol (volume-control) attachment as part of the IV tubing set-up. The main purpose for selecting a Buretrol attachment is to: a. avoid fluid overload. b. aid in measuring intake. c. administer antibiotics. d. ensure adequate intravenous fluid intake. ANS: A A volume-control device such as a Buretrol or an infusion pump allows the nurse to set a specific volume of fluid to be given in a specific period of time (usually 1 hour) and decreases the risk of inadvertently administering a large amount of fluid. Although the use of a volume-control device allows for accurate measurement of intake, the primary purpose for using this equipment is to prevent fluid overload. Medications such as antibiotics can be administered with a volumecontrol device; however, this is not the primary purpose. 12. Which is the most important nursing action before discharge for a mother who is apprehensive about giving her child insulin? a. Review the side effects of insulin with the mother. b. Have the mother verbalize that she knows the importance of follow-up care. c. Observe the mother while she administers an insulin injection. d. Help the mother devise a rotation schedule for injections. ANS: C It is important that the nurse evaluate the mothers ability to give the insulin injection prior to discharge. Watching her give the injection to the child will give the nurse an opportunity to offer assistance and correct any errors. Although reviewing side effects is important, this could be done over the phone or by the pharmacist when the medication is picked up. Having the mother verbalize her knowledge of the importance of follow-up care is important but not directly

relevant to the mothers concern. Helping the mother devise a rotation schedule for injections is important but not as important as having the mother demonstrate the procedure. 13. A nurse has just initiated an intravenous piggyback of gentamicin (Garamycin). What is the best time for a trough serum level to be measured? a. Just before the next dose b. When the infusion is finished c. One hour after the medication is administered d. Depends on the specific medication ANS: A The medication trough is the level at which the serum concentration is lowest. Trough levels are usually obtained just before the next medication dose. The serum concentration would be increasing as the infusion finishes. This is not the concentration trough. The peak concentration, or the concentration after the medication has been distributed, varies according to the specific medication. Trough is always the lowest just before the next medication dose. 14. A nurse should routinely ask a colleague to double-check a medication calculation and the actual medication before administering which medications? a. Antibiotics b. Acetaminophen c. Anticonvulsants d. Anticoagulants ANS: D The nurse should ask another nurse to check the dosage calculation and the medication before administering anticoagulants. The nurse always double-checks a dosage calculation, but it is not necessary to have a second nurse check the medication before administering antibiotics, acetaminophen, or anticonvulsant medications. 15. Which nursing action is correct when administering heparin subcutaneously? a. Insert the needle with the bevel up at a 15-degree angle. b. Insert the needle into the skin at a 45-degree angle. c. Inject the needle into the tissue on the upper back. d. Massage the injection site when the injection is complete. ANS: B For a subcutaneous injection, the nurse would pinch the skin and inject at a 45-degree angle. Inserting the needle with the bevel up at a 15-degree angle is the technique used for an intradermal injection. The upper back is used for intradermal injections. The nurse would not massage the site after administering heparin. 16. Which indicates that a school-age child is using a metered-dose inhaler correctly? a. The child uses his inhaled steroid before the bronchodilator. b. The child exhales forcefully as he squeezes the inhaler. c. d.

The child holds his breath for 10 seconds after the first puff. The child waits 10 minutes before taking a second puff.

ANS: C After a puff, the child should hold his breath for about 10 seconds or until he counts slowly to 5. If one of the childs medications is an inhaled steroid, it should be administered last. The child should inhale slowly as the inhaler is squeezed or depressed. The child does not need to wait this long to take a second puff of medication. He can take a second puff after holding his breath for 10 seconds. 17. Which step is appropriate when using EMLA cream before intravenous catheter insertion? a. Rub a liberal amount of cream into the skin thoroughly. b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure. d. Use the smallest amount of cream necessary to numb the skin surface. ANS: C The cream should be left in place for a minimum of 1 hour and up to 2 hours. The EMLA cream should not be rubbed into the skin. After the cream is applied to the skin surface, it is covered with a transparent occlusive dressing. The nurse would use a liberal amount of EMLA cream. 18. A child is receiving intravenous fluids. How frequently should the nurse assess and document the condition of the childs intravenous site? a. Every hour b. Every 2 hours c. Every 4 hours d. Every shift ANS: A The nurse assesses and documents an IV site at least every hour for signs and symptoms of infiltration and phlebitis. The nurse should assess a childs IV site more frequently than every 2 to 4 hours or every shift. Serious complications could occur during this time interval. 19. What is the hourly maintenance fluid rate for an intravenous infusion in a child weighing 19.3 kilograms? a. 19 milliliters b. 45 milliliters c. 61 milliliters d. 95 milliliters ANS: C The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg: 1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kg between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 20. The nurse administering an IV piggyback medication to a preschool child should take which action? a. Dilute the medication in at least 20 milliliters and infuse over at least 15 minutes. b. Flush the IV tubing before and after the infusion with normal saline solution.

c. Inject the medication into the IV catheter using the port closest to the child. d. Inject the medication into the IV tubing in the direction away from the child. ANS: A Medications given by IV piggyback are diluted in at least 20 milliliters of IV solution and administered over at least 15 minutes. When administering medications by IV piggyback, the nurse flushes the tubing after the medication has infused, usually with 16 to 20 milliliters of IV solution. The nurse is using the IV push method when injecting medication into the IV tubing using the port closest to the child. The IV retrograde method involves clamping the IV tubing below the injection port and injecting medication into the tubing in a direction away from the child, causing it to flow into the tubing above the injection port. 21. What nursing action is indicated when a child receiving a unit of packed red blood cells complains of chills, headache, and nausea? a. Continue the infusion and take the childs vital signs. b. Stop the infusion immediately and notify the physician. c. Slow the infusion and assess for cessation of symptoms. d. Start a dextrose solution and stay with the child. ANS: B If a reaction is suspected, as in this case, the transfusion is stopped immediately and the physician is notified. If the child is displaying signs of a transfusion reaction, the transfusion cannot continue. Dextrose solutions are never infused with blood products because the dextrose causes hemolysis. This action does not address the blood infusion. Chapter 7: Geriatrics 1. The nurse is aware that information derived from a pharmaceutical companys drug testing to establish therapeutic dose ranges may not be appropriate for the older adult because testing: a. is not done long enough. b. does not require adequate follow-up. c. is not well regulated by the U.S. Food and Drug Administration. d. is usually tested on healthy young persons. ANS: D Long and rigorously regulated drug testing procedures most often use healthy young adults as drug testers. 2. The nurse assesses the older adult patient for evidence of the onset of the effectiveness of an oral preparation because age-related changes in the concentration of gastric acid can: a. change the chemical composition of the drug. b. increase the distribution. c. decrease the strength of the drug. d. retard absorption. ANS: D Decreased gastric acid can decrease the speed of absorption.

3. The nurse is aware that age-related changes in the stomach that can cause increased drug absorption and possibly toxicity include: a. decreased gastric motility. b. gastric reflux disease. c. inability of gastric cells to transport the drug. d. decreased peristalsis. ANS: A Decreased motility leaves the drug in contact with the gastric mucosa for a longer period of time, which leads to increased absorption. Peristalsis is rhythmic movements of the bowels. 4. To help prevent lithium toxicity in the older adult, the nurse modifies the nursing care plan to include interventions to: a. increase fluid intake to 3500 mL daily. b. have the patient ambulate for 10 minutes after the drug is administered. c. prohibit citrus fruit in the diet. d. administer a prescribed stool softener to ensure a daily bowel movement. ANS: A Increase of fluids will help allow water-soluble drugs such as lithium to be diluted in the bloodstream more effectively and excreted more rapidly. 5. The nurse takes into consideration that as adipose tissue replaces muscle mass in the older adult, a person taking a fat-soluble drug such as diazepam (Valium) several times a day would exhibit: a. tachycardia. b. a hangover effect. c. agitation. d. hypertension. ANS: B Fat-soluble drugs become trapped in the adipose tissue and are slowly released into the bloodstream, increasing the drugs concentration. 6. The nurse cautions the older adult who is taking the protein-bound drug warfarin (Coumadin) that, with age-related reduced plasma protein levels, the risk of an adverse reaction is high because: a. unbound active drug molecules continue to circulate in the bloodstream. b. the bleeding and clotting times will decrease, as evidenced by the PT and INR. c. the drug becomes ineffective and does not deliver its intended therapeutic action. d. renal damage can occur from the altered drug molecules. ANS: A Unbound drug molecules will still be circulating, leading to excess drug in the bloodstream. In this situation the bleeding and clotting times will be decreased. 7. The nurse frequently assesses the older adult who is on a psychotropic drug for an overdose because:

a. b.

older adults are less active. the older adult has fewer cognitive capabilities.

c. brain receptors have become hypersensitive. d. receptor sites have lower perfusion. ANS: C Brain receptors in the older adult become hypersensitive as age increases, resulting in an exaggerated response to pharmacologic therapy. 8. The major risk of polypharmacy for the older adult is: a. ignorance about his or her prescriptions. b. taking over-the-counter preparations. c. being treated by more than one physician. d. taking old prescriptions rather than consulting a physician. ANS: C Although all the options may offer an opportunity for polypharmacy, the major risk is that of the patient being treated by more than one physician at the same time. 9. The home health nurse would be most concerned about self-medicating errors for the older adult living alone who is a type 1 diabetic and is: a. afflicted with early Parkinson disease. b. visually impaired. c. a rheumatoid arthritic with stiffened hands. d. paralyzed from the waist down. ANS: B The visually impaired diabetic is at the greatest risk for a medication error by incorrectly preparing an insulin injection. 10. The medication nurse is aware that the most reliable method of patient identification for administration of medications is: a. a photograph of the patient. b. an identification bracelet. c. asking the patient to repeat his or her name. d. use of the patients room number. ANS: B The use of an identification bracelet is the most accurate and reliable method to identify the patient. 11. The physician has written an order to convert an enteric-coated medication from the pill form to the liquid form. The nurse should: transcribe the order and change the medication administration record to show the liquid a. form. b. use up the rest of the tablets by crushing them and giving them dissolved in water. c.

order the liquid form from the pharmacy as ordered.

d. inquire if the physician wants the dose to be the same as the pill. ANS: D Because liquids are absorbed more rapidly, the dose might need to be lowered or the schedule of administration changed to avoid an overdose. Enteric-coated medications should not be crushed. 12. When the patient complains that the several pills at the 8 AM dose stick in her throat, the nurse could facilitate administration by: a. suggesting that she take all the pills at one time with a mouthful of water. b. offering the patient one pill at a time. c. crushing all the pills and mixing them in the patients breakfast cereal. d. offering a sip of water before and after each pill. ANS: D Offering water before and after administration counteracts the dry mouth that causes the pills to stick. Offering one pill at a time without water does not address the problem of sticking. 13. The nurse is aware that medicating with transdermal patches requires that the nurse should: a. apply the patch at the same site every day and carry out documentation. b. fold and dispose of the used patch in the sharps container. c. warm the patch in his or her hands before application. d. cover the patch with a light gauze dressing to prevent dislodgement. ANS: B The used patch should be folded with the sticky sides together and disposed of in the sharps container for environmental safety. 14. When the medication nurse offers a pill to the older adult patient, the patient asks, What is this and what is it for? The nurses best response would be: a. Im not at liberty to discuss your medication. You need to talk to your doctor. b. Thats a feel good pill that will make you feel better. c. Its a cephalosporin that has been ordered to treat your URI. d. Its an antibiotic for the infection in your urine. ANS: D Patients have the right to know what they are taking and given a reasonable rationale for its use that they can understand. 15. When the 80-year-old female patient refuses to take a medication because it burns her stomach, the medication nurse should: a. crush the pill and mix it with the dessert on her meal tray. b. insist that she take it for her own good. c. circle and initial the dose time to show nonadministration. d. document the reason for refusal and report the refusal to the charge nurse. ANS: D The nurse should carry out documentation of the reason for refusal and report the refusal. 16. For the older adult patient receiving the bronchodilator theophylline, the nurse would assess for as evidence of an overdose.

a. b.

tachycardia confusion

c. hypotension d. lethargy ANS: A Tachycardia is a significant side effect of theophylline. 17. When the 75-year-old man who has been on a protocol of chlorpromazine (Thorazine) begins to and complain of difficulty swallowing, the nurse notifies the physician. a. cough b. wheeze c. drool d. gag ANS: C Drooling and difficulty swallowing are signs of drug toxicity to chlorpromazine (Thorazine). 18. The nurse preparing to administer 1 mL of vitamin B12 intramuscularly to an emaciated 82year-old patient would choose a -inch needle to inject into the site. a. 1.5; upper outer quadrant of the gluteus maximus b. 1.5; ventral gluteal c. 1; deltoid d. 1; ventral gluteal ANS: D The 1-inch needle to be injected into the ventral gluteal site is the safest choice for the emaciated patient. The location is easily accessible and free from major nerves of vessels. The deltoid is a poor site except for very small dosages. 19. The nurse explains that the Beers criteria provide guidelines for: a. medications best avoided by the elderly independent of diagnosis. b. diagnostic procedures that are considered inappropriate for a diagnosis. c. penalties for extended care facilities that allow administration of particular drugs. d. assessments necessary before the prescription of particular drugs. ANS: A The Beers criteria lists medications best not prescribed for the elderly. The lists are updated regularly, most recently in 2010. 20. The nurse preparing to crush a patients oral medications can crush the: a. plain antihypertensive medication tablet. b. sublingual tablet of nitroglycerin. c. timed-release capsule for gastric reflux. d. enteric-coated aspirin. ANS: A

Only the plain tablet can be crushed. Timed-release, sublingual medications, and enteric-coated medications should not be crushed. Chapter 8: Palliative Care 1. The nurse believes that a client is eligible as a participant for The National Hospice

Reimbursement Act of 1986. This act mandated that: 1. clients with terminal illnesses are reimbursed. 2. a physician must order hospice to be reimbursed. 3.

to receive reimbursement that client must be eligible for Medicare. to receive benefits, the physician must certify that the client has a limited life expectancy of 6 months or less.

4. ANS: 4 he Medicare hospice benefit is a reimbursement benefit for those with a prognosis of 6 months or less to live (certified by a physician). The act does not mandate reimbursement to clients with terminal illnesses, physicians do not have to order hospice for reimbursement, nor does a client have to be eligible for Medicare for hospice eligibility. 2. After a Native American client has died, the family begins the practice of purifying the body. The nurse realizes that the deceased client may stay with the family for what period of time? 1. 12 hours 2. 24 hours

3. 36 hours 4. 48 hours ANS: 3 Native Americans believe that the soul departs from the body 36 hours after death. The family may want the body to remain at the place of death for this period. The other choices are incorrect lengths of time according to Native American culture. 3.A client is receiving care for symptoms; however, the treatment will not alter the course of the disease. This client is receiving which type of care? 1. Hospital-based 2. Managed 3. Palliative 4. Therapeutic ANS: 3 Palliative care, or comfort care, is directed at providing relief to a terminally ill client through symptom and pain relief. The goal is not curative. Care for symptoms that will not alter the course of the disease does not need to be provided in the hospital. Managed care is guided through the direction of a primary care physician. Therapeutic is a type of care that focuses on a specific treatment for a health problem. 4.A client diagnosed with a terminal illness is receiving an opioid/acetaminophen combination for pain control. The nurse realizes this client is being managed at which step of the World Health Organization approach to pain management?

1. 2.

Step 1 Step 2

3. Step 3 4. Step 4 ANS: 2 The World Health Organization approach to pain management involves three steps. Step 1: Clients are treated with around-the-clock doses of nonopioids. Step 2: The use of opioid/acetaminophen combinations are used to treat mild to moderate pain. Step 3: Strong opioids are used. There is no Step 4 in the World Health Organizations approach to pain management. 5.A dying client is surrounded by family and friends at home. The hospice nurse talks with the spouse of the dying client to ensure that everything the family needs during this time is being done. The nurse is providing support to: 1. the client. 2. the bereaved. 3. ensure compliance with the hospice rules and regulations. 4. determine if the spouse understands that the client is dying. ANS: 2 Supporting the familys rituals and cultural practices gives structure to support the bereaved through this painful process when people are vulnerable and feel off balance. The nurse is not providing support to the client. The nurse is not providing support to ensure compliance with the hospice rules and regulations. The nurse is also not providing support to determine if the spouse understands that the client is dying. 6. A client of the Hispanic culture is nearing death and the family requests that the client be prepared for discharge. The nurse realizes that the reason the family and client want to return home is because: 1. individuals within this culture do not trust hospital caregivers. 2. the family wants to have a spiritual healer care for the client. 3.

it is bad luck to die in the hospital. the spirit may get lost if the client dies in the hospital, and it will not be able to find its way home.

4. ANS: 4 Within the Hispanic culture, the client and family may not want to die in the hospital because the spirit may get lost and will not be able to find its way home. The reason the family and client want to return home is not because of a distrust of hospital caregivers. The family may want to have a spiritual healer conduct a ceremony for the client, but this does not need to be done in the home. Members of the Hispanic culture do not believe that it is bad luck to die in the hospital. 7. During the period of time when a client diagnosed with a terminal illness became comatose, a health care proxy made decisions about the clients care. When the client regained consciousness a few days later, the nurse consulted whom regarding the clients ongoing care decisions? 1. The client

2. 3.

The health care proxy The clients family

4. The clients physician ANS: 1 A health care proxy is in effect whenever the client is unable to communicate and ceases to be in effect as soon as the client regains decision-making capacity. The nurse should consult with the client regarding the clients ongoing care decisions. The nurse should not consult with the health care proxy, the family, or the physician. 8. The nurse is concerned that the spouse of a terminally ill client is experiencing Anticipatory Grieving when which of the following is assessed? 1. Confidence in the ability to care for the ill client at home 2. Expressing anger about the clients pending death and crying throughout the day 3. Large social support system 4. Knowledge of equipment function ANS: 2 Anticipatory grieving is the intellectual and emotional responses and behaviors by which individuals work through the process of modifying self-concept based on the perception of potential loss. Anger and crying about the clients pending death are signs of Anticipatory Grieving. The other assessment findings are evidence that the spouse is accepting the caregiver role. 9. The nurse administers additional intravenous medication to a hospice client with uncontrollable pain. After receiving the additional medication, the client demonstrates apneic periods and bradycardia. Which of the following does this nurses actions suggest? 1. Euthanasia 2. Assisted suicide 3. Double effect 4. Malpractice ANS: 3 The principle of double effect means that increasing the dose of medication to achieve pain control, even if death is hastened, is ethically justified. Euthanasia is the administration of medication to purposefully cause anothers death. Assisted suicide is the practice of providing medication to a client with the intent that the client use the medication to voluntarily commit suicide. Malpractice is conducting some aspect of care that causes a client harm. 10.A client with a terminal illness was ingesting morphine sulfate 10 mg by mouth every 6 hours for pain. To ensure that the client receives the same degree of pain control when delivering the same medication through the intravenous route, which of the following should the nurse do? 1. Provide morphine sulfate 10 mg intravenous every 6 hours. 2. Provide morphine sulfate 20 mg intravenous every 4 hours. 3.

Provide a different medication since morphine sulfate cannot be given through the intravenous route.

Consult a dose equivalent table to determine the dose of morphine sulfate the client will need through the intravenous route.

4. ANS: 4 Dose equivalent tables should be used by the nurse when analgesics or the routes of administration are changed. The nurse should not provide the same dosage of the medication through the intravenous route since this may be too much. Morphine sulfate can be administered through the intravenous route. 11.A terminally ill client is experiencing nausea. Which of the following interventions can be used to help the client at this time? 1. Administer diphenhydramine (Benadryl) as prescribed. 2. Provide three regular meals.

3. Limit mouth care. 4. Restrict iced fluids. ANS: 1 Diphenhydramine (Benadryl) acts on the vomiting center in the medulla. This is the intervention that would be the most helpful to the client at this time. The client should be provided with small, frequent meals. Mouth care should be provided when necessary. Iced fluids are helpful for dry mouth. 12.A terminally ill client is more alert and talkative, and she is requesting specific foods to eat. The nurse should caution the family regarding the clients behavior because this could indicate: 1. total remission of the disease process. 2. final surprising rally before retreating. 3. the client is cured of the terminal illness. 4. the client was misdiagnosed. ANS: 2 Nurses should prepare the family of a terminally ill client for an occasional final surprising rally in which the client becomes temporarily more alert and responsive before retreating. The period of alertness does not indicate total remission of the disease process, the clients being cured of the terminal illness, or the clients being misdiagnosed. 13. The nurse is concerned that a hospice client is approaching death when which of the following is assessed? 1. Respiratory rate 16 and regular 2. Blood pressure 110/60 mmHg 3. Restlessness, irritability, and anxiety 4. Periods of wakefulness are greater than periods of sleep ANS: 3 Symptoms of hypoxia include restlessness, irritability, and anxiety. Respirations of 16 and regular is a normal respiratory rate. Blood pressure of 110/60 mmHg is within normal limits. Periods of wakefulness being greater than periods of sleep is also a normal physiological finding.

14. The nurse is providing a terminally ill client with morphine for pain control. In addition to

this medication, which of the following can be provided to enhance analgesic effect? (Select all that apply.) 1. Antihypertensive 2. Antidepressant 3. 4.

Antibiotic Antiemetic

5. Anticonvulsant 6. Corticosteroid ANS: 2, 5, 6 Adjuvant medications can enhance analgesic effect and include antidepressants, anticonvulsants, and corticosteroids. Antihypertensives, antibiotics, and antiemetics are not considered adjuvant medications for pain control. 15.A client with a terminal illness refuses pain medication. The nurse realizes that the client may decline pain medication for which of the following reasons? (Select all that apply.) 1. Fear that the pain means the disease is worse 2. Insufficient health plan benefits to pay for the medication 3. 4.

Cultural background prevents the use of pain medication Fear of becoming addicted to pain medication

5. Fear of side effects 6. Concern about being labeled as a bad client ANS: 1, 4, 5, 6 Client barriers to sufficient pain management include fear that the disease is worse, fear of becoming addicted to pain medication, fear of side effects, and concern about being labeled as a bad client. Insufficient health plan benefits to pay for the medication and cultural background preventing the use of pain medication are not identified client barriers to sufficient pain management. Chapter 9: Clinical Toxicology 1. Which of the following statements are true characterizations of poisonings in children and adults? A. Medicines are the most common cause of poisoning in adults and children. B. More children die from poisonings than adults. C. Only adults may act purposefully or with obvious intent to ingest a substance that may be poisonous. D. Only children may not recognize a product's risk for poisoning. 2. Which one of these examples of first aid for poisoning is correct?

A. Immediately rinse the eye with sterile water when a chemical is splashed on it. B. For an ingested poison, 2 to 4 ounces (60-120 mL) of water can be given unless the person is unconscious, having convulsions or cannot swallow. C. Contact a poison control center after symptoms develop. D. Inhaled poisons typically cannot penetrate a handkerchief over the nostrils so that it can be used to protect against fumes in order to rescue someone. 3. In which of the following circumstances should the particular form of gastric decontamination be used for a person who swallowed something that could be poisonous? A. Gastric lavage should be used for routinely for those who have ingested a liquid or small tablet. B. Single-dose activated charcoal should be considered for most ingestions if contraindications are not present. C. Whole bowel irrigation should be started for any ingestion of a plant, foreign body or large tablet. D. A cathartic such as magnesium citrate should be administered for all ingestions. 4. A 24-year-old woman who has acutely ingested immediate-release acetaminophen tablets 10 hours ago has a serum acetaminophen concentration of 100 µg/mL (660 µmol/L). Her only complaint is nausea and she has vomited several times in the past two hours. No other drugs are suspected. Which of the following would be appropriate? A. Repeat the serum concentration and wait two hours for the results. B. Administer activated charcoal orally. C. Begin therapy with intravenous acetylcysteine. D. Begin therapy with oral acetylcysteine. 5. Which of the following is a potential advantage of the intravenous formulation of acetylcysteine compared to the oral formulation? A. Medication administration errors are infrequent with the intravenous formulation. B. The duration of therapy is shorter with the intravenous formulation. C. The total dose of acetylcysteine is greater with the intravenous formulation.

D. The systemic adverse effects are no different than those with the oral formulation. 6. What is the preferred treatment for a 55-year-old farmer who is exhibiting excessive bronchial and oronasal secretions following exposure to an organophosphate insecticide and is otherwise healthy? A. Atropine intravenously B. Diphenhydramine orally C. Physostigmine intramuscularly D. Pralidoxime intramuscularly 7. Which of the following is true regarding the treatment of an organophosphate insecticide poisoning? A. Doses of atropine necessary to treat organophosphate poisoning are similar to those normally used to treat simple bradycardia in patients not poisoned with organophosphates. B. An endpoint of therapy with atropine is an acceptable heart rate. C. Excessive drying of bronchial secretions may contribute to death. D. An endpoint of therapy with pralidoxime is an improved and acceptable respiratory effort. 8. Which of the following is true regarding calcium channel antagonist overdose? A. The drugs in the chemical classes of calcium channel antagonists differ in their predominant toxicity upon overdose. B. Hypoglycemia occurs due to excess insulin release. C. Concurrent ingestion of beta adrenergic blockers or digoxin may worsen the cardiovascular toxicity. D. The onset of toxicity of immediate-release formulations is often delayed by 6 to 18 hours. 9. Beyond standard supportive care, what drug, given intravenously, is preferred as the first choice for bradycardia and hypotension from a calcium channel antagonist overdose? A. Calcium chloride B. Glucagon

C. Insulin-dextrose D. Lipid intravenous emulsion 10. Which of the following is true for iron poisoning? A. Vomiting typically begins 1 to 2 days after ingestion. B. A serum iron concentration of 200 mcg/dL (35.8 µmol/L) within the six hours of iron ingestion is associated with severe systemic iron toxicity. C. An abdominal radiograph can reliably detect solid iron tablets. D. Hypotension, acidosis and gastrointestinal bleeding are frequently observed following ingestion of toxic amounts of iron. 11. Which of the following is true regarding deferoxamine therapy for acute iron poisoning? A. Intramuscular injection is the preferred route of administration for patients with manifestations of severe iron poisoning. B. It typically changes the urine to a dark green color in the presence of iron in the urine. C. Some endpoints of therapy include when the urine returns to normal color, the patient is asymptomatic and the serum iron concentration is approaching the normal physiologic range. D. If it is given by continuous intravenous infusion, infusion rates beyond 15 mg/kg/h have been associated with acute kidney injury. 12. Which collection of sign and symptoms would suggest an acute overdose of an opioid? A. Depressed respirations, miosis, and unresponsiveness. B. Hypotension, bradycardia, and hyperglycemia. C. Muscle fasciculations, miosis, and shortness of breath. D. Vomiting, diarrhea, and hypotension. 13. Which of the following can be a factor in poor reversal of opioid toxicity by naloxone? A. Gastrointestinal hypomotility B. Hyperglycemia C. Opioid dependence

D. Overdose with other drugs that have sedating effects 14. Dermal exposure to which of the following chemical weapons is most likely to produce seizures and increased body secretions? A. Chlorine B. Hydrogen cyanide C. Lewisite D. Sarin 15. The pharmacologic mechanism of action of a nerve agent is most similar to which of the following drug categories? A. Anticholinergics B. Anticholinesterases C. Calcium channel blockers D. Opioids ANSWERS 1. A. 2.

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Chapter 10: Clinical Management of Potential Bioterrorism-related Conditions 1. Select the CORRECT example of an intentional act of bioterrorism. A. Flinging a dead body into a drinking well. B. Ebola patient spreading the infection to healthcare worker. C. Traveling to country and acquiring measles. D. Coughing with secondary pneumonic plague. 2. Which of the following is the CORRECT parameter which defines an organism as a Category A critical biological agent? A. One with a low morbidity rate. B. One with a low mortality rate. C. One that has the greatest potential for major public health and medical impact. D. One requiring no special action for public health preparedness. 3. Identify the statement which states a CORRECT challenge or concept with postexposure prophylaxis for biological agents of concern. A. It is easy to assess who was exposed, especially if agent is contagious. B. Clinicians also have to assess who is at risk for developing disease and its potential sequelae. C. Since category A agents have a low mortality rate a "watch and wait" approach for anthrax and plague, for example, is prudent. D. Before starting therapy it is recommended to wait for antimicrobial sensitivity data to help decrease potential for antibiotic resistance.

4. elect the organization or agency with the reputable, up-to-date recommendations for clinicians and the public on a variety of bioterrorism conditions and infectious disease outbreaks. A. CDC B. CNN C. DEA D. FBI 5. Of the bioterrorism-related infections discussed in detail in this chapter which has caused recent "naturally-occurring" outbreaks in U.S. from rodents and dogs? A. Anthrax B. MERS C. Pertussis D. Plague 6. Select the MOST appropriate antimicrobial treatment for anthrax. A. Patients with inhalation anthrax and suspected meningitis should be treated with two different antibiotics with activity against B. anthracis. B. Patients with cutaneous anthrax of the arm or hand only should be treated with two different antibiotics with activity against B. anthracis. C. Raxibacumab monotherapy is a treatment option for patients with inhalation anthrax. D. Ciprofloxacin is considered a reasonable option to include in an empiric treatment regimen for pregnant patients with anthrax. 7. The duration for inhalation plague postexposure prophylaxis is: A. 7 days B. 10 days C. 14 days D. 60 days 8. Select the MOST appropriate agents for the treatment of a patient with Ebola virus disease.

A. Electrolytes and acetaminophen B. Fluids and electrolytes C. Fluids and non-steroidal anti-inflammatory drugs (NSAIDS) D. Electrolytes and ribavirin 9. What should you consider immediately to reduce the risk of transmission of Ebola virus in a patient with fever and malaise after recently returning from a trip to West Africa? A. Isolate the patient in a negative pressure room after confirmation of the diagnosis of Ebola virus disease. B. Administer influenza vaccine and offer oseltamivir if the patient has not been previously vaccinated. C. Monitor the patient daily for 21 days for signs of hemorrhaging, vomiting or diarrhea. D. Donning of PPE (personal protective equipment) which includes gown, gloves, goggles, and surgical mask. 10. Identify the INCORRECT statement about measles vaccination. A. The measles vaccine is comprised of a 3-dose series with the second and third doses given at 1 month and 6 months after the initial dose. B. Recent studies show that vaccinating children with MMR may reduce the risk of developing asthma. C. From 2000 to 2013 measles vaccination was estimated to have prevented 15.6 million deaths worldwide. D. Prior to measles vaccination efforts beginning in 1978 1,000 cases of chronic disability due to measles-related acute encephalitis were reported annually. 11. Select the zoonotic host believed to be responsible for the transmission of MERS to humans. A. Dogs B. Rats C. Mosquitoes D. Camels

12. Identify the correct preventive action for pertussis in pregnant women. A. DTaP booster is recommended for all women during the 27 to 36 weeks of gestation. B. Tdap booster is recommended for all women during the 27 to 36 weeks of gestation. C. Either DTaP or Tdap can be used as a booster for all women during the 27 to 36 weeks of gestation. D. Tdap booster is recommended for all women during the 13 to 28 weeks of gestation to ensure enough time for the development of, and transfer of passive immunity, to the infant before birth. 13. Recommended antibiotics (treatment and/or postexposure prophylaxis) for children 1 to 5 months old exposed to pertussis include: A. Erythromycin, azithromycin, and clarithromycin. B. Erythromycin, TMP-SMZ and clarithromycin. C. Azithromycin, clarithromycin, and TMP-SMZ. D. Only erythromycin and azithromycin. 14. Which of the following biological agents does NOT have a currently available vaccination for preexposure protection. A. Anthrax B. MERS C. Pertussis D. Measles 15. Match the CORRECT infectious disease outbreak after a natural disaster with the appropriate cause. A. Cholera: inadequate water and sanitation systems B. E. coli: vector-borne C. Measles: blunt trauma D. Tetanus: overcrowding

16. Select the CORRECT recommended vaccinations responders assisting with recovery efforts in the U.S. after a natural disaster. A. Cholera and meningococcal B. Hepatitis A and B C. Tetanus and hepatitis B D. Tetanus and typhoid ANSWERS 1. A. 2.

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Chapter 11: Cardiovascular Testing

1. A patient with a murmur is suspected of having an abnormal heart valve. Which test would be most appropriate to evaluate the presence and severity of this condition? A. 12-lead electrocardiogram (ECG) B. Holter monitor C. Exercise stress test D. Transthoracic echocardiogram E. Myocardial perfusion scan 2. A patient complains of intermittent palpitations. Which test would you order to assess this patient's condition? A. Positron emission tomography (PET) scan B. Holter monitor C. Exercise stress test D. Transthoracic echocardiogram E. Myocardial perfusion scan 3. A 63-year-old truck driver with a history of diabetes mellitus, cigarette smoking, and a sedentary lifestyle due to severe right knee osteoarthritis has new onset chest pain. Which is the most reasonable test to evaluate myocardial ischemia in this patient? A. Adenosine myocardial perfusion scan B. Exercise stress test C. Exercise myocardial perfusion study D. Cardiac computed tomography (CT) imaging E. Cardiac catheterization 4. A 45-year-old woman reports intermittent palpitations and near syncope. A 12-lead ECG demonstrates a prolonged QT interval. Of the following medications she has been prescribed, which may cause QT prolongation and torsades de pointes (ie, polymorphic ventricular tachycardia)? A. Verapamil B. Metoprolol C. Metformin D. Neurontin E. Clarithromycin ANSWERS 1. D. 2. B. 3. A. 4. E. Bottom of Form Chapter 12: Cardiac Arrest 1) Which of the following statements is TRUE? A. The incidence of ventricular fibrillation (VF) at the initial rhythm for in-hospital cardiac arrest is roughly 80%. B. Although once the most common initial rhythm encountered with out-of-hospital cardiac arrest, the incidence of VF or pulseless ventricular tachycardia (PVT) is decreasing markedly. C. In-hospital cardiac arrest is typically characterized by atrial fibrillation leading to VF. D. Survival with VF is lower than that observed with pulseless electrical activity (PEA).

E. Pediatric cardiac arrests are usually due to cardiac-related etiologies. 2) Which of the following are factors proven to enhance prehospital survival? A. Occurrence of a witnessed arrest. B. Rapid implementation of bystander cardiopulmonary resuscitation (CPR). C. Presence of VF as the initial rhythm. D. Early defibrillation. E. All of the above. 3) Which of the following statements is TRUE? A. The recommended rate for chest compressions is 60 beats per minute. B. The first action upon recognition of a patient with cardiac arrest is to begin chest compressions. C. CPR should be performed using cycles of 30 chest compressions followed by 2 rescue breaths. D. The presence of a pulse should be assessed immediately following a defibrillation attempt in patients with VF/PVT. E. None of the above. 4) The concept of cardiocerebral resuscitation (CCR) entails which of the following? A. Continuous chest compressions for bystander resuscitation. B. Use of a three-phase time-sensitive model for defibrillation. C. Use of hypothermia for all comatose patients. D. Early emergent catheterization for all resuscitated victims. E. All of the above. 5) Which of the following statements is TRUE? A. Epinephrine should be administered immediately upon recognition of a patient with cardiac arrest. B. CPR should be provided immediately to a patient with cardiac arrest with minimal interruptions in chest compressions. C. Initial defibrillation attempts should consist of 3 shocks with 360 J. D. Early advanced cardiac life support (ACLS) is the most crucial link in the "chain of survival." E. None of the above. 6) Which of the following statements is TRUE? A. Coronary perfusion pressures of at least 5 mm Hg are associated with a higher rate of return of spontaneous circulation (ROSC). B. Phenylephrine is superior to epinephrine for treatment of VF. C. The effectiveness of epinephrine is thought to be due to its α2 effects. D. Epinephrine is associated with a higher incidence of hospital discharge than norepinephrine. E. None of the above. 7) Which of the following statements is TRUE? A. Vasopressin is shorter acting than epinephrine. B. The vasoconstrictor effect of vasopressin is due to its effects on α1-receptors. C. The dose of vasopressin for VF is 40 units every 3 to 5 minutes. D. The effect of vasopressin can be blunted with metabolic acidosis. E. Vasopressin has a more favorable effect than epinephrine on myocardial oxygen demand in the postresuscitative phase. 8) Which of the following is a potential adverse effect related to IV amiodarone?

A. ypotension B. Seizures C. Torsades de pointes D. Diarrhea E. Hypokalemia 9) Which of the following is the drug of choice for torsades de pointes? A. Adenosine B. Amiodarone C. Lidocaine D. Magnesium sulfate E. Procainamide 10) Which of the following statements is TRUE? A. Therapeutic hypothermia has no effect on the pharmacokinetics or pharmacodynamics of medications used in the postresuscitative setting. B. Target temperatures for therapeutic hypothermia are 32°C to 38°C and should be maintained for 24 to 48 hours. C. The goal of therapeutic hypothermia is to protect from cerebral injury caused by destructive enzymatic reactions that occur following cardiac arrest. D. There are no adverse effects associated with therapeutic hypothermia. E. None of the above. 11) Which of the following is an acceptable therapy for asystole? A. Atropine B. Defibrillation C. Amiodarone D. Epinephrine E. None of the above 12) Which of the following is a cause of PEA? A. Hypovolemia B. Drug overdose C. Tension pneumothorax D. Hypokalemia E. All of the above 13) Which of the following is not a potentially harmful effect of sodium bicarbonate. A. Tissue hypercarbia B. Intracellular acidosis C. Iatrogenic alkalosis D. Hyperkalemia E. Decrease in myocardial contractility 14) If IV access cannot be readily obtained, which of the following is the preferred alternative route for drug administration? A. Endotracheal B. Intraosseous C. Intracardiac D. Subcutaneous E. None of the above 15) The first drug administered following electrical defibrillation following VF is

A. Epinephrine B. Amiodarone C. Lidocaine D. Sodium bicarbonate E. Atropine Chapter 13: Hypertension 1) A 78-year-old man has a past medical history of hypertension for 10 years. His BP today is 158/82 mm Hg (156/84 mm Hg when repeated), heart rate is 60 beats/min, serum creatinine is 1.2 mg/dL, and potassium is 4.3 mEq/L. He is currently on lisinopril 40 mg daily and amlodipine 10 mg daily, weighs 73 kg, is 70″ tall, smokes one pack cigarettes daily, and consumes two to three ethanol-containing drinks weekly. Which of the following is the most appropriate medication to add to his antihypertensive regimen? A. Verapamil B. Losartan C. Hydrochlorothiazide D. Metoprolol succinate 2) A 78-year-old man has a past medical history of hypertension for 10 years. His BP today is 158/82 mm Hg (156/84 mm Hg when repeated), heart rate is 60 beats/min, serum creatinine is 1.2 mg/dL, and potassium is 4.3 mEq/L. He is currently on lisinopril 40 mg daily and amlodipine 10 mg daily, weighs 73 kg, is 70″ tall, smokes one pack cigarettes daily, and consumes two to three ethanol-containing drinks weekly. Which of the following lifestyle modifications is most reasonable to recommend in this patient to specifically lower his BP? A. Weight loss B. Smoking cessation C. Adopting a DASH eating plan D. Decreasing ethanol consumption 3) A 37-year-old woman has a BP measurement of 160/100 mm Hg when she first arrives for a routine physical examination by a medical assistant. She has no previous history of hypertension, and the only other time she had been seen by her primary care physician, her BP was 120/80 mm Hg. She is extensively interviewed and examined, and has no signs of acute or chronic hypertension-associated end-organ damage. Her physician measures her BP again 20 minutes later, and it is 142/92 mm Hg (140/90 mm Hg when repeated). Her most recent fasting lipid panel was also normal. Which of the following is the most accurate clinical assessment of her present situation? A. Prehypertension B. Elevated blood pressure C. Stage 1 hypertension D. White coat hypertension 4) A 37-year-old woman has a BP measurement of 160/100 mm Hg when she first arrives for a routine physical examination by a medical assistant. She has no previous history of hypertension, and the only other time she had been seen by her primary care physician, her BP was 120/80 mm Hg. She is extensively interviewed and examined, and has no signs of acute or chronic hypertension-associated end-organ damage. Her physician measures her BP again 20 minutes later, and it is 142/92 mm Hg (140/90 mm Hg when repeated). Her most recent fasting lipid panel was also normal. Which of the following is the most appropriate BP goal in this patient?

A. <120/80 mm Hg B. <130/80 mm Hg C. <140/90 mm Hg D. <150/90 mm Hg 5) A 60-year-old woman with hypertension, type 2 diabetes, and heart failure with reduced ejection fracture is seen 2 months after experiencing an acute myocardial infarction. She also has a history of dyslipidemia. Her present BP is 130/84 mm Hg (132/82 mm Hg when repeated) and her heart rate is 60 beats/min. Her serum creatinine is 1.1 mg/dL, serum potassium is 3.5 mEq/L, and spot urinalysis shows 20 mg albumin/g creatinine. She currently has no peripheral or pulmonary edema. She is taking furosemide 40 mg twice daily, carvedilol 25 mg twice daily and enalapril 20 mg twice daily. Which of the following medical conditions is/are a compelling indication(s) for the use of carvedilol in this patient as a first-line agent? A. Diabetes B. Recent MI C. Chronic kidney disease D. Advanced age 6) A 60-year-old woman with hypertension, type 2 diabetes, and heart failure with reduced ejection fracture is seen 2 months after experiencing an acute myocardial infarction. She also has a history of dyslipidemia. Her present BP is 130/84 mm Hg (132/82 mm Hg when repeated) and her heart rate is 60 beats/min. Her serum creatinine is 1.1 mg/dL, serum potassium is 3.5 mEq/L, and spot urinalysis shows 20 mg albumin/g creatinine. She currently has no peripheral or pulmonary edema. She is taking furosemide 40 mg twice daily, carvedilol 25 mg twice daily and enalapril 20 mg twice daily. Which of the following statements is most appropriate to include when counseling this patient regarding her antihypertensive therapy? A. It will be possible to stop enalapril once your BP is at goal. B. Long-term benefits of these medications are a reduced risk of CV events. C. If you experience new onset depression you should stop taking carvedilol. D. If you experience dry cough, stop taking lisinopril because this can lead to angioedema. 7) Which of the following statements is/are true regarding ARBs in the treatment of hypertension? A. An ARB is first-line because of demonstrated BP lowering and reduced risk of CV events. B. The ALLHAT study showed that nonfatal MI and coronary heart disease are reduced more with ARB therapy than with amlodipine or chlorthalidone. C. An ARB is preferred over an ACEi in patients with chronic kidney disease. D. An ACEi should be added to ARB therapy in patients with hypertension who are not yet at their BP goal value. 8) Which of the following is true regarding prehypertension? A. Any patients with a BP value greater than 120/80 mm Hg is classified as prehypertension. B. Guidelines recommend lifestyle modifications in all patients with prehypertension. C. Less than 50% of patients with prehypertension develop hypertension within their lifetime. D. Patients with prehypertension have equal CV risk compared to patients with normal BP values. 9) A 70-year-old woman with hypertension and type 2 diabetes has been on diltiazem extended release 240 mg daily for 6 years. She was on lisinopril several years ago, but it was stopped due to a dry cough. She was first diagnosed with hypertension when her blood pressure was 180/82 mm Hg. Today, her blood pressure is 158/78 mm Hg (160/76 mm Hg when repeated) and her

heart rate is 100 beats/min. Her urinalysis shows 100 mg albuminuria/24 hours, serum creatinine is 1.6 mg/dL, potassium is 4.1 mEq/L, weight is 75 kg, and height is 66″. Her only complaint is headache. Which of the following is/are routine monitoring parameters/tests for her current antihypertensive drug therapy? A. Heart rate B. Serum potassium, sodium, and magnesium C. Serum creatinine and BUN D. Electrocardiogram 10) A 70-year-old woman with hypertension and type 2 diabetes has been on diltiazem extended release 240 mg daily for 6 years. She was on lisinopril several years ago, but it was stopped due to a dry cough. She was first diagnosed with hypertension when her blood pressure was 180/82 mm Hg. Today, her blood pressure is 158/78 mm Hg (160/76 mm Hg when repeated) and her heart rate is 100 beats/min. Her urinalysis shows 100 mg albuminuria/24 hours, serum creatinine is 1.6 mg/dL, potassium is 4.1 mEq/L, weight is 75 kg, and height is 66″. Her only complaint is headache. Losartan 50 mg daily is added to her regimen. Four weeks later, her BP is 146/82 and 148/80 mm Hg, serum creatinine is 1.9 mg/dL, and potassium has increased to 4.4 mEq/L. Which of the following is the most appropriate option to treat this patient's hypertension? A. Increase losartan to 100 mg daily B. Add hydrochlorothiazide 25 mg daily C. Add spironolactone 25 mg daily D. Decrease losartan to 25 mg daily 11) Which of the following is true regarding the use of arterial vasodilators (hydralazine or minoxidil) in the treatment of hypertension? A. Severe bradycardia occurs when they are used in combination with a β-blocker. B. Both can cause severe rebound hypertension when stopped abruptly. C. Both are poorly tolerated because of anticholinergic side effects. D. Both should be given in combination with a diuretic and a β-blocker. 12) A 65-year-old woman with type 2 diabetes, hypertension, osteoporosis, and atrial fibrillation has a BP of 150/96 mm Hg (150/90 mm Hg when repeated), heart rate of 68 beats/min, potassium of 3.2 mEq/L, and a serum creatinine of 2.3 mg/dL. She reports an allergy to hydrochlorothiazide (severe gout). Presently, she is on diltiazem CD 360 mg daily. Which of the following drug regimens would be the most appropriate to add to her regimen? A. Chlorthalidone 12.5 mg daily B. Amlodipine 5 mg daily C. Atenolol 25 mg daily D. Valsartan 160 mg daily 13) Which of the following is preferred as add-on therapy for a patient who is post-MI (1 month ago) with a BP of 146/88 mm Hg (144/86 mm Hg when repeated) while treated with metoprolol succinate 200 mg daily? A. Chlorthalidone B. Verapamil C. Amlodipine D. Lisinopril 14) Which of the following is preferred as initial antihypertensive therapy for a 63-year-old woman who is diagnosed with hypertension and has a history of ischemic stroke (6 months ago), with a BP of 186/108 mm Hg (184/106 mm Hg when repeated)?

A. A thiazide with an ACEi B. A thiazide with a nonselective β-blocker C. A thiazide alone D. An ACEi with an ARB 15) A 52-year-old man has chronic stable angina and hypertension. He is experiencing ischemic chest pain twice weekly while being treated with metoprolol succinate 100 mg daily. His BP is 146/90 mm Hg (144/92 mm Hg when repeated), and heart rate is 58 beats/min. Which of the following is the most appropriate agent to add in this patient? A. Lisinopril 20 mg daily B. Diltiazem SR 180 mg daily C. Amlodipine 5 mg daily D. Irbesartan 150 mg daily 16) A 69-year-old woman with a history of angioedema (from lisinopril), hypertension, and type 2 diabetes is currently receiving hydrochlorothiazide 25 mg daily and carvedilol 25 mg twice daily. Today her blood pressure is 138/82 mm Hg (138/84 mm Hg when repeated) and heart rate is 52 beats/min. Urinalysis shows 400 mg albumin/24 hours, serum creatinine is 1.2 mg/dL, potassium is 3.8 mEq/dL, weight is 90 kg, and height is 65″. She complains of heartburn, a dry cough, constipation, and fatigue when she exercises. She normally exercises three times per week, and follows a DASH eating plan. Which of her complaints is most likely from one of her antihypertensive medications? A. Heartburn B. Dry cough C. Constipation D. Fatigue 17) A 69-year-old woman with a history of angioedema (from lisinopril), hypertension, and type 2 diabetes is currently receiving hydrochlorothiazide 25 mg daily and carvedilol 25 mg twice daily. Today her blood pressure is 138/82 mm Hg (138/84 mm Hg when repeated) and heart rate is 52 beats/min. Urinalysis shows 400 mg albumin/24 hours, serum creatinine is 1.2 mg/dL, potassium is 3.8 mEq/dL, weight is 90 kg, and height is 65″. She complains of heartburn, a dry cough, constipation, and fatigue when she exercises. She normally exercises three times per week, and follows a DASH eating plan. Which of the following is the most appropriate modification to her regimen? A. Decrease carvedilol to 12.5 mg twice daily and add enalapril. B. Decrease carvedilol to 12.5 mg twice daily and add valsartan. C. Replace hydrochlorothiazide with spironolactone and felodipine. D. Replace carvedilol with valsartan. 18) A 69-year-old woman with a history of angioedema (from lisinopril), hypertension, and type 2 diabetes is currently receiving hydrochlorothiazide 25 mg daily and carvedilol 25 mg twice daily. Today her blood pressure is 138/82 mm Hg (138/84 mm Hg when repeated) and heart rate is 52 beats/min. Urinalysis shows 400 mg albumin/24 hours, serum creatinine is 1.2 mg/dL, potassium is 3.8 mEq/dL, weight is 90 kg, and height is 65″. She complains of heartburn, a dry cough, constipation, and fatigue when she exercises. She normally exercises three times per week, and follows a DASH eating plan. The patient reports taking several nonprescription medications including aspirin 81 mg daily, a multivitamin daily, acetaminophen, and loratadine. She asks you if these are safe to take because of her hypertension. Which of the following is the most appropriate response?

A. You should stop taking these until you have discussed this with your primary care physician. B. Acetaminophen can increase your blood pressure; you should use naproxen instead. C. Loratadine can increase your blood pressure; you should use pseudoephedrine if needed. D. These medications are generally safe to use in patients with hypertension, even if not controlled. 19) A 55-year-old man with hypertension and no other chronic medical problems is currently treated with hydrochlorothiazide 50 mg daily, irbesartan 300 mg daily, carvedilol 25 mg twice daily, and amlodipine 10 mg daily. His BP is 144/96 mm Hg (146/94 mm Hg when repeated). He is adherent with all of these medications. Serum creatinine is 1.2 mg/dL, potassium is 3.7 mEq/L, and all other laboratory values are normal. Which of the following is the most appropriate to add to his regimen? A. Terazosin 2 mg daily B. Spironolactone 25 mg daily C. Clonidine 0.1 mg twice daily D. Chlorthalidone 12.5 mg daily 20) A patient with newly diagnosed hypertension asks you for advice lifestyle modifications to lower BP. Which of the following is/are appropriate recommendations? A. Decrease your dietary intake of table salt and processed foods. B. Increase your daily ingestion of red meat. C. Start 45 to 60 minutes of vigorous exercise daily. D. Decrease your daily fiber intake

Chapter 14: Chronic Heart Failure 1) A 64-year-old African-American male with a 2 year history of HFrEF secondary to an MI returns to the clinic for a routine follow-up. He continues to have fatigue and dyspnea on minimal exertion. His serum electrolytes, creatinine clearance, and other labs are within normal limits. His LVEF by echo is 35%. His cardiovascular drug regimen is unchanged over the previous 3 months except that digoxin was started one month ago. His current digoxin plasma concentration is 1.8 ng/mL collected approximately 18 hours after his previous dose. Enalapril 10 mg twice daily Carvedilol 25 mg twice daily Furosemide 40 mg twice daily Digoxin 0.25 mg daily Spironolactone 25 mg daily Esomeprazole 25 mg daily ASA 81 mg daily Atorvastatin 40 mg at bedtime Which of the following is the most appropriate approach to his digoxin therapy? A. Decrease the digoxin dose to 0.125 mg/day B. Decrease the digoxin dose to 0.0625 mg/day C. Discontinue digoxin D. No changes in digoxin therapy are indicated

2) 64-year-old African-American male with a 2 year history of HFrEF secondary to an MI returns to the clinic for a routine follow-up. He continues to have fatigue and dyspnea on minimal exertion. His serum electrolytes, creatinine clearance, and other labs are within normal limits. His LVEF by echo is 35%. His cardiovascular drug regimen is unchanged over the previous 3 months except that digoxin was started one month ago. His current digoxin plasma concentration is 1.8 ng/mL collected approximately 18 hours after his previous dose. Enalapril 10 mg twice daily Carvedilol 25 mg twice daily Furosemide 40 mg twice daily Digoxin 0.25 mg daily Spironolactone 25 mg daily Esomeprazole 25 mg daily ASA 81 mg daily Atorvastatin 40 mg at bedtime Which of the following would be the most appropriate recommendation to improve the longterm outcome of this patient? A. Add hydralazine/isosorbide dinitrate 37.5 mg/20 mg three times daily B. Add amlodipine C. Add sacubitril/valsartan D. Change enalapril to candesartan 3) Cough is an adverse effect associated with which of the following medications? A. Carvedilol B. Candesartan C. Sacubitril/valsartan D. Torsemide 4) Which of the following medications can exacerbate HFrEF? A. Metformin B. Diltiazem C. Rosuvastatin D. Amiodarone 5) Which of the following best describes the use of beta-blockers for treating HFrEF? A. The carvedilol dose should be decreased in patients with a creatinine clearance <30 mL/min B. Only cardioselective agents are effective C. Therapy should be initiated at the target dose and titrated down if not tolerated D. Therapy should be initiated in patients that are clinically stable without volume overload 6) Which of the following adverse effects of ramipril can be avoided by switching to candesartan? A. Fetal toxicity B. Renal insufficiency C. Hyperkalemia D. Cough 7) Which of the following is correct about the pharmacotherapy of HFpEF?. A. Beta-blockers reduce mortality B. Beta-blocker therapy can be used safely in this population but does not improve mortality

C. CE inhibitors are the only agents that have been shown to reduce mortality in the HFpEF population D. Beta-blocker therapy is contraindicated in patients with HFpEF. 8) Which of the following are risk factors for spironolactone-induced hyperkalemia? A. Concomitant isosorbide dinitrate therapy B. Concomitant valsartan therapy C. Concomitant furosemide therapy D. Concomitant metolazone therapy 9) Which of the following should be used to monitor loop diuretic therapy in patients with heart failure? A. Daily weights, serum potassium, serum magnesium B. Thyroid stimulating hormone (TSH) and free T4 C. Hemoglobin A1C and fasting blood sugar D. Fasting lipid profile 10) HFpEF is best characterized by which of the following statements? A. It is caused by impaired contractility due to hypertension B. Patients with HFpEF have large increases in end diastolic volume C. Only patients with HFrEF develop pulmonary edema D. Patients with HFpEF experience significant left ventricular pressure changes with relatively small changes in volume 11) A patient with a history of hypertension was recently diagnosed with Stage C HFrEF. Current medications include sustained release diltiazem 180 mg QD, digoxin 0.125 mg QD, and furosemide 40 mg QD. The patient's vital signs are currently: BP 145/90 and pulse 68 BPM. Which of the following changes should be recommended in this patient's drug therapy? A. Change diltiazem to verapamil B. Add torsemide C. Discontinue diltiazem and initiate ramipril and carvedilol therapy D. Add ivabradine to the present therapy 12) What is the most appropriate therapy for a patient with HFrEF that develops enalaprilinduced angioedema? A. Ramipril B. Sacubitril/valsartan C. Amlodipine D. Hydralazine/isosorbide dinitrate 13) A 63 year old female with stage C HFrEF is currently taking enalapril 5 mg twice daily, furosemide 40 mg twice daily, digoxin 0.125 mg qd, and metoprolol succinate 25 mg daily. Today, she presents with increasing shortness of breath, fatigue, and ankle swelling. She also reports an 8 pound weight gain over the past week. Her labs are significant for serum potassium of 5.2 mEq/L and serum creatinine of 2.2 mg/dL. Which of the following interventions is most appropriate? A. Increase the dose of furosemide to 80 mg bid B. Increase the dose of carvedilol to 6.25 mg bid C. Start spironolactone 12.5 mg qd D. Increase the dose of digoxin to 0.25 mg qd 14) A patient with HFrEF is in normal sinus rhythm and is currently receiving an lisinopril 20 mg daily, carvedilol 50 mg twice daily, digoxin 0.125 mg daily, spironolactone 25 mg daily, and

furosemide 40 mg twice daily. Vital signs are BP 110/75 mm Hg and pulse 85 BPM. All labs are within normal limits. Which of the following would be the most appropriate medication to add? A. Ivabradine B. Sacubitril/valsartan C. Amlodipine D. Eplerenone 15) A female patient with HFpEF also has diabetes, hypertension, hyperlipidemia, asthma, and atrial fibrillation. Currently, her vital signs are: HR 118 BPM and BP 128/85 mm Hg. Her current labs include serum creatinine 1.0 mg/dL, serum potassium 4.3 mEq/L, and HgbA1c 6.8%. Current medications include hydrochlorothiazide 25 mg q AM, lisinopril 10 mg daily, atorvastatin 20 mg daily, aspirin 81 mg daily, metformin 1000 mg BID, Advair 250/50 1 puff BID, and albuterol PRN. Which of the following is the most appropriate medication to add at this time? A. Metoprolol B. Ivabradine C. Diltiazem D. Eplerenone Chapter 15: Acute Decompensated Heart Failure 1) A 58-year-old male with a history of ischemic cardiomyopathy presents to clinic with orthopnea, dyspnea with minimal exertion, 3+ pitting edema, fatigue, anorexia, nausea, and early satiety. These signs and symptoms are consistent with: A. Volume overload only B. Low cardiac output only C. Both volume overload and low cardiac output D. Neither volume overload or low cardiac output 2) A 58-year-old male with a history of ischemic cardiomyopathy presents to clinic with orthopnea, dyspnea with minimal exertion, 3+ pitting edema, fatigue, anorexia, nausea, and early satiety. This patient is admitted and a pulmonary artery catheter is placed. The pulmonary capillary wedge pressure (PCWP) is 28 mm Hg and the cardiac index is 1.8 L/min/m2 (0.03 L/s/m2). These hemodynamic values are consistent with which one of the following hemodynamic subsets? A. I B. II C. III D. IV 3) All of the following strategies would be reasonable for overcoming diuretic resistance in a patient currently taking furosemide 40 mg orally twice daily, except: A. Changing to spironolactone 25 mg daily B. Increasing the dose of furosemide to 80 mg orally twice daily C. Changing to furosemide 40 mg IV twice daily D. Adding metolazone 2.5 mg orally twice daily 4) A patient is admitted with acute decompensated heart failure and evidence of low cardiac output. The patient's current medications include lisinopril 20 mg daily, furosemide 40 mg twice a day, metoprolol CR/XL 200 mg daily, and digoxin 0.125 mg daily. The patient has been stable

on these doses for the previous 4 months. It is decided that inotropic therapy is indicated. Which do you recommend? A. Dopamine B. Dobutamine C. Milrinone D. Either B or C 5) A 57-year-old African American male with ischemic cardiomyopathy (ejection fraction [EF] 25% [0.25]) presents to the emergency department (ED) with an acute decompensated heart failure (ADHF) exacerbation. His vital signs include blood pressure 103/77 mm Hg, heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% (0.91) on 4 L by nasal cannula. Physical examination reveals jugular venous distension (JVD), crackles at bases, ascites, and trace bilateral lower extremity edema. He admits to a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased and reports strict adherence to both dietary restrictions and medications. In the ED, he has already received furosemide 160 mg IV × 1 dose with minimal response in urine output. Pertinent labs include potassium 5.1 mEq/L (5.1 mmol/L), brain natriuretic peptide (BNP) 950 pg/mL (275 pmol/L), blood urea nitrogen (BUN) 41 mg/dL (14.6 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline). The patient's medications on admission include lisinopril 10 mg daily, metoprolol XL 150 mg daily, and furosemide 120 mg twice daily. Which of the following should occur with this patient's therapy? A. Continue metoprolol at current dose B. Discontinue metoprolol immediately C. Reduce metoprolol to last tolerated dose D. Change metoprolol to atenolol 6) A 57-year-old African American male with ischemic cardiomyopathy (ejection fraction [EF] 25% [0.25]) presents to the emergency department (ED) with an acute decompensated heart failure (ADHF) exacerbation. His vital signs include blood pressure 103/77 mm Hg, heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% (0.91) on 4 L by nasal cannula. Physical examination reveals jugular venous distension (JVD), crackles at bases, ascites, and trace bilateral lower extremity edema. He admits to a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased and reports strict adherence to both dietary restrictions and medications. In the ED, he has already received furosemide 160 mg IV × 1 dose with minimal response in urine output. Pertinent labs include potassium 5.1 mEq/L (5.1 mmol/L), brain natriuretic peptide (BNP) 950 pg/mL (275 pmol/L), blood urea nitrogen (BUN) 41 mg/dL (14.6 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline). The patient's medications on admission include lisinopril 10 mg daily, metoprolol XL 150 mg daily, and furosemide 120 mg twice daily. Which of the following would be appropriate to manage this patient's fluid overload? A. Initiate furosemide 160 mg IV twice daily B. Initiate furosemide 240 mg IV twice daily C. Initiate furosemide 160 mg IV plus metolazone 5 mg by mouth daily D. Initiate furosemide 5 mg/h IV continuous infusion 7) A 57-year-old African American male with ischemic cardiomyopathy (ejection fraction [EF] 25% [0.25]) presents to the emergency department (ED) with an acute decompensated heart failure (ADHF) exacerbation. His vital signs include blood pressure 103/77 mm Hg, heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% (0.91) on 4 L by nasal cannula.

Physical examination reveals jugular venous distension (JVD), crackles at bases, ascites, and trace bilateral lower extremity edema. He admits to a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased and reports strict adherence to both dietary restrictions and medications. In the ED, he has already received furosemide 160 mg IV × 1 dose with minimal response in urine output. Pertinent labs include potassium 5.1 mEq/L (5.1 mmol/L), brain natriuretic peptide (BNP) 950 pg/mL (275 pmol/L), blood urea nitrogen (BUN) 41 mg/dL (14.6 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline). The patient's medications on admission include lisinopril 10 mg daily, metoprolol XL 150 mg daily, and furosemide 120 mg twice daily. Which of the following guideline-directed medical therapies would be appropriate to initiate prior to this patient's discharge? Note: assume discharge labs are nearly identical to admission labs. A. Spironolactone 25 mg by mouth daily B. Digoxin 0.125 mg by mouth daily C. Candesartan 4 mg by mouth daily D. Hydralazine 37.5 mg and isosorbide dinitrate 20 mg by mouth three times daily 8) A 63-year-old female with hypertensive cardiomyopathy (EF 30-35% [0.30-0.35]) presents with a chief complaint of "always feeling tired." Her daughter reported that the patient's exercise tolerance has significantly declined recently despite strict adherence to a low sodium diet and medications that include enalapril 7.5 mg twice daily, carvedilol 12.5 mg twice daily, furosemide 80 mg twice daily, and digoxin 0.125 mg daily. Vital signs include blood pressure 92/57 mm Hg (mild orthostasis), heart rate 95 bpm, and respiratory rate 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L (135 mmol/L), potassium 4.9 mEq/L (4.9 mmol/L), blood urea nitrogen (BUN) 45 mg/dL (16.1 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline BUN/SCr 27/1.1 [SI: 9.6/97]). Upon further questioning, the patient admits to occasional dizziness. Which one of the following clinical categories best describes this patient? A. Warm and dry B. Warm and wet C. Cold and dry D. Cold and wet 9) A 63-year-old female with hypertensive cardiomyopathy (EF 30-35% [0.30-0.35]) presents with a chief complaint of "always feeling tired." Her daughter reported that the patient's exercise tolerance has significantly declined recently despite strict adherence to a low sodium diet and medications that include enalapril 7.5 mg twice daily, carvedilol 12.5 mg twice daily, furosemide 80 mg twice daily, and digoxin 0.125 mg daily. Vital signs include blood pressure 92/57 mm Hg (mild orthostasis), heart rate 95 bpm, and respiratory rate 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L (135 mmol/L), potassium 4.9 mEq/L (4.9 mmol/L), blood urea nitrogen (BUN) 45 mg/dL (16.1 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline BUN/SCr 27/1.1 [SI: 9.6/97]). Upon further questioning, the patient admits to occasional dizziness. Which of the following laboratory parameters would assist with confirming the volume status of this patient? A. C-reactive protein B. Brain natriuretic peptide C. Serum albumin D. Hemoglobin

10) A 63-year-old female with hypertensive cardiomyopathy (EF 30-35% [0.30-0.35]) presents with a chief complaint of "always feeling tired." Her daughter reported that the patient's exercise tolerance has significantly declined recently despite strict adherence to a low sodium diet and medications that include enalapril 7.5 mg twice daily, carvedilol 12.5 mg twice daily, furosemide 80 mg twice daily, and digoxin 0.125 mg daily. Vital signs include blood pressure 92/57 mm Hg (mild orthostasis), heart rate 95 bpm, and respiratory rate 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L (135 mmol/L), potassium 4.9 mEq/L (4.9 mmol/L), blood urea nitrogen (BUN) 45 mg/dL (16.1 mmol/L), and serum creatinine (SCr) 2.2 mg/dL (194 µmol/L) (baseline BUN/SCr 27/1.1 [SI: 9.6/97]). Upon further questioning, the patient admits to occasional dizziness. Which one of the following is the optimal initial intervention for this patient? A. Change furosemide to 80 mg IV twice daily B. Hold furosemide and initiate cautious hydration with IV fluids C. Hold carvedilol and initiate dobutamine at 2 mcg/kg/min D. Increase carvedilol to 25 mg by mouth twice daily 11) An 84-year-old white male with ischemic cardiomyopathy (EF 20%-25% [0.20-0.25]) presents to the hospital with ADHF. Vital signs include blood pressure 89/55 mm Hg, heart rate 93 bpm (no orthostasis present), and respiratory rate 20 rpm. Physical examination reveals JVD, positive S3, bilateral crackles throughout on lung auscultation, and 3+ bilateral edema to the thighs. Chest radiograph reveals pulmonary edema and pleural effusions. Hemodynamic measurements obtained by pulmonary artery catheter include PCWP 28 mm Hg, cardiac index 1.7 L/min/m2 (0.028 L/s/m2), and systemic vascular resistance (SVR) 1,600 dyne s cm−5 (160 MPa s m−3). His laboratory values are all normal, except BUN 34 mg/dL (12.1 mmol/L), and SCr 1.5 mg/dL (133 µmol/L) (baseline BUN/SCr 32 and 0.9 [SI: 11.4 and 80]). Medications on admission include lisinopril 10 mg daily, bisoprolol 10 mg daily, bumetanide 2 mg twice daily, simvastatin 40 mg daily, and aspirin 81 mg/day. Which of the following is an appropriate initial treatment strategy for this patient? A. Furosemide 80 mg IV twice daily B. Furosemide 80 mg IV twice daily plus sodium nitroprusside 0.2 mcg/kg/min C. Furosemide 20 mg/h IV continuous infusion D. Sodium nitroprusside 0.2 mcg/kg/min 12) An 84-year-old white male with ischemic cardiomyopathy (EF 20%-25% [0.20-0.25]) presents to the hospital with ADHF. Vital signs include blood pressure 89/55 mm Hg, heart rate 93 bpm (no orthostasis present), and respiratory rate 20 rpm. Physical examination reveals JVD, positive S3, bilateral crackles throughout on lung auscultation, and 3+ bilateral edema to the thighs. Chest radiograph reveals pulmonary edema and pleural effusions. Hemodynamic measurements obtained by pulmonary artery catheter include PCWP 28 mm Hg, cardiac index 1.7 L/min/m2 (0.028 L/s/m2), and systemic vascular resistance (SVR) 1,600 dyne s cm−5 (160 MPa s m−3). His laboratory values are all normal, except BUN 34 mg/dL (12.1 mmol/L), and SCr 1.5 mg/dL (133 µmol/L) (baseline BUN/SCr 32 and 0.9 [SI: 11.4 and 80]). Medications on admission include lisinopril 10 mg daily, bisoprolol 10 mg daily, bumetanide 2 mg twice daily, simvastatin 40 mg daily, and aspirin 81 mg/day. After the patient's volume status is optimized, his CI and SVR have not changed substantially, and his vital signs and oral heart failure medications remain essentially unchanged with the exception of his diuretic dose. Which of the following therapies are now appropriate to manage this patient's ADHF? A. Sodium nitroprusside 0.1 mcg/kg/min IV continuous infusion

B. Nitroglycerin 25 mcg/min IV continuous infusion C. Enalaprilat 2.5 mg IV every 6 hours D. Dobutamine 2 mcg/kg/min IV continuous infusion

Chapter 16: Stable Ischemic Heart Disease Patients with ischemic coronary vessel disease and acute coronary syndrome (ACS) are classified as low or high risk for acute myocardial infarction based on characteristics that 1. include significant: A) heart murmurs. B) C)

ECG changes. pulmonary disease.

D) pericardial effusion. ANS. B 2. The nurse takes into consideration that age-related changes can affect the peripheral circulation because of: a. sclerosed blood vessels. b. hypotension. c. inactivity. d. poor nutrition. ANS: A 3. The nurse instructs a patient that the pain of angina is due to ischemia of the myocardium, which is brought on by which factors? (Select all that apply.) a. Exertion b. Emotional excitement c. d.

Eating heavy meals Exposure to cold

e. Allergic reaction ANS: A, B, C, D Angina is not brought on by allergy. 4. The patient with angina asks what to do if the first nitroglycerin tablet (NGT) does not relieve the pain. What instruction by the nurse is correct? a. Take 2 tablets 10 minutes after the first dose and go to the ER if you are still having pain. Take a second tablet 15 minutes after the first dose and call the physician if you are still b. having pain. c. Take 2 more tablets 30 minutes apart, and then rest for 20 minutes. d. Take 2 more tablets 5 minutes apart and notify the physician if your pain is not relieved. ANS: D

If the first NTG tablet does not relieve pain, 2 more tablets 5 minutes apart should be taken. If pain is not relieved within 15 minutes, notify the physician. 5. The nurse explains the difference between exertional angina and unstable angina is that unstable angina occurs: a. on heavy exertion. b. when the blood pressure increases sharply. c. when the body reacts to high stress levels. d. unpredictably, even in sleep. ANS: D Unstable angina attacks are unpredictable and do not follow a pattern as do stable angina attacks. Unstable angina can progress into a myocardial infarction (MI) and a medical emergency. 6. The nurse suggests to the patient with angina that a daily dose of 81 mg of aspirin is an inexpensive therapy to help: a. reduce clotting. b. dilate coronary vessels. c. alleviate pain associated with angina. d. lower cholesterol. ANS: A Daily doses of aspirin reduce clotting by prolonging clotting time, thus helping prevent clots that can cause an MI. 7. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? a. The patient rates the pain at a level 3 to 5 (0 to 10 scale). b. The patient states that the pain wakes me up at night. c. The patient says that the frequency of the pain has increased over the last few weeks. d. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet. ANS: D Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina. 8. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient? a. Acute pain related to myocardial ischemia b. Anxiety related to perceived threat of death c. Decreased cardiac output related to cardiogenic shock d. Activity intolerance related to decreased cardiac output ANS: C

All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart). 9. Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetals (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will a. reduce the fight or flight response. b. decrease spasm of the coronary arteries. c. increase the force of myocardial contraction. d. help prevent clotting in the coronary arteries. ANS: B Prinzmetals angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet inhibitors, such as aspirin, help prevent coronary artery thrombosis, and b-blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand. 10. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if a. the patient is restless and agitated. b. the blood pressure is 190/110 mm Hg. c. the patient complains about feeling anxious. d. the cardiac monitor shows a heart rate of 45. ANS: D Patients taking b-blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects. 11. Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for a. decreased blood pressure and apical pulse rate. b. fewer complaints of having cold hands and feet. c. improvement in the quality of the peripheral pulses. d. the ability to do daily activities without chest discomfort. ANS: D Because the medication is ordered to improve the patients angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the goal of decreased angina has been met. The noncardioselective b-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature. 12. A patient with a nonST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin? a. Platelet aggregation is enhanced by IV heparin infusion. b. Heparin will dissolve the clot that is blocking blood flow to the heart.

c. Coronary artery plaque size and adherence are decreased with heparin. d. Heparin will prevent the development of new clots in the coronary arteries. ANS: D Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation. 13. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication? a. Check blood pressure. b. Monitor apical pulse rate. c. Monitor for dysrhythmias. d. Ask about chest discomfort. ANS: D The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective. Chapter 17: Acute Coronary Syndromes 1.A client is learning about cholesterol. The nurse explains that the good cholesterol transports plasma cholesterol away from plaques and to the liver for metabolism. This type of cholesterol is called: 1. high-density lipoprotein. 2. low-density lipoprotein. 3. very-high-density lipoprotein. 4. very-low-density lipoprotein. ANS: 1 High-density lipoprotein transports plasma cholesterol away from atherosclerotic plaques and to the liver for metabolism and excretion. Low-density lipoproteins, or bad cholesterol, are the main component of the atherosclerotic plaque. Very-low-density lipoproteins are considered more atherogenic and are more common in men and people with diabetes. 2.A client has a blood pressure of 124/78 mmHg and a triglyceride level of 160 mg/dL. Based on these results, the nurse knows that the client has: 1. an optimal blood pressure and triglyceride level. 2. a prehypertensive blood pressure and an optimal triglyceride level. 3. a prehypertensive blood pressure and a borderline high triglyceride level. 4. stage I hypertension and a high triglyceride level. ANS: 3 Prehypertensive blood pressure ranges systolically from 120 to 139 mmHg or diastolically from 80 to 90 mmHg. Stage I hypertension is systolic blood pressure (SBP) of 140 to 159 mmHg or a

diastolic blood pressure (DBP) of 90 to 99 mmHg. Optimal triglyceride levels are less than 150 mg/dL. Triglyceride levels from 150 to 199 mg/dL are considered borderline high. Triglyceride levels at 200 to 499 mg/dL are considered high. 3. The nurse measures a clients blood pressure to be 158/92 mmHg. The nurse recognizes that this blood pressure is classified as: 1. normal. 2. prehypertension. 3. stage I hypertension. 4. stage II hypertension. ANS: 3 Normal blood pressure is SBP less than 120 mmHg and DBP less than 80 mmHg. A prehypertensive state is SBP of 120 to 139 mmHg or DBP of 80 to 90 mmHg. Stage I hypertension is SBP of 140 to 159 mmHg or DBP of 90 to 99 mmHg. Stage II hypertension is a SBP of 160 mmHg or higher or a DBP of 100 mmHg or higher. A. client is complaining of chest pain that occurs during exercise. This pain is relieved when the client rests. The nurse realizes that this client is experiencing which type of angina? 1. Prinzmetals variant angina 2. Silent angina 3. Stable angina 4. Unstable angina ANS: 3 Stable angina is precipitated by factors that increase oxygen demand or reduce oxygen supply. Chest pain occurs predictably with the same onset, duration, and intensity and is relieved when the precipitating factor is removed or with nitroglycerin. Unstable angina is typified by an increase in frequency, duration, and intensity of symptoms at lower levels of activity and even at rest. Prinzmetals variant angina is a coronary artery spasm. Silent angina can occur with no pain at all and is common in diabetic patients. 5.A client diagnosed with stable angina is undergoing a 12-lead electrocardiogram. Which of the following results is not expected? 1. ST segment depression 2. ST segment elevation 3. T-wave flattening 4. T-wave inversion ANS: 2 During an episode of angina, T-wave flattening or inversions and ST segment depression may be seen on the electrocardiogram due to subendocardial ischemia. ST segment elevation is seen with impending or acute myocardial infarction. 6.A client is scheduled for a cardiac angiogram. Which of the following should the nurse instruct the client about this diagnostic test? 1. It is noninvasive. 2. Contrast dye is injected.

3. Clients can move about after the procedure. 4. General anesthesia is used. ANS: 2 A cardiac angiogram is a procedure that visualizes the structures of the heart and vessels. This is an invasive procedure; however, it does not need general anesthesia. The client is awake during the procedure. A contrast dye is injected, and the client may feel a warm sensation. The client must maintain bed rest with the leg straight for up to 4 to 6 hours after the catheter is removed. 7.When planning the care of a client diagnosed with stable angina, which of the following would be considered a goal of treatment? 1. Decrease in ischemia and episodes of angina 2. Prevent myocardial infection 3. Reduction of risk factors 4. Reduction of stress by education ANS: 1 The primary goal for the treatment of stable angina is to improve the quality of life by decreasing episodes of angina and ischemia. The second goal is to increase the quantity of life by preventing progression to myocardial infarction and death. Reduction of risk factors and education are both parts of a treatment plan. 8.A client is prescribed a beta-blocker for treatment of coronary artery disease. Which of the following is the client most likely going to be prescribed? 1. Amlodipine 2. Atenolol 3. Diltiazem hydrochloride 4. Nicardipine ANS: 2 Amlodipine, diltiazem hydrochloride, and nicardipine are all calcium channel blockers. Atenolol is a beta-blocker. 9.A client tells the nurse that using nitroglycerin tablets causes a tingling sensation and a headache. The nurse knows that this is: 1. an emergency. 2. an allergic reaction. 3. evidence of toxicity. 4. expected. ANS: 4 Nitroglycerin tablets will cause a tingling sensation and can cause feelings of the heart pounding, as well as flushing and headache. These symptoms are not an emergency, an allergic reaction, or evidence of toxicity. These symptoms are expected with nitroglycerin tablets. 10.A nurse is considering contraindications to fibrinolytic therapy. Which of the following patients is an appropriate candidate for fibrinolytic therapy? 1. A patent with a peptic ulcer disease

2. 3.

A patient with a history of hemorrhagic stroke A patient with a history of a motor vehicle accident 1 year ago

4. A patient with inflammatory bowel disease ANS: 3 Contraindications to fibrinolytic therapy include active internal bleeding, active inflammatory bowel disease, active peptic ulcer disease, active pericarditis, defective homeostasis, gastrointestinal/genitourinary bleeding for less than 6 months, history of hemorrhagic stroke, known bleeding disorders, neurologic procedure within the past 2 months, recent surgery or trauma within 2 months, pregnancy, suspected aortic dissection, and uncontrolled hypertension. 11.A client is participating in cardiac rehabilitation and is currently engaging in supervised exercise, counseling, and education. The nurse realizes this client is in which phase of cardiac rehabilitation? 1. Phase I 2. Phase II 3. Phase III 4. Phase IV ANS: 3 Phase I of cardiac rehabilitation begins in the hospital. Phase II of cardiac rehabilitation is the transitional phase and centers around recovery at home with increasing activity. Phase II of cardiac rehabilitation occurs in an outpatient rehabilitation facility, and it focuses on supervised exercise, counseling, and education. Phase IV of cardiac rehabilitation is the maintenance phase and focuses on long-term changes. 12.A client tells the nurse that he ingests an NSAID when the angina pain gets really bad, and it eliminates the pain. The nurse suspects the client is experiencing: 1. musculoskeletal pain. 2. aortic dissection. 3. mitral valve prolapse. 4. pericarditis. ANS: 1 Musculoskeletal pain is relieved with NSAIDs. The pain of aortic dissection and pericarditis would not be relieved with NSAIDs. Mitral valve prolapse may or may not have associated chest discomfort. 13.A client is prescribed nicotinic acid as part of treatment for coronary artery disease. Which of the following should the nurse instruct the client regarding this medication? 1. Ingest an aspirin 30 minutes before taking the medication and after eating. 2. Expect a gritty taste. 3. 4. ANS: 1

Anticipate constipation. Expect fatigue with this medication.

Instructions to the client prescribed nicotinic acid include ingesting an aspirin 30 minutes to 1 hour before the medication and after food. A gritty taste is not associated with this medication. Constipation is not an expected gastrointestinal side effect of this medication. This medication does not cause fatigue. 14. The nurse is assessing the pain of a client experiencing angina. Which of the following should be included in this assessment? (Select all that apply.) 1. Precipitating event 2. Quality 3. 4.

Radiation Severity

5. Timing 6. Medication ANS: 1, 2, 3, 4, 5 The memory aid PQRST can be used to assess a client experiencing symptoms of angina, and it includes precipitating event, quality, radiation, severity, and timing. Medication is not a part of this assessment. 15.A client is at risk for coronary artery disease. Which of the following should the nurse instruct as modifiable risk factors for this health condition? (Select all that apply.) 1. Alcohol consumption 2. Diabetes mellitus 3. 4.

Family history Gender

5. Low daily fruit intake 6. Psychosocial index ANS: 1, 2, 5, 6 Nonmodifiable risk factors are age, gender, and family history. Modifiable risk factors include hyperlipidemia, hypertension, tobacco abuse, diabetes mellitus, abdominal obesity, lack of physical activity, low daily fruit and vegetable intake, alcohol consumption, and psychosocial index. 16.A client is diagnosed with angina after describing the type of pain she experiences. Which of the following are characteristics of anginal pain? (Select all that apply.) 1. Pressure 2. Heavy 3. 4.

Squeezing Stabbing

5. Sharp 6. Demonstrates a clenched fist over the sternum ANS: 1, 2, 3, 6

Angina pain is typically described as pressure, heavy, squeezing, and it is demonstrated by placing a clenched fist over the sternum. This hand posture is referred to as Levines sign which is the universal sign for angina. Angina pain is not stabbing or sharp. 17.A client is experiencing a sudden onset of chest pain. Which of the following will the nurse do to manage this chest pain? 1. Administer intravenous morphine as prescribed. 2. Provide oxygen. 3. 4.

Insert an indwelling urinary catheter. Position the client on the left side.

5. Administer nitroglycerin as prescribed. 6. Administer aspirin as prescribed. ANS: 1, 2, 5, 6 The emergency management of chest pain follows the memory aid MONA; that is, morphine, oxygen, nitroglycerin, and aspirin. An indwelling urinary catheter and positioning the client on the left side are not interventions for the emergency management of chest pain. Chapter 18: The Arrhythmias 1) Which of the following sweat chloride values are diagnostic of cystic fibrosis (CF)? A. 90 mmol/L B. 30 mmol/L C. 55 mmol/L D. 10 mmol/L 2) Anti-inflammatory therapy in CF patients is most easily done with: A. Azithromycin B. High-dose ibuprofen C. Glucocorticoids D. Acetaminophen 3) Sputum cultures can be used in the CF patient to check: A. What organisms are colonizing the lungs. B. How much of an organism is growing. C. The susceptibility pattern of bacteria. D. All of the above. 4) What mutation is commonly identified in the CF patient? A. G551D B. R117H C. ΔF508 D. G54ZX 5) The following are all true regarding nonclassic CF except: A. Males may be sterile B. Adequate pancreatic exocrine function C. May have pulmonary disease D. Normal sweat chloride values 6) Pseudomonas aeruginosa and Stenotrophomonas could be covered by: A. Ceftriaxone + amikacin + trimethoprim/sulfamethoxazole

B. Ceftazidime + ertapenem C. Piperacillin + gentamicin+ doxycycline D. Cefepime + azithromycin + doxycycline 7) A 5-year-old patient needs an aminoglycoside. Based on typical CF pharmacokinetics, what adjustments will you expect to make? A. Increase the dose, shorten the interval B. Increase the dose, extend the interval C. Decrease the dose, shorten the interval D. Decrease the dose, extend the interval 8) Airway clearance therapy: the sequence of therapy should be: (A) TOBI®; (B) Albuterol; (C) Pulmozyme®; and (D) Hypertonic saline A. A,B,C,D B. D,A,B,C C. C,B,D,A D. B,D,C,A 9) Which of the following vitamins should be supplemented in the CF patient? A. Vitamin C B. Vitamin B C. Vitamin D D. All of the above 10) Pulmozyme® is a: A. Corticosteroid B. Bronchodilator C. Osmotic agent D. Enzyme 11) The following statements regarding Burkholderia cepacia are all true except: A. Treated by ceftazidime and trimethoprim/sulfamethoxazole B. Transmitted from patient to patient C. Gram-positive organism D. Misidentified for Pseudomonas 12) The most appropriate treatment choice for CFRD is: A. Metformin B. Insulin C. Rosiglitazone D. Acarbose 13) Two parents that are both carriers for CF have a boy, what are the chances he may have CF? A. 100% B. 75% C. 50% D. 25% 14) According to the CF Foundation, what body mass index (BMI) percentile is considered "nutritional failure" in children? A. 75th percentile B. 50th percentile C. 10th percentile D. 90th percentile

15) 10-year-old CF patient weighs 80 pounds (36 kg). What is a reasonable pancreatic enzyme dosing regimen? A. 360,000 lipase units with each meal B. 200,000 lipase units with each meal C. Three Creon® 24,000 lipase unit capsules with each meal D. Two Zenpep® 5,000 lipase unit capsules with each meal Chapter 19: Venous Thromboembolism 1) XT is a 55-year-old male (Ht = 63" [160 cm], Wt = 80 kg) who presents to the ED and is diagnosed with a new unprovoked LLE DVT and PE. He has no significant PMH and he takes no other medications. All baseline labs are within normal limits. Which of the following is the best initial treatment regimen to discharge XT from the ED with? A. Enoxaparin 80 mg subcutaneously BID × 5 days + Edoxaban 60 mg PO daily B. Enoxaparin 80 mg subcutaneously BID × 5 days then Edoxaban 60 mg PO daily C. Enoxaparin 120 mg subcutaneously BID × 5 days + warfarin 5 mg PO daily D. Enoxaparin 120 mg subcutaneously daily × 5 days then warfarin 5 mg PO daily 2) Which of the following vitamin K dependent clotting factors has the shortest half-life? A. Factor X B. Factor IX C. Factor VII D. Factor II 3) A 70-year-old male patient with DVT and a baseline INR of 1.1 is started on warfarin 5 mg daily on day 1 and day 2 as well as enoxaparin 80 mg SC BID. He has no history of malignancy, malnutrition, heart failure, alcohol abuse, or liver dysfunction. His INR today (Day 3) is 1.5. Select the best warfarin dose for Day 3: A. 10 mg B. 5 mg C. 1 mg D. HOLD warfarin today 4) A patient is confused about what her INR result means. Which one of the following statements best describes what she needs to understand about her INR results? A. When the INR is below 2.0 she is at increased risk for bleeding. B. When the INR is between 2 and 3 she can continue the same dose of warfarin. C. When the INR is below 2.0 her dose of warfarin may need to be adjusted. D. When the INR is higher than 3.0 she is at increased risk for having another VTE. 5) NB is a 57-year-old 5'8" Caucasian woman weighing 60 kg admitted to the hospital for elective total knee replacement surgery. Her past medical history includes anxiety and hypertension. Her other prescription medications include lisinopril 20 mg daily and paroxetine 20 mg daily. Preoperative labs include: WBC 8.9 × 103/mm3 (8.9 × 109/L) , Hct 47.0 (0.47), Hgb 15.7 g/dL (157 g/L; 9.74 mmol/L), Platelets 220,000/mm3(220 × 109/L), Na 134 mEq/L (mmol/L), K 4.9 mEq/L (mmol/L), Cl 101 mEq/L (mmol/L), CO2 22 mEq/L (mmol/L), BUN 28 mg/dL (10.0 mmol/L), SCr 1.1 mg/dL (97 µmol/L). Which of the following is the best recommendation for pharmacological VTE prophylaxis to reduce NB's VTE risk following her knee replacement surgery? A. Enoxaparin 60 mg subcutaneously BID B. Fondaparinux 7.5 mg subcutaneously daily

C. Rivaroxaban 10 mg PO daily D. Apixaban 5 mg PO BID 6) Which of the following is the most appropriate duration of apixaban therapy for a patient who experienced a first DVT while taking estrogen-containing contraceptives? A. 6 weeks B. 3 months C. 6 months D. Indefinite 7) Which of the following is the most appropriate drug to administer for bleeding due to an accidental warfarin overdose? A. Vitamin K B. Protamine C. Idarucizumab D. Andexanet alfa E. Aripazine 8) SJ is a 76-year-old African-American male (Height = 69 inches [175 cm], weight = 105 kg) who is diagnosed with PE. His current medications include: Lisinopril 40 mg PO daily, hydrochlorothiazide 25 mg PO daily, Atorvastatin 40 mg PO daily. Labs include WBC 10.1 × 103/mm3 (10.1 × 109/L), Hct 46.4% (0.464) , Hgb 16.0 g/dL (160 g/L; 9.93 mmol/L), Platelets 325,000/mm3 (325 × 109/L), Na 134 mEq/L (mmol/L), K 4.1 mEq/L (mmol/L), Cl 102 mEq/L (mmol/L), CO2 21 mEq/L (mmol/L), BUN 26 mg/dL (9.3 mmol/L), serum Cr 2.3 mg/dL (203 µmol/L). What is the best recommendation for initial parenteral anticoagulant treatment for SJ's acute PE? A. Fondaparinux 7.5 mg subcutaneously daily B. Dalteparin 5,000 units subcutaneously daily C. Enoxaparin 100 mg subcutaneously twice daily D. UFH 10,000 unit bolus with 2,000 units/h continuous infusion 1) A patient's INR is 1.6 following a significant dietary change. Which of the following is the most likely explanation for today's lab result? A. Eating more green leafy vegetables than usual B. Eating fewer green leafy vegetables than usual C. Drinking grapefruit juice D. Drinking cranberry juice 2) Which of the following is the most appropriate anticoagulation regimen for treatment of VTE during pregnancy? A. Warfarin B. Dabigatran C. Enoxaparin D. Unfractionated heparin 3) A 66-year-old male presents with unilateral leg pain, redness, and swelling. His past medical history is significant for hypertension only. D-dimer is elevated. Which of the following is the most appropriate next step? A. Unfractionated heparin B. Apixaban C. Compression ultrasound D. Computed tomography scanning

4) In which of the following clinical scenarios would anti-Xa monitoring be recommended during LMWH treatment? A. Long-term cancer-associated DVT treatment with CrCL less than 30mL/min (<0.5 mL/s) B. Initial DVT treatment for a patient weighing 48 kg C. Initial PE treatment in an 80-year-old female D. VTE prophylaxis after hip fracture surgery 5) Which of the following is not a risk factor for DVT in hospitalized patients? A. Cancer B. Hypertension C. Age > 70 years D. Estrogen therapy 6) Which of the following should be included in patient education for outpatient DVT treatment with enoxaparin and warfarin? A. Avoid vitamin K-rich foods B. The interpretation of an INR result C. Discontinue enoxaparin therapy in 5 days D. Inject enoxaparin with needle at a 45-degree angle to skin 7) Which of the following is the most appropriate prophylaxis strategy for a general surgery patient at high risk of VTE with ongoing bleeding? A. Aspirin B. Edoxaban C. Inferior vena cava filter D. Intermittent pneumatic compression devices

Chapter 20: Stroke 1. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA). ANS: C The patients symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patients symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA. 2. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c.

that Plavix will dissolve clots in the cerebral arteries.

d. that Plavix will reduce cerebral artery plaque formation. ANS: B Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. 3. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, I dont need the aspirin today. I dont have any aches or pains. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order. ANS: C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patients refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. DIF: Cognitive Level: Application REF: 1468-1469 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop). ANS: B Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. 5. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patients blood pressure (BP) is usually about 180/90 mm Hg. ANS: D Hypertension is the single most important modifiable risk factor and this patients hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic

everages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension. 6. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin). ANS: D The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patients care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. 7. A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan ANS: D Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan. 8. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway ANS: D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.

9. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patients blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache. ANS: A To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. 10. Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor). ANS: C Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN. 11. After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c.

A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) d. scheduled ANS: A PA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical. 12. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking.

c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases. ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths. 13. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score. ANS: A The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed. 14. A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient. ANS: C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.

Chapter 21: Dyslipidemia 1) Which one of the following is the best choice for the treatment of Type I (Fredricson, Levy, Lees classification) Hyperlipidemia? A. Rosuvastatin B. Colestipol C. Ezetimibe D. Lovastatin E. Dietary fat restriction 2) In the recently reported ARBITER 6-HALTS study, the risk of major cardiovascular events was reported to be 5% in the ezetimibe + state group compared to 1% in the niacin + statin group. What is the NNT for the niacin + statin group?

A. B. 25 C. 37 D. 53 E. 81 3) Based on the ACC/AHA Blood Cholesterol report which level of 10-year risk merits highintensity statin therapy? A. 1%-4% B. 5% C. ≥7.5% D. >10% E. C and D 4) What is the correct dose of alirocumab? A. 50 mg SQ weekly B. 75 mg SQ every 2 weeks C. 150 mg SQ weekly D. B and C 5) All of the following are consider to CHD risk equivalents EXCEPT (slide 51): A. Asthma B. Diabetes C. Symptomatic carotid artery disease D. Peripheral arterial disease E. Abdominal aortic aneurysm 6) All of the following are consider to traditional risk factors EXCEPT (slide 56): A. Cigarette smoking B. Hypertension C. HDL cholesterol >60 mg/dL D. Males ≥45 years old E. Family history of premature CHD 7) A patient presents with a total cholesterol of 245 mg/dL, an HDL of 35 mg/dL and triglycerides of 350 mg/dL. What is the non-HDL concentration? A. 105 mg/dL B. 140 mg/dL C. 210 mg/dL D. 240 mg/dL E. 545 mg/dL 8) Which one of the following has the mechanism of action of upregulating LDL receptors and interfering with the synthesis of cholesterol? A. Niacin B. Fibrates C. Bile acid binding resins D. Statins E. Cholesterol absorption inhibition 9) Which category of drug therapy can raise HDL the most? A. Niacin B. Fibrates

C. Bile acid binding resins D. Statins E. Cholesterol absorption inhibition 10) Which one of the following states is the most potent LDL lowering drug? A. Lovastatin B. Pravastatin C. Rosuvastatin D. Simvastatin E. Fluvastatin 11) What is the most common adverse effect of niacin? A. Constipation B. Flatulence C. Cholelithiasis D. Pulmonary edema E. Flushing 12) Which one of the following is a risk factor for the development of myositis with gemfibrozil? A. Gender B. Combination therapy with a statin C. Routine exercise D. High ambient temperature E. Time of administration Chapter 22: Peripheral Arterial Disease 1) Although it’s an invasive test, ankle-brachial index (ABI) is used to diagnose PAD. A. True

B. False 2) Which conditions can mimic PAD and should be ruled out when making a differential diagnosis? A. Deep venous thrombosis

B. Peripheral neuropathy

C. Arthritis

D. A and B only

E. A, B, and C 3) The Heart Outcomes Prevention Evaluation (HOPE) study demonstrated which class of antihypertensives reduced blood pressure and other cardiovascular events in patients with PAD? A. β-Blockers

B. ACE inhibitors

C. Calcium channel blockers

D. Thiazide diuretics 4) For patients with PAD, ATP III recommends non–high-density lipoprotein levels of: A. <150 mg/dL (<3.88 mmol/L)

B. <130 mg/dL (<3.36 mmol/L)

C. <100 mg/dL (<2.59 mmol/L)

D. <70 mg/dL (<1.81 mmol/L) 5) Due to the high prevalence of PAD among diabetic patients, the American Diabetes Association recommends ABI screening for: A. All Type II diabetics

B. All Type I and Type II diabetics

C. All diabetics >50 years of age

D. All diabetics with coexisting hypertension 6) Which of the following conditions is listed in the “black box” warning for cilostazol? A. PAD with coexisting congestive heart failure

B. PAD with coexisting atrial fibrillation

C. PAD with coexisting supraventricular tachycardia

D. All of the above 7) Which of the following recommendation(s) by the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy for patients with PAD is true? A. Ticlopidine is recommended over clopidogrel.

B. Clopidogrel is recommended over no antiplatelet therapy.

C. Pentoxifylline is recommended in patients with intermittent claudication.

D. All of the above are true. 8) Intermittent claudication is defined as: A. Discomfort, pain, cramping in an affected extremity during exercise that resolves within a few minutes by resting

B. Discomfort, pain, cramping in an affected extremity during rest that resolves within a few minutes of light to moderate exercise

C. Discomfort, pain, cramping in an affected extremity most often felt at night while the patient is lying in bed 9) Which of the following is associated with more prevalent PAD? A. Smoking

B. Hypercholesterolemia

C. Impaired renal function

D. A and B only

E. A, B, and C 10) In patients with PAD, the prevalence of death from cardiovascular disease is: A. 30%

B. 50%

C. 75%

D. 90% 11) Walking exercise programs for patients with PAD have been proven to delay the onset of claudication. A. True

B. False 12) The Antithrombotic Trialists’ Collaboration (ATC) concluded that which medication leads to a significant reduction in serious vascular events (12%) in “high-risk” patients, such as those with PAD? A. Aspirin

B. Clopidogrel

C. Ticlopidine

D. Pentoxifylline ANSWERS: 1.B 2.E

3.B 4.B 5.C 6.A 7.B 8.A 9.E 10.C 11.A 12.A Chapter 23: Use of Vasopressors and Inotropes in the Pharmacotherapy of Shock 1) Which of the following conditions can result in a lowering of blood pressure in critically ill patients? A. Decreased cardiac output B. Decreased pulmonary capillary wedge pressure C. Systemic vasodilation D. All of the above E. None of the above 2) The central venous pressure (CVP) catheter is a device that is used to effectively perform what function in critically ill patients? A. Obtain venous blood samples. B. Administer drugs directly into the central circulation C. Accurately determine blood volume D. A and B only E. All of the above 3) Which of the following statements about central venous oxygen saturation is correct? A. It indirectly measures oxygen extraction by tissues. B. It may be low in inadequately volume-resuscitated patients with septic shock. C. It measures adequacy of volume resuscitation more accurately than does blood pressure measurement. D. It should be targeted to a value in excess of 70%. E. All of the above 4) Which of the following parameters is a measurement of regional perfusion? A. Arterial blood lactate concentration B. Arterial gastric mucosal PCO2 gap C. Oxygen delivery D. Oxygen consumption E. Systemic vascular resistance 5) Stimulation of the beta adrenergic receptor by agonists results in a physiologic response mediated by which of the following? A. Inositoltrisphosphate B. Cyclic AMP C. Cyclic GMP D. Intramucosal pHi E. Nitric oxide

6) Which of the following drugs stimulates only α adrenergic receptors? A. Dobutamine B. Dopamine C. Phenylephrine D. Epinephrine E. Norepinephrine 7) Which of the following outcomes is a goal that should be achieved within THREE hours of presentation in a patient with septic shock? A. CVP of 8 to 12 mm Hg B. Fluid administration of 30 mL/kg C. ScvO2 greater than 70% D. Hematocrit greater than 30% E. All of the above 8) Which of the following explains the development of lactic acidosis by a catecholamine? A. Enhanced vasoconstriction in peripheral arteries B. Enhanced glycogenolysis C. Mobilization of lactate from peripheral tissues D. A and B only E. All of the above 9) Which of the following catecholamines is associated with a fall in intramucosal pHi and rise in blood lactate concentration during treatment? A. Dobutamine B. Dopamine C. Phenylephrine D. Epinephrine E. Norepinephrine 10) Which of the following catecholamines is preferred as the initial agent when treating hypotension in a septic shock patient? A. Dobutamine B. Dopamine C. Phenylephrine D. Epinephrine E. Norepinephrine 11) Which adverse drug effect is not seen with dobutamine? A. Tachycardia B. Bradycardia C. Hypotension D. Decreased cardiac output E. Decreased mesenteric perfusion 12) Which of the following statements is true regarding the use of corticosteroid therapy for the treatment of sepsis? A. It should be used in all patients with sepsis. B. It should be started within 48 hours of the diagnosis of severe sepsis. C. It should be used when hemodynamic goals are not achieved despite fluid resuscitation and vasopressor therapy. D. It should be used only when plasma markers of inflammation are elevated.

E. It should be used when serum cortisol concentration increases >9 mcg/dL after adrenocorticotropic hormone stimulation test. 13) Which of the following statements is true regarding the use of vasopressin in septic shock? A. Studies have shown that it reduces mortality when it is added to vasopressors. B. Studies have shown that it reduces organ dysfunction when it is the first-line agent for septic shock. C. Studies have shown that it increases blood pressure while reducing the dose of other vasopressors when it is added to vasopressors. D. All of the above. E. A and B. 14) A colleague asks you about studies comparing dopamine and norepinephrine for septic shock therapy. Which of the following is the most appropriate answer? A. Dopamine may be associated with better blood pressure control and less tachyarrhythmias. B. Norepinephrine may be associated with better blood pressure control and less tachyarrhythmias. C. Both agents are associated with good blood pressure control and rare rates of less tachyarrhythmias. D. Both agents are associated with poor blood pressure control and high rates of less tachyarrhythmias. 15) All of the following are similarities between phenylephrine and norepinephrine, except? A. Both agents show mixed effects on myocardial performance in sepsis. B. Both agents may be dosed in µg/kg/min. C. Both agents may cause tachycardia via β1 stimulation. D. Both agents may contribute to ischemic side effects. E. Both agents are not available as premixed ready-to-use solutions. 16) Which of the following receptors is most likely to cause immunomodulation when stimulated? A. β1 B. β2 C. α1 D. Dopamine E. V1 17) Extravasation of a vasopressor catecholamine can be treated with intradermal injections of which of the following agents? A. Phentolamine B. Phenylephrine C. Nitric oxide D. Vasopressin E. Dobutamine

Chapter 24: Hypovolemic Shock 1. The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patients arrival, the nurse will obtain a. 500 mL of 5% albumin.

b. c.

lactated Ringers solution. two 14-gauge IV catheters.

d. dopamine (Intropin) infusion. ANS: C A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringers solution should be used cautiously and will not be ordered until the patient has been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, crystalloids should be used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the initial therapy for hypovolemic shock. 2. Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Pulmonary artery wedge pressure (PAWP) is normal. d. Mean arterial pressure (MAP) is 65 mm Hg. ANS: B Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion. 3. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine? a. The patients central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted. ANS: A Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patients low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration. 4. A patient with hypovolemic shock is experiencing oliguria due to hemorrhage. Which should the nurse recognize as the most likely cause of the patients oliguria? a. End-stage renal failure b. Secretion of aldosterone c. Inadequate oral fluid intake d. Obstructed urinary catheter ANS: B Stimulation of the renin-angiotensin-aldosterone system from decreased cardiac output causes vasoconstriction and retention of sodium and water to decrease further fluid loss, resulting in

oliguria. A. There is no evidence to support that the patient is in end-stage renal failure. C. Since the patient is in hypovolemic shock, it is unlikely that oral fluids are being provided. D. There is not enough information to support that a urinary catheter is kinked in this patient. 5. The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patients urine output drops to 15 mL for one hour of monitoring? a. Document the finding. b. Flush the urinary catheter c. Clamp the catheter for 30 minutes. d. Immediately report the drop in urine output. ANS: D The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Cells in the kidneys die when there is a lack of oxygen and nutrients. If there is widespread damage to the kidneys, complete renal failure is likely. A. The nurse needs to do more than document the findings. B. The urinary catheter does not need to be flushed. C. Clamping the catheter for 30 minutes is not going to improve the patients urine output. 6. A patient is admitted for care because of heat stroke. Why should the nurse include interventions to prevent the onset of shock? a. The heat causes excessive dilation of veins and arteries. b. Inability to tolerate oral fluids could lead to more water lost. c. Parasympathetic stimulation causes blood to pool in the extremities. d. Excessive water lost through sweating can lead to hypovolemic shock. ANS: D Heat exhaustion or heatstroke can also cause hypovolemic shock by excessive water loss through sweating. A. Excessive dilation of veins and arteries can lead to distributive shock. B. There is no evidence to support that the patient is unable to tolerate oral fluids. C. Parasympathetic stimulation causing blood to pool in the extremities is associated with neurogenic shock. 7. A patient who had surgery 3 days ago has a temperature of 98F (36.6C), blood pressure 82/72 mm Hg, pulse 120 beats/minute, and respirations 30/minute. Which type of shock should the nurse suspect is occurring in this patient? a. Septic b. Neurogenic c. Cardiogenic d. Hypovolemic ANS: A During the early, or warm, phase of septic shock, blood pressure, urine output, and neck vein size may be normal, but the skin is warm and flushed. Fever is present in the majority of patients, although some may have a subnormal temperature. D. Septic shock progresses to a second phase with signs and symptoms similar to hypovolemic shock: hypotension; oliguria; tachycardia; tachypnea; flat jugular and peripheral veins; and cold, clammy skin. Body temperature may be normal or subnormal. B. C. There is no reason to suspect that this patient is experiencing neurogenic or cardiogenic shock.

8. Patients are being treated in the intensive care unit for anaphylactic, septic, and neurogenic shock. For which type of shock should the nurse plan to provide care? a. Obstructive b. Distributive c. Cardiogenic d. Hypovolemic ANS: B Subcategories of distributive shock include anaphylactic, septic, and neurogenic shock. A. Obstructive shock is caused by a blockage of blood flow in the cardiovascular circuit outside the heart. C. Cardiogenic shock is caused by heart pump failure. D. Hypovolemic shock is caused by a decrease in the circulating blood volume. 9. The nurse determines that a patient with hypovolemic shock is improving. What did the nurse observe to come to this conclusion? (Select all that apply.) a. Heart rate increasing b. Respiratory rate increasing c. Present of peripheral pulses d. Systolic blood pressure increasing e. Urine output 20 mL over the last hour ANS: C, D Perfusion is first evident in peripheral pulses. An increase in blood pressure occurs because of an improvement in circulating blood volume. A. B. Increasing heart and respiratory rates indicate that the patient is not improving. E. A urine output of less than 30 mL per hour indicates insufficient perfusion of the kidneys caused by the shock.

Chapter 25: Introduction to Pulmonary Function Testing 1. What part of a normal breath (tidal volume) reaches the alveoli? A) One-quarter B) One-half C) Two-thirds D) One hundred percent

2. All the lung volumes can be measured by spirometry except A) tidal volumes. B) inspiratory reserve volume. C) expiratory reserve volume. D) residual volume.

3. A pulmonary function test is labeled abnormal when the results A) decline over time. B) fall outside the 95 percent confidence level for age, height, and sex.

C) D)

fall outside the 95 percent confidence level for age, weight, and height. fall outside the 99th percentile for age and sex.

4. The sum of the four primary lung volumes (tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual volume) equals A) the functional residual capacity (FRC). B) the vital capacity (VC). C) the total lung capacity (TLC). D) the maximum ventilatory volume (MVV).

5. The definition of obstruction of PFTs is best defined by A) an FEV1/FVC that is less than 70 to 75 percent of predicted. B) an FVC that is less than 75 percent of predicted. C) a maximal midexpiratory flow that is les than 70 to 75 percent of predicted. D) a total lung capacity that is les than 70 to 75 percent of predicted.

6. One can determine the total lung capacity (TLC) by A) helium dilution. B) nitrogen washout. C) body plethysmography. D) all of the above.

7.Restrictive lung disease is best defined by which of the following parameters? A) A reduced diffusion capacity B) A reduced forced expiratory flow for 1 second (FEV1) C) A reduced forced vital capacity (FVC) D) A reduced total lung capacity (TLC)

8. Normal pulmonary function tests with a reduced DLCO (diffusion capacity) would be most suggestive of A) a pulmonary emboli. B) asthma. C) COPD. D) interstitial lung disease.

9. The best test to separate asthma from COPD is A) the 6-minute walk. B) FEV1/FVC. C) DLCO. D) bronchodilator challenge.

10. The most suggestive pulmonary function for neuromuscular disease is A) a reduction in the total lung capacity (TLC). B) a flat flow-volume loop. C) a reduced force vital capacity (FVC). D) a reduced maximum inspiratory pressure (MIP).

11. Pulse oximetry is least predictive of true oxygen saturation when A) the PCO2 is elevated. B) carbon monoxide is elevated. C) the patient is febrile. D) the patient is exercising.

12. The presence of hypoxemia with a normal A-a gradient usually implies A) an acid-base disturbance. B) the presence of a shunt. C) hypoventilation. D) severe ventilation-to-perfusion (V/Q) imbalance.

13. Exercise testing can be used to assess all the following except A) dyspnea on exertion. B) evaluation of disability. C) unstable angina. D) effects of a rehabilitation program. E) exercise-induced bronchospasm.

14. A ventilatory limitation to exercise may be characterized by all the following except A) a reduced VO2max. B) gas exchange abnormalities. C) normal ventilatory reserve. D) normal O2 pulse.

15. Cardiac limitation to exercise is best characterized by A) normal VO2max. B) reduced O2 pulse. C) desaturation. D) increased anaerobic threshold. Answers 1.C

2.C 3.B 4.D 5.C 6.A 7.C 8.D 9.C 10.A 11.C 12.B 13.B 14.C 15.C Chapter 26: Asthma 1) The aerosol particle size most likely to deposit in the lower airways is: A. 10-20 μm B. 5-10 μm C. 1-5 μm D. 0.1-0.5 μm 2) Advantages of spacer devices include all of the following except: A. Enhanced lung delivery B. Decreased oropharyngeal deposition of drug C. Increased percent of drug particles achieving respirable droplet size D. Standardization of spacers to make them substitutable 3) An objective assessment used to monitor response to therapy in an acute severe asthma exacerbation include which one of the following: A. Functional exhaled nitric oxide (FeNO) B. Impulse Oscillometry C. Serum cortisol levels D. Pulse oximetry 4) Pharmacologic responses to β2-agonists include all of the following except: A. Increased neuromuscular transmission B. Smooth muscle relaxation C. Stimulate uterine contractions D. Vasodilation of the vasculature 5) A predominant risk factor for children to have continued asthma is: A. Atopy B. Birth weight in the 95% percentile C. Early exposure to cats or dogs D. Family history of medication allergy E. Rural environment 6) Which one of the following statements is CORRECT about the major characteristics of marketed dry powder inhalers (DPIs) used to deliver drugs to the lungs? A. Drug delivery is breath-actuated, requiring minimal hand-lung coordination by the patient.

B. DPI's have been standardized to require the same inspiratory flow rate. C. Only inhaled corticosteroids are available as a DPI. D. Slow inhalation from the device is needed for optimal lung deposition of the powder 7) Which one of the following statements is CORRECT concerning the use of leukotriene modifiers in asthma management? A. Evidence to support causality of suicidal thoughts and suicide with use of LTRA's is lacking B. LTRAs are more effective than LABAs as add-on to ICS therapy moderate persistent asthma C. Montelukast has increased efficacy over short-acting inhaled β2-agonists for the treatment of EIB D. Use of leukotriene modifiers is limited due to the potential for renal toxicity. 8) Which one of the following statements is CORRECT concerning omalizumab in the treatment of asthma? A. It is a recombinant anti-IgM antibody B. It is administered subQ with a slow absorption rate C. It is approved for patients greater than age 5 with moderate persistent asthma D. It is the only biologic currently approved to treat asthma 9) A 37 year old female presents with the following: FEV1 76% predicted, use of albuterol (for rescue) 5-6 days/week, waking with asthma symptoms 4-5 times/month, and increased asthma symptoms during her daily walk to work and workouts. Her asthma severity would be classified as: A. Intermittent B. Mild C. Moderate D. Persistent 10) Preferred therapy options for your 37 year old patient would be: A. SABA prn plus short course OCS B. SABA prn plus low dose ICS/LABA C. SABA prn plus medium dose ICS/LAMA D. SABA prn plus high dose ICS E. Referral to specialist 11) Which one of the following is NOT a mediator associated with airway inflammation? A. Histamine B. Goblet cells C. Leukotrienes D. Prostaglandins 12) Which of the following statements is CORRECT concerning ICS in the treatment of asthma? A. Available ICS are equipotent based on a mcg to mcg comparison B. Advantages are high topical potency and low systemic activity C. Response to therapy is prompt, with resolution of symptoms within 3-4 days D. Therapeutic index is irrelevant to the delivery device 13) Regarding LABA's, all of the following are correct except: A. Are more β2 selective and lipid soluble than albuterol B. Combination ICS/LABA treatment provides greater asthma control than increasing the dose of ICS alone C. Tolerance may occur with chronic therapy

D. Onset of action is slower than albuterol, approximately 30 minutes 14) Which of the following medications is NOT associated with triggering of asthma symptoms? A. Acetaminophen B. Naproxen C. Propranolol D. Penicillin 15) Which one of the following is NOT an example of a dry powder inhaler? A. Diskus B. Ellipta C. Flexhaler D. Respimat E. Twisthaler

Chapter 27: Chronic Obstructive Pulmonary Disease 1. A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective? a. Change the oxygen flow rate to the highest prescribed rate. b. Reinforce the ongoing use of pursed lip breathing techniques. c. Educate the patient to use the Flutter airway clearance device. d. Teach the patient about consistent use of inhaled corticosteroids. ANS: C Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patients problem of thick mucous secretions. DIF: Cognitive Level: Application REF: 623 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. After the nurse has completed diet teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a body mass index (BMI) of 20, which patient statement indicates that the teaching has been effective? a. I will drink lots of fluids with my meals. b. I will have ice cream as a snack every day. c. I will exercise for 15 minutes before meals. d. I will decrease my intake of meat or poultry. ANS: B High-calorie foods like ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals to prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD. DIF: Cognitive Level: Application REF: 625 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

3. When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include? a. Stop exercising if you start to feel short of breath. b. Use the bronchodilator before you start to exercise. c. Breathe in and out through the mouth while you exercise. d. Upper body exercise should be avoided to prevent dyspnea. ANS: B Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using a pursed lip technique). Upperbody exercise can improve the mechanics of breathing in patients with COPD. 4. The nurse coaches a patient with chronic obstructive pulmonary disease to make one long huff when performing huff coughing. What should the nurse explain as the purpose of the long huff when using this approach to clear the airway? a. Increases oxygenation b. Removes excess carbon dioxide c. Ensures thorough lung expansion d. Helps to open and clear smaller airways ANS: D A short huff helps clear larger airways, while a longer huff held out for several seconds helps open and clear smaller airways. A. B. C. A shorter huff is not used to increase oxygenation, remove excess carbon dioxide, or ensure thorough lung expansion. 5. The patient with long-term emphysema is admitted with a secondary diagnosis of cor

pulmonale. What should the nurse anticipate? The patient will present with edema of the lower extremities and extended neck veins due a. to hypertension of the pulmonary circulation. The patient will present with a dry hacking cough and chest pain due to constriction of the b. pulmonary vein. The patient will present with hypertension and a headache related to pulmonary c. hypertension. d. The patient will present with unlabored respiration and cyanosis around the mouth. ANS: A COPD can lead to cor pulmonale, an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. Cor pulmonale results in the presence of edema in the lower extremities, as well as in the sacral and perineal area, distended neck veins, and enlargement of the liver with ascites. 6. A nurse is providing home care for a patient with chronic obstructive pulmonary disease COPD). Which order should the nurse question? a. Low-sodium diet b. Increase activity as tolerated

c. Oxygen 4 L/min per nasal cannula d. Tiotropium (Spiriva) inhalation once daily ANS: C Oxygen is generally ordered at a flow rate of 1 to 2 L/min for patients with chronic lung disease. Higher flow rates may suppress the hypoxic drive in patients who are chronic CO2 retainers. B. D. Tiotropium and increasing activity as tolerated are common orders in COPD. A. A lowsodium diet is not contraindicated.

7. A patient with chronic obstructive pulmonary disease is prescribed methylprednisolone (SoluMedrol). For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem? a. Dry secretions b. Treat infection c. Improve the oxygen-carrying capacity of hemoglobin d. Reduce airway inflammation ANS: C Corticosteroids are potent anti-inflammatory agents. A. B. They do not dry secretions, and they may cause infection to worsen. C. They do not directly affect oxygenation. 8. The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease. Which medication can help reduce acute dyspnea associated with this disease? a. PO cortisone b. IV morphine c. IV propranolol (Inderal) d. IM meperidine (Demerol) ANS: B IV morphine helps acute dyspnea and anxiety in patients with end-stage disease. A. Cortisone may reduce inflammation, but the oral route is too slow for acute dyspnea. D. Meperidine has not been shown to reduce dyspnea. C. Propranolol is a beta blocker and may aggravate bronchoconstriction.

Chapter 28: Pulmonary Arterial Hypertension 1.A 57-year-old female with systemic sclerosis presents with progressive breathlessness. Her spirometry is well preserved but the diffusion capacity of the lungs for carbon monoxide (DLCO) is 45% of predicted. There is no fibrosis or thromboembolic disease on computed tomography (CT) scanning of her lungs. Right heart catheterization reveals a mean pulmonary arterial pressure of 42 mm Hg (normal values <25 mm Hg) and a pulmonary arterial wedge pressure of 12 mm Hg (normal values ≤15 mm Hg) together with a reduced cardiac output. The likely form of pulmonary hypertension is: a. Pulmonary arterial hypertension (PAH) (group 1). b.Pulmonary hypertension associated with left heart disease (group 2). c.Pulmonary hypertension associated with lung disease (group 3). d.Chronic thromboembolic pulmonary hypertension (group 4).

e.Pulmonary hypertension associated with multifactorial mechanisms (group 5). ANS. D 2. A 34-year-old female presents with a new diagnosis of severe idiopathic pulmonary arterial hypertension (PAH). There is no response to inhaled nitric oxide at right heart catheterization. She is severely limited (WHO functional class IV). Use of the following is the most appropriate initial method of commencing pulmonary vasodilation: (a). Sildenafil. (b). Ambrisentan. (c). High-dose calcium channel blocker. d). Intravenous prostanoid. (e). Riociguat. ANS. A. 3. A 42-year-old with idiopathic pulmonary arterial hypertension (PAH) who is normally treated with sildenafil and who is anticoagulated with warfarin is admitted with a 24-h history of marked deterioration in exercise capacity. His blood pressure is 95/60 mm Hg, heart rate 130 beats min−1 and saturation 95% on room air. Chest X-ray shows clear lung fields and his C-reactive protein is 3 mg litre−1 (normal range is <8 mg litre−1) ECG demonstrates new-onset atrial flutter with 2:1 atrioventricular block. The most appropriate management is: a. Addition of an endothelin receptor antagonist. b. Commencement of intravenous iloprost. c. Commencement of intravenous dobutamine. d. DC cardioversion. e. Increase in sildenafil dose. ANS.C 4. A 63-year-old female with pulmonary arterial hypertension (PAH) associated with systemic sclerosis is admitted with increased breathlessness. She is currently treated with sildenafil and ambrisentan. Her blood pressure is 110/65 mm Hg, heart rate 95 beats min−1 and saturation 94% on room air. Her ECG shows sinus rhythm and a chest X-ray shows a new small right-sided pleural effusion. Her C-reactive protein is 4 mg litre−1 (normal range is <8 mg litre−1) and her creatinine is 115 μmol litre−1 (normal range is 49–90 μmol litre−1). She has a raised jugular venous pressure and pitting oedema to her thigh. The most appropriate initial treatment is: (a). Further reduction of right ventricular afterload with the addition of intravenous prostanoid. (b). Improvement in right ventricular contractility with the addition of intravenous dobutamine. (c). Improvement in systemic perfusion pressures with the addition of intravenous norepinephrine. (d). Optimization of right ventricular preload with the addition of intravenous loop diuretic. (e). Optimization of right ventricular preload with a fluid challenge Critical care management of pulmonary hypertension Ans. E.

Chapter 29: Cystic Fibrosis

1. Which action will be included in the plan of care for a 23-year-old with cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours. ANS: D Routine scheduling of airway clearance techniques is an essential intervention for patients with CF. A sweat chloride test is used to diagnose CF, but it does not provide any information about the effectiveness of therapy. There is no indication that the patient is terminally ill. Patients with CF lose excessive sodium in their sweat and require high amounts of dietary sodium. 25. A patient who is hospitalized with cystic fibrosis (CF) coughs up large quantities of thick green mucus. The nurse will plan to teach the patient about a. antibiotic resistance. b. inhaled bronchodilators. c. oral corticosteroid therapy. d. aerosolized tobramycin (TOBI). ANS: D The color of the mucus and the patients history of CF suggest Pseudomonas infection; TOBI is the standard of care for treatment of Pseudomonas in patients with CF. Oral corticosteroids and inhaled bronchodilators will not be effective in treating the respiratory infection; the effectiveness of bronchodilators has not been established for CF. Pseudomonas infections are usually responsive (not resistant) to TOBI. 2. A 20-year-old patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which initial response by the nurse is best? a. Are you aware of the normal lifespan for patients with CF? b. Do you need any information to help you with the decision? c. You will need to have genetic counseling before making a decision. d. Many women with CF do not have difficulty in conceiving children. ANS: B The nurses initial response should be to assess the patients knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patients comments. The other responses are accurate, but the nurse should first assess the patients understanding about the issues surrounding pregnancy. 3. A patient with cystic fibrosis (CF) has blood glucose levels that are consistently 200 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Educate the patient about administration of insulin. c.

Give oral hypoglycemic medications before meals.

d. Evaluate the patients home use of pancreatic enzymes. ANS: B The glucose levels indicate that the patient has developed CF-related diabetes; insulin therapy will be required. Since the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. Patients with CF need a high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of hyperglycemia in a patient with CF.

Chapter 30: Drug-Induced Pulmonary Diseases 1) What role do leukotriene modifiers play in the treatment of aspirin-sensitive asthma? A. They block aspirin-induced reaction. B. They make the "desensitization to aspirin" process more successful. C. They shift the dose response curve of aspirin to the right. D. The 5-lipooxygennase inhibitors are more effective. 2) Drug-induced apnea may occur in any of the following situation except: A. Slow IV administration of diazepam and phenobarbital to stop seizures in emergency departments. B. Rapid administration of any of the benzodiazepines. C. Critically ill patients receiving neuromuscular blockers for more than 2 days. D. Local spinal anesthesia. 3) All the following drugs may induce pulmonary edema except: A. Meperidine B. Ethchlorovynol C. Terbutaline D. Losartan 4) The preferred treatment option for angiotensin-converting enzyme (ACE)-inhibitor induced cough is: A. Withdrawal of the ACE inhibitor. B. Cromolyn sodium since it is the most studied agent with minimal toxicity. C. Switch to another ACE inhibitor. D. Theophylline. 5) Which one of the statements is false regarding aspirin-sensitive asthma? A. Aspirin sensitivity occurs in less than 20% of asthmatics. B. All aspirin-sensitive asthmatics fit the classic "aspirin-triad" picture. C. The frequency increases up to 23% in patients with nasal polyps. D. The frequency of aspirin-induced bronchospasm increases with age. 6) Aspirin-sensitive asthmatics are more likely to have an adverse reaction to which one of the following? A. Yellow azo dye tartrazine B. Sodium benzoate C. Acetaminophen D. b and c 7) What is the most common drug-induced respiratory problem? A. Pulmonary edema B. Apnea C. Pulmonary fibrosis

D. Bronchospasm 8) Which one of the following statements regarding the risk factors for ACE inhibitor-induced cough is false? A. Cough is more common in women than men. B. Patients with hyperreactive airways appear to be at greater risk. C. African-American and Chinese have a higher incidence of cough. D. Cough occurs with all ACE inhibitors. 9) Which one of the following groups of drugs is more likely to cause pulmonary edema? A. Bleomycin, cyclophosphamide B. Fenfluramine, pindolol C. Methysergid, methotrexate D. Heroin, corticosteroids 10) Which one of the following statements is true regarding ACE inhibitor-induced cough? A. The cough is dry, nonproductive and persistent. B. It can happen up to one year after initiation of therapy. C. It recurs with rechallenge. D. The chest X-ray and pulmonary function tests are normal. E. All of the above. 11) What is the most sensitive test for chronic fibrosis? A. Diffusing capacity of carbon monoxide B. Serial pulmonary function test C. Chest radiograph D. Gallium scan 12) Which one of the following statements is true regarding carmustin lung toxicity? A. Routine monitoring can prevent lung toxicity. B. Lung toxicity may be delayed up to 10 years after administration. C. Corticosteroids are effective in reducing the damage. D. The risk factor for pulmonary fibrosis is the cumulative dose of carmustin. 13) Regarding amiodarone lung toxicity, all of the following are true except: A. Monitoring patients receiving more than 400 mg daily every 4 to 6 months may be useful in detecting early disease. B. Patients usually improve on discontinuation of the drug. C. Routine spirometry appears to be predictive for identifying patients at risk. D. Corticosteroids is effective and drug of choice for amiodarone-induced lung toxicity 14) What is the most common manifestation for methotrexate induced lung toxicity? A. Reduction in the diffusing capacity of carbon monoxide. B. Reduction in lung volume. C. Chills, fever, and malaise. D. All of the above. 15) Which one of the following drugs may cause Loeffler syndrome? A. Sulfonamide B. Oxygen C. Bleomycin D. Methadone 16) All of the following are predisposing factors for the development of cytotoxic drug-induced pulmonary fibrosis except:

A. Concurrent radiotherapy B. High doses C. Cumulative doses D. Oxygen therapy Chapter 31: Evaluation of the Gastrointestinal Tract 1) A patient presenting with water diarrhea and a history of antibiotics 2 months ago should have their stool checked for: A. Helicobacter pylori B. Clostridium difficile toxin C. Enterobacter cloacae D. Escherichia coli toxin 2) The preferred imaging method to detect an intra-abdominal malignancy is: A. Small bowel enteroclysis B. Computed tomography C. Plain radiography films D. Barium swallow with radiography 3) In a patient presenting with signs and symptoms of acute liver failure, which of the following agents has been associated with liver damage? A. Phenytoin B. Ciprofloxacin C. Atractylis gummifera D. All of the above 4) Bacteria associated with infectious diarrhea include: A. Streptococcus pyogenes B. E coli C. Klebsiella oxytoca D. H pylori 5) Serum sodium or potassium may indicative of which of the following GI tract disorders? A. Hepatic dysfunction. B. Diarrheal illnesses. C. Gastroesophageal reflux disease (GERD). D. a and c are correct. 6) Patients presenting with symptoms of upper GI symptoms need careful questioning to distinguish reflux disease from: A. Gastric ulcer B. C difficile associated disease C. Anemia D. Hiatal hernia 7) A 55-year-old woman comes to your clinic pharmacy with complaints of dysphagia and a burning sensation in her throat. Which of the following is the correct course of action for this patient? A. Treat this patient with a proton pump inhibitor (PPI). B. Recommend prn antacid every 4 to 6 hours. C. Immediately refer this patient to her primary care provider. D. Continue monitoring symptoms and treat with a PPI if no improvement in 2 weeks.

8) In a patient to be examined with a wireless capsular pH monitoring system, data collection can be enhanced by: A. Giving a PPI 12 hours before the procedure. B. Have the patient avoid all food during the study. C. Examining patients not receiving acid-suppressive therapy. D. Give an oral benzodiazepine to relax the patient during the study. 9) Which test should be used in a patient with suspected reflux disease but not responding to a PPI? A. Ambulatory pH monitoring B. Capsule endoscopy C. Multichannel intraluminal impedance D. Endoscopic ultrasound 10) Pain associated with pancreatitis usually: A. Rapidly develops and resolves within a few minutes. B. Typically evolves over hours and last for days. C. Is episodical, with complaints occurring only in the morning. D. Often presents with gastritis and dyspepsia. 11) An often overlooked assessment of gastrointestinal disease is: A. Cardiopulmonary examination B. Medication history C. Surgical history D. Duration and severity of pain 12) A 69-year-old gentleman presents with bleeding from the upper gastrointestinal tract. Which of the following laboratory tests is often elevated in a patient with an upper gastrointestinal tractbleed? A. Troponin B. Blood urea nitrogen C. White blood cell count D. C-reactive 13) In a patient presenting with signs and symptoms consistent with hepatitis C, which of the following laboratory test is an indirect measurement of hepatic function? A. Erythrocyte sedimentation rate B. Prothrombin time and international normalized ratio (INR) C. Serum creatinine D. Atrial natriuretic peptide 14) Double contrast techniques enhance the visualization of the inside wall lining of the esophagus, stomach, and duodenum by: A. Gas expansion that allows for the barium sulfate to coat the inner surface of the organ. B. Chemiluminescence. C. Penetration of the fat-soluble contrast agent around the small intestine. D. Dilation of the lower colon by barium sulfate. 15) Ultrasonography is a useful diagnostic method to define: A. Bleeding gastric ulcer. B. Malt lymphoma in the small bowel and colon. C. Vascular abnormalities in the abdominal tract. D. The GI tract in a patient presenting with water diarrhea.

Chapter 32: Gastroesophageal Reflux Disease 1) Aggressive factors that can promote esophageal damage include all of the following except: A. Bicarbonate B. Gastric acid C. Pancreatic enzymes D. Bile acids E. Pepsin 2) An "alarm" symptom associated with GERD is: A. Chest pain B. Regurgitation C. Dysphagia D. Belching 3) The following is true regarding patients who present with symptom-based esophageal GERD syndromes: A. Symptoms are always less severe than those presenting with erosive esophagitis B. Symptoms are always easier to treat than those presenting with erosive esophagitis C. H2-receptor antagonists are the preferred treatment D. Symptoms can be as severe as those seen in patients with erosive esophagitis E. Maintenance therapy will not be needed 4) Elderly patients with GERD can have the following defect in one of their protective host defense mechanisms: A. Decreased saliva production B. Increased bile acid production C. Increased GI motility D. Increased gastric emptying E. Decreased acid production 5) All of the following are tissue injury-based GERD syndromes except: A. Strictures B. Barrett's esophagus C. Esophageal adenocarcinoma D. Chest pain E. Esophagitis 6) Endoscopic evaluation is indicated in which of the following patients? A. 47-year old white male with persistent typical GERD symptoms on omeprazole 20 mg BID B. 53-year old African-American female with a 10 year history of typical GERD symptoms well controlled on current proton pump inhibitor therapy C. 32-year old white female with persistent heartburn after two week trial of OTC omeprazole 20 mg daily D. 38-year old African-American male with recurrence of symptoms after trial off of esomeprazole 20 mg daily 7) In a patient with partial response to proton pump inhibitor therapy, which of the following are appropriate therapeutic strategies? A. Increase the once daily proton pump inhibitor to twice daily dosing B. Add famotidine 20 mg orally twice daily to the proton pump inhibitor regimen

C. Switch to an alternative proton pump inhibitor dosed once daily D. Add baclofen 10 mg orally three times daily to proton pump inhibitor regimen E. Both A and C 8) Which of the following would be the preferred treatment for symptom relief and healing of erosive esophagitis? A. Ranitidine 150 mg orally twice daily × 8 weeks B. Esomeprazole 20 mg orally once daily × 8 weeks C. Famotidine 20 mg orally twice daily × 4 weeks D. Pantoprazole 40 mg orally twice daily × 12 weeks E. Lansoprazole 30 mg orally once daily × 2 weeks 9) American College of Gastroenterology guidelines recommend which of the following lifestyle modifications? A. Weight loss in overweight patients B. Elimination of potential food triggers in all patients C. Elevating the head of the bed in patients with daytime symptoms D. Implementation of lifestyle modifications in all patients E. Avoidance of meals 30-60 minutes before bed in patients with nocturnal symptoms 10) The preferred initial treatment option for a 45-year old male presenting with a 3-month history of severe, continuous GERD symptoms is: A. Patient-directed therapy with OTC omeprazole B. Prescription strength H2-receptor antagonist C. Prescription strength proton pump inhibitor D. Antireflux surgery E. Endoscopic therapy 11) Proton pump inhibitors exert their action by: A. Stimulating histamine-2 receptors in the gastric parietal cells B. Inhibiting gastric H+/K+-adenosine triphosphate in gastric parietal cells C. Inhibiting Na+/K+-adenosine biphosphate in the gastric parietal cells D. Inhibiting epithelial growth factor in the stomach E. Increasing GI motility 12) Which of the following regimens would be most appropriate to prevent osteoporosis in a 25 year marathon runner on esomeprazole 20 mg daily for typical GERD symptoms? A. Calcium carbonate 1250 mg three times daily B. Calcium citrate 500 mg once daily C. Elemental calcium 1.5 grams plus vitamin D 400 units once daily D. Calcium chloride IV once monthly E. No calcium indicated since she does not have risk factors for osteoporosis 13) All of the following represent potential adverse effects of proton pump inhibitor maintenance therapy except: A. Vitamin B12 deficiency B. Hypomagnesemia C. Bone fractures D. Clostridium difficile infection E. Hyperkalemia 14) Which of the following patients would be most appropriate for a trial of patient-directed over-the-counter proton pump inhibitor therapy?

A. 32 year-old white female with 12 month history of dysphagia and weight loss B. 28 year-old male with asthma and chronic cough C. 67 year-old male one week history of heartburn and chest pain D. 52 year-old male with one week history of daily heartburn and belching E. 44 year-old female with 6 month history of daily heartburn and regurgitation 15) The following patient is the best candidate for maintenance therapy for GERD: A. 25-year old patient with intermittent GERD symptoms B. 3-month old baby with intermittent regurgitation of feeds C. 45-year old patient who relapses after an 8-week course of proton pump inhibitor therapy D. 45-year old patient with scleroderma E. C and D Chapter 33: Peptic Ulcer Disease and Related Disorders 1) Nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers differ from Helicobacter pylori-associated ulcers in that an NSAID-induced ulcer is: A. Most likely located in the stomach. B. Most likely associated with less severe upper gastrointestinal (GI) bleeding. C. Most likely associated with a greater degree of ulcer-related epigastric pain. D. Most likely associated with gastric acid hypersecretion. 2) Which of the following best describes the presentation of patients with H pylori-induced ulcers? A. Deep ulcer depth B. A duodenal ulcer C. Epigastric pain D. Damage to the gastric mucosa 3) A 30-year-old woman with a medical history of rheumatoid arthritis is H pylori-negative but undergoes endoscopy revealing a NSAID-induced ulcer. Assuming she has to continue the NSAID following a brief interruption, which is the preferred medication for ulcer healing and prevention of future ulcers? A. Misoprostol B. Omeprazole C. Ranitidine D. Sucralfate 4) A 43-year-old white woman with no known drug allergies presents to her primary care physician with a 2-week history of epigastric pain. She has no recent history of NSAID or antibiotic use. A serum antibody for H pylori is obtained and is positive. Which of the following would be considered the preferred initial therapy for H pylori? A. Proton pump inhibitor (PPI) + metronidazole + levofloxacin B. PPI + metronidazole + clarithromycin C. PPI + amoxicillin + clarithromycin D. PPI + metronidazole + bismuth + tetracycline 5) Which of the following is an endoscopic test used to diagnose H pylori? A. Urea breath test B. Mucosal biopsy C. Fecal antigen D. Antibody detection

6) A patient calls the pharmacy to complain about her tongue turning black after starting a new regimen for peptic ulcer disease (PUD). Which medication is causing the side effect? A. Amoxicillin B. Bismuth subsalicylate C. Clarithromycin D. Metronidazole 7) What is the recommended duration for initial treatment of H pylori using clarithromycinbased triple therapy? A. 5 days B. 7 days C. 14 days D. 21 days 8) A 65-year-old woman who takes high-dose nabumetone for rheumatoid arthritis and warfarin for atrial fibrillation. Which of the following regimen(s) is/are recommended for prevention of NSAID-induced ulcers? A. Add PPI to current regimen B. Change NSAID to celecoxib C. Change NSAID to ibuprofen + PPI D. A and B E. All of the above 9) Chronic PUD-related bleeding differs from stress-related mucosal bleeding (SRMB) in that chronic PUD-related bleeding: A. Occurs due to mucosal ischemia from decreased gastric blood flow. B. Usually occurs from a single vessel. C. Requires aggressive resuscitation as initial management. D. Results in a mortality rate of 50%. 10) A 48-year-old man was admitted to the medical ICU 48 hours ago with acute respiratory failure and subsequent intubation. He is currently receiving mechanical ventilation, has no renal insufficiency, and does not have a working NG tube. What is the best option for stress related mucosal bleeding prophylaxis for this patient? A. Calcium carbonate 500 mg by mouth as needed. B. Pantoprazole 40 mg IV daily. C. Sucralfate 1 g by mouth four times daily. D. Famotidine 20 mg IV twice daily. 11) Which of the following is true about Zollinger-Ellison syndrome (ZES)? A. ZES is the underlying cause of PUD in 0.1% to 1% of patients. B. A minority of patients develop large peptic ulcers in the distal duodenum. C. Gastrectomy is the only effective treatment of controlling gastric acid hypersecretion. D. Antisecretory therapy with PPIs is an ineffective means of medically managing ZES. 12) A medical student recently heard about a new "hybrid" treatment regimen for H pylori eradication and requests a literature search on this topic. Which of the following best represents a "hybrid" regimen? A. Omeprazole, clarithromycin, and amoxicillin taken together for 14 days. B. Ranitidine, bismuth, tetracycline, and metronidazole taken together for 10 days. C. Pantoprazole and amoxicillin taken together on days 1 to 5, followed by pantoprazole, clarithromycin, and metronidazole on days 6 to 10.

D. Rabeprazole and amoxicillin together for days 1 to 14, along with clarithromycin and metronidazole on days 7 to 14.

Chapter 34: Inflammatory Bowel Disease 1) A patient with ulcerative colitis with extensive disease has disease located: A. only in the rectal area B. in the rectum and sigmoid colon C. in the terminal ileum D. throughout the majority of the colon 2) In patients with Crohn's disease symptoms may be worsened by which of the following factors? A. Use of acetaminophen B. High fiber diet C. Tobacco use D. Exercise 3) Which enzyme's activity should be evaluated prior to initiation of therapy in patients receiving azathioprine? A. Xanthine oxidase B. CYP2D6 C. TPMT D. HLA DRPHLA-DR2 4) Which of the following is more characteristic of Ulcerative Colitis disease than Crohn's Disease? A. Confinement of disease to the colon and rectum B. Fistula formation C. Cobblestone pattern of inflammation D. Deep inflammation of the intestinal mucosa 5) Which adverse effect occurs at a higher rate in patients receiving the combination of infliximab and azathioprine? A. Pancreatitis B. Lymphoma C. Hepatitis D. Encephalopathy 6) Which of the following drugs is administered subcutaneously? A. Vedolizumab B. Adalimumab C. Natalizumab D. Infliximab 7) Probiotics may be effective in treating which complication of inflammatory bowel disease? A. Pouchitis B. Fistula formation C. Pseudopolyps D. Anal fissures 8) Which one of the following is a potential adverse effect of natalizumab? A. Primary sclerosing cholangitis

B. Progressive multifocal leukoencephalopathy C. Pulmonary fibrosis D. Heart failure 9) Antibody development to infliximab may result in: A. increased trough concentrations B. increase in duration of action C. reduction in therapeutic efficacy D. reduction in infusion related adverse events 10) Which drug is recommended for acute treatment of a hospitalized patient with fulminant active ulcerative colitis who has failed maximum doses of intravenous corticosteroids? A. Azathioprine B. Cyclosporine C. Budesonide D. Methotrexate 11) Which medication may induce infertility in male patients with inflammatory bowel disease? A. Mesalamine B. Sulfasalazine C. Certolizumab D. Golimumab 12) Which medication may induce the development of toxic megacolon in a patient with active inflammatory bowel disease? A. Budesonide B. VSL #3 C. Prednisone D. Loperamide 13) Which medication is most effective for treatment of fistulizing Crohn's disease? A. Sulfasalazine B. Ciprofloxacin C. Infliximab D. Methylprednisolone 14) Which supplement may be required in patients receiving long-term therapy with sulfasalazine? A. Zinc B. Folic acid C. Vitamin D D. Calcium 15) Which of the following is an extraintestinal manifestation of inflammatory bowel disease? A. Erythema nodosum B. Hypothyroidism C. Hypertension D. Glaucoma

Chapter 35: Nausea and Vomiting

1) A patient who is about to undergo their 3rd cycle of chemotherapy develops severe nausea and vomiting one night prior to her next round of chemotherapy. Which of the following is the BESTdescription of the type of nausea and vomiting this patient is experiencing? A. Acute CINV B. Delayed CINV C. Anticipatory nausea and vomiting D. Breakthrough nausea and vomiting 2) Which area of the brain is responsible for control of chemically induced vomiting? A. Vomiting Center B. Medulla C. Cerebral cortex D. Chemoreceptor trigger zone 3) GJ is an 82 YOM who just had a knee replacement and is experiencing postoperative nausea and vomiting (PONV). The provider would like to use a safe medication in this geriatric patient. Which of the following is the best recommendation for GJ? A. Promethazine B. Metoclopramide C. Scopolamine D. Ondansetron 4) A patient is undergoing chemotherapy and is having a difficult time taking her oral medications, especially her 5-HT3-RA therapy during her chemotherapy. Which of the following agents has alternative dosage forms other than just oral or IV? A. Granisetron B. Dolasetron C. Palonosetron D. Ondansetron 5) Which of the following would be the BEST option for prevention of acute chemotherapy induced nausea and vomiting in an individual who is receiving a moderately emetogenic chemotherapy regimen? A. Day 1: IV Palonosetron + Dexamethasone 20 mg PO B. Day 1: Aprepitant 125 mg PO + Dexamethasone 20 mg PO + Ondansetron 16 mg PO C. Day 1: Olanzapine 10 mg PO + Dolasetron 100 mg IV D. Day 1: Netupitant/Palonosetron-300 mg/0.5 mg PO + Prochlorperazine 10 mg IV 6) A patient is receiving a highly emetogenic chemotherapy regimen and received the following regimen for prevention of acute CINV: olanzapine + dexamethasone + ondansetron. Which of the following would be the BEST regimen to prevent the occurrence of delayed CINV in this patient? A. Dexamethasone B. Dexamethasone + Olanzapine C. Dexamethasone + Aprepitant D. Olanzapine 7) Which of the following is considered as a risk factor for developing postoperative nausea and vomiting? A. Use of local anesthetics B. Positive smoking history C. History of motion sickness

D. ge more than 70 years old 8) A 35 YOF patient is found to be at high risk for developing PONV. Which of the following would be the BEST therapy for prevention of PONV in this patient? A. Haloperidol + Droperidol B. Ondansetron + Dexamethasone C. Dexamethasone + Droperidol D. Rolapitant + Dolasetron 9) A patient is about to undergo Total body irradiation. Which of the following would be the BEST preventative antiemetic regimen for this patient? A. Ondansetron throughout radiation + Dexamethasone on fractions 1-5 B. Metoclopramide on fraction 1 + Prochlorperazine on fractions 1-5 C. Netupitant/palonosetron on fractions 1-5 D. Rolapitant on fraction 1 + Ondansetron on fractions 1-5 10) Which of the following medications would be considered first-line in the prevention of nausea and vomiting related to motion sickness? A. Cetirizine B. Ginger C. Scopolamine D. Ondansetron 11) An appropriate nonpharmacologic recommendation for a pregnant patient with nausea and vomiting includes: A. Eating large meals B. Eating two times a day C. Using ginger D. Smelling trigger odors 12) MJ is a 32 yo AAF who is pregnant with her first child and nonpharmacologic therapies are no longer helping her nausea and vomiting. Which of the following is the recommended first-line therapy for the treatment of nausea and vomiting in a pregnant woman? A. Meclizine B. Metoclopramide C. Ondansetron D. Doxylamine 13) Which of the following treatments is contraindicated in children less than 2 years old due to the risk of fatal respiratory depression? A. Metoclopramide B. Promethazine C. Probiotics D. Ondansetron 14) Which of the following is the most appropriate treatment to prevent CINV for a child who is receiving a chemotherapy regimen of high emetic risk? A. Ondansetron + dexamethasone B. Dexamethasone C. Ondansetron D. Prochlorperazine 15) Which of the following class of antiemetics have been found to be less effective in individuals who are "ultra-metabolizers" of CYP2D6?

A. 5-HT3-RAs B. NK1 antagonist C. Steroids D. Phenothiazines Chapter 36: Diarrhea, Constipation, and Irritable Bowel Syndrome 1) Bacterial organisms responsible for the most episodes of infectious diarrhea include all of the following except: A. E. coli B. Salmonella C. Campylobacter D. Pseudomonas E. Shigella 2) Absorption from the intestines occurs via the following process(es): A. Active transport B. Diffusion C. Solvent drag D. A and B E. All of the above 3) This type of diarrhea occurs when a stimulating substance either increases secretion or decreases absorption of water and electrolytes: A. Osmotic B. Exudative C. Secretory D. Transitory E. Hydrostatic 4) This type of diarrhea is distinguishable from other types because it ceases if the patient resorts to a fasting state: A. Osmotic B. Exudative C. Secretory D. Altered intestinal motility E. None of the above 5) Which statement about acute diarrhea is true? A. It is self-limiting, usually subsiding within 72 hours B. It is secondary to diseases such as diabetes C. It is treatable with bulk-forming laxatives D. It is a long-term condition that waxes and wanes throughout life E. It is always a sign of significant GI disease 6) Which of the following drugs or measures are not advocated for prevention of traveler's diarrhea? A. Special care with drinking water B. Bismuth subsalicylate (BSS) C. Special care with fresh vegetables D. Avoidance of meat products E. Antibiotic prophylaxis

7) If diarrhea occurs, therapeutic goals include all of the following except: A. Prevent excessive water and electrolyte loss B. Provide symptomatic relief C. Manage the diet D. Treat curable causes E. Stop the diarrhea at all costs 8) This antisecretory agent used to treat diarrhea may interact with anticoagulants, interfere with tetracycline absorption, and interfere with some GI radiographic studies: A. Polycarbophil B. Bismuth subsalicylate C. Loperamide D. Paregoric E. Diphenoxylate with atropine 9) Which of the following statements about constipation is true? A. Patients often describe constipation in measures that are easily quantified B. Daily bowel movements are required for health and well-being C. Decreased fiber intake can lead to constipation D. Normal healthy subjects pass at least six stools per week E. Constipation should be treated initially with castor oil 10) Factors found to correlate with constipation, particularly in the elderly, include all of the following except: A. Increased fluid intake B. Number of chronic comorbidities C. Greater frequency in females D. Total number of drugs taken E. Decreased mobility 11) Possible medical causes of constipation include: A. Diabetes B. Hypothyroidism C. Irritable bowel syndrome D. Psychiatric disorders E. All of the above 12) Drugs that may cause constipation include all of the following except: A. Antihistamines B. Magnesium antacids C. Opiates D. Aluminum antacids E. Iron preparations 13) The cornerstone of therapy in the treatment of constipation should include: A. Decrease in fluid intake B. Increase in dietary fiber C. Biofeedback therapy D. Stimulant laxatives E. Anticholinergic drugs 14) Which laxative is preferred first line for treatment of constipation in most patients? A. Lactulose

B. Cascara sagrada C. Bisacodyl D. Polyethylene glycol E. Glycerin 15) To prevent constipation, patients should be advised to include this amount of fiber in their daily diet: A. 10 to 15 g B. 20 to 25 g C. 50 to 55 g D. 100 to 110 g E. 150 to 160 g 16) For patients with opioid-induced constipation, which of the following medications can only be administered in the hospital for short-term use? A. Alvimopan B. Lubiprostone C. Methylnaltrexone D. Naloxegol E. Naloxone 17) Which of the following statements about irritable bowel syndrome (IBS) is/are true? A. It affects up to 80% of adults worldwide B. It is equally prevalent in both men and women C. It is characterized by abdominal pain, disturbed defecation, and bloating D. It is known to be of viral origin E. All of the above 18) The major pathophysiologic cause of irritable bowel syndrome is believed to be: A. Bipolar disorder B. Norwalk and rotavirus C. Laxative abuse D. Visceral hypersensitivity E. E. coli 19) Current procedures used in the diagnosis of irritable bowel syndrome include: A. Manning or Rome III criteria B. Sigmoidoscopy or colonoscopy C. Occult blood test and examination for parasites D. CBC and erythrocyte sedimentation rate E. All of the above 20) Which of the following treatment measures is recommended in constipation-predominant IBS? A. Saline cathartics B. Loperamide C. Mineral oil D. Dietary fiber E. Lactulose 21) In addition to avoidance of certain food products, which of the following treatments is recommended in diarrhea-predominant IBS? A. Saline cathartics

B. Loperamide C. Mineral oil D. Dietary fiber E. Lactulose 22) Non-GI manifestations of IBS include all of the following except: A. Increased passage of mucus B. Urinary symptoms C. Heart palpitations D. Dyspareunia E. Fatigue 23) Which of the following drug classes have been used for their analgesic effects in patients suffering from IBS-associated pain? A. Tricyclic compounds B. Serotonin reuptake inhibitors (SSRIs) C. Preprandial doses of anticholinergic drugs D. A and B E. All of the above Chapter 37: Portal Hypertension and Cirrhosis 1) Cirrhosis can be caused by all of the following except: A. Excessive alcohol intake B. Hepatitis B C. Methimazole-induced D. Nonalcoholic steatohepatitis 2) A patient has the following information: albumin 4.1 g/dL (41 g/L), serum bilirubin 3.3 mg/dL (56.4 µmol/L), prothrombin time of 5 seconds, no ascites, and no encephalopathy. In terms of Child-Pugh score, what is the patient's severity? A. Grade A B. Grade B C. Grade C D. Grade D 3) Which diuretic regimen is preferred among a 64-year-old woman with marked abdominal distention and bulging flanks with dullness? A. Amiloride B. Eplerenone C. Hydrochlorothiazide D. Spironolactone plus furosemide 4) A 42-year-old gentleman was intolerant to lactulose for hepatic encephalopathy. What is an appropriate alternative agent for this patient based on the information above? A. Ceftriaxone B. Neomycin C. Norfloxacin D. Rifamycin 5) Which beta-blocker would be the preferred medication for a patient requiring primary prophylaxis for gastroesophageal varices? A. Atenolol

B. Bisoprolol C. Metoprolol D. Nadolol 6) For gastroesophageal varices, a beta-blocker should be titrated to aim for a heart of beats per minutes. A. 55 to 60 B. 65 to 70 C. 70 to 75 D. 85 to 90 7) A patient develops type 1 hepatorenal syndrome and would require which non-pharmacologic option to cure this condition? A. Hemodialysis B. Paracentesis C. Sclerotherapy D. Transplantation 8) The patient was successfully treated for an episode of spontaneous bacterial peritonitis (SBP). Which option is the most appropriate antibiotic as indefinite therapy for secondary prophylaxis of SBP? A. Metronidazole B. Neomycin C. Norfloxacin D. Rifaximin 9) A 47-year-old woman with a history of alcoholic cirrhosis is admitted to the hospital and the team plans to initiate empiric therapy for spontaneous bacterial peritonitis. Which one of the following options is the best course of action at this time? A. Albumin B. Cefotaxime C. Vancomycin plus tobramycin D. Trimethoprim/sulfamethoxazole 10) A patient presents to the emergency department with moderate hepatic encephalopathy. In addition to supportive care, which medication would be first-line therapy to reduce nitrogenous load? A. Lactulose B. Metronidazole C. Neomycin D. Rifaximin 11) Which medication should be discontinued among a patient with cirrhosis and ascites? A. Furosemide B. Lisinopril C. Naproxen D. Spironolactone 12) A patient is admitted to the hospital, requiring management of acute variceal hemorrhage. The patient has a history of myocardial infarction (6 months ago). Which medication is the best intervention to decrease portal blood flow and pressure? A. Nitroglycerin B. Octreotide

C. Terlipressin D. Vasopressin 13) A 42-year-old gentleman presented to the emergency department with large bleeding varices, based on an esophagogastroduodenoscopy. Which goal would be appropriate based on the patient's condition? A. Achieve a systolic blood pressure of 80 mm Hg with fluid resuscitation B. Target a daily amount of protein intake (1.2 to 1.5 g/kg/day) C. Maintain a hemoglobin concentration above 8 g/dL (80 g/L; 4.97 mmol/L) D. Restrict sodium intake to 2,000 mg per day 14) A patient is prescribed and adherent with spironolactone plus furosemide for ascites. Laboratory monitoring should include all of the following except: A. Blood glucose B. Serum creatinine C. Potassium D. Sodium 15) Which of the following is a laboratory abnormality possibly indicative of cirrhosis? A. Hyperalbuminemia B. Low alkaline phosphatase C. Low prothrombin time D. Thrombocytopenia 16) Drugs metabolized through which of the following processes are most likely to be affected by cirrhosis? A. Conjugation B. Hydrolysis C. Oxidation D. Sulfation Chapter 38: Drug-Induced Liver Disease 1) Which of the following phrases most accurately characterizes the burden of Drug-Induced Liver Disease and associated disorders? A. severe nearly epidemic in scope B. so modest, it could be consider a rarified concern C. significant in terms of causing liver dysfunction and failure D. significant in terms of deaths due to drug misadventures 2) Autoimmune reactions in the liver are mediated by which of the following cell types? A. Schwan cells B. B cells C. Chief cells D. Hepatocytes C. Kupffer cells 3) The onset of signs and symptoms associated with nonallergic idiosyncratic reactions is usually noted as (fill in the blank) after the start of therapy. A. hours B. a few days C. days D. months

E. years 4) What mechanism is associated with acetaminophen toxicity? A. bioactivation B. disruption of calcium homeostasis C. idiosyncratic reactions D. stimulations of autoimmunity E. disruption of cholestatic flow 5) Which of the laboratory profiles strongly suggests hepatocellular injury? (normal ranges) A. ALT = 40 U/L (5–36); TBL = 2.1 mg/dL (0.3–1.0); Alk Phos = 145 U/L (30–120) B. ALT = 152 U/L (5–36); TBL = 6.1 mg/dL (0.3–1.0); Alk Phos = 28 U/L (30–120) C. ALT = 33 U/L (5–36); TBL = 3.2 mg/dL (0.3–1.0); Alk Phos = 385 U/L (30–120) 6) Which of the laboratory profiles strongly suggests cholestatic injury? (normal values) A. ALT = 40 U/L (5–36); TBL = 2.1 mg/dL (0.3–1.0); Alk Phos = 145 U/L (30–120) B. ALT = 152 U/L (5–36); TBL = 6.1 mg/dL (0.3–1.0); Alk Phos = 28 U/L (30–120) C. ALT = 33 U/L (5–36); TBL = 3.2 mg/dL (0.3–1.0); Alk Phos = 385 U/L (30–120) 7) Which of the following is the direct cause of centrolobular necrosis associated with acetaminophen overdose? A. N-acetyl-p-benzoquinone imine B. Amiodarone-to-N-desethylamiodarone C. N-acetyltransferase-2 D. Pyrrolizidine alkaloids E. Antinuclear antibodies 8) Glutathione provides what sacrificial reactive group to the toxic metabolite of acetaminophen? A. hydroxyl group B. sulfhydryl group C. amino group D. carboxylic group E. cyanide group 9) Nonalcoholic fatty liver disease is associated with all but one of the following chronic conditions? A. osteoarthritis B. type 2 diabetes mellitus C. hyperlipidemia D. hypertension E. morbid obesity 10) Which of the following occupations are associated with a greater risk of hepatic disease? A. Bus drivers B. Farmers C. Carpenters D. Lawyers E. Pharmacists

Chapter 39: Pancreatitis 1) Which of the following etiologies of acute pancreatitis is the most common in the United States?

A. Gallstones B. Medications C. Alcohol D. ERCP 2) Which of the following medications has a probable association as a cause of acute pancreatitis? A. Pravastatin B. Opiates C. Hydrochlorothiazide D. Bactrim 3) Which of the following is correct concerning the course of acute pancreatitis? A. About half of patients have a severe course with a mortality rate over 50% B. The gold standard for identifying patients at risk for a severe course is serum lipase C. There is no role for CECT in the diagnosis or staging of acute pancreatitis D. Scoring systems combine multiple factors to predict the clinical course of acute pancreatitis 4) Which of the following is correct regarding fluid replacement in acute pancreatitis? A. Patients at risk for renal or cardiovascular complications should be fluid restricted B. Fluid and electrolyte requirements are minimal in patients with mild disease C. Guidelines recommend 5 – 10 mL/kg/h of initial fluid replacement D. Sequestered fluid in the peritoneal or retroperitoneal space should not be replaced 5) Which of the following is the best nutrition therapy for a patient who is on hospital day 5 with slowly resolving severe acute pancreatitis? A. Oral nutrition with a low-fat diet B. Enteral nutrition support via the nasogastric route C. Total parenteral nutrition D. Combined enteral and parenteral nutrition 6) Which of the following is correct with respect to the use of opioid analgesics for pain associated with acute pancreatitis? A. Avoid agents that cause spasm of the sphincter of Oddi B. Morphine is often used do to longer duration of action C. Syntheitc opioids are the preferred agents D. Merperidine is the agent of choice 7) Which is of the following is correct regarding studies evaluating the use of prophylactic antibiotics in acute pancreatitis? A. No benefit has been demonstrated in acute pancreatitis without infection B. Studies using carbapenems show a decrease in pancreatic infection C. The largest studies demonstrate the greatest benefit D. Studies enrolling patients without necrosis show a decrease in mortality 8) Which of the following pathogenic mechanisms for the development of chronic pancreatitis results in fatty degeneration of the pancreas secondary to lipid accumulation due to the presence of metabolites of alcohol? A. Ductal obstruction B. Oxidative stress C. Peri-ductular necrosis D. Toxic-metabolic 9) Which of the following is most indicative of chronic pancreatitis?

A. Serum trypsinogen of 10 ng/mL (μg/L) B. Fecal elastase of 400 μg/g stool C. Weight gain D. Watery diarrhea 10) Which of the following is the best recommendation for a 47-year-old man with chronic pancreatitis who smokes and still has steatorrhea despite maximum pancreatic enzyme supplementation? A. Begin an antisecretory agent and medium chain triglyceride supplementation B. Quit smoking and begin medium chain triglyceride supplementation C. Begin an antisecretory agent, quit smoking, and reduce fat intake D. Begin alternative enzyme supplement and reduce fat intake 11) Which of the following is the best therapy for treating pain from chronic pancreatitis in a 51year-old woman with a past medical history of a bleeding gastric ulcer who is no longer getting relief from acetaminophen 650 mg orally four times daily? A. Fentanyl 25 μg/h transdermal patch every 72 hours B. Hydrocodone/acetaminophen 5/500 mg orally four times daily C. Ibuprofen 400 mg orally three times daily D. Tramadol 50 mg orally four times daily 12) Which of the following patients with chronic pancreatitis is the best candidate for pancreatic enzyme supplementation? A. Steatorrhea with persistent weight loss B. Steatorrhea without weight loss C. Fecal fat estimation of 2 grams per day D. Worsening pain despite opioids 13) Which of the following pancreatic enzyme supplement dose forms could be administered through an enteral feeding tube in an acidic solution? A. Minitablets B. Enteric-coated beads C. Microspheres with bicarbonate buffer D. Minimicrospheres 14) Which of the following is the best option for a patient with persistent steatorrhea who has not gained weight despite receiving the maximum dose of minimicrosphere enzyme supplements administered during meals? A. Change to microspheres B. Add an antisecretory agent C. Administer supplements before meals D. Administer supplements with applesauce 15) Which of the following should regularly be assessed in a patient receiving opioids for pain associated with chronic pancreatitis? A. Steatorrhea B. Weight loss C. Respiratory depression D. Constipation

Chapter 40: Viral Hepatitis

1) A 22-year-old college student is found to have hepatitis A virus (HAV). Per his report, he recently returned from a 3-day trip to a high-end resort in a country known to have high rates of HAV. He ate all of his meals at the resort, with the exception of a snack and drink he bought from a local vendor on the beach. Which of the following are risk factors for HAV infection? A. Contaminated ice or water in his drink from vendor B. Contaminated snack from vendor C. Contaminated food at resort D. Contaminated drinks or ice at resort E. All of the above are risks for HAV 2) The 22-year-old student complains of some loss of appetite, nausea, and vomiting. Which of the following is most appropriate for management of his acute HAV? A. Adefovir B. Daclatasvir C. Lamivudine D. Sofosbuvir E. Supportive care 3) The 21-year-old roommate of the infected student is concerned about becoming infected with HAV. Per the medical record, she received the first dose of the HAV vaccine 1 year ago. She is otherwise healthy. Which of the following is the most appropriate recommendations? A. Offer immunoglobulin (Ig) now. B. Restart her HAV vaccine schedule now. C. Offer Ig now and restart her HAV vaccine schedule. D. Reassure her that there is a high level of protection with one dose of the vaccine and recommend a booster shot now to complete the series. 4) JM, 54-year-old woman, is to undergo rituximab therapy. As part of her baseline laboratories, she is found to be hepatitis B surface antigen (HBsAg)-positive. Which of the following is the most appropriate recommendation regarding her rituximab therapy? A. She can proceed with rituximab therapy. She is not at risk for hepatitis B virus (HBV). B. She can proceed with rituximab therapy but will need close follow-up to see if her HBV is reactivated. If it is reactivated, then she will need HBV antiviral therapy. C. She will need HBV antiviral prophylaxis before starting rituximab because she is at risk for HBV reactivation with rituximab therapy. D. Additional laboratories are needed to understand if JM's HBsAg positivity is related to prior vaccination. 5) A patient has completed one dose of the HBV vaccine. She is scheduled to receive her second dose of vaccine but the same brand of vaccine is not available. Which of the following is the BEST recommendation in this situation? A. Continue her vaccine schedule with the available vaccine. Vaccines are interchangeable and require multiple doses for optimal effect. B. Defer the vaccine until the same brand is available. Vaccines are not interchangeable. C. Defer the vaccine until the same brand is available. HBV vaccine response is high with the first dose so she is likely already adequately protected. D. Restart her vaccine schedule with the currently available vaccine. 6) According to the American Association for the Study of Liver Diseases (AASLD), all of the following are options for noncirrhotic patients with chronic HBV infection EXCEPT? A. Adefovir

B. Entecavir C. Pegylated interferon (peg-IFN) D. Tenofovir 7) Which of the following agents is concerning for having a low-barrier to resistance? A. Entecavir B. Lamivudine C. peg-IFN D. Tenofovir 8) All of the following HBV antivirals also have activity against human immunodeficiency virus (HIV) EXCEPT: A. Adefovir B. Emtricitabine C. Lamivudine D. Tenofovir 9) A 45-year-old man is found to be hepatitis C virus (HCV) antibody positive. Which of the following is the most correct interpretation of this result? A. He is immune to HCV. B. He has active HCV. C. He has either acute or chronic HCV. D. He needs further evaluation. 10) Which of the following is an appropriate treatment regimen for a noncirrhotic patient with HCV genotype (GT) 2? A. Ledipasvir/sofosbuvir for 12 weeks B. Ombitasvir/paritaprevir/ritonavir + dasabuvir for 12 weeks C. Sofosbuvir and ribavirin for 12 weeks D. Sofosbuvir and ribavirin for 16 weeks 11) Which of the following is an appropriate treatment regimen for a cirrhotic (Child-Turcotte Pugh [CTP] class A) patient with HCV GT1b? A. Daclatasvir and sofosbuvir for 12 weeks B. Ombitasvir/paritaprevir/ritonavir + dasabuvir for 12 weeks C. Sofosbuvir and ribavirin for 16 weeks D. Sofosbuvir and ribavirin + peg-IFN for 12 weeks 12) Which of the following is an appropriate treatment regimen for a cirrhotic (CTP class B) patient with HCV GT1a? A. Daclatasvir + ribavirin + peg-IFN for 12 weeks B. Ledipasvir/sofosbuvir for 12 weeks C. Ombitasvir/paritaprevir/ritonavir + dasabuvir for 12 weeks D. Sofosbuvir and ribavirin for 16 weeks 13) Which of the following is the BEST treatment regimen for a noncirrhotic patient with HCV GT1b who has renal insufficiency with an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73m2? A. Ledipasvir/sofosbuvir for 12 weeks B. Ombitasvir/paritaprevir/ritonavir + dasabuvir for 12 weeks C. Ombitasvir/paritaprevir/ritonavir + dasabuvir and ribavirin for 12 weeks D. Simeprevir and sofosbuvir for 12 weeks

14) Which of the following is a treatment option for a noncirrhotic, treatment-naïve patient with HCV GT3? A. Daclatasvir and sofosbuvir for 12 weeks B. Ledipasvir/sofosbuvir for 12 weeks C. Ombitasvir/paritaprevir/ritonavir + dasabuvir for 12 weeks D. Sofosbuvir and ribavirin for 16 weeks 15) A female patient of childbearing capacity is to start treatment with sofosbuvir + ribavirin for 12 weeks. All of the following are correct counseling point for women on ribavirin EXCEPT: A. Avoid pregnancy for 6 months after completing treatment. B. Discontinue any ethinyl estradiol containing products prior to start of therapy due to druginteraction concerns. C. Ribavirin is a teratogenic agent—avoid pregnancy while on treatment. D. Use two forms of contraception while on ribavirin.

Chapter 41: Celiac Disease 1) Which of the following cancers is of particular concern in patients with celiac disease? A. Renal cell carcinoma B. Glioma C. Breast cancer D. Adenocarcinoma 2) Family members of a celiac disease patient can be screened for the disease using which of the following tests? A. CD4 count B. Antigliadin antibodies C. Tissue transglutaminase D. HLA DQ2 and DQ8 3) Which of the following disorders is more likely to be present in individuals with celiac disease? A. Diabetes mellitus B. Asthma C. Cardiac hyperplasia D. Dyslipidemia 4) Which of the following recommendations is appropriate for patients with celiac disease? A. They should receive an influenza vaccine annually B. They should be screened for dyslipidemia annually C. They must use only use topical products that are gluten free D. They must have a skin biopsy to detect dermatitis herpetiformis even in the absence of skin symptoms 5) When should diagnostic measures occur? A. Before a gluten free diet is initiated B. At the same time that a gluten free diet is initiated C. After a gluten free diet is initiated D. With no consideration to timing of initiation of a gluten free diet 6) Which of the following nutritional deficiencies does not need to be assessed in newly diagnosed patients with celiac disease?

A. Iron B. Vitamin D C. Zinc D. Calcium 7) Overall goals of treatment of celiac disease routinely include which of the following? A. Improving glucose control B. Reversing the consequences of malabsorption C. Reversing renal damage D. Enhancing weight loss 8) Which of the following agents has been suggested to contribute to the development of celiac disease or sprue-like bowel disease? A. Methotrexate B. Ibuprofen C. Pioglitazone D. Acetaminophen 9) In celiac disease the integrity of the tissue junctions of the intestinal epithelium is: A. Strengthened B. The same as in non-celiac disease patients C. Compromised D. Unable to be assessed 10) Signs associated with celiac disease include all of the following except: A. Weight loss B. Infertility C. Aphthous ulcers D. Hirsutism 11) What percent of adult patients have refractory celiac disease? A. 5 B. 10 C. 15 D. 20 12) Which of the following may be safely ingested by a patient with celiac disease? A. Graham flour B. Triticale C. Bran D. Buckwheat 13) In active celiac disease, damaged cells release which enzyme that modifies gluten? A. Interleukin-15 B. Tissue transglutaminase C. Pancrease D. Pepsin 14) The prevalence of celiac disease appears to be: A. Increasing B. Decreasing C. Staying the same D. Decreasing in some countries and remaining the same in others

15) When clinical improvement often is observed in celiac disease patients after initiating a strict gluten-free diet? A. 2 to 3 years B. 1 to 2 years C. 6 months to 1 year D. Within days or weeks Chapter 42: Evaluation of Kidney Function 1) The glomerulus is primarily responsible for of unbound drug in the kidney: A. Filtration B. Reabsorption C. Secretion D. Endocytosis 2) Active drug secretion occurs most often in which of the following nephron segments: A. Glomerulus B. Proximal tubule C. Loop of Henle D. Distal tubule 3) Which of the following is/are involved in drug efflux at the basolateral membrane of the proximal tubule: A. MRP1 B. ENT1 C. OAT4 D. Both A and B 4) According to the intact nephron hypothesis, reabsorption and single nephron glomerular filtration rate (GFR) in the surviving nephrons: A. Increases, increases B. Decreases, decreases C. Increases, decreases D. Decreases, increases 5) The kidney is responsible for synthesizing each of the following hormones, EXCEPT: A. Erythropoietin B. Prostaglandin C. Parathyroid hormone D. Renin 6) The decreased serum creatinine values observed during dobutamine therapy are likely due to: A. Analytical interference B. Increased tubular secretion of creatinine C. Increased GFR caused by dobutamine D. Increased muscle breakdown 7) Which of the following renal function indices is least influenced by changes in fluid or volume status: A. Serum creatinine B. Blood urea nitrogen C. Urine specific gravity D. Urine sodium

8) Which of the following renal function indices is least affected by dietary protein intake: A. Serum creatinine B. Blood urea nitrogen C. Creatinine clearance D. Urine sodium 9) The most appropriate method for initial testing of proteinuria in a patient with chronic kidney disease (CKD) risk factors is: A. Urine protein:albumin ratio B. Urine albumin:creatinine ratio C. 24-hour urine protein excretion D. Urine dipstick for total protein 10) Each of the following provides an accurate measure of GFR, except: A. Iohexol clearance B. Iothalamate clearance C. Inulin clearance D. Probenecid clearance 11) Which of the following equations is most appropriate for estimating a patient's GFR for the purpose of determining their CKD category/stage? A. 6-variable MDRD B. CKD-EPI equation C. CKD_cysC equation D. BIS equation 12) The authoritative source that provides the FDA-approved recommendations for drug dosage recommendations in renal impairment is: A. ePocrates B. Drugdex/Micromedex C. AHFS Drug Information D. Approved Product labelling (package insert) 13) When using the Cockcroft-Gault (CG) equation to estimate creatinine clearance in obese patients, it is recommended that lean body weight be used in patients with: A. BMI ≥ 40 kg/m2 B. BMI 30 to 39 kg/m2 C. BMI 25 to 29 kg/m2 D. None of the above 14) J.S. is a 70-year-old African American male (5′8″ [173 cm], 85 kg) with a history of hypertension and CKD. His serum creatinine today is 1.50 mg/dL (133 μmol/L) (using the IDMS calibrated assay). What is his estimated creatinine clearance? A. 55.0 mL/min (0.92 mL/s) B. 43.5 mL/min (0.72 mL/s) C. 37.2 mL/min (0.62 mL/s) D. 29.4 mL/min (0.49 mL/s) 15) What is J.S.'s estimated GFR (in mL/min/1.73 m2)? A. 56.0 mL/min/1.73 m2 B. 49.4 mL/min/1.73 m2 C. 35.0 mL/min/1.73 m2 D. 30.2 mL/min/1.73 m2

16) What is J.S.'s estimated GFR when expressed in mL/min? A. 38.9 mL/min B. 45.6 mL/min C. 65.2 mL/min D. 72.1 mL/min 17) J.R. is a 68-year-old Caucasian man (60 kg, 5′7″ [170 cm]) with a history of hypertension, cerebral stroke, and benign prostatic hypertrophy. He presents to the ambulatory care clinic today for evaluation of a viral infection to be treated with acyclovir. His serum creatinine value today is 0.63 mg/dL (56 μmol/L). Which one of the following approaches should be used to assess this patient's renal function for the purpose of renal dose adjustment for acyclovir? A. Measure a chromium-labeled ethylenediaminetetraacetic acid GFR B. Estimate creatinine clearance using the CG equation C. Estimate GFR using the MDRD equation D. Conduct a timed 24-hour urine collection 18) An appropriate clinical monitoring plan to evaluate renal protective therapy in patients with CKD should include each of the following items EXCEPT: A. Estimated creatinine clearance B. Urinary albumin:creatinine C. Urinary cystatin C concentration D. Estimated GFR 19) The elevation in serum creatinine observed during cobicistat therapy is most likely attributed to: A. Tubular apoptosis B. Acute interstitial injury C. Afferent arteriole vasoconstriction D. Inhibition of OCT2 and MAT1- mediated tubular secretion of creatinine 20) In the clinical setting, the renal clearance of PAH is considered an index of . A. Fractional excretion of sodium B. Renal plasma or blood flow C. Glomerular filtration rate D. Renal tubular reabsorption Chapter 43: Acute Kidney Injury 1) A 81-year-old male long-term care resident is admitted to the hospital with altered mental status. His admission laboratory values show a blood urea nitrogen (BUN) of 43 mg/dL (15.4 mmol/L) and serum creatinine (Scr) of 2.8 mg/dL (248 µmol/L). Urinalysis reveals presence of white blood cells, red blood cells, and granular casts. His calculated fractional excretion of sodium (FENa) is 2.2%. The most likely etiology of AKI is A. Intrinsic AKI B. Bladder obstruction C. Postrenal AKI D. Functional AKI E. Volume depletion 2) A 56-year-old man presents to the hospital with AKI. Based on the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) classification system, which of the following parameters should be used to determine the severity of his kidney injury?

