TEST BANK for Edmunds' Pharmacology for the Primary Care Provider 5th Edition by Lutz; Visovsky; Zam by digitaldownload87

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Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs. Change Test Bank MULTIPLE CHOICE 1. Which of the following has influenced an emphasis on primary care education in medical

schools? a.

Changes in Medicare reimbursement methods recommended in 1992

Competition from nonphysicians desiring to meet primary care shortages

The need for monopolistic control in the marketplace of primary outpatient care

The recognition that nonphysicians have variable success providing primary care

ANS: A

The Physician Payment Review Commission in 1992 directly increased financial reimbursement to clinicians who provide primary care. Coupled with a shortage of primary care providers, this incentive led medical schools to place greater emphasis on preparing primary care physicians. Competition from nonphysicians increased coincidentally as professionals from other disciplines stepped up to meet the needs. Nonphysicians have had increasing success at providing primary care and have been shown to be safe and effective. DIF: Cognitive Level: Remembering (Knowledge)

REF: 2

2. Which of the following statements is true about the prescribing practices of physicians? a.

Older physicians tend to prescribe more appropriate medications than younger physicians.

Antibiotic medications remain in the top five classifications of medications prescribed.

Most physicians rely on a “therapeutic armamentarium” that consists of less than 100 drug preparations per physician.

The dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies.

ANS: D

Even though most physicians claim to place little weight on drug advertisements,

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Pharmaceutical representatives, and patient preference and state that they rely on academic sources for drug information, a study showed that commercial rather than scientific sources of drug information dominated their drug information materials. Younger physicians tend to prescribe fewer and more appropriate drugs. Antibiotics have dropped out of the top five classifications of drugs prescribed. Most physicians have a therapeutic armamentarium of about 144 drugs. DIF: Cognitive Level: Remembering (Knowledge)

REF: 3

3. As primary care nurse practitioners (NPs) continue to develop their role as prescribers of

medications, it will be important to: a.

attain the same level of expertise as physicians who currently prescribe medications.

learn from the experiences of physicians and develop expertise based on evidencebased practice.

maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices.

develop relationships with pharmaceutical representatives to learn about new medications as they are developed.

ANS: B

As nonphysicians develop the roles associated with prescriptive authority, it will be important to learn from the past experiences of physicians and to develop prescribing practices based on evidence-based medicine. It is hoped that all prescribers, including physicians and nurse practitioners, will strive to do better than in the past. NPs should work toward prescriptive authority and for practice that is not supervised by another professional. Pharmaceutical representatives provide information that carries some bias. Academic sources are better. DIF: Cognitive Level: Applying (Application)

REF: 4

Chapter 02: Historical Review of Prescriptive Authority : The Role of Nurses (NPs, CNMs, CRNAs, and CNSs) and Physician Assistants Test Bank MULTIPLE CHOICE 1. A primary care NP will begin practicing in a state in which the governor has opted out of

the federal facility reimbursement requirement. The NP should be aware that this defines how NPs may write prescriptions:

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without physician supervision in private practice.

as CRNAs without physician supervision in a hospital setting.

in any situation but will not be reimbursed for this by government insurers.

only with physician supervision in both private practice and a hospital setting.

ANS: B

In 2001, the Centers for Medicare and Medicaid Services changed the federal physician supervision rule for CRNAs to allow state governors to opt out, allowing CRNAs to write prescriptions and dispense drugs without physician supervision. DIF: Cognitive Level: Understanding (Comprehension)

REF: 9

2. CRNAs in most states: a.

must have a Drug Enforcement Administration (DEA) number to practice.

must have prescriptive authority to practice.

order and administer controlled substances but do not have full prescriptive authority.

administer medications, including controlled substances, under direct physician supervision.