A. Scr B. Estimated glomerular filtration rate (eGFR) C. Scr and BUN D. Scr and urine output E. BUN and urine output 3) A 52-year-old (80 kg) man is in the intensive care unit with sepsis and AKI. His Scr increased from a baseline of 1 mg/dL to 2.1 mg/dL (88 μmol/L-186 µmol/L). His urine output in the past 24 hours was 1250 mL. According to the Kidney Disease Improving Global Outcomes (KDIGO) AKI classification, which stage of AKI does this patient have? A. Stage I B. Stage II C. Stage III D. Stage IV E. Stage V 4) Which of the following laboratory markers is most likely to provide the earliest detection of AKI? A. Tissue inhibitor of metalloproteinases (TIMP) 2 B. Scr C. Urine output D. BUN E. Glomerular filtration rate 5) A 56-year-old woman with a history of Stage III chronic kidney disease is scheduled for diagnostic imaging requiring contrast dye administration. Her Scr is 2.2 mg/dL (194 µmol/L) and BUN is 30 mg/dL (10.7 mmol/L). Her complete blood count and electrolytes are all within normal range. Which of the following medications would you recommend to decrease her risk of contrast-induced nephropathy? A. Theophylline B. Renal replacement therapy (RRT) C. Furosemide D. Isotonic saline infusion E. Fenoldapam 6) Which of the following strategies can be used to overcome diuretic resistance in a fluidoverloaded patient who is poorly responding to bolus doses of furosemide? A. Change furosemide to bumetanide B. Add bumetanide C. Change furosemide to a continuous infusion D. Change furosemide to hydrochlorothiazide E. Add torsemide 7) A 36-year-old man is diagnosed with intrinsic AKI secondary to a prolonged exposure to intravenous tobramycin. Which of the following pathophysiologic processes has most likely occurred in this case? A. Glomerular damage secondary to severe inflammation B. Drug hypersensitivity reaction leading to interstitial inflammation C. Increased renal perfusion D. Bladder outlet obstruction E. Tubular epithelial cell damage

8) Which of the following statements regarding prevention and treatment of AKI is correct? A. Administration of isotonic saline hydration can hasten recovery from AKI. B. Administration of sodium bicarbonate hydration can reverse tubular cell damage that has resulted from renal ischemia. C. Intermittent hemodialysis is effective in preventing development of AKI. D. Continuous renal replacement therapy is effective in preventing contrast-induced nephropathy. E. Supportive care targeting acid-base, electrolyte, and fluid balance is the mainstay of therapy for AKI. 9) An 82-year-old woman is admitted to the medical intensive care unit with AKI. Her laboratory results indicate the following: Na 133 mEq/L (mmol/L), K 4.8 mEq/L (mmol/L), Cl 95 mEq/L (mmol/L), CO2 22 mEq/L (mmol/L), PO4 6.6 mg/dL (2.13 mmol/L), Ca 8.1 mg/dL (2.03 mmol/L), BUN 33 mg/dL (11.8 mmol/L), Scr 2.8 mg/dL (248 µmol/L). Which of the following electrolyte abnormalities does she have that are commonly found in patients with AKI? A. Hyperphosphatemia B. Hyperkalemia C. Hyponatremia D. Hypercalcemia E. Hyperchloremia 10) Which of the following medications is most likely to cause of acute tubular necrosis in a 75year-old hospitalized patient? A. N-acetylcysteine B. Acyclovir C. Dopamine D. Contrast dye E. Cefepime 11) Per 2012 KDIGO AKI guidelines, which of the following intravenous fluids is recommended as first-line therapy for the prevention of AKI? A. 0.45% saline B. 0.9% saline C. Hydroxyethyl starch D. 20% albumin E. 0.25% saline 12) You get a call from a physician inquiring about use of fenoldapam for prevention of AKI. Which of the following would be the most appropriate response to this question? A. Fenoldapam is recommended for prevention of AKI but patient should be monitored for hypotension. B. Dopamine is more effective than fenoldapam in preventing AKI. C. Fenoldapam should be used in combination with dopamine to prevent AKI. D. Fenoldapam is not recommended for prevention but can be used for the treatment of AKI. E. Fenoldapam is not recommended for prevention of AKI due to lack of benefit and risk of hypotension. 13) Which of the following dialysis modalities is/are most likely to cause hypotension? A. Intermittent hemodialysis B. Continuous venovenous hemofiltration (CVVH) C. Continuous venovenous hemodialysis (CVVHD)

D. Continuous venovenous hemodiafiltration (CVVHDF) E. Sustained low-efficiency dialysis (SLED) 14) A 72-year-old critically ill man with AKI requires vancomycin for the treatment of ventilator-associated pneumonia. When determining how to individualize vancomycin dosing for this patient, all of the following parameters need to be taken into account except A. Serum phosphorus values B. Scr C. Urine output D. Fluid status E. Utilization of RRT 15) Which of the following statements about drug dosing considerations in AKI is correct? A. Drug clearances attained by intermittent hemodialysis, continuous renal replacement therapy (CRRT), and hybrid RRT are generally similar. B. Drug clearance is expected to increase when higher ultrafiltration rates are used during CRRT. C. Drug clearance is expected to decrease when higher dialysate flow rates are used during CRRT. D. Drug clearance between patients with AKI and chronic kidney disease is expected to be similar. E. Drug clearance is unaffected by different RRTs.

Chapter 44: Chronic Kidney Disease 1) A 51-year-old man with an eGFR of 37 mL/min/1.73 m2 and an albumin-to-creatinine (ACR) ratio of 27.3 mg/g (3.1 mg/mmol) would be classified at what albuminuria and KDIGO category of CKD? A. 3a, A1 B. 3a, A2 C. 3b, A1 D. 3b, A2 2) A 44-year-old woman with a history of CKD due to type 2 diabetes presents to your primary care clinic. Her most recent ACR is 113 mg/g (12.8 mg/mmol), her eGFR is 44 mL/min/1.73 m2, and blood pressure is 137/88 mm Hg. She is on chlorthalidone 12.5 mg po daily as her only antihypertensive drug. Which of the following recommendations is most appropriate? A. No changes, blood pressure is at target. B. Increase chlorthalidone to 25 mg po daily. C. Start ramipril 2.5 mg po daily. D. Start amlodipine 5 mg po daily. 3) Patients with CKD and an eGFR less than 60 mL/min/1.73m2 who have severe vomiting, diarrhea, or are dehydrated should be instructed to hold which of the following medications? A. Enalapril B. Metformin C. Furosemide D. All of the above 4) Hypertensive patients with CKD should limit dietary sodium to less than: A. 1 g/day

B. 1.5 g/day C. 2 g/day D. 2.5 g/day 5) According to the KDIGO guideline, what is the blood pressure target in a patient with CKD and ACR of 22 mg/g (2.5 mg/mmol)? A. ≤125/75 mm Hg B. ≤130/80 mm Hg C. ≤140/90 mm Hg D. ≤150/90 mm Hg 6) A 67-year-old woman with diabetic CKD, ACR = 55.4 mg/g (6.3 mg/mmol), serum potassium = 4.5 mEq/L (mmol/L), and an eGFR = 38 mL/min/1.73 m2 is started on irbesartan 75 mg po once daily. The eGFR and serum potassium levels should be monitored at what time point after initiation of therapy? A. In ≤2 weeks B. Within 2 to 4 weeks C. Within 4 to 12 weeks D. At the next clinic visit in 6 months 7) According to the KDIGO guideline, what is the target blood pressure in a patient with kidney disease secondary to long-standing hypertension and an ACR = 423 mg/g (48.8 mg/mmol)? A. ≤125/75 mm Hg B. ≤130/80 mm Hg C. ≤140/90 mm Hg D. ≤150/90 mm Hg 8) A 28-year-old female patient with diabetic CKD and albuminuria on an angiotensinconverting enzyme inhibitor (ACEI) becomes pregnant. The ACEI is discontinued. Which of the following drugs has been shown to reduce albuminuria and is safe for use in pregnancy? A. Verapamil B. Metoprolol C. Spironolactone D. Aliskiren 9) Which of the following agents would be preferred in a patient with end-stage renal disease (ESRD) with a parathyroid hormone (PTH) of 700 pg/mL (ng/L; 75 pmol/L) and persistently elevated calcium levels? A. Cinacalcet B. Cholecalciferol C. Calcitriol D. Ergocalciferol 10) A patient with ESRD who has just started hemodialysis (HD) has a PTH of 500 pg/mL (ng/L; 54 pmol/L), a phosphorus of 7.4 mg/dL (2.39 mmol/L), a calcium of 9.8 mg/dL (2.45 mmol/L), and an albumin of 3 g/dL (30 g/L). She current receives calcitriol 1 μg IV three times weekly with HD, calcium acetate 1,334 mg three times daily with meals, and ergocalciferol 50,000 IU once weekly. Which of the following is most appropriate to control her CKD-MBD? A. Discontinue the calcium acetate and begin a 2-month course of aluminum hydroxide with meals. B. Increase the calcium acetate to 2,001 mg with meals. C. Increase the calcitriol dose to 1.5 μg IV three times weekly.

D. Discontinue the calcium acetate and begin lanthanum carbonate. 11) A 45-year-old man with CKD category 3b (eGFR of 42 mL/min/1.73 m2) is seen in the nephrology clinic. His laboratories today show the following: hemoglobin (Hb) 8.5 g/dL (85 g/L; 5.28 mmol/L) (down from 10.5 g/dL [105 g/L; 6.52 mmol/L] 3 months ago), TSat 34% (0.34), serum ferritin 210 ng/mL (μg/L; 4.72 pmol/L). He reports feeling tired and less able to do his activities of daily living. Workup shows no signs of active bleeding. Should this patient be started on an erythropoietic stimulating agent (ESA) and what is the rationale? A. Yes, his Hb is below 10 g/dL (100 g/L; 6.21 mmol/L) and the extent of decline indicates a high likelihood of needing a blood transfusion. B. Yes, an ESA is indicated to enhance his quality of life and decrease mortality risk. C. No, an ESA will not be effective since his iron indices are low and iron should be administered first. D. No, his Hb is above 8 g/dL (80 g/L; 4.97 mmol/L) and he has not had a large decline in Hb since his last visit. 12) A patient with CKD is to be started on oral iron for iron deficiency. This patient should be instructed to do which of the following? A. Avoid taking sucroferric oxyhydroxide within 2 hours of oral iron. B. Take iron with meals to increase absorption in the gastrointestinal (GI) tract. C. Take at least 200 mg of elemental iron per day if tolerated. D. Take an antacid with iron to minimize the risk of GI adverse effects. 13) A patient with CKD 4 is noted to be iron-deficient and is prescribed a full course of IV iron (1-1.5 g total). She will receive the total dose of IV iron divided over two clinic visits (today and 1 week later). Which regimen is most appropriate to administer at each visit? A. Ferumoxytol 510 mg IV push over 5 minutes. B. Iron dextran 25 mg test dose followed by infusion of 500 mg over 30 minutes. C. Ferric carboxymaltose 750 mg infused over 30 minutes. D. Ferric gluconate 500 mg infused over 30 minutes. 14) Which of the following is a potential advantage of using ferric citrate as a phosphate binding agent compared to other available phosphate binders? A. It is available in a powder formulation. B. It may increase iron indices. C. It is available as a chewable tablet. D. It can be given intravenously or orally. 15) According to KDIGO guidelines statin therapy is recommended for primary prevention of cardiovascular events in which of the following patients? A. 60-year-old man with ESRD not previously on a statin. B. 40-year-old man with CKD 3b with coronary artery disease. C. 38-year-old woman with CKD 2 and hypertension. D. Statins are recommended only for secondary prevention in patients with CKD.

Chapter 45: Hemodialysis and Peritoneal Dialysis 1) The most commonly used treatment for end-stage renal disease is: A. Continuous renal replacement therapy B. Peritoneal dialysis C. Hemodialysis

D. Renal transplantation 2) In comparison to hemodialysis, peritoneal dialysis: A. Is associated with higher clearance rates for both solutes and water B. Enables closer monitoring of the patient C. Is associated with a lower technique failure rate D. May result in better preservation of residual renal function 3) Which of the following is the most important indication for initiation of chronic dialysis therapy? A. Blood urea nitrogen concentration greater than 60 mg/dL (21.4 mmol/L) B. Estimated glomerular filtration rate less than 25 mL/min/1.73 m2 C. Persistent symptoms, such as nausea and uncontrolled hypertension D. Hyperphosphatemia 4) Because of lower rates of infection and thrombosis associated with its use, which of the following HD vascular access is considered to be the most desirable to use clinically? A. Arteriovenous graft B. Arteriovenous fistula C. Central venous catheter D. Venous catheter 5) Which of the following dialysis membranes is most likely to remove large molecular weight substances during hemodialysis? A. Conventional hemodialysis B. High-efficiency hemodialysis C. High-flux hemodialysis D. Peritoneal membrane 6) Which of the following statements is not true regarding peritoneal dialysis? A. In comparison to hemodialysis, peritoneal dialysis is less efficient at removing solutes and water B. During peritoneal dialysis, there is countercurrent flow of blood and dialysate, which increases diffusion and convection C. Blood flow to the peritoneal membrane can be regulated but to a lesser degree than blood flow through a vascular access in hemodialysis D. The peritoneal membrane functions as the semipermeable membrane 7) To provide adequate peritoneal dialysis: A. Weekly Kt/V should exceed 1.7 for CAPD patients B. Daily Kt/V should exceed 1.7 for CAPD patients C. Residual renal function is not considered an important factor in Kt/V D. Kt/V should be at least 2.0 for patients without residual renal function 8) RC is a 63 year-old patient with ESRD receiving outpatient hemodialysis thrice weekly that experiences intradialytic hypotension. What nonpharmacologic approaches should be considered to minimize RC's intradialytic hypotension? A. Stretching exercises B. Trendelenburg position C. Encourage food and beverage intake during dialysis D. Increase the dialysate temperature 9) The preferred route for antibiotics to treat peritonitis in PD patients is:

A. Intravenously, using dosing based on a renal function (eGFR) of less than 15 mL/min/1.73m2 B. Intravenously, increasing the dose by 25% for patients with daily urine output greater than 100 mL C. Intraperitoneally, with one large antibiotic dose given in one exchange per day in CAPD patients D. Intraperitoneally, with the same antibiotic dosing used for CAPD and APD patients 10) Which of the following is true regarding PD catheter-related infections? A. Topical antibiotics and disinfectants are ineffective in preventing PD catheter-related infections B. Vancomycin is the antibiotic of choice for gram positive PD catheter-related infections C. PD catheter-related infections that progress to peritonitis seldom require catheter removal D. Gram positive organisms should be treated with an oral penicillinase-resistant penicillin or a first generation cephalosporin such as cephalexin 11) A 62-year-old Male who receives regular hemodialysis for the past 3 years with an AV graft has diminished blood flow through his AV graft. Which one of the following would be best to restore AV graft blood flow for this patient? A. alteplase B. tenecteplase C. heparin D. 4% sodium citrate 12) AV graft blood flow for this patient has been restored and the nephrologist is discussing adding an oral agent to prevent AV graft thrombosis in this patient. Which one of the following would be best to recommend for this patient at this time? A. warfarin B. aspirin C. fish oil supplement D. no therapy 13) A 67-year-old Female hemodialysis patient receiving regular hemodialysis for the past year has had several episodes of symptomatic intradialytic hypotension that was being treated with midodrine. The patient complained of tingling in her hands and feet and subsequently stopped taking midodrine. Which one of the following would be best to recommend for this patient at this time? A. Advise the patient to take midodrine as needed B. Initiate paroxetine 10 mg once daily on non-hemodialysis days C. Initiate intra-nasal desmopressin acetate 1 spray 3 times a week D. Review vital readings and current medications for this patient 14) A 71year-old Female peritoneal dialysis patient has been diagnosed with a catheter exit-site infection and empiric antibiotic therapy needs to be initiated. Which one of the following would be best to recommend for this patient at this time? A. vancomycin B. rifampin C. cephalexin D. ciprofloxacin

15) The prevention of hemodialysis catheter exit-site infections requires a multi-step approach that includes a topical antibiotic applied to the exit-site and/or catheter tip. Which of the following agents may increase the risk of fungal infections in peritoneal dialysis patients? A. mupirocin ointment B. gentamicin cream C. povidine-iodine solution D. polysporin triple ointment

Chapter 46: Drug-Induced Kidney Disease 1) Regarding drug-induced kidney disease, all of the following are applicable except: A. temporal relationship with potentially toxic agent B. the offending agent is rarely identified C. significant source of morbidity in the hospital setting D. abrupt and sustained reduction in GFR E. the most common presentation in the hospital setting is acute tubular necrosis 2) Hemodynamically mediated kidney injury induced by angiotensin converting enzyme inhibitors (ACEI) involves all of the following except: A. enhanced efferent arteriolar constriction B. patients with renal artery stenosis at increased risk C. decrease in glomerular capillary hydrostatic pressure D. reduced glomerular ultrafiltration E. none of the above 3) The most common manifestation of drug-induced kidney disease is: A. proteinuria B. pyuria C. hematuria D. a decline in the glomerular filtration rate (GFR) E. a reduction in tubular secretion 4) Each of the following statements regarding aminoglycoside-induced acute tubular necrosis is true except: A. risk factors include prolonged therapy and increased age B. it manifests as a gradual rise in serum creatinine 4-6 weeks after exposure to the drug C. patients typically present with non-oliguria, maintaining urine volumes greater than 500 mL/day D. toxicity of various aminoglycosides is related to cationic charge of the drug E. "once-daily" dosing may be one method to maintain antimicrobial efficacy while reducing nephrotoxicity 5) Which of the following drugs has been associated with chronic interstitial nephritis? A. cyclosporine B. ifosfamide C. lithium D. streptozotocin E. all of the above 6) Which of the following drugs has been associated with collapsing glomerulosclerosis? A. propylthiouracil

B. aminoglycosides C. pamidronate D. radiographic contrast media E. hydralazine 7) The preferred agent for preventing cisplatin induced nephrotoxicity is: A. fenoldopam B. amifostine C. dopamine D. acetylcysteine E. mesna 8) The following renal structural-functional alteration is associated with exposure to radiographic contrast media: A. allergic interstitial nephritis B. intratubular obstruction C. glomerularsclerosis D. acute tubular necrosis E. papillary necrosis 9) All of the following strategies may be used to prevent radiographic contrast media nephrotoxicity except: A. amifostine B. acetylcysteine C. low osmolality agents D. hydration E. reduced doses of contrast 10) All of the following drugs are linked to the development of ANCA-positive vasculitis except: A. hydralazine B. allopurinol C. warfarin D. propylthiouracil E. penicillamine 11) Which of the following drugs would be the most likely culprit in a patient with newly diagnosed renal intratubular obstruction? A. ibuprofen B. losartan C. amphotericin B D. ciprofloxacin E. acyclovir 12) The preferred treatment for a patient with drug-induced minimal change glomerular injury accompanied by interstitial nephritis is: A. amifostine B. cyclophosphamide C. pamidronate D. prednisone E. hydration 13) A 60-year old woman with a 5-year history of NSAID use is prescribed enalapril and develops acute kidney injury. What is the most likely cause of her acute kidney injury?

A. acute allergic interstitial nephritis B. chronic interstitial nephritis C. minimal change glomerular injury D. focal segmental glomerulosclerosis E. hemodynamically-mediated kidney injury 14) The signs and symptoms of penicillin-induced allergic interstitial nephritis include all of the following except: A. rash, eosinophilia, pyuria B. fever, eosinophilia, reduced intraglomerular pressure C. fever, rash, eosinophilia D. elevated serum creatinine, rash, eosinophilia E. hematuria, proteinuria, oliguria 15) The calineurin inhibitor cyclosporine has been implicated in which of the following? A. allergic interstitial nephritis B. thrombotic microangiopathy C. chronic interstitial nephritis D. hemodynamically mediated kidney injury E. all of the above Chapter 47: Glomerulonephritis 1) Which of the following may appear in patients with nephritic syndrome but not nephrotic syndrome? A. proteinuria B. edema C. hyperlipidemia D. hypercoagulable state E. hematuria 2) Albuminuria, above the normal threshold of 30 to 300 mg per day, is associated with: A. increased all-cause mortality B. progression to ESRD C. fatal cardiovascular events D. non-fatal cardiovascular events E. all of the above 3) Patients with nephrotic syndrome are commonly advised to: A. restrict sodium intake B. restrict protein intake C. consume a low-fat diet D. all of the above E. A and B only 4) Which of the following may be used to reduce proteinuria for patients with glomerulonephritis? A. angiotensin-converting enzyme (ACE) inhibitor B. angiotensin II receptor blocker C. combined use of angiotensin-converting enzyme (ACE) inhibitor and angiotensin II receptor blocker D. non-steroidal anti-inflammatory agent

E. all of the above 5) Which of the following parameters is useful to predicting the risk for renal function deterioration in patients with glomerulonephritis? A. edema B. proteinuria C. coagulopathy D. a and b only E. A, B and C 6) Use of statins in patients with glomerulonephritis may: A. reduce VLDL and LDL cholesterol levels B. reduce risk for cardiovascular disease C. reduce renal function decline D. reduce the proteinuria progression E. all of the above 7) Pediatric patients with minimal-change nephropathy often respond well to steroid therapy. Which of the following undetected lesion may be found in patients who are resistant to therapy? A. lupus nephritis B. focal segmental glomerulonephritis C. immunoglobulin A nephropathy D. membranous nephropathy E. membranoproliferative glomerulonephritis 8) Which of the following agents is/are often used as first-line therapy for inducing remission in patients with recently diagnosed minimal-change nephropathy? A. steroid B. steroid and cyclosporine C. steroid and azathioprine D. steroid and cyclophosphamide E. steroid and mycophenolate mofetil 9) Which of the following is correct regarding the use of cyclosporine for the treatment of minimal-change nephropathy? A. Cyclosporine is often effective in inducing remission during relapse B. Cyclosporine is useful for patients who are steroid dependent C. The disease-free period is not often sustained after therapy discontinuation D. Nephrotoxicity is a concern after long-term use E. All of the above are correct 10) Which of the following are risk factors associated with rapid renal function decline in patients with focal segmental glomerulonephritis? A. severe proteinuria B. high serum creatinine concentration at initial diagnosis C. initial steroid resistance D. interstitial fibrosis E. all of the above are correct 11) A patient with IgA nephropathy who has proteinuria of 0.5-1 g/day should be: A. given ACEI or ARB to control blood pressure and reduce urinary protein excretion B. given fish oil C. given steroid treatment

D. given cytotoxic agents E. given mycophenolate mofetil 12) Which of the following is/are commonly considered when selecting the optimal treatment for patients with lupus nephritis? A. disease activity according to pathologic findings B. duration of symptoms C. extent of proteinuria D. a and b only E. all A, B and C 13) Which of the following is frequently used for chronic maintenance treatment of lupus nephritis? A. steroid B. cytotoxic agent C. cyclosporine D. mycophenolate mofetil E. fish oil 14) Annual eye examination for possible retinal toxicity should be conducted for patients receiving long-term use of the following agent? A. fish oil B. cytotoxic agent C. cyclosporine D. mycophenolate mofetil E. hydroxychloroquine 15) Antibiotic treatment after poststreptococcal glomerulonephritis may: A. prevent subsequent poststreptococcal glomerulonephritis B. reduce severity of disease C. prevent the spread of infection to family members D. both B and C E. both A and C Chapter 48: Drug Therapy Individualization for Patients with Chronic Kidney Disease 1) What are the mechanisms for the variability in absorption of drugs observed in chronic kidney disease (CKD) patients? A. Drug interactions B. Delayed gastric emptying C. Increased gastric acidity D. (A) and (B) E. All of the above 2) All of the following are potential mechanisms by which the volume of distribution of drugs is increased in patients with CKD EXCEPT? A. Decreased plasma protein binding B. Increased tissue binding C. Increased fluid excretion D. Increased fluid status 3) Increased concentrations of α1-acid glycoprotein have been attributed to a reduction in plasma protein binding of basic drugs.

A. True B. False 4) Renal clearance of a drug is a composite of all of the following EXCEPT: A. Absorption B. Glomerular filtration rate (GFR) C. Reabsorption D. Secretion 5) Metabolites of drugs may have pharmacological action that is very similar to the parent drug, such as A. Acetaminophen B. Allopurinol C. Meperidine D. Metoprolol 6) Based on recent dosage-adjustment guidelines and references, which of the following CLcr ranges appropriately represents severe renal insufficiency? A. Severe: 30 to 59 mL/min (0.50-0.99 mL/s) B. Severe: 10 to 30 mL/min (0.17-0.50 mL/s) C. Severe: <15 mL/min (<0.25 mL/s) D. Severe: <50 mL/min (<0.83 mL/s) 7) References to primary literature are ONLY provided in which one of these reference manuals? A. Aronoff's Drug Prescribing in Renal Failure B. Renal Drug Handbook C. Lexicomp D. Micromedex E. American Hospital Formulary Service (AHFS) 8) Which of the following statements regarding the Rowland and Tozer method for estimating the total body clearance (CL) of CKD patients using is true? A. The fraction of the drug that is eliminated renally unchanged (ƒe) in subjects with normal renal function must be known. B. This method can be used for drugs with known alternations in their metabolism among CKD patients. C. It is applicable when the drug obeys nonlinear kinetic principles. D. The change in CL must be disproportional to CLcr. 9) A patient who has a CLcr of 20 mL/min (0.33 mL/s) is to receive an antibiotic that has a ƒe of 85%. Based on this information, calculate the kinetic parameter/dosage-adjustment factor (Q). A. 0.29 B. 0.15 C. 0.39 D. 0.5 10) A patient with diabetes who has a CLcr of 15 mL/min (0.25 mL/s) is to receive a pain medication that has a ƒe of 75%. Based on this information, calculate the most appropriate dose for this patient. The normal dose is 500 mg. A. 225 B. 175 C. 325 D. 500

11) Which of the following statements regarding the effects of dose and dosing interval adjustments in patients with reduced renal function is true? A. If the dose is reduced while the dosing interval remains unchanged, the peak will be higher and the trough lower. B. If the dose remains unchanged while the dosing interval is increased, the peak and trough concentrations in patients with reduced renal function will be similar to those in patients with normal renal function. C. If the dose is reduced while the dosing interval remains unchanged, the peak and trough concentrations in patients with reduced renal function will be similar to those in patients with normal renal function. D. If the dose remains unchanged while the dosing interval is increased, the peak will be higher and the trough lower. 12) A 58-year-old, 80-kg man with a measured CLcr of 25 mL/min (0.42 mL/s) is to receive intravenous ciprofloxacin. The usual dose of ciprofloxacin is 500 mg every 12 hours for patients with normal renal function. Calculate the dose you would recommend to be given every 12 hours for this patient. The relationship between ciprofloxacin clearance (CL/F) and renal function is CL/F (mL/min) = 2.83 (CLcr in mL/min) + 363 or CL/F (mL/s) = 2.83 (CLcr in mL/s) + 6.05. A. 280 B. 250 C. 310 D. 500 13) Which of the following statements regarding drug dialyzability by peritoneal dialysis is true? A. Drug compounds that are unionized at physiologic pH will diffuse across the member more slowly than ionized compounds. B. Blood flow and peritoneal membrane surface area are intrinsic properties of the peritoneal membrane that affect drug removal. C. Peritoneal dialysis is more effective than hemodialysis (HD) at removing drugs. D. Peritoneal drug clearance is higher for extensively protein bound drugs. 14) Which of the following drugs is most likely to be removed by high flux HD? A. Amlodipine (MW = 567; VD = 21.0 L/kg; Plasma protein binding >95%) B. Atenolol (MW = 266; VD = 1.1 L/kg; Plasma protein binding = 3%) C. Clindamycin (MW= 476; VD = 0.8 L/kg; Plasma protein binding = 94%) D. Apixaban (MW = 460; VD = 0.3 L/kg; Plasma protein binding = 87%) 15) A.T. is a 70-year-old woman who is receiving high-flux dialysis for 4 hours on Tuesdays, Thursdays, and Saturdays on the first dialysis shift of the day (8 am to 12 noon). She has developed shingles (Herpes zoster) and the physician has prescribed acyclovir 800 mg every 12 hours. The molecular weight is 225 Da, protein binding is 30% and volume of distribution is 0.81L/kg. How would you advise the patient on the timing of the acyclovir doses on non-dialysis and dialysis days? A. On non-dialysis days: 800 mg at 8 am and 8 pm. On dialysis days 800 mg at noon and before bed, that is, 10 pm. B. On non-dialysis and on dialysis days 800 mg at 8 am and 8 pm. C. On non-dialysis days 800 mg at 8 am and 8 pm and on dialysis days 800 mg at 8 am, 400 mg at noon and 800 mg at 8 pm. D. None of the above.

Chapter 49: Disorders of Sodium and Water Homeostasis 1) An 85-year-old woman (weight, 55 kg; height, 5'4' [163 cm]) presents with twitching and seizures due to the abrupt development of hypovolemic hypotonic hyponatremia. Her serum sodium concentration is 115 mEq/L (mmol/L). What is this patient's sodium deficit (use 135 mEq/L [mmol/L] as desired serum sodium)? A. 440 mEq (mmol) B. 495 mEq (mmol) C. 660 mEq (mmol) D. 688 mEq (mmol) 2) Which of the following is the appropriate initial treatment for a patient with central diabetes insipidus (DI)? A. Amiloride B. Desmopressin C. Furosemide D. 3% NaCl 3) A patient was started on bumetanide approximately 1 week ago and during a follow-up appointment is noted to be confused, lethargic, and weak. She is hemodynamically stable and without orthostasis. Her serum sodium is found to be 159 mEq/L (mmol/L). Which one of the following is the most appropriate initial fluid to administer to this patient? A. 0.9% NaCl B. Lactated Ringer's C. 3% NaCl D. 0.45% NaCl 4) A patient known to have type 1 diabetes is admitted with a serum glucose concentration of 990 mg/dL (54.9 mmol/L) and a serum sodium concentration of 124 mEq/L (mmol/L). He is a little drowsy but has no other central nervous system-related symptoms. This patient's hyponatremia should be treated with administration of which one of the following infusions? A. 3% NaCl B. Dextrose 5% in water C. 0.9% NaCl D. Vasopressin 5) Excessive sodium bicarbonate supplementation would result in which one of the following sodium disorders? A. Hypovolemic hypernatremia B. Euvolemic hypernatremia C. Hypervolemic hypernatremia D. Hypervolemic hyponatremia 6) Serum osmolality is primarily determined by which one of the following? A. Serum glucose concentration B. Serum sodium concentration C. Serum bicarbonate concentration D. Serum blood urea nitrogen concentration 7) A 75-year-old woman (weight 60 kg) is being seen in clinic for continued treatment of her lung cancer. Upon physical examination, she has good skin turgor, no lower extremity edema, and appears well hydrated. She has no complaints. Routine laboratory values drawn just before clinic were: Na 121 mEq/L (mmol/L), K 2.4 mEq/L (mmol/L), Cl 89 mEq/L (mmol/L), CO2 17

mEq/L (mmol/L), BUN 23 mg/dL (8.2 mmol/L), creatinine 0.8 mg/dL (71 mcmol/L), glucose 95 mg/dL (5.3 mmol/L), Ca 6.9 mg/dL (1.73 mmol/L), Uosm 395 mOsm/kg (mmol/kg), UNa 29 mEq/L (mmol/L), albumin 2 g/dL (20 g/L). What is the MOST likely cause of this patient's hyponatremia? A. Excess sodium excretion B. Nephrogenic diabetes insipidus C. Gastrointestinal (GI) tract fluid losses D. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 8) The medical intern has never managed a patient with severe hyponatremia before and asks your assistance in developing a plan. His patient's serum sodium is 120 mEq/L (mmol/L). Which of the following is the MAXIMUM serum sodium concentration which should be obtained in 6 hours IF the serum sodium concentration is increased at the MAXIMUM recommended rate? A. 123 mEq/L (mmol/L) B. 126 mEq/L (mmol/L) C. 132 mEq/L (mmol/L) D. 140 mEq/L (mmol/L) 9) A 48-year-old woman presents with a 2-day history of fatigue, lethargy, anorexia, and vomiting. Her medical history is significant for malignant melanoma and hypertension. Her current medication list includes morphine sulfate, gabapentin, hydrochlorothiazide, and senna/docusate. On admission her laboratory values are: Na 144 mEq/L (mmol/L), K 3.7 mEq/L (mmol/L), Cl 101 mEq/L (mmol/L), CO2 38 mEq/L (mmol/L), BUN 28 mg/dL (10 mmol/L), creatinine 1.5 mg/dL (133 mcmol/L), glucose 95 mg/dL (5.3 mmol/L), Ca 16 mg/dL (4 mmol/L), Mg 1.8 mg/dL (0.74 mmol/L), phosphorus 3.5 mg/dL (1.13 mmol/L), albumin 2.1 g/dL (21 g/L). In addition to stopping the thiazide diuretic, which one of the following is the MOST appropriate initial pharmacotherapy intervention for this patient's hypercalcemia? A. Observation only; recheck ionized calcium in 6 hours. B. Initiate an infusion of Dextrose 5% in water (D5W) at 100 mL/h. C. Initiate an oral bisphosphonate. D. Initiate 0.9% NaCl at 300 mL/h with furosemide 40 mg IV every 4 hours. 10) A 72-year-old man (weight, 70 kg) was started on furosemide approximately 2 weeks ago for significant heart failure and pulmonary edema. He presents today with a BP of 76/30 mmHg, HR of 138 bpm, and significant orthostasis. His serum sodium is 164 mEq/L (mmol/L). Which of thefollowing is the MOST appropriate initial intervention? A. A 500-mL IV bolus of Dextrose 5% in water (D5W) over 30 minutes. B. A 1000-mL IV bolus of 0.9% NaCl over 30 minutes. C. A 500-mL IV bolus of 0.9% NaCl over 60 minutes. D. A 1000-mL IV bolus of Dextrose 5% / 0.45% NaCl over 30 minutes. 11) Thiazide diuretics reach their site of action in the renal tubular lumen via which of the following processes? A. Active secretion by proximal tubular cells B. Glomerular filtration by proximal tubular cells C. Diffusion from the systemic circulation

D. Reabsorption by proximal tubular cells 12) A 58-year-old man with severe heart failure has recurrent 3+ lower extremity pitting edema and pulmonary congestion. His physician increased his furosemide dose to 80 mg every 6 hours 1 week ago without resolution of his symptoms. His glomerular filtration rate is 30 mL/min (0.5 mL/s) and urine output is approximately 0.4 mL/kg/h. His oxygen saturation is 96% on room air. What is the most appropriate change to his diuretic therapy at this time? A. Increase the furosemide dosage. B. Stop oral furosemide; start continuous IV furosemide infusion. C. Add torsemide. D. Add metolazone. 13) A 26-year-old with congenital nephrogenic DI is intubated after sustaining multiple traumatic injuries in a motor vehicle accident. The patient's serum sodium is 151 mEq/L (mmol/L), and her 24-hour urine output is 6 L. Which of the following treatments should be considered in addition to D5W at 275 mL/h for the next 24 hours? A. Amiloride 5 mg per gastric tube daily B. Hydrochlorothiazide 25 mg per gastric tube daily C. Sodium restriction to 4,000 mg NaCl per day D. Demeclocycline 300 mg three times daily 14) How will a 1200-mL bolus of D5/0.2% NaCl change the extracellular fluid (ECF) and intracellular fluid (ICF) compartment volumes? A. Increase the ECF by 1200 mL B. Increase the ICF by 1200 mL C. Increase the ECF by 600 mL and the ICF by 600 mL D. Increase the ECF by 300 mL and the ICF by 900 mL 15) A 49-year-old man is admitted to the hospital with acute decompensated heart failure and a serum sodium of 130 mEq/L (mmol/L). His left ventricular ejection fraction is 35% (0.35). His home oral furosemide is converted to intermittent intravenous doses. The patient's serum sodium continues to decrease (currently 118 mEq/L [mmol/L]), and he is becoming increasingly confused and somnolent. Which of the following is the most appropriate treatment to initiate in this patient? A. Demeclocycline 300 mg by mouth three times daily B. Dietary sodium restriction to 2,000 mg/day C. Conivaptan 20 mg IV over 30 minutes then 20 mg over 24 hours (0.83 mg/h) D. Tolvaptan 15 mg by mouth daily

Chapter 50: Disorders of Calcium and Phosphorus Homeostasis 1) A malignancy associated with hypercalcemia from PTH-related protein is: A. Squamous cell lung carcinoma B. Prostate C. Leukemia D. Cervical E. Multiple myeloma 2) A 68-year-old woman with primary hyperparathyroidism and severe alcoholism presents with a serum total calcium of 8.3 mg/dL (2.08 mmol/L), serum albumin of 1.2 g/dL (12 g/L), serum

phosphorus 2.3 mg/dL (0.74 mmol/L). Her symptoms include weakness and polyuria. Which of the following electrolyte disorders is responsible for her symptoms? A. Hypocalcemia. B. Hypercalcemia. C. Hyperphosphatemia. D. Hypophosphatemia. E. She does not have an electrolyte disorder. 3) A 56-year-old woman with stage 4 breast cancer presents to the emergency department with profound weakness, abdominal pain with nausea and vomiting, and profound dehydration. Laboratory analysis reveals: sodium 135 mEq/L (mmol/L), potassium 4.5 mEq/L (mmol/L), chloride 101 mEq/L(mmol/L), bicarbonate 24 mEq/L (mmol/L), serum creatinine 1.2 mg/dL (106 µmol/L), BUN 40 mg/dL (14.3 mmol/L), and total calcium 14.2 mg/dL (3.55 mmol/L). What is the most likely cause of her hypercalcemia? A. Primary hyperparathyroidism B. Secondary hyperparathyroidism associated with kidney disease C. Bone metastases D. Excessive endogenous vitamin D production 4) Which of the following is the most appropriate initial therapy for this patient? A. Hemodialysis with a low calcium bath B. High dose IV loop diuretic C. Saline hydration D. IV bisphosphonate E. Subcutaneous calcitonin 5) A 65-year-old woman with asymptomatic hypercalcemia secondary to metastatic breast cancer presents with a serum calcium of 12.2 mg/dL (3.05 mmol/L). Her serum creatinine is 0.9 mg/dL (80 µmol/L) and estimated glomerular filtration rate (GFR) is more than 60 mL/min/1.73 m2. The decision is made to initiate therapy with an agent that inhibits bone resorption. Based on the efficacy and toxicity profile of the following agents, which would be the most appropriate to initiate in this patient? A. Prednisone B. Zoledronic acid C. Calcitonin D. Denosumab 6) Which of the following could be considered for treatment of a 65-year-old woman with primary hyperparathyroidism to reduce stone number and diameter? A. Cinacalcet B. Calcium-restricted diet C. Lithotripsy D. Calcium binding exchange resin 7) The most appropriate therapy for hypocalcemia in a patient post bariatric surgery with estimated GFR more than 60 mL/min/1.73m2: A. Ergocalciferol B. Doxercalciferol C. Paricalcitol D. Calcitriol

8) A 35-year-old man is status post a parathyroidectomy and develops hungry bone syndrome with seizures and tetany postoperatively. His ionized calcium is 1.0 mmol/L (0.25 mmol/L). He is treated with calcium gluconate 2 g IV. Which of the following is not appropriate regarding the administration of calcium gluconate? A. Electrocardiogram (ECG) monitoring is required B. Administer IV push C. Check serum calcium every 4 to 6 hours D. Administer by slow infusion over 2 to 4 hours 9) A 85-year-old patient with chronic kidney disease stage 3b (estimated GFR 40 ml/min/1.73m2). Her present medications include ramipril 10 mg qd, furosemide 80 mg BID, and amlodipine 10 mg qd. She is scheduled to have a colonoscopy and she is advised to purchase a sodium phosphate bowel preparation (Fleet Phospho-Soda). All but which of the following put her at increased risk for phosphate nephropathy or acute kidney injury? A. Chronic kidney disease B. Ramipril therapy C. Amlodipine therapy D. Diuretic therapy 10) A 45-year-old man on with stage 4 chronic kidney disease with a hemoglobin of 8 g/dL (80 g/L; 4.97 mmol/L), transferrin saturation 12% and ferritin 75 ng/mL (mcg/L) is scheduled to receive a 750-mg dose of ferric carboxymaltose IV. Three days after the infusion he calls the office and complains of symptoms of myalgias and weakness. An important electrolyte disorder to evaluate for determination of the etiology of his symptoms is: A. Hyperphosphatemia B. Hypophosphatemia C. Hypercalcemia D. Hypocalcemia 11) A patient in the ICU has gram-negative sepsis. Laboratory data reveal arterial pH 7.5, pCO2 28 mm Hg (3.7 kPa), bicarbonate 21 mEq/L (mmol/L), pO2 52 mm Hg (6.9 kPa) and serum phosphorus 1.8 mg/dL (0.58 mmol/L), and potassium 5.9 mEq/L (mmol/L). Which of the following best describes the pathogenesis of his hypophosphotemia? A. Increased renal excretion B. Extracellular fluid dilution C. Redistribution D. Binding to serum calcium 12) Hemolysis related to hypophosphatemia is most likely caused by which of the following? A. Altered cardiac conduction B. Depletion of adenosine triphosphate (ATP) stores C. Myocardial cell apoptosis D. All of the above 13) An 85-year-old patient who resides in a nursing home develops hypophosphatemia (serum phosphorus 1.1 mg/dL [0.36 mmol/L]) secondary to limited oral intake associated with advanced dementia. His other laboratory data include: serum potassium 3.4 mEq/L (mmol/L) and total corrected calcium 8.5 mg/dL (2.13 mmol/L). Which of the following is the best therapy to initiate in this patient? A. Neutra-phos-K B. K-phos Neutral

C. Neutra-phos D. Potassium phosphate IV 14) A 42-year-old patient receiving hemodialysis has a parathyroidectomy. He develops symptomatic hypocalcemia immediately post-surgery. The most likely cause of this is: A. Vitamin D deficiency B. Hypothyroidism C. Hungry bone syndrome D. Hypomagnesemia 15) A 32 year old patient with chronic kidney disease is picking up a prescription for cinacalcet should be counseled on which potential adverse effect? A. nephrolithiasis B. tingling around the mouth (paresthesia) C. extrapyramidal symptoms D. orange tinged urine Chapter 51: Disorders of Potassium and Magnesium Homeostasis 1) Which of the following treatments for hyperkalemia works by preventing intestinal absorption of potassium? A. Albuterol B. Sodium polystyrene sulfonate C. Sodium bicarbonate D. Insulin + dextrose 2) Which of the following drugs would be expected to result in hyperkalemia? A. Hydrochlorothiazide B. Fosinopril C. Furosemide D. Albuterol 3) A patient has the following symptoms on presentation: lethargy, decreased deep tendon reflexes, somnolence. She most likely has which of the following conditions? A. Hypokalemia B. Hyperkalemia C. Hypomagnesemia D. Hypermagnesemia 4) Which of the following is immediate first-line therapy for hyperkalemia associated with electrocardiogram (ECG) changes? A. Furosemide 40 mg PO B. Calcium gluconate 1 g IV C. Hemodialysis D. Regular insulin 10 Units IV 5) Which of the following statements regarding IV potassium is correct? A. The infusion rate should not exceed 10 mEq/h (mmol/h) in a peripheral line. B. IV potassium is preferred in all hospitalized patients. C. Potassium should be diluted in dextrose 5% water. D. Continuous ECG monitoring is always necessary when infusing potassium. 6) A patient who cannot tolerate oral potassium preparations most likely has which of the following adverse effects?

A. Itching B. Hypoglycemia C. Gastrointestinal (GI) upset D. Muscle cramps 7) A patient presents with Trousseau sign. She most likely has which of the following conditions? A. Hypokalemia B. Hyperkalemia C. Hypomagnesemia D. Hypermagnesemia 8) A patient presents with ventricular fibrillation on ECG. He most likely has which of the following conditions? A. Hypokalemia B. Hyperkalemia C. Hypomagnesemia D. Hypermagnesemia 9) Your patient develops hyperkalemia (without ECG changes) as a result of severe metabolic acidosis. Which of the following is considered the first-line treatment option? A. IV calcium gluconate B. Insulin + dextrose C. Albuterol D. Sodium bicarbonate 10) Which of the following is a possible adverse effect of intravenous magnesium replacement therapy? A. Diarrhea B. Renal failure C. Muscle pain D. Flushing 11) A patient on a general medicine floor has morning laboratories drawn, which include a serum potassium of 3.2 mEq/L (mmol/L) and serum magnesium of 0.9 mg/dL (0.37 mmol/L). He is given 40 mEq (mmol) of liquid potassium chloride by mouth. Repeat laboratories drawn 8 hours later reveal a serum potassium of 3.4 mEq/L (mmol/L) and serum magnesium 0.9 mg/dL (0.37 mmol/L). What is the most appropriate therapy to order for this patient to increase his serum potassium? A. Potassium chloride 60 mEq (mmol) PO B. Magnesium sulfate 2 g IV C. Potassium chloride 40 mEq (mmol) IV D. Magnesium oxide 400 mg PO 12) Proton pump inhibitors cause hypomagnesemia through which mechanism? A. Hormone-induced renal losses B. Internal redistribution C. Reduced GI intake D. Reduced GI absorption 13) Disorders of potassium primarily affect the cardiovascular system and which other system? A. Neuromuscular B. Renal

C. Skeletal D. GI 14) Which of the following does not affect potassium homeostasis? A. Acid–base balance B. Body fluid tonicity C. Circulating acetylcholine D. Urinary excretion 15) Which of the following patients is most likely to develop hypermagnesemia? A. A 40-year-old alcoholic receiving treatment for acute alcohol withdrawal. B. A 35-year-old patient receiving treatment for fungemia with amphotericin B. C. A 65-year-old patient with end-stage renal disease (ESRD) who has missed the past 2 dialysis sessions. D. A 17-year-old patient with newly diagnosed hypothyroidism.

Chapter 52: Acid–Base Disorders 1) A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08 PCO2 80 mm Hg (10.6 kPa), HCO3 23 mEq/L (mmol/L). His most recent serum labs demonstrated: Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L) and TCO2 23 mEq/L (mmol/L). His acid–base disturbance is: A. Respiratory acidosis with an elevated anion gap B. Respiratory acidosis with a normal anion gap C. Metabolic alkalosis D. Metabolic acidosis with a normal non-anion gap E. Metabolic acidosis with an elevated anion gap 2) A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08 PCO2 80 mm Hg (10.6 kPa), HCO3 23 mEq/L (mmol/L). His most recent serum labs demonstrated: Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L) and TCO2 23 mEq/L (mmol/L). Which of the following is most true about extracellular buffering? A. The magnesium-potassium system plays an important initial role. B. The bicarbonate system is the most important because it is not dependent on the amount of bicarbonate that is filtered by the kidney. C. The phosphate buffer system plays a limited role given extracellular phosphate concentrations are low. D. The carbonic acid buffering system plays a minimal role given the low amount of CO2 produced by the body. E. The stomach plays an important role give its ability to alter the amount gastric acid it produces. 3) A 31-year-old man, LG, was found to be unresponsive and apneic by an off-duty nurse a block away from the emergency department where she works. He was quickly brought to the emergency department where an arterial blood gas (ABG) sample revealed the following: pH 7.08 PCO2 80 mm Hg (10.6 kPa), HCO3 23 mEq/L (mmol/L). His most recent serum labs

demonstrated: Na 130 mEq/L (mmol/L); Cl 111 mEq/L (mmol/L) and TCO2 23 mEq/L (mmol/L). Following the administration of naloxone 10mg IV × 1 to LG, which of the following statements is most true regarding the expected compensation for his acid–base disturbance? A. Compensation will occur over the next 2 hours by the renal accumulation of bicarbonate. B. Compensation will occur over the next 24 hours as his respiratory rate decreases. C. Compensation will occur over the next 24 hours as his respiratory rate increases. D. Compensation will occur over the next 2 hours by the renal elimination of bicarbonate. E. Compensation will occur over the next 2 hours as his respiratory rate increases. 4) A 68-year-old man, KL, (weight = 70kg; height = 69 inches [175 cm]), with a longstanding history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is: pH 7.30, PCO2 34 mmHg (4.5 kPa), HCO3 15 mEq/L (mmol/L), and his PO2 80 mmHg (10.6 kPa) and his most recent serum labs demonstrate: Na 135 mEq/L (mmol/L); K 5.4 mEg/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. His acid–base disturbance is: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis (with a normal anion gap) E. Metabolic acidosis (with an elevated anion gap) 5) A 68-year-old man, KL, (weight = 70kg; height = 69 inches [175 cm]), with a longstanding history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is: pH 7.30, PCO2 34 mmHg (4.5 kPa), HCO3 15 mEq/L (mmol/L), and his PO2 80 mmHg (10.6 kPa) and his most recent serum labs demonstrate: Na 135 mEq/L (mmol/L); K 5.4 mEg/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. Which of the following conditions best explains his current acid–base status? A. Diabetic ketoacidosis B. Septic shock C. Proximal (type II) renal tubular acidosis (RTA) D. Distal (type IV) RTA E. Type 1 RTA 6) A 68-year-old man, KL, (weight = 70kg; height = 69 inches [175 cm]), with a longstanding history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is: pH 7.30, PCO2 34 mmHg (4.5 kPa), HCO3 15 mEq/L (mmol/L), and his PO2 80 mmHg (10.6 kPa) and his most recent serum labs demonstrate: Na 135 mEq/L (mmol/L); K 5.4 mEg/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. KL is found to be hypertensive (BP 170/92 mm Hg) and the medical resident asks you if there is an antihypertensive that should be avoided in KL based on the underlying condition that is felt to be contributing to KL's current acid–base status. Which of the following agent should be avoided in KL at this time? A. Angiotensin converting enzyme (ACE) inhibitor B. Clonidine C. Hydralazine

D. Amlodopine E. Long-acting nifedipine 7) A 68-year-old man, KL, (weight = 70kg; height = 69 inches [175 cm]), with a longstanding history of poorly controlled diabetes, is admitted to the medical floor of a hospital with a diagnosis of community-acquired pneumonia. His most recent ABG is: pH 7.30, PCO2 34 mmHg (4.5 kPa), HCO3 15 mEq/L (mmol/L), and his PO2 80 mmHg (10.6 kPa) and his most recent serum labs demonstrate: Na 135 mEq/L (mmol/L); K 5.4 mEg/L (mmol/L), Cl 116 mEq/L (mmol/L), TCO2 15 mEq/L (mmol/L), and blood glucose 146 mg/dL (8.1 mmol/L). He is hemodynamically stable. A decision is made to administer IV sodium bicarbonate to KL. What is the most appropriate sodium bicarbonate loading dose to administer? A. 1026 mEq/L (mmol/L) B. 833 mEq/L (mmol/L) C. 595 mEq/L (mmol/L) D. 315 mEq/L (mmol/L) E. 168 mEq/L (mmol/L) 8) Which of the following human immunodeficiency virus (HIV) medications has been most associated with lactic acidosis? A. Rilpivirine B. Efavirenz C. Stavudine D. Elvitegravir E. Delavirdine 9) Which of the following statement is most true regarding RTA? A. Proximal RTA (type II) is caused by a defect in the proximal tubule which prevents bicarbonate from being reabsorbed. B. Distal RTA (type IV) can be caused by aldosterone resistance and often results in hypokalemia. C. Proximal RTA (type II) and distal RTA (type I) are associated with sodium wasting and hypokalemia. D. Renal tubular acidosis is usually associated with a high anion gap resulting from an increase in unmeasured anions. E. None of the above is TRUE. 10) A 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), HCO3 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L); Cl 83 mEq/L (mmol/L); K 4.9 mEq/L (mmol/L); and glucose 345 mg/dL (19.1 mmol/L). His acid–base disturbance is: A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis (normal anion gap) E. Metabolic acidosis (elevated anion gap)

11) 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), HCO3 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L); Cl 83 mEq/L (mmol/L); K 4.9 mEq/L (mmol/L); and glucose 345 mg/dL (19.1 mmol/L). Which of the following statements is true regarding the expected compensation for his acid–base disturbance: A. Compensation will occur within days by the renal excretion of bicarbonate. B. Compensation will occur within days by renal reabsorption of bicarbonate. C. Compensation will occur within hours by increasing the respiratory rate. D. Compensation will occur within hours by decreasing the respiratory rate. E. None of the above is TRUE. 12) A 31-year-old man presents with lethargy, weakness, labored respiration, and confusion. He has had diabetes for 15 years, and has been suffering from the "intestinal flu" for a day or so, for which he has been avoiding food to help prevent further vomiting and "make his stomach ache go away." Since he stopped eating, he thought that it would be a good idea to stop taking his insulin. When seen in the emergency department his urine dipped positive for both glucose and ketones and his breath had a strange sweet, fruity smell. The following arterial blood gas data was obtained: pH 7.27, PCO2 23 mm Hg (3.1 kPa), HCO3 10 mEq/L (mmol/L). His most recent serum chemistries are as follows: Na 132 mEq/L (mmol/L); Cl 83 mEq/L (mmol/L); K 4.9 mEq/L (mmol/L); and glucose 345 mg/dL (19.1 mmol/L). Which of the following is most true regarding lactic acidosis? A. Has rarely been reported with linezolid therapy of more than 4 weeks duration. B. Administration of propofol at a dose of 10 mcg/kg/min for one day increases a patient's risk for lactic acidosis. C. Occurs when the serum lactate concentration exceeds 2 mEq/L (mmol/L). D. Nucleoside-analogue reverse transcriptase-induced lactic acidosis is caused by the inhibition of the enzyme RNA gamma alpha. E. None of the above is TRUE. 13) Which of the following is most correct regarding administration of IV sodium bicarbonate to a patient with septic shock who has a high anion gap metabolic acidosis with an arterial pH of 7.29? A. Sodium bicarbonate use will reduce mortality. B. Sodium bicarbonate use may paradoxically reduce intracellular pH. C. Sodium bicarbonate use should be reserved for only those patients with an arterial pH less than or equal to 7.25. D. Sodium bicarbonate use will reduce the efficacy of norepinephrine. E. Sodium bicarbonate use will increase the risk for ventricular tachyarrhythmias. 14) Which of the following statements is most true regarding respiratory acidosis? A. Respiratory acidosis is common in patients who are wildly agitated in the emergency department. B. Respiratory acidosis is a primary increase in PCO2 resulting in a decreased arterial pH.

C. The PCO2 is the primary stimulus to breathe in a patient with end-stage chronic obstructive pulmonary disease who is managed at home with oxygen therapy. D. Renal bicarbonate excretion is an expected response to respiratory acidosis. E. None of the above is TRUE. 15) Which of the following therapies would be most likely administered to a patient with a sodium chloride-resistant metabolic alkalosis? A. Acetazolamide B. Arginine monohydrochloride C. Ammonium chloride D. IV hydrochloric acid E. Spironolactone 16) Which of the following treatments should be avoided in a patient with severe metabolic acidosis who has end-stage liver disease? A. Hemodialysis B. Sodium bicarbonate C. Tromethamine (THAM) D. Acetazolamide E. Ammonium chloride Chapter 53: Evaluation of Neurologic Illness 1) When evaluating a spinal lesion near a bone, the best imaging choice would be which of the following? A. Computed tomography (CT) B. Computed tomography angiography (CTA) C. Magnetic resonance imaging (MRI) D. Single-photon emission computed tomography (SPECT) 2) Lumbar puncture is useful in the diagnosis of which of the following? A. Epilepsy B. Ischemic stroke C. Meningitis D. Parkinson disease 3) Which of the following is a component of the neurologic examination? A. Abdominal rebound B. Gait C. Heart sounds D. Skin turgor 4) You are presented with the following cerebrospinal fluid (CSF) results: red blood cells = 400/mm3 (400 × 106/L), white blood cells = 0/mm3 (0 × 106/L), protein = 200 mg/dL (2.0 g/L), and xanthochromia. Which of the following is the best interpretation? A. Meningitis B. Multiple sclerosis C. Normal D. Subarachnoid hemorrhage 5) A patient presents with bilateral leg weakness, difficulty urinating, and numbness from the waist down. Which of the following is the best imaging technique to localize the lesion? A. Functional MRI of the spine

B. MRI of the head C. MRI of the spine D. SPECT scan of the head 6) Elements of the pediatric neurologic history may include which of the following: A. (EEG) Electroencephalography B. Evaluation of developmental milestones C. Evaluation of respiratory symptoms D. Measurement of waist girth 7) When obtaining a history on an adult patient with recent numbness and tingling in her left arm, which of the following should be asked? A. What exacerbates the symptoms? B. What causes the arm to throb? C. Were there any anomalies when you were born? D. When was your last menstrual period? 8) For which of the following patients could a lumbar puncture (LP) be performed? A. A patient with a coagulopathy B. A patient with symptoms of meningitis C. A patient with a space-occupying lesion with mass effect D. A patient with papilledema 9) A patient presents with headache and fever. CSF is obtained with the following results: red blood cells = 0/mm3 (0 × 106/L), white blood cells = 215/mm3 (215 × 106/L), protein = 200 mg/dL (2.0 g/L), and glucose 15 mg/dL (0.8 mmol/L). Which of the following is the best interpretation? A. Meningitis B. Multiple sclerosis C. Normal D. Subarachnoid hemorrhage 10) Which of the following neurologic examination techniques is most useful to diagnose a patient with myasthenia gravis? A. Reflexes B. Gait C. Cerebellar function D. Cranial nerve examination 11) A patient presents with decreased strength, reflex changes, and cranial nerve findings. Which of the following diagnoses should be considered? A. Meningitis B. Parkinson disease C. Amyotrophic lateral sclerosis D. Peripheral neuropathy 12) You are asked to evaluate the pharmacotherapy of a patient with Parkinson disease. Which of the following neurologic examination techniques will you use to assess the effects of the therapy? A. Cranial nerve evaluation B. Sensation testing C. Motor function evaluation D. Reflex testing

13) You are participating in a study of a new agent for cerebellar degeneration. Which of the following tests should be performed at study visits? A. Memory tests B. Reflex testing C. Visual acuity testing D. Finger-to-nose testing 14) You watch a neurologist perform the following tests: tandem walking, walking on tiptoe, Romberg testing. Which of the following is he/she likely assessing? A. Mental status B. Reflexes C. Cranial nerves D. Gait 15) A patient presents with a suspected small vessel vasculitic stroke. Which of the following tests provides the best images of the small vessels? A. Conventional dye angiography B. Computed tomography C. Magnetic resonance angiography D. Transcranial Doppler ultrasonography

Chapter 54: Alzheimer Disease 1) Which of the following is the most common form of dementia among older adults? A. Lewy body dementia B. Vascular dementia C. Alzheimer disease D. Organic brain syndrome 2) Genetic susceptibility to late-onset AD is primarily linked to which of the following? A. Apolipoprotein E4 genotype B. Presenilin gene mutations C. Amyloid precursor protein mutations D. Apolipoprotein E2 genotype 3) Which of the following statements is TRUE regarding the pathophysiology of AD? A. AD is caused by amyloid plaques B. AD is caused by neurofibrillary tangles C. AD is caused by inflammatory brain processes D. The cause of AD is not completely understood 4) When initiating pharmacologic treatment for a patient with a new diagnosis of AD, which of the following would be the safest and most effective option? A. Vitamin E B. Donepezil C. Ginkgo biloba D. Estrogen 5) Which acetylcholinesterase inhibitor inhibits both butyrylcholinesterase and acetylcholinesterase? A. Donepezil B. Galantamine

C. Memantine D. Rivastigmine 6) Which prescription medication approved to treat AD is also approved to treat dementia associated with Parkinson disease? A. Donepezil B. Galantamine C. Memantine D. Rivastigmine 7) Which of the following interventions is considered first-line therapy for behavioral and psychiatric symptoms of dementia? A. Sertraline B. Quetiapine C. Carbamazepine D. Multisensory stimulation 8) AM is an 87-year-old man who was diagnosed with AD and vascular dementia 2 years ago. At that time, he was started on donepezil 5 mg daily and has continued on that dose since the diagnosis was made. He denies any difficulty tolerating the drug. He takes warfarin for atrial fibrillation and lisinopril for hypertension. AM's wife notes that his memory has declined significantly over the last several months. Which of the following statements is TRUE regarding AM's donepezil therapy? A. AM is receiving an appropriate maintenance dose of donepezil B. AM has not been titrated to the target maintenance dose of donepezil C. Donepezil is not appropriate therapy for a patient in AM's stage of AD D. Donepezil should be avoided in patients with vascular dementia and atrial fibrillation 9) AM is an 87-year-old man who was diagnosed with AD and vascular dementia 2 years ago. At that time, he was started on donepezil 5 mg daily and has continued on that dose since the diagnosis was made. He denies any difficulty tolerating the drug. He takes warfarin for atrial fibrillation and lisinopril for hypertension. AM's wife notes that his memory has declined significantly over the last several months. AM's wife confides in you that she is planning to start AM on a supplement for brain health that contains Ginkgo biloba. What would be the most appropriate advice to offer AM's wife regarding Gingko biloba? A. Ginkgo biloba is appropriate therapy for AM because it is more effective than donepezil B. Ginkgo biloba should be avoided in AM because of its potential to worsen cognitive outcomes C. Ginkgo biloba should be avoided in AM because of its potential drug interaction with warfarin D. Ginkgo biloba is appropriate for AM because it is effective for treating both AD and atrial fibrillation 10) AM is an 87-year-old man who was diagnosed with AD and vascular dementia 2 years ago. At that time, he was started on donepezil 5 mg daily and has continued on that dose since the diagnosis was made. He denies any difficulty tolerating the drug. He takes warfarin for atrial fibrillation and lisinopril for hypertension. AM's wife notes that his memory has declined significantly over the last several months. Which of the following is an appropriate recommendation for AM's wife regarding management of AM's cardiovascular disease? A. Since AM has been diagnosed with dementia, hypertension control is no longer necessary

B. Since AM has been diagnosed with dementia, the risks of continuing warfarin outweigh the potential benefits C. Since AM has been diagnosed with dementia, clopidogrel and aspirin should be added to AM's drug regimen to improve vascular health D. Since AM has been diagnosed with dementia, treating hypertension and atrial fibrillation is recommended to optimize brain vascular health 11) LR is an 84-year-old woman who was diagnosed with AD 4 years ago. Her symptoms first became apparent to her family about 1 year before the diagnosis was made. Her mini-mental state examination (MMSE) score is 14, she is unable to perform most activities of daily living, and she does not recognize her caregivers on some days. Which of the following drugs/drug combinations has NOT been shown to be effective therapy for LR's stage of AD? A. Donepezil 10 mg nightly at bedtime + rivastigmine 6 mg twice daily B. Donepezil 10 mg nightly at bedtime C. Memantine 10 mg twice daily D. Donepezil 10 mg nightly at bedtime + memantine 5 mg twice daily 12) LR is an 84-year-old woman who was diagnosed with AD 4 years ago. Her symptoms first became apparent to her family about 1 year before the diagnosis was made. Her mini-mental state examination (MMSE) score is 14, she is unable to perform most activities of daily living, and she does not recognize her caregivers on some days. LR's husband asks about using Tylenol PM to help his wife fall asleep. What would you recommend? A. Tylenol PM is preferred over prescription sedative/hypnotics to treat insomnia in patients with AD B. Tylenol PM is preferred for both pain and insomnia because it may enhance the effects of cholinesterase inhibitors in patients with AD C. Tylenol PM should be avoided because of the pharmacokinetic drug interaction between diphenhydramine and memantine D. Tylenol PM should be avoided because diphenhydramine may worsen cognitive function 13) PP is a 77-year-old woman who was diagnosed with AD 2 months ago. Her MMSE score at the time of diagnosis was 21. At that time, donepezil was started at a dose of 5 mg nightly at bedtime. Would it be considered appropriate to add memantine to her drug regimen at this time? A. Yes; PP has moderate AD B. Yes; PP is unlikely to respond to donepezil C. No; PP has mild AD D. No; memantine should never be added to cholinesterase inhibitor therapy 14) Of the following, which is the most common side effect of donepezil? A. Elevated blood pressure B. Elevated blood glucose C. Agitation D. Diarrhea 15) Which of the following counseling points would be appropriate to discuss with a newly diagnosed patient and their family in regard to expectations of AD therapy? A. Combination therapy with a cholinesterase inhibitor plus memantine usually halts the progression of AD B. The risk of prescription drug side effects outweighs the benefit in mild disease C. The time to reach significant functional decline may be delayed by drug therapy, but the disease will continue to progress

D. Memory noticeably improves for most patients when therapy is first initiated Chapter 55: Multiple Sclerosis 1) At the time of diagnosis, the most common form of multiple sclerosis (MS) is? A. Primary-progressive B. Relapsing-progressive C. Relapsing-remitting D. Secondary-progressive 2) JM is a 32-year-old male who presents with gait disturbance and loss of balance. His magnetic resonance imaging (MRI) shows a high T2 burden of disease with multiple lesions in multiple locations in the brain. Which of the following is not a poor prognostic factor for JM? A. Age B. Gender C. Initial presentation of symptoms D. MRI presentation 3) In the case above, JM's physician decides to initiate natalizumab therapy 300 mg IV every 4 weeks. Which of the following is not a monitoring parameter? A. Liver function tests B. Anti-JCV Antibodies C. Tuberculin skin test D. MRI 4) Which of the following is used in the treatment of an exacerbation (attack/relapse) of MS? A. Oral Immunoglobulin B. High-dose IV methylprednisolone C. Low-dose oral prednisone D. Mitoxantrone 5) PJ is a 47-year-old female with RRMS who presents to the clinic with complaints of fatigue. The physician decides to prescribe a medication for the symptomatic treatment of fatigue. Which of the following agents would not be appropriate? A. Methylphenidate 5 mg every morning B. Modafinil 200 mg every morning C. Amantadine 100 mg twice daily D. Dextromethorphan/quinidine 20 mg/10 mg every morning 6) Which is true about spasticity in MS? A. Spasticity occurs early after a patient is diagnosed with MS B. Increased muscle tone due to spasticity in late stage MS can help to decrease falls due to weakness C. Fluoxetine is a first-line agent to treat spasticity D. Baclofen is useful orally, intrathecally, and IV for spasticity 7) When counseling a patient about interferon therapy for MS, you should communicate to the patient which important aspect regarding efficacy? A. He or she will start to notice a change in symptoms immediately B. He or she must freeze the medication C. It may take up to 1 or 2 years to see a change on the MRI D. The medication works best if a double dose is given 8) Interferon-βla (Rebif) differs from Interferon-βla (Avonex) in what way?

A. Rebif is given once per week B. Rebif is given as an intramuscular injection C. Rebif is given three times per week D. Rebif causes tissue necrosis 9) SW is a 55-year-old male currently on Interferon-βla (Rebif) 44 mcg subcutaneously three times per week, warfarin, and amiodarone. In the past 6 months, he has had three exacerbations and multiple new enhancing lesions on MRI. Following discontinuation of Rebif what is the best next step in his course of therapy? A. Natalizumab B. Glatiramer acetate C. Mitoxantrone D. Fingolimod 10) Which of the following is not a side effect seen with interferon therapy (Avonex, Betaseron, Extavia, Rebif, or Peginterferon)? A. Flu-like symptoms B. Depression C. Chest tightness and facial flushing D. Skin injection-site reactions 11) SC, a 30-year-old female, was prescribed teriflunomide 7 mg orally daily for the treatment of her relapsing MS. Which of the following counseling points is false? A. Teriflunomide is a pregnancy category X medication and a contraceptive method is recommended. B. Alopecia, nausea, headache, and paresthesias are common side effects associated with teriflunomide. C. A cholestyramine washout may be considered if pregnancy is desired. D. Teriflunomide causes secondary leukemia in 1 in 1,400 patients. 12) Efficacy of the interferons can be attributed to which mechanism of action? A. β1-blockade B. α1 - and β1-blockade C. Immune system dysregulation in the CNS D. Immune system modulation in the periphery and at the blood–brain barrier 13) Glatiramer acetate (Copaxone) is thought to act by which of the following mechanisms of action? A. Decrease matrix metalloproteinases B. Inhibition of the proliferation of reactive T-cells C. Decreased number of adhesion molecules D. Blockage of the binding of major histocompatibility (MHC) class II products to myelin basic protein (MBP) 14) MB, a 35-year-old female with RRMS, asks you about an MS drug that requires a 6-hour observation period. Which of the following drugs requires a 6-hour observation monitoring period? A. Mitoxantrone B. Natalizumab C. Fingolimod D. Interferon-βla

15) CC, a 52-year-old female, is having difficulty walking without stopping every 25 feet (7-8 m) or so to take a break. Which of the following drugs is the most appropriate choice for CC at this time? A. Mitoxantrone B. Modafinil C. Interferon-βla (Extavia) D. Dalfampridine 16) Which agent is contraindicated in pregnancy? A. Glatiramer acetate B. Teriflunomide C. Mitoxantrone D. Natalizumab 17) PW is a 30-year-old female diagnosed with RRMS approximately 10 years ago, and now wants to switch to a DMT that is given the leastfrequently. Which of the following DMTs is initially given as an infusion once a year for 5 consecutive days? A. Teriflunomide B. Fingolimod C. Natalizumab D. Alemtuzumab

Chapter 56: Epilepsy 1) At what age is the incidence of epilepsy the highest? A. Childhood B. Adolescence C. Elderly D. both A and B E. both A and C 2) The key feature of generalized onset seizures is: A. onset in one hemisphere B. onset in both hemispheres C. spread to both hemispheres D. onset accompanied by aura 3) The key feature of focal dyscognitive seizures is: A. onset in one hemisphere B. impairment of consciousness C. onset accompanied by aura D. evolution to bilateral convulsions 4) Nonpharmacologic therapy of the epilepsy patient can involve all of the following in the appropriate patient except: A. temporal lobe surgery B. low glycemic index diet treatment C. acupuncture D. vagal nerve stimulator 5) Which antiseizure drug's serum level is most affected by the pregnancy state: A. levetiracetam

B. lamotrigine C. phenytoin D. carbamazepine E. lacosamide 6) Which antiseizure drug is most likely associated with major congenital malformations: A. vigabatrin B. primidone C. phenytoin D. zonisamide E. valproic acid 7) Which antiseizure drug may aggravate (generalized) childhood absence epilepsy? A. phenytoin B. valproic acid C. ethosuximide D. carbamazepine E. both A and D are correct 8) Which antiseizure drug is generally a CYP450 inhibitor? A. carbamazepine B. phenytoin C. phenobarbital D. valproic acid 9) Which antiseizure drug is associated with irreversible vision loss after long-term use? A. vigabatrin B. lacosamide C. levetiracetam D. valproic acid E. rufinamide 10) Which antiseizure drug is often associated with increased irritability? A. felbamate B. clobazam C. levetiracetam D. lamotrigine E. phenytoin 11) Mr. H has a history of calcium phosphate kidney stones and is allergic to sulfa. Which is the worst choice of antiseizure drug to use in the treatment of Mr. H's partial seizures? A. topiramate B. lacosamide C. zonisamide D. carbamazepine E. oxcarbazepine 12) Which antiseizure drug is more likely to cause speech or language problems? A. valproic acid B. tiagabine C. phenytoin D. topiramate E. none are correct

13) A drug-resistant epilepsy patient is one who has failed: A. one drug B. two drugs C. three drugs D. more than three drugs 14) In a patient taking an older enzyme inducer antiseizure drug, which form of birth-control does not need a back-up method to avoid pregnancy? A. transdermal contraceptive patch B. emergency contraceptive pill C. oral contraceptive pills D. hormone-releasing intrauterine device system 15) Which antiseizure drug has saturable GI absorption, and therefore should not be given in large doses all at once: A. gabapentin B. tiagabine C. pregabalin D. lacosamide E. none are correct 16) Which statement is false? A. generalized tonic clonic seizures are always associated with loss of consciousness B. focal seizures can involve sensory or focal motor features C. absence seizures can be almost nondetectable D. staring spells associated with focal dyscognitive seizures are the same as absence seizures Chapter 57: Status Epilepticus 1) An 8-year-old is brought by ambulance to the ER. His mother says he had fallen to the ground and began twitching and jerking both arms and legs. The jerking lasted for about 2 to 3 minutes, after which he would wake up, but have no memory of the event. This pattern of events recurred for what seemed like an hour before the ambulance arrived. Which of the following is true? A. He has nonconvulsive status epilepticus. B. He has cluster seizures. C. He has partial status epilepticus. D. He has generalized convulsive status epilepticus. 2) When the EMTs arrive at the home the child is still seizing. Which of the following should the EMTs administer? A. IM diazepam B. IM phenytoin C. PR diazepam D. IN phenobarbital 3) A 32-year-old arrives in the Emergency Department due to a generalized convulsive seizure. To date he has received one dose of a benzodiazepine, what would you recommend be done? A. Administer lorazepam and phenytoin or fosphenytoin B. Administer diazepam and phenobarbital C. Administer another dose of the benzodiazepine D. Do not give anticonvulsants until an EEG is performed 4) Which of the following is a risk factor for poor outcome in a patient with GCSE?

A. Prolonged duration of seizure B. Age C. Unknown etiology for the seizure D. Gender 5) Which of the following is true regarding IV fosphenytoin and IV phenytoin? A. Phenytoin causes pruritus, whereas fosphenytoin does not. B. Fosphenytoin does not cause arrhythmias, whereas phenytoin does. C. A phenytoin concentration should be drawn 1 hour after a loading phenytoin; whereas a phenytoin concentration should be drawn 2 hours after a dose of fosphenytoin. D. The rate of administration is the same for both drugs. 6) Which of the following is true regarding diazepam and lorazepam? A. Lorazepam has a more rapid onset than diazepam. B. Diazepam is not metabolized while lorazepam is metabolized. C. Lorazepam has a longer duration of action than does diazepam. D. Diazepam can be given IM, while lorazepam can only be given IV. 7) A 57-year-old (wt 85 kg) man with a history of complex partial seizures (2 per month) presents to the ER because of a "long" seizure at home that was at least partly witnessed by his wife. He was given lorazepam and is now seizure free. He chronically received Carbatrol 600 mg BID. All chemistries, including liver function test and CBC are normal. What would you recommend as part of this patient's work-up? A. STAT EEG B. STAT MRI C. Carbamazepine concentration D. Lorazepam concentration 8) Tachyphylaxis is most commonly associated with which of the following? A. Midazolam B. Ketamine C. Propofol D. Phenobarbital 9) Which of the following should not be administered IM in GCSE? A. Midazolam B. Phenobarbital C. Diazepam D. Fosphenytoin 10) Which of the following is associated with metabolic acidosis? A. Propylene glycol B. Levetiracetam C. Lidocaine D. Valproate 11) Which of the following may be given by IV push? A. Phenytoin B. Fosphenytoin C. Phenobarbital D. Midazolam 12) The pharmacodynamics effects of which of the following is reduced if the seizure persist for more than 30 minutes.

A. Lorazepam B. Phenobarbital C. Valproate D. Levetiracetam 13) Which of the following agents does not contain propylene glycol? A. Phenobarbital B. Phenytoin C. Diazepam D. Fosphenytoin 14) Which of the following is true regarding IN midazolam? A. It should not be used in infants B. The entire dose should be administered in the same nostril C. The syringe used to administer the IN midazolam should be overfilled by 0.1 mL D. Effectiveness is the same whether or not an atomizer is used 15) A 2-year-old child is transported to the emergency department following a generalized tonic– clonic seizure. The mother states that the child does not have epilepsy, but does take Flonase, Singular, Theo-Dur, and albuterol prn. He is afebrile. As part of the initial workup, which test would be most helpful in evaluating his seizure etiology? A. Blood electrolytes B. Liver function test C. STAT EEG D. Serum theophylline concentration Chapter 58: Acute Management of the Brain Injury Patient 1) Which of the following events is the most common cause of traumatic brain injury (TBI)? A. Gunshot wounds B. Sport and recreational accidents C. Motor vehicle accidents D. Falls 2) Which of the following ranges of Glasgow Coma Scale (GCS) scores is consistent with a severe TBI? A. 1-3 B. 3-8 C. 9-12 D. 13-15 3) Which of the following is thought to be a key component in the pathophysiology of secondary neuronal injury after TBI? A. Hyperglycemia B. Cellular calcium influx C. Inflammatory mediators D. Lactic acidosis 4) Cerebral perfusion pressure is defined as: A. (MAP−ICP)/CVR B. MAP × ICP C. MAP−ICP D. (MAP−ICP) × CVR

5) Which of the following represents "goal" values in an adult patient with a severe TBI? A. ICP ≥20 mm Hg (≥2.7 kPa), MAP ≥90 mm Hg (≥12.0 kPa). B. ICP <20 mm Hg (<2.7 kPa), MAP ≥120 mm Hg (≥16.0 kPa). C. ICP <20 mm Hg (<2.7 kPa), MAP ≥90 mm Hg (≥12.0 kPa). D. ICP ≥20 mm Hg (≥2.7 kPa), MAP ≥120 mm Hg (≥16.0 kPa). 6) Which of the following is the primary advantage of a ventriculostomy over an intraparenchymal ICP monitor? A. Cerebrospinal fluid can be drained to lower ICP. B. Less difficult and invasive to perform placement. C. Lower complication rate. D. Superior outcomes in clinical trials. 7) Which of the following is generally the sedative of choice for controlling ICP in TBI patients? A. Midazolam B. Pentobarbital C. Propofol D. Dexmedetomidine 8) Which of the following is the best initial therapy for lowering ICP in a severe TBI patient with pulmonary edema from congestive heart failure? A. Mannitol B. Hypertonic saline C. Pentobarbital coma D. Furosemide 9) Which of the following is an adverse event associated with serum osmolality exceeding 320 mOsm/kg (320 mmol/kg) secondary to mannitol therapy? A. Hyperglycemia B. Acute renal dysfunction C. Acute hepatic dysfunction D. Hemolytic anemia 10) A patient with a severe TBI is having intermittent ICPs in the mid to high 20s (mm Hg; ~3.33.9 kPa) despite treatment with a propofol infusion (4 mg/kg/hour) and intermittent doses of mannitol and hypertonic saline. Which of the following should be added for ICP control at this time? A. Fentanyl infusion B. Neuromuscular blocker C. Pentobarbital coma D. Furosemide 11) Which of the following is the most common dose-limiting adverse event of pentobarbital coma? A. Hypotension B. GI hypomotility C. Pulmonary edema D. Hypertriglyceridemia 12) Which of the following describes the most appropriate use of therapeutic hyperventilation for ICP control in the management of TBI patients? A. Used briefly to a PCO2 goal of 30 to 35 mm Hg (4.0-4.7 kPa) during the first 24 hours after TBI.

B. Used briefly to a PCO2 goal of 30 to 35 mm Hg (4.0-4.7 kPa) but only beyond the first 24 hours after a TBI. C. Used to an aggressive PCO2 goal of less than 25 mm Hg (3.3 kPa) anytime during therapy. D. Used to an aggressive PCO2 goal of less than 25 mm Hg (3.3 kPa) only as a second-line therapy. 13) Which of the following best describes drug selection for seizure prophylaxis after a severe TBI? A. Levetiracetam should be used because it doesn't require serum monitoring and has fewer adverse events than phenytoin. B. Valproic acid can be used because it performed similarly to phenytoin in a large randomized controlled trial. C. Phenytoin is the drug of choice and can be used for early and late seizure prophylaxis. D. Phenytoin is the drug of choice and should be used for seven days in patients without seizures. 14) Which of the following best describes the current role for therapeutic hypothermia in the management of TBI patients? A. It should never be used because of poor results in large clinical trials. B. It should be used as one of the second-line therapies for treating elevated ICP. C. It could be used as a last-line therapy, but there are no firm recommendations. D. It should be used for prevention of intracranial hypertension but not treatment. 15) Which of the following agents has been shown in a randomized controlled trial to improve short-term cognitive function in TBI patients? A. Amantadine B. HMG-CoA reductase inhibitors C. Donepezil D. Progesterone Chapter 59: Parkinson Disease 1) Parkinson disease (PD) is characterized by a nigrostriatal deficiency of: A. Acetylcholine B. Dopamine C. Norepinephrine D. Serotonin 2) The clinical diagnosis of parkinsonism is based on the presence of bradykinesia and at least one of three other features: muscular rigidity, resting tremor, and: A. Dystonia B. Nystagmus C. Postural instability D. Seizures 3) Which of the following is the most effective drug for PD? A. Amantadine B. Carbidopa/levodopa C. Pramipexole D. Rasagiline 4) An 80-year-old with newly diagnosed PD and a history of memory problems and confusion is best treated with:

A. Amantadine B. Carbidopa/levodopa C. Trihexyphenidyl D. Ropinirole 5) The mechanism of action for entacapone is: A. COMT inhibition B. MAO-B inhibition C. D2-receptor inhibition D. Dopa-decarboxylase inhibition 6) Which of the following will not worsen PD symptoms? A. Haloperidol B. Metoclopramide C. Prochlorperazine D. Rasagiline 7) A patient with PD is taking carbidopa/levodopa 25/100 mg three times a day, and reports that he tends to slow down 2 hours before his next carbidopa/levodopa dose. This patient is most likely experiencing: A. Delayed onset response B. Dyskinesia C. Freezing D. Wearing off 8) A 70-year-old patient taking carbidopa/levodopa 25/100 mg three times a day for PD is experiencing end-of-dose wearing off. The best next step is to: A. Add tolcapone. B. Consider surgery. C. Add trihexyphenidyl. D. Increase carbidopa/levodopa to four times daily. 9) A 63-year-old patient taking carbidopa/levodopa 25/100 mg four times a day for PD is experiencing end-of-dose wearing off. The best recommendation is to: A. Add tolcapone. B. Add entacapone. C. Consider deep-brain stimulation (DBS). D. Change carbidopa/levodopa to three times a day. 10) A 72-year-old patient with moderate-severe PD was placed on carbidopa/levodopa 25/100 mg three times a day by his primary care physician. He is complaining of nausea and stomachupset since starting the medication. The best recommendation is to: A. Increase the carbidopa/levodopa dose by 50%. B. Discontinue the medication and switch to rasagiline. C. Discontinue the medication and switch to a ropinirole. D. Recommend taking carbidopa/levodopa with a nonprotein snack. 11) A 71-year-old patient has had PD for 8 years and is currently taking pramipexole 1.5 mg three times a day and carbidopa/levodopa 25/100 mg four times a day. His wife claims that he is complaining of seeing spiders and bugs running across the floor and imaginary children in their house. The first thing to do is: A. Increase the pramipexole dose. B. Reduce the pramipexole dose.

C. Increase the carbidopa/levodopa dose. D. Reduce the carbidopa/levodopa dose. 12) A 65-year-old patient with PD is experiencing moderate dyskinesias that are bothersome. The patient is on carbidopa/levodopa 25/100 mg two tablets at 7 AM and one tablet at 11 AM, 2 PM, 5 PM, 8 PM, and 11 PM. Which of the following is most appropriate: A. Add amantadine. B. Add entacapone. C. Add rasagiline. D. Add pramipexole. 13) A 63-year-old patient with PD has done well on rasagiline 1 mg once a day and ropinirole 4 mg three times a day for several years. In the past, higher doses of ropinirole resulted in excessive drowsiness. He now needs more symptom relief. The best recommendation would be to: A. Add carbidopa/levodopa. B. Add entacapone. C. Add pramipexole. D. Consider DBS surgery. 14) Which of the following is not a side effect of dopamine agonists? A. Drowsiness B. Nausea C. Impulse control disorder D. Livedo reticularis 15) A 74-year-old patient has had PD for 8 years and is currently taking carbidopa/levodopa 25/100 mg one and a half tablets five times a day. His medical history is also significant for pancytopenia. He is experiencing troublesome hallucinations. Previous attempts to lower his carbidopa/levodopa dose were not tolerated due to significant worsening of motor symptoms. The best recommendation is to add: A. Chlorpromazine B. Clozapine C. Haloperidol D. Quetiapine Chapter 60: Pain Management 1) Which of the following is a maladaptive pain state? A. Acute postoperative pain B. Ankle sprain C. Fibromyalgia D. Pain associated with an infection 2) In which phase of nociception is a noxious stimulus converted into an action potential? A. Conduction B. Transduction C. Transmission D. Modulation 3) Which of the following is an excitatory neurotransmitter involved in pain transmission? A. Β-endorphin B. γ-aminobutyric acid (GABA)

C. Glutamate D. Norepinephrine 4) What mechanism is principally involved in the maintenance of maladaptive pain states? A. Altered pain processing in the CNS B. Upregulation of sodium channels in the PNS C. Excessive prostaglandin synthesis D. Overproduction of endorphin neuropeptides 5) Which of the following is believed to augment the descending inhibitory pathway to produce analgesia? A. Cognitive behavioral therapy B. Massage C. Mindfulness-based stress reduction D. Transcutaneous electrical stimulation (TENS) 6) The dose of breakthrough pain medication (exception rapid-acting fentanyl) is generally calculated as… A. 5% of the total daily dose of opioids B. 10-15% of the total daily dose of opioids C. 25-50% of the total daily dose of opioids D. 50-75% of the total daily dose of opioids 7) Which of the following options is an optimal non-opioid medication for a person with significant musculoskeletal pain and comorbid depression? A. Amitriptyline B. Duloxetine C. Lamotrigine D. Milnacipran 8) When initiating oral transmucosal fentanyl citrate (Actiq and generics), the most appropriate starting dose is: A. The lowest available dosage form B. One half of the 24-hour morphine equivalent intake C. Equal to the 24-hour morphine equivalent intake D. Twice the 24-hour morphine equivalent intake 9) Which of the following adverse effects is considered a transient side effect of opioids? A. Hypogonadism B. Somnolence C. Constipation D. Pruritus 10) You have a patient that is currently being treated with erythromycin (potent CYP 3A4 inhibitor) for diabetic gastroparesis. She has painful diabetic peripheral neuropathy and is on numerous adjuvant analgesics with no effect. The decision has been made to place the patient on long term opioid therapy. Which of the following opioids would you NOT recommend due to potential drug–drug interactions? A. Morphine B. Hydromorphone C. Oxycodone D. Fentanyl 11) Which of the following best describes the mechanism of action of tapentadol (Nucynta)?