ANS: C

Only five states grant independent prescriptive authority to CRNAs. CRNAs do not require prescriptive authority because they dispense a drug immediately to a patient and do not prescribe. Without prescriptive authority, they do not need a DEA number. DIF: Cognitive Level: Understanding (Comprehension)

REF: 9

3. A CNM: a.

may treat only women.

has prescriptive authority in all 50 states.

may administer only drugs used during labor and delivery.

may practice only in birthing centers and home birth settings.

ANS: B

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CNMs have prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings. DIF: Cognitive Level: Remembering (Knowledge)

REF: 9

4. In every state, prescriptive authority for NPs includes the ability to write prescriptions: a.

for controlled substances.

for specified classifications of medications.

without physician-mandated involvement.

with full, independent prescriptive authority.

ANS: B

All states now have some degree of prescriptive authority granted to NPs, but not all states allow authority to prescribe controlled substances. Many states still require some degree of physician involvement with certain types of drugs. DIF: Cognitive Level: Understanding (Comprehension)

REF: 12

5. The current trend toward transitioning NP programs to the doctoral level will mean that: a.

NPs licensed in one state may practice in other states.

full prescriptive authority will be granted to all NPs with doctoral degrees.

NPs will be better prepared to meet emerging health care needs of patients.

requirements for physician supervision of NPs will be removed in all states.

ANS: C

The American Association of Colleges of Nursing has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will still be required to meet licensure requirements of each state. DIF: Cognitive Level: Understanding (Comprehension)

REF: 12

6. An important difference between physician assistants (PAs) and NPs is PAs: a.

always work under physician supervision.

are not required to follow drug treatment

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protocols. c.

may write for all drug categories with physician co-signatures.

have both inpatient and outpatient independent prescriptive authority.

ANS: A

PAs commonly have co-signature requirements and work under physician supervision. DIF: Cognitive Level: Understanding (Comprehension)

REF: 17

Chapter 03: General Pharmacokinetic and Pharmacodynamic Principles Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African-

American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of: a.

bioavailability.

pharmacokinetics.

pharmacodynamics.

anatomy and physiology.

ANS: B

Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions. DIF: Cognitive Level: Understanding (Comprehension)

REF: 21

2. A patient asks the primary care NP which medication to use for mild to moderate pain.

The NP should recommend: a.

APAP.

Tylenol.

acetaminophen.

any over-the-counter pain product.

ANS: C

Providers should use generic drug names when prescribing drugs or recommending them

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to patients, unless a particular brand is essential for some reason. Because acetaminophen can have many trade names, it is important for patients to understand that the drug is the same for all to avoid overdosing on acetaminophen. APAP is a commonly used abbreviation but should not be used when recommending the drug to patients. DIF: Cognitive Level: Applying (Application)

REF: 21

3. A patient wants to know why a cheaper version of a drug cannot be used when the

primary care NP writes a prescription for a specific brand name of the drug and writes, “Dispense as Written.” The NP should explain that a different brand of this drug: a.

may cause different adverse effects.

does not necessarily have the same therapeutic effect.

is likely to be less safe than the brand specified in the prescription.

may vary in the amount of drug that reaches the site of action in the body.

ANS: D

Different formulations of the same drug may have varying degrees of bioavailability, and it may be important to stick to a particular brand for drugs with narrow therapeutic ranges. All drugs with similar active ingredients should have the same therapeutic actions and side effects and should be equally safe. DIF: Cognitive Level: Applying (Application)

REF: 22

4. A primary care NP wishes to order a drug that will be effective immediately after

administration of the drug. Which route should the NP choose? a.

Rectal

Topical

Sublingual

Intramuscular

ANS: C

The sublingual route is preferred for quick action because the drug is directly absorbed into the bloodstream and avoids the pass through of the liver, where much of an oral drug is metabolized. Rectal routes have unpredictable absorption rates. Topical routes are the slowest. Intramuscular routes are slow. DIF: Cognitive Level: Remembering (Knowledge)

REF: 22

5. A patient receives an inhaled corticosteroid to treat asthma. The patient asks the primary

care NP why the drug is given by this route instead of orally. The NP should explain that the inhaled form:

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is absorbed less quickly.

has reduced bioavailability.

has fewer systemic side effects.

provides dosing that is easier to regulate.