A. Mu opioid agonist B. Mu opioid agonist plus serotonin > norepinephrine reuptake inhibition C. Mu opioid agonist plus norepinephrine > serotonin reuptake inhibition D. None of the above 12) Which of the following two analgesics are actually prodrugs requiring metabolism to their active metabolite for analgesia? A. Hydrocodone and hydromorphone B. Codeine and tramadol C. Tramadol and tapentadol D. Morphine and codeine 13) When starting methadone, titration (increase) in dosing should NOT occur more frequently than: A. Once a day B. Twice a week C. Weekly D. Monthly 14) Which of the following would be considered components of a risk mitigation strategy for monitoring misuse or abuse with opioid prescriptions? A. Prescription Drug Monitoring Programs B. Urine Drug Screening C. Patient-Provider Agreements D. All of the above

Chapter 61: Headache Disorders 1) Which one of the following is NOT a type of primary headache disorder? A. Migraine B. Tension C. Cluster D. Vascular 2) Migraine pain is believed to result from activity in which one of the following systems? A. Perivascular B. Trigeminovascular C. Extravascular D. Tuberofundibular 3) In migraine, genetic factors appear to: A. Lower the threshold for environmental triggers B. Raise the threshold for environmental triggers C. Decrease levels of excitatory amino acids D. Maintain normal levels of extracellular potassium 4) The migraine aura is defined by which one of the following? A. Positive focal neurologic symptoms that follow an attack B. Negative focal neurologic symptoms that precede an attack C. Positive and negative focal neurologic symptoms that follow an attack D. Positive and negative focal neurologic symptoms that precede or accompany an attack 5) Migraine aura typically lasts:

A. Less than 20 minutes B. Less than 60 minutes C. More than 60 minutes D. More than 120 minutes 6) Which one of the following is not part of International Headache Society diagnostic criteria for migraine without aura? A. At least two attacks B. Headache that lasts 4 to 72 hours (untreated or unsuccessfully treated) C. Has at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravation by or avoidance of routine physical activity D. During headache at least nausea, vomiting, or both or photophobia and phonophobia 7) Which one of the following drug or drug classes is not used in the acute treatment of migraine headaches? A. Ergot Alkaloids B. Antidepressants C. NSAIDs D. Serotonin Agonists 8) Patients may benefit from adherence to a wellness program that may include all of the following except: A. Regular exercise B. Regular eating habits C. Smoking cessation D. Increasing caffeine intake 9) Medication-overuse headache is most commonly implicated with use of: A. Simple analgesics B. Combination analgesics C. Antiemetics D. Triptans 10) Which of the following is the most common adverse effect of the ergotamine derivatives? A. Painful extremities B. Peripheral ischemia C. Nausea and vomiting D. Continuous paresthesias 11) Which of the following preventive treatments for migraine is associated with weight loss: A. Propranolol B. Divalproex sodium C. Topiramate D. Amitriptyline 12) Which one of the following oral triptans has the longest half-life, but the slowest onset of action? A. Sumatriptan B. Eletriptan C. Naratriptan D. Frovatriptan 13) Which triptan has established efficacy in migraine prevention? A. Naratriptan

B. Sumatriptan C. Frovatriptan D. Eletriptan 14) Which of the following would not be appropriate for migraine prophylaxis? A. Metoprolol B. Acebutolol C. Atenolol D. Propranolol 15) Which of the following vitamins has evidence to support efficacy in migraine prevention? A. Ascorbic acid B. Riboflavin C. Cyanocobalamin D. Pyridoxine

Chapter 62: Assessment of Psychiatric Disorders 1) Which resource would be helpful in identifying the diagnostic criteria for schizophrenia? A. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition B. American Psychiatric Association Practice Guidelines for Psychiatric Evaluation C. Mini Mental Status Examination (MMSE) D. Brief Psychiatric Rating Scale (BPRS) 2) Which term best describes the ability of a psychiatric rating scale to determine a symptom or disorder is absent when the patient does not have the related condition? A. Reliability B. Validity C. Sensitivity D. Specificity 3) The primary care clinic providers would like to implement a depression screening tool. The scale needs to be completed by the patient in a short amount of time while waiting to see the clinician. Results would then be assessed by the clinician to determine risk of depression. Select the most appropriate rating scale for depression based on this practice setting. A. Hamilton Depression Rating Scale (HDRS) B. Montgomery-Asberg Depression Rating Scale (MADRS) C. Clinical Global Impressions Scale (CGI) D. Patient Health Questionnaire (PHQ-9) 4) A patient is experiencing the following symptoms: inability to sit still, pacing, feelings of inner restlessness. He does not complain of any anxiety or being worried about anything in particular. The patient was started on an antipsychotic 2 weeks ago. Which rating scale would be the most appropriate to assess these symptoms? A. Abnormal Involuntary Movement Scale (AIMS) B. Barnes Akathisia Rating Scale (BARS) C. Dyskinesia Identification System: Condensed User Scale (DISCUS) D. Modified Simpson-Angus Scale (MSAS) 5) The clinician asks a patient with a history of schizophrenia the following question during the clinical interview: "Do you feel that people plot against you?" Which target symptoms of schizophrenia is this question addressing?

A. Auditory hallucinations B. Thought broadcasting C. Paranoid delusions D. Grandiose delusions 6) Which statement is true regarding a psychiatric history obtained during the clinical interview? A. Baseline or highest level of functioning does not influence treatment goals. B. Psychiatric history should include both the patient's and patient's family history. C. Family history of medication response does not influence medication selection. D. Only the description of the current psychiatric episode influences the diagnosis. 7) Which statement is true regarding medical comorbidities in a patient with serious persistent mental illness (SPMI) compared to the general population? A. Patients with SPMI receive the same level of medical care as the general population. B. Patients with SPMI have an overall lower prevalence of modifiable risk factors. C. Patients with SPMI have a shortened life span compared to the general population. D. Diabetes risk is higher in the general population compared to patients with SPMI. 8) Which statement correctly describes a limitation associated with the use of psychiatric rating scales in the clinical setting? A. Some clinician-rated scales require a substantial time commitment to administer. B. Psychiatric rating scales are less useful in the clinical setting than the research setting. C. Rating scales do not provide evidence of longitudinal changes in severity of illness. D. Rating scales are only helpful when used initially to diagnose a mental illness. 9) A 21-year-old patient with no previous history of mental illness is admitted to the inpatient psychiatry unit. The patient presented with a recent acute change in mental status. The patient is paranoid, irritable, confused, and complains of hearing threatening voices. Which answer correctly identifies the component(s) of an initial assessment? A. Mental status examination only. B. Mental status examination, Mini Mental Status Examination (MMSE), medication history and urine drug screen. C. Mental status examination, physical examination, medical and psychiatric history, medication history, and laboratory data (blood chemistry and urine drug screen). D. Mental status examination, physical examination, medical and psychiatric history, medication history, laboratory data (blood chemistry and urine drug screen), and the Beck Depression Inventory (BDI). 10) A patient with schizophrenia has taken clozapine for the last 5 years with good response. The patient's clozapine level was 550 ng/mL (1.68 μmol/L 6 months ago. The patient's symptoms of schizophrenia are currently controlled. The patient lives in a group home where a staff member administers the medication twice a day. An outpatient psychiatrist recently started the patient on an antidepressant medication for symptoms of depression. What is the justification for ordering an additional serum clozapine level in this patient? A. Evaluate efficacy of clozapine for schizophrenia. B. Detect medication nonadherence to clozapine. C. Identify clozapine side effects (ie, agranulocytosis). D. Detect a drug interaction between clozapine and antidepressant. 11) The following finding is identified during a mental status examination: "Several times during the interview, the patient laughed inappropriately about the recent death of a loved one." Which section of the mental status examination should this observation be documented?

A. Affect and Mood B. Evaluation of Cognition C. Insight and Judgment D. Thought and Perceptual Disturbances 12) Which statement is true regarding the mental status examination (MSE)? A. It is based only on observation of the patient. B. It is a shorted version of the Mini Mental Status Examination (MMSE). C. It provides a systematic method of organizing and reporting current behaviors, thoughts, perceptions and functioning. D. It should be used independently of other assessments to identify the presenting illness and contributing factors. 13) Which communication technique has been found useful in working with a patient who becomes angry and defensive after your inquiry about suspected alcohol or drug use? A. Requesting for a release of information to contact a significant other. B. Closed-ended questioning followed by open-ended questioning. C. A motivational interview technique called "Roll with Resistance". D. An interview technique that utilizes passive listening and reflection. 14) A 91-year-old nursing home patient presents to the emergency department with recent mental status changes including dizziness, confusion, and aggression over the past two days. The patient scored a 20 on the Mini Mental Status Examination (MMSE). In addition to the mental status examination (MSE), what additional information is needed to complete a thorough evaluation? A. Blood chemistry, complete blood count, and urinalysis B. Hamilton Depression Rating Scale (HDRS) score C. Electrocardiogram and pharmacogenomics testing D. Patient Health Questionnaire (PHQ-9) score 15) A 6-year-old male student has been having behavioral problems in the classroom that are very disruptive to the other students and affecting his scholastic performance. The parents have noticed some of these behaviors at home but were hoping they would go away. His behavior consists of leaving his seat without permission, climbing on the classroom desks and windows, unable to finish homework, forgetful, and loses assignments on multiple occasions. Which test or assessment could help clarify this patient's diagnosis? A. The Clock Drawing Test B. Mini-Mental State Examination C. Wechsler Intelligence Scale for Children—Revised D. Blessed Information Memory Concentration test Chapter 63: Attention Deficit/Hyperactivity Disorder 1) A 4-year-old child exhibits severe hyperactivity at preschool and is asked to leave preschool due to aggression, impulsivity, and not following directions. Which of the following statements describes an additional diagnostic criterion needed for a diagnosis of ADHD? A. The symptom duration would need to be 6 weeks. B. These impairing symptoms are also present at home. C. The patient must be at least 6 years old. D. Learning disability needs to be ruled out.

2) A teacher's aide asks about the most likely cause of new onset tics (throat clearing) in a 9-year old with ADHD and Tourette disorder treated with Quillivant 20 mg daily and clonidine 0.1 mg at bedtime (same doses for 3 months)? The best answer is: A. Too much sugar in the diet. B. Quillivant dose is too high. C. Clonidine dose is too low. D. Natural course of tic disorder. 3) A deficiency in this substance has been shown to contribute to ADHD symptoms: A. Ferritin B. Cyanocobalamin C. Folate D. Omega-3 fatty acids 4) Which statement should be included when counseling a family on the risks and benefits of stimulant therapy? A. The risk of an adverse cardiac event for a child with ADHD taking a stimulant is two times greater than an untreated child. B. Stimulant therapy for ADHD can increase the risk of severe brain injury. C. The risk of decreased growth and insomnia is greater with immediate release stimulants for ADHD. D. Atomoxetine is less likely associated with liver injury compared to stimulant. 5) Which of the following statements most accurately describes the clinical presentation of adult ADHD? A. Hyperactivity and impulsivity are the most prominent symptoms. B. Adults frequently report racing thoughts, mood swings, and insomnia. C. Disorganization increases in frequency and severity over the adult life span. D. Distractibility and difficulty with sustained mental effort are most common. 6) What structural brain changes are thought to correlate with persistence of ADHD into adulthood? A. Enlarged ventricles and diminished basal ganglia B. Underdevelopment of the locus coeruleus C. Overgrown lateral lobe of the amygdala D. Cortical thinning and decreased brain volume 7) Which of the following is an appropriate starting dose of atomoxetine for a 10-year-old (100 lb [45 kg]) child with ADHD? A. 20 mg twice daily B. 25 mg in the morning C. 10 mg twice daily D. 30 mg at bedtime 8) A 12-year-old girl diagnosed with ADHD and a learning disability is suspended from school for marijuana use. She was started on lisdexamfetamine 6 weeks ago, but prescription records show only a 30-day supply was dispensed. Which factor is most likely to have contributed to an increased risk of substance abuse in this patient? A. Comorbid learning disability B. Diagnosis of ADHD C. Female gender D. Taking lisdexamfetamine

9) Counseling should be provided on the risk of hepatotoxicity with which medication used for the management of ADHD? A. Lisdexamfetamine B. Bupropion C. Atomoxetine D. Guanfacine 10) Which of the following statements is accurate regarding the treatment of ADHD in a patient with autism spectrum disorder (ASD)? A. Methylphenidate has the best chance for efficacy in less severe ASD. B. Once daily formulations of stimulants are less effective than immediate release. C. α2-Adrenergic agonists may improve both ADHD symptoms and irritability. D. Atomoxetine is first-line treatment due to its ability to lessen anxiety over tics. 11) A 14-year-old has taken Aptensio XR 60 mg with no improvement in symptoms but fairly good tolerability (occasional insomnia). Which alternative treatment has the most chance for therapeutic benefit? A. Focalin XR B. Kapvay XR C. Intuniv XR D. Adderall XR 12) In a patient with bipolar disorder and severe inattention and hyperactivity, the following treatment plan is most appropriate: A. Stabilize mood first with lithium or other mood stabilizer, and then consider whether low dose stimulant is needed for inattention and hyperactivity. B. Manage ADHD with bupropion, and then consider adding a mood stabilizer or atypical antipsychotic once ADHD symptoms are controlled. C. Avoid stimulants as they will worsen mania; give atomoxetine to manage both ADHD and bipolar disorder. D. Start extended release guanfacine to manage ADHD, and then consider adjunctive lithium or atypical antipsychotic. 13) Potential advantages of α2-adrenergic agonists over stimulants for ADHD include: A. More rapid onset of therapeutic effect B. Less insomnia, anorexia, and growth effects C. Greater efficacy for inattentive symptoms D. Effective for children, teens, and adults 14) A 10-year-old with ADHD and conduct disorder with severe aggression is taking 54 mg of osmotically released oral delivery system (OROS) methylphenidate. BP is 116/68, pulse 60, weight is 50 kg. What intervention has the most evidence for efficacy in managing aggression in this patient? A. Increase dose of OROS methylphenidate to 72 mg B. Add guanfacine 1 mg twice daily C. Change from OROS methylphenidate to atomoxetine D. Add risperidone 0.5 mg twice daily 15) Studies have shown that adjunctive behavioral interventions administered to youth with ADHD: A. Are more effective than stimulant medications. B. Are not likely to be administered in the classroom.

C. May allow for lower effective doses of stimulant. D. Are more effective for inattention than hyperactivity. Chapter 64: Eating Disorders 1) Which of the following eating disorders became a new, stand-alone diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders? A. Anorexia nervosa B. Bulimia nervosa C. Night eating syndrome D. Binge-eating disorder 2) Suspected deficiencies of serotonin have commonly been linked to anorexia nervosa, primarily thought to be the result of a reduction in the intake of which of the following amino acids? A. Glycine B. Tyrosine C. Glutamine D. Tryptophan 3) Which of the following is/are required when considering a diagnosis of anorexia nervosa? A. Restriction of energy intake leading to low body weight B. Undue influence of body shape on self-evaluation C. Behavior that interferes with weight gain D. All of the above 4) A 15-year-old female is being evaluated for a possible diagnosis of anorexia nervosa. Her history reveals that she has a sister diagnosed with anorexia nervosa, her father is diagnosed and treated for schizophrenia, and she has been treated for asthma since a young age. Which of the following are considered positive risk factors for developing anorexia nervosa? A. Medical illness B. Sibling with anorexia nervosa C. Presence of thought disorder D. All of the above 5) A 17-year-old female with anorexia nervosa is currently undergoing caloric restoration at a rate 800 cal/day (3347 J/day). The physician is most worried about: A. Refeeding syndrome B. Cardia arrhythmia C. Unfeeding syndrome D. Renal failure 6) Which of the following antipsychotic medications has demonstrated effectiveness in combination with day hospital treatment at increasing weight gain and also as treatment alone to improve BMI? A. Quetiapine B. Risperidone C. Olanzapine D. All of the above 7) A 13-year-old female presents with suspected anorexia nervosa. She has expressed concerns about her weight for the past 6 months, however significant weight loss has been noted in just the past month. She indicates that she is just trying to eat less and be more healthy, stating "I'm just

not hungry." She has a fear of gaining weight and has obsessive thoughts about being perceived as "fat and ugly." She has recently started vomiting after eating her one meal a day for fear of gaining too much weight. Her parents note that she has become more withdrawn and that her anxiety level has increased. Which of the following is the most preferred initial form of therapy? A. Family-based treatment B. Cognitive behavioral therapy C. Interpersonal psychotherapy D. Specialist supportive clinical management 8) One of the first-lines of treatment for binge-eating disorder is which of the following? A. Lisdexamfetamine B. Dialectical behavior therapy C. Escitalopram D. Cognitive behavioral therapy 9) Data from clinical trials and small case reports suggest which of the following dosing regimens to be the most appropriate in treating adults with binge-eating disorder? A. Citalopram 80 mg daily B. Topiramate 400 mg daily C. Olanzapine 15 mg daily D. Sertraline 100 mg daily 10) JS is a 22-year-old female diagnosed with bulimia nervosa. Which characteristic below does not fit with the diagnostic criteria for BN? A. Average height and weight at presentation but has periods where she fluctuates between overweight and underweight B. Presenting symptoms of anxiety, history of substance abuse, and difficulty with personal relationships C. Several times a month she eats excessively and feels very guilty about it afterward D. Lack of concern over her body image 11) Which treatment option has demonstrated weight loss in obese patients with BED when paired with a calorie-restricted diet? A. Topirimate B. Fluoxetine C. Orlistat D. Zonisamide 12) A 20-year-old female presents to her primary care physician with complaints of anxiety, fatigue, and esophageal pain and irritation. Physical exam reveals she is of average height and weight, but she has enlarged salivary glands and multiple dental carries. What is the most likely diagnosis? A. Anorexia nervosa B. Binge eating disorder C. Bulimia nervosa D. Night eating syndrome 13) All of the following are acceptable pharmacologic treatments for bulimia nervosa except: A. Fluoxetine 60 mg/day B. Phenelzine 90 mg/day C. Bupropion 300 mg/day D. Desipramine 150 mg/day

14) Of the following agents, which has demonstrated effectiveness for BN in randomized placebo-controlled trials? A. Zonisamide B. Topiramate C. Naltrexone D. Ondansetron 15) SB is a 23-year-old patient who has been diagnosed with BN and referred for cognitive behavioral therapy for a first treatment approach. She lives in a rural area where she has no access to a certified therapist or specialist in this field. What would be an appropriate alternative for SB? A. Recommend treatment with medication alone B. Recommend online CBT C. Recommend group yoga to target anxiety symptoms D. Recommend a local 12-step program

Chapter 65: Substance-Related Disorders I: Overview and Depressants, Stimulants, and Hallucinogens 1) In 2014, an estimated Americans aged 12 or older were current (past month) illicit drug users. A. 2.3 million B. 5 million C. 27 million D. 75 million E. 90 million 2) Tolerance to the effects of an abused drug can be defined as: A. Physiologic adaptation to the effect of drugs, so as to diminish effects with constant dosages or to maintain the intensity and duration of effects through increased dosage. B. Any use of a drug that varies from a socially or medically accepted use. C. The emotional state of craving a drug either for its positive effect or to avoid negative effects associated with its absence. D. Any use of drugs that causes physical, psychologic, economic, legal, or social harm to the individual user or to others affected by the drug user's behavior. E. A physiologic state of adaptation to a drug or alcohol, usually characterized by the development of tolerance to drug effects and the emergence of a withdrawal syndrome during prolonged abstinence. 3) The most commonly used illicit drug in the United States is which of the following? A. LSD B. MDMA C. Marijuana D. Cocaine E. Heroin 4) What is the purpose of The Monitoring the Future Study conducted at the University of Michigan? A. To determine what types of drugs are causing emergency department visits at metropolitan hospitals.

B. To study changes in the beliefs, attitudes, and behavior of young people toward drugs in the United States. C. To serve as the primary source of statistical information on the use of illegal drugs by the U.S. population. D. To determine the types of drugs that are associated with drug-related mortality. E. To serve as an early warning system such that prevention and treatment efforts can be tailored to the recent trends in substance abuse. 5) Carisoprodol is metabolized in the body to which of the following compounds? A. Diazepam B. Nor-propoxyphene C. Chloral Hydrate D. 11- hydroxyl alprazolam E. Meprobamate 6) Which of the following compounds is associated with drug facilitated sexual assault? A. y-hydroxybutyrate (GHB) B. Amphetamine C. MDMA D. Methadone E. Fentanyl 7) High doses of cocaine and/or prolonged use can trigger symptoms of A. Paranoia B. Hypothyroidism C. Osteoporosis D. Lassitude E. Bradycardia 8) When smoked, crack cocaine has a longer duration of action than powdered cocaine used intranasally. A. True B. False 9) Methamphetamine can be manufactured in home laboratories using which of the following as starting materials? A. LSD B. Pseudoephedrine C. y-Butyrolactone D. Cocaine E. Dopamine 10) What is the name of the impurity formed during the clandestine manufacture of MDMA (also known as Ecstasy) that has been shown to be a potent hyperthermic agent. A. MDMA methyl esther B. Methamphetamine Succinate C. Paramethoxy amphetamine (PMA) D. Isophenylalanine E. Nor-meperidine 11) Which of the following describe the acute effects of inhalants? A. Inhalants depress the CNS, producing decreased respiration and blood pressure. B. Inhalants stimulate the CNS, producing increased respiration and blood pressure.

C. Users report increased, accurate perceptions of time and space. D. Users can become diabetic in the face of pre-existing renal disease. E. Both A and D are accurate descriptions of inhalant effects. 12) There is increasing evidence that MDMA can cause structural damage to neurons in the brain. A. Serotonergic B. Dopaminergic C. Adrenergic D. Gabaminergic E. Cholinergic 13) According to the latest statistics from the Mississippi Marijuana Potency Monitoring Project at the University of Mississippi School of Pharmacy, the average THC (delta-9tetrahydrocannabinol) content in tested samples of marijuana in 2013 was: A. 3.52% B. 21.44% C. 0.625% D. 65.8% E. 12.55% 14) What percentage of treated substance-dependent patients will relapse at least once? A. 10% B. 25% C. 50% D. 75% E. 90% 15) Which of the following is true regarding ultrarapid detoxification from opiate dependence? A. This technique has become the "standard of care" for treating opiate dependence. B. It has been proved to be a cost-effective alternative to outpatient detoxification. C. More research is needed using rigorous research methods, longer-term outcomes, and comparisons with other methods of treatment before this technique can gain widespread acceptance. D. This technique has been outlawed by the DEA because of the high rate of relapse and the greater intensity of withdrawal with subsequent episodes of opiate abuse. E. A recent meta-analysis has shown this technique to be clearly superior to conventional methods of detoxification, both in short- and long-term outcomes. Chapter 66: Substance-Related Disorders II: Alcohol, Nicotine, and Caffeine 1) Based on the DSM-5 criteria: A patient must meet of the 11 criteria during a 12month period to establish the diagnosis of alcohol use disorder (AUD). A. One B. Two C. Three D. Four 2) The lethal dose of alcohol is associated with blood levels typically greater than or equal to . A. 80 mg/dL (17 mmol/L) B. 100 mg/dL (22 mmol/L)

C. 200 mg/dL (43 mmol/L) D. 400 mg/dL (87 mmol/L) 3) Which of the following laboratory studies should be ordered in a patient suspected of a toxic ingestion of alcohol? A. BAC (blood alcohol concentration) B. CBC (complete blood count) C. BMP (basic metabolic panel) D. All of the above 4) Which of the following assessment tools can be used when evaluating a patient in acute alcohol withdrawal? A. CAGE Questionnaire B. Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) C. Alcohol Use Disorders Identification Test (AUDIT) D. Fast Alcohol Screening Test (FAST) 5) The preferred class of medications used in treatment of alcohol withdrawal is A. Barbiturates B. Antidepressants C. Benzodiazepines D. Anticonvulsants 6) Which of the following treatment options will help prevent the development of WernickeKorsakoff syndrome? A. Thiamine B. Riboflavin C. Magnesium D. Biotin 7) There are four medications currently approved for pharmacological management of alcohol dependence in the United States: disulfiram, oral naltrexone, intermuscular naltrexone, and acamprosate. Which of these approved medications is a GABAergic agonist that modulates alcohol cravings? A. Disulfiram B. Oral naltrexone C. Intermuscular naltrexone D. Acamprosate 8) Which of the following medications approved for pharmacological management of alcohol dependence would not be a good choice for a patient with a recent history of a myocardial infarction? A. Disulfiram B. Oral naltrexone C. Intermuscular naltrexone D. Acamprosate 9) Which of the following statements regarding smoking cessation is true? A. Self-help materials, such as pamphlets are just as effective as counseling sessions in achieving smoking cessation. B. Three-minute counseling sessions have not been found to be effective in helping patients achieve smoking cessation.

C. Nicotine-replacement therapy (NRT) alone without counseling is effective in achieving smoking cessation. D. All statements above are true statements. 10) Which of the following NRT's would be appropriate for a 45-year-old woman who smokes 35 cigarettes per day? Her past medical history includes hypertension and epilepsy. Her medication allergies include ACE Inhibitors and adhesive. A. Bupropion 150 mg po daily for 3 days then increase to twice daily B. Nicotine Gum 2 mg: Chew and park gum as directed every 1 to 2 hours as needed C. Nicotine Gum 4 mg: Chew and park gum as directed every 1 to 2 hours as needed D. Nicotine Patch 21 mg/day: Apply 1 patch to skin daily; rotate application sites 11) Which of the following agents are considered second line therapy for smoking cessation treatment? A. Nicotine Lozenge B. Bupropion C. Varenicline D. Nortriptyline 12) Which of the following statements is false in regards to Varenicline? A. The recommended dosage is 0.5 mg by mouth daily for 3 days, 0.5 mg twice daily for 3 days, then increase to 1 mg daily for 11 weeks. B. 12 weeks of therapy with Varenicline can be followed by an additional 12 weeks of therapy if cessation has not been achieved. C. Varenicline has a black box warning due to possible serious neuropsychiatric events including depression, suicide ideation, suicide attempt, and completed suicide. D. Varenicline has a black box warning due to increased risks of cardiac events including myocardial infarctions. 13) A 25-year-old female would like help with smoking cessation since she just found out she is 2 months pregnant. She is currently smoking 12 cigarettes per day. Which of the following recommendations is the best recommendation based on current evidence? A. Start Nicotine gum 2 mg: Chew and park 1 piece of gum every 1 to 2 hours as needed B. Contact your primary care provider and request a prescription for Varenicline C. Recommend she call 1-800-QUIT-NOW to begin counseling services D. Contact your primary care provider and request a prescription for Bupropion 14) Which of the following is not considered a caffeine-related diagnosis under the DSM-5? A. Caffeine Use Disorder B. Caffeine Intoxication C. Caffeine Withdrawal D. Unspecified Caffeine-Related Disorder 15) The March of Dimes recommends that pregnant women limit caffeine intake to mg/day. A. 100 B. 200 C. 300 D. 400 Chapter 67: Schizophrenia

1) Which of the following is the most accurate statement regarding the potential etiology of schizophrenia? A. Schizophrenia is likely caused by the affected individual having an oppressive mother during early childhood development. B. Genetics studies suggest a Mendelian genetic relationship for developing schizophrenia. C. PET studies indicate that schizophrenia is a degenerative brain disorder. D. Schizophrenia may be caused by variety of genetic polymorphisms in combination with an environmental assault in utero. 2) A recent theory regarding the pathophysiology of schizophrenia suggests that a predrome phase of the illness is associated with A. Excessive synthesis and release of serotonin from presynaptic receptors. B. Decreased density of D2 receptors in the meso caudate. C. Glutamatergic synaptic dysfunction resulting in a glutamatergic signaling defect. D. Increased density of D2 receptors in the prefrontal cortex. E. Hyperactivity of gamma-amino-butyric acid (GABA) pathways. 3) Symptom domains that are characteristic of a diagnosis of schizophrenia include all of the following except: A. Cognitive impairment B. Depression C. Negative symptoms D. Positive symptoms 4) The four core interventions that have been shown to improve the quality of life in individuals with early schizophrenia include all of the following except: A. Family psychoeducation B. Personalized medication management C. Psychoanalysis D. Resilience-focused individual therapy E. Supported employment and education 5) Which of the following most accurately reflects the initial workup (ie, evaluation) of a patient suspected of having schizophrenia? A. Mental status exam, physical exam, neurological exam, social history, laboratory work-up, and PET scan B. Mental status exam, physical exam, neurological exam, social history, laboratory workup, and MRI scan C. Mental status exam, physical exam, neurological exam, social history, family history, and a CSF homovanillic acid (HVA) level D. Mental status exam, physical exam, neurological exam, family history, laboratory work-up, and a CSF 5-hydroxyindolacetic acid (5-HIAA) level E. Mental status exam, physical exam, neurological exam, family history, social history, and laboratory workup 6) Based upon both efficacy and safety, which of the following are evidence based first-line pharmacotherapy options in a patient experiencing the first psychotic episode associated with schizophrenia? A. Aripiprazole, risperidone, and ziprasidone B. Perphenazine, quetiapine, and risperidone C. Haloperidol, olanzapine, and quetiapine

D. Aripiprazole, lurasidone, and ziprasidone E. Brexpiprazole, iloperidone, and risperidone 7) O.Y. is a 27-year-old male with schizophrenia. This is his second psychiatric hospitalization. He has most recently been treated with risperidone. He currently presents in an acute psychotic episode with fulminate suicidal ideation, and a serious suicide attempt prior to hospitalization. Based on this information, which of the following antipsychotics would be the best choice for this patient at the present time? A. Clozapine B. Haloperidol C. Lurasidone D. Risperidone E. Ziprasidone 8) Which of the following are interventions which may increase the treatment adherence of individuals with schizophrenia? A. Cognitive behavioral therapy B. Involvement of families C. Patient information about the disorder and treatment D. Consumer to consumer groups E. All of the above may be helpful 9) B.W. is a 33-year-old woman with schizophrenia in an acute exacerbation. She has had previous unsuccessful medication trials with risperidone and olanzapine. Her risperidone trial was at a maximum dose of 6 mg/day for 6 months, and her olanzapine regimen was for a maximum dose of 20 mg daily for 9 months. Patient adherence with treatment was deemed to be adequate during the previous medication trials. Based on the available information, which of the following is the most appropriate medication intervention at the present time? A. Asenapine B. Cariprazine C. Clozapine D. Haloperidol E. Lurasidone 10) The rapid on, rapid off theory of atypicality is best associated with which of the following antipsychotics? A. Aripiprazole B. Olanzapine C. Quetiapine D. Risperidone E. Ziprasidone 11) C.H. is a 25-year-old woman with a diagnosis of schizophrenia. She has been previously treated with haloperidol and risperidone. Since starting risperidone, she has complained of weight gain. In comparing her current weight with that prior to starting risperidone, she has gained about 8 pounds (3.6 kg). She inquires about a change in medication to an antipsychotic that is less likely to cause weight gain. Based on this request, which of the following would be the best choice? A. Ziprasidone B. Chlorpromazine C. Clozapine

D. lanzapine E. Quetiapine 12) J.B. is a 34-year-old male with a diagnosis of schizophrenia. He has previously been treated with haloperidol, perphenazine, and fluphenazine decanoate. He has had persistent difficulty with extrapyramidal side effects, including Parkinson symptoms and dystonic reactions. These symptoms have been treated with benztropine and diphenhydramine, but he still has breakthrough EPS symptoms. Which of the following would be the poorest antipsychotic treatment option for this patient? A. Aripiprazole B. Olanzapine C. Quetiapine D. Brexpiprazole E. Risperidone 13) B.C. is a 35-year-old woman with a diagnosis of schizophrenia. In the past she has taken haloperidol and risperidone and experienced Parkinson symptoms on both of these medications. She has been taking olanzapine 15 mg daily for the past 6 months. She recently went to see her family physician for complaints of fatigue, excessive thirst, and frequent urination. Her physician obtains a fasting blood glucose, which is 180 mg/dL (10 mmol/L). Although her psychotic symptoms are reasonably well controlled, her physician deems that it is best to change her antipsychotic medication. Based on the information above, which of the following would be the best choice? A. Aripiprazole B. Clozapine C. Haloperidol D. Quetiapine E. Risperidone 14) D.D. is a 66-year-old man with a diagnosis of schizophrenia. He also has diagnosis of benign prostatic hypertrophy, hypertension, and gastroesophageal reflux disorder (GERD). His medication regimen includes quetiapine, hydrochlorothiazide, metoclopramide, and ranitidine. Over the past 3 months he has developed a shuffling gait, drooling, and a resting tremor. In screening the patient's profile, which of the following might represent a drug interaction? A. Ranitidine is inhibiting the metabolism of quetiapine, causing the patient to develop Parkinson symptoms. B. Hydrochlorthiazide alteration of quetiapine elimination in the kidneys is resulting in Parkinson symptoms C. Ranitidine's dopaminergic blockade in combination with quetiapine is producing Parkinson symptoms. D. Metoclopramide alteration of quetiapine metabolism is causing Parkinson symptoms. E. Metoclopramide's dopaminergic blockade in combination with quetiapine is producing Parkinson symptoms. 15) After initiating a new antipsychotic in a patient with schizophrenia, appropriate routine monitoring parameters are best reflected by: A. Brief standardized clinical rating scales, weight, blood pressure, waist circumference, blood glucose, serum lipids B. Positive and negative symptom rating scale, weight, antipsychotic serum concentration, waist circumference, blood glucose, serum lipids

C. Brief standardized clinical rating scales, weight, blood pressure, blood glucose, serum lipids, electrocardiogram D. Positive and negative symptom rating scale, weight, blood pressure, blood glucose, serum lipids, electrocardiogram Chapter 68: Major Depressive Disorder 1) Which of the following statements is correct when considering the addition of an SSRI to a medication regimen that includes a chronic NSAID prescription? A. Combination must be avoided and is contraindicated B. Use this combination with caution and monitor patient closely C. Combination is associated with enhanced antidepressant efficacy D. Combination is associated with increased risk for clot formation 2) According to a recent report from the CDC, one particular antidepressant medication may be a 'safer' choice, in regards to antidepressant use early in pregnancy. Please choose the MOST appropriate antidepressant: A. Paroxetine B. Fluoxetine C. Bupropion D. Sertraline 3) Which of the following antidepressants is associated with multi-modal serotonergic effects? A. Mirtazapine B. Vilazodone C. Vortioxetine D. All of the above 4) According to the British Association of Psychopharmacology (BAP) guidelines, which of the following antidepressants may be associated with the BEST efficacy/adverse effects ratio? A. Bupropion B. Sertraline C. Vortioxetine D. Vilazodone 5) Augmentation to some extent of activity in the following neurotransmitter systems have been implicated in the pathophysiology of antidepressant-induced sexual dysfunction: A. Dopaminergic B. Noradrenergic C. Serotonergic D. All of the above 6) In a patient who has successfully achieved remission following the acute phase of treatment, which of the following is the most important factor to consider regarding the decision as to how long treatment should be continued? A. Prescription co-payment cost B. Risk of depressive recurrence C. Brand name product availability D. Caregiver preference 7) If you were going to recommend a specific literature-based exercise parameter to a patient foraugmenting SSRI efficacy, which of the following instructions would be correct? A. Focus on overall calories "burned" per week from exercise

B. Focus on reaching your peak exercise intensity each session C. Focus on activities with little to no impact, such as swimming D. None of the above 8) In a patient experiencing a major depressive episode, which of the following steps should be confirmed prior to labeling them a medication nonresponder? A. Adequate dose for adequate duration B. Adherence to prescribed regimen C. Proper monitoring of response D. All the above 9) In order to meet criteria for a major depressive episode (MDE), the patient must exhibit the following symptoms according to the DSM-5: A. Depressed mood most of the day every day for at least 1 week B. At least four of the symptoms as listed in the DSM-5 for MDE C. Impairment in some area of functioning (eg, social, occupational) D. History of "switch" into mania following antidepressant treatment 10) Which of the following scenarios is considered a pharmacokinetic drug interaction, instead of a pharmacodynamic drug interaction? A. Fluoxetine inhibits the metabolism of metoprolol via CYP2D6 B. Fluoxetine taken with linezolid leading to serotonin syndrome C. All the above D. None of the above 11) If serotonin syndrome is suspected in a patient being treated with antidepressants, which of the following is the most likely symptom that should be identified: A. Clonus B. Asterixis C. Priapism D. None of the above 12) When considering next-step antidepressant treatment in a patient who has not achieved full remission, which of the following approaches are supported by the evidence, according to the British Association of Psychopharmacology (BAP) guidelines and the STAR*D trial? A. Switch antidepressant B. Augment Antidepressant C. All the above D. None of the above 13) Elderly patients taking antidepressants have a efficacy effect size compared to younger adults. A. Equal B. Smaller C. Larger D. No comparative data 14) Which of the following antidepressants have been associated with sustained elevated blood pressure that requires close monitoring during treatment and possible dose adjustments? A. Desvenlafaxine B. Venlafaxine C. Levomilnacipran D. All the above

15) Although associations between antidepressant use and suicidality risk are complex, recent evidence suggests that which of the following antidepressants may be associated with a protective effect from suicidality among adults and older patients? A. Venlafaxine B. Mirtazapine C. Paroxetine D. Sertraline Chapter 69: Bipolar Disorder 1) The preferred treatment option for a 20-year-old patient with bipolar disorder who has severe liver disease is: A. Valproic acid (VPA) B. Lithium C. Carbamazepine D. Oxcarbazepine 2) During the lag time for onset of action of lithium, an appropriate adjunctive medication for acute mania might include a medication from which of the following classes? A. Antihistamines B. Benzodiazepines C. Beta-blockers D. Antidepressants 3) Lamotrigine should be used for which phase of bipolar disorder? A. Acute mania B. Acute depression C. Maintenance D. Rapid cycling 4) If lamotrigine is initiated in a patient receiving VPA, the starting dose of lamotrigine should be: A. Lower than if started in a patient not receiving VPA. B. Higher than if started in a patient not receiving VPA. C. The same as in a patient not receiving VPA. D. Lamotrigine is contraindicated in patients receiving VPA. 5) Which of the following laboratory tests is needed prior to initiating therapy with VPA: A. Potassium level B. Liver function test C. Thyroid function test D. Magnesium level 6) Which adverse effect is more frequently associated with oxcarbazepine than carbamazepine: A. Ataxia B. Nausea and vomiting C. Stevens johnson syndrome D. Hyponatremia 7) All of the following are symptoms of acute mania except: A. Grandiosity B. Racing thoughts C. Decreased appetite

D. Pressured speech 8) Antidepressants may be considered when treating a patient with bipolar disorder who is currently: A. Depressed, with a history of treatment resistant depression B. Not depressed, but has a history of severe depression before each manic episode C. Hypomanic, but has a history of severe depression D. Manic, but has a history of severe depression after a manic episode 9) A diagnosis of bipolar I disorder comes only after a patient has a: A. Manic episode B. Hypomanic episode C. Depressed episode D. A and B 10) Antipsychotics could be used in a patient displaying which of the following symptoms: A. Mania with psychotic features B. Mania without psychotic features C. Depression with psychotic features D. All of the above 11) A first line treatment option in a patient with bipolar disorder current episode manic is: A. Lithium B. Carbamazepine C. Lamotrigine D. Oxcarbazepine 12) Which of the following medication lists would be appropriate for a patient who is currently experiencing a manic episode? A. Lamotrigine, lorazepam, olanzapine B. Carbamazepine, fluoxetine, olanzapine C. Haloperidol, lorazepam, fluoxetine D. VPA, lorazepam, olanzapine 13) Which medication has an FDA indication for the treatment of bipolar depression: A. Olanzapine B. Quetiapine C. Risperidone D. Ziprasidone 14) Which medication has an FDA indication for maintenance therapy in bipolar disorder: A. Olanzapine B. Quetiapine C. Risperidone D. Ziprasidone 15) Which of the following laboratory tests is needed prior to initiating lithium therapy: A. Potassium level B. Platelet count C. Thyroid function test D. Magnesium level Chapter 70: Anxiety Disorders: Generalized Anxiety, Panic, and Social Anxiety Disorders

1) A 25-year-old patient presents with panic attacks occurring two to three times weekly. Symptoms that occur during the attacks include shortness of breath, tachycardia, paresthesias, dizziness, and palpitations. Upon further questioning, the patient states that the attacks occur during times of fear of talking with strangers, writing a check in front of someone, or in any situation that they feel scrutinized by others or likelihood of humiliation. Based on clinical presentation, the panic attacks this patient is experiencing are most likely associated with which of the following anxiety disorders? A. Panic disorder B. Social anxiety disorder C. Generalized anxiety disorder D. Obsessive-compulsive disorder 2) Which of the following brain structures is located in the temporal lobe and plays a critical role in the assessment and learned response to fear? A. Amydala B. Hippocampus C. Hypothalamus D. Locus ceruleus 3) A 48-year-old patient with hypertension, rheumatoid arthritis, and gastroesophageal reflux disease presents with symptoms of anxiety including palpitations, diaphoresis, and jitteriness. The patient's medication regimen includes prednisone, chlorthalidone, enalapril, and ranitidine. Which medication is most likely to contribute to symptoms of anxiety? A. Lisinopril B. Ranitidine C. Prednisone D. Chlorthalidone 4) Patients with panic disorder should be started at one-fourth to one-half of the dose of escitalopram used to treat depression in order to decrease the risk for which of the following? A. Weight gain B. Sedative effects C. Jitteriness syndrome D. Sexual dysfunction 5) A 23-year-old construction worker presents for pharmacotherapy for a new diagnosis of panic disorder. The patient has a history of opioid use disorder and asthma. Based on evidence-based guidelines, which of the following is most appropriate regimen to recommend? A. Buspirone 5 mg orally three times daily B. Paroxetine 10 mg orally daily in the morning C. Alprazolam extended- release 2 mg orally at bedtime D. Atenolol 25 mg orally an hour before anticipated anxiety 6) A 26-year-old patient with generalized anxiety disorder who responds to acute treatment with duloxetine should continue on it for at least what period of time? A. 1 month B. 3 months C. 6 months D. 12 months 7) A 35-year-old patient with panic disorder has been well-maintained on sertraline 150 mg daily and clonazepam 1 mg twice daily for 2 years. As a result of a recent hospitalization, several

medications have been added to the regimen, and the patient is experiencing significant breakthrough anxiety. Which of the following new medications is most likely to interact with the clonazepam and result in increased anxiety? A. Pantoprazole B. Carbamazepine C. Lithium carbonate D. Warfarin sodium 8) A patient with panic disorder has been treated successfully with paroxetine 60 mg daily for 6 months. The patient inquires about discontinuation of therapy. Which of the following is the most appropriate plan for discontinuation of paroxetine? A. Continue therapy for 6 more months, then attempt to taper the paroxetine over 4 to 6 months. B. Add clonazepam to the regimen and attempt to taper paroxetine over 2 months. C. Continue therapy for 3 more months, then attempt to taper paroxetine by decreasing the dose 25% weekly. D. Convert paroxetine to fluoxetine, then taper the fluoxetine after 6 months of therapy. 9) A patient has been treated with clonazepam 1 mg three times daily for panic disorder for 18 months. Upon discontinuation of therapy, the clonazepam should be tapered over how many weeks to reduce the chance for relapse? A. 2 B. 4 C. 6 D. 12 10) A patient with social anxiety disorder has failed therapy with sertraline and paroxetine. Based on evidence-based treatment guidelines, which of the following medications would be preferred for the next trial of pharmacotherapy? A. Mirtazapine B. Bupropion C. Pregabalin D. Venlafaxine 11) A 39-year-old patient is being treated for treatment-resistant generalized anxiety disorder with escitalopram 30 mg daily and quetiapine XR 100 mg at bedtime. Which of the following are the most appropriate monitoring parameters for this patient? A. Liebowitz Social Anxiety Scale, weight, complete blood count B. Hamilton Anxiety Scale, body mass index, fasting blood sugar C. Fall risk, weight, complete blood count, basic metabolic panel D. Suicidality risk, ophthalmic exam every 6 months, blood pressure 12) You are consulted on the case of a 70-year-old patient with newly diagnosed generalized anxiety disorder who has severe anxiety requiring pharmacotherapy with a quick onset of effect. You are asked to select the most appropriate benzodiazepine and educate the patient that this agent is safer in the elderly because of its route of metabolism. Which of the following benzodiazepines do you recommend and provide education about to the patient? A. Alprazolam B. Lorazepam C. Clorazepate D. Chlordiazepoxide

13) The long-term goal of therapy in the treatment of generalized anxiety disorder, panic disorder, and social anxiety disorder is which of the following? A. Few to minimal core symptoms B. Partial response after 12 weeks C. Ability to taper adjunctive agent D. Complete remission of symptoms 14) A 32-year-old patient presents with significant social anxiety disorder. The patient is not interested in pharmacotherapy, but is agreeable to nonpharmacologic methods of treatment. If nonpharmacologic methods are prescribed, which of the following would be most appropriate? A. Sympathectomy B. Psychological debriefing C. Cognitive behavioral therapy D. Transcranial neurostimulation 15) A 27-year-old patient with a history of substance abuse is being treated for panic disorder. Which of the following medications is associated with the risk of dependence with chronic and prolonged use? A. Buspirone B. Clonazpeam C. Venlafaxine D. Gabapentin

Chapter 71: Posttraumatic Stress Disorder and Obsessive-Compulsive Disorder 1) Which of the following best describes the pathophysiology of posttraumatic stress disorder (PTSD)? A. Low concentrations of cortisol B. High levels of neuropeptide Y C. Dysregulation of dopamine function D. Decreased secretion of corticotropin-releasing factor 2) Which of the following is considered an intrusion symptom of PTSD? A. Irritability or anger outbursts B. Avoiding feelings about the trauma C. Recurrent disturbing dreams of the event D. Inability to recall an important aspect of the event 3) In order to meet the diagnostic criteria for acute stress disorder a patient has to have resolution of symptoms by which of the following durations? A. 3 days B. 4 weeks C. 3 months D. 1 year 4) A 19-year-old college student was sexually assaulted at an off-campus party by an acquaintance 2 months ago. She presents to the outpatient clinic with complaints of difficulty falling and staying asleep, irritability, feeling numb, and being easily startled. She says that she has intrusive memories of the event, is missing at least 1 day of school a week, and avoids talking with her family and friends about the event. You note that on examination she has a restricted range of affect and appears nervous. She refused to talk about the details of the event.

She is diagnosed with PTSD. What is the most appropriate first-line pharmacologic management of this patient? A. Paroxetine 10 mg every day B. Olanzapine 5 mg twice daily C. Diazepam 5 mg 3 times a day D. Amitriptyline 10 mg at bedtime 5) Which of the following agents has the most evidence to support use as an augmenting agent in patients with PTSD who are on antidepressant therapy and continue to complain of avoidance symptoms? A. Prazosin B. Zolpidem C. Lorazepam D. Risperidone 6) A 41-year-old Marine veteran from the war in Afghanistan was diagnosed with PTSD 6 months ago. The patient has had a reduction in symptoms but continues to complain about memories of witnessing the deaths of three close friends during combat and Afghani children being gunned down by the Taliban. He continually blames himself for the deaths of his friends and is estranged from his wife. He is currently on sertraline 100 mg daily and has been on this dose for a month. What is the best recommendation at this time? A. Add quetiapine 25 mg daily B. Add phenelzine 15 mg at bedtime C. Increase sertraline to 150 mg daily D. Switch to venlafaxine extended-release 37.5 mg daily 7) Which of the following nonpharmacologic treatments has been found to be the most effective in the management of PTSD? A. Relaxation training B. Deep brain stimulation C. Electroconvulsive therapy D. Trauma-focused cognitive behavioral therapy 8) A 29-year-old patient with PTSD is seen in the outpatient clinic for a follow-up appointment. The patient has been on venlafaxine extended-release 225 mg daily for the past 6 months. The patient reports reduction in symptoms by 75% and has returned to work as a school teacher. The patient asks how much longer they should remain on medication. Which of the following minimum durations of time should you discuss with the patient? A. 3 months B. 6 months C. 9 months D. 12 months 9) Results of neuroimaging studies suggest that there is a dysfunction in which of the following areas of the brain in patients with obsessive-compulsive disorder (OCD)? A. Nigrostriatal tract B. Hypothalamic pituitary axis C. Ventromedial prefrontal cortex D. Cortical-striatal-thalamic circuit 10) Which of the following is an example of a compulsion that a patient with OCD may complain about?

A. Repeated thoughts of doubt. B. Repetitive urges to place pens in a proper order. C. Repeating the same verse from the bible silently. D. Recurring thoughts of feeling contaminated after touching objects. 11) A nurse practitioner would like to initiate paroxetine in a 20-year-old patient with OCD. Which of the following daily starting doses would you recommend? A. 20 mg B. 37.5 mg C. 50 mg D. 75 mg 12) An 11-year-old boy has been diagnosed with OCD. The patient's obsessions involve contamination. The patient's mother reports that the child showers three times a day and is constantly washing his hands to the point of cracked and bleeding hands. This is beginning to interfere with the family's routines and the patient's ability to complete school work and homework assignments. The mother requests that the patient be placed on medication. The patient is currently not taking any medications. Which of the following would be the most appropriate recommendation? A. Risperidone 1 mg 2 times daily B. Clomipramine 25 mg at bedtime C. Venlafaxine 25 mg 3 times daily D. Fluoxetine 10 mg every morning 13) Which of the following is the most effective and least invasive nonpharmacological treatment for OCD? A. Ablative neurosurgery B. Deep brain stimulation C. Exposure and response prevention D. Trauma-focused cognitive behavioral therapy 14) A 32-year-old man with a 10-year history of OCD complains of an increase in symptoms of fears that his son will be hit by a tractor trailer and die. This obsession has led to the patient knocking on wood for up to 2 hours daily. The patient has been on escitalopram 20 mg daily for the past 3 years. The patient lives in a rural area without access to psychotherapy. Which of the following would be the best augmenting agent to try? A. Quetiapine B. Haloperidol C. Venlafaxine D. Aripiprazole 15) A patient with newly diagnosed OCD has been on citalopram 20 mg daily for the past 3 months with a 50% reduction of symptoms based on the Yale-Brown Obsessive-Complusive Disorder Scale. The patient inquires as to how much longer it is recommended that they stay on this medication. What is the most appropriate response? A. 3 days B. 9 weeks C. 9 months D. 3 years 16) Which of the following parameters should be obtained at baseline and checked at each visit in patients maintained on clomipramine 75 mg twice daily for OCD?

A. Weight B. Blood glucose C. Electrocardiogram D. Complete blood count Chapter 72: Sleep–Wake Disorders 1) SB is a 28-year-old woman who complains that she has had difficulty sleeping over the past several weeks and that it is beginning to interfere with her work. She states that she had been working long hours and feeling stressed, so she has been doing aerobics before bed around 10 PM. What would you recommend initially to SB? A. Trazodone B. Flurazepam C. Cognitive therapy D. Zolpidem E. Sleep hygiene 2) Mrs. D, a 35-year-old woman, complains of difficulty with sleep onset for more than 12 weeks. She has appropriately tried sleep-hygiene therapy, but that has not worked. The plan is to initiate medication therapy. If the patient has no contraindications, and no medical causes for these sleep difficulties, which of the following therapies would you start with? A. Amitriptyline B. Fluoxetine C. Doxepin D. Citalopram E. Zolpidem 3) A 42-year-old woman who recently lost her husband tells you that she is not sleeping at night. After questioning her further, you determine that she does not have depression or substance abuse. What would you recommend? A. Educate her concerning sleep hygiene. B. Recommend a trial of a short-acting benzodiazepine-receptor agonists (BZDRA). C. Recommend a trial of fluoxetine. D. Recommend a trial of amitriptyline. 4) A 27-year-old woman has trouble with waking up in the middle of the night. Which of the following is least likely to be effective for her if taken at bedtime? A. Zaleplon B. Temazepam C. Zolpidem CR D. Estazolam 5) What is the best way to avoid tolerance and dependence in this patient? A. Use high-dose BZDRA therapy for as long as possible. B. Use high-dose BZDRA therapy for as short a time as possible. C. Use low-dose BZDRA therapy for as long as possible. D. Use low-dose BZDRA therapy for as short a time as possible. 6) A 28-year-old woman has a chief complaint of insomnia occurring for the past 5 months. She just graduated from pharmacy school, and she spends the evening worrying if she has made a mistake during her busy days at work. All other psychiatric and medical conditions have been ruled out. How would you approach treating this patient?

A. Recommend a short-term trial of lorazepam. B. Recommend a short-term trial of clonazepam. C. Recommend an approach that would include education concerning good sleep hygiene, supportive therapy, and trazodone as an adjunct if needed. D. Recommend cognitive therapy alone. 7) A 34-year-old man begins working overnight shifts. He finds that he has difficulty sleeping during daytime hours. What is the best recommendation you can provide him to help with his complaint? A. Drink alcohol after his work shift to help him fall asleep. B. Take melatonin, ramelteon, or a short-acting BZDRA at bedtime. C. Take an selective serotonin reuptake inhibitor (SSRI) after work to help him fall asleep. D. Take modafinil prior to going to work to help him stay awake overnight. 8) A 54-year-old man has been having difficulty maintaining sleep. He sleeps fine until around 1 AM when he wakes up. He would like to sleep until 6:30 AM. Which of the following would bethe most appropriate? A. Diazepam 5 mg PO at bedtime. B. Eszopiclone 3 mg PO when he awakens at 1 AM. C. Zolpidem 3.5 mg SL when he awakens at 1 AM. D. Flurazepam 30 mg PO at bedtime. 9) A 46-year-old man with chronic obstructive pulmonary disease has difficulty falling asleep. Which pharmacologic agent would you recommend in this patient? A. Temazepam B. Amitriptyline C. Ramelteon D. Levothyroxine 10) DB is a 58-year-old man with obstructive sleep apnea (OSA) and daytime sleepiness. What is the best therapy for him? A. Tracheostomy B. Modafinil C. Uvulopalatopharyngoplasty D. Oral appliances E. Continuous positive airway pressure 11) Sleep apnea can lead to all of the following sequelae except? A. Depression B. Stroke C. Hypertension D. REM parasomnias 12) Which of the following is the standard of treatment for daytime sleepiness associated with narcolepsy? A. Methamphetamine B. Modafinil C. Zolpidem D. Imipramine 13) Which of the following is the most effective treatment for cataplexy associated with narcolepsy? A. Methamphetamine

B. Medroxyprogesterone acetate C. Modafinil D. Sodium oxybate 14) It is believed that RLS results from: A. Hypocretin-orexin neuron dysfunction in the hypothalamus B. Repetitive airway closure during sleep C. Iron handling abnormalities in the substantia nigra D. Loss of serotonin receptors in the dorsal raphe nucleus. 15) Which of the following would be the correct recommendation for a patient with obsessive compulsive disorder and RLS who has difficulty falling asleep due to his RLS? A. Zolpidem B. Doxepin C. Ropinirole D. Pramipexole Chapter 73: Disorders Associated with Intellectual Disabilities 1) Which of the following terms associated with intellectual disabilities may refer to clinician perceptions that can lead to overlooking psychiatric disorders? A. Inattentiveness B. Functional adaptations C. Syndrome-specific features, such as hand-flapping or self-hugging D. Diagnostic overshadowing 2) Advanced age of which family member is most frequently identified as a risk factor for Down syndrome (DS)? A. Maternal grandmother B. Father C. Mother D. Combined mother and father 3) MJ, a 39-year-old woman diagnosed with DS and mild to moderate intellectual impairment, presents to the psychiatric clinic accompanied by her family. Her parents report she has become increasingly irritable over the past 6 months, more socially withdrawn, and unable to complete previously simple tasks. The family is interested in pharmacotherapy. Based on this information, which would you recommend for an initial trial? A. Desipramine B. Phenelzine C. Memantine D. Donepezil 4) A 5-year-old child experienced normal development until about 2 years of age when her parents noticed she did not talk as much as her peers and did not make good eye contact with her parents. As a toddler she played with her sister, but now prefers solitary play. Parents, teachers, and clinicians now suspect the child meets criteria for diagnosis of autism spectrum disorder. Which feature would help confirm this diagnosis—as opposed to another diagnosis such as Rett (RTT) syndrome? A. Hand–wringing. B. Bruxism. C. Scoliosis.

D. Restricted preferences for only certain toys and/or foods, including marked preference for sameness. 5) A colleague requests a consult for a 16-year-old patient with DS recently diagnosed with bipolar disorder and started on lithium. You state that: A. The current evidence suggests no monitoring is needed. B. A significant causal link exists between these comorbidities. C. Closer thyroid monitoring may be needed in this patient. D. Renal function may be impaired in persons with DS. 6) A child with a confirmed diagnosis of autism spectrum disorder (ASD) is in your pediatric clinic. What is the most common neurological problem in children with a diagnosis of ASD? A. Seizure disorder B. Tourette disorder C. RTT syndrome D. Neurogenic scoliosis 7) The parent of a child with ASD complicated by extremely aggressive behaviors asks about a trial of risperidone for these challenging behaviors. Nonpharmacologic strategies have already been implemented with limited success. You discuss this potential medication therapy with the mother and explain that: A. First-generation antipsychotic agents are less expensive and equally effective as secondgeneration agents. B. Evidence-based trial results indicate secretin may be a better therapeutic option for this child. C. The parent should check for complementary and alternative medication options as these have strong support for efficacy. D. Risperidone has the strongest evidence-based results in treating aggressive behaviors associated with ASD. 8) Early diagnosis and appropriate treatment is important for children with ASD in order to: A. Promote maximal learning, improve behaviors/communications, and engage in recreation/social/occupational activities. B. Implement pharmacotherapy and titrate the dose as quickly as possible. C. Justify institutional placement for vocational training opportunities. D. Enroll the parents and child in support groups and counseling. 9) Parents bring their 18-month-old child to your pediatric clinic. They mention the child does not enjoy playing with his/her siblings, has no interest in his/her parents, and has not begun to speak single words. What guidance should be given to these parents? A. Refer the family to a developmental evaluation center for a multidisciplinary workup. B. Minimize their concerns due to the young age of the child and reevaluate in 6 months. C. Refer the family to a support group for parents of children with ASD. D. Discuss neuroimaging to rule out brain pathology or injury. 10) As part of a medical workup for a child with suspected ASD, which of the following is not commonly performed? A. Detailed medical and developmental history. B. Lead or heavy metals testing, especially if pica is present. C. Genetic testing of parents and child. D. Electrocardiography at baseline and in 6 months.

11) What clinical condition associated with personality and behavior changes may present in DS adults? A. Hypothyroidism B. Obsessive-compulsive disorder C. Alzheimer disease D. Megakaryoblastic leukemia 12) What is the most common seizure presentation in RTT syndrome? A. Partial with secondary generalization B. Generalized tonic-clonic C. Myoclonic or Jacksonian D. Absence with secondary generalization 13) RTT syndrome-associated stereotypies have been found to be A. Maintained by negative environmental reinforcement. B. Indicators of an ASD comorbidity. C. Linked to specific genetic mutations. D. Responsive to second-generation antipsychotics. 14) DS immunologic abnormalities may necessitate medication regimen adjustments associated with the treatment of which condition? A. Leukemia B. Scoliosis C. Seizures D. Hypothyroidism 15) What is the most effective treatment to date for RTT syndrome-related scoliosis? A. High calcium and vitamin D diets. B. Frequent feedings to ensure adequate caloric intake. C. Surgical intervention to decrease the curvature. D. Relaxation therapy and massage to release muscle tension.

Chapter 74: Diabetes Mellitus 1) Type 1 diabetes mellitus is characterized by: A. Absolute insulin deficiency, beta cell destruction, most present as adolescents B. Primary insulin resistance, most present as adults C. Obesity, high postprandial GLP-1 levels D. Intrinsic hyperinsulinemia E. Antibodies to insulin receptors 2) Type 2 diabetes mellitus is NOT characterized by: A. Insulin resistance B. A major reduction in hepatic glucose output C. A decline in β-cell function and/or mass over time D. Low postprandial GLP-1 levels E. A higher postprandial glucagon 3) Which of the following properly performed laboratory values would be diagnostic for diabetes mellitus? A. A fasting plasma glucose of 110 mg/dL (6.1 mmol/L)

B. A random plasma glucose of 140 mg/dL (7.8 mmol/L) after a meal, but the patient states they feel fine, sleep well, and have gained 10 lb (4.5 kg) over the last 6 months C. A plasma glucose of 187 mg/dL (10.4 mmol/L) at 2 hours on a 75-g oral glucose tolerance test (OGTT) D. A hemoglobin A1c value of 6.6% (0.066; 49 mmol/mol Hb) 4) An adolescent is newly diagnosed with diabetes mellitus. The father, who also has diabetes, was diagnosed when he was 21 years old after an employment screening and his glucose has been well controlled on a sulfonylurea. He is now 47 years old. What is the likely etiology of their diabetes mellitus? A. Type 2 DM B. Mature-onset diabetes in the young (MODY) C. Type 1 DM D. Latent autoimmune diabetes in adults (LADA) 5) How is the hormone amylin affected in diabetes mellitus? A. Reduced fasting levels in newly diagnosed type 2 DM B. Severe resistance to its action at target tissues C. Absolute deficiency in type 1 DM D. There is no change 6) A patient with poorly controlled type 2 diabetes mellitus with extreme insulin resistance is currently on a total daily dose of 300 units of U-100 insulin. They are being transitioned to a concentrated insulin preparation. Which of the following would be appropriate? A. U-200 insulin degludec: inject 300 units subcutaneously daily (Given as 2 injections of 150 units each) B. U-500 regular insulin: inject 100 units (20 units as measured by the unit markings of a U-100 syringe) subcutaneously three times daily before meals C. U-300 insulin glargine: inject 300 units subcutaneously daily (given as 4 injections of 75 units each) D. All are correct 7) Sodium glucose cotransporter-2 inhibitors (SGLT2 inhibitors) result in all of the following except: A. Improved satiety B. Lower blood pressure C. Promote weight loss D. Increase the risk of orthostatic hypotension E. Increase the risk of genitourinary infections 8) Dipeptidyl peptidase 4 (DPP-4) inhibitors have been associated with a risk of all except: A. Very rare cases of severe arthralgia B. Heart failure C. Severe immunodeficiency syndrome D. Severe rash, including Stevens-Johnson syndrome 9) A 110-kg patient with type 2 diabetes mellitus is taking insulin glargine 82 units at bedtime and scheduled doses of 12 units of insulin lispro three times a day before each meal plus additional lispro for hyperglycemia. The patient has been consistently having bedtime blood glucose (BG) values of 200-250 mg/dL (11.1-13.9 mmol/L), but the pre-evening meal glucose is 100-130 mg/dL (5.6-7.2 mmol/L). In addition, the morning fasting BGs in the 70-90 mg/dL (3.9-

5.0 mmol/L) range. The HbA1c is currently 7.6% (0.076; 60 mmol/mol Hb) with a goal less than 7% (less than 0.07; 53 mmol/mol Hb). The next best step is to: A. Increase the dose of insulin glargine to 90 units injected subcutaneously at bedtime. A 10% increase. B. Keep the dose of insulin glargine the same, but change the timing of the injection from bedtime to morning. C. Increase the dose of insulin lispro at the evening meal, but decrease the insulin glargine by an equal number of units. D. Advise the patient to begin 6-8 units of insulin lispro at bedtime to correct for the hyperglycemia. E. Tell the patient to decrease the carbohydrate intake at lunch. 10) An obese patient with type 2 diabetes mellitus is taking 76 units of insulin degludec daily along with three scheduled doses of 18 units of insulin aspart before each meal (total daily dose of insulin = 130 units). You would like to advise them how to treat hyperglycemia by using additional insulin aspart. Please determine their estimated correction factor. A. 1 extra unit of insulin aspart will lower blood glucose by 6 mg/dL (0.3 mmol/L). B. 1 extra unit of insulin aspart will lower blood glucose by 10 mg/dL (0.6 mmol/L). C. 1 extra unit of insulin aspart will lower blood glucose by 15 mg/dL (0.8 mmol/L). D. 1 extra unit of insulin aspart will lower blood glucose by 25 mg/dL (1.4 mmol/L). E. 1 extra unit of insulin aspart will lower blood glucose by 60 mg/dL (3.3 mmol/L). 11) Please choose the correct statement. A. Diabetes mellitus associated with cystic fibrosis involves severe insulin resistance. B. Diabetes mellitus is most often due to autoimmune destruction of pancreatic β-cells. C. The incidence of MODY diabetes increases with age. D. Type 1 diabetes accounts for about 20% of cases of diabetes. E. All of the above are incorrect. 12) Which one of the following insulin products has a terminal half-life greater than 24 hours? A. Glulisine B. NPH C. Lispro D. Degludec 13) A patient arrives to your clinic for assessment. The current provider wishes you to assess their pharmacotherapy treatment as they feel he is doing the best he can with lifestyle interventions. All lab work, vital signs, and physical examination are normal/at goal except for mild background retinopathy and chronic kidney disease (eGFR 49 mL/min/1.73m2) with microalbuminuria. Current therapy: Metformin 500 mg BID with meals, Dapagliflozin 10 mg daily, Lisinopril 40 mg daily, rosuvastatin 20 mg daily. Which medication must be adjusted or stopped? A. Dapagliflozin B. Metformin C. Lisinopril D. Rosuvastatin

14) A patient arrives to the pharmacy and states she has a prescription for metformin, as she was diagnosed with gestational diabetes mellitus (GDM). A. Call the doctor to ask if they can switch to glyburide, which has more data. B. Call the doctor to ask if she can be switched to insulin therapy for gestational diabetes as several treatments are Pregnancy Category B. C. Fill the prescription after counseling. Make her aware that metformin is not currently approved for the treatment of gestational diabetes. D. Fill the prescription after switching it to extended release, as it is much better tolerated in pregnancy. 15) GM is a 59-year-old white female here for evaluation of her diabetes. All labs are normal except that her HbA1c is currently 8.6% (0.086; 70 mmol/mol Hb), her vitals are normal, but her BMI is 34 kg/m2. She is currently taking metformin 1,000 mg twice daily and canagliflozin 300 mg daily. She has hypertension and dyslipidemia. She states she is doing all she can with nonpharmacological and after interview you agree. What would be a good next step? A. Levemir 20 units at bedtime B. Dulaglutide 0.75 mg weekly C. Glimepiride 4 mg daily D. Linagliptin 5 mg daily E. All of the above 16) A patient presents to the emergency room with a random plasma glucose of 452 mg/dL (25.1 mmol/L), a 2 day history of a gastrointestinal virus with associated nausea, vomiting, and diarrhea, and dehydration. They currently take insulin. No other history is known. Which of the following scenarios would diagnose the patient? A. Diabetic ketoacidosis (DKA) if small ketones in the blood, but is 67 years old. B. Hyperosmolar hyperglycemic state (HHS) if the patient has mental status changes. C. HHS if the patient has a serum osmolality of 332 mOsm/kg (mmol/kg), but a normal anion gap. D. HHS if the person is less than 30 years old. E. All of the above are correct. 17) A 84-year-old man presents to clinic for a routine follow-up. He has a history of type 2 diabetes, hypertension, dyslipidemia, and coronary heart disease with a myocardial infarction requiring stents. He resides in a long-term care facility. He is currently taking metformin 500 mg twice daily, sitagliptin 50 mg daily, and insulin glargine 26 units daily. His current HbA1c is 9.6% (0.096; 81 mmol/mol Hb). What is his goal HbA1c? A. HbA1c less than 5% (0.05; 31 mmol/mol Hb) B. HbA1c less than 6.5% (0.065; 48 mmol/mol Hb) C. HbA1c less than 8% (0.08; 64 mmol/mol Hb) D. HbA1c less than 9% (0.09; 75 mmol/mol Hb) 18) CS has type 1 DM. She is 16 years old and currently uses an insulin pump to control her diabetes. Her basal rate is 0.3 units/h between 12 and 4 AM, 0.6 units/h the rest of the day. She uses insulin lispro. She has an insulin/carbohydrate ratio of 1/20 and a correction factor of 1 units/25 mg/dL (1 unit/1.4 mmol/L). Her goal HbA1c is less than 7% (less than 0.07; less than 53 mmol/mol Hb). She is going to eat a small apple, a piece of white bread toast with a piece of cheese for a snack. Her current blood glucose reading is 242 mg/dL (13.4 mmol/L), and she won't eat again for 4 hours. How much insulin lispro should she bolus for this snack? A. 2 units

B. 6 units C. 10 units D. 8 units Chapter 75: Thyroid Disorders 1) Which of the following symptoms would lead you to suspect hyperthyroidism in a female patient you are evaluating? A. Heavy menses B. Weight gain C. Brittle nails D. Delayed relaxation phase of the patellar reflexes E. Increased anxiety 2) Which of the following symptoms would lead you to suspect hypothyroidism in a patient you are evaluating? A. Diarrhea B. Increased appetite C. Cold sensitivity D. Hyperreflexia E. Weight loss 3) You suspect that a patient with hyperthyroidism has Graves' disease. Which of the following patterns on a RAIU and scan would confirm your diagnosis? A. Low uptake B. Uniformly increased uptake C. Patchy uptake D. A single area of high uptake within one lobe E. No uptake 4) Which of the following statements is true regarding the medical treatment of hyperthyroidism? A. Methimazole has a shorter half-life than propylthiouracil B. A common side effect of these agents is renal impairment C. Both propylthiouracil and methimazole are concentrated within the thyroid gland D. It takes 4-8 months of thionamide therapy before thyroid hormone levels begin to decrease E. Methimazole is more strongly bound to plasma proteins compared to PTU. 5) Which of the following statements about thionamides (PTU and methimazole) is correct: A. Methimazole must be administered three times daily B. Methimazole and PTU increase the stores of thyroglobulin within the thyroid gland C. PTU use is contraindicated during the first trimester of pregnancy D. PTU is considerably more potent than methimazole E. The side effects of PTU and methimazole include gastrointestinal symptoms 6) The following statements about thionamides (propylthiouracil [PTU] and methimazole) are correct EXCEPT: A. Mild leukopenia can be seen with PTU, methimazole, and with Graves' disease itself B. Methimazole and PTU serve as substrates for the iodinating intermediate of thyroid peroxidase C. PTU may increase the efficacy of later treatment with radioactive iodine D. Methimazole is generally considered first-line therapy for hyperthyroidism

E. The side effects of PTU and methimazole can include development of a rash 7) Which of the following statement about radioactive iodine therapy of hyperthyroidism is correct: A. Men are more likely to become hypothyroid after radioactive iodine therapy B. Treatment doses of radioiodine may be based on a fixed dose approach or a calculated dose approach C. If a first dose of radioactive iodine is ineffective, a second radioactive iodine dose cannot be given D. Hypothyroidism generally occurs approximately 6 days after radioiodine administration E. Radioactive iodine therapy is a useful treatment during pregnancy and lactation 8) Which of the following therapies is inappropriate for the treatment of thyroid storm? A. Administering a β-blocker as initial therapy B. Administering iodine as initial therapy C. Administering PTU as initial therapy D. Administering methimazole as initial therapy E. Employing cooling measures 9) Which of the following statement about thyroid hormones is correct? A. T4 has a half-life of about a day B. T3 has to be given subcutaneously C. The thyroid gland produces mostly T3 and a small amount of T4 D. TSH concentrations are generally not helpful when titrating a hypothyroid patient's dose of thyroid hormone E. T4 can be thought of as a prohormone as it is converted into the active hormone T3 10) Which of the following is NOT a potential cause of hypothyroidism? A. Hashimoto's thyroiditis B. Radioactive iodine therapy C. Pituitary failure D. β-Blocker therapy E. Over-treatment with thionamides 11) Which are the following statements is true regarding levothyroxine? A. Its absorption is unaffected by administration with food B. Thirty percent of an oral dose is absorbed C. It produces stable serum levels of both T4 and T3 D. Potential side effects include hepatitis and agranulocytosis E. New steady state levels of T4 are reached approximately 6 days after a dosage change 12) Which are the following parameters has the greatest effect on levothyroxine dose requirement in an adult? A. Sex B. Age C. Height D. Waist circumference E. Weight 13) Which are the following statements is true regarding liothyronine (synthetic T3)? A. It has a half-life of about 1 hour B. It has been used in combination with PTU therapy C. It produces stable serum levels of both T4 and T3

D. The side effects can include palpitations and insomnia E. It is the treatment of choice for hypothyroidism 14) Which of the following statements is true regarding the treatment of myxedema coma? A. High dose liothyronine is most effective B. Oral levothyroxine is the mainstay of therapy C. β-Blockers are routinely administered D. Intravenous levothyroxine is advisable E. Aspirin therapy is necessary 15) Which of the following therapies is considered standard treatment for hypothyroidism? A. Liothyronine monotherapy B. Levothyroxine therapy C. Thyroid extract therapy D. Iodine therapy E. Levothyroxine/liothyronine combination therapy Chapter 76: Adrenal Gland Disorders 1.A client is diagnosed with primary adrenal insufficiency. The nurse realizes that this disorder affects which of the following glands? 1. Adrenal cortex 2. Adrenal medulla 3. Thyroid 4. Pituitary ANS: 1 Mineralocorticoids, glucocorticoids, and androgens are produced in the adrenal cortex. The principal mineralocorticoid is aldosterone. The adrenal medulla secretes the catecholamines. The thyroid and pituitary do not secrete aldosterone. 2. The nurse is assessing a client diagnosed with hyperaldosteronism. Which of the following would take the least priority during this period? 1. Assessment of breath sounds 2. Cardiac monitoring 3. Assistance with activities of daily living (ADLs) 4. Review of electrolyte levels ANS: 3 The first priority for the nurse is to monitor cardiac and respiratory status. Cardiac status can be impaired because of changes in potassium levels, and fluid balance can be impaired because of sodium, affecting the respiratory status. After the client is stabilized, the nurse can assist the client with activities of daily living. 3. A patient enters the emergency department in adrenal crisis. The patient is lethargic and vital signs are blood pressure 85/52 mm Hg and pulse 88 beats/min. Which event in the patients week most likely precipitated this crisis? a. Eating a high-fat diet b. Being laid off from a job

c. Taking Tylenol for a headache d. Maintaining usual exercise of walking each night ANS: B Stress causes a need for an increase in cortisol, the bodys stress hormone. Being laid off is a stressor. A. C. D. Tylenol, walking, and a high-fat diet are not unusually stressful.

4. The nurse is assisting with discharge of a patient with Addisons disease following an adrenal crisis. Which instruction is most important for the nurse to reinforce? a. The need for a well-balanced diet b. How to monitor blood glucose levels c. The importance of 30 minutes of exercise each day d. The importance of taking steroid replacements as prescribed ANS: D Steroid replacements are essential because the patient with Addisons disease does not have adequate steroid hormones. B. Blood glucose levels are monitored if a patient is on high-dose steroids, not for replacement steroids. A. C. Diet and exercise are important but are not immediately life-threatening if not carried out.

5. A patient with an adrenal disorder is prescribed fludrocortisone. What is important for the nurse to monitor in this patient? a. Serum calcium levels b. Serum potassium levels c. Thyroid hormone levels d. Serum magnesium levels ANS: B Fludrocortisone is a mineral corticoid replacement, so it will cause sodium and water retention and potassium loss. Potassium should be monitored. A. C. D. It will not directly affect calcium, magnesium, or thyroid hormone levels. 6. The healthcare provider left an order to discontinue prednisone (Deltasone, Meticorten, Orasone, others). The highest priority action for the nurse is to: a. contact the healthcare provider to determine a tapering schedule. b. explain to the client that the drug will be immediately stopped. c. contact the pharmacist to determine a tapering schedule. d. begin gradually decreasing the prednisone dose. ANS: A Prednisone must be tapered to avoid adrenal insufficiency. Chapter 77: Pituitary Gland Disorders 1) Which of the following physiologic functions is not regulated by anterior pituitary hormones? A. Growth B. Thyroid function C. Ovulation

D. Uterine contraction 2) Which of the following clinical characteristics is common to acromegalic patients? A. Diarrhea B. Increased shoe size C. Weight loss D. Alopecia 3) The preferred initial treatment option for a patient recently diagnosed with acromegaly is: A. Bromocriptine B. Lanreotide C. Transsphenoidal surgery D. Radiation therapy 4) KL is a 58-year-old man who was recently diagnosed with acromegaly. His medical history is significant for type 2 diabetes and obesity. He is currently complaining of fatigue, joint pain, increased sweating, and headaches. He is not a candidate for transsphenoidal surgery. Which of the following treatments is most appropriate for first-line treatment of KL's symptoms? A. Bromocriptine B. Cabergoline C. Octreotide D. Radiation therapy 5) Which of the following information is most important to provide to an acromegalic patient with a new prescription for lanreotide? A. Concomitant therapy with ursodeoxycholic acid is needed to prevent gallstones. B. The most common adverse effect of lanreotide therapy is headache. C. A standard multiple vitamin is recommended during therapy. D. GI adverse effects should subside within 10 to 14 days of therapy. 6) Which of the following clinical characteristics is common to patients with GHD short stature? A. Normal GH serum concentrations. B. Physical height <2 standard deviations below the population mean. C. Malnutrition. D. None of the above. 7) Which of the following assessments need to be considered for the diagnosis of GH deficiency? A. Bone age and growth velocity B. GH response to provocative stimuli C. Serum insulin-like growth factor-1 (IGF-1) concentrations D. All of the above 8) For which of the following conditions does recombinant human GH therapy have a definitive role? A. Chronic fatigue syndrome B. GHD short stature C. Natural aging D. None of the above 9) Which of the following parameters should be monitored in a patient receiving recombinant human growth hormone therapy? A. IGF-1 B. Blood glucose

C. Thyroid function D. All of the above 10) Which of the following clinical characteristics is common in women with hyperprolactinemia? A. Menstrual irregularities B. Darkened skin C. Dry mouth D. Increased blood glucose 11) Which of the following classes of medications is most likely to cause drug-induced hyperprolactinemia? A. β-Blockers B. Antidepressants C. Antihistamines D. Oral contraceptives 12) LJ is a 29-year-old woman who has been diagnosed with a prolactin-secreting adenoma that is 8 mm in diameter. She complains of amenorrhea for 1 year and galactorrhea from both breasts. Which of the following treatments is most appropriate for first-line treatment of LJ's symptoms? A. Radiation therapy B. Transsphenoidal surgery C. Dopamine agonist therapy D. Somatostatin analog therapy 13) Which of the following dopamine agonists would be an appropriate choice for a patient trying to conceive? A. Cabergoline B. Ropinirole C. Bromocriptine D. Pramipexole 14) CM is a 30-year-old woman diagnosed with hyperprolactinemia. She recently began therapy with cabergoline. Which of the following medications should be considered as adjunctive therapy in CM? A. Human GH B. Oral contraceptives C. Multivitamins D. Antacids 15) Which of the following treatments may be required for patients with panhypopituitarism? A. Thyroid replacement B. Recombinant human GH C. Glucocorticoids D. All of the above Chapter 78: Pregnancy and Lactation: Therapeutic Considerations 1) Which of the following drug properties limits the ability of a drug to readily transfer across the placenta: A. Low protein binding B. Molecular weight below 500 daltons C. Hydrophilicity

D. Weak base 2) Which of the following types of data to evaluate drug safety during pregnancy is least likely to be available? A. Case study or case series B. Case-control study C. Retrospective cohort study D. Randomized, controlled trial 3) A 36-year-old woman with an active seizure disorder is contemplating pregnancy. Your recommendation to her is: A. Switch antiepileptic treatment to a medication not known to cause neural tube defects B. Take folic acid 4 mg daily during the first trimester C. Take folic acid 4 mg daily before conception followed by 4 mg daily during at least the first trimester D. Increase dietary intake of folic acid 4) A 29-year-old woman who is at week 37 is complaining of constipation for the past 3 days despite increasing her dietary fiber and water intake. Which of the following recommendations is not appropriate? A. Polyethylene glycol B. Castor oil C. Bisacodyl D. Senna E. None of the above is appropriate 5) Which of the following interventions decreases the risk of developing preeclampsia during pregnancy in women at risk for preeclampsia? A. Bedrest B. Low-dose aspirin C. Oral calcium supplementation D. Oral lisinopril E. Intravenous magnesium sulfate infusion 6) For a woman at 34 weeks of gestation with an acute deep vein thrombosis, the treatment of choice is: A. Dabigatran B. Unfractionated heparin C. Warfarin D. Low molecular weight heparin 7) Which of the following is not an appropriate choice for treatment of acute cystitis in a 32year-old woman at 27 weeks of gestation: A. Doxycycline B. Cephalexin C. Nitrofurantoin D. Amoxicillin/clavulanate 8) Which of the following management strategies is used to reduce the risk of congenital malformations in infants born to mothers with epilepsy? A. Switch drug therapy to phenobarbital B. Use low doses of several antiepileptic drugs to minimize dose of each received by the mother

C. Use only one antiepileptic drug, if possible D. Drug withdrawal before conception to minimize drug exposure 9) An appropriate treatment for a pregnant woman who has an acute migraine headache not responsive to ibuprofen is: A. Sumatriptan B. Ergotamine C. Caffeine D. Rizatriptan E. Propranolol 10) A 23-year-old woman had intermittent asthma treated with albuterol before pregnancy. Now at 13 weeks of gestation she is increasingly having symptoms and meets the definition for persistent asthma. The most appropriate treatment for this patient is: A. Use only albuterol for the duration of the pregnancy B. Continue albuterol and add cromolyn C. Change from albuterol to budesonide (low dose) D. Continue albuterol and add budesonide (low dose) E. Continue albuterol and add oral prednisone 11) Which of the following statements about antenatal corticosteroids is true: A. They are used to prevent preterm premature rupture of the membranes. B. They provide tocolysis in the setting of preterm labor. C. They should be readministered when there is risk of delivering within 7 days but a previous course of therapy has been administered. D. They ripen the cervix in pregnant women beyond 40 weeks of gestation. E. They prevent postpartum hemorrhage. 12) A 29-year-old woman of 16 weeks of gestation has a prior history of spontaneous preterm birth with her first child. Which of the following therapies should be initiated now to prevent the occurrence of a preterm birth in this singleton pregnancy? A. Terbutaline B. Nifedipine C. Antenatal corticosteroids D. Intravenous magnesium E. Hydroxyprogesterone 13) A woman diagnosed with gestational diabetes has failed first-line treatment with dietary and lifestyle modifications. Preferred drug treatment options include all of the following except: A. Insulin glargine B. Intermediate-acting insulin (ie, NPH) C. Glyburide D. Metformin E. Short-acting insulin (eg, regular) 14) Which of the following treatments are appropriate to recommend for a woman in labor with a positive screen for Group B Streptococcus at 35 weeks of gestation? The patient has no drug allergies. A. Penicillin G B. Ampicillin C. Clindamycin D. A and B only

E. A, B, and C 15) Strategies to lower infant exposure to medications through breast milk include all of the following except: A. Recommend a drug with a shorter half-life. B. Recommend a drug with a low bioavailability. C. Recommend a highly protein bound drug. D. Recommend a drug considered safe for use in an infant. E. Recommend a highly lipophilic drug. 16) The most common cause of infectious mastitis is: A. Streptococcus pyogenes B. Escherichia coli C. Staphylococcus aureus D. Candida albicans Chapter 79: Contraception 1) A 36-year-old woman who is non-adherent to medications is seeking contraception. PMH: mitral valve prolapse. Current medications: Toprol XL 25 mg every day, Centrum every day. Social history: smoker, occasional drinking. Family history: non-contributory. What would be the most appropriate response? A. Combined oral contraceptive B. Progestin-only oral contraceptive C. Injectable depot medroxyprogesterone acetate D. Vaginal ring contraceptive 2) A 32-year-old woman comes to the pharmacy to pick up her prescription for norgestimate/ethinyl estradiol (Ortho-Cyclen). She complains of significant nausea and headaches since starting her oral contraceptive 5 months ago. What is the most appropriate recommendation at this time? A. Call her physician to change her prescription to another oral contraceptive with less estrogen B. Call her physician to change her prescription to another oral contraceptive with less progestin C. Buy a home pregnancy test to rule out pregnancy D. Wait another 1 to 2 months to see if symptoms improve 3) A 33-year-old nonobese woman wants to discuss her contraceptive options. She is married with two children and does not desire to have additional children. Her medical history includes hypertension and migraines with aura. Which one of the following is the best approach to hormonal contraception for this patient? A. Ortho-Cyclen (combined oral contraceptive) B. Nexplanon (implantable contraceptive) C. Ortho Evra (transdermal patch) D. Nuvaring (vaginal ring contraceptive) 4) An 18-year-old obese woman with a seizure disorder seeks contraception today. She is taking phenytoin. Which of the following contraceptive methods would be most appropriate? A. Combined oral contraceptive (with 35 mcg of ethinyl estradiol) B. Mirena intrauterine device C. Transdermal contraceptive

D. Nexplanon subdermal implant 5) A 23-year-old frantic woman comes to the pharmacy asking for advice. She had sexual intercourse last night and her partner's condom broke. She states that she is currently taking a low-dose combined oral contraceptive but missed the last 2 days of pills. What do you recommend? A. Take two oral contraceptive pills today and then two pills tomorrow. Resume normal dosing for remainder of month B. Buy an over-the-counter levonorgestrel-containing emergency contraception at the pharmacy C. Make an appointment with her physician to discuss emergency contraception D. Take two oral contraceptive pills now and then two more pills in 72 hours. Resume normal dosing for remainder of month. 6) A 22-year-old woman has been prescribed rifampin antibiotic for 7 days. Her only medication is Mircette (a low dose combined oral contraceptive). What is the most appropriate counseling point for her today? A. Make an appointment with your physician to insert a levonorgestrel-IUD (Mirena) while you are on the antibiotic. B. There are no true documented drug interactions with any antibiotics and oral contraceptives, therefore taking both together will be fine. C. Use an additional nonhormonal contraceptive (ie, condoms) while taking the rifampin and oral contraceptive and continue with the additional contraceptive for 7 days after the rifampin has been discontinued. D. Administer levonorgestrel-containing EC daily while on the rifampin therapy. 7) In which of the following situations would it be unacceptable to recommend combined oralcontraceptives? A. Sickle cell disease B. Hypertension treated with a diuretic and an average blood pressure of 166/88 mm Hg C. History of migraines without aura in women less than 35 year of age D. Dyslipidemia without coronary artery disease treated to goal LDL with a statin 8) Which one of the following is a noncontraceptive benefit of oral contraceptives? A. Prevention of sexually transmitted diseases B. Decreased risk of cervical cancer C. Decrease in serum triglycerides D. Decreased risk of endometrial and ovarian cancers 9) LR is a 27-year-old woman who started on a low dose combined oral contraceptive containing 20 mcg ethinyl estradiol (EE) 2 months ago. She went out of town for the weekend and missed one dose of her medication yesterday. It is the second week of her pill pack. She is now asking for your opinion on how she should handle the situation. What would be the most appropriate response? A. Take an active tablet as soon as possible plus your regularly scheduled tablet for today (2 tablets total today) and then continue taking tablets daily, 1 each day as prescribed. No additional contraceptive protection is recommended. B. Take an active tablet as soon as possible (2 tablets on that day) and then continue taking tablets daily, 1 each day. Use condoms or abstain from sex until tablets have been taken for 7 days in a row. Finish the active tablets in the current pack and start a new pack the next day (ie, do not take the 7 inactive tablets).