ANS: C

An inhaled corticosteroid goes directly to the site of action and does not have to pass through gastrointestinal tract absorption or the liver to get to the lungs. It is generally well absorbed at this site, although dosing is not necessarily easier to regulate because it is not always clear how much of an inhaled drug gets into the lungs. DIF: Cognitive Level: Applying (Application)

REF: 21

6. A patient takes an oral medication that causes gastrointestinal upset. The patient asks the

primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may: a.

alter drug absorption.

alter drug distribution.

lead to drug toxicity.

increase stomach upset.

ANS: A

Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset. DIF: Cognitive Level: Applying (Application)

REF: 22

7. A patient will begin taking two drugs that are both protein-bound. The primary care NP

should: a.

prescribe increased doses of both drugs.

monitor drug levels, actions, and side effects.

teach the patient to increase intake of protein.

stagger the doses of drugs to be given 1 hour apart.

ANS: B

Protein-bound drugs bind to albumin, and serum albumin levels may affect how drugs are distributed. The provider should monitor drug levels, actions, and side effects and change dosing accordingly. Increasing the dose of both drugs is not recommended unless monitoring indicates. Increasing dietary protein does not affect this. Staggering the drugs

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will not affect this. DIF: Cognitive Level: Applying (Application)

REF: 25

8. A patient is taking drug A and drug B. The primary care NP notes increased effects of

drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: a.

inhibitor.

substrate.

inducer.

metabolizer.

ANS: A

If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. DIF: Cognitive Level: Applying (Application)

REF: 26 - 27

9. The primary care NP should understand that a drug is at a therapeutic level when it is: a.

at peak plasma level.

past 4 or 5 half-lives.

at its steady plasma state.

between minimal effective concentration and toxic levels.

ANS: D

The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives. DIF: Cognitive Level: Applying (Application)

REF: 31

10. A primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear

kinetics. The NP should: a.

monitor frequently for desired and adverse effects.

administer a much higher initial dose as a loading dose.

monitor creatinine clearance at baseline and periodically.

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administer the drug via a route that avoids the first-pass effect.

d. ANS: A

Drugs with nonlinear kinetics are not eliminated based on dose or concentration of the drug, and these drugs have a narrow therapeutic window and must be monitored closely for desired effects and toxicity. DIF: Cognitive Level: Applying (Application)

REF: 32

11. A primary care NP is prescribing a drug for a patient who does not take any other

medications. The NP should realize that: a.

CYP450 enzyme reactions will not interfere with this drug’s metabolism.

substrates such as alcohol cannot interfere with the drug when the patient is abstaining.

food-drug interactions are limited to those where food enhances or inhibits drug absorption.

a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required.

ANS: D

Drugs are not the only substances that interfere with drug kinetics and dynamics. The primary care NP should conduct a thorough history of food and alcohol intake, smoking, and over-the-counter and herbal supplements to identify things that might interfere with a drug. All of these may interfere with CYP enzymes. Alcohol intake can influence this even when the patient is abstaining because of long-term effects on the liver. DIF: Cognitive Level: Understanding (Comprehension)

REF: 38-39

Chapter 04: Special Populations: Geriatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is considering a possible drug regimen for an 80-year-old

patient who reports being forgetful. To promote adherence to the regimen, the NP should: a.

select drugs that can be given once or twice daily.

provide detailed written instructions for each medication.

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order medications that can be given on an empty stomach.

instruct the patient to take a lower dose if side effects occur.

ANS: A

To promote adherence in elderly patients, selecting the smallest number of medications with the simplest dose regimens is recommended, with once-daily dosing preferred. Instructions should be simplified. Drug dosing should be timed with mealtimes to help patients remember to take them. Lower dosing may be necessary with some drugs, but patients should not do this without consulting their provider. DIF: Cognitive Level: Applying (Application)

REF: 57 - 58

2. A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To

help ensure patient safety, the NP prescribing this medication should: a.

assess this patient’s usual sleeping patterns.

ask the patient about problems with constipation.

obtain a baseline creatinine clearance test before the first dose.

perform a thorough evaluation of cognitive and motor abilities.

ANS: D

The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. DIF:

Cognitive Level: Applying (Application)

REF: 50| 55

3. A thin 90-year-old patient who will begin taking warfarin has experienced a recent weight

loss of 15 pounds. The NP caring for this patient should: a.

obtain a baseline liver function test (LFT) before starting the drug.

write the initial prescription at the lowest possible dose.

encourage the patient to consume a diet high in fat and protein.

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counsel the patient to take the drug with food to enhance absorption.

d. ANS: B

A common age change that affects the distribution of drugs in older adults is a decrease in serum albumin. Significant changes that may affect drug therapy may be seen in malnourished elderly patients. Warfarin has a high binding affinity with albumin. Significant decreases in albumin may result in a greater free concentration of highly protein-bound drugs. It is important to order the lowest possible dose and titrate upward as needed. A baseline LFT is not indicated. A diet high in fat and protein is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 50 - 51

4. An 86-year-old patient is seen in clinic for a scheduled follow-up after starting a new oral

medication 1 month prior. The patient reports no change in symptoms, and a laboratory test reveals a subtherapeutic serum drug level. The NP caring for this patient should: a.

consider ordering more frequent dosing of the drug.

titrate the patient’s dose upward and recheck in 1 month.

ask the patient about any increased frequency of bowel movements.

determine the number of pills left in the patient’s prescription bottle.

ANS: D

Because of cost concerns, poor understanding of a drug’s actions, or confusion about how to take a medication, many elderly patients do not comply with drug regimens and may not take drugs as prescribed. Before increasing the frequency or amount of a drug, it is important to assess first whether or not the patient has been taking the drug as ordered. Counting the number of pills in the bottle will help the provider assess whether the patient is taking the drug as ordered. Changes in gastric motility do not generally have major effects on the effectiveness or serum drug levels of medications. DIF: Cognitive Level: Applying (Application)

REF: 57 - 58

5. An NP learns that a 90-year-old patient is chronically constipated and has frequent

problems with acid reflux. The NP notes a weight loss of 20 pounds in this patient in the previous 6 months. Which of the following drugs that this patient is taking is cause for concern? a.

Quinidine

Naproxen

Calcium citrate

Calcium channel blocker

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ANS: B

Naproxen has a high binding affinity for protein, and these drugs can become toxic in patients who may have low serum albumin because of the amount of free drug in serum. Constipation and acid reflux may cause problems with absorption for some drugs, but not the drugs listed. DIF: Cognitive Level: Analyzing (Analysis)

REF: 50 - 52

6. An NP is caring for a 70-year-old patient who reports having seasonal allergies with

severe rhinorrhea. Using the Beers criteria, which of the following medications should the NP recommend for this patient? a.

Loratadine (Claritin)

Hydroxyzine (Vistaril)

Diphenhydramine (Benadryl)

Chlorpheniramine maleate (Chlorphen 12)

ANS: A

Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible. DIF: Cognitive Level: Applying (Application)

REF: 57

7. An NP orders an inhaled corticosteroid 2 puffs twice daily and an albuterol metered-dose

inhaler 2 puffs every 4 hours as needed for cough or wheezing for a 65-year-old patient with recent onset of reactive airways disease who reports symptoms occurring every 1 or 2 weeks. At a follow-up appointment several months later, the patient reports no change in frequency of symptoms. The NP’s initial action should be to: a.

order spirometry to evaluate pulmonary function.

prescribe a systemic corticosteroid to help with symptoms.

ask the patient to describe how the medications are taken each day.

give the patient detailed information about the use of metered-dose inhalers.