C. iscard the current pack, allow bleeding to occur and then restart a new pack, taking 1 tablet each day. Use condoms or abstain from sex until the new pill pack has been taken for 7 days in a row. D. Make an appointment with a physician as soon as possible for insertion of a coppercontaining IUD. 10) KR is a 39-year-old nonsmoking female with a history of migraines with aura. She has two children with no immediate plans for others. She is obese and weighs 115 kg and does not want to gain any more weight. What contraceptive method would be the best option? A. Levonorgestrel IUD (Skyla) B. Injectable depot medroxyprogesterone acetate C. Combined oral contraceptive D. Vaginal ring contraceptive 11) The most clinically useful indicator of approaching ovulation is: A. Estrogen surge B. LH surge C. Progesterone drop D. Corpus luteum degeneration 12) A 36-year-old patient who is fairly non-adherent to medications and has never been on hormonal contraception in the past is requesting contraception. She is a smoker. What would be the most appropriate recommendation? A. Nuvaring (vaginal contraceptive) B. Ortho-Cyclen (combined oral contraceptive) C. Injectable depot medroxyprogesterone acetate D. Micronor (progestin-only pill) 13) Use of the vaginal contraceptive ring would be most appropriate in which of the following women? A. 30-year-old woman with hypothyroidism B. 38-year-old woman who smokes one-pack-per-day C. 36-year-old woman with migraines D. 28 year-old breastfeeding woman 18 days postpartum 14) AT is a 26-year-old female with a history significant for depression, dysmenorrhea, and smoking. She is not currently using hormonal contraception. She and her boyfriend did not use a condom and had unprotected sexual intercourse 5 days ago. What is the most appropriaterecommendation? A. Buy over-the-counter levonorgestrel-containing emergency contraception at the pharmacy B. Buy a home pregnancy test C. Inform her there is no emergency contraception option for her particular situation D. Call her clinician with a recommendation for a verbal order for ulipristal emergency contraception 15) A 25-year-old single, nulliparous, nonsmoking female with no significant medical history wants an easy, highly effective, and quickly reversible contraceptive method. What would you recommend? A. Combined oral contraceptive B. Progestin Implant (Nexplanon) C. Injectable depot medroxyprogesterone acetate D. Progestin-only oral contraceptive

Chapter 80: Menstruation-Related Disorders 1) ST is a 17-year-old female who complains of amenorrhea for 4 months. She experienced menarche at the age of 14 years. A pregnancy test is performed and found to be negative. She is a distance runner who describes her appetite as "healthy." What is the next step in evaluating this complaint? A. Check her serum prolactin concentration B. Check her thyroid-stimulating hormone (TSH) concentration C. Quantify her level of exercise relative to the amenorrhea D. Evaluate whether she may have anorexia 2) Regardless of the etiology of amenorrhea, which of the following lifestyle interventions is most appropriate? A. Increase the dietary intake of folate and vitamin E B. Increase the dietary intake calcium and vitamin D C. Decrease the intake of alcohol D. Decrease the level of exercise 3) KS is a 36-year-old female who has not had a period for 8 months. She is not pregnant; her serum prolactin concentration is observed to be twice the upper limit of normal. She displays no symptoms of polycystic ovary syndrome (PCOS). Which of the following is most appropriate for KS at this time? A. An oral contraceptive containing 30 µg ethinyl estradiol plus levonorgestrel B. Bromocriptine 2.5 mg by mouth three times daily C. Medroxyprogesterone acetate (MPA) 10 mg by mouth for 10 days D. Metformin 1,000 mg by mouth twice daily 4) AB is a 35-year-old female who presents for follow-up of treatment for heavy menstrual bleeding (HMB). She has been taking tranexamic acid 1,300 mg by mouth every 8 hours for 4 days at the start of menses for the past two menstrual cycles. She notes that there appears to have been minimal improvement in her HMB. Her menses continue to last approximately 7 days per month. A CBC shows an overall 2 g/dL (20 g/L; 1.24 mmol/L) drop in hemoglobin over the past 15 months. Her hemoglobin has not decreased any further since starting the tranexamic acid. Her past medical history is significant for a deep vein thrombosis 3 years ago secondary to an oral contraceptive. Assuming a repeat CBC and follow-up in 2 months, which of the following is most appropriate option for AB at this time? A. Continue tranexamic acid 1,300 mg by mouth every 8 hours for the full 7 days of menstrual bleeding during menses B. Discontinue tranexamic acid and begin a combination oral contraceptive with 50 µg ethinyl estradiol plus desogestrel C. Discontinue tranexamic acid and begin diclofenac by mouth every 8 hours at the start of menses and for the duration of menstrual bleeding D. Continue tranexamic acid and add the levonorgestrel intrauterine system (IUS) releasing 20 µg levonorgestrel daily 5) Which of the following statements is true regarding the levonorgestrel IUS in women with HMB? A. It should never be used in nulliparous women B. It reduces menstrual flow by a maximum of 25% C. It is a therapeutic option for any woman at low risk for sexually transmitted diseases

D. Its use increases the need for hysterectomy 6) In women with PCOS as a cause of abnormal uterine bleeding with ovulatory dysfunction, which of the following may result in improved menstrual irregularity and ovulatory function, reduced hirsutism, increased insulin sensitivity, and improved response to fertility treatments? A. Metformin B. Rosiglitazone C. Smoking cessation D. Weight loss 7) BB is a 32-year-old female who presents with complaints of irregular menses. She is hirsute around the jaw line, her BMI is 32 kg/m2, and her waist circumference is 40 inches (102 cm). A pelvic ultrasound reveals polycystic ovaries. Which of the following is most appropriate for BB? A. A combination oral contraceptive containing ethinyl estradiol and drospirenone B. A combination oral contraceptive containing ethinyl estradiol and levonorgestrel C. Metformin 850 mg by mouth twice daily D. The LNG-IUS 8) Hyperkalemia is most likely to result from which of the following products used in the management of PCOS? A. A combination oral contraceptive containing ethinyl estradiol and drospirenone B. A combination oral contraceptive containing ethinyl estradiol and levonorgestrel C. Metformin 850 mg by mouth twice daily D. Injectable MPA, 150 mg dosed every12 weeks 9) Improved insulin sensitivity in patients with PCOS may result in a reduction in circulating androgen concentrations, increased ovulation rates, and improved glucose tolerance. This may occur with: A. Estrogen therapy alone B. Combination oral contraceptive C. MPA D. Metformin 10) Excessive anovulatory bleeding in the adolescent population should result in an evaluation for: A. Hypoprothrombinemia B. Hyperandrogenism C. Hypoestrogenism D. Hypothyroidism 11) Which of the following agents is most appropriate for the management of dysmenorrhea in an adolescent who is not sexually active? A. Depot MPA 150 mg intramuscularly every 12 weeks B. Ibuprofen 800 mg by mouth three times daily during menses C. LNG-IUS releasing 20 µg levonorgestrel daily D. Oral contraceptive with 35 µg ethinyl estradiol plus norgestimate daily 12) The most cost-effective treatment for menorrhagia is: A. A combination oral contraceptive B. LNG-IUS C. Oral MPA D. Depot MPA

13) Which of the following nonpharmacologic options is effective for the treatment of dysmenorrhea? A. High protein diet B. Topical ice packs C. Reduced exercise D. Topical heat 14) Dysmenorrhea is experienced by as many as % of women of childbearing age. A. 20 B. 40 C. 70 D. 90 15) CO is a 30-year-old woman diagnosed with PMDD after charting her symptoms for two cycles and attempting (and failing) nonpharmacologic interventions for her symptoms. She is married and does not wish to use any form of birth control. Which of the following agents would be most appropriate for managing CO's PMDD? A. Continuous treatment with paroxetine B. Luteal phase treatment with paroxetine C. Luteal phase treatment with fluoxetine D. 90 µg levonorgestrel and 20 µg ethinyl estradiol dosed continuously for 12 months Chapter 81: Endometriosis 1) Which of the following is a risk factor for developing endometriosis? A. Excessive exercise B. Having more than three children C. Late onset of menarche D. Short menstrual cycles 2) Which of the following proposed pathophysiologic mechanisms of endometriosis describes a hormonal stimulus triggering cells in the peritoneal lining to differentiate to endometrial cells? A. Hematogenous spread B. Induction theory C. Mullerian rests D. Stem cell theory 3) Which of the following pathophysiologic alterations have been implicated in causing endometriosis pain? A. Dampening of dorsal root neuronal activity B. Decreased levels of circulating prostaglandins C. Enhanced macrophage activity D. Increased density of nerve receptors in endometriotic tissue 4) Which of the following is true regarding the role of endometriosis in infertility? A. Increase in antral follicle count due to hormonal alterations. B. Infertility is directly related to oocyte production in women with endometriosis, so donor-egg in vitro fertilization (IVF) has high success rates. C. Physical effects of endometriotic lesions fully account for the reduced fertility seen with the diagnosis. D. Proinflammatory cytokines create a hostile environment for sperm-oocytes interactions. 5) Which of the following statements is true regarding add-back therapy?

A. dd-back therapy prevents hot flashes and bone loss. B. Add-back therapy is likely to stimulate new endometrial growth. C. Add-back therapy is only started after 12 months of GnRH agonist therapy. D. Add-back therapy dosing is similar to the hormonal doses used in contraception. 6) A 43-year-old woman with severe endometriosis has continued pain despite treatment with GnRH agonists, combined hormonal contraceptives (CHCs), danazol, and several surgeries. Which of the following is a reasonable strategy to try at this time? A. Anastrozole monotherapy B. Depot medroxyprogesterone acetate C. Letrozole combined with norethindrone acetate D. Levonorgestrel-releasing intrauterine system (LNG-IUS) 7) Which of the following side effects is common to the GnRH agonists, aromatase inhibitors, and depot medroxyprogesterone? A. Bone mineral density loss B. Breakthrough bleeding C. Hot flashes D. Nausea/vomiting 8) JW, a 34-year-old woman with endometriosis, underwent conservative laparoscopic surgery 12 months ago in an attempt to improve her fertility. She has not yet achieved pregnancy. What is the most logical next step in JW's treatment plan? A. Continue watchful waiting. B. Start a GnRH agonist. C. Start oral CHCs. D. Start assisted-reproductive efforts. 9) KS is a 15-year-old adolescent girl who presents to her family practitioner for follow-up after presenting with severe menstrual pain 6 months prior. At that time, she was prescribed a lowdose combined oral contraceptive pill continuously. Today, KS reports that her pain has not improved. Based on this information, which of the following options is most appropriate at this time? A. Change current oral contraceptive to cyclic dosing. B. Refer for laparoscopic evaluation. C. Switch therapy to the LNG-IUS. D. Switch therapy to subcutaneous leuprolide. 10) What characteristic would preclude use of combined oral contraceptive pills to treat endometriosis pain in a woman over age 35 due to increased risk of serious side effects? A. Controlled hypertension B. Family history of heart attack C. Smoking D. Tension headaches 11) RH is a 21-year-old, unmarried, college student with severe endometriosis pain that has been unresponsive to 6 months treatment with depot medroxyprogesterone. Her past medical history also includes seasonal allergic rhinitis, asthma, migraine with aura, and allergy to aspirin products. Her medications include loratadine 10 mg by mouth daily, fluticasone/salmeterol 100/50 one puff twice a day, albuterol HFA two puffs every 6 hours as needed, and sumatriptan 50 mg by mouth as needed. RH has good prescription drug insurance that covers all commonly used endometriosis treatments. In addition to discontinuation of the depot medroxyprogesterone,

which of the following treatment recommendations would be best for RH based on the information given? A. Start oral danazol. B. Start a low-dose combined oral contraceptive pill. C. Start letrozole and oral medroxyprogesterone acetate. D. Start leuprolide, estradiol, norethindrone acetate, and oxycodone. 12) Which of the following monitoring plans is most appropriate for a patient who has been prescribed danazol for endometriosis? A. Pain relief at 2 months and routine liver function and cholesterol tests B. Pain relief at 6 months and bone mineral density scan annually C. Pain relief at 2 months and routine kidney function tests D. Pain relief at 6 months and assessment for hot flashes 13) Which of the following statements is most accurate regarding treatment of severe menopausal symptoms after radical hysterectomy in patients with endometriosis? A. Systemic monotherapy with estrogen can be prescribed indefinitely. B. All hormone therapy should be avoided as the risk of reactivating endometriosis is high. C. Systemic therapy with estrogen-progestin should be considered until the natural age of menopause. D. Local estrogen therapy for vaginal symptoms may be used, but systemic therapy with estrogen and progestin should be avoided. 14) A 28-year-old woman with known endometriosis presents with a primary complaint of infertility (unable to conceive after trying for over 2 years). She took CHCs in her early 20s for associated pain, but has not required hormonal treatment in several years. Which of the following is the best choice for her today? A. Celecoxib for 1 month B. Combined hormonal contraception for 3 months C. GnRH agonist for 6 months D. Laparoscopic surgery 15) A 22-year-old woman with endometriosis recently underwent laparoscopic surgery to treat pain unresponsive to depot medroxyprogesterone. Which of the following would be the best option for secondary prevention of recurrent dysmenorrhea after surgery? A. Danazol B. Letrozole C. Leuprolide D. LNG-IUS Chapter 82: Hormone Therapy in Women 1) The most effective treatment to alleviate postmenopausal vasomotor symptoms (hot flushes and night sweats) is: A. Estrogen therapy B. A selective estrogen-receptor modulator (SERM) C. Testosterone therapy D. Clonidine 2) Which of the following CYP450 isoenzymes metabolizes both estrogen and medroxyprogesterone? A. 3A4

B. 1A2 C. 2D6 D. All of the above 3) Continued vasomotor symptoms in a 52-year-old postmenopausal woman with a history of hysterectomy receiving 0.3 mg of oral conjugated equine estrogens can best be managed by: A. Changing to a SERM B. Increasing the daily estrogen dose C. Decreasing the daily estrogen dose D. Changing to gabapentin 4) A 54-year-old postmenopausal woman reports vaginal dryness and itching and pain with intercourse. She has not experienced any other problems associated with menopause and has an intact uterus. Which of the following recommendations would have the best benefit-risk balance for managing her symptoms? A. Vaginal estrogen cream + oral progestogen B. Vaginal estrogen cream C. Oral conjugated estrogen + medroxyprogesterone acetate D. Transdermal estradiol + micronized oral progesterone 5) Conjugated equine estrogen and medroxyprogesterone therapy can increase the risk of: A. Venous thromboembolism B. Stroke C. Colon cancer D. Both A and B 6) Which of the following would be the best option to treat moderate hot flushes in a 55-year-old woman with breast cancer? A. Estrogen B. Progestogen C. Paroxetine D. Tibolone 7) In women with hormone-receptor-positive breast cancer suffering from hot flushes, tibolone has been associated with: A. An increased risk for breast cancer recurrence B. A decreased risk for breast cancer recurrence C. No effect in breast cancer recurrence D. An increased risk of thrombocytopenia 8) Elevation in the serum concentrations of which of the following hormones in a 30-year-old woman can aid in confirming the diagnosis of primary ovarian insufficiency? A. TSH B. Prolactin C. FSH D. Estradiol 9) Long-term hormone therapy can be routinely prescribed for which of the following conditions? A. Coronary heart disease B. Dementia unresponsive to other therapies C. Prevention of colon cancer D. None of the above

10) Which of the following is considered a low dose of oral conjugated equine estrogens? A. 0.9 mg daily B. 0.625 mg C. 0.3 mg D. 1.25 mg 11) For osteoporosis prevention, a 65-year-old woman at high risk for breast cancer may receive: A. Estrogen B. Raloxifene C. Clonidine D. Testosterone 12) Which of the following is most effective for the treatment of severe hot flushes in a 54-yearold healthy menopausal woman? A. Estrogen and progestogen therapy B. Black cohosh C. Bazedoxifene D. Paroxetine 13) A common adverse effect experienced by women taking raloxifene is: A. Gastrointestinal upset B. Hot flushes and night sweats C. Vaginal spotting D. Headache 14) Young women with primary amenorrhea in whom secondary sex characteristics have failed to develop should initially receive: A. High doses of estrogen with a progestin B. Low doses of estrogen with a progestin C. High doses of estrogen without a progestin D. Low doses of estrogen without a progestin 15) Women with primary ovarian insufficiency should reassess whether to continue or discontinue the use of hormone therapy: A. Around the age of natural menopause B. After 1 year of hormone therapy use C. After 5 years of hormone therapy use D. They should receive life-long hormone therapy Chapter 83: Erectile Dysfunction 1) Which of the following medications is administered as a tablet which should be put on the tongue and allowed to be dissolved? It should not be swallowed? A. Muse B. Stendra C. Myrbetriq D. Staxyn E. Detrol 2) After three doses of tadalafil 10 mg taken on demand on three separate occasions, the patient returns to the physician's office to complain that the medication is not working. His erectile dysfunction has not responded to treatment. The most appropriate action that the physician should take at this time is:

A. Discontinue tadalafil and switch the patient to a vacuum erection device. B. Lower the tadalafil dose to 5 mg and instruct the patient to take it daily, not on demand. C. Continue with tadalafil 10 mg on demand for a total of 7-8 doses, and review the instructions for proper use. D. Increase the tadalafil dose to 20 mg and instruct the patient to try this the next time. E. Combine tadalafil 10 mg with intracavernosal alprostadil and instruct the patient to take both on demand. 3) If a phosphodiesterase type 5 inhibitor is taken with a potent CYP 3A4 inducer, the drug interaction may result in: A. Decreased efficacy of the phosphodiesterase type 54 inhibitor. B. Priapism C. Increased blood pressure D. Acute hearing loss E. Nausea and vomiting 4) Which one of the following statements about phosphodiesterase type 5 inhibitors is correct? A. If a patient is taking an alpha-adrenergic antagonist, blood pressure should be stabilized before starting the phosphodiesterase type 5 inhibitor. B. If the patient has taken a nitrate, all phosphodiesterase type 5 inhibitors should be held for at least one week. C. Sildenafil prolongs the QT interval in patients taking quinidine or procainamide. D. The combination of erythromycin and a phosphodiesterase type 5 inhibitor will result in severe coughing. E. The combination of a phosphodiesterase type 5 inhibitor and intracavernosal alprostadil will likely result in hypotension. 5) If a patient develops an acute loss of vision in one eye while taking a phosphodiesterase type 5 inhibitor, it is most likely due to: A. Cataracts B. Floppy iris syndrome C. Cyanopsia D. Nonarteritic anterior ischemic optic neuropathy E. Retinitis pigmentosa 6) Which one of the following statements about intracavernosal alprostadil is correct? A. Alprostadil inhibits adenylate cyclase and increases the level of epinephrine in cavernosal tissue. B. It has a high potential to produce systemic adverse effects. C. The injections can be self-administered. D. When administering a dose, both sides of the corpora cavernosa must be injected with alprostadil. E. When administering a dose, alprostadil should be injected into one side of the corpus spongiosum. 7) Which one of these testosterone supplements is most often associated with hepatotoxicity? A. Oral alkylated testosterone tablets B. Transdermal testosterone gel C. Buccal testosterone patches D. Transdermal testosterone patch E. Testosterone undecanoate injections

8) Which one of these testosterone supplements must be administered at a facility with a REMS program? A. Transdermal testosterone gel B. Buccal testosterone patches C. Oral alkylated testosterone tablets D. Testosterone undecanoate injections E. Testosterone enanthate injections 9) Which one of the following adverse effects of testosterone supplements necessitates discontinuing its use? A. Azoospermia B. Hematocrit of 55% C. Gynecomastia D. Sodium retention E. Doubling of ALT and AST over baseline 10) When should the Princeton Consensus Panel guidelines be used? A. To assess patients for cardiac side effects of phosphodiesterase type 5 inhibitors B. To identify patients who can be safely treated with medications for erectile dysfunction C. To monitor a patient's therapeutic response to alprostadil D. To assess the severity of a patients erectile dysfunction E. To diagnose the type of sexual dysfunction that a patient has 11) Which one of the following statements about the phosphodiesterase type 5 inhibitors-nitrate interaction is correct? A. Transdermal nitrates can be used safely with phosphodiesterase type 5 inhibitors. B. When compared to vardenafil, tadalafil has less potential to interact with nitrates. C. The mechanism of the interaction is that both phosphodiesterase type 5 inhibitors and nitrates increase cGMP. D. The interaction produce dry mouth, constipation, and decreased sweating. E. If taken in low enough doses, phosphodiesterase inhibitors will not interact with nitrates. 12) Which one of the following drugs/drug classes commonly causes erectile dysfunction? A. Testosterone supplements B. Glipizide C. Aspirin D. Beta-adrenergic antagonists E. Mirabegron 13) Which of the following statements about VED's is correct? A. A VED is only effective if use is combined with a phosphodiesterase type 5 inhibitor or alprostadil. B. Penile pain is a common reason why patients cannot tolerate its use and discontinue use after a few attempts. C. A rubber ring is applied to the erect penis to prolong the erection after VED use. D. Prior to activating the VED, lidocaine jelly should be applied to the penis. E. A male patient with severe arthritis of both hands is a contraindication to VED use. 14) Which statement about Caverject is correct? A. It is injected IM prior to sexual intercourse. B. It works by increasing intracavernosal production of cAMP. C. It is considered first line treatment of erectile dysfunction.

D. Pulmonary oil embolism has been associated with its use. E. Multiple doses during the day can be given. 15) Which one of the following statements is correct about phosphodiesterase type 5 inhibitors used for the treatment of erectile dysfunction? A. They are highly effective in all patients. B. They improve libido, and correct erectile dysfunction and ejaculation disorders. C. Sildenafil exhibits no significant drug-food interactions. D. They enhance sexual performance in patients with normal erectile function. E. Patients should take no more than one dose per day. Chapter 84: Benign Prostatic Hyperplasia 1) A patient complains of lower urinary tract symptoms (LUTS) despite treatment with tamsulosin 0.4 mg daily for 1 month. The patient's American Urological Association (AUA) symptom index was 25 at baseline, and is now 16. Which of the following statements is a correct interpretation of the change in the AUA symptom index? A. The reduction in the AUA symptom score is considered clinically significant. B. The patient probably didn't answer the AUA symptom index questions correctly which explains why he is still complaining of LUTS. C. Based on the patient's current AUA symptom index, the patient requires a prostatectomy. D. The patient's current AUA symptom score indicates that the patient has mild symptoms. E. The change in the AUA symptom score indicates that tamsulosin had no effect on reducing the patient's symptoms. 2) Which of the following statements about α-adrenergic antagonists is correct? A. Alfuzosin is a pharmacologically uroselective agent. B. Titrating up the dose of silodosin over 2 to 3 weeks is essential for the best effect. C. Immediate-release terazosin is more likely to cause syncope than tamsulosin. D. Concurrent use of tamsulosin with antihypertensives is not recommended. E. Prazosin is not recommended for benign prostatic hyperplasia (BPH) because it causes hearing loss. 3) Which one of the statements about α-adrenergic antagonists and floppy iris syndrome is correct? A. Only tamsulosin has been associated with this adverse effect. B. Vision loss is typically reversible. C. A hallmark of this side effect is small pupils that are not responsive to mydriatic agents. D. α-Adrenergic antagonists should be stopped 2 weeks before cataract surgery. E. Cataract surgery is a contraindication for α-adrenergic antagonist use. 4) What is the appropriate minimum length of a clinical trial of a 5α-reductase inhibitor? A. 3 to 6 hours B. 3 to 6 days C. 3 to 6 weeks D. 3 to 6 months E. 3 to 6 years 5) Which one of the following statements about combination therapy using a 5α-reductase inhibitor and an α-adrenergic antagonist for BPH is correct? A. The combination produces more adverse effects that using either drug alone.

B. The combination is indicated in patients with a prostate gland of 20 g or less and moderate to severe LUTS. C. LUTS responds quicker to the combination than to either drug used alone. D. Combination therapy does not delay disease progression or reduce the need for surgery. E. Combination therapy increases the risk of high grade prostate cancer, but not either drug alone. 6) Which one of the following medications can worsen LUTS? A. Hydrochlorothiazide B. Hydrocortisone C. Valsartan D. Glipizide E. Amoxicillin 7) A patient has a urinary flow rate of 12 mL/s, AUA symptom index of 7, and a prostate gland size of 20 g. The best management approach is: A. Watchful waiting B. An α-adrenergic antagonist C. A 5α-reductase inhibitor D. A combination of an α-adrenergic antagonist and a 5α-reductase inhibitor E. A combination of tolterodine plus an α-adrenergic antagonist 8) A 60-year-old patient has moderate LUTS due to BPH and erectile dysfunction. He is sexually active. The best management approach is: A. Watchful waiting B. An α-adrenergic antagonist C. A 5α-reductase inhibitor D. A phosphodiesterase type 5 inhibitor E. A combination of an α-adrenergic antagonist and a 5α-reductase inhibitor 9) For patients with BPH and essential hypertension, it is not recommended to treat both conditions with a single α-adrenergic antagonist. This is because patients would be at increased risk of: A. Orthostatic hypotension B. Congestive heart failure C. Pulmonary embolism D. Renal failure E. Liver failure 10) When used for BPH, which one of the following statements about tolterodine is correct? A. It reduces the size of an enlarged prostate gland. B. It halts disease progression. C. It reduces irritative voiding symptoms. D. It decreases prostate-specific antigen (PSA) levels. E. It may decrease postvoid residual (PVR). 11) When used for LUTS, which one of the following statements about mirabegron is correct? A. It halts disease progression. B. It reduces irritative voiding symptoms. C. It reduces obstructive voiding symptoms. D. It decreases PSA levels. E. It may increase PVR.

12) When counseling a patient taking tamsulosin, which one of the following instructions is correct? A. Take each dose after the same meal each day. B. Start with 1 mg/day and slowly titrate up over several weeks. C. This should not be taken with nitrates. D. It can be taken in divided doses during the day. E. It works on the bladder to reduce voiding symptoms. 13) A patient with BPH has an AUA symptom score of 15 (out of 35) and a prostate of 25 g. The best choice treatment is: A. Watchful waiting B. An α-adrenergic antagonist C. A 5α-reductase inhibitor D. A combination of an α-adrenergic antagonist and a 5α-reductase inhibitor E. A prostatectomy 14) Which one of the following statements is true about drug treatment for BPH? A. Alfuzosin inhibits 5α-reductase. B. Terazosin selectively inhibits α1A-adrenergic receptors. C. A medication must shrink the prostate to be effective for BPH. D. All of the α-adrenergic antagonists are equally effective. E. An effective treatment will lower the peak urinary flow rate. 15) For which one of the following conditions in a patient with BPH should an anticholinergic agent be avoided? A. Urinary flow rate of 12 mL/second B. Involuntary detrusor contractions C. Prostate gland of 30 g D. A history of diabetes mellitus E. A PVR of 250 to 300 mL or more Chapter 85: Urinary Incontinence 1. The nurse is collecting data from a patient with stress incontinence. Which finding should the nurse document? a. The patient is unable to tell when there is the need to urinate. b. The patient is unable to hold urine when under emotional stress. c. The patient is unable to reach the bathroom and urinates in underwear. d. The patient loses small amounts of urine when he or she coughs or sneezes. ANS: D Stress incontinence is the involuntary loss of less than 50 mL of urine associated with increasing abdominal pressure during coughing, sneezing, laughing, or other physical activities. A. B. C. These statements do not describe stress incontinence. 2. The nurse is caring for a male patient with functional incontinence. What action should the nurse take to help prevent incontinence? a. Teach the patient how to do Kegel exercises. b. Ensure that the patient has ready access to the urinal. c. Teach the patient to increase the time between voiding. d. Give the patient cranberry juice to keep the urine acidic.

NS: B Functional incontinence is the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation, so ensuring access to a urinal is important. A. Kegel exercises are helpful with stress or urge incontinence. C. Prolonging the time between voiding is helpful for urge incontinence. D. Cranberry juice does not affect continence. 3. A female patient is embarrassed because of not being able to walk to the bathroom in time before become incontinent of urine. Which type of incontinence should the nurse plan care for this patient? a. Urge b. Total c. Stress d. Functional ANS: A Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. The patient typically reports being unable to make it to the bathroom in time. B. Total incontinence is a continuous and unpredictable loss of urine. It usually results from surgery, trauma, or a malformation of the ureter. C. Stress incontinence is the involuntary loss of less than 50 mL of urine associated with increasing abdominal pressure during coughing, sneezing, laughing, or other physical activities. D. Functional incontinence is the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation. 4. The nurse is making a visit to the home of a patient with functional incontinence. Which observation indicates that teaching about the disorder has been effective? a. Patient wearing sweat pants b. Patient drinking a cup of coffee c. Patient sitting with the legs elevated d. Patient restricting fluid intake after 6 pm. ANS: A If clothing is inhibiting timely voiding for the patient with functional incontinence, the patient should be instructed to wear clothing with Velcro fasteners or sweat pants. B. Coffee is a bladder irrigant and could precipitate voiding. C. Elevating the legs is not an action appropriate for functional incontinence. D. Restricting fluids after 6 pm is not an appropriate action for functional incontinence. 5.A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. Which nursing intervention does the nurse include in developing a plan of care? a. Restrict fluids after the evening meal b. Insert an indwelling catheter c. d. ANS: D

Assist the patient to the bathroom every 2 hours Apply absorbent incontinence pads

Use of protective undergarments may help to keep the patient and the patients clothing dry. Confused patients are high risk for falls. Restricting fluids will only decrease incontinence during the night and will exacerbate the dehydration and electrolyte imbalance. 6. Which action can reduce the risk of skin impairment secondary to urinary incontinence? a. Decreasing fluid intake b. Catheterization of the elderly patient c. Limiting the use of medication (diuretics, etc.) d. Frequent toileting and meticulous skin care ANS: D Frequent toileting of the incontinent patient will prevent retained moisture in undergarments and bed linens and will preserve the integrity of the skin. 7. Why are urinary tract infections (UTI) common in older adults? (Select all that apply.) a. Older adults have weakened musculature in the bladder and urethra. b. Older adults have urinary stasis. c. d.

Older adults have increased bladder capacity. Older adults have diminished neurologic sensation.

e. The effects of medications such as diuretics that many older adults take. ANS: A, B, D, E Urinary frequency, urgency, nocturia, retention, and incontinence are common with aging. These occur because of weakened musculature in the bladder and urethra, diminished neurologic sensation combined with decreased bladder capacity, and the effects of medications such as diuretics. Older women are at risk for stress incontinence because of hormonal changes and weakened pelvic musculature. Inadequate fluid intake (less than 1000 to 2000 mL per 24 hours) can lead to urinary stasis. Chapter 86: Function and Evaluation of the Immune System 1. The nurse determines that a patient has long-term immunity against a disease. Which part of the immune system should the nurse recognize is responsible for this patients long-term immunity? a. IgE b. IgG c. Mast cells d. Plasma cells 2. The nurse is reviewing the immune system prior to discussing the actions with a patient. What type of cell should the nurse identify that is involved in cell-mediated immunity and has a cytotoxic action on tumor cells? a. Lysosomes b. Memory cells c. Natural killer cells d. Histocompatibility cells 3. The nurse is caring for a patient who is experiencing an immune response involving B and T cells. Which type of immunity is the patient demonstrating? a. Passive immunity

b. Humoral immunity c. Acquired immunity d. Cell-mediated immunity 4. A patient is experiencing an immune response that involves the T lymphocytes. For which types of immunity should the nurse plan care for this patient? a. Passive immunity b. Humoral immunity c. Acquired immunity d. Cell-mediated immunity 5. The nurse is preparing an injection for an individual who requires passive immunity. In which situation would passive immunity be indicated? a. For permanent immunity against a disease b. To overcome an allergic reaction that is relatively mild c. To have ready-made antibodies after an exposure to pathogens d. As a booster dose to stimulate the production of specific antibodies 6. The nurse notes that a patients eosinophil level is elevated. For which health problem should the nurse plan care for this patient? a. Cancer b. Allergic reactions c. Acute viral infections d. Autoimmune diseases 7. The nurse is administering medications to a patient. Which medications should the nurse understand is being given to suppress C-reactive protein levels? a. Aspirin and steroids b. Antibiotics and diuretics c. Epinephrine and antihistamines d. Antihypertensives and antineoplastic agents 8. The nurse is caring for a patient being tested for rheumatoid arthritis. In reviewing laboratory values, which should the nurse recognize as being diagnostic of rheumatoid arthritis? a. C-reactive protein = 12 mg/L b. Rheumatoid factor is negative. c. White blood cells = 6000/mm3 d. Antinuclear antibody test is negative. 9. The nurse has contributed to a staff education program on immunity. Which participant response indicates a correct understanding of the type of immunity that protects newborns for the first 3 months of life as a result of maternal transmission of IgG? a. Active natural immunity occurs. b. Passive natural immunity occurs. c. Active artificial immunity occurs. d. Passive artificial immunity occurs. 10. The nurse is reinforcing teaching to a person who has tested positive for HIV. Which test should the nurse explain is done to confirm the diagnosis of HIV? a. Western blot b. Rheumatoid factor c. Antinuclear antibodies d. Immunoglobulin assay

11. The nurse is reinforcing teaching to a person being tested for HIV in a clinic. Which test should the nurse explain is done first in HIV testing? a. ELISA test b. Western blot test c. Viral load studies d. Rheumatoid factor test 12. The nurse has contributed to an educational program for staff members. Which statement made by a staff member indicates a correct understanding of how passive immunity is provided? a. Having an acute disease. b. Administration of a toxoid. c. Administration of a vaccine. d. Administration of immunoglobulin. 13. The nurse provides care to older adults. What should the nurse recognize as being more likely to occur in an older adult than in a younger adult? a. High fevers b. Fewer infections c. More autoimmune disorders d. Greater antibody production 14. The nurse has administered prescribed allergen injections twice a week for several weeks to an individual with a bee sting allergy. The patient misses three appointments. What action should the nurse take on the patients next visit? a. Consult physician to confirm the dosage to be given. b. Administer the same dosage as was given at the last visit. c. Administer the dosage as originally prescribed for that visit. d. Tell the patient that the entire immunotherapy schedule needs to be restarted. 15. The nurse is caring for a patient with an infection. Which immunoglobulin should the nurse understand is produced first when an infection occurs? a. IgD b. IgE c. IgG d. IgM 16. During data collection, the nurse learns the patient is allergic to shellfish. Which precautions should be implemented during the patients hospitalization? a. The patient should be placed in a private room. b. The kitchen should use dedicated equipment for all of the patients food preparation. c. Iodine-based skin preparations should be replaced with different bactericidal cleansers. d. The patients allergy should be noted on the medical record and communicated clearly to all caretakers. 17. The nurse is reviewing the immune system with a patient newly diagnosed with an autoimmune disorder. What should the nurse explain as the purpose of antibodies? a. They destroy foreign antigens. b. Work on many different antigens c. Are specific according to blood type d. Attach to antigens to label them for destruction 18. A patient prescribed corticosteroids for arthritis is surprised to learn of an immune

disorder. What should the nurse explain as the reason for the patient not demonstrating typical signs of immune dysfunction? a. The arthritis is masking the normal immune response. b. The corticosteroids are causing the thymus gland to malfunction. c. The arthritis is interfering with the function of immunoglobulins. d. Corticosteroids are impacting normal immune response functioning. Multiple Response Identify one or more choices that best complete the statement or answer the question. 19. The nurse is assisting in the preparation of a teaching plan for an older patient. What information about maintaining a healthy immune system should the nurse recommend be included in this plan? (Select all that apply.) a. Get a pneumovax vaccine yearly. b. Obtain a varicella booster every 3 years. c. Get a diphtheria and tetanus booster every 10 years. d. Avoid people with colds or other infectious illnesses. e. Get an influenza vaccine yearly before influenza season. f. Obtain vaccination against hepatitis B if infection risk is moderate to high. 20. The nurse is caring for a patient with anemia. Which laboratory results should the nurse identify as being consistent with this diagnosis? (Select all that apply.) a. RDW = 12% in a 28-year-old female b. MCV = 72/mm3 in a 19-year-old female c. WBC = 7 109/L in a 39-year-old male d. RBC = 4.4 1012/L in a 31-year-old male e. WBC = 5.2 109/L in a 22-year-old female f. RBC = 5.7 1012/L in a 43-year-old female 21. The nurse has contributed to an educational program for staff members on immunity and classes of antibodies. Which statements indicate that the staff member understandings information about classes of antibodies? (Select all that apply.) a. IgG crosses the placenta. b. IgA is found in breast milk. c. IgD is found on natural killer cells. d. IgG provides short-term immunity. e. IgE is not involved in allergic reactions. f. IgM is found in blood and lymph drainage. 22. The nurse is providing care for a patient who is to start receiving immunotherapy for severe environmental allergies. Which information should the nurse reinforce for patient and family education? (Select all that apply.) a. You will have to have shots about once a month for the treatment to work. b. After the first shot, well be able to teach you how to give your own allergy shots at home. c. You will need to remain in the clinic for half an hour after your shot in case you have any reaction. d. The shots have medicine that helps slow down your immune system so you arent sick all the time. e. Reactions can occur up to 24 hours after the injection, so it is important to watch for any problems. f. Small amounts of things you are allergic to are being given in the shot so your body can

become less sensitive to them. 23. The nurse is caring for a patient with an immune disorder. Which classifications of medication should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Antibiotics b. Epinephrine c. Anticoagulants d. Antihistamines e. Corticosteroids 1. ANS: B IgG provides long-term immunity following a vaccine or illness recovery. A. IgE is responsible for allergic reactions. C. Mast cells contribute to inflammation. D. Plasma cells respond to foreign antigens. 2. ANS: C Cytotoxic, or killer, T cells (CD8) are able to lyse cells such as cancer cells. A. B. D. These cells do not have a cytotoxic action on tumor cells. 3. ANS: B Humoral immunity involves primarily B cells but is assisted by T cells. A. C. D. These types of immunity do not use both B and T cells. 4. ANS: D Cell-mediated immunity involves T cells. A. B. C. These types of immunity involve other types of cells. 5. ANS: C Artificially acquired passive immunity involves injection of preformed antibodies; this may help prevent disease after exposure to a pathogen. A. B. D. These situations are not appropriate for the injection of an antibody. 6. ANS: B Eosinophils elevate with type I hypersensitivity reactions such as allergic rhinitis or anaphylaxis. A. C. D. Eosinophils do not elevate in cancer, acute viral infections, or with autoimmune diseases. 7. ANS: A A normal C-reactive protein level is less than10 mg/L; an elevated level is present in rheumatoid arthritis, cancer, and systemic lupus erythematosus (SLE). This level is suppressed by aspirin and steroids. B. C. D. These medications are not used to suppress C-reactive protein levels. 8. ANS: A A normal C-reactive protein level is less than 10 mg/L; an elevated level is present in rheumatoid arthritis, cancer, and systemic lupus erythematosus (SLE). B. D. Antinuclear antibody (ANA) and rheumatoid factor are positive in the presence of rheumatoid arthritis. C. This is a normal white blood cell (WBC) count, which measures immune function. 9. ANS: B One form of naturally acquired passive immunity includes placental transmission of antibodies from mother to fetus. D. Artificially acquired passive immunity involves injection of preformed antibodies; this may help prevent disease after exposure to a pathogen such as the hepatitis B virus. A. Active immunity means that the person produces his or her own antibodies. C. Artificially acquired active immunity occurs as the result of a vaccine that stimulates production of antibodies and memory cells.

10. NS: A Western blot is used as a confirmation test for HIV. D. Immunoglobulin assays are completed to determine the presence of an infection. B. C. These are tests done to determine the presence of rheumatoid arthritis. 11. ANS: A Antibodies in the patients blood are tested for HIV antigen test plates. Positive ELISA results may indicate HIV infection, but results must be confirmed by another test. B. This test is often used to confirm a diagnosis of HIV. C. Viral load studies are completed to determine the percentage of viral infection that is present. D. Rheumatoid factor test is used to confirm rheumatoid arthritis. 12. ANS: D Artificially acquired passive immunity involves injection of preformed antibodies. Antibodies are made up of immunoglobulins. A. B. C. These do not explain how passive immunity is provided. 13. ANS: C The efficiency of the immune system decreases with age, so older people are more susceptible to infections and autoimmune disorders. A. Older patients are unlikely to experience high fevers. B. Infections might be increased because of altered immunity. D. Antibody production is altered with aging. 14. ANS: A It is important that the patient does not miss an allergen injection dose. If this happens, the allergen strength may need to be reduced, so the physician should be consulted. B. C. The same dose given on the last visit might be too strong since the patient missed three injections. D. The physician will determine the immunotherapy schedule. This is beyond the nurses scope of practice. 15. ANS: D IgM is produced first in an infection. A. IgD are antigen-specific receptors on B lymphocytes. B. IgE are important in allergic reactions. C. IgG crosses the placenta to provide passive immunity in newborns. 16. ANS: D It is important to clearly communicate patient allergies, so necessary precautions can be taken. C. It is not necessary to exchange the povidone-iodine solution found in procedural kits for a noniodine-based bactericidal cleanser. A. The patient does not need a private room. B. Shellfish is not a common ingredient in numerous foods, so dedicated equipment is not required. 17. ANS: D Antibodies are also called immunoglobulins (Ig) or gamma globulins and are glycoproteins produced by plasma cells in response to foreign antigens. Antibodies attach to antigens to label them for destruction. A. They do not themselves destroy foreign antigens. B. Each antibody is specific for only one antigen. C. There are five classes of human antibodies, designated by letter names: IgG, IgA, IgM, IgD, and IgE. They are not specific according to blood type. 18. ANS: C If the immune system is suppressed or functioning abnormally, this normal inflammatory response may not occur. Thus, the patient may have only a low-grade fever with none of the other signs of inflammation or infection. Corticosteroids can mask or impact normal immune response functioning. A. B. C. These are not reasons why the patient is not demonstrating typical signs of an immune disorder.

19. ANS: C, D, E, F The immune system is less effective with age, so avoiding those with infections is helpful. Immunizations for older adults include diphtheria tetanus booster every 10 years, pneumovax once in a lifetime, influenza vaccine yearly, and hepatitis B vaccine if medium to high risk for exposure to hepatitis B. A. A Pneumovax vaccine is not needed every year. B. A varicella booster is not needed every 3 years. 20. ANS: D, E The normal number of red blood cells per mm of blood for a man is 4.7 to 6.1 1012/L; for a female is 4.2 to 5.4 1012/L; low values indicate anemia. Mean corpuscular volume (MCV) and red blood cell distribution width (RDW) are used to help determine the cause of anemia. B. This value is low and indicative of anemia. A. This is normal. C. E. WBC count is indicative of immune function and is not used to determine the presence of anemia. 21. ANS: A, B, F IgA is found in breast milk. IgG crosses the placenta. IgM is found in blood and lymph fluid. D. IgG produces long-term immunity after vaccination or illness. C. IgD is found on B cells. E. IgE is involved in allergic reactions. 22. ANS: C, F B. When administering the allergen injection, it is important to understand that an anaphylactic reaction can occur. A physician and emergency equipment should be readily available. C. The patient should be observed following the injection for about 20 to 30 minutes to detect a reaction. D. F. Immunotherapy is used to help desensitize a patient and involves injecting small amounts of an extract of the allergen. A. The subcutaneous injections are given once or twice a week initially with a very dilute preparation. E. The patient and family should be taught that a reaction could occur up to 24 hours after the injection and how to respond if it does occur. 23. ANS: A, B, D, E Medications are one of the primary treatment options for immune disorders. General categories of these medications include epinephrine, corticosteroids, antihistamines, histamine (H2) blockers, decongestants, mast cell stabilizers, antivirals, antibiotics, immunosuppressants, interferon, leukotriene antagonists, and hormone therapy. C. Anticoagulants are not prescribed for immune disorders. Chapter 87: Systemic Lupus Erythematosus 1) Which of the following individuals would be at highest risk for developing idiopathic SLE? A. 20-year-old African American female B. 25-year-old white female C. 30-year-old Hispanic male D. 40-year-old Asian male 2) There is evidence that SLE can be precipitated in a genetically susceptible individual by: A. Epstein–Barr virus B. Pesticides C. Ultraviolet light D. All of the above 3) A patient is being considered for a trial of a new drug for lupus. She has a malar rash, oral ulcers, and joint tenderness. The study requires that participants fulfill the 2012 Systemic Lupus International Collaborating Clinics Classification Criteria for SLE. What additional finding would qualify this individual for the trial?

A. nticardiolipin antibody B. Proteinuria of 1 g in 24 hours C. Seizures D. White blood cell count of 5,000/mm3 4) Patients with SLE should be encouraged to stop smoking. It has been associated with all of the following except: A. Decreased effectiveness of hydroxychloroquine B. Decreased titers of anti-double-stranded DNA C. Increased incidence of hemorrhagic cystitis with cyclophosphamide D. Increased incidence of rash with scarring 5) Which of the following drugs decreases survival of B cells by inhibiting B-lymphocyte stimulator? A. Abatacept B. Belimumab C. Rituximab D. Tocilizumab 6) A 20-year-old African American woman develops Class III lupus nephritis. What is the recommended induction treatment for her disease? A. High-dose IV cyclophosphamide B. Low-dose IV cyclophosphamide C. Mycophenolate mofetil D. Rituximab 7) A patient with generalized SLE develops severe neurologic manifestations thought to be related to inflammation. There is good evidence supporting the use of the following drugs in this situation except: A. Azathioprine B. Belimumab C. Cyclophosphamide D. Methylprednisolone 8) A patient has cutaneous lupus on her face and treatment is needed. She is very concerned about her appearance. Which of the following is most associated with causing skin atrophy and telangiectasias? A. Hydroxychloroquine B. Methotrexate C. Topical pimecrolimus D. Topical triamcinolone acetonide 9) A 35-year-old woman who wants to have a baby in the future is found to have SLE. Which of the following drugs has the greatest potential to adversely affect fertility? A. Azathioprine B. Cyclophosphamide C. Hydroxychloroquine D. Mycophenolate mofetil 10) Which of the following drugs used to treat SLE could be started before pregnancy and continued throughout pregnancy with the leastpotential for harm to a fetus? A. Cyclophosphamide B. Dexamethasone

C. Hydroxychloroquine D. Mycophenolate mofetil 11) A patient with definite antiphospholipid syndrome had her first venous thrombosis and was treated for the acute episode. What should initially be used for secondary thromboprophylaxis for this patient? A. Low-molecular-weight heparin in prophylactic doses B. Low-dose aspirin C. Simvastatin D. Warfarin adjusted to an international normalized ratio (INR) of 2 to 3 12) What manifestation of SLE is common in idiopathic lupus but rare in drug-induced lupus? A. Arthritis B. Nephritis C. Pleuritis D. Rash 13) A patient is receiving belimumab for treatment of SLE. His immunization history and needs are being assessed. Which of the following vaccines should be avoided while he is receiving that drug? A. Hepatitis B B. Influenza C. Pneumococcal D. Zoster 14) A patient who is going to be treated with cyclophosphamide is considered to be at significant risk for hemorrhagic cystitis. Which of the following will decrease her chances of developing this complication? A. Alkalinization of urine B. Cholestyramine C. Folic acid D. Mesna 15) Eye examinations are recommended for patients receiving: A. Belimumab B. Cyclophosphamide C. Hydroxychloroquine D. Mycophenolate mofetil Chapter 88: Drug Allergy A patient with Parkinsons disease is taking an anticholinergic drug to decrease the tremors and drooling caused by the disease process. The patient complains that he is 1. having trouble voiding. The nurse would explain that this is what? A) A hypersensitive action of the drug B) C)

A primary action of the drug An allergic action of the drug

D) Ans:

A secondary action of the drug D Feedback:

2. A)

Sometimes the drug dosage can be adjusted so that the desired effect is achieved without producing undesired secondary reactions. But sometimes this is not possible, and the adverse effects are almost inevitable. In such cases, the patient needs to be informed that these effects may occur and counseled about ways to cope with the undesired effects. The situation described is not a hypersensitivity reaction that would indicate an allergic reaction, a primary reaction that would be excessive therapeutic response, or an allergic reaction to the drug. The nurse is assessing a patient new to the clinic. The patient says she is allergic to penicillin. What would be the nurses appropriate next action? Ascertain the exact nature of the patients response to the drug.

B) C)

Document the patient is allergic to penicillin. Mark the patients chart in red that she has a penicillin allergy.

Continue to assess the patient for other allergies.

Ans:

A Feedback: Ask additional questions of patients who state that they have a drug allergy to ascertain the exact nature of the response and whether it is a true drug allergy. Patients may confuse secondary actions of the drug with an allergy. Only after it was determined the action was truly an allergy would the nurse document the allergy, mark the patients chart, and continue to assess for other allergies.

3. A client with otitis media is ordered to receive amoxicillin (Amoxil). The client discloses to the nurse that she is allergic to penicillin. What is the highest priority action on the part of the nurse? a. Notify the healthcare provider that the client is allergic to penicillin. b. Encourage the client to take the dose under close monitoring. c. Administer half of the amoxicillin dose under supervision. d. Report the amoxicillin order to the supervisor. ANS: A Any medication allergy should be reported to the healthcare provider. 4. A client has relayed instructions from a physician regarding an allergy to a type of antibiotic therapy. The nurse would question which instruction? a. Wear a Medic Alert bracelet that indicates the allergy. b. Avoid all penicillin-type drugs. c. Inform all healthcare providers of the allergy. d. Restrict fluids when taking the antibiotic. ANS: D

Fluids should be encouraged with antibiotic therapy, so such an order would need to be questioned.

5. A client who reports an allergy to penicillin is ordered to receive cephalexin (Keflex). The correct action for the nurse is to: a. administer the medication as ordered with additional fluids. b. administer the medication and carefully observe for allergic reaction. c. call the physician to change the order because of the allergy history. d. administer another antibiotic after consulting the pharmacist. ANS: B There is a cross-sensitivity between penicillin and cephalosporin medications. The nurse should observe for allergic reactions.

Chapter 89: Solid-Organ Transplantation 1) Which of the following patients would NOT be a candidate for liver transplantation? A. A 33-year old female with acute liver failure secondary to intentional acetaminophen overdose B. A 48-year old male with end stage liver disease secondary to autoimmune hepatitis C. A 52-year old female with cirrhosis secondary to hepatitis B and active breast cancer D. A 64-year old male with a hepatocellular carcinoma and chronic hepatitis C 2) Living donor transplant is employed for which organ types? A. Kidney only B. Liver only C. Kidney and liver D. Kidney, liver and lung 3) Which of the following is NOT true regarding induction immunosuppression strategies? A. They are used patients at high risk of rejection. B. They are used to delay the initiation of nephrotoxic medications. C. They always include lymphocyte-depleting agents. D. They can include calcineurin inhibitors. 4) Antibody mediated rejection is evidenced by allograft dysfunction, presence of donor-specific antibodies (DSA), and C4d deposition on biopsy. Which therapy may result in a significant decrease in DSA? A. Basiliximab B. Bortezomib C. Methylprednisolone D. Tacrolimus 5) A 48-year old male received a heart transplant 6 months ago. He has a preexisting renal insufficiency, hypertension (BP = 160/95) and hyperlipidemia. His most recent heart biopsy showed no signs of rejection. His current immunosuppressant regimen is: tacrolimus 3 mg by mouth twice a day (last concentration 11 ng/mL[mcg/L; 14 nmol/L]), mycophenolate mofetil 1,000 mg by mouth twice daily and prednisone 5 mg by mouth daily. Which of the following is true?

A. Replacing tacrolimus with everolimus may improve his hypertension and hyperlipidemia. B. Replacing tacrolimus with sirolimus may improve his kidney function and hypertension. C. Replacing tacrolimus with cyclosporine may improve his hypertension and kidney function. D. Replacing tacrolimus with sirolimus may improve his kidney function and hemoglobin. 6) A 34-year old female kidney transplant recipient is receiving an immunosuppressant regimen consisting of tacrolimus and mycophenolate mofetil. She is 3 months post-transplant and has stable renal function. She is complaining of excessive hair loss. What change can the clinician consider? A. Change mycophenolate to azathioprine. B. Change tacrolimus to cyclosporine. C. Add everolimus to her regimen. D. Add belatacept to her regimen. 7) Which of the following immunosuppressants has the longest half-life? A. Cyclosporine B. Tacrolimus C. Everolimus D. Sirolimus 8) A 42-year old transplant recipient presents with the following immunosuppressive regimen: tacrolimus extended release tablet 5 mg daily, mycophenolate mofetil 1,000 mg twice daily and prednisone 5 mg daily. Your pharmacy does not current have all these specific formulations. Which of the following substitutions would be reasonable? A. Change mycophenolate mofetil 1,000 mg twice daily to mycophenolate sodium 1,000 mg twice daily. B. Change tacrolimus extended release tablet 5 mg daily to tacrolimus extended release capsule 5 mg daily. C. Change tacrolimus extended release tablet 5 mg daily to tacrolimus immediate release capsule 2.5 mg twice daily. D. Change mycophenolate mofetil to mycophenolate sodium 720 mg twice daily. 9) A 47-year old 70 kg heart transplant recipient is currently receiving the following: tacrolimus, azathioprine, sirolimus, valganciclovir, sulfamethoxazole-trimethoprim thrice weekly and nystatin. His most recent laboratory evaluation revealed: WBC 2,100/mm3 (2.1 × 10 9/L), Hgb 11.8g/dL(118 g/L; 7.32 mmol/L), Scr 1.3 mg/dL (115 µmol/L), and tacrolimus 11 ng/mL (mcg/L; 14 nmol/L). Which of the following is not likely contributing to his leukopenia? A. Azathioprine B. Sirolimus C. Tacrolimus D. Valganciclovir 10) Which immunosuppressive medication is not likely to have increased AUC during treatment of hepatitis C infection with ombitasvir/paritaprevir/ritonavir + dasabuvir? A. Cyclosporine B. Everolimus C. Mycophenolic Acid D. Sirolimus E. Tacrolimus 11) A 56-year old female with a liver transplant is receiving an immunosuppressive regimen consisting of tacrolimus and mycophenolate. She presents with a fever and increased WBC.

Empiric broad spectrum anti-infective therapy is being considered. Which of the following statements is true? A. Azole antifungals will decrease hepatic metabolism of mycophenolate and increase concentrations. B. Penicillins will compete for tubular secretion with tacrolimus and increase concentrations. C. Azole antifungals will inhibit hepatic metabolism of tacrolimus and increase concentrations. D. Penicillins will compete for biliary secretion with of tacrolimus and increase concentrations. 12) A 57-year old male with a kidney transplant is diagnosed with post-transplant BK nephropathy. His current immunosuppressant regimen consists of: tacrolimus 6 mg by mouth twice daily and sirolimus 3 mg by mouth daily. Which of the following changes should the clinician consider? A. Increase sirolimus dose B. Change sirolimus to mycophenolate C. Decrease tacrolimus dose D. Change tacrolimus to belatacept 13) Which of the following statements is true? A. Cyclosporine increases MPA concentrations due to interference with enterohepatic recycling of MPAG. B. Febuxostat inhibits xanthine oxidase, the enzyme responsible for elimination of MPAG. C. Phenytoin decreases tacrolimus levels by inducing activity of CYP 3A4 enzymes. D. Proton-pump inhibitors reduce cyclosporine levels by inhibiting gastrointestinal absorption. 14) A 42-year old female who is being discharged after receiving a heart transplant 2 weeks ago. Which of the following is NOT an appropriate monitoring plan for the next month? A. Serum creatinine should be monitored once or twice a week. B. Liver function tests should be monitored weekly. C. Tacrolimus levels should be monitored once or twice a week. D. Lipid panels should be monitored every 3 months. 15) Which of the following strategies is an appropriate approach to reduce morbidity associated with immunosuppression-related complications? A. Give valganciclovir to reduce the risk of post-transplant cytomegalovirus disease. B. Avoid calcium channel blockers for the treatment of hypertension due to the risk for drugdrug interactions. C. Avoid statins as treatment for sirolimus-induced hyperlipidemia due to drug-drug interactions. D. Give insulin as the first-line approach to treating new-onset diabetes mellitus after transplantation. Chapter 90: Osteoarthritis 1) Risk factors for the development of osteoarthritis (OA) include: A. Smoking B. Participation in running C. Being underweight D. Advanced age E. B and D

2) Patient education for OA, such as programs in which volunteers regularly contact patients A. Has not yet been demonstrated to provide benefit to OA patients B. Is too expensive to recommend for general use by OA patients C. Should emphasize the "wear and tear" nature of OA as part of the educational message D. Has been shown to improve pain and functional status of OA patients E. All of the above 3) Matrix metalloproteinases (MMPs) A. Are naturally occurring chemokines that work primarily by recruiting neutrophils and macrophages to the inflamed synovium B. Help trigger degradation of articular cartilage by cleaving peptide bonds in proteoglycans C. Are stimulated by tissue inhibitors of metalloproteinases (TIMPS) D. Must be activated before they can ease the pain of OA E. B and C 4) Which of the following are required for an accurate and appropriate diagnosis of OA? A. Patient history and physical examination B. Patient history, physical examination, and radiologic evaluation C. Physical examination and magnetic resonance imaging D. Patient history, physical examination, and positive response to pharmacologic treatment E. Any of the above is accurate and appropriate 5) Acetaminophen A. Is recommended as an appropriate initial treatment in OA B. Should be given on a scheduled basis for optimal pain control C. Can be associated with hepatotoxicity at doses below 4 g/day D. Provides mild analgesia E. All of the above 6) Traditional, nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) A. Block access of arachidonic acid to both COX-1 and COX-2 enzymes. B. Promote platelet aggregation through blockade of COX-2 activity. C. Promote prostaglandin and bicarbonate production in gastric mucosa through blockade of COX-2 activity. D. Counteract t renal vasoconstriction by promoting formation of renal prostaglandins. E. Are anti-inflammatory at low doses and analgesic at higher doses. 7) NSAIDs: A. Are associated with thousands of serious or life-threatening GI adverse events every year B. Provide superior relief of OA pain in some individuals C. Will usually produce symptoms of dyspepsia or abdominal discomfort as a prelude to serious GI adverse events D. When used in anti-inflammatory doses, should be consistently monitored by serum levels E. A and B 8) NSAIDs: A. Are recommended as an alternative to acetaminophen for controlling inflammation associated with OA. B. Provide pain relief by the inhibition of prostaglandins. C. Provide cardioprotective effects similar to aspirin. D. Increase renal blood flow, causing sodium and potassium excretion. E. B and C.

9) Celecoxib, a COX-2 selective inhibitor: A. Blocks the COX- 2 enzyme with little or no inhibition of COX-1 B. Is more effective at relieving pain than nonselective NSAIDs C. Is much safer to use in patients with cardiovascular disease D. Carries a manufacturer's warning against use in sulfa allergic patients E. A and D 10) Intra-articular corticosteroids: A. Have no role in OA, as this disease does not have any inflammatory component B. Are recommended as maintenance therapy for patients who cannot tolerate NSAIDs and who have severe OA C. Can be administered up to 12 times per year for the treatment of severe OA pain D. Are associated with hyperglycemia in patients without diabetes mellitus E. Should not be used for the treatment of hip OA 11) Hyaluronic acid injectable material: A. Is made using recombinant technology B. Provides a long-term increase in viscosity of synovial fluid C. Is a low cost pharmacologic therapy D. Is highly effective when compared to placebo vehicle injections E. Is less effective than intra-articular corticosteroids 12) Recommended treatment options for OA patients who have failed acetaminophen include: A. Nonselective NSAIDs used at analgesic doses, if the patient is not at high risk for GI bleeding B. Nonselective NSAIDs with an H2 antagonist to prevent GI bleeding in the high-risk patient C. COX-2 selective inhibitors with sucralfate in the high-risk patient D. COX-2 selective inhibitors with misoprostol in the high-risk patient E. None of the above 13) Knee replacement surgery should be considered in the patient with OA: A. If the patient prefers not to try oral medications such as acetaminophen B. If there is significant disability and interference with daily functioning C. If the patient refuses treatment with low-dose NSAIDs D. If the patient is at high-risk for NSAID-related GI bleeding E. If the patient does not respond to topical therapy with NSAIDs 14) Topical capsaicin therapy for the treatment of OA pain: A. Produces systemic adverse effects B. Provides therapeutic results within 48 hours C. Is most effective when used on an as needed basis D. Must be used four times daily for best results E. Is most appropriate for the treatment of hand OA 15) Which of the following patients is best suited to opioid analgesic therapy for their OA symptoms? A. History of alcoholism B. History of small bowel obstruction C. History of traumatic fall on home stairs D. History of myocardial infarction E. History of poor adherence to medications

Chapter 91: Rheumatoid Arthritis 1) Which of the following is not useful in evaluating therapeutic outcomes in patients with rheumatoid arthritis (RA)? A. Reduction in rheumatoid factor (RF) blood tests B. Radiographs of involved joints C. Changes in duration of morning stiffness D. Ability to perform usual daily tasks 2) Which of the following pharmacologic agents reduce RA symptoms but do not impede radiographic joint damage? A. Indomethacin B. Methotrexate C. Prednisone D. Etanercept 3) Monitoring of methotrexate therapy should include which of the following: A. Complete blood count (CBC), aspartate aminotransferase (AST) or alanine aminotransferase (ALT), and albumin B. CBC and urinalysis C. Eye examinations every 6 months D. CBC, creatinine, and glucose 4) Which of the following is an appropriate initial dosing regimen for methotrexate in an adult with RA? A. 50 mg orally daily B. 50 mg orally once weekly C. 7.5 mg orally daily D. 7.5 mg orally once weekly 5) Leflunomide monitoring would include all of the following except: A. Pregnancy B. CBC C. ALT D. Serum creatinine 6) If leflunomide needs to be rapidly eliminated from the body, which of the following drugs may be used to assist? A. Cholestyramine B. Sevelamer C. Hydrochlorothiazide D. Activated charcoal 7) Which of the following is true regarding sulfasalazine therapy? A. Eye examinations should be done every 6 months to assess for visual changes. B. Therapy should be discontinued if urine and skin turn a yellow-orange color. C. Administration with antibiotics may decrease sulfasalazine absorption. D. Administration with iron supplements increases sulfasalazine absorption. 8) Black box warnings for tofacitinib include which of the following? A. Liver failure B. Serious infection C. Elevated lipids D. Tendon rupture

9) Which of the following biologic response modifiers reduces activity of interleukin (IL) 6? A. Etanercept B. Tocilizumab C. Abatacept D. Anakinra 10) To prevent the development of antibodies, it is recommended that infliximab be given with which of the following drug? A. Cyclosporine B. Prednisone C. Methotrexate D. Adalimumab 11) AS is a 67-year-old man who after over the past 3 months has had subtle onset of joint pain and swelling, stiffness, and fatigue. He was diagnosed with RA at his rheumatology appointment today with DAS28 score of 3.5. Other pertinent medical history includes type 2 diabetes mellitus (T2DM), hypertension (HTN), hyperlipidemia, history of alcohol abuse (quit 25 years ago), and untreated hepatitis C. Current medications include glargine insulin 15 units once daily, glipizide 10 mg twice daily, and lisinopril 20 mg daily. He has additionally been taking over-the-counter (OTC) naproxen for pain as recommended on the bottle. His BP today in clinic was 142/86 mm Hg, and labs last month showing A1c of 7.6% (0.076; 60 mmol/mol Hb), Scr 1.2 mg/dL (106 µmol/L), AST 58 IU/L (normal range 13-47) (0.97 µkat/L [0.22-0.78 µkat/L]), ALT 62 IU/L (normal range 5-40) (1.03 µkat/L [0.08-0.67 µkat/L]), albumin 3.1 g/dL (normal range 3.0-4.6) (31 g/L [30-46 g/L]). CBC with platelets 3 months ago was within normal limits. The rheumatology fellow asks for your recommendation regarding preferred agent to start in this patient. Which of the following is the best agent to recommend? A. Methotrexate B. Tocilizumab C. Hydroxychloroquine D. Leflunomide 12) Adverse reactions to tocilizumab include all of the following except: A. Infusion-related reactions B. Elevated liver functions C. Multiple sclerosis-like illness D. Elevated plasma lipids 13) An intra-articular injection of long-acting corticosteroids can be of use in: A. Generalized flares of joint symptoms B. Patients who have rheumatoid nodules C. Patients with Cushing syndrome and RA D. Patients with one or a few active, swollen joints 14) MB is a 36-year-old woman who was diagnosed with RA 2 years ago. Today, she returns to the clinic with active RA with 8 swollen joints after 6 months of methotrexate monotherapy. A decision is made to discontinue methotrexate and initiate etanercept. Which of the following needs to be completed before starting etanercept? A. TB skin test, assess liver and kidney function, discuss costs B. TB skin test, pregnancy test, administer needed attenuated vaccines C. Pregnancy test, heart failure screening, assess liver function D. TB skin test, assess for infections, administer needed live vaccines

15) MB is a 36-year-old woman who was diagnosed with RA 2 years ago. Today, she returns to the clinic with active RA with 8 swollen joints after 6 months of methotrexate monotherapy. A decision is made to discontinue methotrexate and initiate etanercept. MB did not receive adequate benefit from etanercept monotherapy. She continues to have active rheumatoid arthritis with pain and swelling of 20 joints. Her morning stiffness lasts more than 6 hours. Which of the following options would provide the best chance of achieving disease control in this patient? A. Add adalimumab B. Add methotrexate C. Switch to sulfasalazine D. Switch to leflunomide Chapter 92: Osteoporosis and Osteomalacia 1) Which statement is true about bone physiology and pathophysiology? A. Estrogen is important in women and men to prevent bone resorption. B. Bone loss due to aging is predominantly from increased osteoclast apoptosis. C. Osteoprotegerin prevents RANKL from binding to the Wnt signaling pathway. D. Sclerostin inhibits cathepsin K, thereby decreasing bone resorption. 2) FRAX ® should be used to calculate fracture risk in which patient to determine whether there is a need for therapy? A. A 70-year-old man currently on denosumab therapy B. A postmenopausal woman with a T-score of the lumbar spine of −3.0 C. A 58-year-old postmenopausal woman with past breast cancer currently on raloxifene D. A 66-year-old woman with a T-score of the total hip of −2.0 E. A 70-year-old woman with a T-score of the spine of −3.0 and a low-trauma vertebral fracture 3) A 66-year-old man asks for recommendations for calcium and vitamin D. According to the National Osteoporosis Foundation, which daily intake do you recommend that he achieve? A. Calcium 1000 mg and vitamin D 600 units B. Calcium 1000 mg and vitamin D 800 units C. Calcium 1200 mg and vitamin D 600 units D. Calcium 1200 mg and vitamin D 1000 units E. Calcium 1500 mg and vitamin D 2000 units 4) A patient's T-scores on DXA are femoral neck (right) −2.2 and lumbar spine −2.8. How would you interpret these DXA results? A. Normal bone density B. Low bone density (osteopenia) C. Osteoporosis 5) In which of the following women should bisphosphonate therapy be recommended? A woman with a A. T-score femoral neck of 0.2 B. T-score femoral neck of −0.9 C. T-score lumbar spine of −1.8, T-score femoral neck of −2.1 and 10-year probability of hip fracture of 2% D. T-score lumbar spine of −2.2 and 10-year probability of hip fracture of 5% E. T-score femoral neck of −2.3 and 10-year probability of major osteoporotic fracture of 15%

6) In a 78-year-old woman a vertebral fracture assessment (VFA) reveals a spinal fracture. Her lowest T-score is −2.8 at the left femoral neck. She denies any pain. Which agent should be recommended for treatment? A. Ibandronate B. Bazedoxifene and conjugated equine estrogens C. Raloxifene D. Risedronate E. Teriparatide 7) An 80-year-old man has difficulty swallowing both food and medications after a stroke. Which agent represents first-line therapy for osteoporosis in this patient? A. Subcutaneous teriparatide B. Subcutaneous denosumab C. Intranasal calcitonin D. Effervescent alendronate 8) Which of the following should be completed prior to initiating therapy with denosumab? A. Correct any underlying hypocalcemia prior to administration B. Educate the patient on the need to remain upright after administration C. Inform the patient that the drug cannot be used for more than 2 years D. Determine the patient's thromboembolic risk 9) Which instruction for administration should be relayed to a patient on delayed release risedronate? A. Take after breakfast B. Remain upright for 15 minutes after taking C. Take with at least 8 ounces (~240 mL) of water D. Take together with your calcium and vitamin D tablet 10) A 65-year-old woman is taking osteoporosis prescription medication. She has high blood pressure, hypercholesterolemia, and type 2 diabetes. She has a problem with constipation. After using motivational interviewing, you find she cannot increase her diet to achieve the recommended daily allowances. Her current intake of calcium = 700 mg and vitamin D = 100 units. Which is the best supplement recommendation? A. Calcium 250 mg plus 400 units vitamin D combo bid B. Calcium citrate 600 mg daily, vitamin D 800 units daily C. Calcium carbonate 1200 mg daily, vitamin D 400 units daily D. Two multivitamins daily 11) How does teriparatide work? A. Inhibit osteoblast secretion of RANKL B. Inhibit release of bone destroying enzymes C. Inhibit osteoclast binding to the bone D. Inhibit osteoclast maturation and function E. Increase wnt signaling pathway to increase osteoblasts and bone formation 12) A 70-year-old man with asymptomatic hypogonadism is diagnosed with osteoporosis. He is found to be at high risk for hip fracture. Which of the following is the best initial treatment? A. Risedronate and testosterone B. Denosumab and testosterone C. Alendronate alone D. Ibandronate alone

E. Testosterone alone 13) You identify a 75-year-old woman who has not refilled her alendronate prescription for the last 3 months. She tells you she is concerned about osteonecrosis of the jaw (ONJ). Your response is? A. There is no risk of ONJ with oral osteoporosis medications. B. ONJ only happens in patients with cancer. C. Due to the risk of ONJ, you call her doctor to get it switched to raloxifene. D. ONJ is very rare and she should continue alendronate since she is more likely to have a hip fracture. 14) Which medication and common adverse effects statement is correct? A. Raloxifene—hot flushes, blood clots B. Calcitonin—rhinitis, atypical fractures C. Denosumab—increased cholesterol, serious infections D. Alendronate—nausea, osteonecrosis of the jaw E. Bazedoxifene and conjugated equine estrogens—blood clots, atypical fractures 15) Ms. Martinez, a 48-year-old premenopausal woman, with a long standing history of inflammatory bowel disease for which she takes 7.5 mg prednisone daily, is discussing the results of her DXA examination—Z-score lumbar spine −2.8 and femoral neck (right) −2.6. Besides a bone health lifestyle, what should she begin today? A. All medications are contraindicated, so she should try running every day. B. Data support bisphosphonates to prevent fractures in premenopausal women, but concerns exist about impact on fetus. C. Phytoestrogens can prevent osteoporosis, decrease fracture risk, and are safe during pregnancy. D. If she uses birth control, she could start a bisphosphonate, although little data exist about its long-term safety prior to menopause. 16) Mr. Jones, a 60-year-old man who just started treatment for prostate cancer, wants to know why his doctor wants to start an osteoporosis medication. Your best answer is? A. Cancer and some chemotherapy agents cause bone loss and fractures that can be prevented with these medications. B. Because of your age, he prescribed it to prevent age-induced osteoporosis. C. This medication will prevent high serum calcium and other bone related problems associated with your cancer. D. The osteoporosis medication is not needed. Chapter 93: Gout and Hyperuricemia 1. A client diagnosed with acute gout is prescribed allopurinol (Zyloprim). The nurse is reviewing the clients medication history and will contact the healthcare provider if the client is taking: a. diphenhydramine (Benadryl). b. metoclopramide (Reglan). c. propranolol (Inderal). d. warfarin (Coumadin). ANS: D

Allopurinol (Zyloprim) increases the effects of warfarin (Coumadin). Allopurinol does not interact with diphenhydramine, metoclopramide, and propranolol. 2. The client has been ordered to be treated with Benemid. What is the highest priority instruction to give the client? a. Take on an empty stomach. b. Increase fluid intake. c. Take with food. d. Limit fluid intake. ANS: B The client who is being treated with Benemid should increase his fluid intake because this will promote the urinary excretion of uric acid. Chapter 94: Glaucoma 1. How does untreated elevated intraocular pressure eventually lead to visual impairment? a. It compresses blood vessels and causes hypoxia of the photoreceptors. b. It clouds the lens and prevents light from striking the photoreceptors. c. It constricts the pupil and prevents light from entering the posterior chamber. d. It pushes the cornea forward and distorts the placement of the image on the retina. ANS: A The photoreceptors of the retina are the part of the sensory nerve that respond to light and enable vision. These receptors require a constant supply of oxygen. Higher than normal intraocular pressure compresses retinal vessels and limits or prevents blood flow to these receptors. As a result of this lack of oxygen, the receptors die and are not replaced. Loss of any photoreceptors reduces vision. Loss of them all causes total blindness. PTS: 0 DIF: Cognitive Level: Understanding (Comprehension) REF: p. 468 TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 2. Which statement regarding primary open-angle glaucoma (POAG) is true? a. It is most common in children. b. The major cause is trauma to the eye. c. The problem usually affects both eyes. d. The first symptom is chronic eye pain. ANS: C POAG is the most common form of glaucoma and is much more common in older adults. It does not occur as a result of trauma and usually affects both eyes, although one eye may be affected to a greater degree than the other. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF: p. 468 TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 3. Which precaution is most important for the nurse to teach a patient who is prescribed any type of eye drug administered as eye drops? a. Apply only the number of drops prescribed. b. Stop the drug immediately if eye redness occurs. c. Wear dark glasses for 1 hour after placing the eye drops. d. Apply pressure to the corner of the eye after the drug has been placed.

ANS: A Not only can eye drops enter the circulatory system and have systemic effects, excessive drops for some types of drugs for glaucoma can reduce intraocular pressure to dangerously low levels. Many patients do not consider any topical drug, including eye drops, to be real medication and believe that more drug is better. Patients must be taught to use all eye drugs exactly as prescribed, and not use more drug than is prescribed. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Health Promotion and Maintenance 4. Which safety precaution does the nurse teach a patient who is prescribed eye drops or eye ointment? a. Wash your hands before and after applying the drug. b. Do not share your eye medications with anyone else. c. Avoid drinking alcoholic beverages while taking this drug. d. Do not drive or use heavy equipment while your vision is blurred. ANS: D Both eye drops and eye ointments can blur vision immediately after instillation. Vision may remain blurry with eye ointments until the ointment is removed. Patients must not drive, operate heavy equipment, or perform any skill requiring precision (e.g., drawing up an insulin dose) until vision is clear. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Health Promotion and Maintenance 5. Which assessment is most important for the nurse to perform before instilling latanoprost (Xalatan) into a patients eyes? a. Measure the patients temperature. b. Measure the patients intraocular pressure. c. Check the cornea for abrasions or open areas. d. Assess heart rate and rhythm for 1 full minute. ANS: C Latanoprost is a prostaglandin agonist. These drugs should not be applied unless the cornea is completely intact. Measuring intraocular pressure is not necessary when a diagnosis of glaucoma has been established. Prostaglandin agonists, even if systemically absorbed, do not affect body temperature, or heart rate and rhythm. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe and Effective Care Environment 6. A patient has been taking bimatoprost (Lumigan) for the last 2 months. Which statement by the patient indicates to the nurse a correct understanding of this drug therapy? a. When my eyes are red or itchy, I should wait until the next day to use my glaucoma medicine. b. Even though my intraocular pressure is now normal, I will continue to take the drug once daily. c. One indication that I have used too much of this drug is when my vision becomes blurry or fuzzy. d. If I forget to take the eye drops one day, I should apply them as soon as I remember them the next day and also take the regular dose for that day.

ANS: B Primary open angle glaucoma is not cured by drugs and the eye drops must be used as prescribed continually for control of intraocular pressure. Prostaglandin agonists are applied just once daily. If one days dose is forgotten, the patient should not take it along with the next days dose. Overusing drugs from this class reduces their effectiveness. Eye redness and itchiness are expected as temporary local responses to eye drugs. They are not a reason to withhold the drug. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Health Promotion and Maintenance 7. A patient who has been using travoprost (Travatan) eye drops for glaucoma reports that the eye lashes seem longer and thicker. What is the nurses best action? a. Teach the patient that the drug is absorbed by the blood vessels of the eye and has no effect on other eye or lid structures. b. Instruct the patient to apply only the number of drops prescribed and to blot the area with cotton balls after each dose. c. Remind the patient that eye drops are liquid and that wet lashes appear both longer and thicker. d. Reassure the patient that this is an expected response to the drug and no action is needed. ANS: D An expected side effect of prostaglandin agonists is longer and thicker eyelashes on the side in which eye drops are applied. In fact, there is now a special formulation of the drug to be applied just to the lashes to increase length and thickness. In addition, the lashes, iris, and lid may become darker. Other than reassurance, no action is needed. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Psychosocial Integrity 8. How do beta-adrenergic blocking agents (antagonists) lower intraocular pressure? a. They increase the rate that the vitreous humor is reabsorbed. b. They slow the production of aqueous humor inside the eye. c. They reduce systemic blood pressure, which results in lower intraocular pressure. d. They increase the movement of aqueous humor from the posterior chamber into the anterior chamber. ANS: B Beta-adrenergic blocking agents, more commonly known as beta blockers, bind to adrenergic receptor sites and act as antagonists. They block the receptor and prevent the naturally occurring adrenalin from binding to the receptor. Selectively blocking beta-adrenergic receptors in the eye causes less aqueous humor to be produced by the ciliary bodies. These drugs also cause the fluid to be absorbed slightly better so that less remains in the eye to contribute to intraocular pressure. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF: pp. 473-474 TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 9. A patient is prescribed an ophthalmic beta-blocking agent for the treatment of glaucoma. Which precaution does the nurse teach the patient to prevent orthostatic hypotension? a. Change positions slowly. b. Take your pulse rate at least four times each day. c. Be sure to lie down for at least 10 minutes after putting the drops into your eyes.

d. Apply pressure to the inside corner of your eye when putting the drops into the eye. ANS: D Beta-blocking agents can cause hypotension if the eye drops are absorbed systemically. Nasal punctal occlusion during eye drop instillation keeps the drug in contact with the eye structures longer and decreases systemic absorption and side effects. The other precautions listed reduce the risk of falling if orthostatic hypotension occurs, but they do not prevent the drop in blood pressure. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Health Promotion and Maintenance 10. A patient who has been prescribed timolol (Timoptic) for the last month reports that his asthma is worse. What is the nurses best response? a. Check the patients breath sounds and pulse rate. b. Hold the dose and notify the prescriber immediately. c. Ask the patient what drugs he takes to control his asthma. d. Reassure the patient that this is an expected response and requires no action. ANS: A Timolol is a nonspecific beta blocker that can have systemic effects. It can cause bronchoconstriction and can make heart failure worse with backing of fluid into the lungs. The first action is to determine whether the patient needs immediate attention for either bronchoconstriction or possible heart failure. This is done by assessing breath sounds with a stethoscope and checking the pulse for rate, strength, and regularity. If a pulse oximeter is available, it should be used to assess the patients degree of oxygen saturation. The results of this assessment along with the patients report are then provided to the prescriber. It is likely that the class of drugs used to control this patients glaucoma will need to be changed. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 11. What is the most important assessment question for the nurse to ask a patient who is newly prescribed apraclonidine (Iopidine) for glaucoma? a. How long have you had glaucoma? b. What other medications are you currently taking? c. Have you had any difficulty with retaining urine? d. Do you have asthma or any chronic respiratory problem? ANS: B Apraclonidine is an adrenergic agonist. It should not be taken with certain types of psychiatric drugs, especially monoamine oxidase (MAO) inhibitors. Before giving the first dose of any drug from this class it is important to know what other prescribed and over-the-counter drugs the patient is taking to avoid serious drug interactions. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe and Effective Care Environment 12. Which assessment is most important for the nurse to perform after administering the first dose of dipivefrin (Propine) to a patient with glaucoma? a. Compare urine output with fluid intake. b. Listen to breath sounds bilaterally. c. Assess level of consciousness.

d. heck pupil size. ANS: C Dipivefrin is an adrenergic agonist. A common side effect is drowsiness, which increases the patients risk for falls and other injuries. Although drugs from this class cause midriasis (pupillary dilation), this is an expected response and not a change that must be assessed. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 13. When the nurse shines a penlight into the eyes of a patient who is prescribed brimonidine (Alphagan P), the pupils of both eyes remain equally dilated. What is the nurses best action? a. Document the response as the only action. b. Hold the next dose and notify the prescriber. c. Assess the patients hand grasp strength bilaterally. d. Remind the patient to wear sunglasses when outdoors. ANS: D Brimonidine is an adrenergic agonist. It causes pupils to dilate even when plenty of light is present. This is an expected response, not an adverse reaction, and does not indicate true neurologic changes. However, the patient should protect his or her eyes from excessive light by wearing sunglasses when outdoors or in any brightly lit environment. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Health Promotion and Maintenance 14. What is the most important action for the nurse to perform after administering eye drops to a patient who is prescribed pilocarpine (Ocu-Carpine)? a. Place the patient in the supine position. b. Wipe the excess drug from the patients skin. c. Instruct the patient to keep the eyes closed for 2 minutes. d. Check pupillary responses by shining a penlight into each eye. ANS: B Pilocarpine is a cholinergic drug that can be absorbed through the skin and cause many systemic effects, including headache, flushing, increased saliva, and sweating. If excessive amounts are absorbed, the patient can develop more severe problems such as asthma, hypotension, heart block and other rhythm problems, abdominal cramps, diarrhea, urinary incontinence, vomiting, and dizziness. The usual dosage is two drops per eye, which increases the chances that some drug will overflow onto the skin. Wiping any drug that falls on the skin prevents these severe problems. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Safe and Effective Care Environment 15. A patient who has been prescribed echothiophate (Phospholine Iodide) for the last 2 weeks reports all of the following symptoms or conditions. Which symptom or condition does the nurse report to the prescriber immediately? a. Excessive drooling b. Pinpoint pupils c. Cold hands d. Dry mouth ANS: A

Echothiophate is a cholinergic drug. A sign of cholinergic toxicity is excessive drooling. If this occurs, other problems, especially slow heart rate, are about to occur also. The patient needs to receive anticholinergic drugs immediately to counteract this toxicity. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 16. What is the most important precaution for the nurse to teach an older patient who is prescribed a glaucoma drug that causes miosis? a. Wear sunglasses until the drug wears off. b. Use at least a 30 SPF sunscreen when going outdoors. c. Avoid driving or operating hazardous machinery until the drug wears off. d. Increase the light indoors because vision will be decreased in low-light environments. ANS: D Miosis is a decrease in pupil size, which lets in less light and reduces visual acuity. Older adults already have a smaller pupil size as a result of the aging process. This problem combined with the drug increases the risk for falls and other injuries. Increasing environmental lighting improves vision and reduces the risk for injury. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Health Promotion and Maintenance 17. Which question is most important for the nurse to ask a patient who is prescribed acetazolamide (Diamox) before administering the first dose? a. Do you have diabetes? b. Are you allergic to sulfa drugs? c. How long have you had glaucoma? d. Do you eat grapefruit or drink grapefruit juice? ANS: B Acetazolamide has a chemical structure similar to sulfa drugs. Patients who have allergies to sulfa drugs often have an allergic reaction to acetazolamide. Although acetazolamide can increase or decrease blood glucose levels, and knowing whether the patient has diabetes is also important, an allergy to sulfa drugs is more likely to result in an adverse reaction. PTS: 1 DIF: Cognitive Level: Applying (Application) or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe and Effective Care Environment Chapter 95: Allergic Rhinitis 1) Persistent allergic rhinitis is a year-round disease that can be caused by which of the following? A. Dust mites B. Timothy grass pollen C. Ragweed pollen D. Kentucky bluegrass pollen E. Mosquitoes 2) Inflammatory mediators produce all of the following in the nose except: A. decreased vascular permeability B. rhinorrhea C. nasal congestion

D. sneezing E. vasodilation 3) Which of the following statements are true regarding complications of allergic rhinitis? A. Nose bleeds can result from mucosal hyperemia and inflammation B. The relationship between allergic rhinitis and asthma is stronger with seasonal allergic rhinitis compared to perennial C. Allergic shiners are the result of venous pooling under the eyes D. All of the above are true E. Only a and c are true 4) Prior to skin testing, which of the following drugs should be stopped for at least 10 days? A. olopatadine B. pseudoephedrine C. intranasal fluticasone D. loratadine E. cromolyn 5) Each of the following statements about allergens is true except: A. Cross-allergenicity is common with pollen from sycamore, cedar, and birch trees. B. Cross-allergenicity is common with pollen from Kentucky bluegrass, fescue and timothy grass. C. Energy efficient homes contain higher levels of dust mite fecal proteins. D. Mold spores are known to cause perennial and seasonal allergic rhinitis. 6) Which of the following is true regarding avoidance of allergens? A. It is easy to accomplish for allergy sufferers. B. Avoidance of offending allergens is the most direct method of preventing allergic rhinitis. C. Removing a cat from the home will result in improved symptoms within 2 days. D. Controlling dusts mites can be accomplished by replacing carpet, with symptoms improving within days. 7) The following are true of antihistamine therapy except: A. If a dose is missed, the patient should double the next dose only if using a peripherally selective agent. B. Patients must be counseled on the potential for drowsiness, even with the newer non-sedating agents. C. Patients with enlarged prostates may not be good candidates for antihistamine therapy. D. If a patient receiving diphenhydramine develops tolerance to the therapeutic effect, changing to an antihistamine in a different chemical class may be effective. 8) Patients experiencing allergic conjunctivitis while receiving nasal steroids may benefit from having what drug added to their regimen? A. azelastine B. cromolyn sodium C. levocabastine D. an intranasal decongestant E. a systemic decongestant 9) Rhinitis medicamentosa may be a complication of which of the following drugs: A. diphenhydramine B. sublingual immunotherapy C. fluticasone

D. xymetazoline E. clemastine 10) The following statements regarding systemic decongestants are true except: A. Development of rhinitis medicamentosa is not a problem. B. Ephedrine is most commonly used because it produces no measurable change in blood pressure. C. Action typically lasts longer than topical decongestants. D. They are less effective for immediate relief of symptoms compared to topical decongestants. 11) Intranasal beclomethasone: A. is most effective in seasonal allergic rhinitis if therapy is started a couple of weeks prior to the onset of the patient's allergic symptoms. B. causes significant HPA suppression so it should not be used in preteens. C. provides no added benefit in asthma patients with allergic rhinitis. D. causes drowsiness at approximately one-half the rate seen with diphenhydramine. 12) The following are common (>5% incidence) side effects seen with sublingual immunotherapy except: A. Mouth edema B. Peripheral edema C. Ear pruritis D. Throat irritation 13) The following statements about subcutaneous immunotherapy are true except: A. Candidates should have a history of symptoms controlled by antihistamines and/or nasal steroids. B. It is a slow/gradual process. C. Effectiveness has been demonstrated in clinical trials using pollen extracts. D. Three years of immunotherapy may be sufficient to give some patients lasting benefits. 14) Which of the following is true regarding sublingual immunotherapy: A. The tablets are dissolved under the tongue and swallowed immediately. B. Prescriptions may be accompanied with a prescription for an epinephrine pen only if the physician considers the patient high risk. C. The therapy must be given year round to maintain effect. D. The first dose must be given in the physician's office where the patient is observed for 30 minutes. 15) Key elements of evaluation the therapeutic outcome of a patient with allergic rhinitis include: A. the effect of the disease on the patient's life B. the efficacy of the treatment regimen C. the tolerability of the treatment regimen D. the patient's satisfaction of the treatment regimen E. all of the above Chapter 96: Acne Vulgaris The client receives a topical medication for treatment of an acne-like skin disorder. The nurse completes medication education and evaluates learning has occurred when the client makes which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply. 1. My daughter has a similar problem so she can use this too. 2. I will call my doctor if I notice a change in my symptoms. 3. I will apply the medication only to the affected area. 4. I do not need to shower prior to using this medication. 5. My medication only needs to be applied once a day. Correct Answer: 2,3 Rationale 1: Clients should not share medications; the daughter should have an evaluation herself. Rationale 2: The client must notify the physician if the symptoms change. Rationale 3: Medications can be irritating so they should be applied only to the affected area. Rationale 4: The medication should be applied to clean skin, so it is a good idea to shower prior to using this medication. Rationale 5: Some topical medications need to be applied more than once a day. 2.A teenager is taking isotretinoin (Accutane) for treatment of severe acne. The nurse has completed medication education with her mother, and evaluates additional learning is required when the mother makes which statement? 1. We can expect that her skin will be less oily. 2. She needs to be on a reliable method of birth control now. 3. At least I do not need to worry about her self-concept now. 4. I will pay particular attention to her mood now. Correct Answer: 3 Rationale 1: Isotretinoin (Accutane) decreases oil production. Rationale 2: Isotretinoin (Accutane) is Pregnancy Category X. Rationale 3: Severe depression with resulting suicidal ideation can be caused by this drug; the mother must pay attention to her mood. Rationale 4: Isotretinoin (Accutane) can cause severe depression with resulting suicidal ideation; the mother needs to talk to her daughter about her self-concept. 3. A client has been prescribed tretinoin (Avita) for treatment of acne. Which medication information should the nurse provide? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. It will take several weeks for you to see improvement in your skin. 2. You should continue using your over-the-counter oil drying medication until you start to see effects from this medication. 3. Mild sun exposure will help this medication work more effectively. 4. You will likely notice redness and scaling of your skin while using this medication. 5. Continue to take the tetracycline previously prescribed for your cystic acne. Correct Answer: 1,4 Rationale 1: Initial improvement may take 4-8 weeks, while maximum therapeutic benefit may take 5-6 months. Rationale 2: The client should avoid preparations that dry the skin. Rationale 3: The client should avoid direct exposure to sunlight while using this medication. Rationale 4: Redness and scaling are expected effects of this medication. Rationale 5: Additive phototoxicity can occur if tretinoin is used concurrently with tetracycline.