ANS: C

It is essential to explore with the older patient what he or she is actually doing with regard to daily medication use and compare this against the “prescribed” medication regimen before ordering further tests, prescribing any increase in medications, or providing further education. DIF: Cognitive Level: Applying (Application)

REF: 57 - 58

Chapter 05: Special Populations: Pediatrics

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Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is preparing to prescribe a medication for a 5-year-old child. To

determine the correct dose for this child, the NP should: a.

calculate the dose at one third of the recommended adult dose.

estimate the child’s body surface area (BSA) to calculate the medication dose.

divide the recommended adult dose by the child’s weight in kilograms (kg).

follow the drug manufacturer’s recommendations for medication dosing.

ANS: D

The package insert provided by the manufacturer is the best source for pediatric dose recommendations. Approximated reduction in the adult dose is not a safe or effective way of calculating pediatric doses of medications, so using a third of the adult dose may not be safe. Errors inherent in determining BSA make this method less reliable than dose based on accurate weights. Dividing the adult dose by the child’s weight is incorrect. DIF: Cognitive Level: Understanding (Comprehension)

REF: 64 - 65

2. An NP is prescribing a drug that is known to be safe in children but is unable to find

recommendations about drug dosing. The recommended adult dose is 100 mg per dose. The child weighs 14 kg. Using Clark’s rule, the NP should order mg per dose. a.

9.3

ANS: A

Clark’s rule suggests dividing the weight of the child in kg by the weight of an adult in kg and multiplying the result by the adult dose to get an approximation of the child’s dose. The average adult weighs 150 lb, or 70 kg. The equation is: 14 kg/70 kg = 0.2. 0.2 100 = 20 mg. DIF: Cognitive Level: Understanding (Comprehension)

REF: 65

3. A child who weighs 22 lb, 2 oz needs a medication. The NP learns that the recommended

dosing for this drug is 25 to 30 mg per kg per day in three divided doses. The NP should order:

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100 mg daily.

100 mg tid.

300 mg daily.

300 mg tid.

ANS: B

The NP should first convert the child’s weight to kg, which is about 10 kg. The dose is then calculated to be 250 to 300 mg per day in three divided doses, which is 83 to 100 mg per dose given tid. DIF: Cognitive Level: Applying (Application)

REF: 65

4. The mother of a 3-year-old child who weighs 15 kg tells the NP that she has liquid

acetaminophen at home but does not know what dose to give her child. The NP should tell the mother: a.

to give 1 teaspoon every 4 to 6 hours as needed.

to throw away the old medication and get a new bottle.

that she may give 5 to 7.5 mL per dose every 4 to 6 hours.

to find out whether she has a preparation made for infants or children.

ANS: D

Acetaminophen drops for infants are three times as concentrated as the oral liquid for children. The drops have been pulled from the market, but many parents may still have old preparations on hand. The NP should first determine which preparation this mother has before giving dosage recommendations. If the mother has the oral liquid for children, answers A and C would both be acceptable because the concentration is 160 mg per 5 mL. The mother should not be counseled to throw away the medication until the NP has more information. DIF: Cognitive Level: Applying (Application)

REF: 65

5. The parent of a toddler asks the NP about using a topical antihistamine to treat the child’s

atopic dermatitis symptoms. The NP should tell the parent that: a.

topical medications have fewer side effects in children.

medications given by this route are not absorbed well in young children.

topical application of an antihistamine may result in drug toxicity in children.

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it is important to apply topical medications liberally over a large surface area.

ANS: C

Children have the potential for increased absorption through the skin because their skin is thinner and more sensitive, increasing their risk for drug toxicity. Topical medications have enhanced side effects in children. Topical medications are readily absorbed by children. Applying topical medications liberally over a large surface area would increase the risk of toxicity. DIF: Cognitive Level: Understanding (Comprehension)

REF: 67 - 68

6. An NP is prescribing a medication for a 6-month-old infant. The medication comes in the

following formulations. Which one should the NP select to improve absorption and distribution of the medication? a.

Oral elixir

Rectal suppository

Lipid soluble compound

Sustained-release capsule

ANS: A

An elixir is a solution in which the drug molecules are dissolved and evenly distributed. Most oral drugs in soluble solutions are readily absorbed from the gastrointestinal tract, and the fact that the drug is evenly distributed helps to ensure that each dose will have equal amounts of the drug. Rectal suppositories generally should be avoided for drug administration, primarily because children may not retain the dosage form long enough to receive the entire dose. Drugs that are lipid soluble may not distribute well in infants. Drugs may pass quickly through the gastrointestinal tract in infants, making sustained release preparations less well absorbed. DIF: Cognitive Level: Understanding (Comprehension)

REF: 60| 61| 66

7. An NP prescribes an oral elixir medication for a child who is to take 1 tsp PO bid. When

counseling the child’s parents about administering this drug, the NP should tell them to: a.

shake the medication well before giving each dose.

mix the medication with cereal or applesauce to improve its taste.

administer the medication on an empty stomach to enhance absorption.

use a syringe purchased at the pharmacy to measure the medication accurately.

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ANS: D

Because the measured volume of “teaspoons” ranges from 2.5 to 7.8 mL, parents should obtain a calibrated medicine spoon or syringe from the pharmacy for dosing small children. Elixirs are solutions in which the drug molecules are dissolved and evenly distributed, so there is no need to shake the drug before each dose. Mixing a drug with food can be problematic if the child does not eat all of the food. An elixir does not need to be administered on an empty stomach. DIF: Cognitive Level: Understanding (Comprehension)

REF: 66 - 67| 69

8. A 4-month-old infant has a viral illness with high fever and cough. The infant’s parent

asks the NP about what to give the infant to help with symptoms. The NP should prescribe which of the following? a.

Aspirin to treat the fever

Acetaminophen as needed

Dextromethorphan for coughing

An antibiotic to prevent increased infection

ANS: B

Infants should not be given aspirin, which carries a risk of Reye’s syndrome, or dextromethorphan, which has an increased risk of respiratory depression in infants. An antibiotic is not indicated unless there is a known bacterial infection. Acetaminophen is safe for infants. DIF: Cognitive Level: Applying (Application)

REF: 64

9. A parent brings a 5-year-old child to a clinic for a hospital follow-up appointment. The

child is taking a medication at a dose equal to an adult dose. The parent reports that the medication is not producing the desired effects. The NP should: a.

order renal function tests.

prescribe another medication to treat this child’s symptoms.

discontinue the drug and observe the child for toxic side effects.

obtain a serum drug level and consider increasing the drug dose.

ANS: D

By a child’s first birthday, the liver’s metabolic capabilities are not only mature but also more vigorous than the adult liver, meaning that certain drugs may need to be given in higher doses or more often. It is prudent to obtain a serum drug level and then consider increasing the dose to achieve the desired effect. Renal function tests are not indicated. Unless the child is experiencing toxic effects, the drug does not need to be discontinued.

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DIF: Cognitive Level: Applying (Application)

REF: 62| 66 - 67

10. An NP is prescribing an antibiotic for a child who will need to take a total of 750 mg per

day. Which dosing regimen should the NP prescribe to promote compliance? a.

250 mg/5 mL—375 mg PO bid

250 mg/5 mL—250 mg PO tid

500 mg/5 mL—375 mg PO bid

500 mg/5 mL—250 mg PO tid

ANS: C

To improve compliance with a drug regimen, convenient dosage forms and dosing schedules should be chosen when possible. A 500 mg/5 mL preparation means that a smaller volume can be given to achieve the desired dose. A bid dosing schedule is more likely to be followed than one that is tid. DIF: Cognitive Level: Applying (Application)

REF: 69

11. An NP sees a preschooler in clinic for the first time. When obtaining a medication

history, the NP notes that the child is taking a medication for which safety and effectiveness in children has not been established in drug information literature. The NP should: a.

discontinue the medication.

order serum drug levels to evaluate toxicity.

report the prescribing provider to the Food and Drug Administration (FDA).

ask the parent about the drug’s use and side effects.