4. A patient is prescribed vitamin A acid (Retin-A) as treatment of acne vulgaris. What should the nurse instruct the patient about the purpose of this medication? (Select all that apply.) a. It decreases scarring. b. It loosens pore plugs. c. It kills bacteria in follicles. d. It stabilizes hormone levels.It stimulates the immune system. e. It prevents occurrence of comedomes. ANS: B, F Vitamin A acid (Retin-A, tretinoin) loosens pore plugs and prevents occurrence of new comedones. C. Antibiotics kill bacteria. D. Estrogen therapy stabilizes hormone levels. A. Dermabrasion can treat scarring. E. This medication does not stimulate the immune system.

Chapter 97: Psoriasis A client has psoriasis. Prior to beginning education, the nurse assesses the client. Which statement indicates the client has a correct knowledge base about his illness? 1. I wish there were some way besides medications to treat my psoriasis. 2. Treatment can help lessen the discomfort of my psoriasis. 3. Systemic medications are the only medications that are effective. 4. No medications are effective for treating my disorder. Correct Answer: 2 Rationale 1: . Ultraviolet light is also effective as an alternative to medication. Rationale 2: There are some medications that are effective in treating psoriasis. Rationale 3: Topical medications are also effective for treating psoriasis. Rationale 4: At this time, treatment can help lessen the discomfort of psoriasis. The nurse is preparing a patient with a history of psoriasis for ultraviolet light therapy with psoralen (PUVA). What is important for the nurse to teach the patient prior to initiating therapy? a. You will need to return in 1 week for blood tests for liver function. b. It is expected that you will experience pain and burning at the treatment sites. c. You will need to take your psoralen tablets for 1 week following the treatment. d. Plan to wear dark glasses during the treatment, and for the whole day following treatment. ANS: D Oral psoralen tablets (a photosensitizing agent) followed by exposure to UVA is called PUVA therapy. PUVA therapy temporarily inhibits DNA synthesis, which is antimitotic. Because psoralen is a photosensitizing agent, the patient must not only wear dark glasses during the treatment period, but also for the entire day after a treatment. A. B. The long-term safety of PUVA therapy is still unknown. Possible side effects include increased skin carcinomas, premature skin aging, and actinic keratosis C. The medication does not need to be taken for 1 week following the treatment.

3. The nurse is assisting a patient with psoriasis apply coal tar to the skin. What action should the nurse anticipate providing after the tar is applied to the patient? a. Expose the patient UV light. b. Application of occlusive dressings. c. Have the patient sit in a warm environment. d. Provide the patient with 16 ounces of warm fluids. ANS: A Tar preparations may be prescribed for the patient with psoriasis. The tar acts as an antimitotic, slowing the epidermal cell division. Coal tar is commonly used in combination with UV light. B. Occlusive dressings are not used with tars. C. D. There is no need for the patient to sit in a warm environment or to drink warm fluids after the tar is applied. Chapter 98: Atopic Dermatitis 1.The client receives topical glucocorticoids for the treatment of dermatitis. The nurse has completed medication education and evaluates that learning has occurred when the client makes which statement? 1. A pill would be more effective than this messy lotion that I have to use. 2. If this medication doesnt help me, there is nothing left to try. 3. Use of this lotion is really a lot safer and more effective than a pill. 4. Long-term use of this lotion can lead to dependence on the drug. Correct Answer: 3 Rationale 1: Topical agents, not oral agents, are the most effective treatment for dermatitis. Rationale 2: If topical medications are ineffective, they can be augmented with oral agents. Rationale 3: Topical agents are less likely to cause systemic effects than are oral medications, so they are safer and they are more effective.. Rationale 4: Dependence does not occur with glucocorticoids. 2.Dermatitis is characterized by 1. flaky, silver scales. 2. swelling of nasal tissues. 3. small papules. 4. pruritus. Correct Answer: 4 Rationale 1: Psoriasis produces red plaques with silver scales. Rationale 2: Rosacea psoriasis causes swelling around the nasal tissue. Rationale 3: Rosacea produces small papules with no pus. Rationale 4: Dermatitis is characterized by redness, pain, and pruritus. 3. The nurse is planning care for a patient with dermatitis. What interventions should be included in this patients plan of care? (Select all that apply.) a. Pat the skin dry after bathing b. Apply cool moist compresses c. Encourage a high-protein diet d. Provide skin care first thing in the morning e. Keep fingernails short to prevent scratching

NS: A, B, C, E The patients skin should be patted dry after bathing to prevent further trauma. Cool moist compresses should be applied to relieve inflammation and itching. A high-protein diet promotes healing. Keeping fingernails short helps prevent scratching. D. Skin care should be provided at bedtime to promote comfortable sleep.

Chapter 99: Dermatologic Drug Reactions and Common Skin Conditions 1) A 21-year-old male presents to the outpatient clinic complaining of a sore area on his thigh. He said it started as just one sore that was red and tender. On physical examination, several discrete nodules are present that are fluctuant and painful. The man states that he is allergic to penicillin, although he does not know the type of reaction that he had. He is afebrile and routine labs (complete blood count, chemistry panel) are normal. The most appropriate therapy for this patient would be: A. Cephalexin

B. Incision and drainage

C. Linezolid or vancomycin

D. Penicillin VK 2) A 76-year-old man presents to the emergency department with complaints of a burning pain on his lower leg. Physical examination reveals an erythematous, edematous lesion with a raised border that is sharply demarcated from uninfected skin. The man stated that he felt like he had the flu (fever, tired) before the pain began. His vital signs showed a temperature of 38.3°C (101°F) and a CBC revealed a white blood cell count of 17,000 cells/mm3 (17 × 109/L). The man stated that he was allergic to clarithromycin (made him sick to his stomach). The most appropriate therapy for this patient would be: A. Dicloxacillin

B. Erythromycin

C. Nafcillin

D. Penicillin G

3) A 5-year-old girl is brought to the clinic with complaints of itchy blisters on her face. Her face has a small area of erythema with a mixture of small vesicles filled with clear serous fluid and some larger pustules. Thin golden-yellow crusts of previously ruptured vesicles also cover her face. The child is afebrile, and has a normal complete blood count and no known drug allergies. The most appropriate therapy for this patient would be: A. Erythromycin

B. Incision and drainage

C. Mupirocin

D. Penicillin G 4) A 15-year-old male is brought to the emergency department by his parents with complaints of fever, chills, and headache. The young man stated that several days ago he had developed a blister on his right hand from pitching baseball. On physical examination, a bright red, narrow streak extends from the blister to his armpit. Regional lymph nodes are enlarged and tender. A complete blood count was performed that showed his white blood cell count to be elevated. The most appropriate therapy for this patient would be: A. Ciprofloxacin

B. Mupirocin

C. Penicillin G

D. Vancomycin 5) A 32-year-old female presents to her family clinician complaining that her lower leg feels hot and painful. Physical examination shows the lower leg to have erythema and edema, and it is warm to the touch. The erythematous area is nonelevated and has poorly defined margins. The woman is afebrile and her complete blood count is normal. She has no known allergies. The most appropriate empiric therapy for this patient would be: A. Dicloxacillin

B. Linezolid orally

C. Penicillin VK + clindamycin

D. Vancomycin or daptomycin 6) A 24-year-old female presents to her family clinician complaining of a sore she thought might be from a spider bite. Physical examination reveals a purulent lesion on her lower left face, surrounded by a 2 cm diameter area of redness and swelling. An aspirate of the purulent material showed many white blood cells and many gram-positive cocci in clusters. A complete blood count revealed a slightly elevated white blood count. The patient was afebrile and had no known allergies. The most appropriate therapy for this patient would be: A. Drainage of the lesion, followed by ciprofloxacin

B. Drainage of the lesion, followed by penicillin VK

C. Drainage of the lesion, followed by trimethoprim–sulfamethoxazole

D. Drainage of the lesion, followed by vancomycin 7) A 54-year-old male presents to the emergency department complaining of severe pain in his left lower leg. His leg is hot, swollen, and erythematous without sharp margins. Fluid-filled bullae were present; Gram stain of the clear fluid revealed gram-positive cocci in chains. Vital signs reveal a high temperature (40°C [104°F]), and a complete blood count revealed an elevated white blood count (22,000 cells/mm3 [22 × 109/L]). The most appropriate therapy for this patient would be: A. Clindamycin

B. Penicillin G

C. Surgical debridement

D. All of the above 8) A 68-year-old female presents to the diabetes clinic for a routine visit. She has no complaints. Her past medical history is significant for diabetes mellitus, hyperlipidemia, hypertension, and chronic renal insufficiency. Vital signs showed an elevated blood pressure; an elevated glucose was noted on a chemistry panel. Physical examination reveals a small ulcer on the sole of her

right foot. The lesion is erythematous, with the presence of pus and a foul-smelling odor. The patient has allergies to penicillin, ceftriaxone (difficulty breathing with both), and sulfa (rash). She has received multiple courses of antibiotic therapy previously, but the wound has never completely healed. The clinician counsels the patient on the importance of glucose and blood pressure control, as well as selfexamination and care of her feet. He also initiates antimicrobial therapy for the infection on her foot, which he judges to be mild in severity. The most appropriate therapy for this patient would be: A. Amoxicillin–clavulanic acid

B. Cephalexin

C. Moxifloxacin

D. Trimethoprim–sulfamethoxazole 9) One week later the patient in the preceding question returns with no improvement in her ulcer. She states that she has been compliant in taking her therapy as prescribed. The clinician obtains a small aspirated sample for culture and sensitivity. The Gram stain shows many white blood cells and many gram-positive cocci in clusters. The culture grew methicillin-resistant Staphylococcus aureus (MRSA), which was resistant to penicillin, cephalexin, and erythromycin, but sensitive to clindamycin, doxycycline, levofloxacin, gentamicin, trimethoprim–sulfamethoxazole, and vancomycin. Anaerobic cultures were still pending. Appropriate management of this patient at this time would be: A. Switch therapy to doxycycline.

B. Switch therapy to gentamicin.

C. Switch therapy to trimethoprim–sulfamethoxazole.

D. Switch therapy to vancomycin. 10) Treatment failures with clindamycin in patients with erythromycin-resistant/clindamycinsusceptible strains of S. aureus or Streptococcus pyogenes could be explained by: A. High bacterial inoculum

B. Inducible clindamycin resistance (positive D-test)

C. Inducible clindamycin resistance via a mecA gene

D. Presence of Panton-Valentine leukocidin 11) The most important aspect in the prevention of pressure sores is: A. Eliminating friction

B. Eliminating moisture

C. Eliminating pressure

D. Prophylactic topical antibiotics 12) An 8-year-old female was brought to the emergency department immediately after being bitten by a neighbor’s dog. The bite left a small laceration, but no signs of infection were present. The most appropriate management of this patient’s wound would be: A. Incision and drainage

B. Irrigation, immobilization, and elevation

C. Prophylaxis with doxycycline or ciprofloxacin

D. Tetanus–diphtheria toxoids and rabies prophylaxis 13) The most appropriate therapy for an infected dog or cat bite would be: A. Amoxicillin–clavulanic acid

B. Cephalexin

C. Penicillin VK + clindamycin

D. ancomycin 14) A 16-year-old male is brought to the emergency department with a bite wound to his arm suffered 3 hours ago during a fight at school. The wound shows no signs at infection at this time. The most appropriate therapy for this patient would be: A. Amoxicillin–clavulanic acid for 3 to 5 days

B. Cephalexin for 5 to 10 days

C. Clindamycin or erythromycin for 7 to 10 days

D. No antimicrobial therapy at this time 15) Antimicrobial therapy for clenched-fist injuries should include agents with antimicrobial activity against the following organism(s): A. CA-MRSA

B. Eikenella corrodens, Staphylococcus aureus, and anaerobes

C. Eikenella corrodens, Pasteurella multocida, and Staphylococcus aureus

D. Pasteurella multocida, Staphylococcus aureus, and Streptococcus pyogenes ANSWERS: 1.B 2.D 3.C 4.C 5.A 6.C 7.D 8.C 9.A 10.B 11.C 12.B 13.A 14.A

15.B Chapter 100: Anemias The nurse is caring for a patient in end-stage renal failure and anemia. What is the cause 1. of this patients anemia? A) Low serum iron levels B) C)

Low erythropoietin levels Inadequate oxygenation of tissue

D) Ans:

Lack of B12 and folic acid intake B Feedback: Anemia can occur if erythropoietin levels are low. This is seen in association with renal failure, when the kidneys are no longer able to produce erythropoietin. Low iron levels, hypoxia, and vitamin deficiency are not likely to be the primary cause of anemia in a patient with kidney failure.

2. A)

A 2-year-old child weighing 32 pounds is to take ferrous sulfate (Feosol) 6 mg/kg/d PO. How many milligram will the child receive per dose? 47 mg

B) C)

67 mg 87 mg

D) Ans:

107 mg C Feedback: The nurse will administer 87 mg per dose. The childs weight is first converted to kilograms by dividing 32 by 2.2, or 32/2.2 = 14.5 kg. Next, calculate the dose by multiplying weight times mg/kg/d or 14.5 6 = 87 mg.

3. A)

A nurse caring for a 28-year-old woman with renal failure is to start the patient on epoetin alfa therapy for iron replacement. What will the nurse assess before initiating therapy? Weight

B) C)

Last menstrual period Intake and output (I & O) for a 24-hour period

D) Ans:

Blood type B Feedback: The use of epoetin alfa is not recommended during pregnancy or lactation because of potential adverse effects to the fetus or baby. It is important to determine that the patient is not pregnant before drug therapy has started so the nurse would assess when the patient

4. A)

last menstruated. The patients weight, I & O, and blood type are not important factors in determining whether the drug can be used. The nurse improves patient compliance with the drug regimen of epoetin alfa by providing what? An appointment card for each drug administration day

B) C)

A calendar to mark the days of the week the drug is to be administered A referral for community transportation

The telephone number of the pharmacy where the medication can be purchased

Ans:

B Feedback: The nurse should provide the patient with a calendar with the days the drug is to be administered marked clearly to remind her when the dose is due. The patient can be taught to self-administer the drug so there is no need for an appointment or arranging transportation. The patient can use her choice of pharmacy and would not need the telephone number.

5. A)

A patient who has anemia and a severe GI absorption disorder has been ordered iron dextran (INFeD). What is the most appropriate nursing diagnosis for the patient related to the administration of this drug? Acute pain related to drug administration

B) C)

Deficient knowledge regarding drug therapy Risk for injury related to CNS effects

Disturbed body image related to drug staining of teeth

Ans:

A Feedback: Iron dextran is a parenteral form of iron. It is given intramuscularly and must be given by the Z-track method. It can be very painful. Certainly, deficient knowledge and risk for injury are appropriate diagnoses for this patient but would not be related to the administration of the drug. Because this medication is not given orally, tooth staining would not be a concern.

6. A)

A 22-year-old woman who has severe dysmenorrhea has been prescribed ferrous gluconate (Fergon) to treat iron deficiency anemia. What is it important for the nurse to instruct the patient to avoid when taking the drug? Eggs

B) C)

Chocolate Pork

D) Ans:

Whole wheat A

Feedback: Iron is not absorbed if taken with antacids, eggs, milk, coffee, or tea. These substances should not be administered concurrently. Chocolate, pork, and whole wheat do not produce drugfood interactions when consumed with an iron supplement. 7. A)

The nurse develops a care plan for a patient who has been prescribed a folic acid derivative that includes what priority nursing diagnosis? Deficient knowledge regarding drug therapy

B) C)

Monitor possibility of hypersensitivity reactions Acute pain related to injection or nasal irritation

Risk for fluid volume imbalance related to cardiovascular effects

Ans:

D Feedback: Nursing diagnoses related to drug therapy might include: Risk for fluid volume imbalance related to cardiovascular effects. Deficient knowledge and acute pain might apply to this patient, but the priority nursing diagnosis this patient, but the priority nursing diagnosis for this patient is the risk for fluid imbalance related to cardiovascular effects. Monitoring for hypersensitivity is not a nursing diagnosis.

8. A)

Before administering an iron preparation, what should the nurse assess? Red blood cell count (RBC)

B) C)

Hematocrit and hemoglobin Aspartate aminotransferase levels

D) Ans:

Serum creatinine levels B Feedback: Hematocrit and hemoglobin levels should be assessed before administration because the drug will be evaluated for effectiveness by the response of these levels to drug treatment. These levels are also used to determine dosage. Counting RBCs would indicate the number of blood cells per cubic millimeter but not iron or oxygen content. Aspartate aminotransferase levels are associated with liver function and serum creatinine levels are associated with renal function.

9. A)

What ordered dosage for epoetin alfa (Procrit) could the nurse administer without needing to question the order? 0.45 mcg/kg IV once per week

B) C)

1 mg/d IM 100 mg/d PO

150 units/kg subcutaneously three times per week

Ans:

Feedback: An appropriate dosage of epoetin alfa is 50 to 100 units/kg IV or subcutaneously, 3 days a week. Darbepoetin alfa can be administered by IV or subcutaneously once a week, and the usual dose is 0.45 mcg/kg. Folic acid (Folvite) is administered orally, IM, subcutaneously or IV; the usual dosage is 1 mg. The usual dose of ferrous sulfate is 100 to 200 mg/d PO. 10. A)

After assessing the patient receiving erythropoietin drug therapy, the nurse suspects what finding is an adverse effect of erythropoietin drug therapy? Constipation

B) C)

Hypotension Edema

D) Ans:

Depression C Feedback: Potential adverse effects of an erythropoietin are edema, nausea, vomiting, chest pain, diarrhea, and hypertension. Options A, B, and D are not associated with these drugs.

11. A)

A 62-year-old female patient is started on vitamin B12 for pernicious anemia. When the nurse develops the plan of care, what expected outcome will the nurse include? Decreased bleeding

B) C)

Increased hemoglobin Decreased joint pain

D) Ans:

Less fatigue B Feedback: Vitamin B12 is essential for normal functioning of red blood cells (RBCs) so the drug would be evaluated as successful in treating the disorder if the patients hemoglobin and RBC count increased after administration. Expected outcomes do not include decreased bleeding, decreased joint pain, or less fatigue.

12. A)

A 50-year-old patient with pernicious anemia asks why she cant just take a vitamin B12pill instead of getting an injection. What is the nurses best response to her question? Pernicious anemia is caused by the bodys inability to absorb vitamin B12.

Oral ingestion of vitamin B12 irritates the GI tract and bleeding could occur.

C) D)

Pernicious anemia alters mucous membrane lining of the bowel and impairs absorption. With severe deficiencies like yours, oral vitamin B12 does not work fast enough.

Ans:

A Feedback:

13. A)

Vitamin B12 cannot be taken orally, because one problem with pernicious anemia is an inability by the patient to absorb vitamin B12 due to low levels of intrinsic factor. Other options are incorrect. The nurse instructs a patient taking oral iron preparations about which potential adverse effect? Clay-colored stools

B) C)

Hypotension Constipation

D) Ans:

Frequent flatus C Feedback: The most common adverse effects associated with oral iron supplements are related to direct GI irritation (e.g., GI upset, anorexia, nausea, vomiting, diarrhea, dark stools, and constipation). Oral iron supplements do not cause hypotension, clay-colored stools, or frequent flatus.

14. A)

When providing patient teaching for a 30-year-old primigravida diagnosed with sickle cell anemia, but not currently in crisis, the priority teaching point is what? Avoidance of infection

B) C)

Constipation prevention Control of pain

D) Ans:

Iron-rich foods A Feedback: Severe, acute episodes of sickling with blood vessel occlusion may be associated with acute infections and the bodys reactions to the immune and inflammatory responses. Avoidance of infection is, then, a priority teaching point. Pain would be a concern only if the patient is in crisis. Constipation prevention and iron-rich foods would not be the priority at this time.

15. A)

What drugs might the nurse administer that have been developed to stimulate erythropoiesis? (Select all that apply.) Levoleucovorin

B) C)

Hydroxocobalamin Darbepoetin alfa

D) E)

Methoxy polyethylene glycol-epoetin beta Epoetin alfa

Ans:

C, D, E

Feedback: Patients who are no longer able to produce enough erythropoietin in the kidneys may benefit from treatment with exogenous erythropoietin (EPO), which is available as the drugs epoetin alfa (Epogen, Procrit), darbepoetin alfa (Aranesp), and methoxy polyethylene glycol-epoetin beta (Mircera). Both darbepoetin alfa and methoxy polyethylene glycol-epoetin beta are approved to treat anemias associated with chronic renal failure, including patients receiving dialysis. Levoleucovorin and hydroxocobalamin are not erythropoiesis-stimulating agents. 16. A)

What anemia does the nurse classify as a type of hemolytic anemia? Iron deficiency anemia

B) C)

Megaloblastic anemia Pernicious anemia

D) Ans:

Sickle cell anemia D Feedback: Another type of anemia is hemolytic anemia, which involves a lysing of red blood cells because of genetic factors or from exposure to toxins. Sickle cell anemia is a type of hemolytic anemia. Iron deficiency and megaloblastic anemias are different classifications of anemia.

17. A)

What medication does the nurse administer to treat anemia associated with chronic renal failure? Methoxy polyethylene glycol-epoetin beta

B) C)

Ferrous sulfate exsiccated Levoleucovorin

D) Ans:

Hydroxyurea A

18. A)

Feedback: Both darbepoetin alfa and methoxy polyethylene glycol-epoetin beta are approved to treat forms of anemia associated with chronic renal failure, including in patients receiving dialysis. Ferrous sulfate exsiccated is used to treat iron deficiency. Levoleucovorin is administered to diminish toxicity and counteract the effects of impaired methotrexate elimination and of inadvertent overdose of folic acid antagonists after high-dose methotrexate therapy for osteosarcoma. Hydroxyurea is used to reduce the frequency of painful sickle cell crises and to decrease the need for blood transfusions in adults with sickle cell anemia. The nurse is caring for a patient diagnosed with pernicious anemia and anticipates this patient will require supplemental what? Iron

B) C)

Vitamin B12 Erythropoietin

D) Ans:

Oxygen B Feedback: Pernicious anemia occurs when the gastric mucosa cannot produce intrinsic factor and vitamin B12 cannot be absorbed. Other options are incorrect.

19. A)

When providing patient teaching the nurse warns the patient to avoid what triggers of an episode of sickling? (Select all that apply.) Acute infections

B) C)

Immune response Exposure to heat

D) E)

Inflammatory responses Metabolic alkalosis

Ans:

20. A)

A, B, D Feedback: Severe, acute episodes of sickling with occluded blood vessels may be associated with acute infections and the bodys reactions to the immune and inflammatory responses. Exposure to heat and metabolic alkalosis are not considered triggers. The nurse teaches hemodialysis patients that anemia occurs because damaged kidneys fail to produce what? Erythropoietin

B) C)

Renin Angiotensin

D) Ans:

Urine A Feedback: People with chronic renal failure are often anemic because their kidneys are unable to produce erythropoietin. The production of renin and angiotensin impact the patients blood pressure. Anemia is not caused by lack of urine production.

21. A) B) C)

A patient has been prescribed epoetin alfa. The nurse determines the drug is contraindicated as a result of what finding in the patient history? Asthma Irritable bowel syndrome Hypertension

D) Ans:

Shortness of breath C Feedback: Erythropoiesis-stimulating agents are contraindicated in the presence of uncontrolled hypertension because of the risk of worsening hypertension when red blood cell counts increase and the pressure within the vascular system also increases. There is no contraindication to the use of erythropoiesis-stimulating agents for patients with asthma, irritable bowel syndrome, or shortness of breath.

22. A) B) C) D) Ans:

An older adult patient, diagnosed with pernicious anemia, asks the nurse what causes this disorder. The nurses best response is that there is a lack of intrinsic factor secreted needed for absorption of vitamin B12 where? Large bowel Lower esophagus Stomach Small bowel D Feedback: Intrinsic factor, also secreted by the gastric mucosa, combines with dietary vitamin B12so that the vitamin can be absorbed in the ileum, located in the small bowel. Other options are incorrect.

Chapter 101: Coagulation Disorders 1) The genetic inheritance pattern for hemophilia is: A. Autosomal dominant B. Autosomal recessive C. X-linked D. Genetic polymorphism 2) The factor deficit in hemophilia B is: A. Factor II B. Factor VII C. Factor VIII D. Factor IX 3) Which of the following is not considered a goal of Hemophilia therapy? A. Prevent bleeding episodes B. Prevent long term complications C. Eradicate inhibitors D. Arrest bleeding if it occurs 4) Patients with severe hemophilia have % factor activity level. A. <1% B. 1-4% C. 3-5% D. >5%

5) The first-line therapeutic approach to treating an active bleed in a patient with severe hemophilia without inhibitors is: A. Plasma derived factor replacement B. Recombinant factor replacement C. Activated prothrombin complex concentrates (aPCCs) D. Desmopressin E. Anti-thrombolytic 6) Which is a true statement regarding prophylaxis therapy for hemophilia? A. Not recommended by any national organization B. Recommended approach but optimal dosing and schedule is not well defined C. Proven cost effective D. Patient compliance is not a factor in overall outcome 7) The most impactful therapeutic complication of therapy for hemophilia patients is: A. Infection B. Cost C. Inhibitor formation D. Target joint formation 8) Which of the following agents should be used to treat an acute bleed in a patient with hemophilia B with inhibitors? A. High doses of recombinant FVIII B. Low doses of recombinant FIX administered for long periods of time C. Activated prothrombin complex concentrates D. Activated FVII 9) The appropriate approach to treating an acute bleed in a patient with hemophilia A with a 7BU inhibitor level is: A. Activated prothrombin complex concentrates B. High dose recombinant FVIII C. High dose plasma derived FVIII D. High dose recombinant FIX 10) Which of the following is not considered adjunctive therapy for patients with mild to moderate hemophilia with an acute bleed? A. Recombinant factor replacement B. Desmopressin C. Anti-thrombolytics D. RICE 11) How much does one unit/kg of factor VIII increase the factor activity level in a patient with hemophilia A? A. <1% B. 1% C. 2% D. 50% 12) What would be the appropriate dose of recombinant factor IX for an adult patient with severe hemophilia B requiring a 50% correction? A. 25 units/kg B. 50 units/kg C. 60 units/kg

D. 70 units/kg 13) What is the von Willebrand factor defect associated with type 2 disease? A. Qualitative B. Quantitative C. Absence D. Abundance 14) Which of the following factor products can be used to treat severe bleeding episodes in patients with von Willebrand disease? A. Activated prothrombin complex concentrates B. Activated FVII C. Recombinant FVIII D. Plasma derived FVIII 15) Which of the following is a true statement regarding desmopressin? A. Desmopressin is effective in patients with severe hemophilia A B. Desmopressin is effective in patients with severe hemophilia B C. Desmopressin exhibits tachyphylaxis with repeated dosing D. Desmopressin is effective in all patients with von Willebrand disease Chapter 102: Sickle Cell Disease 1) Which one of the following actions should not be part of a pretravel health consultation? A. Conduct a medical history B. Prescribe or recommend empiric antibiotic for symptomatic traveler’s diarrhea C. Assess the risk of malaria at the traveler’s destination D. Provide travelers insurance or medical evacuation insurance 2) Which medication type(s) may not be permitted on entry to some restrictive countries? A. Psychotropic medications B. Narcotic pain medications C. Unlabeled melatonin tablets D. All of the above 3) A 40 year old newly diagnosed HIV-positive man wishes to travel to rural Mexico to serve on a mission trip. He has just started antiretroviral therapy. His last CD4+ cell count was 100 cells/mm3 (0.1 × 109/L). He asks if he should receive the Hepatitis A vaccine. The best answer would be: A. It is contraindicated for HIV-positive patients B. He is at risk from contracting Hepatitis from the vaccine C. He should wait until his CD4+ cell count is more than 200 cells/mm3 (>0.2 × 109/L) D. He should/will only derive a protective benefit if his CD4+ cell count is more than 500 cells/mm3 (>0.5 × 109/L). 4) Which one of the following travelers should be given a medical exemption waiver for Yellow Fever vaccination? A. A child age 5 years B. An HIV-infected patient with a CD4+ count of 100 cells/mm3 (0.1 × 109/L). C. A breastfeeding mother D. An asthmatic patient who takes inhaled steroids

5) While preparing a medical kit for travel to Thailand, a traveler notes that there have been increased reports of norfloxacin-resistant Campylobacter in the region he plans to travel. His first line antibiotic for empiric treatment of traveler’s diarrhea should be: A. Azithromycin B. Bismuth subsalicylate C. Ciprofloxacin D. Metronidazole E. Antibiotics should never be used to empirically treat traveler’s diarrhea 6) Which antimalarial prophylactic agent carries the strongest safety warning for use in pregnant travelers? A. Chloroquine B. Doxycycline C. Mefloquine D. Atovaquone-proguanil 7) Fever reduction in a patient with severe Dengue fever is best done with: A. Aspirin B. Acetaminophen C. Ibuprofen D. Naproxen E. Corticosteroids 8) All of the following are advisable methods for limiting mosquito-borne infection in high risk areas except: A. Applying 10% DEET repellent on a daily basis B. Using insecticide-treated bed netting C. Wearing protective clothing that limits access to human skin D. Spraying clothing with insect repellant or insecticide 9) The first line treatment for all high altitude illnesses is: A. Nifedipine B. Hydration C. Descent D. Melatonin E. Dexamethasone 10) The following medication, used to treat acute mountain sickness (AMS), would be contraindicated in patients with an allergy to sulfonamides. A. Nifedipine B. Acebutolol C. Dexamethasone D. Acetazolamide E. Sildenafil 11) Which of the following medications is used most frequently to prevent AMS? A. Sildenafil B. Acetazolamide C. Acebutolol D. Nifedipine E. Oxycodone

12) The following medication would be the most appropriate treatment to adjust circadian rhythms in patients with jet lag who cannot adjust their sleep patterns prior to travel. A. Modafinil B. Melatonin C. Clonidine D. Diazepam E. Zolpidem 13) Which of the following risks lead to traveler’s thrombosis specifically in patients more than 75 (>190 cm) inches tall? A. Popliteal vein compression B. Inability to recline C. Restricted movement D. Decreased venous valves E. Reduced need to ambulate 14) Which of the following preventative modalities has been shown to reduce asymptomatic clots when used appropriately and has minimal risk? A. Compression Stockings B. Aspirin C. Hydration D. Low molecular weight heparin E. Edoxaban 15) Which of the following is the most common psychiatric reason for evacuation from international travel? A. Generalized anxiety disorder B. Schizophrenia C. Agoraphobia D. Mania E. Depression Chapter 103: Drug-Induced Hematologic Disorders 1) The incidence of drug-induced hematologic diseases is best established by use of which method? A. Meta-analyses B. Phase II trials C. Post-marketing surveillance D. Randomized controlled trials 2) Initial management of suspected heparin-induced thrombocytopenia (HIT) should include which as the first step? A. Removal of the offending agent B. Initiation of argatroban C. Initiation of warfarin D. Order for a Stat CBC E. Preparation for blood transfusion 3) When is it appropriate to re-challenge a patient with an agent suspected to cause drug-induced hematologic disease in order to confirm the diagnosis? A. In stable patients

B. At the patient’s request C. When antibiotics are implicated D. Re-challenges should be avoided 4) When evaluating drugs as a possible cause of drug-induced hematological disease, clinicians should use which approach? A. Employ an ADR probability scale B. Expect a definite diagnosis C. Rely on laboratory data for confirmation D. Rule out agents started in the distant past 5) Which is considered the most severe drug-induced hematologic disease? A. Agranulocytosis B. Aplastic anemia C. Hemolytic anemia D. Megaloblastic anemia E. Thrombocytopenia 6) When evaluating a patient for possible aplastic anemia, which of the following is the most likely cause? A. Acetaminophen B. Metformin C. Phenytoin D. Simvastatin 7) In patients with acquired aplastic anemia who are not candidates for HSCT, initial standard treatment includes: A. Cyclosporin monotherapy B. Cyclosporin and ATG C. Tacrolimus and ATG D. Sirolimus monotherapy 8) The most commonly reported cause of drug-induced hemolytic anemia is: A. Propylthiouracil B. Phenytoin C. Penicillin D. Piperacillin 9) Drug-induced thrombocytopenia can be differentiated from idiopathic thrombocytopenia purpura (ITP) by: A. Presence of bleeding B. Rapid onset after administration of drug C. Platelets < 20 × 109 D. A and C E. A, B, and C 10) Which of the following drugs is most likely to cause megaloblastic anemia? A. Methotrexate B. Metformin C. Clozapine D. Doxycycline 11) A patient with history of HIT presents with deep vein thrombosis in the left lower extremity. Outpatient treatment should include:

A. Argatroban B. Fondaparinux C. Enoxaparin D. Warfarin 12) Which of the following medications are not associated with direct toxicity on neutrophils? A. Penicillin B. Carbamazepine C. Sulfonamides D. Procainamide 13) Granulocyte colony-stimulating factor should be considered for use if a patient’s neutrophil count, due to drug-induced agranulocytosis, falls below A. 5,000 cells/mm3 B. 500 cells/mm3 C. 1,000 cells/mm3 D. 100 cells/mm3 14) Which test is best used to diagnose drug-induced hemolytic anemia? A. Hemoglobin B. Direct Coombs C. Reticulocyte count D. Red blood cell count 15) Treatment of drug-induced megaloblastic anemia should include which of the following? A. Initiation of folinic acid B. Removal of the causative drug C. Initiation of vitamin B12 D. A and B E. A, B, and C Chapter 104: Laboratory Tests to Direct Antimicrobial Pharmacotherapy 1) Choose the correct statement(s) regarding the white blood cell (WBC) count and differential A. WBC are usually elevated in response to infection B. The normal range of the WBC is 12,500-20,000 cells/mm3 (12.5-20.0 × 109/L) C. WBC is nonspecific and can be elevated in response to a number of noninfectious conditions D. Neutrophils are the most common type of WBC in the blood E. A, C, and D 2) The inflammatory process initiated by infection can set up a complex host responses which include: A. Activation of the complement cascade B. An increase in the erythrocyte sedimentation rate C. Elevations of C-reactive protein D. Increased production of interleukins and tumor necrosis factor E. All of the above 3) Which of the following circumstances would not be considered colonization with normal flora? A. S. epidermidis found on the skin B. S. aureus in the bloodstream

C. E. coli in the urine D. Viridans streptococci found in the nasopharnx E. B and C 4) Choose the correct statement(s) regarding the Gram stain and use of cultures to identify potential pathogens A. The Gram stain may provide a presumptive diagnosis and identify whether the pathogen is Gram-positive or negative and a bacillus or cocci B. Cultures can provide definitive pathogen identification and differentiate organisms on the basis of biochemical characteristics C. Every effort should be made to avoid culture contamination D. Even with automated systems, detection of bacteria or fungi within a few hours is not yet possible E. A, B, and C 5) Although widely employed, the use of hybridization probes is often limited by their lack of sensitivity. A. True B. False 6) Which of the following is incorrect regarding the use of nucleic acid amplification? A. Polymerase chain reaction (PCR) is based on the capability of a DNA polymerase to copy and elongate a targeted strain of DNA B. Each PCR cycle doubles the amount of DNA originally present C. PCR techniques are useful for detecting fastidious or slowing growing organisms D. Gene markers for resistance for M. tuberculosis and methicillin-resistant S. aureus are two examples where PCR techniques have been employed E. All of the above 7) The benefit of rapid diagnostic technology is to: A. Quickly identify and or rule out infectious pathogens B. Streamline antimicrobial therapy C. Improve infection control measures such as isolation D. All of the above 8) One limitation of microtiter MIC testing is that: A. There is a limited ability to automate the test procedures B. Microtiter MICs have little to no value in the contemporary management of infections C. Microtiter MICs may overestimate in vivo beta-lactam activity D. There is a wide variation in the MIC test procedures due to inadequate standardization 9) Which of the following is incorrect regarding MIC testing? A. Defined as the lowest concentration of a given antimicrobial that will kill (99.9%) of the patient's organism after 18-24 hours incubation B. Defined as the lowest concentration of given antimicrobial that will visually inhibit the organism from growing after 18-24 hours incubation C. Kirby-Bauer Test is a qualitative MIC test that can be used for organisms that grow rapidly on artificial media with MIC results expressed as mg/L D. An E-test can be used as quantitative test expressed as mg/L to measure a MIC 10) MM is a patient with pneumonia and a lung abscess. Staphylococcus aureus (susceptible to vancomycin via microtiter MICs) grew from a properly-obtained sample of the patient's sputum.

Vancomycin therapy was started, but the patient has not responded to 7 days of therapy. Which of the following would be the LEAST LIKELY explanation for the failure? A. The presence of vancomycin-resistant Staphylococcus aureus (VRSA) B. A peak vancomycin serum concentration less than 25 mcg/mL (mg/L; 17 µmol/L) C. Inadequate penetration of the vancomycin to the site of the infection D. An undetectable vancomycin serum trough concentration 11) Which of the following statements is NOT true concerning antimicrobial susceptibility testing and its application to the management of infections? A. An infection due to an antimicrobial-resistant organism will not respond to treatment with maximal doses B. A modification of the disk diffusion test method can be used to detect beta-lactamase production C. Automated susceptibility test systems can interface with pharmacy records to help assess appropriateness of antimicrobial therapy. D. Newly-developed testing methods for Mycobacteria have reduced susceptibility reporting time to less than 28 days 12) A patient has a lung infection due to Pseudomonas aeruginosa. He currently is receiving therapy with a fluoroquinolone that on average produces a peak serum concentration of 5 mcg/mL (mg/L) and an AUC of 100. The MIC for this fluoroquinolone against his infecting pathogen is 2 mcg/mL (mg/L). Which of the following statements is TRUE? A. The data provided are incomplete, since the pharmacodynamic predictor of activity for fluoroquinolones is the time above the MIC B. The fluoroquinolone's peak-to-MIC ratio is optimized for this pathogen C. The fluoroquinolone's AUC-to-MIC ratio is optimized for this pathogen D. The fluoroquinolone should be avoided due to concern for development of resistance 13) Which of the following statements is FALSE concerning "once-daily" [extended interval] aminoglycoside dosage regimens? A. The higher doses produce higher peak serum concentrations which maximize antimicrobial activity B. Peak and/or mid-dose serum concentrations should be routinely monitored C. Nomograms can be used to determine dosage regimens. D. Limitations in the clinical studies of "once daily" regimens has prevented widespread use 14) Which of the following methods would be LEAST APPROPRIATE for determining the individual antimicrobial serum concentrations during a clinical study that evaluates the effectiveness of the combination of two antimicrobial agents to treat pneumonia? A. Fluorescence polarization immunoassay B. Radioimmunoassay C. Microbiologic assay D. High-pressure liquid chromatography 15) A microtiter fractional inhibitory concentration experiment is performed to assess the effects of a combination of a new fluoroquinolone and a new aminoglycoside. The following data are generated: A. Fluoroquinolone MIC: 1 mcg/mL (mg/L) B. Aminoglycoside MIC: 1 mcg/mL (mg/L) C. Lowest concentration of the fluoroquinolone that inhibits growth in the presence of aminoglycoside: 0.1 mcg/mL (mg/L)

D. Lowest concentration of aminoglycoside that inhibits growth in the presence of fluoroquinolone: 0.2 mcg/mL (mg/L) 16) Which of the following statements is FALSE concerning special in vitro tests of antimicrobial susceptibility? A. Demonstration of in vitro antagonism for two antimicrobials correlates strongly with in vivo antagonism B. MBCs can be helpful to guide antimicrobial treatment of infections such as endocarditis C. Timed-kill curve tests can be used determine the effect of concentration on antimicrobial killing activity D. The administration interval can be prolonged for an antimicrobial with a postantibiotic effect 17) Which figure(s) represent(s) bacterial growth phase in the presence of a fully susceptible antibiotic?

A. Figure A only B. Figure B only C. Figure C only D. Figure A & C 18) Which figure(s) represent(s) resistant bacteria in the presence of an antibiotic?

A. Figure A only B. Figure B only

C. Figure C only D. Figure A & C Chapter 105: Antimicrobial Regimen Selection 1. A patient allergic to penicillin is being evaluated for a gram-negative infection. Which antimicrobial drug class would the health care provider be cautious in prescribing because of a possible cross sensitivity and/or allergic reaction? a. Cephalosporins b. Aminoglycosides c. Sulfonamides d. Quinolones ANS: A Cephalosporins may be used with caution as alternatives when patients are allergic to the penicillins, but cephalosporins are chemically similar in structure to penicillins and may produce a cross sensitivity and/or allergic reaction. Aminoglycosides, sulfonamides, and quinolones do not tend to produce cross sensitivities. DIF: Cognitive Level: Comprehension REF: p. 736 OBJ: 7 | 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. The health care provider has prescribed penicillin and probenecid for a patient with a sexually transmitted disease. What is the purpose of combining these medications? a. To accelerate the excretion of the penicillin b. To inhibit the absorption of penicillin to allow the drug to remain in the transport phase c. To inhibit the excretion of the penicillin d. To reduce toxic effects associated with penicillin ANS: C The combination therapy of penicillin and probenecid allows the penicillin to remain in the body longer, which enhances drug availability and action. The combination may be used advantageously in treating serious or resistant infections. Probenecid inhibits the excretion of penicillin, slows down the excretion of penicillin, and does not affect absorption or toxic effects. DIF: Cognitive Level: Comprehension REF: p. 730 OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. An older adult who has septicemia is receiving IV aminoglycoside therapy. Which symptom is most important for the nurse to monitor? a. Bone marrow suppression b. Ototoxicity c. Gastrointestinal (GI) distress d. Photosensitivity ANS: B Eighth cranial nerve damage can result from aminoglycoside therapy. Patients should be monitored during therapy and after therapy has been discontinued for signs and symptoms of

ototoxicity, including dizziness, tinnitus, and progressive hearing loss. Aminoglycosides do not produce bone marrow depression; this is characteristic of treatment with chloramphenicol. Aminoglycosides do not typically produce GI distress. Aminogylcosides do not produce photosensitivity; this is characteristic of treatment with glycylcyclines. DIF: Cognitive Level: Application REF: p. 729 OBJ: 7 | 8 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. On what is the selection of an antimicrobial agent based? a. Sensitivity of the microorganism to the drug b. Half life of the medication c. Therapeutic levels of the drug d. Bioavailability of the drug ANS: A The selection of the antimicrobial agent must be based on the sensitivity of the pathogen and the possible toxicity to the patient. The half life of the drug is not a concern with selection in comparison to sensitivity. Therapeutic levels of the drug are not criteria for selection. Bioavailability is a lesser concern than sensitivity. DIF: Cognitive Level: Comprehension REF: p. 727 OBJ: 6 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 5. A patient is scheduled to take tetracycline and aluminum hydroxide (Amphojel) at the same time. When will the nurse administer the medications to achieve the optimal effects? a. Both medications together b. Amphojel 30 minutes before tetracycline c. Tetracycline with orange juice d. Tetracycline 1 hour before Amphojel ANS: D For optimal effectiveness, tetracyclines should be administered 1 hour before or 2 hours after ingesting antacids, milk, or other dairy products, or products containing calcium, aluminum, magnesium, or iron. Taking the drugs this closely together will most likely inhibit absorption of the antibiotic. Tetracycline does not tend to interact with orange juice, but the beverage may be contraindicated in a patient who needs to take antacids. DIF: Cognitive Level: Application REF: pp. 750-751 OBJ: 7 | 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 6. Which conditions may occur with the administration of broad spectrum antibiotics over an extended period of time? a. Cross sensitivity b. Immunosuppression c. Secondary infection d. Immunity ANS: C

Secondary infections, such as oral thrush, genital and anal pruritus, and vaginitis, can occur with prolonged use of broad spectrum antibiotics. Secondary infections result when normal flora are eliminated, which causes disease producing microorganisms to multiply. Cross sensitivities develop during repeat exposures, not over a prolonged period. Immunosuppression does not develop over a prolonged interval of administration. Immunity is not produced by exposure to antibiotics. DIF: Cognitive Level: Knowledge REF: pp. 729-730 OBJ: 7 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 7. A patient is admitted with glomerulonephritis. IV gentamicin therapy is started after cultures indicate gram negative bacilli in the blood. The patient also receives IV furosemide (Lasix). The nurse will monitor for signs and symptoms of toxicity related to which organ? a. Kidneys b. Pancreas c. Liver d. Brain ANS: A The results of urinalysis and kidney function tests should be closely monitored when a patient is on aminoglycoside therapy. Patients also receiving cephalosporins, enflurane, methoxyflurane, vancomycin, and diuretics, when combined with aminoglycosides, have a greater potential for nephrotoxicity. The pancreas is not vulnerable to damage from aminogylcosides. Bone marrow suppression is a result of toxicity from treatment with chloramphenicol. Central nervous system toxicities may result from toxic effects of treatment with aminoglycosides, but are not related to interactions between the antibiotic and diuretics. DIF: Cognitive Level: Comprehension REF: p. 731 OBJ: 7 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 8. Which drug is the cornerstone of treatment for prophylaxis and treatment of tuberculosis (TB)? a. Amphotericin B (Abelcet) b. Streptomycin (Streptomycin) c. Isoniazid (Nydrazid) d. Acyclovir (Zovirax) ANS: C Isoniazid has been the mainstay for years in the treatment and prevention of TB. The mechanism of action of isoniazid is not fully known. Isoniazid appears to disrupt the Mycobacterium tuberculosis cell wall and inhibit replication. Amphotericin B is used in the treatment of fungal infections. Streptomycin is an aminoglycoside used to treat bacterial infections. Acyclovir is used in the treatment of viral infections associated with herpes simplex virus. DIF: Cognitive Level: Comprehension REF: p. 752 OBJ: 6 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

9. A patient indicates during the nursing assessment that he is currently taking zidovudine (Retrovir). For which condition is the patient being treated? a. Influenza A b. HIV infection c. TB d. Herpes simplex ANS: B Zidovudine (Retrovir) is an antiviral agent that is effective in certain patients with HIV 1 infection. Zidovudine inhibits viral replication, reduces the risk and severity of opportunistic infections, and improves immune status. Zidovudine is not used to treat influenza, TB, or herpes infections. DIF: Cognitive Level: Knowledge REF: p. 787 OBJ: 6 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 10. Which drug is incompatible with heparin? a. Gentamicin b. Ampicillin (Unasyn) c. Ticarcillin (Timentin) d. Ciprofloxacin (Cipro) ANS: A Gentamicin is incompatible with heparin. Ampicillin, ticarcillin, and ciprofloxacin are compatible with heparin. DIF: Cognitive Level: Knowledge REF: pp. 733-734 OBJ: 7 | 8 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 11. What adverse effect may manifest as dizziness, tinnitus, and progressive hearing loss? a. Ear infection b. Drug allergy c. Ototoxicity d. Idiosyncratic reaction ANS: C Damage to the eighth cranial nerve (ototoxicity) can occur from drug therapy, particularly from aminoglycosides. This may initially be manifested by dizziness, tinnitus, and progressive hearing loss. Ear infection is not an adverse effect of drug therapy. Drug allergy is not manifested by hearing loss. Idiosyncratic reaction to a medication is an unusual, unpredictable response specific to a particular person. Unlike allergy, it can occur on first exposure to the medication; unlike an adverse effect, it only affects very few individuals, possibly with a genetic or metabolic abnormality. DIF: Cognitive Level: Comprehension REF: p. 729 | p. 733 OBJ: 7 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse will monitor patients on cephalosporins and loop diuretics for which adverse effect? a. Hepatic toxicity b. Ototoxicity c. Nephrotoxicity d. Splenotoxicity ANS: C Patients receiving cephalosporins, aminoglycosides, polymyxin B, vancomycin, and loop diuretics concurrently should be assessed for signs of nephrotoxicity. Urinalysis and kidney function tests should be monitored for abnormal results. Cephalosporins are unlikely to cause liver toxicity, ototoxicity, or spleen toxicity. DIF: Cognitive Level: Comprehension REF: p. 731 | p. 733 OBJ: 7 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is caring for a patient being treated with an antimicrobial agent for the diagnosis of a sexually transmitted infection. Which statement made by the patient shows a need for further education? a. I will use a barrier method when having sexual intercourse during therapy. b. I will increase fluid intake to 2000 to 3000 mL/day. c. I will increase protein in my diet. d. I will rest frequently. ANS: A Patients should be instructed to refrain from sexual intercourse during therapy for sexually transmitted infections. Fluids should be increased to 2000 to 3000 mL/day, protein should be increased, and adequate rest should be encouraged. DIF: Cognitive Level: Analysis REF: p. 731 OBJ: 4 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 14. Which patient can safely be treated with a fluoroquinolone medication? a. A 40 year old on steroid therapy b. A 15 year old with a sore throat c. A 70 year old with a gait abnormality d. A 30 year old with a fractured tibia ANS: D Fluoroquinolones are safe to prescribe for a 30 year old with a fractured tibia. Fluoroquinolones should not be prescribed for patients taking corticosteroids, patients younger than 18 years, or patients older than 60 years. DIF: Cognitive Level: Analysis REF: p. 746 OBJ: 6 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity MULTIPLE RESPONSE

15. An older adult with a history of asthma, rhinitis, and no known drug allergies has been admitted to receive IV antimicrobial therapy for bronchitis. The patient has received the oral form of the antimicrobial agent in the past. Which factors increase the risk for an allergic reaction? (Select all that apply.) a. Medical history of asthma b. The patients age c. d.

IV antimicrobial therapy Medical history of rhinitis

e. Subsequent use of the same antimicrobial therapy ANS: A, D, E Patients with a history of asthma, allergies, or rhinitis should be closely monitored for possible allergic reaction. Subsequent use of the same antimicrobial therapy may only pose a risk if a reaction occurred with the first administration of the drug; in this case, repeat exposures to a previously sensitized substance can be fatal. Older adults, because of physiologic changes of aging, require close observation for therapeutic response and drug toxicity, but not necessarily for allergic reaction. The route of administration does not increase the risk of an allergic reaction. DIF: Cognitive Level: Application REF: p. 730 OBJ: 7 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 16. A patient has been receiving home health care and IV antimicrobial therapy for osteomyelitis (infection of the bone) of the lower right leg for the past 4 weeks. What will the nurse assess to evaluate the effectiveness of the antimicrobial agent? (Select all that apply.) a. Pain of the right leg b. Patient temperature c. d.

Presence of edema, redness, or swelling in the right lower leg Culture and sensitivity parameters at the drug completion

e. Complete blood count (CBC) and sedimentation rate laboratory values ANS: A, B, C, E Ongoing evaluation of treatment effectiveness includes assessing for pain of the affected leg, monitoring the patients temperature, observing the affected extremity for decreased signs of infection (including reduced swelling, wound discharge, and redness), and monitoring the CBC and sedimentation rate through regular laboratory data. Culture and sensitivity testing should be completed before therapy to determine the most effective drug for therapy. DIF: Cognitive Level: Application REF: p. 730 OBJ: 1 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 17. Which drugs may reach toxic blood levels if administered with macrolide antibiotics? (Select all that apply.) a. Benzodiazepines b. Digoxin c.

NSAIDs

d. e.

HMG CoA reductase inhibitors Diuretics

f. Theophylline ANS: A, B, D, F Macrolide antibiotics may inhibit the metabolism of benzodiazepines, digoxin, HMG CoA reductase inhibitors, and theophylline, causing accumulation and potential toxicity. NSAIDs and diuretics are not inhibited by macrolide antibiotics. DIF: Cognitive Level: Comprehension REF: p. 741 OBJ: 7 | 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 18. The nurse is planning to administer ertapenem IV to a patient in the intensive care unit. When preparing this medication, the nurse will consider reconstituting it with: (Select all that apply.) a. water. b. bacteriostatic water. c. d.

0.9% sodium chloride. 0.45% dextrose.

e. 1% lidocaine. ANS: A, B, C Ertapenem for IV use should be reconstituted with water for injection, bacteriostatic water for injection, or 0.9% sodium chloride (normal saline) for injection. Ertapenem should not be reconstituted with dextrose solutions or 1% lidocaine injection. Chapter 106: Central Nervous System Infections 1) By definition, encephalitis is an infection of the A. Pia mater B. Brain tissue C. Sub-arachnoid space D. Dura mater 2) What would you expect the CSF chemistry to look like in a case of bacterial meningitis A. Presence of red blood cells B. CSF protein level: 40 mg/dL (400 mg/L) C. WBC >10/mm3 (> 10 × 106/L)all mononuclear D. Decreased glucose (30% of serum glucose concentration) E. All of the above are true 3) All of the following are a cause of CNS infections EXCEPT A. Bacteria B. Viruses C. Fungi D. Parasites E. All are causes of CNS infections 4) The most important laboratory tests needed to diagnose bacterial meningitis are A. Gram stain and aerobic culture

B. CBC with differential C. Enzyme immunoassay (EIA) and polymerase chain reaction (PCR) D. MRI or head CT scan E. PCR testing 5) Penicillin resistance has been seen in A. Streptococcus pneumoniae B. Neisseria meningitides C. Haemophilus influenzae D. All the above 6) The pneumococcal 13-valent conjugate vaccine (PCV13) is recommended in which of the following populations: A. Adults ≥ 60 years of age B. Healthy infants at 2 months of age C. Individuals who are immunocompromised D. All of the above 7) Appropriate initial (empiric) therapy for Listeria monocytogenes meningitis (pending antibiotic susceptibility data) includes A. Ampicillin plus gentamicin B. Vancomycin alone C. Vancomycin plus cefotaxime D. Cefotaxime alone 8) The microorganism specific to meningitis cases in neonate is A. Streptococcus pneumoniae B. Group B Streptococcus C. Haemophilus Influenzae D. All the above 9) Which of the following antibiotics are optimally dosed to ensure adequate CNS penetration in an adult with normal renal function A. Linezolid 600 mg IV every 8 hours B. Meropenem 1 gram IV every 8 hours C. Ceftriaxone 2 grams IV every 12 hours D. Ampicillin 2 grams IV every 8 hours 10) Tuberculous meningitis is often identified by A. Cellular bacterial gram stain B. Negative purified protein derivative (PPD) C. Paralysis of nerve VI D. Stress test 11) The most common form of fungal meningitis in the United States is A. Cryptococcus neoformans B. Candida albicans C. Torulopsis glabrata D. Aspergillus spp. 12) The most common CNS complication associated with AIDS is A. Tuberculous meningitis B. HIV encephalitis C. Cryptococcus neoformans meningitis

D. Alzheimer's disease 13) The use of dexamethasone in meningitis has been questioned due to the A. Corticosteroid's tendency to worsen inflammation B. Possible decrease in drug penetration into the CNS C. Corticosteroid's effects on lipid profile D. Cost of corticosteroids 14) Close contacts of meningitis patients should receive prophylaxis in cases of A. Haemophilus influenzae B. Listeria monocytogenes C. Staphylococcus aureus D. Streptococcus pneumoniae 15) Multidrug resistant Streptococcus pneumoniae may force clinicians to resort to agents such as A. Aztreonam B. Erythromycin C. Tigecycline D. Linezolid Chapter 107: Lower Respiratory Tract Infections 1. A patient has questions regarding a recently prescribed antitussive agent. Which response by the nurse is the best? a. It will eliminate your cough at night. b. It will reduce the frequency of your cough. c. It should be used in the morning. d. It should be taken before sleep. ANS: B Antitussive agents act by suppressing the cough center in the brain. The expected therapeutic outcome is reduced frequency of nonproductive cough to promote rest. Antitussive agents should be taken as prescribed by the health care provider. Antitussives are not likely to eliminate a cough. Antitussives should be taken throughout the day. DIF: Cognitive Level: Comprehension REF: p. 489 OBJ: 5 | 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which is a common expectorant in over-the-counter medications? a. Dextromethorphan b. Diphenhydramine c. Guaifenesin d. Codeine ANS: C Guaifenesin is used for symptomatic relief of conditions characterized by a dry, nonproductive cough such as the common cold, bronchitis, laryngitis, pharyngitis, and sinusitis. Guaifenesin is also used to remove mucous plugs from the respiratory tract. Dextromethorphan is an antitussive.

Diphenhydramine is an anticholinergic agent with antihistaminic and antitussive properties. Codeine is an antitussive. DIF: Cognitive Level: Knowledge REF: pp. 494-495 OBJ: N/A TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. What is the reason for administering potassium iodide to a patient with emphysema? a. To increase blood iodide levels b. To decrease mucus viscosity c. To reduce metabolic needs of the body d. To decrease bronchial irritation ANS: B Potassium iodide acts as an expectorant by stimulating the bronchial glands to secrete. This will decrease the viscosity of mucous plugs, which makes it easier for patients to cough up the dry hardened plugs blocking the bronchial tubes. Potassium iodide is not given to increase serum potassium iodide levels. Potassium does not reduce metabolic needs of the body or bronchial irritation. DIF: Cognitive Level: Application REF: pp. 494-495 OBJ: 5 | 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. Within minutes of the initiation of a nebulizer treatment with a sympathomimetic bronchodilator, the patient turns on his call light and states that he feels panicky and his heart is racing. Which action will the nurse take? a. Reassure the patient this is expected. b. Add more diluents to the nebulizer. c. Administer a sedative. d. Stop treatment and notify the health care provider. ANS: D Sympathomimetic drugs increase sympathetic nervous stimulation. Symptoms such as nervousness, palpitations, tremors, tachycardia, and anxiety typically are dose related. These symptoms should be reported to the health care provider immediately because the patient may require a decreased dosage. These symptoms could lead to further complications if allowed to persist and are not common adverse effects. Although this may be a common result, it is not an expected outcome. Diluting the medication would not decrease the dose. Although a sedative might be appropriate for the patient, this is not the intervention of choice. DIF: Cognitive Level: Analysis REF: pp. 497-498 OBJ: 5 | 7 | 9 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 5. Premedication assessments before the use of anticholinergic bronchodilating agents should verify that the patient has no history of which condition? a. Diabetes b. Hypertension c.

Liver disease

d. Glaucoma ANS: D Anticholinergic bronchodilating agents cause mydriasis (dilation of the pupils) and cycloplegia (loss of power in the ciliary muscle); therefore, they should not be used in patients with a history of closed angle glaucoma. Diabetes, hypertension, and liver disease are not affected by the use of anticholinergic bronchodilating agents. DIF: Cognitive Level: Comprehension REF: pp. 500-501 OBJ: 7 | 9 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe, Effective Care Environment 6. A patient is seen in the emergency department. The patient had been maintained on theophylline (Theo Dur), and a blood sample reveals the serum theophylline level is subtherapeutic. Which may cause a subtherapeutic serum level? a. Cimetidine use b. Drug tolerance c. Smoking d. Overuse of the inhaler ANS: C The patient is not tolerant to the drug if the serum theophylline levels are too low. Cimetidine would enhance the effects of theophylline, not decrease the effects. Smoking reduces the therapeutic effects of xanthine derivatives, including theophylline. Overuse of the inhaler would cause a high level of serum theophylline. DIF: Cognitive Level: Application REF: p. 493 | p. 502 OBJ: 7 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 7. What is the action of zafirlukast (Accolate), a leukotriene receptor antagonist? a. Dilates the alveolar sacs b. Decreases leukotriene release c. Inhibits histamine release d. Increases viscosity of secretions ANS: B Leukotrienes are a class of anti inflammatory agents that block leukotriene formation, and they are part of the inflammatory pathway that causes bronchoconstriction. Leukotrienes work to reduce bronchoconstriction, and they do not inhibit histamine release or affect viscosity of secretions. DIF: Cognitive Level: Knowledge REF: pp. 505-506 OBJ: 6 | 10 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 8. What is albuterol (Proventil) used to treat? a. Acute bronchospasm b. Acute allergies c.

Nasal congestion

d. Dyspnea on exertion ANS: A The short-acting beta agonists have a rapid onset (few minutes) and are used to treat acute bronchospasm. Beta agonists are not used to treat allergies. Decongestants are used for nasal congestion. Long-acting beta agonists are used for exertional dyspnea. DIF: Cognitive Level: Knowledge REF: pp. 497-498 OBJ: 8 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 9. From where do the fluids of the respiratory tract originate? a. Specialized mucous glands called goblet cells b. Lymph fluid drawn across nasal membranes by osmosis c. Specialized beta cells in the islets of Langerhans d. Cells that produce aqueous humor ANS: A The fluids of the respiratory tract originate from specialized mucous glands (goblet cells) and serous glands that line the respiratory tract. The goblet cells produce gelatinous mucus that forms a thin layer over the interior surfaces of the trachea, bronchi, and bronchioles. Lymph does not make up fluid in the respiratory tract. The beta cells in the islets of Langerhans are located in the pancreas. Cells that produce aqueous humor are located in the interior of the eye. DIF: Cognitive Level: Knowledge REF: p. 484 OBJ: 1 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 10. What structures in the respiratory tract assist in removing foreign bodies such as smoke and bacteria? a. Villi b. Golgi bodies c. Ciliary hairs d. Erector pili ANS: C Normally, respiratory tract fluid forms a protective layer over the trachea, bronchi, and bronchioles. Foreign bodies, such as smoke particles and bacteria, are caught in the respiratory tract fluid and are swept upward by ciliary hairs that line the bronchi and trachea to the larynx, where they are removed by the cough reflex. The villi are hair like protrusions into the intestine emanating from the wall of the intestine. The purpose of the villi is to slow the passage of food and allow food particles to be captured among these finger like villi, so that the blood inside the villi can absorb the nutrients in the food. The primary function of the Golgi apparatus, an organelle found in most eukaryotic cells, is to process proteins targeted to the plasma membrane, lysosomes, or endosomes and those that will be formed from the cell and to sort them within vesicles. Thus, it functions as a central delivery system for the cell. Erector pili are small muscles that cause hairs on the skin to rise when contracted. DIF: Cognitive Level: Knowledge REF: p. 484 OBJ: 1 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is providing instruction about ipratropium (Atrovent) to a patient with chronic obstructive pulmonary disease (COPD). Which is a common adverse effect that tends to resolve with therapy? a. Anxiety b. Dry mouth c. Tachycardia d. Urine retention ANS: B Dry mouth is usually mild and tends to resolve with continued therapy. Anxiety, tachycardia, and urine retention are not common adverse effects. DIF: Cognitive Level: Knowledge REF: p. 501 OBJ: 5 | 9 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. An adult patient is admitted for an asthma attack. Which assessment obtained by the nurse would support that albuterol (Proventil) was effective? a. Decrease in wheezing present on auscultation b. Less dyspnea while positioned in a high Fowlers position c. Sputum production is clear and watery d. Respiratory rate decreased to 38 breaths/min ANS: A A bronchodilator would open the airways and result in a reduction of wheezing. Less dyspnea while positioned in a high Fowlers position, clear and watery sputum, and a respiratory rate decreased to 38 breaths/min would not indicate that the medication was effective. DIF: Cognitive Level: Application REF: p. 498 OBJ: 8 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. A child has been diagnosed with asthma and the nurse is providing education to the family. Which statement by the mother indicates a need for further teaching? a. I will place the stuffed animals in the freezer overnight. b. We will confine our dog to the kitchen area. c. I should wash bedding in hot water. d. A damp cloth should be used when I dust. ANS: B Pets should be removed from the home or kept outside if at all possible. DIF: Cognitive Level: Application REF: p. 493 OBJ: 5 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is providing nutrition information to a patient diagnosed with a lower respiratory tract disease. What is the rationale for limiting caffeine? a. Caffeine increases the respiratory rate. b. Caffeine can result in thicker lung secretions.

c. Caffeine will increase the anxiety response associated with dyspnea. d. Caffeine can cause bronchospasm. ANS: B Avoid caffeine containing beverages because caffeine is a weak diuretic. Diuresis promotes thickening of lung secretions, making it more difficult to expectorate them. DIF: Cognitive Level: Application REF: pp. 493-494 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 15. The nurse is teaching a patient with a history of COPD to self administer tiotropium (Spiriva) by dry powder inhalation. Which information provided by the nurse is accurate? a. The medication capsules can be used multiple times. b. Press on the canister while inhaling. c. Avoid breathing into the mouthpiece. d. Wash the device with cold water. ANS: C The patient should not breathe into the mouthpiece at any time. Capsules are meant to be used as a single dose and should be disposed of after taking the daily dose. The HandiHaler uses capsules of medication that should be pierced before the patient inhales. The inhaler should be washed with hot water. Chapter 108: Upper Respiratory Tract Infections 1) Which of the following are recommended before taking an initial observation approach in a patient with acute otitis media? A. Temperature less than 39°C [102.2°F] B. Joint decision-making with patients and caregivers C. Action plan to administer antibiotics if symptoms worsen within 48 to 72 hours D. All of the above must be in place before recommending initial observation 2) Which of the following characteristics can help differentiate between acute otitis media and otitis media with effusion? A. Middle ear effusion B. Cough C. Ear pain D. Two of the above are correct 3) Which of the following is considered to be a first-line recommendation for the treatment of a 1-year old child with acute otitis media and a fever of 103°F (39.4°C)? A. Azithromycin B. Amoxicillin C. Ceftriaxone D. Cefuroxime 4) A child with moderate symptoms of acute otitis media returns to clinic after taking amoxicillin for 4 days without improvement, which of these alternatives would you recommend? A. Amoxicillin-clavulanate B. Trimethoprim-sulfamethoxazole C. Ceftriaxone

D. Erythromycin-sulfisoxazole 5) Which of the following vaccines can help prevent episodes of acute otitis media? A. Pneumococcal conjugate vaccine B. Seasonal influenza vaccine C. Tetanus, diphtheria, and pertussis vaccine D. Two of the above are correct 6) Which of the following patients should receive amoxicillin-clavulanate instead of amoxicillin for acute otitis media? A. Patient who received amoxicillin for another infection 2 weeks prior to this visit B. Patient with purulent conjunctivitis and acute otitis media C. Both of these patients should receive amoxicillin-clavulanate instead of amoxicillin D. Neither of these patients should receive amoxicillin-clavulanate instead of amoxicillin 7) Which of the following is the most common pathogen in acute rhinosinusitis? A. Viruses B. Streptococcus pneumoniae C. Haemophilus influenzae D. Moraxella catarrhalis 8) Which of the following is suggestive of bacterial versus viral rhinosinusitis? A. Persistent symptoms for ten days or more B. Worsening of symptoms after seven days C. Lack of symptomatic response to nonprescription nasal decongestants D. All of the above are correct 9) Which of the following is considered to be a first-line recommendation for the treatment of a 68-year old man with a 2-week history of persistent nasal congestion and sinus pain? The man received 10 days of clindamycin when he was hospitalized for a skin abscess 2 months ago A. Amoxicillin-clavulanate B. Clarithromycin C. Levofloxacin D. Amoxicillin 10) Which of the following nonprescription medications is recommended for the management of patients with acute bacterial rhinosinusitis? A. Nasal antihistamine B. Oral antihistamine C. Nasal decongestant D. None of the above are recommended for a patient with acute bacterial rhinosinusitis 11) A 10-year old male presents to the pediatrician's office with severe throat pain and dysphagia. His highest temperature was 99.9°F (37.7°C). During the physical exam, he is found to have swollen tonsils but no swelling of the anterior cervical nodes. Based on the above information, when is antibiotic therapy indicated? A. Clinical criteria present and low index of suspicion B. Clinical criteria and RADT test positive C. Clinical criteria and pending laboratory results D. B and C 12) Which of the following is NOT consistent with the clinical presentation of GABHS pharyngitis? A. Enlarged, tender lymph nodes

B. Sore throat C. No cough D. Conjunctivitis 13) A local daycare reports several cases of GABHS pharyngitis. How many days must pass before the risk of additional cases is no longer a concern? A. 1 day B. 5 days C. 10 days D. 14 days 14) The most appropriate therapy for a young adult (weighing 70 kg) diagnosed with GABHS pharyngitis and has a penicillin allergy (anaphylaxis) is A. Tetracycline 500 mg PO twice daily for 10 days B. Levofloxacin 750 mg PO daily for 10 days C. Penicillin V 500 mg PO twice daily for 10 days D. Azithromycin 500 mg PO once daily for one day, then 250 mg once daily for 4 days 15) A 9-year old female (weighing 30 kg) is diagnosed with pharyngitis. Which of the following is most appropriate? A. Amoxicillin suspension 400 mg/5 mL—Take 12.5 mL PO once daily for 10 days B. Clindamycin hydrochloride 75 mg capsules—Take 3 capsules PO three times daily for 10 days C. Sulfamethoxazole-trimethoprim 200 mg/40 mg/5 mL oral suspension—Take 3 teaspoonfuls PO twice daily for 5 days D. Penicillin benzathine 0.6 million units IM—Administer 1 dose Chapter 109: Influenza 1) A 21-year-old, otherwise healthy, female college student presents to clinic with history of 4 days of fever, myalgia, dry cough, and malaise. She is diagnosed with influenza A infection. What would be the most appropriate recommendation for her? A. Oseltamivir 75 mg once daily for 5 days B. Maintenance of fluid intake, warm tea, and cough lozenges C. Oseltamivir 75 mg plus rimantadine 100 mg twice daily for 5 days D. Zanamivir 10 mg twice daily for 5 days plus maintenance of fluid intake, warm tea, and cough lozenges 2) Which of the following characteristics is true for the influenza B virus? A. Responsible for the seasonal epidemics of influenza B. Typically associated with sporadic outbreaks C. Categorized into subtypes based on hemagglutinin and neuraminidase D. Does not cause disease in humans 3) Which of the following statements is true regarding antigenic drift and antigenic shift? A. Antigenic shift occurs when point mutations in the surface antigens of a particular subtype create antigenic variants, resulting in small changes in the hemagglutinin and/or neuraminidase molecules. B. Antigenic drift occurs when the influenza virus acquires a new hemagglutinin and/or neuraminidase via genetic reassortment. C. Antigenic shift causes seasonal epidemics of influenza and is the rationale behind the recommendation for annual vaccination.

D. Antigenic drift causes seasonal epidemics of influenza and is the rationale behind the recommendation for annual vaccination. 4) What elements are needed for an avian influenza pandemic to occur? A. Sustained transmission from human to human B. Direct transmission from bird to human C. An influenza virus against which humans have no immunity D. All of the above 5) The influenza virus can be transmitted person-to-person via which of the following mechanisms? A. Influenza virus is not transmitted person-to-person. B. Via inhalation of respiratory droplets after someone sneezes C. Contact with an object contaminated with respiratory secretions, such as a used tissue D. Both B and C could allow viral transmission. 6) How long after the onset of illness are children considered infectious? A. 2 days B. 5 days C. 7 days D. ≥10 days 7) Which of the following patients should not receive the live-attenuated influenza vaccine (LAIV)? A. A 45-year-old male hemodialysis patient with a hypersensitivity to eggs B. A healthy 2-year-old girl C. A 37-year-old female with HIV and a CD4 cell count of 150 cells/mm3 (0.15 x 109/L) D. A healthy 39-year-old accountant 8) A 52-year-old female presents with fever, malaise, non-productive cough, and sore throat for the last 5 days. She is diagnosed with influenza. What other signs and symptoms of influenza would be classical for this patient? A. Rhinitis B. Nausea and vomiting C. Otitis media D. None of the above is classical signs and symptoms of influenza. 9) Which diagnostic test would be the most appropriate to use in the patient from #8 to provide a rapid result? A. Rapid antigen test B. Direct fluorescence antibody test C. Viral culture D. All of the above could be used in this patient for rapid diagnosis. 10) In which of the following patients would prophylaxis with an antiviral medication be appropriate? A. A vaccinated (received 1 month ago) 74-year-old male resident of a long-term care facility with a current influenza outbreak. B. A 54-year-old female presenting to clinic to receive her influenza vaccination because she heard about several influenza cases in the community. C. An unvaccinated 34-year-old mother of three (healthy children aged 3, 6, and 9 years). D. Prophylaxis with antiviral medication is appropriate in all of the above.

11) Which of the following is the most appropriate prophylactic regimen for the patient(s) requiring prophylaxis from #10? A. Rimantadine 200 mg once daily for the duration of influenza activity. B. Zanamivir 10 mg twice daily for 5 days. C. Oseltamivir 75 mg daily for up to a week after last documented influenza infection. D. Zanamivir 10 mg twice daily for 2 days. 12) Which of the following statements is true? A. Thimerosal-free vaccines are available because thimerosal causes autism. B. No thimerosal-free formulations of the influenza vaccine are available. C. No scientifically persuasive evidence exists to suggest harm from thimerosal exposure from a vaccine. D. The risks of using a thimerosal-containing vaccine outweigh the benefits of receiving the influenza vaccine. 13) Which of the following patients is not at high risk for complications or severe disease from seasonal influenza infection? A. A 28-year-old pregnant woman at 34 weeks' gestation with no significant medical history. B. A 47-year-old male with hypertension successfully managed with lisinopril. C. An 82-year-old female residing in a nursing home. D. A 12-year-old boy with asthma. 14) Adamantane monotherapy would be most appropriate in which of the following situations? A. Prophylaxis for patients in a nursing home during an influenza A outbreak. B. Prophylaxis for patients in a nursing home during an influenza B outbreak. C. Treatment of a 58-year-old male presenting within 36 hours of the onset of illness. D. Use of the adamantanes is not appropriate for monotherapy because of rapid development of resistance. 15) What are the primary subtypes of influenza A that have been circulating among humans over the past 30 years? A. H3N2 and H1N1v B. H3N2 and H5N1 C. H3N2 and H1N1 D. H2N2 and H5N1 Chapter 110: Skin and Soft-Tissue Infections 1) A 26 year-old male presents to the outpatient clinic complaining of a sore area on his upper back. He said it started as just one sore that was red and tender. On physical exam, several discrete nodules are present that are fluctuant, painful, and surrounded by areas of erythema and edema 1-2 cm in diameter. The man states that he is allergic to penicillin, although he does not know the type of reaction that he had. His temperature is 38.5oC; other vital signs are within normal limits. His white blood cell count is elevated at 14,300 cells/µL (14.3 × 109 /L). The most appropriate initial therapy for this patient would be: A. incision and drainage only B. incision and drainage, followed by oral linezolid C. incision and drainage, followed by oral doxycycline D. incision and drainage, followed by intravenous vancomycin 2) A 76-year-old man presents to the emergency department with complaints of a burning pain on his lower leg. Physical exam reveals an erythematous, edematous lesion with a raised border

that is sharply demarcated from uninfected skin. The man stated that he felt like he had the flu (fever, tired) before the pain began. His vital signs showed a temperature of 101°F (38.3 oC) and a CBC revealed a white blood cell count of 15,100 cells/µL (15.1 x 109/L). The man states that he is allergic to erythromycin (it made him sick to his stomach). The most appropriate therapy for this patient would be: A. oral dicloxacillin B. oral clarithromycin C. oral trimethoprim-sulfamethoxazole D. oral penicillin VK 3) A 3-year-old girl is brought to the clinic with complaints of itchy blisters on her face. Her face has three small areas (approximately 15 cm2total) of erythema with a mixture of small vesicles filled with clear serous fluid and some larger pustules. Thin golden-yellow crusts of previously ruptured vesicles also cover her face. The child is afebrile, has a normal complete blood count and no known drug allergies. The most appropriate therapy for this patient would be: A. oral dicloxacillin B. incision and drainage alone with no antibiotics C. topical retapamulin ointment D. oral penicillin VK 4) A 15-year-old male is brought to the emergency department by his parents with complaints of fever, chills, and headache. The young man stated that several days ago he had developed a blister on his right hand from pitching baseballs during practice. On physical exam, a bright red, narrow streak extends from the blister to his armpit. Regional lymph nodes are enlarged and tender. A complete blood count was performed that showed his white blood cell count to be elevated. The most appropriate therapy for this patient would be: A. oral ciprofloxacin B. topical mupirocin ointment C. intravenous penicillin G D. intravenous vancomycin 5) A 32-year-old female presents to her family physician complaining that her lower leg feels hot and painful. Physical exam shows the lower leg to have erythema, edema, and it is very warm to the touch. The erythematous area is nonelevated and has poorly defined margins. There is no drainage or exudates and no evidence of abscesses. She has no recollection of any trauma or injury to the area. The woman has normal vital signs and her complete blood count is normal. She has no known allergies. The most appropriate empiric therapy for this patient would be: A. oral dicloxacillin B. oral trimethoprim-sulfamethoxazole C. oral penicillin VK + clindamycin D. oral levofloxacin 6) A 24-year-old female presents to her family clinician complaining of a sore she thought might be from a spider bite. Physical exam reveals a purulent lesion on her lower left leg, surrounded by a 1 cm diameter area of redness and swelling. The patient is afebrile and has a normal white blood cell count. She has no known allergies. The most appropriate therapy for this patient would be: A. incision and drainage of the lesion with no antibiotics required B. incision and drainage of the lesion, followed by penicillin VK C. incision and drainage of the lesion, followed by oral ciprofloxacin

D. incision and drainage of the lesion, followed by oral trimethoprim-sulfamethoxazole 7) A 54-year-old obese male presents to the emergency department complaining of severe pain in his left lower leg. His leg is hot, swollen and erythematous without any sharp margins; most of the calf from ankle to knee is affected. The lesion is remarkable for a deep cut 4 cm in length which is draining a yellowish, purulent-looking fluid. The patients states that he injured himself at home when he was cleaning out his garage and was cut by a piece of sheet metal. Vital signs reveal a high temperature (104°F [40.0 °C]) and a complete blood count revealed an elevated white blood count (22,000 cells/mm3 [22 × 109/L]). He has no known allergies. Along with proper wound care, the most appropriate therapy for this patient would be: A. oral cephalexin B. oral trimethoprim-sulfamethoxazole C. oral amoxicillin-clavulanate D. oral levofloxacin 8) A 68-year-old female presents to the diabetes clinic for a routine visit. She has no complaints. Her past medical history is significant for diabetes mellitus, hyperlipidemia, hypertension, and chronic renal insufficiency. Vital signs showed an elevated blood pressure; an elevated glucose was noted on a chemistry panel. Physical exam revealed a small ulcer on the sole of her right foot. The lesion is erythematous, with the presence of pus and a foul-smelling odor. The patient has allergies to penicillin, ceftriaxone (difficulty breathing with both) and sulfa (rash). She has received multiple courses of antibiotic therapy previously, but the wound has never completely healed. The clinician counsels the patient on the importance of glucose and blood pressure control, as well as self-exam and care of her feet. He also initiates antimicrobial therapy for the infection on her foot, which he judges to be mild in severity. The most appropriate therapy for this patient would be: A. oral amoxicillin-clavulanic acid B. oral cephalexin C. oral moxifloxacin D. oral trimethoprim-sulfamethoxazole 9) One week later the patient in the preceding question returns with no improvement in her ulcer. She states that she has been compliant in taking her therapy as prescribed. The clinician obtains a small aspirated sample for culture and sensitivity. The gram stain shows many white blood cells and many gram-positive cocci in clusters. The culture grew methicillin-resistant Staphylococcus aureus (MRSA), which was resistant to penicillin, cephalexin, and erythromycin, but sensitive to clindamycin, doxycycline, levofloxacin, gentamicin, trimethoprim-sulfamethoxazole, and vancomycin. Anaerobic cultures were still pending. Appropriate management of this patient at this time would be: A. switch therapy to oral doxycycline B. switch therapy to intravenous gentamicin C. switch therapy to oral trimethoprim-sulfamethoxazole D. switch therapy to intravenous vancomycin 10) A 55-year-old male with a history of poorly controlled Type 1 diabetes mellitus is admitted to the hospital with suspected necrotizing fasciitis involving the perineum and lower abdomen. The affected area is extremely erythematous, swollen and taught, hot to the touch, and exquisitely painful. The patient has a temperature of 103.6oF (39.8oC) and a white blood cell count of 22,000 cells/µL (22 × 109 /L). He has no known drug allergies. The most appropriate initiation therapy of this patient's infection would be:

A. intravenous piperacillin-tazobactam B. intravenous ceftriaxone plus linezolid C. intravenous penicillin G plus clindamycin D. intravenous meropenem plus vancomycin 11) The most important aspect in the prevention of pressure sores is: A. eliminating friction B. eliminating moisture C. eliminating pressure D. eliminating moisture 12) An 8-year-old female is brought to the emergency department immediately after being bitten on the right side of her face by a neighbor's dog. The bite wound involves multiple deep puncture wounds and some significant tearing of the surrounding tissues. The most appropriate management of this patient's wound would be: A. proper wound care alone, no antibiotics needed B. oral antibiotic prophylaxis for 3-5 days C. oral antibiotic prophylaxis for 7-10 days D. tetanus-diphtheria toxoids and rabies prophylaxis, no antibiotics needed 13) The most appropriate therapy for an infected dog or cat bite would be: A. oral amoxicillin-clavulanic acid B. oral cephalexin C. oral penicillin VK + clindamycin D. intravenous vancomycin 14) A 16-year-old male is brought to the emergency department with a human bite wound to his arm suffered three hours ago during a fight at school. The wound shows no signs of infection at this time. The most appropriate therapy for this patient would be: A. oral amoxicillin-clavulanic acid for 3 to 5 days B. oral cephalexin for 5 to 10 days C. oral clindamycin for 7 to 10 days D. no antimicrobial therapy at this time 15) Antimicrobial therapy for infections resulting from human clenched-fist injuries should include agents with antimicrobial activity against the following organism(s): A. CA-MRSA B. Eikenella corrodens, Staphylococcus aureus, and anaerobes C. Eikenella corrodens, Pasteurella multocida, and Staphylococcus aureus, D. Pasteurella multocida, Staphylococcus aureus, and Streptococcus pyogenes Chapter 111: Infective Endocarditis 1) Based on IE diagnostic criteria, the two most important parameters for the diagnosis of the infection are: A. Laboratory abnormalities and positive blood cultures B. Positive blood cultures and echocardiographic changes C. Electrocardiogram changes and positive physical findings D. Positive physical findings and positive blood cultures 2) A 41-year-old woman has prosthetic valve endocarditis due to coagulase-negative staphylococci that is methicillin resistant. She has no known drug allergies, and her renal function is within normal limits. Which of the following regimens is most appropriate?

A. Nafcillin 2 g every 4 hours for 6 weeks and gentamicin 1 mg/kg every 8 hours for 6 weeks B. Vancomycin 15 mg/kg IV every 12 hours for 6 weeks, plus gentamicin 1 mg/kg every 8 hours for the initial 2 weeks C. Nafcillin 2 g every 4 hours and rifampin 300 mg orally every 8 hours for 6 weeks, plus gentamicin 1 mg/kg D. Vancomycin 15 mg/kg IV every 12 hours and rifampin 300 mg orally every 8 hours for 6 weeks, plus gentamicin 1 mg/kg once daily for the initial 2 weeks 3) Which statement is true concerning standard monitoring parameters in patients receiving appropriate endocarditis treatment? A. Serum bactericidal titers should be obtained during the first week of therapy B. The goal peak gentamicin concentration should be 6 mcg/mL (mg/L; 12.5 μmol/L) C. Blood cultures should be negative within a few days D. The MBC should be determined for all streptococci 4) A patient who recently had mitral valve replacement (38 days ago) was admitted to the clinic with persistent fever and malaise. Endocarditis is suspected, and the most likely etiology is: A. Group A streptococci B. Viridans streptococci C. Staphylococcus epidermidis D. Enterococcus faecalis 5) A 35-year-old IV drug abuser has been diagnosed with tricuspid valve endocarditis due to methicillin-sensitive Staphylococcus aureus. Other than IV drug abuse, his past medical history is noncontributory. He has no known drug allergies, has normal renal function, and appears in no apparent distress. Which of the following IV regimens would be most appropriate? A. Nafcillin 2 g every 4 hours for 2 weeks B. Vancomycin 15 mg/kg every 12 hours for 4 weeks plus gentamicin 3 mg/kg once daily for 2 weeks C. Nafcillin 2 g every 4 hours for 4 weeks D. Nafcillin 2 g every 4 hours for 4 weeks plus gentamicin 3 mg/kg once daily for 4 weeks 6) The condition associated with the highest risk of developing infective endocarditis (IE) is: A. Mitral valve prolapse with regurgitation B. The presence of a prosthetic heart valve C. Rheumatic fever without valvular defects D. Intravenous drug abuse 7) A 74-year-old man with a history of endocarditis underwent prostate surgery 3 weeks ago. For the past week he has had persistent fever and weakness. Blood cultures are pending, but an echocardiogram suggests a potential change consistent with new endocarditis. If the patient is subsequently diagnosed with this infection, the most likely organism is: A. Group A streptococci B. Viridans streptococci C. S. epidermidis D. E. faecalis 8) Which situation is least likely to lead to "culture-negative" endocarditis? A. The use of antibiotics prior to blood culture sampling B. Gram-negative bacteria from the HACEK group (eg, Kingella kingae) C. Nonbacterial etiologies (eg, fungi) D. Unidentified subacute, left-sided infective endocarditis

9) A 64-year-old man presents to the emergency department with chest pain, fever, fatigue, and arthralgias. His past medical history is significant for rheumatic heart disease and a dental procedure a few weeks before admission. He currently shows no "stigmata" of endocarditis on physical examination, although endocarditis is suspected. The most likely organism is: A. Viridans streptococci B. Staphylococcus aureus C. Enterococcus fecalis D. Pseudomonas aeruginosa 10) In a patient with subacute endocarditis, which one of the following laboratory findings does not support the diagnosis? A. Normocytic, normochromic anemia B. Proteinuria C. Thrombocytopenia 11) With regard to the general treatment of infective endocarditis, which of the following statements is false? A. High-dose parenteral therapy is necessary to ensure adequate penetration of the agent into the vegetation. B. Clinical cure can only occur if synergistic aminoglycosides are used in combination with a βlactam agent. C. Bactericidal antibiotics are necessary for clinical cure. D. Antimicrobial treatment is continued for weeks because the organisms are located in an area of impaired host defenses, and complete bacterial eradication is difficult. 12) According to the AHA, extended-interval dosing of aminoglycosides is a reasonable option for endocarditis caused by: A. Streptococci B. Staphylococci C. Enterococci D. HACEK microorganisms 13) Which organism is not commonly associated in infective endocarditis? A. Candida albicans B. Enterococcus faecalis C. Staphylococcus aureus D. Viridans streptococcus 14) TH is a 60-year-old woman who has developed endocarditis with viridans streptococci (MIC ≤0.1 mcg/mL [mg/L]) on a native heart valve. The patient has no known drug allergies and normal renal function. Which of the following IV regimens is most appropriate? A. Ceftriaxone 2 g once daily for 2 weeks B. Penicillin G 12 to 18 million units every 24 hours for 4 weeks C. Cefazolin 2 g every 8 hours for 2 weeks plus gentamicin 1 mg/kg every 8 hours for 2 weeks D. Penicillin G 12 to 18 million units/24 hours for 4 weeks plus gentamicin 1 mg/kg every 8 hours for 2 weeks 15) A 52-year-old woman with a prior history of infective endocarditis is scheduled for a major dental extraction in 3 days. She is allergic to penicillin. Her physician asks whether she should receive antibiotic prophylaxis before her procedure. The most appropriate response is: A. Yes, ampicillin 2 g orally 1 hour before the procedure B. Yes, clindamycin 600 mg orally 1 hour before the procedure

C. Yes, cephalexin 500 mg orally 2 hours before the procedure D. No, the most recent guidelines do not recommend prophylaxis in this situation Chapter 112: Tuberculosis 1) A 42-year-old man is receiving treatment for pulmonary TB. He has received 9 weeks of daily rifampin, isoniazid, ethambutol, and pyrazinamide. His sputum smear and cultures have been negative. Susceptibility results have just been made available and indicate the isolate is resistant to isoniazid. Which of the following would be the most appropriate recommendation for your patient at this time? A. Discontinue isoniazid, continue rifampin, pyrazinamide, and ethambutol × 6 months B. Discontinue isoniazid, continue rifampin, pyrazinamide, ethambutol, and add levofloxacin × 4 months C. Discontinue isoniazid and ethambutol, continue rifampin and pyrazinamide × 4 months D. Discontinue isoniazid, pyrazinamide and ethambutol, continue rifampin × 4 months 2) TC is a 74-year-old-man recently diagnosed with multidrug-resistant (MDR)-TB. His physician is thinking about starting a regimen of amikacin, levofloxacin, cycloserine, and paminosalicylic acid, but is uncertain if this is correct. Therefore, he asks you to evaluate this proposed regimen. You note that his susceptibility tests indicate his organism is susceptible to: amikacin, ethambutol, levofloxacin, cycloserine and p-aminosalicylic acid. His estimated creatinine clearance is 25 mL/min (0.42 mL/s); he has a history of psychosis. From this information, you recommend the following: A. Replace the planned cycloserine with ethambutol; make adjustments to AK for renal dysfunction. B. Continue the planned regimen, but make adjustments to amikacin for renal dysfunction C. Replace p-aminosalicylic acid with ethambutol; make adjustments to amikacin for renal dysfunction. D. Treat with levofloxacin, cycloserine, and p-aminosalicylic acid. 3) Which one of the following patients presenting with cough, fever, and weight loss would be at greatest risk of having TB disease? A. Joe, who recently travelled to a resort in Cancun, Mexico. B. Emily, who volunteers on holidays at a homeless shelter. C. Brian, who works at a Vietamese restaurant. D. Lisa, who is on infliximab for rheumatoid arthritis. 4) SL has been on antituberculosis treatment for 2 months, which of the following tests would be most appropriate to determine her response to therapy? A. Mantoux test B. Nucleic acid amplification test C. Acid fast baccili (AFB) culture D. Interferon Gamma release assay (QuantiFERON®-TB Gold) 5) After being discharged from the hospital, LB comes to your pharmacy with prescriptions to continue her antituberculosis regimen. Which of the following drugs would cause pruritus and orange discoloration of her urine, sputum, sweat, and tears? A. Isoniazid B. Ethambutol C. Rifampin D. Pyrazinamide

6) A 68-year-old Asian male with active TB has been on a four-drug anti-TB medication (rifampin, isoniazid, pyrazinamide, and ethambutol) regimen for 5 weeks. He complains that his right big toe has been painful for 2 weeks and recently he has a hard time walking around the house. On examination, the right big toe is tender and red. Laboratory testing shows an elevated uric acid level and gout is suspected. Which of the following anti-TB medications is most likely associated with this side effect? A. Isoniazid B. Pyrazinamide C. Rifampin D. Ethambutol 7) An otherwise healthy 29-year-old Asian female with active TB has been improving symptomatically after 6 weeks of anti-TB medications (rifampin, isoniazid, pyrazinamide, and ethambutol). However, for the past 2 weeks, she has noticed trouble reading phone numbers in the phonebook, and has had trouble reading the newspaper. On examination, her visual acuity and red/green perception are diminished. The most likely diagnosis is: A. Ethambutol-associated optic neuritis B. Isoniazid-induced hepatitis C. Macular degeneration D. TB dissemination to her eyes 8) BC is a 36-year-old patient severely immunocompromised with human immunodeficiency virus (HIV) and TB coinfection. Which of the following is the most appropriate treatment approach in this patient? A. Defer antiretroviral therapy until after TB treatment. B. Start antiretroviral therapy and then then treat start TB treatment 4 weeks later. C. Start TB therapy and then start antiretroviral therapy as soon as possible after. D. Start both antiretroviral therapy and TB treatment together, as soon as possible. 9) A 55-year-old emergency room nurse was exposed to TB 4 weeks ago. Susceptibility data are pending for the patient's isolate. Her current purified protein derivative (PPD) was read as 8 mm induration. She has no symptoms and her chest X-ray is normal. Which of the following is the best option in this patient? A. No treatment is needed at this time because the patient is asymptomatic. B. Rifampin daily for 12 months. C. Isoniazid daily for 9 months. D. Rifampin and pyrazinamide for 4 months. 10) Which of the following regimens would be the best option for a 26-year-old pregnant female recently diagnosed with active TB? A. Isoniazid, rifampin, and pyrazinamide B. Isoniazid, rifampin, and ethambutol C. Isoniazid, ethambutol, and pyrazinamide D. Isoniazid, rifampin, and streptomycin 11) A 67-year-old man has received 8 weeks of therapy with rifampin, isoniazid, ethambutol, and pyrazinamide. His sputum was negative for AFB within 2 weeks of initiating therapy. Laboratory test are drawn and liver function tests are reported as: AST 166 IU/L (8-48 IU/L) and ALT 96 IU/L (7-55 IU/L) (or AST 2.77 µkat/L [0.13-0.80 µkat/L] and ALT 1.60 µkat/L [0.120.92 µkat/L]) . Which of the following would be the best option for the patient at this time?

A. Discontinue isoniazid and rifampin, start pyrazinamide, levofloxacin, and ethionamide. B. Discontinue isoniazid and rifampin, add moxifloxacin and check serum concentrations of his TB drugs. C. Discontinue all TB drugs, continue to recheck liver function tests and restart same treatment when liver function returns to normal. D. Continue current treatment and continue to monitor for continued elevation of liver function tests. 12) A 23-year-old Hispanic male with HIV infection and active TB is receiving highly active antiretroviral therapy and antituberculous treatment with rifabutin, isoniazid, pyrazinamide, and ethambutol by directly observed treatment (DOT). He reports that his right eye has been hurting him for 3 days and is now red. What is the most likely medication induced condition? A. Ethambutol-induced optic neuritis B. Isoniazid-induced peripheral neuropathy C. Pyrazinamide-induced acidosis leading to optic neuritis D. Rifabutin-related uveitis 13) Which of the following regimens is not an option for treatment of latent TB infection? A. Rifampin daily × 4 months B. Isoniazid and rifapentine DOT once weekly × 3 months C. Isoniazid and rifampin daily for 6 months D. Isoniazid DOT twice weekly for 6 months 14) TS is a 58-year-old woman with drug susceptible TB. She has been on four-drug antituberculosis treatment for 6 weeks and is still smear-positive. Which of the following options below would be the most appropriate to do at this time? A. Add streptomycin to her regimen and check serum concentrations of her TB drugs. B. Continue treatment, M. tuberculosis is slow growing and 6 weeks is not enough time to convert to smear-negative C. Inform the patient that her treatment will need to be extended to 12 months. D. Continue current treatment and check serum concentrations of her TB drugs. 15) Rifabutin should be chosen over rifapentine or rifampin when a patient is on certain combined antiretroviral combinations because it: A. Has a better side effect profile in HIV-positive patients. B. Is less likely to induce hepatic clearance of the antiretroviral drugs. C. It has a lower risk of uveitis. D. Serum concentration monitoring is available for rifabutin. Chapter 113: Gastrointestinal Infections and Enterotoxigenic Poisonings 1) The most common cause of infectious diarrhea in American children is which of the following pathogens? A. Vibrio cholerae B. Campylobacter jejuni C. Yersinia enterocolitica D. Escherichia coli E. Rotavirus 2) Which of the following pathogens is associated with dysentery (bloody) diarrhea? A. V cholerae B. Escherichia coli

C. Clostridium difficile D. Y enterocolitica 3) Which of the following statements regarding the treatment of E. coli-related infectious diarrhea is FALSE? A. Initial treatment should include appropriate hydration with low-osmolar or isotonic fluid replacement. B. The use of antimotility agents, like loperamide, could potentially increase diarrheal symptoms due to prolonged exposure to bacterial toxin. C. Using fluoroquinolone agents for treatment of this infection is appropriate when bloody stools are present and serotype is undetermined. D. None of the above are FALSE. 4) Which of the following causes of dysentery diarrhea currently has an available vaccine in the United States that may prevent some species of the disease? A. Shigellosis. B. Campylobacteriosis. C. Salmonellosis. D. Yersiniosis. E. None of the above have available vaccine. 5) Which of the following statements regarding rehydration therapy in a patient with gastroenteritis is FALSE? A. Intravenous fluid replacement is indicated in all pediatric patients with infectious diarrhea. B. Glucose and other simple sugars in high concentrations can worsen diarrhea in a patient acutely ill with gastroenteritis. C. If a patient presents with gastroenteritis and an ileus, intravenous fluid replacement is indicated. D. None of the above are FALSE. 6) Which of the following statements regarding diagnosis of Clostridium difficile infection (CDI) is/are TRUE? A. Diagnosis of CDI requires presence of bacterial-released toxin and a host response to that toxin. B. Testing for toxin production in CDI with solid, formed stools is appropriate to ensure eradication of the organism. C. CDI diagnosis requires anaerobic cultures for confirmation. D. All of the above are true. 7) According to current guidelines, what class of antimicrobials would be indicated for treatment in a 62 year-old patient with confirmed enterocolitis due to a Salmonella species? A. Cephalosporin B. Aminoglycoside C. Macrolide D. Fluoroquinolone 8) Treatment for an adult with campylobacteriosis that started having bloody diarrhea 2 days ago should be initiated on which of the following medication? A. Ciprofloxacin. B. Doxycycline. C. Metronidazole. D. Azithromycin.

E. No antimicrobial therapy is warranted. 9) Which of the following viral causes of infectious gastroenteritis could be seen during the winter months and would be common in adults? A. Rotavirus B. Norovirus C. Astrovirus D. Coronavirus 10) Which of the following situations would warrant vancomycin therapy rather than metronidazole for CDI treatment? A. Patient with CDI-related paralytic ileus. B. CDI with diarrhea symptoms and without fever following ciprofloxacin therapy. C. Patient with CDI-related diarrhea and a WBC of 17,500 cells/mm3 (17.5 × 109/L) D. All of the above. E. Only TWO of the above. 11) According to current guidelines, a patient diagnosed with first-episode CDI that is determined to be critically ill (has systemic symptoms including hypotension) should be treated with which of the following for C. difficile treatment? A. Metronidazole PO B. Vancomycin PO C. Vancomycin IV D. Fidaxomicin PO 12) Which of the following statements is/are TRUE regarding CDI prevention? A. Hand washing with soap and water can help prevent person-to-person transmission of CDI. B. Room disinfection after a CDI patient is discharged must be performed with alcohol-based cleaners. C. C. difficile spores survive only hours outside the host, so time is another method of preventing CDI transmission. D. Respiratory precautions (masks and face shields) should be utilized when entering and taking care of a CDI patient. E. None of the above are TRUE. 13) Which of the following would NOT be considered a common pathogen in causing traveler's diarrhea? A. Enterotoxigenic Escherichia coli B. Rotavirus C. Shigella dysenteriae D. Vibrio cholerae E. All of the above are common pathogens in traveler's diarrhea 14) Recommended prophylaxis for traveler's diarrhea should include which of the following? A. Education on proper food and personal hygiene. B. Famotidine 20 mg PO twice daily while traveling. C. Ciprofloxacin 750 mg PO once daily while traveling. D. All of the above should be recommended. 15) A patient is having some diarrhea and is diagnosed with food poisoning following eating potato salad and tapioca pudding at his family reunion. In all likelihood, the causative pathogen in Staphylococcus aureus. Which of the following antibacterials should be recommended for his treatment in combination with ORT?

A. Ciprofloxacin B. Azithromycin C. Trimethoprim/sulfamethoxazole D. Linezolid E. No antibiotic therapy is warranted Chapter 114: Intra-Abdominal Infections 1) A patient presents with an abscess in the abdomen, most likely associated with a perforated diverticulum in the colon. Which of the following would be the most appropriate initial antimicrobial regimen? A. Ceftriaxone plus metronidazole B. Clindamycin C. Ampicillin–sulbactam D. Gentamicin plus metronidazole 2) Which of the following is the best choice for complicated intra-abdominal infections due to extended-spectrum beta-lacatmase-producing Enterobacteriaceae? A. Tigecycline B. Sulfamethoxazole/trimethoprim C. Polymyxin B or Colistin D. Meropenem 3) The appropriate duration of antimicrobial treatment for acute contamination of the abdomen without established infection is: A. 24 hours or less B. 10 days C. 3 days D. 4 to 7 days 4) Which of the following would be considered optimal therapy for community-acquired acute cholecystitis? A. Meropenem B. Ciprofloxacin C. Ceftriaxone D. Cefepime 5) Identify the correct statement: A. Mild-to-moderate community acquired complicated intra-abdominal infections DO NOT require empiric coverage for Enterococcusspp. B. Empiric coverage for methicillin-resistant Staphylococcus aureus is routinely required for healthcare-associated complicated intra-abdominal infections. C. Empiric coverage for Candida spp. is routinely required for high risk/severe community acquired complicated intra-abdominal infections. D. Empiric coverage for Candida spp. is routinely required for mild-to-moderate community acquired complicated intra-abdominal infections. 6) In patients with primary peritonitis, bacteria may enter the abdomen via all of the following routes, except: A. Through a cerebrospinal–peritoneal shunt B. Through the damage done to the GI tract by blunt trauma C. Through the bloodstream when there is no damage to the GI tract

D. Through a peritoneal dialysis catheter 7) Which of the following statements is false? A. Antimicrobial regimens for secondary intra-abdominal infections should cover a broad spectrum of aerobic and anaerobic bacteria. B. Antimicrobial treatment of acute bacterial contamination after trauma to the GI tract is adequately treated with an antianaerobic cephalosporin. C. Most patients should not complete their antimicrobial regimen orally after an uncomplicated secondary intra-abdominal infection. D. Four to seven days of antimicrobial treatment is typically adequate for intra-abdominal infections with adequate source control. 8) The leukocyte count from ascitic fluid consistent with bacterial peritonitis is: A. >100 leukocytes/mm3 (>0.1 × 109/L) B. >250 leukocytes/mm3 (>0.25 × 109/L) C. >500 leukocytes/mm3 (>0.5 × 109/L) D. >1000 leukocytes/mm3 (>1 × 109/L) 9) Which of the following requires the empiric coverage of anaerobes? A. Primary (spontaneous) bacterial peritonitis B. Community-acquired acute cholecystitis C. Mild-to-moderate community-acquired complicated intra-abdominal infection D. Peritoneal dialysis-associated peritonitis 10) Which of the following regimens is reliably active against both Enterobacteriaceae such as E coli AND anaerobes such as Bacteroides fragilis? A. Levofloxacin B. Ceftriaxone plus metronidazole C. Cefepime plus clindamycin D. Ampicillin/sulbactam 11) Identify the incorrect statement regarding complicated healthcare-associated intra-abdominal infections in adults. A. Microbiologic results and the patient's history of infecting organisms should guide empiric antibiotic therapy. B. Ampicillin–sulbactam is appropriate for the treatment of complicated healthcare-associated intra-abdominal infections. C. Piperacillin–tazobactam is appropriate for the treatment of healthcare-associated complicated intra-abdominal infections. D. Ertapenem is appropriate for the treatment of complicated healthcare-associated intraabdominal infections. 12) Which of the following organisms should be routinely treated empirically in patients with high-risk/severe community acquired complicated intra-abdominal infection? A. Vancomycin-resistant Enterococcus spp. B. Methicillin-resistant S aureus C. Pseudomonas aeruginosa D. Acinetobacter baumannii 13) The most reasonable initial intraperitoneal empiric antimicrobial therapy for a 46-year-old male patient with peritonitis and a history of immediate hypersensitivity reaction to penicillin is A. Cefazolin plus ceftazidime (LD 500 mg/L, MD 125 mg/L for each) B. Cefepime (LD 500 mg/L, MD 125 mg/L)

C. Vancomycin (LD 1,000 mg/L, MD 25 mg/L) plus tobramycin (LD 8 mg/L, MD 4 mg/L) D. Metronidazole (LD 250 mg/L, MD 50 mg/L) 14) A 23-year-old woman in good health is determined to have a perforated appendix. Which of the following is the best antimicrobial regimen for this patient? A. Cefazolin plus vancomycin B. Ceftriaxone plus metronidazole C. Aztreonam plus vancomycin D. Cefazolin plus gentamicin 15) The most important component of treatment of a perforated appendix is A. Using the best antimicrobial regimen B. Aggressive IV fluid therapy C. A surgical procedure, including drainage and repair D. Enteral nutrition supplementation Chapter 115: Parasitic Diseases 1. A recommended antiparasitic drug for an 18-month-old child with giardiasis includes: A. Albendazole B. Benznidazole C. Mebendazole D. Metronidazole E. Tinidazole 2. JC is a 35-year-old man with HIV infection presents with profuse, watery, nonbloody diarrhea. He stopped taking antiretroviral therapy 5 years ago and his most recent CD4+ T-cell count is 35 cells/mm3 (35 × 106/L). Stool samples are collected and a Cryptosporidium direct fluorescent antibody test returns positive. JC should receive: A. Oral fluids and tinidazole B. Loperamide and nitazoxanide C. Opium tincture and metronidazole D. Antiretroviral therapy and nitazoxanide E. Antiretroviral therapy and metronidazole 3. AT is a 27-year-old resident of San Diego who returns from Mexico and presents with severe abdominal cramps, blood-streaked diarrhea with mucus. She is afebrile but has moderate leukocytosis. Right upper quadrant ultrasound and abdominal computed tomography show two

large abscesses in right lobe of her liver. To diagnose AT with amebiasis, a clinician should order: A. Ova and parasite (O&P) stool tests for E. dispar. B. O&P stool tests for E. moshkovskii. C. Stool cultures to identify E. histolytica. D. Serologic tests to identify E. dispar. E. Serologic tests to identify E. histolytica. 4. Patients with amebiasis who are asymptomatic cyst passers should receive luminal agents such as: A. Iodoquinol and albendazole B. Iodoquinol and paramomycin C. Metronidazole and paramomycin D. Metronidazole and tinidazole E. Tinidazole and paramomycin 5. Patients with amebic liver abscesses should receive tissue-acting agents such as: A. Iodoquinol and albendazole B. Iodoquinol and paramomycin C. Metronidazole and paramomycin D. Metronidazole and tinidazole E. Tinidazole and paramomycin 6. Disseminated strongyloidiasis is most likely to occur in a patient who: A. Swims in lakes and rivers B. Drinks untreated well water C. Receives albendazole

D. Receives ivermectin E. Receives high-dose corticosteroids 7. LL is a 52-year-old recent immigrant of Columbia who has been diagnosed with neurocysticercosis. Taenia solium cysts are found to be located in the basal meninges and in the fourth ventricles by magnetic resonance imaging (MRI). Treatment of this patient may include surgical cyst removal, antiepileptic drugs, corticosteroids, and antihelminthic therapy. Which of these options may lead to worsening of neurocysticercosis symptoms? A. Phenytoin B. Metronidazole C. Dexamethasone D. Surgical cyst removal E. Albendazole and praziquantel 8. MC is a 4-year-old boy with fever, hepatosplenomegaly, abdominal pain, and wheezing who is diagnosed with toxocariasis. MC should receive: A. Albendazole B. Benznidazole C. Fluconazole D. Metronidazole E. Tinidazole 9. TG is a 45-year-old man traveling to Kenya in 6 months. According to the Centers for Disease Control and Prevention (CDC) Yellow Book, the relative risk for malaria is moderate and chloroquine-resistant P. falciparum is prevalent. His current medications include lisinopril, duloxetine, and zolpidem as needed for insomnia. A recommended malaria chemoprophylaxis regimen is: A. Doxycycline 100 mg po once daily B. Primaquine 30 mg base po once daily C. Mefloquine 228 mg base po once weekly D. Hydroxychloroquine 310 mg base po once weekly

E. Atovaquone/proquanil 62.5 mg/25 mg po once weekly 10. Severe falciparum malaria requires a patient to be admitted to an acute care unit and treated with: A. Artesunate B. Artemether-lumefantrine C. Atovaquone-proguanil D. Quinine sulfate E. Mefloquine 11. An arteminisin-based regimen that may be used to treat uncomplicated chloroquine-resistant malaria includes: A. Artesunate B. Artemether-lumefantrine C. Atovaqone-proguanil D. Quinine sulfate E. Mefloquine 12. RT is a 41-year-old Mexican man who has lived in California for the past 20 years and makes frequent trips to Guadalajara to visit his sisters. Two days ago after he returns from 3week trip, he began complaining of fever, nausea, vomiting, and left eye swelling. He is diagnosed with Chagas disease (Trypanosoma cruzi). RT should receive: A. Albendazole B. Benznidazole C. Metronidazole D. Nifurtimox E. Nitazoxanide 13. Chronic T. cruzi infection or Chagas disease is likely to lead to:

A. Asthma B. Cardiomyopathy C. Epilepsy D. Lactic acidosis E. Liver failure 14. An alternative prescription-only agent for Pediculosis capitis (head lice) in which permethrin resistance has been documented includes: A. Crotamiton 10% topical lotion B. Lindane 1% shampoo or lotion C. Spinosad 0.9% topical suspension D. Permethrin 5% topical cream E. Pyrethrins plus piperonyl butoxide shampoo 15. The drug regimen of choice for scabies treatment is: A. Crotamiton 10% topical lotion B. Lindane 1% shampoo or lotion C. Spinosad 0.9% topical suspension D. Permethrin 5% topical cream E. Pyrethrins plus piperonyl butoxide shampoo ANSWERS 1. D 2.

10.

11.

12.

13.

14.

15. D Chapter 116: Urinary Tract Infections and Prostatitis 1) A recommended antiparasitic drug for an 18-month-old child with giardiasis includes: A. Albendazole B. Benznidazole C. Mebendazole D. Metronidazole E. Tinidazole 2) JC is a 35-year-old man with HIV infection presents with profuse, watery, nonbloody diarrhea. He stopped taking antiretroviral therapy 5 years ago and his most recent CD4+ T-cell count is 35 cells/mm3 (35 × 106/L). Stool samples are collected and a Cryptosporidium direct fluorescent antibody test returns positive. JC should receive: A. Oral fluids and tinidazole B. Loperamide and nitazoxanide C. Opium tincture and metronidazole D. Antiretroviral therapy and nitazoxanide E. Antiretroviral therapy and metronidazole 3) AT is a 27-year-old resident of San Diego who returns from Mexico and presents with severe abdominal cramps, blood-streaked diarrhea with mucus. She is afebrile but has moderate leukocytosis. Right upper quadrant ultrasound and abdominal computed tomography show two large abscesses in right lobe of her liver. To diagnose AT with amebiasis, a clinician should order: A. Ova and parasite (O&P) stool tests for E. dispar. B. O&P stool tests for E. moshkovskii. C. Stool cultures to identify E. histolytica. D. Serologic tests to identify E. dispar. E. Serologic tests to identify E. histolytica.

4) Patients with amebiasis who are asymptomatic cyst passers should receive luminal agents such as: A. Iodoquinol and albendazole B. Iodoquinol and paramomycin C. Metronidazole and paramomycin D. Metronidazole and tinidazole E. Tinidazole and paramomycin 5) Patients with amebic liver abscesses should receive tissue-acting agents such as: A. Iodoquinol and albendazole B. Iodoquinol and paramomycin C. Metronidazole and paramomycin D. Metronidazole and tinidazole E. Tinidazole and paramomycin 6) Disseminated strongyloidiasis is most likely to occur in a patient who: A. Swims in lakes and rivers B. Drinks untreated well water C. Receives albendazole D. Receives ivermectin E. Receives high-dose corticosteroids 7) LL is a 52-year-old recent immigrant of Columbia who has been diagnosed with neurocysticercosis. Taenia solium cysts are found to be located in the basal meninges and in the fourth ventricles by magnetic resonance imaging (MRI). Treatment of this patient may include surgical cyst removal, antiepileptic drugs, corticosteroids, and antihelminthic therapy. Which of these options may lead to worsening of neurocysticercosis symptoms? A. Phenytoin B. Metronidazole C. Dexamethasone D. Surgical cyst removal E. Albendazole and praziquantel 8) MC is a 4-year-old boy with fever, hepatosplenomegaly, abdominal pain, and wheezing who is diagnosed with toxocariasis. MC should receive: A. Albendazole B. Benznidazole C. Fluconazole D. Metronidazole E. Tinidazole 9) TG is a 45-year-old man traveling to Kenya in 6 months. According to the Centers for Disease Control and Prevention (CDC) Yellow Book, the relative risk for malaria is moderate and chloroquine-resistant P. falciparum is prevalent. His current medications include lisinopril, duloxetine, and zolpidem as needed for insomnia. A recommended malaria chemoprophylaxis regimen is: A. Doxycycline 100 mg po once daily B. Primaquine 30 mg base po once daily C. Mefloquine 228 mg base po once weekly D. Hydroxychloroquine 310 mg base po once weekly E. Atovaquone/proquanil 62.5 mg/25 mg po once weekly

10) Severe falciparum malaria requires a patient to be admitted to an acute care unit and treated with: A. Artesunate B. Artemether-lumefantrine C. Atovaquone-proguanil D. Quinine sulfate E. Mefloquine 11) An arteminisin-based regimen that may be used to treat uncomplicated chloroquine-resistant malaria includes: A. Artesunate B. Artemether-lumefantrine C. Atovaqone-proguanil D. Quinine sulfate E. Mefloquine 12) RT is a 41-year-old Mexican man who has lived in California for the past 20 years and makes frequent trips to Guadalajara to visit his sisters. Two days ago after he returns from 3week trip, he began complaining of fever, nausea, vomiting, and left eye swelling. He is diagnosed with Chagas disease (Trypanosoma cruzi). RT should receive: A. Albendazole B. Benznidazole C. Metronidazole D. Nifurtimox E. Nitazoxanide 13) Chronic T. cruzi infection or Chagas disease is likely to lead to: A. Asthma B. Cardiomyopathy C. Epilepsy D. Lactic acidosis E. Liver failure 14) An alternative prescription-only agent for Pediculosis capitis (head lice) in which permethrin resistance has been documented includes: A. Crotamiton 10% topical lotion B. Lindane 1% shampoo or lotion C. Spinosad 0.9% topical suspension D. Permethrin 5% topical cream E. Pyrethrins plus piperonyl butoxide shampoo 15) The drug regimen of choice for scabies treatment is: A. Crotamiton 10% topical lotion B. Lindane 1% shampoo or lotion C. Spinosad 0.9% topical suspension D. Permethrin 5% topical cream E. Pyrethrins plus piperonyl butoxide shampoo

Chapter 117: Sexually Transmitted Diseases 1. The nurse explains why viruses are so difficult to treat when making what statement? Viruses are contained inside the human cell and cannot be destroyed without A) destroying the cell. Release of interferons by the host cell makes the virus replicate more quickly B) allowing the virus to spread. Drugs exist to treat all viral infections but they carry serious adverse effects and the C) benefit often does not outweigh the risk. Individual antiviral drugs are often effective in treating many different viruses D) because one virus in a category behaves like others in the same category. Ans: A

2. A)

Feedback: Because viruses are contained inside human cells while they are in the body, researchers have difficulty developing effective drugs that destroy a virus without harming the human host. Interferons are released by the host in response to viral invasion of a cell and act to prevent the replication of that particular virus. Some interferons that affect particular viruses can now be genetically engineered to treat particular viral infections. Other drugs that are used in treating viral infections are not natural substances and have been effective against only a limited number of viruses. Very few viruses are treatable with medications; a few more can be prevented through immunization but most have no known treatment. Each antiviral is generally only suited to treat the single virus it was developed for and will not be effective against other viruses. While calculating the drug dose of antiviral medications for children who have AIDS a pediatric nurse uses what? The viral complications

B) C)

The childs age The severity of the virus

D) Ans:

The childs weight D Feedback: Antiviral medication dosages for children are calculated according to weight. There is no scientific data available concerning dosages based on complications or severity of illness. The ethical dilemma using children in drug studies is always a concern. Children must be monitored very carefully for adverse effects on kidneys, bone marrow, and the liver. The complications and severity of the disease may determine which drug is prescribed.

3. A)

A patient taking nevirapine (Viramune) as part of combination therapy for treatment of HIV took 200 mg/daily PO for 14 days. The patient is now taking 200 mg PO bid. How many mg of the medication is the patient taking daily? 100 mg

B) C)

200 mg 300 mg

D) Ans:

400 mg D Feedback: The patient is to take 200 mg bid, which means twice a day. (200 times 2 equals 400 mg daily.)

4. A)

What medication is only administered intravenously and is used to treat cytomegalovirus (CMV)? Cidofovir (Vistide)

B) C)

Foscarnet (Foscavir) Valacyclovir (Valtrex)

D) Ans:

Valganciclovir (Valcyte) B Feedback: Foscarnet (Foscavir) is administered IV only. Ganciclovir and (Cytovene) can be administered by IV and orally. Valganciclovir (Valcyte) and Valacyclovir (Valtrex) are administered only by the oral route.

5. A)

A hospitalized patient is receiving an antiviral drug to treat cytomegalovirus. What is the nurses priority action after administering the antiviral drug? Monitor vital signs every hour.

B) C)

Decrease fluid intake. Keep side rails up.

Encourage the patient to ambulate 10 minutes after each dose.

Ans:

C Feedback: Antiviral drugs for herpes and cytomegalovirus can cause confusion, dizziness, and other central nervous system (CNS) effects. Side rails should be up after administration to protect the patient from injury until risk for these adverse effects is lowered because not every patient will experience these effects. The patient should not be encouraged to walk after each dose because of the risk of falls if adverse effects occur. Fluid intake should be slightly increased to help decrease risk of nephrotoxicity. Vital signs should be monitored, but it would not be necessary to take them every hour unless serious adverse effects occur.

6. A)

A nurse is caring for a patient with HIV. What lab tests would the nurse monitor when a protease inhibitor has been ordered for this patient? A fasting blood sugar and 2-hour postprandial blood sugar

B) C)

Urine specific gravity and urine pH Serum alanine aminotransferase and bilirubin

D) Ans:

Arterial blood gases and O2 saturation C Feedback: Serum alanine aminotransferase and bilirubin are monitored when a protease inhibitor is used due to the risk of liver damage and the need to monitor liver function. Cholesterol and triglycerides may also be elevated by the drug and should be monitored. Protease inhibitors are metabolized in the liver and partially by the cytochrome P450 oxidase system. Although some cases of kidney stones have been related to protease inhibitors use, the greatest risk is to the liver and therefore urine specific gravity and urine pH, which indicate renal function, would be less critical to assess. Lab tests for blood sugar and arterial blood gases would not be directly affected by hepatic function.

7. A)

A patient with renal impairment and HIV has had a medication change. What drug would be considered the drug of choice for this patient? Atazanivir (Reyataz)

B) C)

Lopinavir (Kaletra) Nelfinavir (Viracept)

D) Ans:

Ritonavir (Norvir) C Feedback: Nelfinavir is the best choice for a patient with renal impairment because very little of the drug is excreted through the kidney, with most being excreted in feces. The other drugs are all excreted through both the urine and feces, so patients with renal impairment might need dosage adjustments to avoid toxicity.

8. A)

The nurse is caring for a patient with hepatitis B. The patient is taking adefovir (Hepsera). Which medication would the nurse question if it were ordered? Cimetidine (Tagament)

B) C)

Diltiazem (Cardizem) Diphenhydramine (Benadryl)

D) Ans:

Telbivudine (Tyzeka) D Feedback: Telbivudine is an antihepatitis B agent, and when given with adefovir (Hepsera) can result in severe hepatomegaly with steatosis, sometimes fatal. Cimetidine is a histamine-2 antagonist, diltiazem is a calcium channel blocker, and diphenhydramine is a firstgeneration antihistamine. These drugs are normally not considered nephrotoxic and could be used with adefovir.

9. A)

A nurse is caring for a stroke victim in the intensive care unit. The nurse notices a cold sore and requests medication. Docosanol (Abreva) is ordered. Before applying the medication, the nurse would first? Clean the area to be treated and then pat it dry.

B) C)

Assess the area for open lesions or abrasions. Put gloves on to protect herself.

D) Ans:

Prepare applicator for drug administration. B Feedback: The nurse would assess the area first to make sure no open lesions or abrasions could allow for systemic absorption of the drug. Then the nurse would clean the area and pat it dry. The nurse may apply the medication using gloves or an applicator.

10. A) B) C) D) Ans:

11. A)

A patient with AIDS is taking an antiviral agent. What comment by the patient would indicate that the teaching plan was effective? I feel like I do when I have the flu. I will continue to take the over-the-counter medication for my allergies. Excessive fatigue and a severe headache are common adverse effects of my medication. This drug will cure AIDS. A Feedback: Common adverse effects of antiviral agents are flu-like symptoms, which may be related to the underlying disease. Excessive fatigue and a severe headache can indicate a serious complication and should be reported immediately. Antiviral agents do not cure the disease. HIV causes loss of helper T-cell function. This causes the immune system to be depressed and allows opportunistic infections to occur. Antiviral agents reduce the number of mutant viruses that are formed and spread to noninfected cells. The school nurse is preparing a lecture on hepatitis B for a health class in high school. What is an important teaching point for the nurse to include about the transmission of hepatitis B? (Select all that apply.) Hepatitis B is transmitted through the bite of an insect.

B) C)

Hepatitis B is transmitted through sexual contact. Hepatitis B is transmitted through blood-to-blood contact.

D) E)

Hepatitis B is transmitted from the mother to her unborn baby. Hepatitis B is transmitted through nonsexual household contact.

Ans:

B, C, D Feedback:

12. A)

Hepatitis B is transmitted from one person to another through sexual contact, blood-toblood contact, or perinatally. It is not transmitted through casual contact. Several studies involving more than 1,000 uninfected, nonsexual household contacts with persons with hepatitis B infection (including siblings, parents, and children) have shown no evidence of casual transmission. Hepatitis B is not spread by mosquitoes or other insect vectors. A 21-year-old woman presents with cytomegalovirus (CMV). The LPN says, Ive never heard of CMV before. The nurse explains to the LPN that this infection is most often seen with patients diagnosed with what? HIV

B) C)

Influenza Autoimmune disorder

D) Ans:

Hepatitis B A Feedback: CMV is an opportunistic infection that is most often diagnosed in patients with HIV or who are immunocompromised because those with a healthy immune system can fight off CMV. CMV would not be diagnosed in patients with influenza, an autoimmune disorder, or hepatitis B because the immune system would be strong enough to destroy the CMV pathogen.

13. A) B)

The nurse is assessing a patient admitted with AIDS who is taking a nonnucleoside reverse transcriptase inhibitor. What nursing diagnosis is most likely to be appropriate for this patient? Risk for injury related to central nervous system (CNS) effects of the drug

C) D)

Excess fluid volume related to renal failure Imbalanced nutrition: Less than body requirements, related to gastrointestinal (GI) effects of the drugs Ineffective health maintenance related to spiritual distress

Ans:

C Feedback: The adverse effects most commonly experienced with these drugs are GI relateddry mouth, constipation or diarrhea, nausea, abdominal pain, and dyspepsia. As a result, this patient is most at risk for imbalanced nutrition; less than body requirements. CNS effects are not common with this classification of drug. Renal failure is not a common adverse effect. Nothing indicates the possibility of spiritual distress in this situation.

14.1 4 . A)

A patient has just been diagnosed with HIV. When developing the teaching plan, what information would the nurse share with this patient related to use of alternative or complementary therapies? Complementary therapies such as acupuncture or herbal therapy are dangerous to patients with HIV and you are discouraged from exploring these types of therapy.

C) D) Ans:

Researchers have not looked at the benefits of alternative therapy for patients with HIV, so it is suggested you avoid these therapies until research data are available. Alternative therapies have benefits and risks. Are there any types of alternative or complementary therapies that you follow or are there any herbs or supplements that you take? You do not take herbs or practice some type of alternative medicine such as acupuncture, massage therapy, hypnosis, or diet therapy, do you? C Feedback: With a new diagnosis of HIV, it is important for the nurse to assess the patient for use of alternative therapies because some alternative therapies are contraindicated while on antiviral medication. Options A and D are negative statements that discourage the patient from sharing information with the nurse. Option B gives the patient information, but does not elicit information in return and is therefore inappropriate for the nurse to use.

15. A)

The nurse is caring for a patient hospitalized with hepatitis B. The family comes to visit and a family member asks the nurse if it is safe to visit. What is the nurses best response? You seem fearful. Why do you think you are at risk?

B) C)

Dont worry, you will not contract the disease from the patient. There is no risk unless you come in contact with blood and body fluids.

The patient should be isolated and have limited visitation.

Ans:

C Feedback: Visitors should be reassured that they are not at risk of contracting the virus unless they come in contact with blood or body fluids. It is never appropriate to tell someone not to worry because it is neither effective nor appropriate. The reason the family member is fearful is obvious, so these questions are demeaning. Visitation does not need to be limited.

16. A)

A patient newly diagnosed with HIV is receiving patient teaching from the clinic nurse about antiviral medications. What would the nurse tell the patient needs to be reported to a health care provider? Dizziness

B) C)

Constipation Vomiting

D) Ans:

Rash D Feedback: All options provided have the potential to be an adverse effect of antiviral medications prescribed to treat HIV. Most can be managed through diet or over-the-counter

17. A)

medications but a rash needs to be reported immediately because it could indicate a potentially serious reaction and requires immediate intervention. The nurse is planning care for an AIDS patient admitted with chronic severe diarrhea secondary to adverse effects of the antiviral drugs prescribed. What would be the most appropriate goal for this patient? Patient will show improved nutritional status evidenced by weight gain.

Alleviation or reduction of signs and symptoms of AIDS.

Patient will be able to demonstrate the effectiveness of the teaching plan. Patient will state that comfort and safety measures are effective and show compliance with the regimen. A

D) Ans:

Feedback: Severe chronic diarrhea is likely to result in malnutrition and weight loss along with potential alterations in fluid and electrolyte balance. The best indicator of improvement would be an improvement in nutritional status as indicated by weight gain. Although the other outcomes might be applicable to a patient with AIDS, weight gain is the priority concern for a patient with severe chronic diarrhea.

18. A)

A nurse practitioner is teaching a health class in the local high school. The NP informs the class about hepatitis B. What occupation does the NP inform the class is at the greatest risk for contracting hepatitis B? Policemen

B) C)

Health care workers Educators

D) Ans:

Fire fighters B Feedback: Health care workers are at especially high risk for contracting hepatitis B due to needle sticks and contact with the blood of infected patients. Policemen, educators, and fire fighters are not considered at high risk for contracting hepatitis B although they do face some risk because of contact with blood and body fluids.

19. A)

What liver function test is a sensitive indicator of injury to liver cells and useful in detecting acute liver disease such as hepatitis? Clotting factors

B) C)

SGGT Serum aminotransferases

D) Ans:

Alkaline phosphatase C

Feedback: Antiviral drugs are indicated for the treatment of adults with chronic hepatitis B who have evidence of active viral replication and evidence of either persistent elevations in serum aminotransferases or histologically active disease. The drugs inhibit reverse transcriptase in the hepatitis B virus and cause DNA chain termination, leading to blocked viral replication and decreased viral load. Clotting factor alterations will be seen only in cases of severe liver damage. Serum gamma-glutamyl transferase and alkaline phosphatase may elevate with liver damage, but serum aminotransferases are the best indicator of hepatitis B 20. A)

What drug would the nurse administer to treat chronic hepatitis C in children and adults who relapse after interferon-alfa therapy? Zanamivir (Relenza)

B) C)

Acyclovir (Zovirax) Cidofovir (Vistide)

D) Ans:

Ribavirin (Virazole) D

21. A)

Feedback: Ribavirin is used in combination with interferon alfa-2b as an oral drug for the treatment of chronic hepatitis C in children and adults who relapse after inferferon alfa therapy. Cidofovir is used to treat cytomegalovirus (CMV) in AIDS patients. Virazole is used to treat uncomplicated infuenza infections. Acyclovir is used for herpes infections. Some antiviral agents are given locally to treat local viral infections. How do these medications work? (Select all that apply.) Interfere with viral metabolic processes

B) C)

Interfere with viral cellular replication Interfere with host metabolic processes

D) E)

Interfere with viral transcription Increase antibody production

Ans:

22. A)

A, B Feedback: These antiviral agents act on viruses by interfering with normal viral replication and metabolic processes. They are indicated for specific local viral infections. The medications do not interfere with the invaded cell or with viral transcription and they do not increase antibody production. The nurse admits a patient for treatment of cytomegalovirus (CMV). The patient has been ordered foscarnet (Foscavir), 40 mg/kg q812h given over 2 hours. By what route would the nurse administer this drug? Sub q

B) IV C)

D) Ans:

PO B Feedback: Foscarnet is available in intravenous (IV) form only. It reaches peak levels at the end of the infusion and has a half-life of 4 hours. About 90% of foscarnet is excreted unchanged in the urine making it highly toxic to the kidneys. Use caution and at reduced dosage in patients with renal impairment. Options A, C, and D are incorrect.

23. A)

A patient comes to the clinic with a herpes outbreak. The nurse notes from the patients chart that the patient is just beginning a course of antibiotics prescribed by another physician in the clinic. What classification of antibiotic should not be taken with an antiviral medication used to treat herpes? Penicillin

B) C)

Beta-Lactam Aminoglycoside

D) Ans:

Macrolide C Feedback: The risk of nephrotoxicity increases when agents indicated for the treatment of herpes and cytomegalovirus are used in combination with other nephrotoxic drugs, such as the aminoglycoside antibiotics. No contraindication exists for penicillins, beta-lactams, or macrolide antibiotics.

24. A)

A nonnucleoside reverse transcriptase inhibitor has direct effects on the HIV virus activities within the cell. What drug is a nonnucleoside reverse transcriptase inhibitor? Econazole nitrate (Spectazole)

B) C)

Oxaliplatin (Eloxatin) Olanzapine (Zyprexa)

D) Ans:

Efavirenz (Sustiva) D Feedback: The nonnucleoside reverse transcriptase inhibitors now available include: delavirdine (Rescriptor), efavirenz (Sustiva), and nevirapine (Viramune). Econazole nitrate is an antifungal cream, olanzapine is an atypical antipsychotic, and oxaliplatin is an antineoplastic agent.

25. A)

The nurse is caring for a patient who is taking adefovir to treat hepatitis B. The nurse would hold the medication and notify the health care provider if assessing the signs and symptoms of what? (Select all that apply.) Lactic acidosis

B) C)

Hepatotoxicity Headache

D) E)

Nausea Asthenia

Ans:

A, B Feedback: Withdraw the drug and monitor the patient if he or she develops signs of lactic acidosis or hepatotoxicity because these adverse effects can be life threatening. Headache, nausea, and asthenia are potential adverse effects but are not life threatening and would not require withdrawal of the drug.

26. A)

For what viruses might the nurse administer acyclovir (Zovirax)? (Select all that apply.) Herpes simplex virus

B) C)

Shingles Chickenpox

D) E)

HIV Cytomegalovirus (CMV)

Ans:

27. A)

A, B, C Feedback: Acyclovir is indicated for the treatment of herpes simplex virus, shingles, and chickenpox as well as topically for treating herpes labialis. Acyclovir is not effective against HIV or CMV. The nurse is caring for a pregnant woman diagnosed with HIV on prenatal drug screening. What medication would the nurse expect to administer to reduce the risk of maternal to fetal transmission of the virus? Lamivudine (Epivir)

B) C)

Zidovudine (Retrovir) Stavudine (Zerit XR)

D) Ans:

Tenofovir (Viread) B Feedback:

AZT, or zidovudine is administered to prevent the transmission of HIV from mother to child and can be administered to both after birth to treat symptomatic HIV. The other medications (options A, C, and D) are not used for this purpose. Chapter 118: Bone and Joint Infections 1) What type of osteomyelitis occurs most commonly in children? A. Chronic B. Contiguous C. Direct inoculation D. Hematogenous 2) Infectious arthritis most commonly involves how many joints? A. 1 B. 2 C. 3 D. 4 3) Hematogenous osteomyelitis most commonly occurs in what age group? A. Adults between 18 and 50 years of age B. Adults over 50 years of age C. Children under 16 years of age D. Neonates 4) In what age group is a case of osteomyelitis likely to lead to a secondary joint infection? A. Adults between 18 and 50 years of age B. Adults over 50 years of age C. Children under 16 years of age D. Neonates 5) What is the most common organism causing hematogenous osteomyelitis? A. Group B streptococcus B. Haemophilus influenzae C. Pseudomonas aeruginosa D. Staphylococcus aureus 6) What organisms are likely found in patients with diabetes affected by osteomyelitis? A. Anaerobic B. Gram negative C. Gram positive D. Multiple organisms 7) What is the most common organism causing adult nongonococcal bacterial arthritis? A. E. coli B. P. aeruginosa C. S. aureus D. S. pyogenes 8) What would be a useful monitoring strategy for a patient with osteomyelitis? A. Daily C-reactive protein B. Daily white blood cell count C. Six months erythrocyte sedimentation rate D. Weekly C-reactive protein

9) Oral ciprofloxacin for osteomyelitis would be most likely to FAIL with which infecting organism? A. Serratia marcescens B. S. aureus C. Enterobacter cloacae D. E. coli 10) Which antimicrobial regimen would be most appropriate for empiric coverage of hematogenous osteomyelitis in a 7-year-old boy? A. Ampicillin B. Cefuroxime C. Ciprofloxacin D. Nafcillin 11) Which antimicrobial regimen would be most appropriate for empiric coverage of hematogenous osteomyelitis in an IV drug abuser? A. Cefepime B. Clindamycin C. Nafcillin plus cefotaxime D. Vancomycin 12) Which agent is commonly used in antimicrobial cement spacers? A. Ampicillin B. Ceftriaxone C. Ciprofloxacin D. Tobramycin 13) Which antimicrobial would require CBC monitoring if used for an extended duration? A. Ampicillin B. Ceftriaxone C. Linezolid D. Metronidazole 14) What location is common for contiguous osteomyelitis to occur? A. Foot B. Humerus C. Mandible D. Vertebrae 15) What duration of therapy might be most appropriate for a patient with vertebral osteomyelitis caused by Gram-negative bacteria? A. 2-4 weeks B. 4-6 weeks C. 6-12 weeks D. 12-14 weeks Chapter 119: Sepsis and Septic Shock 1) Regarding the common pathogens in sepsis and septic shock, which of the following statements is correct? A. Since the late 1970s, gram-positive organisms continued to be the predominant pathogens. B. Staphylococcus aureus, Streptococcus pneumoniae, and coagulase-negative staphylococci are the common gram-positive pathogens.

C. Escherichia coli is the most frequent cause of sepsis fatality. D. Non-albicans Candida species have become the most common causes of fungal sepsis. 2) The following mediators are proinflammatory EXCEPT: A. Tumor necrosis factor-α (TNF-α) B. Interleukin (IL)-6 C. IL-8 D. Activated protein C 3) Complication associated with sepsis is: A. Persistent hypotension B. Disseminated intravascular coagulation (DIC) C. Acute respiratory distress syndrome (ARDS) D. Acute renal failure E. All of the above 4) The preferred treatment option for a 56-year-old man with community-acquired pneumonia who was recently prescribed azithromycin for sinusitis is: A. Ertapenem B. Moxifloxacin C. Tigecycline D. Doxycycline E. Clarithromycin 5) The following treatment regimen is preferred in case of nosocomial pneumonia with a suspicion of Pseudomonas aeruginosa: A. Ampicillin/sulbactam B. Ceftriaxone plus azithromycin C. Piperacillin/tazobactam D. Ceftriaxone plus levofloxacin E. Vancomycin plus ertapenem 6) Which of the following agents may not be used to treat hospital-acquired pneumonia secondary to methicillin-resistant S aureus ? A. Vancomycin B. Linezolid C. Televancin D. Daptomycin 7) Polymicrobial infections such as secondary peritonitis can be treated with the following agents EXCEPT: A. Ceftazidime and gentamicin B. Piperacillin/tazobactam C. Meropenem D. Ciprofloxacin plus metronidazole 8) Initial resuscitation bundle should take place within 6 hours in patients with severe sepsis or sepsis-induced tissue hypotension. What are the recommended activities? A. Norepinephrine if not responsive to fluid resuscitation B. Fluid resuscitation with crystalloid C. Empiric broad spectrum antibiotics D. Blood cultures prior to antibiotic administration E. All of the above

9) The preferred agent for a 37-year-old man with an advanced stage of AIDS an candidemia is: A. Imipenem B. Caspofunction C. Itraconazole D. Ketoconazole 10) Regarding hemodynamic support, which of the following agent is the best initial therapeutic intervention? A. 5% albumin B. Lactated Ringer solution C. Normal saline D. Norepinephrine E. Dopamine 11) Dopamine affects the following receptors EXCEPT: A. α1 B. α2 C. β1 D. β2 12) Invasive candidiasis can be treated with the following agents EXCEPT: A. Fluconazole B. Caspofungin C. Amphotericin B deoxycholate D. Itraconazole 13) Which of the following agents is effective against Candida glabrata? A. Fluconazole B. Caspofungin C. Itraconazole D. Ketoconazole 14) Patients are at an increased risk of bleeding if: A. Concurrent therapeutic heparin B. Platelet count of <30 × 109/L C. Recent history of gastrointestinal (GI) bleed D. Chronic severe liver disease E. All of the above 15) Which of the following factors affect the overall prognosis? A. Advanced age B. One or more organ failure C. Positive blood culture of P aeruginosa D. Elevated lactate level and slow clearance E. All of the above Chapter 120: Superficial Fungal Infections 1) The goal of therapy in patients with VVC is A. Resolution of symptoms B. Eradication of viable candida C. A test of cure D. No recurrence within 6 weeks of therapy

2) The following should be recommended as a general approach to treatment of VVC A. Keep vagina clean by douching B. Soothe skin with warm baths C. Avoid harsh soaps D. All the above 3) A young otherwise healthy woman is determined to have VVC. She had the same symptoms 2 years ago. Which of the following would be the best treatment for her? A. Fluconazole 150 mg tablet, 1 orally × 3 day B. Miconazole 200 mg suppository, 1 per vagina × 3 days C. Clotrimazole 100 mg tablet, 1 per vagina × 3 days D. Nystatin 100,000unit tablet, 1 orally × 14 days 4) A 33 year old pregnant female has the classic symptoms of VVC. Which of the following would be the best treatment option for her? A. Tiaconazole 6.5% cream, 1 applicator per vagina × 4 days B. Fluconazole 150 mg, 1 orally × 7 days C. Nystatin 100,000 unit tablet, 1 tablet orally × 14 days D. Clotrimazole 100mg tablet, 1 per vagina × 7 days 5) A young patient with diabetes who has had 4 episodes of VVC in the last 8 months has tested positive for C. glabrata. Which of the following treatments should be used for induction therapy A. Boric acid suppositories 600 mg × 14 days B. Fluconazole 150 mg tablet × 10 days C. 5 Flucytosine cream 1000 mg × 7 days D. Itraconazole 100 mg tablet × 10 days plus oral lactobacillus 6) In an HIV infected patients which of the following is/are important goal/s in the treatment of OPC. A. Effective HAART treatment B. Mycological cure C. Clinical cure D. A and C E. All the above 7) Which of the following products would be best for patients who have a mild form of OPC but also complain of xerostomia and diabetes mellitus? A. Nystatin suspension B. Clotrimazole troche C. Amphotericin B suspension D. Miconazole mucoadhesive tablets 8) A HIV infected patient with mild OPC needs to start therapy which of the following would be the best option. A. Clotrimazole B. Fluconazole C. Itraconazole D. Nystatin 9) A patient has developed OPC due to prolonged antibiotic use. They have minimal discomfort, and are otherwise now healthy. Which of the following is the best recommendation. A. Clotrimazole suspension B. Fluconazole

C. Stop the antibiotic D. A and C 10) A patient with advanced HIV disease is diagnosed with esophageal candidiasis. Which of the following would be the best recommendation. A. Clotrimazole 10 mg troche 5 × daily × 14 days B. Micafungin 150 mg IV × 14 days C. Amphotericin B suspension 5 ml 4 × daily × 14 days D. Voriconazole 200 mg tabs, 1 tab twice daily × 14 days 11) A patient with renal impairment who is undergoing total-body irradiation, has been diagnosed with severe esophageal candidiasis. Which of the following would be the best recommendation? A. Fluconazole B. Amphotericin B C. Anidulafungin D. Voriconazole 12) Which of the following is the best strategy to prevent future episodes of mucosal candidiasis in HIV infected patients A. Primary prophylaxis B. Secondary prophylaxis C. Long-term suppressive therapy D. Appropriate antiretroviral therapy 13) When is oral therapy recommended in patients with tinea pedis? A. Mild infections B. Moccasin-type C. Involvement of the nail D. B or C 14) A patient 76-year-old male with CHF, and diabetes has just been diagnosed with onychomycosis in his fingers. Which of the following would be considered the most effective therapy? A. Terbinafine × 6 weeks B. Terbinafine × 12 weeks C. Itraconazole pulse × 2 months D. Ciclopriox × 48 weeks 15) Which if the following is not a strategy to prevent the recurrence of onychomycosis? A. Protect feet in shared bathing areas B. Keep feet dry C. Manicure with nail polish D. Wear cotton socks Chapter 121: Invasive Fungal Infections 1) In vitro susceptibility testing of antifungal agents: A. Is standardized and available at most hospital clinical microbiology laboratories B. Is not well standardized, and must be interpreted cautiously C. Can alert the clinician to the presence of azole-resistant species of Candida D. Rely on the use of high temperatures and long incubation times, in order to induce hyphal formation

E. Should be performed in all patients in order to assess the appropriateness of the antifungal agent utilized and to monitor for the development of resistance during therapy 2) The in vitro spectrum of activity of echinocandins: A. Includes typical pathogens encountered in the immunosuppressed patient, including Pseudomonas aeruginosa and methicillin- resistant Staphylococcus aureus B. Includes emerging fungal pathogens such as Fusarium and Cryptococcus neoformans C. May differ for various Candida species, depending on whether the mycelial or the yeast form of the pathogen is utilized in testing D. Includes many pathogenic fungi encountered in the immunosuppressed patient, including C. albicans and Aspergillus species E. Has demonstrated the rapid emergence of resistant strains of Candida albicans in patients receiving greater than 2-week therapy 3) SM is a 34-year-old woman currently being treated with voriconazole for invasive pulmonary aspergillosis caused by Aspergillus fumigatus. She develops a skin rash, which you believe due to voriconazole. Which of the following statements is most correct regarding appropriate antifungal therapy for SM? A. An echinocandin should not be utilized, as its chemical structure is similar to that of azole antifungal agents such as fluconazole B. Therapy with an echinocandin (caspofungin or micafungin) is unlikely to cause a rash in this patient, as echinocandins are chemically unrelated to azole antifungal agents C. Micafungin should not be utilized as an alternative agent in this patient, as it demonstrates poor in vitro and in vivo activity against A. fumigatus D. Caspofungin could be utilized as an alternative agent in SM, as it demonstrates excellent in vitro and in vivo activity against E. Fumigatus; however, SM is likely to experience a rash due to cross sensitivity between azoles and echinocandin antifungals F. Micafungin would not be an appropriate alternative agent in this patient, as it demonstrates very poor efficacy in the treatment of pulmonary aspergillosis 4) Blastomycosis is often mild and self-limited and may not require treatment. However, consideration should be given to treating which of the following infected individuals to prevent extrapulmonary dissemination? A. All individuals with moderate to severe pneumonia B. HIV-infected individuals C. Individuals who are immunocompromised D. Patients who have undergone hematopoietic stem cell transplantation E. All of the above 5) RH is a 68-year-old male who is 3 weeks status posthematopoietic stem cell transplantation. As his most recent chest radiograph indicates that he has invasive pulmonary aspergillosis that appears unresponsive to his current therapy with liposomal amphotericin B, his physician wishes to place RH on combination therapy with amphotericin B and caspofungin. Which of the following statements is most correct regarding RH's echinocandin therapy? A. As RH's amphotericin B regimen has resulted in an elevated serum creatinine, his caspofungin dosage may need to be decreased, as caspofungin is eliminated primarily via the kidneys B. The usual IV dosage of caspofungin should be decreased in this patient, as caspofungin clearance is decreased in elderly patients

C. The usual IV dosage of caspofungin may require an increase or decrease, based on the patient's current renal or hepatic function D. IV administration of 50 or 70 mg daily dosages of caspofungin in this patient would be expected to result in proportionally higher plasma concentrations E. Combination therapy with caspofungin and amphotericin B is not recommended, as there is a pharmacodynamic interaction between the two agents 6) When assessing infections caused by Candida species: A. Crude and attributable mortality remains high, in the range of 10% to 20%, respectively, despite the introduction of newer antifungal agents B. Crude and attributable mortality has decreased dramatically in the past 10 years, due to the introduction of newer, more potent antifungal agents C. The proportion of infections caused by C. albicans has increased, while those caused by nonalbicans species has decreased D. Resistance to azoles is rare, and does not "cross" to other azoles E. The clinician should consider alternatives to fluconazole when non-albicans species are isolated during or immediately following azole therapy 7) Visual changes observed in patients during voriconazole therapy: A. Can cause permanent damage to the retina if therapy is continued for greater than 2 weeks B. Generally do not require discontinuation of the drug C. Are observed in less than 1% of patients D. Do not decrease or disappear despite continued therapy E. Are not associated with changes in electroretinogram tracings 8) Plasma level monitoring of antifungals … A. Rarely is necessary unless toxicity is observed B. Should probably be performed in all patients receiving long-term voriconazole therapy for aspergillosis C. Probably is needed for fluconazole, voriconazole, and caspofungin because the efficacy and toxicity of these agents correlate with peak levels D. Is only necessary in patients receiving fluconazole therapy for CNS infections E. Is not useful for voriconazole since neither efficacy nor toxicity is correlated with plasma concentrations 9) According to current (2009) Infectious Diseases Society of America guidelines, initial antifungal therapy for Candida blood stream infections: A. Is similar for all Candida species B. Should always be initiated with fluconazole, due to its low cost and excellent safety profile C. Should always be initiated with echinocandins, since resistance rates of Candida species to fluconazole are high D. Should take into consideration whether the patient is unstable or severely immunocompromised, has a history of recent exposure to fluconazole or other azoles, or if nonalbicans species are suspected E. Should be initiated recommended in all patients, prior to obtaining positive blood cultures, if they are critically ill and not responding to antibacterial agents 10) All of the following statements regarding fungal disease are correct except: A. Histoplasma capsulatum exists as mycelial forms at room temperature and yeast forms at body temperature

B. All patients with early coccidioidal infections should be treated aggressively to prevent disseminated disease C. Blastomycosis often involves skin, bones, joints, and genitourinary tract D. Histoplasmosis may result in mediastinal fibrosis E. Pregnant women are at high risk for developing disseminated coccidioidomycosis 11) All of the following are true regarding infections caused by Candida species except: A. Infections are associated with a low rate of mortality when appropriate antifungal therapy is promptly initiated as soon as a patient becomes febrile B. While C. albicans remains the most common species causing infection, other species, including C. glabrata and C. parapsilosis, have become more common C. The role of antifungal prophylaxis in the surgical ICU remains extremely controversial D. Prophylactic antifungals are indicated in patients with recurrent intestinal perforations and/or anastomotic leak E. Alternatives to fluconazole should be considered when patients have a history of recent exposure to fluconazole or other azoles, and when non-albicans species are isolated 12) In the treatment of coccidioidal meningitis: A. Fluconazole 400 mg daily is the drug of choice B. Must be followed lifelong suppressive therapy C. Ketoconazole should not be recommended routinely due to its poor CNS penetration D. May require intrathecal amphotericin B therapy in patients who do not respond to fluconazole or itraconazole E. All of the above 13) In patients with AIDS who have successfully completed primary therapy, lifelong maintenance therapy to prevent relapse of cryp-tococcal disease: A. Is recommended for all patients after successful completion of primary induction therapy, with fluconazole 400 mg orally daily B. Is necessary and recommended for most patients, utilizing a low dosage of fluconazole (200 mg orally daily) C. The risk of relapse is low provided patients are symptom-free, and are on HAART therapy with a sustained CD4 cell count greater than 100 cells/mL (greater than 0.1 × 106/L) and undetectable viral load D. Ketoconazole is an effective and cost effective therapy E. Oral fluconazole 200 mg/day is less effective but better tolerated than IV administration of amphotericin B 1 mg/kg IV weekly 14) Prophylaxis of candidemia: A. Is recommended in all nonneutropenic patients who are admitted to the ICU B. Is recommended in neutropenic patients for 1 week prior to and 6 months after they become neutropenic C. May be indicated in patients with recurrent intestinal perforations and/or anastomotic leaks D. Should never be utilized since the risk of antifungal resistance is increasing rapidly and our antifungal armamentarium is limited E. Is unnecessary, since prompt initiation of antifungal therapy in patients with clinical, laboratory, or radiologic surrogate markers of infection results in high rates of clinical success 15) Risk factors for invasive candidiasis include all of the following except: A. Long ICU stay B. Prior infection with P. aeruginosa

C. The use of total parenteral nutrition (TPN) D. The presence of acute renal failure E. The presence of central venous catheter

Chapter 122: Infections in Immunocompromised Patients 1) What is the most important risk factor for development of severe infections in cancer patients? A. Alteration of normal flora by chemotherapy and antimicrobial therapy B. Prolonged neutropenia C. Severe mucositis D. Humoral and cellular immune system defects 2) The most common bacterial micro-organism(s) causing infections in neutropenic cancer patients is/are: A. Klebsiella pneumonia. B. Pseudomonas aeruginosa. C. Staphylococci and streptococci. D. Candida species. 3) All of the following are appropriate antibiotic de-escalation strategies for antimicrobial coverage after a period of febrile neutropenia except: A. Antibiotics can be discontinued after an appropriate duration for the isolated organism and site, provided neutropenia has resolved B. In low risk patients, empiric therapy can be de-escalated to an oral regimen after two days of intravenous therapy provided the patient is now afebrile and has no evidence of infection C. In high risk patients, empiric therapy should be de-escalated to narrow spectrum agents once an organism is isolated to prevent antibiotic resistance D. All of the above are appropriate antibiotic de-escalation strategies 4) Which of the following antibiotic regimens is preferred for the initial management of an episode of febrile neutropenia in a hemodynamically stable patient with a MASCC score less than 21? A. Intravenous piperacillin/tazobactam B. Intravenous cefepime plus ciprofloxacin C. Intravenous meropenem plus vancomycin D. Intravenous ceftaroline 5) Which of the following statements regarding initial empiric vancomycin therapy in febrile neutropenic cancer patients is false? A. All initial empiric regimens should contain vancomycin. B. Patients with evidence of IV catheter infections may benefit from initial empiric therapy with vancomycin. C. Decreased mortality from penicillin-resistant viridans streptococcal infections has been observed with initial empiric vancomycin therapy. D. If empiric vancomycin therapy is initiated and no evidence of gram-positive infection is found after 24 to 48 hours, vancomycin should be discontinued. 6) All of the following antimicrobials are reasonable options for prophylaxis of infections in a HSCT patient expected to be profoundly neutropenic for greater than 7 days, except: A. Levofloxacin B. Posaconazole

C. Acyclovir D. Aztreonam 7) Which of the following antibiotic regimens is/are preferred for managing episodes of febrile neutropenia in low risk patients? A. Ciprofloxacin plus amoxicillin/clavulanate B. Vancomycin plus levofloxacin C. Ciprofloxacin plus clindamycin D. Metronidazole plus moxifloxacin 8) All of the following infections would be anticipated during the immediate period (within approximately 1 month) after lung transplantation except: A. Surgical wound infections B. Pneumonia C. Cytomegaolvirus (CMV) disease in a patient who was CMV-seronegative before transplantation D. Reactivation of herpes simplex virus (HSV) infection in a patient who was HSV-seropositive before transplantation 9) Patients undergoing hematopoietic stem cell transplantation are at significant risk for infection in all of the following scenarios except: A. Primary or recurrent Varicella Zoster Virus infection in a patient with graft-versus-host disease B. Cytomegalovirus (CMV) infection in a CMV-seronegative recipient receiving stem cell donations from a CMV-seropositive donor C. Candida or Aspergillus infections in patients receiving allogeneic stem cell transplants D. All of the above 10) Compared to monotherapy, which of the following is true regarding the use of empiric dualgram negative coverage for high risk febrile neutropenic patients: A. Dual therapy is associated with a greater risk of drug-related adverse effects B. Dual therapy is associated with a greater risk of breakthrough resistant infections C. Dual therapy is associated with a lower risk of 30-day mortality D. Dual therapy is associated with a lower risk of secondary fungal infections 11) Patients undergoing hematopoietic stem cell transplantation are routinely recommended to receive all of the following vaccinations within 2 years of transplant except: A. Haemophilus influenzae type B vaccine B. Varicella vaccine C. 23-valent pneumococcal vaccine D. Influenza vaccine 12) Which of the following regimens would be most appropriate for prophylaxis of Pneumocystis jiroveci infection in a double-lung transplant recipient? A. Trimethoprim-sulfamethoxazole 2 double-strength tablet orally twice daily B. Trimethoprim-sulfamethoxazole 1 double-strength tablet orally once daily C. Pentamidine 4 mg/kg intravenously once daily D. Pentamidine 300 mg inhaled once monthly 13) Therapeutic drug monitoring is recommended during use of all of the following agents except: A. Voriconazole B. Vancomycin

C. Posaconazole D. Isavuconazonium 14) An appropriate regimen for the treatment of confirmed invasive pulmonary aspergillosis in a patient undergoing solid organ transplantation would be: A. Fluconazole 800 mg intravenously x one dose, followed by 400 mg intravenously once daily B. Liposomal amphotericin B 1 mg/kg intravenously once daily C. Voriconazole 6 mg/kg intravenously twice daily x two doses, followed by 4 mg/kg intravenously twice daily D. All of the above would be appropriate regimens for the stated patient 15) A 45-year-old female undergoes hematopoietic stem cell transplantation for advanced metastatic breast cancer and develops cytomegalovirus disease two months after transplantation. She is started on ganciclovir 5 mg/kg intravenously every 12 hours. The most important ganciclovir-related adverse effect which should be carefully monitored for in this patient would be: A. Bone marrow suppression B. Mucositis C. Nephrotoxicity D. Central nervous system toxicities Chapter 123: Antimicrobial Prophylaxis in Surgery 1) A patient undergoing a cholecystectomy for acute cholecystitis requires: A. No antibiotic therapy B. Prophylactic antibiotic therapy C. Presumptive antibiotic therapy D. Therapeutic antibiotic therapy 2) According to the National Research Council classification of surgical site infection, antibiotic therapy is not required for: A. Clean procedures B. Clean-contaminated procedures C. Contaminated procedures D. A and B 3) Which of the following are not considered patient-specific risk factors for surgical site infections? A. Smoking history B. Preoperative nutritional status C. Male gender D. Diabetes 4) Which of the following statements about pre-operative nutrition is true? A. Preoperative dietary supplementation with glutamine reduces the risk of postoperative surgical site infections. B. Preoperative dietary supplementation with arginine reduces the risk of postoperative surgical site infections. C. Preoperative dietary supplementation with omega-3 fatty acids reduces the risk of postoperative surgical site infections. D. No dietary supplements have been shown to decrease post-operative surgical site infection.

5) According to the National Nosocomial Infection Surveillance System, which one of the following organisms is most often isolated from surgical site infections? A. Streptococcus pneumonia B. Staphylococcus aureus C. Escherichia coli D. Enterococci sp. 6) The Center for Disease Control recommends that vancomycin should be substituted for a cephalosporin for surgical prophylaxis when: A. Methicillin resistant S. aureus is suspected B. "contaminated" and "dirty" procedures are expected C. Patients with a documented history of a life-threatening allergy to penicillins or cephalosporins. D. The surgical procedure involves implantation of any prosthetic device. E. A and C 7) Which one of the following statements regarding prophylactic antimicrobial regimens is false? A. Therapeutic antimicrobials for unrelated infections can be used in place of a prophylactic antimicrobial regimen provided the antibiotic used has appropriate antimicrobial activity. B. Bactericidal concentrations of antibiotics must be delivered to the surgical site prior to the initial incision. C. Bactericidal concentrations of antibiotics must be maintained throughout the duration of the surgery. D. Antimicrobials should be administered with anesthesia or within 60 minutes prior to the initial incision. 8) Intraoperative re-dosing of antimicrobials are required for surgical procedures longer than A. 5 half-lives of the antibiotic used for prophylaxis B. 2 hours C. 2.5 half-lives of the antibiotic used for prophylaxis D. 6 hours 9) With respect to gastrointestinal surgeries, third-generation cephalosporins are considered to be effective prophylactic regimens for: A. Cholecystectomies B. Gastroduodenal surgeries C. Colorectal surgeries D. All of the above 10) Regarding colorectal surgery, which one of the following statements is true? A. Mechanical bowel preparation (ie, with polyethylene glycol) is an effective way to reduce bacterial load in the colon. B. Most surgeons report routinely using a mechanical bowel preparation in addition to antibiotics prior to elective colorectal surgery. C. Mechanical bowel preparation (ie, with polyethylene glycol) is an effective way to reduce surgical site infection risk after elective colorectal surgery. D. All of the above. E. A and B only. 11) Prophylactic antimicrobial therapy for gastrointestinal endoscopy is recommended for A. All patients as post-procedure bacteremia is common B. No patient as the risk of post procedure infection is low

C. High risk procedures including colonoscopy D. High risk patients including those with prosthetic heart valves 12) Which one of the following statements about hysterectomies is false? A. Cefazolin is the prophylactic drug of choice for vaginal hysterectomies. B. Abdominal hysterectomies are associated with a higher rate of surgical site infections when compared to vaginal hysterectomies. C. It is unnecessary to provide more than 24 hours of prophylactic antimicrobial coverage for abdominal hysterectomies. D. Metronidazole is a reasonable alternative to a cephalosporin for penicillin allergic patients undergoing a hysterectomy. 13) Screening and pre-operative eradication of S. aureus with intranasal mupirocin and chlorhexidine body wash has been shown to reduce surgical site infections A. Only in cardiac surgery B. Only in orthopedic surgery C. Only in neurosurgery D. Both cardiac and orthopedic surgeries 14) Patients suffering an open compound limb fracture: A. Requires no more than 24 hours of prophylactic antibiotics B. Requires no more than a single dose of prophylactic antibiotics C. Requires a course of antibiotics for "presumptive" infection D. None of the above 15) Non-antimicrobial strategies to reduce surgical site infections include all of the following except: A. Permissive hypothermia intraoperatively B. High concentrations of oxygen administration intraoperatively C. Protocolized aseptic technique D. Perioperative normoglycemia Chapter 124: Travel Health 1) Which one of the following actions should not be part of a pretravel health consultation? A. Conduct a medical history B. Prescribe or recommend empiric antibiotic for symptomatic traveler's diarrhea C. Assess the risk of malaria at the traveler's destination D. Provide travelers insurance or medical evacuation insurance 2) Which medication type(s) may not be permitted on entry to some restrictive countries? A. Psychotropic medications B. Narcotic pain medications C. Unlabeled melatonin tablets D. All of the above 3) A 40-year old newly diagnosed HIV-positive man wishes to travel to rural Mexico to serve on a mission trip. He has just started antiretroviral therapy. His last CD4+ cell count was 100 cells/mm3 (0.1 × 109/L). He asks if he should receive the Hepatitis A vaccine. The best answer would be: A. It is contraindicated for HIV-positive patients B. He is at risk from contracting Hepatitis from the vaccine C. He should wait until his CD4+ cell count is more than 200 cells/mm3 (>0.2 × 109/L)

D. He should will only derive a protective benefit if his CD4+ cell count is more than 500 cells/mm3 (>0.5 × 109/L). 4) Which one of the following travelers should be given a medical exemption waiver for Yellow Fever vaccination? A. A child age 5 years B. An HIV-infected patient with a CD4+ count of 100 cells/mm3 (0.1 × 109/L). C. A breastfeeding mother D. An asthmatic patient who takes inhaled steroids 5) While preparing a medical kit for travel to Thailand, a traveler notes that there have been increased reports of norfloxacin-resistant Campylobacter in the region he plans to travel. His first line antibiotic for empiric treatment of traveler's diarrhea should be: A. Azithromycin B. Bismuth subsalicylate C. Ciprofloxacin D. Metronidazole E. Antibiotics should never be used to empirically treat traveler's diarrhea 6) Which antimalarial prophylactic agent carries the strongest safety warning for use in pregnant travelers? A. Chloroquine B. Doxycycline C. Mefloquine D. Atovaquone-proguanil 7) Fever reduction in a patient with severe Dengue fever is best done with: A. Aspirin B. Acetaminophen C. Ibuprofen D. Naproxen E. Corticosteroids 8) All of the following are advisable methods for limiting mosquito-borne infection in high risk areas except: A. Applying 10% DEET repellent on a daily basis B. Using insecticide-treated bed netting C. Wearing protective clothing that limits access to human skin D. Spraying clothing with insect repellant or insecticide 9) The first line treatment for all high altitude illnesses is: A. Nifedipine B. Hydration C. Descent D. Melatonin E. Dexamethasone 10) The following medication, used to treat acute mountain sickness (AMS), would be contraindicated in patients with an allergy to sulfonamides: A. Nifedipine B. Acebutolol C. Dexamethasone D. Acetazolamide

E. Sildenafil 11) Which of the following medications is used most frequently to prevent AMS? A. Sildenafil B. Acetazolamide C. Acebutolol D. Nifedipine E. Oxycodone 12) The following medication would be the most appropriate treatment to adjust circadian rhythms in patients with Jet lag who cannot adjust their sleep patterns prior to travel: A. Modafinil B. Melatonin C. Clonidine D. Diazepam E. Zolpidem 13) Which of the following risks lead to traveler's thrombosis specifically in patients more than 75 (>190 cm) inches tall? A. Popliteal vein compression B. Inability to recline C. Restricted movement D. Decreased venous valves E. Reduced need to ambulate 14) Which of the following preventative modalities has been shown to reduce asymptomatic clots when used appropriately and has minimal risk? A. Compression Stockings B. Aspirin C. Hydration D. Low molecular weight heparin E. Edoxaban 15) Which of the following is the most common psychiatric reason for evacuation from international travel? A. Generalized anxiety disorder B. Schizophrenia C. Agoraphobia D. Mania E. Depression Chapter 125: Vaccines and Immunoglobulins 1) Which of the following is an example of a situation in which vaccine-induced immune response would be poor? A. Live-attenuated influenza vaccine administered to a healthy 12-year-old child B. Hepatitis B vaccine administered with a 1.5-inch (3.8 cm) needle to a 22-year-old woman who weighs 95 kg C. Third dose in the inactivated polio vaccine series administered to a 12-month-old child D. Measles-mumps-rubella vaccine administered to a 4-month-old infant 2) Which of the following is the most likely adverse effect of IVIG use in a patient with immune thromobocytopenia purpura and congestive heart failure?

A. Anaphylaxis associated with native IgM antibodies B. Kawasaki disease C. Volume overload D. Chronic renal failure 3) Michael is a 5-year-old boy who presents for his well-child visit prior to entering kindergarten. His past medical history is unremarkable except for an anaphylactic reaction to amoxicillin 4 days ago when he was being treated for a tooth abscess. He was seen in the emergency room and given prednisone 40 mg daily for 5 days and azithromycin for 5 days. Although he was up-to-date on his childhood immunization at age 36 months, he now presents for routine immunizations prior to entering school. Which of the following strategies is recommended to accomplish administration all needed vaccines as soon as possible? A. Administer DTaP, MMR, IPV today B. Administer DTaP, IPV today, and postpone MMR until he has been off prednisone for 3 months C. Administer no immunizations until he has been off prednisone for 3 months D. Administer DTaP and IPV today and postpone MMR until he has been off antibiotics for 2 weeks 4) Which of the following describes the rationale for Rho(D) antibody treatment? A. Administered to an Rh-negative infant to prevent it from developing antibodies to its red blood cells B. Administered to an Rh-positive mother to prevent her from developing antibodies to her Rhnegative infant C. Administered to an Rh-negative mother to prevent her from developing antibodies that may cause her to become anemic D. Administered to an Rh-negative mother to prevent her from developing antibodies to Rhpositive red blood cells that may cause anemia in the fetus in future pregnancies 5) Which of the following infections is pooled human immunoglobulin useful in preventing? A. Measles B. Diphtheria C. Yellow fever D. Guillain-Barré syndrome 6) A vaccine for a hypothetical viral infection that is particularly problematic in young infants has been developed. The vaccine is a whole virus inactivated preparation that is administered by the intramuscular route. Which of the following is likely true about its use? A. Children younger than 2 years of age will not likely mount an immune response to it. B. Its administration should be separated from the administration of hepatitis B immunoglobulin by 4 months. C. Multiple doses will be required to induce a protective immune response D. A single dose will induce long-term protection 7) Justin is a 22-year-old male who had significant contact with a raccoon deemed to have rabies. The patient received rabies immunoglobulin and began the inactivated rabies vaccine series (doses on days 0, 3, 7, 14, and 28) in the emergency room yesterday. He now presents for follow-up with employee health service. Upon review of his health record including his immunization record, a second dose of a measles-containing vaccine is recommended because he is a healthcare worker. Which of the following strategies is recommended for the second dose of MMR vaccine?

A. Administer an MMR vaccine now B. Administer the MMR vaccine in 4 weeks C. Administer an MMR vaccine in 4 months D. Administer an MMR vaccine in 6 months 8) Sarah is a 24-year-old elementary school teacher who is 14 weeks pregnant. This is her first pregnancy. She was noted to be rubella seronegative on routine prenatal screening laboratory panel. She was age-appropriately immunized as a child. Which of the following recommendations is appropriate for the administration of a dose of rubella-containing vaccine? A. Vaccinate postpartum at hospital discharge B. Vaccinate now to prevent possible congenital rubella syndrome C. Vaccinate 3 months postpartum D. No rubella vaccine should be given as she received the MMR as a child 9) Sarah is a 24-year-old elementary school teacher who is 14 weeks pregnant. This is her first pregnancy. She was noted to be rubella seronegative on routine prenatal screening laboratory panel. She was age-appropriately immunized as a child. Which of the following vaccines are recommended for Sarah during her pregnancy? A. Tdap and inactivated influenza vaccines B. Rubella and live attenuated influenza vaccines C. Td and inactivated influenza vaccines D. No vaccines should be administered during pregnancy 10) Mr. Olden is a 46-year-old man who has just been diagnosed with type 2 diabetes. He has not received any immunizations as an adult that he can remember and has not seen a physician since his military physical. Which of the following vaccines are recommended? A. Hepatitis A series, hepatitis B series, PPSV23, annual inactivated influenza, Tdap B. PPSV23, annual inactivated influenza, Tdap, hepatitis B series C. Hepatitis A series, hepatitis B series D. PCV13, annual influenza, Tdap 11) For which of the following individuals would you recommend PPSV23 revaccination? A. A 72-year-old man with COPD who was vaccinated 5 years ago B. A 66-year-old woman with diabetes who was vaccinated when she was 62 C. A 44-year-old man with HIV who was vaccinated at the time of HIV diagnosis 5 years ago D. A 62-year-old kidney transplant patient who was vaccinated prior to her transplant 3 years ago 12) What action is recommended if the interval between doses of human papillomavirus vaccine is longer than the recommended interval? A. Add one additional dose B. Restart the series from the beginning C. Continue the series, ignoring the prolonged interval D. Perform a serologic test to determine if a vaccine response has been mounted 13) Mr. North is a 48-year-old male who is being seen for a pre-anesthesia physical prior to a planned uncomplicated hernia repair scheduled in two weeks. He smokes a pack of cigarettes daily. He is otherwise healthy, on no medications, and has not been immunized as an adult. Which of the following vaccines are recommended? A. MMR, Td, annual live-attenuated influenza B. Td, annual live-attenuated influenza, Haemophilus influenza type b, meningococcal, PCV 13 followed by PPSV23in eight weeks

C. Tdap, annual inactivated influenza, PPSV23, zoster D. Tdap, annual inactivated influenza, PPSV23 14) Which of the following describes the procedure for administering an intramuscular immunization to an adult? A. Insert the needle at a 45-degree angle. B. Use a 21 to 23 gauge needle in a length of 5/8 inch (1.6 cm). C. Use a 25-gauge needle in a length of 1 to 1.5 inches (2.5 to 3.8 cm). D. Use the deltoid muscle or the gluteus maximus for the injection site 15) Which of the following describes an advantage of the Vaccine Adverse Event Reporting System? A. All vaccine adverse events that occur in the United States are reported. B. Only common adverse events are collected. C. Adverse event rates can be calculated. D. Risk factors for adverse events can be evaluated. Chapter 126: Human Immunodeficiency Virus Infection 1) Which of the following statements regarding the management of Pneumocystis jirovecii pneumonia is false? A. Lifelong prophylaxis is needed even with successful antiretroviral therapy B. Sulfamethoxazole–trimethoprim is the drug of first choice for treatment C. Primary prophylaxis is recommended for patients with fewer than 200 CD4 cells/ µL (200 × 106/L) D. Moderate-to-severe disease should be treated with adjunctive corticosteroids 2) Which of the following regarding the molecular characteristics of HIV is false? A. HIV is a DNA virus B. There are two main types of HIV, HIV-1, and HIV-2 C. There are multiple clades (subtypes) that further distinguish the HIV viruses D. HIV is believed to have originated from a cross-species transmission of a simian immunodeficiency virus from primates to humans. 3) Which of the following signs or symptoms is not commonly associated with primary HIV infection? A. Fever B. Rash C. Rhinitis D. Aseptic meningitis 4) Which of the following is false regarding the integrase strand transfer inhibitors (InSTI)? A. They are relatively well-tolerated compared with other antiretroviral drugs B. Dolutegravir has a higher genetic barrier to resistance compared with elvitegravir and raltegravir C. They are mainly excreted as unchanged drug in urine D. They are recommended as part of first-line ART regimens 5) Which of the following is not an accurate characterization of the HIV epidemic? A. HIV infections are most concentrated in sub-Saharan Africa B. In the United States, approximately 15% of those infected with HIV are unaware of being infected C. The main risk factor for HIV worldwide is men who have sex with men

D. Approximately 35 million humans have HIV infection worldwide 6) Which one of the following statements regarding HIV drug resistance is false? A. A phenotype assay measures the in vitro drug concentration needed for inhibition of the patient's viral isolate B. A genotype assay measures the genetic makeup of the patient's virus and reports the important mutations found C. Nonnucleoside analog reverse transcriptase inhibitors are susceptible to a single genetic mutation in HIV that extends cross-resistance to the class (except etravirine) D. The protease inhibitors class is susceptible to a single genetic mutation in HIV that extends cross-resistance to the class (low genetic barrier) 7) Which of the following statements regarding the transmission of HIV is false? A. Insertive sexual intercourse carries higher risk for HIV acquisition compared with receptive intercourse B. The main modes of HIV transmission are sexual, parenteral, and perinatal C. Condom use reduces the risk of HIV transmission by more than 80% D. HIV can be transmitted from mother to infant via breastfeeding 8) Which of the following is false regarding the 4th generation HIV screening test? A. A positive test must be confirmed to diagnose HIV infection. B. The test detects antibodies to HIV1 and HIV2, as well as P24 antigen. C. The test quantifies HIV-RNA in plasma, saliva, or urine. D. The test improves upon earlier tests by detecting HIV closer to when infection occurred 9) Which of the following is the least relevant consideration for initiating ART in a patient? A. Whether the patient is ready to adhere to ART B. The CD4 count C. The resistance profile of the virus D. The HLA-B5701 test if abacavir is being considered 10) Which of the following steps in the HIV life-cycle establishes lifelong infection? A. Adsorption and penetration B. Reverse transcription C. Viral maturation D. Integration 11) Which two antiretroviral drugs have hepatitis B virus activity and therefore should be used when possible in patients co-infected with hepatitis B virus? A. zidovudine, lamivudine B. abacavir, lamivudine C. tenofovir, emtricitabine D. tenofovir, abacavir 12) Which of the following is the most important drug-drug interaction issue specific to cobicistat or ritonavir? A. Concomitant acid suppression with proton pump inhibitors B. Concomitant drugs that undergo extensive CYP3A4 metabolism C. Concomitant drugs that undergo extensive renal clearance via filtration D. Concomitant drugs that undergo extensive glucuronidation via UGT1A1 13) Which of the following is false regarding pre-exposure prophylaxis (PrEP)? A. A negative HIV test must be confirmed prior to initiating PrEP B. Up to date guidelines should be consulted for PrEP

C. Patients should be monitored with HIV testing at least every 3 months. D. PrEP consists of triple drug therapy 14) Which of the following characteristics is best representative of the nucleoside analog reverse transcriptase (NRTI) inhibitor class? A. Significant drug–drug interaction potential with cytochrome P450 (CYP450) substrates B. A single mutation in HIV reverse transcriptase gene causes cross-resistance to the whole class C. The drugs enter cells, become phosphorylated to the active triphosphate anabolite, and inhibit HIV reverse transcriptase D. Most are extensively metabolized by the liver 15) Which of the following is false regarding chronic illnesses that have emerged in the ARTera? A. Non-AIDS cancers have emerged as a leading cause of mortality and morbidity in the ARTera B. As many as half of the HIV-infected population is over 50 years old in resource rich countries C. Hepatitis C coinfection is rare and should not be treated in patients taking ART D. Respective national guidelines should be used to treat hyperlipidemia and hyperglycemia, with the caveat of monitoring for drug-drug interactions Chapter 127: Cancer Treatment and Chemotherapy 1) Which of the following steps are not parts of the multistage process of carcinogenesis? A. initiation B. promotion C. propagation D. transformation 2) A new genetic alteration is identified in an individual patient's resected tumor. The normal gene product appears to inhibit inappropriate cellular growth and proliferation. Which of the following terms adequately classifies the gene? A. proto-angiogenic gene B. oncogene C. tumor suppressor gene D. DNA repair gene 3) A 62-year-old postmenopausal woman with newly diagnosed breast cancer has a 1 cm tumor mass in her left breast. Additional diagnostic tests show the cancer has not spread to the lymph nodes or distant sites. What is the stage of disease for this patient? A. stage I B. stage II C. stage III D. stage IV 4) A 65-year-old man is recently diagnosed with locally advanced colon cancer. The cancer has spread to regional lymph nodes, but not distant sites. The patient undergoes major surgery to remove the tumor. Following surgery, the patient will receive combination chemotherapy. Which of the following best describes the treatment? A. adjuvant B. curative

C. induction D. palliative 5) The patient will receive oxaliplatin, fluorouracil, and leucovorin. Leucovorin is included in the chemotherapy regimen to: A. reduce fluorouracil toxicity B. increase fluorouracil cytotoxicity C. reduce oxaliplatin toxicity D. increase oxaliplatin cytotoxicity 6) An average risk 55-year-old premenopausal woman with no smoking history should not be counseled regarding the following procedures as part of routine cancer screening? A. pap with HPV DNA test, every 5 years B. mammogram, annually C. colonoscopy, every 10 years D. low-dose helical computed tomography, annually 7) A 60-year-old patient with metastatic, nonsquamous cell lung cancer will be given combination chemotherapy with cisplatin and pemetrexed. You counsel the patient to take oral dexamethasone twice daily starting one day before chemotherapy administration. You tell the patient that the dexamethasone is to minimize the risk of which of the following adverse events? A. emesis B. hypersensitivity C. peripheral edema D. rash 8) Which of the following toxicities is not usually associated with the EGFR inhibitor class of anticancer agents? A. rash B. myelosuppression C. hepatotoxicity D. diarrhea 9) Based on the name, what is the source of the monoclonal antibody trastuzumab? A. murine B. human C. chimeric D. humanized 10) VIP (etoposide, ifosfamide, cisplatin) is a chemotherapy regimen used in the treatment of testicular cancer and is associated with a greater than 20% risk of febrile neutropenia. What is the most appropriate strategy, if any, to prevent neutropenia in a patient who will begin VIP treatment? A. no primary prophylaxis necessary B. primary prophylaxis is only indicated if the patient has patient-specific risk factors C. filgrastim 5 mcg/kg subcutaneously as a one-time dose 24 hours after completion of chemotherapy D. pegfilgrastim 6 mg subcutaneously as a one-time dose 24 hours after completion of chemotherapy E. darbepoetin alfa 150 mcg subcutaneously as a one-time dose 24 hours after completion of chemotherapy 11) Which of the following anticancer agents is considered a biologic therapy?

A. interleukin-2 B. gemcitabine C. crizotinib D. vincristine 12) Which of the following statements regarding the treatment of mucositis in a patient with breast cancer is false? A. clinical trials are lacking to support the use of "magic mouthwash" B. severe cases of mucositis may require intravenous hydration and opioid analgesics C. palifermin should be administered at a dose of 60 mcg/kg/day intravenously for 3 consecutive days D. suspicious mucosal lesions should be cultured 13) Anticancer treatments that affect which of the following intracellular signaling pathways are most likely to cause hypertension and proteinuria? A. VEGF B. CDK C. JAK D. PI3K 14) REMS programs are implemented to ensure that the benefits of a drug outweigh the risks. Which of the following REMS agents is correctly matched with its potentially serious adverse event? A. darbepoetin alfa & autoimmune conditions B. lenalidomide & shortened overall survival in cancer patients C. vandetanib & Torsades de pointes D. alemtuzumab & birth defects 15) A patient presents to clinic approximately 7 weeks after initiation of ipilimumab for the treatment of metastatic melanoma. Over the past 8 days, the patient has experienced abdominal pain, fever, and severe diarrhea (~10 stools per day) not responsive to over-the-counter loperamide. After infectious causes have been ruled out, what is the most appropriate treatment strategy? A. increase the dose and frequency of loperamide B. change the antidiarrheal agent to diphenoxylate/atropine C. counsel the patient on the BRAT diet (bananas, rice, applesauce, toast) D. begin corticosteroids to treat an immune-mediated enterocolitis Chapter 128: Breast Cancer 1) Which of the following are considered risk factors for developing breast cancer? A. Age, late menarche, early menopause. B. Hormone replacement therapy, early menarche, early menopause. C. Age, hormone replacement therapy, first pregnancy after age 30. D. Hormone replacement therapy, first pregnancy after age 30, early menopause. E. Age, first pregnancy after age 30, early menopause. 2) Most women with breast cancer present with: A. A painful, large mass in the skin of the breast. B. A soft mass with pain associated with monthly periods. C. A painful, small mass deep in the muscle of the chest wall. D. A painless lump in the breast.

E. A soft mass with nipple discharge. 3) LG is a woman with newly diagnosed breast cancer. Her tumor was 3 cm in size, with 5 positive lymph nodes upon axillary dissection, and she has no other sites of cancer spread. According to the TNM staging system for breast cancer what stage of breast cancer does LG have? A. Stage IIIC B. Stage IIA C. Stage IIB D. Stage IIIA E. Stage IIIB 4) When comparing breast conserving therapy (BCT) to a modified radical mastectomy, which of the following statements are true: A. Despite slightly higher local recurrence rates, BCT is associated with similar survival outcomes. B. BCT is associated with decreased local recurrence rates. C. A modified radical mastectomy is associated with improved survival. D. These procedures have similar local recurrence rates and survival. E. BCT is associated with increased local recurrence rates and decreased survival. 5) Which of the following adjuvant chemotherapy combinations is most appropriate for the treatment of early stage breast cancer? A. Docetaxel, doxorubicin, cyclophosphamide (TAC) B. Irinotecan, fluorouracil, leucovorin (IFL) C. Cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) D. Doxorubicin, Paclitaxel (AT) E. Doxorubicin, ifosfamide (AI) 6) Which of the following adjuvant endocrine therapy regimens is most appropriate for a postmenopausal woman with early stage breast cancer? A. Anastrozole × 5 years B. Letrozole × 2 years C. Fulvestrant × 2 years D. Tamoxifen × 5 years E. Goserelin × 5 years 7) MR is a 42 y.o. female with newly diagnosed inflammatory right breast cancer. What is the best option for primary therapy at this time? A. Surgery. B. Radiation. C. Endocrine therapy. D. Chemotherapy. E. Chemoradiation. 8) Which of the following stages of breast cancer are generally considered incurable? A. Stage 0 B. Stage IIA C. Stage IIIA D. Stage IIIC E. Stage IV

9) Which of the following hormonal therapies is most appropriate for adjuvant treatment in a premenopausal woman? A. Anastrozole B. Letrozole C. Exemestane D. Tamoxifen E. Fulvestrant 10) SW is a 66 y.o. postmenopausal woman with newly diagnosed metastatic breast cancer to the liver (ER/PR positive; HER2-negative). This was found on routine blood work (elevated transaminases) and was confirmed by CT scan and biopsy. She is otherwise asymptomatic from her cancer and feels well. Which of the following regimens would be best to treat her cancer at this time? A. Letrozole plus palbociclib B. Lapatinib plus capecitabine C. Trastuzumab D. Paclitaxel E. Irinotecan 11) DB is a 35 y.o. premenopausal woman with newly diagnosed metastatic breast cancer (triple negative). She completed adjuvant chemotherapy (anthracycline- and taxane-containing regimen) for a locally advanced breast cancer approximately 7 months ago. She now has widespread lung metastases with shortness of breath and coughing at rest. Which of the following regimens would be most likely to provide symptomatic relief for this patient at this time? A. Letrozole B. Docetaxel with Trastuzumab C. Capecitabine D. Ixabepilone with capecitabine E. Vinorelbine 12) LJ is a 43 y.o. woman with newly diagnosed breast cancer. Her tumor was 4 cm in size, with 6 positive lymph nodes upon axillary dissection, and she has no other sites of cancer. Her tumor is ER/PR negative, HER2 positive by FISH. Which of the following regimens would be most appropriate to treat her early-stage breast cancer? A. Doxorubicin + Cyclophosphamide (AC) → Paclitaxel + Trastuzumab (PH) B. Fluorouracil, doxorubicin, cyclophosphamide (FAC) C. Doxorubicin + Cyclophosphamide (AC) → Paclitaxel (P) D. Docetaxel + Trastuzumab (TH) E. Vinorelbine + Trastuzumab (VH) 13) Which of the following agents prevent HER2 protein dimerization and subsequent cell signaling? A. Lapatinib. B. Pertuzumab. C. Everolimus. D. Trastuzumab. E. Bevacizumab. 14) CB is a 35y.o. woman with a known BRCA1 mutation. According to the American Cancer Society, which of the following screening modalities would be recommended for her annually?

A. Mammogram and clinical breast exam. B. Mammogram alone. C. Breast MRI and mammogram. D. Breast MRI and clinical breast exam. E. Breast MRI alone. 15) According to the NSABP Tamoxifen Prevention Trial (P1), tamoxifen given for 5 years (compared to placebo) is associated with which of the following? A. Increased risk of endometrial cancer and gastrointestinal cancers. B. Increased risk of thromboembolism and endometrial cancer. C. Decreased risk of breast cancer and cataracts. D. Decreased risk of endometrial and breast cancer. E. Increased risk of thromboembolism and osteoporosis. Chapter 129: Lung Cancer The nurse is caring for a patient at risk of severe-to-fatal interstitial lung disease. What 1. antineoplastic agent is the nurse administering that carries this risk? A) Valrubicin (Valstar) B) C)

Erlotinib (Tarceva) Histrelin acetate (Vantas)

D) Ans:

Triptorelin pamoate (Trelstar Depot) B Feedback: Erlotinib inhibits tyrosine kinase associated with epidermal growth factor found on surfaces of normal and cancer cells and causes serious-to-fatal interstitial lung disease. Histrelin inhibits gonadotropic secretion and decreases follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and testosterone levels and suppresses testosterone production. Hot flashes are very common with this drug. Triptorelin pamoate decreases FSH and LH levels and also suppresses testosterone production. It has also been associated with sexual dysfunction, urinary tract symptoms, bone pain, and hot flashes. Valrubicin is used in intravesical therapy for carcinoma in situ of the bladder. It is also associated with severe bladder spasms.

Chapter 130: Colorectal Cancer 1) Which of the following factors is associated with an increased risk of developing colorectal cancer? A. High dietary caffeine intake B. Rectal hemorrhoids C. Gastroesophageal reflux disease D. Chronic ulcerative colitis 2) A 30-year-old healthy male has a father and paternal grandfather who were diagnosed with colon cancer. He is seeking advice so that he may reduce his personal risk of developing colon cancer. Which of the following recommendations is most appropriate?

A. Maintain a healthy BMI; keep physically active; eat a balanced diet. B. Avoid tobacco use; take folic acid and vitamin D supplements daily. C. Take a low dose of aspirin (81-160 mg) orally each day. D. Avoid meat and dairy products; restrict dietary intake to fruit, vegetables, and grains. 3) A 50-year-old healthy female has a father that was diagnosed with hereditary nonpolyposis colorectal cancer (HNPCC) at age 45. What advice for the daughter is most appropriate? A. Her risk for colorectal cancer is low because her father was diagnosed at a younger age. B. She should undergo annual flexible sigmoidoscopy screening for colorectal cancer. C. She should undergo testing for susceptibility to HNPCC. D. Her risk for colorectal cancer is low because HNPCC only affects males. 4) Which of the following statements regarding aspirin as chemoprevention for colorectal cancer is true? A. Chronic daily aspirin use decreases cancer risk and daily aspirin (81 mg/day) is recommended starting at age 50 if life expectancy is longer than 10 years and no risk factors for bleeding B. Higher aspirin doses decrease risk of recurrent polyps and daily aspirin (325 mg/day) is recommended for patients with a history of colorectal polyps. C. Regular daily aspirin (81-325 mg/day) decreases cancer risk in patients with a family history of cancer and is recommended for all patients diagnosed with Lynch syndrome. D. Regular long-term aspirin use (81-325 mg/day) decreases colorectal cancer risk but is currently not recommended in the general population to decrease cancer risk. 5) Which of the following colorectal cancer screening methods is most appropriate for a 55-yearold male that refuses to take a bowel prep as part of the procedure? A. Virtual colonoscopy every 10 years B. Annual digital rectal exam C. Annual fecal occult blood testing D. Annual double-contrast barium enema 6) A 53-year-old female with stage II hypertension is diagnosed with Stage IIB colon cancer following a routine screening colonoscopy. She underwent surgical resection of the mass and regional mesenteric lymph nodes. The tumor was poorly differentiated and showed evidence of lymphatic invasion. Which of the following statements regarding adjuvant chemotherapy for this individual is true? Adjuvant chemotherapy: A. does not benefit patients with stage II colon cancer; she should not receive additional treatment. B. should be offered because her cancer is associated with several poor prognostic factors. C. is standard of care for stage II colon cancer; she should receive treatment. D. is contraindicated in patients with hypertension; she should not receive additional treatment. 7) Which of the following adjuvant treatment regimens for stage III rectal cancer is most appropriate? Postoperative: A. Radiation therapy B. Radiation plus capecitabine plus oxaliplatin chemotherapy C. Capecitabine D. Fluorouracil plus leucovorin 8) A 67-year-old female is diagnosed with stage III cancer of the colon. Her CEA level at time of diagnosis was WNL. Other laboratory test results for CBC, AST, ALT, LDH, and total bilirubin

were also WNL. She underwent a surgical resection of her primary tumor followed by adjuvant capecitabine chemotherapy for a total of 6 months following resection. Which of the following tests is most appropriate to monitor regularly to detect recurrent disease? A. Serum CEA B. CBC and Panel 7 C. PET scan D. Abdominal CT scan 9) A 62-year-old male with a history of type 2 DM and peripheral neuropathy is diagnosed with inoperable metastatic colon cancer. The oncologist has suggested the combination of infusional fluorouracil, leucovorin, and irinotecan (FOLFIRI) as an initial regimen instead of an oxaliplatincontaining regimen based on the treatment toxicity profile. What adverse drug effect should be minimized with FOLFIRI? A. Diarrhea B. Myelosuppression C. Neuropathy D. Hypomagnesemia 10) A 68-year-old male with a history of hypertension was diagnosed with stage IV colorectal cancer. The tumor was KRAS mutant and EGFR positive. At the time of diagnosis, an abdominal CT scan showed two isolated hepatic lesions and a chest X-ray showed no evidence of disease. His blood pressure is controlled with medications. Which of the following preoperative treatment regimens is most appropriate to improve his opportunity for a curative resection? A. Bevacizumab plus capecitabine B. Bevacizumab plus FOLFIRI C. Capecitabine plus oxaliplatin plus ziv-aflibercept plus panitumumab D. FOLFOXIRI plus cetuximab 11) A 61-year-old female with KRAS wild-type metastatic colon cancer was initially treated with FOLFOX. After 6 months of chemotherapy, she experienced a partial response to treatment and therapy was continued. Four months later, she developed worsening abdominal pain and an abdominal CT scan showed new sites of disease in her liver. Her oncologist changed her treatment regimen to FOLFIRI plus bevacizumab. Two months later, imaging studies show an increase in the size and number of liver metastases. Which of the following modifications to her current treatment regimen is now most appropriate? A. Discontinue current regimen; start irinotecan plus cetuximab B. Continue FOLFIRI and bevacizumab; add cetuximab C. Continue FOLFIRI; discontinue bevacizumab; start ziv-aflibercept D. Discontinue current regimen; start FOLFOXIRI plus panitumumab 12) An adult male has metastatic colorectal cancer that has progressed after several combination chemotherapy regimens, including fluorouracil plus leucovorin and irinotecan, cetuximab, bevacizumab plus fluorouracil plus leucovorin and oxaliplatin. Compared to best supportive care, administration of which agent at this time is most likely to improve his survival? A. Regorafenib B. Panitumumab C. ziv-aflibercept D. Capecitabine 13) An adult male with metastatic colorectal cancer is considered for initial systemic chemotherapy. He was genotyped for UGT1A1 as part of the pretreatment evaluation and results

show he is homozygous UGT1A1*28. Based on the results of this test, how might his treatment plan be adjusted? A. Capecitabine might be preferred to fluorouracil in his therapy B. He might not be a candidate for oxaliplatin C. The initial dose of irinotecan might need to be adjusted D. Bevacizumab might be indicated as part of his therapy 14) A 60-year-old female is to receive cetuximab plus irinotecan for metastatic colorectal cancer that progressed with irinotecan, fluorouracil, and leucovorin chemotherapy. She tolerated cycles of previous chemotherapy well, with only minor nausea and occasional loose stools. Which of the following counseling points is most appropriate with regard to this new chemotherapy regimen? A. Infusion-related reactions with cetuximab are common B. Dose-limiting diarrhea is a frequent complication with this regimen C. Cetuximab is associated with a follicular skin rash that may be severe D. Peripheral neuropathy associated with this regimen is often dose limiting 15) A 61-year-old adult female underwent surgical resection 8 months ago for Stage III colon cancer. She received a 6-month postoperative treatment regimen with weekly fluorouracil plus high-dose leucovorin. Routine follow-up imaging and laboratory tests confirmed cancer recurrence in her liver and lungs. She is otherwise asymptomatic and healthy. Which of the following treatments is most appropriate? A. Observe the patient until she develops symptoms, and then start oral capecitabine. B. Start bevacizumab plus irinotecan. C. Start oxaliplatin plus cetuximab. D. Start the FOLFOX regimen (oxaliplatin, fluorouracil, and leucovorin).

Chapter 131: Prostate Cancer The nurse is caring for a patient who is taking bicalutamide (Casodex). For what type of 1. cancer would the nurse administer this drug? A) Bladder B) C)

Colon Breast

D) Ans:

Prostate D Feedback: Bicalutamide (Casodex) is administered in combination with a luteinizing hormone for the treatment of advanced prostate cancer. This medication would not be effective for treating bladder, colon, or breast cancer because it is a hormone modulator and works only on hormone-requiring cancers.

Chapter 132: Lymphomas A patient with leukemia receives rasburicase (Elitek) before administering chemotherapy. 1. What is the nurses priority assessment after administration of this medication?

A) B)

Blood glucose levels Serum potassium levels

C) D)

Serum calcium levels Uric acid levels

Ans:

D Feedback: Rasburicase is approved for the management of plasma uric acid levels in patients with leukemia, lymphoma, and solid malignancies who are receiving antineoplastic therapy associated with tumor lysis and elevated serum uric acid levels. Uric acid levels should be analyzed within 4 hours of each dose of rasburicase. Blood glucose, potassium, and calcium levels should not be affected by administration of the drug.

The nurse is caring for a patient who has just been diagnosed with adenocarcinoma of the pancreas. What antineoplastic does the nurse suspect the patient will receive?

Bleomycin (Blenoxane)

Daunorubicin (DaunoXome)

Idarubicin (Idamycin)

Mitomycin (Mutamycin)

Ans:

D Feedback:

Mitomycin is used in before the treatment of disseminated adenocarcinoma of the stomach and pancreas. Bleomycin is used for palliative treatment of squamous cell carcinomas, testicular cancers, and lymphomas. Daunorubicin is the first-line treatment of advanced HIV infection and associated Kaposis sarcoma. Idarubicin is used in combination therapy for treatment of acute myeloid leukemia in adults. Chlorambucil has been ordered for a patient with Hodgkins disease. The patients son asks the nurse what adverse effects this drug has. What will the nurse include when responding 3. to this question? (Select all that apply.) A)

Tremors

Muscle twitching

Confusion

Gynecomastia

Alopecia

Ans:

A, B, C Feedback:

Chlorambucil is a palliative treatment for chronic lymphocytic leukemia, malignant lymphomas, and Hodgkins disease. Adverse effects include tremors, muscle twitching, confusion, nausea, hepatotoxicity, bone marrow suppression, sterility, and cancer. Chapter 133: Ovarian Cancer 1) Based on the proposed etiology for ovarian cancer, what may have a protective effect to decrease the risk of ovarian cancer? A. Regular menstruation B. Hormone replacement use for 5 years C. No oral contraceptive use D. Multiple children E. Hysterectomy 2) SC is a 34-year-old woman that has not had children yet with a CA125 of 18 U/mL that presents to the ovarian cancer prevention clinic to be screened and counseled on her risk for developing ovarian cancer. Her mother died from ovarian cancer at the age of 56 and her older sister has just been diagnosed with ovarian cancer at the age of 42. SC would like to know if she should worry about developing ovarian cancer too. Does SC need to be concerned? A. No, there is hereditary relationship for the risk of developing ovarian cancer B. No, SC's CA125 is within normal range C. Yes, women with two or more immediate family members with ovarian cancer have an increased risk of developing ovarian cancer D. Yes, women that do not have children before the age of 30 are at an increased risk for ovarian cancer E. Yes, SC has an elevated CA125 and could already have cancer 3) What are the screening recommendations for woman at high risk for the development of ovarian cancer? A. Annual Pap Smeer B. CA-125 level and Transvaginal ultrasound once every 6 months C. Annual pelvic exam D. Both (a) and (c) E. All of the above 4) Which patients should be considered for the addition of neoadjuvant chemotherapy for management of advanced ovarian cancer? A. All patients B. BRCA1/BRCA2+ patients C. Patients with localized disease D. Patients presenting with significant tumor burden E. Patients that are poor surgical candidates 5) The primary treatment of advance ovarian cancer includes which of the following? A. TAH/BSO B. Radiation C. Taxane-platinum chemotherapy regimen D. Both (a) and (c) E. All of the above 6) What patient characteristic is ideal for optimal administration of IP chemotherapy to limit potential adverse effects or complications?

A. Optimally debulked disease B. Non-obese C. Good renal function D. Both (a) and (c) E. All of the above 7) The benefits of intraperitoneal therapy have not been observed in ovarian cancer patients with which of the following factors: A. Greater than 1 cm residual disease B. Bowel resection during primary surgery C. Young age D. Receiving five of six cycles E. Hereditary ovarian cancer 8) In a patient with diabetic neuropathy, what chemotherapy regimen would you recommend for primary chemotherapy treatment of ovarian cancer? A. Paclitaxel 175 mg/m2 over 3 hours plus carboplatin AUC = 5 over 1 hour B. Paclitaxel 135 mg/m2 over 24 hours plus cisplatin 75 mg/m2 over 4 hours C. Paclitaxel 175 mg/m2 over 3 hours plus carboplatin AUC = 5 over 1 hour D. Docetaxel 75 mg/m2 over 1 hours plus carboplatin AUC = 5 over 1 hour E. Docetaxel 75 mg/m2 over 1 hours plus cisplatin 75 mg/m2 over 4 hours 9) A patient is receiving paclitaxel 175 mg/m2 IV over 3 hours with carboplatin AUC 5 for primary treatment of her ovarian cancer, experiences a hypersensitivity reaction during her first paclitaxel infusion. All of the following would be reasonable options to complete her chemotherapy primary treatment except? A. Increase the duration of the paclitaxel infusion time to 6 hours B. Administer premedications including steroid H1-blocker, and H2-blocker 24 hours prior to paclitaxel infusion C. Discontinue paclitaxel and continue with carboplatin alone for the remaining five cycles D. Replace paclitaxel with docetaxel 75 mg/m2 IV given in combination with carboplatin for the remaining five cycles E. All of the above would be reasonable options 10) Addition of bevacizumab to taxane/platinum chemotherapy in the primary treatment of advanced ovarian cancer has demonstrated which of the following outcomes? A. Improvement in progression free survival B. Improvement in overall survival C. Improvement in both progression free and overall survival D. Improvement in quality of life with no impact on progression free survival E. Improvement in quality of life with no impact on overall survival 11) The FDA approved bevacizumab for use in combination with selected chemotherapy for the treatment of recurrent ovarian cancer because of which of the following outcomes? A. Improvement in progression-free survival B. Improvement in overall survival C. Improvement in both progression-free and overall survival D. Improvement in quality of life with no impact on progression-free survival E. Improvement in quality of life with no impact on overall survival 12) Bevacizumab has improved the activity of which of the following chemotherapy agents for the treatment of platinum resistant ovarian cancer?

A. Topotecan B. Gemcitabine C. Docetaxel D. Etoposide E. All of the above 13) DG is a 76-year-woman with ovarian cancer post TAH-BSO. Plan is for DG to receive paclitaxel 175 mg/m2 over 3 hours and carboplatin AUC = 5 every 28 days for a total of six cycles. Height 159 cm, actual body weight 75 kg, adjusted body weight 60.9 kg. Laboratory results: Hg: 12 g/dL, HCT: 36%, Plt: 187 K/μL, WBC: 4.5 K/μL, Electrolytes WNL, BUN: 10 mg/dL, SrCr: 0.9 mg/dL, Total bilirubin: 0.3 mg/dL. CA125: 77 U/mL. What is the appropriate dose of paclitaxel for DJ to receive for each cycle? A. 175 mg B. 265 mg C. 285 mg D. 320 mg E. 350 mg 14) DG is a 76-year-woman with ovarian cancer post TAH-BSO. Plan is for DG to receive paclitaxel 175 mg/m2 over 3 hours and carboplatin AUC = 5 every 28 days for a total of six cycles. Height 159 cm, actual body weight 75 kg, adjusted body weight 60.9 kg. Laboratory results: Hg: 12 g/dL, HCT: 36%, Plt: 187 K/μL, WBC: 4.5 K/μL, Electrolytes WNL, BUN: 10 mg/dL, SrCr: 0.9 mg/dL, Total bilirubin: 0.3 mg/dL. CA125: 77 U/mL. What is the appropriate dose of carboplatin for DJ to receive for each cycle? A. 340 mg B. 380 mg C. 420 mg D. 440 mg E. 495 mg 15) DG is a 76-year-woman with ovarian cancer post TAH-BSO. Plan is for DG to receive paclitaxel 175 mg/m2 over 3 hours and carboplatin AUC = 5 every 28 days for a total of six cycles. Height 159 cm, actual body weight 75 kg, adjusted body weight 60.9 kg. Laboratory results: Hg: 12 g/dL, HCT: 36%, Plt: 187 K/μL, WBC: 4.5 K/μL, Electrolytes WNL, BUN: 10 mg/dL, SrCr: 0.9 mg/dL, Total bilirubin: 0.3 mg/dL. CA125: 77 U/mL. When would you consider consolidation chemotherapy for DJ? A. If after six cycles her CA125 was still greater than 35 U/mL B. Negative physical exam C. Negative CT scan D. Positive PET scan E. All of the above 16) RT is a 27-year-female that presented with a solid mass on her right ovary. She underwent TAH/BSO tumor debulking surgery and was diagnosed with Stage IIA, low grade ovarian cancer. What adjuvant treatment should she receive after surgery? A. Pelvic radiation one-shot B. Observation with routine 3-month followup exams C. Paclitaxel 175 mg/m2 over 3 hours plus carboplatin AUC = 5 over 1 hour for six cycles D. Letrozole 2.5 mg once daily for six cycles E. Bevazicumab 15 mg/kg once every 3 weeks for 12 months

17) MP is a 63-year-old with platinum sensitive, BRCA1 positive recurrent ovarian cancer that is interested in PARP inhibitor. Which common side effect associate with olaparib would she need to be monitored for during therapy? A. Anemia B. Thrombocytopenia C. Neutropenia D. Constipation E. Renal dysfunction 18) Which of the following would be appropriate chemotherapy treatment for patient with recurrent platinum sensitive cancer for a curative intent? A. Six cycles of gemcitabine 1,000 mg/m2 plus cisplatin 40 mg/m2 on days 1 and 15 given once every 28 days B. Six cycles of topotecan 0.75 mg/m2 on days 1, 2, and 3 plus cisplatin 40 mg/m2 on day 1 only given once every 21 days C. Six cycles of liposomal doxorubicin 40 mg/m2 plus carboplatin AUC = 5 over 1 hour given once every 28 days D. Both (A) and (C) E. All of the above 19) What is a common complication of progressive ovarian cancer that may require a surgical intervention for patient comfort? A. New peritoneal implants B. Small bowel obstruction C. Lung nodule D. Ascites E. All of the above 20) What supportive medications should be included in the management of ovarian cancer patient with a small bowel obstruction? A. Ondansetron B. Loperamide C. Oxycodone D. Both A and C E. All of the above 21) Which of the following agents would you recommend in a patient with significant renal insufficiency for the treatment of platinum-resistant recurrent ovarian cancer? A. Weekly paclitaxel B. Gemcitabine C. Topotecan D. Liposomal doxorubicin E. All of the above 22) A patient with recurrent ovarian cancer receiving oxycodone extended release for pain management calls with new complaint of increasing constipation and nausea. What potential complication of ovarian cancer would you want to rule out prior to changing her bowel regimen? A. Small bowel obstruction B. Small bowel perforation C. Ascites accumulation D. Neuropathy

E. Thrombosis Chapter 134: Acute Leukemias 1) Mr. T.Y., a 34-year-old male, is diagnosed with acute promyelocytic leukemia. Which of the following cytogenetic abnormalities is associated with acute promyelocytic leukemia? A. t(9;22) B. t(15;17) C. t(8;14) D. t(8;21) 2) Mr. T.Y., a 34-year-old male, is diagnosed with acute promyelocytic leukemia. He has an excellent performance status, an ejection fraction of 65%, and has no prior history of a myelodysplastic syndrome. Based on the information listed above, what would be the most appropriate treatment regimen? A. Nilotinib 400 mg orally twice daily B. Tretinoin 45 mg/m2/day divided into two doses orally and idarubicin for four doses C. Cytarabine 100 mg/m2 IV continuous infusion daily for 7 days and daunorubicin for 3 days D. Vincristine, prednisone, daunorubicin, and pegaspargase 3) Mr. T.Y., a 34-year-old male, is diagnosed with acute promyelocytic leukemia. He has an excellent performance status, an ejection fraction of 65%, and has no prior history of a myelodysplastic syndrome. All of the following are side effects of the treatment chosen for APL except: A. Prolonged QTc interval B. Disseminated intravascular coagulation C. Hyperleukocytosis D. Differentiation syndrome 4) Poor prognostic factors in acute myeloid leukemia (AML) include: A. Philadelphia chromosome-positive, high WBC at diagnosis, lack of CR after 4-5 weeks of induction chemotherapy B. Older age, normal cytogenetics, low platelet count at diagnosis C. t(15;17), preceding hematologic disorder, low platelet count at diagnosis D. Older age, preceding hematologic disorder, del(5q) 5) C.T. is a 4-year-old male with newly diagnosed pre-B cell ALL. His presenting WBC is 26,000 cells/mm3. Cytogenetic studies are pending. The most appropriate induction regimen for CT is: A. High dose cytarabine plus an anthracycline B. Vincristine, corticosteroid, pegaspargase C. Methotrexate, mercaptopurine, prednisone D. Daunorubicin, cytarabine, etoposide 6) H.R. is a 73-year-old male who presents with fever, increased fatigue, and bruising. A complete blood count reveals a white cell (WBC) count of 900 cells/mm3, Hb of 7.8 g/dL, and platelets of 44,000/mm3. After his workup, he is diagnosed with AML and also develops disseminated intravascular coagulopathy. He has normal cytogenetics. The most appropriate treatment regimen for H.R. is: A. Cytarabine 2,000 mg/m2 IV every 12 hours on days 1, 3, 5 B. All-trans retinoic acid orally 45 mg/m2/day divided into two doses

C. Daunorubicin 45 mg/m2/day on days 1 through 3 plus cytarabine 100 mg/m2/day IV continuous infusion on days 1 through 7 D. Clofarabine 30 mg/m2/day IV on days 1 through 5 7) Which of the following are associated with a good prognosis in pediatric ALL? A. Philadelphia chromosome B. Triple trisomies C. T-cell immunophenotype D. A and C 8) When considering differentiation syndrome, which of the following is false? A. Arsenic is not associated with differentiation syndrome. B. The syndrome may be predicted by the WBC at diagnosis. C. The syndrome is most commonly manifested as fever, weight gain, prolonged QTc syndrome, and respiratory distress. D. The treatment of choice for differentiation syndrome is dexamethasone 10 mg IV twice daily. 9) To establish a diagnosis of acute myeloid leukemia, all of the following tests and procedures are essential except: A. Bone marrow aspirate and biopsy B. Cytogenetic analysis C. Lumbar puncture D. Cytochemical staining 10) Therapy for pediatric acute lymphocytic leukemia (ALL) is divided into five phases. Which of the following describes the correct sequence of treatment? A. Remission induction, consolidation, delayed intensification, interim maintenance, and maintenance B. Interim maintenance, remission induction, delayed intensification, consolidation, and maintenance C. Remission induction, consolidation, interim maintenance, delayed intensification, and maintenance D. Interim maintenance, consolidation, delayed intensification, remission induction, and maintenance 11) All of the following are poor prognostic risk factors for acute lymphoblastic leukemia, except: A. Age less than 1 year B. White blood cell count more than 50,000 cells/mm3 C. t(4;11) or t (9;22) D. TEL-AML 12) PL is a 14-year-old female who has started induction therapy for acute lymphoblastic leukemia. Her monitoring plan should include the following: A. Calcium, phosphorus, uric acid, glucose, CBC, platelets B. Calcium, phosphorus, uric acid, creatinine, glucose, CBC, platelets C. CBC and platelets D. Calcium, phosphorus, CBC 13) J.K. is a 76-year-old who presents with an upper respiratory infection, fatigue, and bruising. She had a past medical history significant for diabetes and peripheral vascular disease. A complete blood count reveals a white cell (WBC) count of 1,200 cells/mm3, Hb of 9 g/dL, and

platelets of 15,000/mm3. After a bone marrow biopsy is performed, she is diagnosed with AML. She has normal cytogenetics. The most appropriate treatment regimen for J.K. is: A. Daunorubicin 90 mg/m2/day IV on days 1 through 3 plus cytarabine 2,000 mg/m2/day continuous IV on days 1 through 7 B. Hydroxyurea 500 mg orally 3 times per day C. Daunorubicin 45 mg/m2/day IV on days 1 through 3 plus vincristine 1.4 mg/m2/day IV on days 1 through 3 D. Azacitidine 75 mg/m2/day IV on days 1 through 7 14) R.L. is a 49-year-old male with newly diagnosed Acute Lymphoblastic Leukemia. Cytogenetic analysis reveals t(9:22). His induction chemotherapy treatment regimen should include which of the following agents? A. Daunorubicin, vinblastine, prednisone, pegaspargase, rituximab B. Doxorubicin, methotrexate, dexamethasone, trastuzumab C. Daunorubicin, vincristine, prednisone, pegaspargase, imatinib D. Clofarabine, cytarabine, dexamethasone, imatinib 15) Y.E. is a 29-year-old female with newly diagnosed Acute Myeloid Leukemia. Cytogenetic analysis reveal a normal karyotype and mutational analysis reveals a mutated NPM1. Her FLT3ITD is negative. Based on this information listed, what would be the most appropriate induction treatment regimen? A. Cytarabine 100 mg/m2/day continuous IV on days 1 through 7 and daunorubicin 90 mg/m2 IV on days 1 through 3 B. Cytarabine 100 mg/m2/day continuous IV on days 1 through 7 and mitoxantrone 10 mg/m2 IV on days 1 through 3 C. Decitabine 20 mg/m2 IV on days 1 through 5 D. Cytarabine 3 g/m2 IV every 12 hours on days 1 through 6 Chapter 135: Chronic Leukemias A patient with acute myeloblastic leukemia is taking doxorubicin. What medication, if ordered, would the nurse recognize as a cardioprotective drug used in combination with 1. doxorubicin? A) Dexrazoxane (Zinecard) B) C)

Ixabepilone (Ixempra) Teniposide (Vumon)

D) Ans:

Vinblastine (Velban) A Feedback: Dexrazoxane is a powerful chelating agent that is a cardioprotective drug that interferes with the cardiotoxic effects of doxorubicin. Ixabepilone (Ixempra) is given in combination with capecitabine for the treatment of patients with metastatic or locally advanced breast cancer. Teniposide is given in combination with other drugs for induction therapy in childhood acute lymphoblastic leukemia. Vinblastine is given in combination with other medications as part of the treatment for advanced testicular germ cell cancer.

2. A)

A patient with acute myeloblastic leukemia is taking doxorubicin. What medication, if ordered, would the nurse recognize as a cardioprotective drug used in combination with doxorubicin? Dexrazoxane (Zinecard)

B) C)

Ixabepilone (Ixempra) Teniposide (Vumon)

D) Ans:

Vinblastine (Velban) A Feedback:

3. A)

Dexrazoxane is a powerful chelating agent that is a cardioprotective drug that interferes with the cardiotoxic effects of doxorubicin. Ixabepilone (Ixempra) is given in combination with capecitabine for the treatment of patients with metastatic or locally advanced breast cancer. Teniposide is given in combination with other drugs for induction therapy in childhood acute lymphoblastic leukemia. Vinblastine is given in combination with other medications as part of the treatment for advanced testicular germ cell cancer. A patient with leukemia receives rasburicase (Elitek) before administering chemotherapy. What is the nurses priority assessment after administration of this medication? Blood glucose levels

B) C)

Serum potassium levels Serum calcium levels

D) Ans:

Uric acid levels D Feedback: Rasburicase is approved for the management of plasma uric acid levels in patients with leukemia, lymphoma, and solid malignancies who are receiving antineoplastic therapy associated with tumor lysis and elevated serum uric acid levels. Uric acid levels should be analyzed within 4 hours of each dose of rasburicase. Blood glucose, potassium, and calcium levels should not be affected by administration of the drug.

4. A female patient prescribed methotrexate for meningeal leukemia is asking the nurse about adverse effects of the drug. What would the nurse tell this patient should be avoided while taking methotrexate? A)Pregnancy B)Aerobic exercise C)Smoking D)Alcohol Ans:A

Feedback: Antimetabolites are contraindicated for use during pregnancy and lactation because of the potential for severe adverse effects on the fetus and neonate. The nurse would not caution the patient against aerobic exercise, smoking, or alcohol use because of the medication she was taking. Chapter 136: Multiple Myeloma 1) Multiple myeloma (MM) is a malignancy characterized by the overproduction of which cell type? A. Myeloid stem cells B. Neutrophils C. Plasma cells D. Platelets 2) Patients with myeloma may present with the following abnormalities: A. Hypercalcemia, renal insufficiency, anemia, bone involvement B. Creatinine elevation, raised beta-2 microglobulin, anemia, bilirubin elevation C. Hypercalcemia, renal insufficiency, immunoglobulin/antibody accumulation, bone involvement D. Elevated C-reactive protein, renal insufficiency, reduced albumin, bilirubin elevation 3) Which is the most appropriate treatment strategy for an 82-year-old patient with newly diagnosed monoclonal gammopathy of undetermined significance (MGUS)? A. Induction therapy with melphalan and prednisone B. Watchful waiting C. Autologous stem cell transplantation D. Induction therapy with lenalidomide and dexamethasone 4) Counseling patients receiving lenalidomide for induction therapy in MM should include all of the following adverse effects EXCEPT: A. Thromboembolic risk B. Neuropathy C. Somnolence D. Diarrhea 5) Autologous hematopoietic stem cell transplantation (HSCT) is recommended for patients with myeloma because: A. Myeloma is typically not sensitive to induction chemotherapy. B. Induction therapy response durations are short-lived. C. Graft versus tumor effect can lead to long-term survival. D. Melphalan induction causes stem cell toxicity necessitating transplant. 6) Which is the preferred maintenance therapy following a stem cell transplant in patients with MM? A. Lenalidomide B. Bortezomib C. Interferon alpha D. Dexamethasone

7) PF is a 40-year-old man with a diagnosis of MM. He presents with ISS stage 3 disease and has cytogenetically high risk disease as classified by the mSMART criteria. What therapy is recommended? A. Induction therapy followed by allogeneic stem cell transplant. B. Induction therapy followed by tandem autologous stem cell transplant. C. Induction therapy followed by autologous, then reduced intensity allogeneic stem cell transplant. D. Induction therapy followed by autologous stem cell transplant. 8) The use of bisphosphonates in patients with MM has been shown to A. Lower the rate of skeletal related events B. Improve pain scores C. Improve overall survival D. All of the above 9) Which laboratory tests predict survival in patients treated with conventional treatment or transplant? A. Serum-free light chains and monoclonal protein B. Beta-2 microglobulin and albumin C. Serum creatinine and immunoglobulins D. Hemoglobin and C-reactive protein 10) Which medication is an oral proteasome inhibitor? A. Bortezomib B. Panobinostat C. Ixazomib D. Lenalidomide 11) RM is a 55-year-old woman with a new diagnosis of MM, ISS Stage 2. She has no additional comorbidities or medical history. Which of the following is an appropriate induction regimen for RM? A. Lenalidomide + bortezomib + dexamethasone (RVd) B. Melphalan + prednisone (MP) C. Vincristine + Doxorubicin + Dexamethasone (VAD) D. Dexamethasone alone 12) A 60-year-old man is receiving bortezomib as part of his treatment regimen for MM. Which of the following supportive medications is recommended? A. Anticoagulation with warfarin B. Antifungal prophylaxis with fluconazole C. Antiviral prophylaxis with valacyclovir D. Antibacterial prophylaxis with levofloxacin 13) The mSMART approach stratifies patients with myeloma into risk levels based on which of the following? A. Serum immunoglobulin levels B. Cytogenetics C. Beta-2 microglobulin D. Serum albumin levels 14) Which of the following is true regarding the initiation of therapy for MM? A. All patients should receive induction therapy as soon as a myeloma diagnosis is made, regardless of symptoms.

B. Patients older than 80 years with symptomatic myeloma should not receive induction therapy. C. Induction therapy should begin when patients are experiencing symptoms of disease. D. Only certain symptoms, including bone pain and fracture, signify the need to initiate therapy. 15) Patient considerations for determining initial management of MM depends on all of the following EXCEPT: A. Transplant eligibility B. Age C. Performance status D. Gender Chapter 137: Myelodysplastic Syndromes 1) Symptoms present in patients with myelodysplastic syndrome include which of the following? A. Dysphagia B. Fatigue C. Painless lymphadenopathy D. All of the above 2) Which of the following tests is routinely done to diagnose a patient with myelodysplastic syndromes (MDS)? A. Bone marrow aspiration and biopsy B. Computed tomography of the chest, abdomen, and pelvis C. Lymph node biopsy D. Magnetic resonance imaging of the brain 3) In regard to the pathophysiology of MDS, patients are found to have: A. Decreased bone marrow proliferation B. Decreased apoptosis C. Reduced response to regulatory cytokines D. All of the above 4) KR is a 36-year-old woman with a history of stage 2A breast cancer. She underwent radical mastectomy; radiation; and adjuvant chemotherapy with doxorubicin, cyclophosphamide, and paclitaxel. She then received 5 years of tamoxifen. On routine follow-up 7 years after her diagnosis of breast cancer, she was found to have a hemoglobin of 9.8 g/dL, neutrophil count of 1.7 × 109 cells/L, and platelets of 67 × 109cells/L. Bone marrow biopsy was consistent with MDS-refractory anemia with excess blasts-2 (RAEB-2). Her cytogenetics revealed a 7q chromosomal deletion. Which of the following medications is her therapy-related MDS most likely related to? A. Doxorubicin B. Cyclophosphamide C. Paclitaxel D. Tamoxifen 5) MB is a 74-year-old man with MDS. His hemoglobin is 6.8 g/dL, neutrophil count is 0.8 × 109 cells/L, and platelets are 43 × 109 cells/L. Bone marrow biopsy reveals 9% blasts. His cytogenetics are normal. What is his IPSS–R score? A. 1.5 B. 3

C. 5.5 D. 6 6) Treatment goals in MDS may include A. Altering the natural history of the disease B. Reducing transfusions C. Improving quality of life D. All of the above 7) What is the most appropriate therapy for a 72-year-old man with MDS associated with an isolated chromosomal 5q deletion? A. Antithymocyte globulin B. Azacitidine C. Lenalidomide D. Thalidomide 8) What is the most effective therapy for a 37-year-old woman with refractory anemia with excess blasts-2 (RAEB-2) noted to have a chromosome 7 abnormality? A. Allogeneic hematopoietic stem cell transplant B. Autologous hematopoietic stem cell transplant C. Lenalidomide D. Darbepoetin 9) Which of the following therapies demonstrated improvement in overall survival in patients with MDS? A. Azacitidine B. Antithymocyte globulin C. Acute myeloid leukemia (AML)-type induction chemotherapy D. Romiplostim 10) Which of the following patients is most likely to respond to antithymocyte globulin? A. A 45-year-old woman with refractory anemia with an isolated chromosomal 5q deletion who has required transfusions for the past 2 years. B. A 35-year-old woman with HLA DR15 expression who has required transfusions for the past month. C. A 72-year-old man with a serum erythropoietin level of 237 mIU/mL who has required red blood cell transfusions for the past 4 months. D. A 55-year-old man with a serum erythropoietin level of 755 mIU/mL and an IPSS-R of 5.5. 11) Mr. Smith is a 78-year-old man with a medical history of heart failure, type II diabetes, and myelodysplastic syndrome-refractory anemia with excess blasts-2 (RAEB-2). He read about iron overload on the MDS foundation website and would like to know what benefits he would have from receiving deferasirox. You explain to him that treatment of iron overload in patients with MDS with deferasirox has been shown to: A. Reverse congestive heart failure and improve shortness of breath. B. Decrease insulin requirements and lower hemoglobin A1C. C. Reverse cirrhosis and improve liver function tests. D. Decrease serum ferritin, a blood test that indicates iron overload. 12) Which of the following patients is most likely to respond to erythropoietin (EPO) therapy? A. A 27-year-old woman requiring six red blood cell transfusions per month for the past 3 months with a serum EPO level of 672 MIU/mL.

B. A 63-year-old man requiring three red blood cell transfusions per month for the past 2 years with a serum EPO level of 512 MIU/mL. C. A 72-year-old woman requiring one red blood cell transfusion per month for the past 3 months with a serum EPO level of 172 MIU/mL. D. A 63-year-old man requiring one red blood cells transfusions per month for the past 2 years with a serum EPO level of 430 MIU/mL. 13) M.K. is a 64-year-old man with refractory anemia with ringed sideroblasts (RARS). He has normal cytogenetics. His hemoglobin is 9 g/dL, neutrophil count is 2.7 × 109 cells/L, and platelets are 107 × 109 cells/L. Which of the following regimens would you recommend for him? A. EPO 40,000 units SC + filgrastim 100 μg SC twice weekly B. EPO 40,000 units SC every 2 weeks C. Darbepoetin 200 μg SC every 2 weeks D. Filgrastim 480 μg SC once daily 14) Common adverse effects of lenalidomide include which of the following? A. Rash and peripheral neuropathy B. Rash and peripheral cytopenias C. QTc interval prolongation and peripheral neuropathy D. Peripheral cytopenias and QTc prolongation 15) Notable adverse effects of DNA hypomethylating agents include which of the following? A. Peripheral cytopenias and hepatotoxicity B. QTc interval prolongation and hepatotoxicity C. Peripheral neuropathy and QTc interval prolongation D. Peripheral cytopenias and peripheral neuropathy Chapter 138: Renal Cell Carcinoma 1) All of the following patients would be at an increased risk of RCC except: A. A male with a 50-pack-year smoking history who continues to smoke

B. A male who uses 2 g of acetaminophen daily for his osteoarthritis

C. An obese male with a body mass index (BMI) of 31

D. A male with a 20-year-history of poorly controlled hypertension 2) Compared with hereditary RCC, sporadic RCC is more likely to be: A. Diagnosed in younger patients

B. Seen concurrently with other malignancies

C. Multicentric rather than unicentric

D. Present in one kidney rather than in both kidneys 3) Von Hippel-Lindau (VHL) can best be described as a/an: A. Oncogene

B. Tumor suppressor gene

C. Receptor tyrosine kinase

D. Substrate for vascular endothelial growth factor (VEGF) 4) Both HIF and VHL play important roles in the development of clear cell RCC. When VHL is unable to bind to HIF…. A. HIF is destroyed by the proteasome rapidly

B. HIF phosphorylates AKT and increases mammalian target of rapamycin (mTOR) activity

C. HIF is able to travel to the cell nucleus and activate genes that increase cell growth

D. HIF methylates important cell growth genes resulting in cell apoptosis 5) The current treatment of RCC has shifted toward targeted therapy against a variety of substances that play a role in the pathogenesis of the disease. All of the following are genes that are directly activated by the HIF complex except: A. Glucose transporter-1

B. Vascular endothelial growth factor (VEGF)

C. Mammalian target of rapamycin (mTOR)

D. Platelet-dependent growth factor (PDGF) 6) The most common presentation of RCC can best be described by which of the following scenarios? A. A patient with flank pain, hematuria, and a palpable abdominal mass

B. A patient with fever and unexplained weight gain

C. A patient with severe bone and new-onset seizures

D. A patient with mild nonspecific symptoms, who undergoes a CT scan for an unrelated GI problem 7) Regardless of stage of disease, which of the following treatment modalities is ideally utilized in the initial management of RCC? A. Surgery

B. Radiation

C. Targeted therapy

D. Immunotherapy 8) Although frequently utilized in the management of RCC, which of the following therapies is not FDA-approved for the treatment of this disease? A. Bevacizumab

B. Interleukin-2

C. Interferon

D. Pazopanib

E. Everolimus 9) Capillary leak syndrome is seen mostly commonly in patients treated with which of the following agents? A. Sorafenib

B. Sunitinib

C. Interferon

D. Interluekin-2

E. Temsirolimus 10) Which of the following targeted therapies is the best choice for the first-line treatment of metastatic RCC in a patient with an MSKCC risk classification of poor risk (three or four of five factors)? A. Sunitinib

B. Temsirolimus

C. Sorafenib

D. Bevacizumab

E. Everolimus 11) Which of the following targeted therapies is the best choice for the second-line treatment of metastatic RCC in an individual who has experienced disease progression on a tyrosine kinase inhibitor? A. Temsirolimus

B. Bevacizumab

C. Sorafenib

D. Pazopanib

E. Everolimus 12) The targeted agent, bevacizumab, is a humanized monoclonal antibody that exerts its biological effect by binding: A. VEGFR on the cell surface of cancer cells

B. EGFR on the cell surface of cancer cells

C. VEGF circulating in the blood stream

D. EGF circulating in the blood stream

E. HER-2/neu circulating in the blood stream 13) The role of chemotherapy in the management of RCC can best be described as: A. Most beneficial in the adjuvant setting following nephrectomy

B. Primarily used in combination with the tyrosine kinase inhibitors

C. Consisting primarily of 5-fluorouracil given concurrently with radiation

D. Minimal because of the high frequency of intrinsic resistance mechanisms 14) The tyrosine kinase inhibitors, sunitinib, sorafenib, and pazopanib, exert their biological effect by binding: A. Intracellular kinase domains resulting in downregulation of a constitutively active signaling pathway

B. Extracelluar kinase domains resulting in downregulation of a constitutively active signaling pathway

C. Intracellular kinase domains resulting in upregulation of a constitutively inactive signaling pathway

D. Extracellular kinase domains resulting in upregulation of a constitutively inactive signaling pathway 15) Which of the following agents are most likely to cause hyperlipidemia, hyperglycemia, and hypercholesterolemia? A. Bevacizumab

B. Pazopanib

C. Sorafenib

D. Sunitinib

E. Temsirolimus ANSWERS: 1.B 2.D 3.B 4.C 5.C 6.D 7.A 8.C 9.D 10.B 11.E 12.C 13.D 14.A 15.E

Chapter 139: Melanoma 1) Which of the following has been identified as a risk factor for melanoma? A. Smoking

B. Alcohol use

C. Intermittent intense sun exposure

D. Age (<15 years of age) 2) Which of the following have been shown to play a role in the development and progression of melanoma? A. Absence of the production of cytokines by melanoma cells

B. A decline in melanoma-directed antibodies associated with disease progression

C. Overstimulation of the immune system resulting in inflammation

D. Lack of mutations in key tumor cell growth pathways 3) The cardinal clinical feature of a cutaneous melanoma is a pigmented skin lesion. The clinical features used to describe the lesion are highlighted by the mnemonic ABCD. The D represents: A. Diameter if the lesion

B. Development of the lesion over time

C. Degree of bleeding

D. Dark color 4) The most appropriate strategy for prevention of melanoma should include: A. Use of sunscreen

B. Education about sun protection

C. Education about self-screening

D. Routine clinical screening 5) Which of the following statements regarding the staging of melanoma is true? A. Preoperative lymphoscintigraphy and intraoperative sentinel node mapping have not been shown to be more effective than surgical resection and analysis of lymph nodes via regional lymph node dissection

B. Ulceration of the melanoma lesion is evaluated in clinical staging, and is used to upstage patients with stage I, II, and III disease

C. All patients with a melanoma require pathologic evaluations of lymph nodes

D. Density of tumor infiltrating lymphocytes of tumor tissue is evaluated in clinical staging, and is used to upstage patients with stage I and II disease 6) Following surgical resection of melanoma, high-risk patients should be considered for adjuvant therapy. Which of the following statements is true? A. High-dose interferon alfa should be used as adjuvant therapy following surgical resectionin all patients with stage I, II, and III disease

B. High-dose aldesleukin should be administered as adjuvant therapy following surgical resection in appropriate patients with stage II and III disease

C. Biochemotherapy should be administered as adjuvant therapy following surgical resection in appropriate patients with stage IB and II disease

D. Clinical trial should be considered for appropriate patients with stage II and III disease, following surgical resection

7) High-dose aldesleukin is used in the management of patients with metastatic melanoma and is associated with the capillary leak syndrome. Manifestations of drug-related capillary leak syndrome include: A. Increase weight, increase serum creatinine, and increase blood pressure

B. Increase weight, increase blood pressure, and increase heart rate

C. Decrease weight, decrease blood pressure, and increase heart rate

D. Increase weight, decrease blood pressure, and increase heart rate 8) Which antineoplastic agent is currently approved for the treatment of melanoma? A. Vinblastine

B. Paclitaxel

C. Dacarbazine

D. Carboplatin 9) Which of the following statements is true regarding the use of targeted therapy in the treatment of melanoma? A. There is no rationale for the use of targeted therapy and it has not been shown to be effective in the treatment of melanoma

B. Studies have shown the use of c-Kit inhibitors in patients with metastatic melanoma resulted in a significant improvement in overall survival, but not response rate

C. Despite the key role protein kinases play in the proliferation of cancer cells, inhibition of these targets has not been shown to improve outcomes in melanoma

D. BRAF mutations are common in melanoma and inhibitors of this target have shown to improve response rate and overall survival

10) When treating a patient with ipilimumab, which of the following would be considered appropriate monitoring or management of the drug? A. Ipilimumab is associated with immune-related adverse events, and options for management include dose holding and steroids

B. Ipilimumab is associated with immune-related adverse events, which only occur during infusion of the drug

C. Ipilimumab is associated with immune-related adverse events, and options for management include nonsteroidal antiinflammatory drugs and methotrexate

D. Ipilimumab is associated with immune-related adverse events, which are acute and always resolve prior to the next cycle of treatment ANSWERS: 1.C 2.B 3.A 4.B 5.C 6.D 7.D 8.C 9.D 10.A Chapter 140: Hematopoietic Stem Cell Transplantation 1) Which of the following statements is false concerning the rationale of hematopoietic stem cell transplantation? A. In some cases, administration of high doses of chemotherapy can overcome resistance mechanisms that have developed in tumor cells, thereby increasing the likelihood of cure.

B. Many chemotherapy agents demonstrate a steep dose–response curve with increased anticancer activity at higher doses. C. Infusion of hematopoietic stem cells acts as a “rescue” from severe hematopoietic toxicity caused by high-dose chemotherapy.

D. Immune-mediated effects play a significant role in the anticancer activity of autologous hematopoietic stem cell transplants. 2) Which of the following mobilization regimens would be most appropriate for a 48-year-old man with non-Hodgkin’s lymphoma in untreated relapse? A. G-CSF 10 mcg/kg twice daily for 5 days followed by GM-CSF 250 mcg/m2/day for 5 days

B. Cyclophosphamide plus etoposide followed by G-CSF 5 mcg/kg/day

C. No mobilization is necessary because of the high concentration of CD34+ cells in the peripheral blood

D. G-CSF 10 mcg/kg daily with plerixafor 480 mcg/kg daily starting on the evening of the fourth day of G-CSF 3) All of the following are advantages of peripheral blood over bone marrow as a source of allogeneic hematopoietic stem cells except A. More rapid engraftment

B. Fewer transfusions

C. Reduced incidence of chronic graft-versus-host disease

D. Higher numbers of CD34+ cells infused 4) LT is a 19-year-old woman with acute lymphocytic leukemia in second complete remission. Her 25-year-old brother is an 8/8 HLA antigen match, and the patient is scheduled to receive a myeloablative allogeneic hematopoietic stem cell transplant. Which of the following conditioning regimens would you expect to be used? A. Cyclophosphamide and total-body irradiation (CyTBI)

B. Cyclophosphamide, BCNU, and VP16 (CBV)

C. Cyclophosphamide alone

D. Cyclophosphamide, thiotepa, and carboplatin (CTC) 5) Which of the following patients would be the least likely to benefit from posttransplant donor lymphocyte infusion (DLI)? A. A 39-year-old man with CML (chronic myeloid leukemia) in cytogenetic relapse

B. A 55-year-old woman with MDS (myelodysplastic syndrome)

C. A 25-year-old man with untreated relapsed ALL

D. A 32-year-old woman with AML relapsing 3 years after transplant 6) All of the following are advantages of nonmyeloablative transplants (NMT) over standard myeloablative transplants except A. Less graft-versus-host disease

B. Lower transplant-related mortality

C. Broader inclusion criteria

D. Ambulatory care or outpatient setting feasible 7) JH is a 35-year-old woman with acute myelogenous leukemia (AML) who is day +24 post BuCy and 8/8 HLA-matched unrelated donor transplant with a increasing bilirubin, maculopapular skin rash over the trunk and back, and intractable nausea and vomiting. She has no hepatomegaly, and her weight has remained stable over her transplant course. Her current medications include tacrolimus, voriconazole, acyclovir, trimethoprim–sulfamethizole (Bactrim DSR), ursodiol, magnesium supplements, and as-needed lorazepam. She is afebrile and is engrafting with a white blood count of 2,100/mm3 and platelet count of 54,000/mm3. What is the most likely diagnosis? A. Hepatic venoocclusive disease

B. Acute graft-versus-host disease

C. Drug hypersensitivity reaction

D. Acute infectious cholecystitis 8) For the case in question #7 what is the most appropriate therapeutic management? A. Discontinue the trimethoprim–sulfamethizole (Bactrim DSR) to see if rash resolves and recommend a topical steroid cream.

B. Begin broad-spectrum antibiotics.

C. Biopsy the liver and institute defibrotide therapy.

D. Start prednisone 1 mg/kg/day. 9) Which of the following agents have been investigated in the treatment of steroid-refractory acute graft-versus-host disease? A. Denileukin diftitox

B. Etanercept

C. Infliximab

D. All of the above 10) Which of the following statements best describes the importance of matching HLA antigens? A. The degree of HLA matching does not impact the risk of graft failure.

B. The number of antigen mismatches correlates with the risk of grade III to IV acute GVHD.

C. Class I, II, and III HLA antigens are equally important for matching.

D. The most important antigens are HLA-A, -B, and -DRB1 and should be matched as closely as possible.

11) Which of the following statements about stem cell sources is true? A. UCB has a higher risk of GVHD but a low risk of graft failure.

B. Bone marrow as a stem cell source has been correlated with an increase in risk of acute GVHD with an associated decrease in overall survival.

C. PBSC used as a stem cell source is associated with more rapid platelet engraftment.

D. All stem cell sources are considered equal; there is no benefit to using one stem cell source over another. 12) CL is a 70-year-old patient with relapsed non-Hodgkin’s lymphoma. The patient has received radiation plus three different chemotherapy regimens for multiple relapses of the lymphoma. He is otherwise eligible for autologous HSCT, but his peripheral CD34+ cell count after 4 days of G-CSF for mobilization is low (<10/µL). Which of the following stem cell mobilization regimens would be most appropriate for CL? A. G-CSF 10 mcg/kg twice daily for 5 days followed by GM-CSF 250 mcg/m2/day for 5 days

B. Cyclophosphamide plus etoposide followed by G-CSF 5 mcg/kg/day

C. No mobilization is necessary because of the high concentration of CD34+ cells in the peripheral blood

D. Addition of plerixafor 480 mcg/kg daily starting on the evening of the fifth day of G-CSF 13) Which of the following conditioning regimens would be the most appropriate for a 48-yearold woman with non-Hodgkin’s lymphoma? A. BEAM (BCNU, etoposide, ara-c, and melphalan)

B. Busulfan and cyclophosphamide

C. Fludarabine and melphalan

D. High-dose melphalan 14) Which of the following posttransplant prophylaxis therapies would be the most appropriate for a 42-year-old patient with Philadelphia chromosome–positive ALL who is at high risk of relapse after myeloablative allogeneic transplant? A. Donor lymphocyte infusion

B. Imatinib

C. Rituximab

D. 5-Azacitidine 15) TB is a 57-year-old man with AML who is 19 days post myeloablative matched related donor peripheral blood stem cell transplant. On examination, it is noted that TB complains of right upper quadrant pain and his abdomen is tight and distended. His laboratory values indicate that he is neutropenic and thrombocytopenic. His complete metabolic panel is normal except for elevated liver enzymes. His nurse also reports that TB has gained 7 kg since his admission. What is the most likely diagnosis for TB? A. Graft-versus-host disease

B. Pancreatitis

C. Sinusoidal obstructive syndrome

D. Infection 16) Which of the following statements about acute GVHD is considered true? A. The number of T-cells within the stem cell source can increase the risk for GVHD.

B. The mortality rate attributable to GVHD exceeds 80%.

C. The age of the donor and recipient does not impact the risk of GVHD.

D. Male donors are associated with a higher risk of chronic GVHD. 17) Which of the following drug combinations would be the most appropriate for GVHD prophylaxis? A. Methylprednisolone 2 mg/kg/day

B. Cyclosporine, methotrexate, and methylprednisolone

C. Tacrolimus and methotrexate

D. Posttransplant cyclosporine 18) Which of the following statements about chronic GVHD could be considered true? A. It primarily affects the skin, liver, and GI tract.

B. The incidence of chronic GVHD is decreasing because of alternative donors.

C. The initial treatment of chronic GVHD is mycophenolate mofetil.

D. A previous history of acute GVHD increases the risk for chronic GVHD. 19) HS is a 48–year-old man who was just diagnosed with severe chronic GVHD of the skin. His physician would like to initiate therapy immediately. Which of the following choices would be the most appropriate for initial therapy for chronic GVHD? A. Prednisone 1 mg/kg/day with cyclosporine

B. Clobetasol

C. Prednisone 0.5 mg/kg/day with mycophenolate

D. Extracorporeal photophoresis Answers: 1.D

2.B 3.C 4.A 5.C 6.A 7.B 8.D 9.D 10.B 11.C 12.D 13.A 14.B 15.C 16.A 17.C 18.D 19.A

Chapter 141: Assessment of Nutrition Status and Nutrition Requirements 1) A 55-year-old man (height, 175 cm [5′9″]; weight, 122.5 kg [270 lb]) is admitted with a new diagnosis of cancer. He has lost 6.8 kg (15 lb) in the last 4 months. Which of the following would be the most appropriate characterization of his nutrition status? A. Normal, healthy nutrition status B. Marasmus C. Acute, disease-related malnutrition D. Chronic, disease-related malnutrition 2) You are working with an interdisciplinary nutrition support team to design a nutrition screening program for your hospital. Which of the following diagnoses should be included as a trigger to identify patients at high risk for nutrition-related complications? A. Asthma exacerbation B. Short bowel syndrome C. New onset seizures D. Community-acquired pneumonia 3) Using his ideal body weight (IBW), how would you characterize the nutrition status of a 65year-old man whose weight is 79.5 kg (175 lb) and height is 190.5 cm (6′3″)? A. Normal, healthy B. Mild malnutrition C. Moderate malnutrition D. Severe malnutrition 4) A 39-year-old woman weighs 113.4 kg (250 lb) and is 165 cm (5′5″). Based on BMI, what is the best interpretation of her current nutrition status? A. Normal, healthy B. Overweight C. Moderate obesity

D. Severe or morbid obesity 5) A patient suffering from severe anorexia/bulimia is to be started on supplemental nutrition via a feeding tube. Which of the following visceral proteins would be the most appropriate to measure the acute response (first 3-4 days) to refeeding in this patient? A. Serum albumin concentration B. Serum transferrin concentration C. Serum prealbumin concentration D. Serum C-reactive protein concentration 6) A patient has been on home parenteral nutrition (PN) for 15 years. His PN regimen has always included a standard trace element cocktail (zinc, chromium, copper, manganese, and selenium daily). Routine laboratories are within reference ranges, except that his total and direct bilirubin concentrations are moderately elevated. Since his last visit 4 months ago, he has developed a tremor, and his wife describes more aggressive behavior. These symptoms are most consistent with which of the following? A. Chromium deficiency B. Copper toxicity C. Manganese toxicity D. Zinc deficiency 7) A patient has an ileostomy after suffering a bowel injury. His daily ostomy output has been high (> 2 L/day) consistently over the past 3 months. He recently developed alopecia and dermatitis. Which trace element deficiency would best explain his symptoms? A. Manganese B. Selenium C. Copper D. Zinc 8) A child with biliary atresia has significant fat malabsorption. On routine laboratory assessment, his serum alkaline phosphatase is elevated, but the other hepatic enzymes are within the reference range. Which of the following laboratory tests should be done to further evaluate the increase in alkaline phosphatase? A. Serum 25-OH-vitamin D B. Serum vitamin A (retinol) C. Serum vitamin E D. Serum prothrombin/international normalized ratio (INR) 9) Which of the following would be the most appropriate initial calorie recommendation for a man who weighs 150 kg (330 lb), is 180 cm (5′11″) tall, and is in the intensive care unit with multiple injuries including head trauma suffered in a motor vehicle crash? A. 1,100 kcal/day (~4600 kJ/day) B. 2,100 kcal/day (~8800 kJ/day) C. 3,750 kcal/day (~15,700 kJ/day) D. 4,500 kcal/day (~18,800 kJ/day) 10) You are conducting an initial nutrition assessment for a critically ill man (50 years old; weight, 134 kg [295 lb]; height, 180 cm [5′11″]; BMI, 41 kg/m2) in the Surgical/Trauma ICU. Which of the following is the most appropriate assessment of this patient's daily protein requirements during this critical illness? A. 132 g B. 188 g

C. 225 g D. 335 g 11) A 8-year-old girl (weight, 15 kg [33 lb]) is admitted to the hospital tonight for surgery in the morning. She has no significant past medical history. She will be NPO (nil per os) after 12 midnight in preparation for anesthesia. She has a peripheral intravenous (IV) catheter. Which of the following would be the most appropriate rate at which to run this patient's maintenance fluids once she is NPO? A. 22 mL/hr B. 52 mL/hr C. 63 mL/hr D. 75 mL/hr 12) A 65-year-old man (weight, 65 kg [143 lb]; height, 180 cm [5′11″]) is in the ICU after suffering several injuries in a motor vehicle accident. He is currently receiving a PN solution which provides 115 g of protein/day. A 24-hr urine was collected and sent for UUN. The results are reported as 12.4 g N per 24 hr. What is his nitrogen balance? A. Negative 6 (-6) B. Positive 6 (+6) C. Negative 2 (-2) D. Positive 2 (+2) 13) A 55-year-old man (weight, 70 kg [154 lb]; height, 178 cm [5′10″]) is receiving PN which provides 2,100 kcal/day or ~8,800 kJ/day (total), 75 g protein/day, and the non-protein calories are distributed 60% CHO:40% fat. A metabolic gas study (indirect calorimetry) was done today. The results of the study are: REE 1,910 kcal/day (~8,000 kJ/day); RQ 0.85. Which of the following is the BEST interpretation of the current amount of calories being provided to this patient? A. An appropriate amount of calories are being provided by his current PN. B. Not enough calories are being provided by his current PN. C. Too many calories are being provided by the current PN. D. There is not enough information provided to determine the adequacy of his calorie intake. 14) Which of the following nutrient imbalances could occur as a result of receiving furosemide 80 mg two times daily? A. Hypercalcemia and thiamine deficiency B. Hypercalcemia and thiamine toxicity C. Hypocalcemia and thiamine deficiency D. Hypocalcemia and thiamine toxicity 15) Long chain triglycerides are the usual fat source in most enteral formulations. Which one of the following is required for the transport of free fatty acids into the mitochondria for oxidation? A. Carnitine B. Bile C. Pancreatic lipase D. Selenium Chapter 142: Parenteral Nutrition 1) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema

revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The best approach for initiating PN for this patient is to begin therapy with a regimen that provides A. The goal-estimated caloric and protein requirements beginning PN day 1. B. 100% dextrose calories on PN day 1 and advance protein dose over 3 to 4 days. C. 25% to 50% calculated caloric requirements on PN day 1 and advance to the goal regimen over 3 to 4 days. D. 75% to 100% calculated caloric requirements PN day 1 and cycle the infusion over 16 hours. 2) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb)

Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The daily gram amount of protein provided by the goal regimen is A. 60 B. 71 C. 86 D. 108 3) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The daily gram amount of dextrose provided by the goal regimen is A. 150 B. 242 C. 360 D. 410 4) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is

receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The approximate daily amount of nitrogen in grams provided by the goal regimen is A. 12 B. 17 C. 25 D. 34 5) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The volumes of 10% amino acids and 70% dextrose stock solutions required to provide daily protein and carbohydrate amounts for the goal regimen are A. 108 mL amino acids; 200 mL dextrose B. 540 mL amino acids; 275 mL dextrose C. 720 mL amino acids; 360 mL dextrose D. 1,080 mL amino acids; 514 mL dextrose 6) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a

pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) The daily total calories (energy) provided by the TPN regimen is A. 1,420 kcal (5,941 kJ) B. 1,820 kcal (7,515 kJ) C. 2,156 kcal (9,021 kJ) D. 2,552 kcal (10,678 kJ) 7) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb)

The total daily amount of IVFE the patient is receiving from all sources is A. 50 g B. 60 g C. 110 g D. 250 g 8) A 65 -year-old woman was admitted to the hospital after a 3-week history of nausea, vomiting, diarrhea, and increasing abdominal girth. The initial physical examination revealed a pelvic mass, which was confirmed by a computed tomography (CT) scan. A barium enema revealed an obstruction of the sigmoid colon. The patient was subsequently taken to surgery for exploratory laparotomy at which time the patient underwent an omentectomy, a jejunal–ileal anastomosis, and central venous access placement. After surgery, the patient developed hypotension and respiratory failure requiring mechanical ventilation. The patient continued to have a distended abdomen on postoperative day 9. A nasogastric tube was placed for low continuous intermittent gastric suction with approximately 600 to 800 mL/day output. The patient has no renal or liver function laboratory abnormalities and remains hemodynamically stable requiring continuous intravenous norepinephrine for blood pressure support. She is receiving propofol 25 mL/h intravenously for sedation. The Nutrition Support Team is consulted to begin parenteral nutrition (PN). The patient's goal regimen was determined to be (final concentrations) 6% amino acids and 20% dextrose at 75 mL/h continuous infusion with 20% IV fat emulsion (IVFE) 250 mL/day co-infused with the PN. Pertinent Data: Height: 6 ft 1 in (185.4 cm) Admission weight: 71 kg (156.5 lb) Weight 2 months prior to admission: 84 kg (185 lb) Present weight: 74 kg (163 lb) Given the patient's current clinical status and therapeutic regimen, the most appropriate intervention to make at this time would be to A. Reduce the parenteral nutrition infusion rate to 35 mL/h. B. Discontinue the IVFE. C. Reduce the amino acid concentration to 4.25%. D. Increase the dextrose concentration to 30%. 9) When used as a component in 2-in-1 PN formulation, IVFE A. Is used to prevent fatty acid deﬁciency B. Is usually the major source of calories in a PN regimen C. Should be infused as a single bag for no longer than 24 hours D. Cannot be administered via a peripheral vein 10) The rationale for cysteine addition to neonatal PN formulations is to: A. Increase pH of PN formulations B. Provide a conditionally essential nutrient C. Improve long chain fatty acid utilization D. Extend the beyond use date 11) Which of the following combinations of additives in a PN solution that provides 105 g amino acids and 350 g dextrose in 1,920 mL per day is most likely to result in an incompatibility?

A. Sodium phosphate 40 mmol/L, calcium gluconate 5 mEq/L (2.5 mmol/L), and sodium bicarbonate 50 mEq/L (50 mmol/L) B. Potassium phosphate 60 mmol/day, calcium gluconate 10 mEq/day (5 mmol/day), and sodium acetate 125 mEq/day (125 mmol/day) C. Potassium phosphate 20 mmol/L, magnesium sulfate 8 mEq/L (4 mmol/L), and ranitidine 150 mg/day D. Magnesium sulfate 32 mEq/day (16 mmol/day), calcium gluconate 10 mEq/day (5 mmol/day), and cysteine 160 mg/day 12) The United States Pharmacopeia–assigned beyond use date for PN formulations is A. 30 hours at room temperature; 9 days refrigerated B. 36 hours at room temperature; 12 days refrigerated C. 48 hours at room temperature; 7 days refrigerated D. 48 hours at room temperature; 14 days refrigerated 13) Which of the following is true regarding nutrition support in a very low birth weight premature neonate? A. Dextrose should be initiated at 14 mg/kg/min. B. Protein should be initiated within the first 24 hours of life. C. IVFE should be withheld for the first day of PN support. D. Fluid should be initiated at 50 mL/kg/day. 14) A 6-week-old infant who was born at 28 weeks of gestation weighs 2 kg and has been receiving PN since birth. The infant's hospital course is significant for necrotizing enterocolitis that required an extensive small bowel resection. The infant is now 1 week postsurgery and is not receiving any enteral feedings. The morning laboratory measurements are significant for a direct bilirubin concentration of 3.2 mg/dL (54.7 µmol/L) and elevated aminotransferases. All other laboratory measurements are within normal limits. PN was initiated and the regimen provides (final concentrations) 2.5% amino acids, 15% dextrose, with standard electrolytes, minerals, vitamins and trace elements infusing continuously at 10 mL/hr and 20% IVFE infusing continuously at 1.3 mL/hr. Which of the following interventions is most appropriate regarding this infant's PN regimen? A. Increase dextrose to 17%; decrease IVFE rate to 0.8 mL/h. B. Increase dextrose to 20%; continue same IVFE dose. C. Decrease dextrose to 12.5%; decrease IVFE rate to 0.5 mL/h. D. Continue same dextrose dose; increase IVFE rate to 1.5 mL/h. 15) A product shortage of injectable cysteine has recently been announced and is expected to continue for at least the next 6 months. Which of the following are rational considerations to ensure PN safety for pediatric patients requiring cysteine-supplemented PN during the shortage? A. None because cysteine is not usually added to pediatric PN formulations. B. All 2-in-1 admixtures should be converted to total nutrient admixtures (TNA). C. Calcium and phosphate solubility limits must be reassessed for PNs previously formulated with cysteine. D. PN amino acid doses must be increased to accommodate cysteine loss. Chapter 143: Enteral Nutrition ) Factors that can increase risk of enteral misconnection include: A. Enteral administration sets with universal spike B. Poor lighting

C. Use of luer syringes for enteral medication delivery D. All of the above 2) Which of the following strategies has been recommended to minimize the risk of aspiration in patients receiving enteral nutrition? A. Keep the head of the bed elevated to a 30- to 45-degree angle B. Add blue food dye to the enteral formula C. Change from continuous to bolus administration D. Change from standard polymeric to high caloric density formula 3) The end-product of bacterial degradation of fiber within the colon is: A. Medium-chain triglycerides B. Long-chain triglycerides C. Short-chain fatty acids D. Omega-3 fatty acids 4) In a patient with gastroparesis who has failed nasogastric feeding and will require long-term enteral nutrition and gastric decompression in the home setting, the preferred access choice is: A. Nasojejunal B. Gastrostomy C. Jejunostomy D. Gastro-jejunostomy 5) An advantage of the bolus method of enteral nutrition administration compared to the continuous method is that it: A. requires less equipment B. is preferred when feeding into the jejunum C. is better tolerated D. is preferred when initiating feeding 6) Enteral nutrition should be avoided in which of the following patients? A. A patient receiving cancer chemotherapy B. A patient with >50% total body surface area burn C. A patient with necrotizing enterocolitis D. A patient with acute pancreatitis 7) Which of the following techniques is most appropriate for medication administration via a nasogastric feeding tube? A. Routinely hold the feeding for one hour before and after administering medications. B. A medication available in a liquid dosage form should be diluted in water prior to administration. C. Pellets contained within a microencapsulated dosage form should generally be crushed prior to administration. D. If more than one medication is scheduled for the same time, they should be mixed prior to administration. 8) When a patient receiving warfarin is transitioned from continuous tube feeding to an oral diet, INR is likely to: A. Increase B. Decrease C. Remain unchanged 9) Components of gut barrier function include all of the following except: A. Gut-associated lymphoid tissue (GALT)

B. Small bowel peristalsis C. Bacterial translocation D. Secretion of hydrochloric acid by the stomach 10) In a geriatric patient with a history of massive stroke and a hemicolectomy, which of the following is an advantage of enteral nutrition via a jejunostomy compared with a gastrostomy? A. Decreased risk of aspiration B. Decreased colostomy output C. Decreased flatulence D. Decreased cost associated with placement 11) When initiating enteral nutrition in a child weighing 20 kg with a jejunostomy, which of the following methods is preferred? A. Continuous infusion at a rate of 50 mL/h B. Continuous infusion at a rate of 20 mL/h C. Bolus administration at a dose of 60 mL every 4 hours D. Bolus administration at a dose of 120 mL every 4 hours 12) Potential advantages of enteral nutrition compared to parenteral nutrition include all of the following except: A. Reduced metabolic complications B. Lower cost C. Improved nitrogen balance D. Reduced risk of cholestasis 13) Which of the following enteral formulas is most likely to contribute to the development of diarrhea? A. Use of a fiber-containing formula B. Use of a peptide-based formula C. Use of an MCT-containing, low fat formula D. Use of a powder formula that requires reconstitution 14) In an adult patient receiving enteral nutrition who experiences a gastric residual volume of 150 mL, which of the following interventions is preferred? A. Hold the feeding B. Decrease the administration rate C. Dilute the formulation and continue the same rate D. No intervention required 15) When should enteral nutrition be initiated in an adult critically ill patient with multiple trauma who is mechanically ventilated? A. Upon arrival to the intensive care unit B. Within 24-48 hours of arrival to the intensive care unit C. Within 5-7 days after hospital admission D. It will depend on the patient's underlying nutritional status

Chapter 144: Obesity

1) Compute the body mass index (BMI) for a 53-year-old Hispanic woman who is 5 ft, 5 in tall and weighs 175 lb (87.5 kg). A. 22 kg/m2

B. 29 kg/m2

C. 35 kg/m2

D. 40 kg/m2 2) According to the National Institutes of Health (NIH) guidelines, which one of the following categories best describe an African American woman with a BMI of 38 kg/m2? A. Normal

B. Overweight

C. Obese

D. Extremely obese 3) All of the following medical conditions are more prevalent in patients with obesity except A. Infertility

B. Diabetes

C. Depression

D. Hyperthyroidism 4) Which of the following initial weight loss goals is most appropriate for a 268-lb (122-kg) patient considering weight loss intervention for obesity?

A. Rapid weight loss of 6 lb (3 kg) over 1 month

B. Rapid weight loss of 13 lb (6.5 kg) over 1 month

C. Gradual weight loss of 26 lb (13 kg) over 6 months

D. Gradual weight loss of 100 lb (50 kg) over 6 months 5) Which one of the following interventions represents the mainstay of weight loss therapy? A. Low-calorie diet, exercise, and behavioral modification

B. Phentermine 30 mg orally every morning

C. Leptin injections

D. Laparoscopic vertically banded gastroplasty 6) Which of the following choices best describes the appropriate criteria for initiation of drug therapy for weight loss after a patient has failed a 6-month trial of diet, exercise, and behavior modification? A. A BMI above 27 kg/m2 with comorbidities or a BMI above 29 kg/m2

B. A BMI above 27 kg/m2 with comorbidities or a BMI above 30 kg/m2

C. A BMI above 25 kg/m2 with comorbidities or a BMI above 30 kg/m2

D. A BMI above 25 kg/m2 with comorbidities or a BMI above 29 kg/m2 7) Which of the following choices best describes the appropriate criteria for consideration of bariatric surgery therapy after a patient has failed trials of lifestyle modification and pharmacologic therapy? A. A BMI above 25 kg/m2 with comorbidities or a BMI above 30 kg/m2

B. A BMI above 30 kg/m2 with comorbidities or a BMI above 35 kg/m2

C. A BMI above 35 kg/m2 with comorbidities or a BMI above 40 kg/m2

D. A BMI above 30 kg/m2 with comorbidities or a BMI above 40 kg/m2 8) All of the following supplements are required to prevent nutritional deficiencies in bariatric surgery patients except A. Calcium citrate

B. Iron

C. Folic acid

D. Potassium chloride 9) Which of the following postoperative considerations is important in bariatric surgery patients? A. Altered drug absorption

B. Altered nutrient absorption

C. Enhanced adverse drug effects

D. All of the above 10) Which of the following medications may require dosing adjustments in patients receiving orlistat therapy? A. Atorvastatin

B. Digoxin

C. Cyclosporine

D. Metformin 11) Which of the following effects would most likely be experienced by a patient taking lorcaserin? A. Paraesthesia

B. Dumping syndrome

C. Headache

D. Dysgeusia 12) Lorcaserin therapy should be discontinued if a patient fails to loss 5% of his or her initial body weight after A. 8 weeks

B. 12 weeks

C. 16 weeks

D. 20 weeks 13) Which of the following effects would most likely be experienced by a patient taking phentermine–topiramate extended release? A. Increased heart rate

B. Dumping syndrome

C. Headache

D. Priapism

14) Which of the following weight loss medications requires monitoring of serum electrolytes and creatinine? A. Lorcaserin

B. Orlistat

C. Diethylpropion

D. Phentermine–topiramate 15) Dietary supplements containing bitter orange can best be described as A. Nonhydrolyzable fiber

B. Sympathomimetic amines

C. Ephedra alkaloids

D. Hoodia extracts ANSWERS: 1.B 2.C 3.D 4.C 5.A 6.B 7.C 8.D 9.D 10.C 11.C 12.B 13.A 14.D 15.B