ANS: D

Many of the drugs and biologic products most widely used in pediatric patients carry disclaimers stating that safety and effectiveness in pediatric patients have not been established. The NP should find out why the drug was prescribed and whether there are any significant side effects. The medication should not be discontinued unless there are known toxic effects. Serum drug levels may be warranted if side effects are reported. The NP would not report the prescribing provider to the FDA unless there are clear, evidencebased contraindications to prescribing a drug to children. DIF: Cognitive Level: Applying (Application)

REF: 67 - 69

Chapter 06: Special Populations: Pregnant and Nursing Women Test Bank MULTIPLE CHOICE

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1. A woman is in the 36th week of pregnancy. The nurse practitioner (NP) providing

prenatal care learns that the woman has a history of two previous urinary tract infections during this pregnancy. A dipstick urinalysis in the office today is negative for leukocyte esterase and nitrites. The NP should: a.

prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis.

order nitrofurantoin daily to minimize the patient’s risk of urinary tract infection late in her pregnancy.

encourage the patient to increase daily water intake and to wear only cotton underwear.

order a voiding cystourethrogram to rule out structural anomalies that may cause urinary tract infection.

ANS: C

For women at risk for recurrent urinary tract infection while pregnant, prevention and treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton underpants. Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract infection during pregnancy, but not after the 36th week of gestation. A voiding cystourethrogram is not indicated and would expose the fetus to radiation. DIF: Cognitive Level: Applying (Application)

REF: 77 - 78

2. A woman tells a primary care NP that she is considering getting pregnant. During a health

history, the NP learns that the patient has seasonal allergies, asthma, and epilepsy, all of which are well controlled with a second-generation antihistamine daily, an inhaled steroid daily with albuterol as needed, and an antiepileptic medication daily. The NP should counsel this patient to: a.

take her asthma medications only when she is having an acute exacerbation.

avoid using antihistamine medications during her first trimester of pregnancy.

discontinue her seizure medications at least 6 months before becoming pregnant.

use only oral corticosteroids and not inhaled steroids while pregnant for improved asthma control.

ANS: B

Optimal treatment of asthma during pregnancy includes treatment of comorbid allergic

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rhinitis, which can trigger symptoms. Antihistamines are recommended after the first trimester, if possible. Asthma medications should be continued during pregnancy because poorly controlled asthma can be detrimental to the fetus; she should continue using her daily inhaled corticosteroid. Although discontinuing seizure medications is optimal, this must be done in conjunction with this woman’s neurologist because management of epilepsy during pregnancy is beyond the scope of the primary care provider. Oral corticosteroids have greater systemic side effects and greater effects on the fetus and should be used only as necessary. DIF: Cognitive Level: Applying (Application)

REF: 78 - 79

3. A woman has just learned she is pregnant and is in her 10th gestational week. The woman

reports that she takes valproic sodium (Depakote) for a seizure disorder and has been seizure-free for several years. The NP should: a.

prescribe folic acid supplements.

change her antiepileptic drug to lamotrigine (Lamictal).

order prophylactic vitamin K to be given in the second trimester.

recommend that she discontinue taking the valproic sodium by 12 weeks.

ANS: A

Maternal folic acid deficiency is induced by anticonvulsants, especially valproic acid, so folic acid supplements must be given. Although antiepileptic drugs can have consequences for the developing fetus, once a woman is pregnant, the benefit-risk ratio favors continued use of the woman’s current antiepileptic medication, so she should not discontinue the medication or change to lamotrigine. Vitamin K is recommended beginning at 36 weeks of gestation and for the newborn at birth to counter the possibility of hemorrhagic disease of the newborn. DIF: Cognitive Level: Applying (Application)

REF: 79

4. A woman who is pregnant develops gestational diabetes. The NP’s initial action is to: a.

prescribe an oral antidiabetic agent.

give her information about diet and exercise.

begin treating her with daily insulin injections.

reassure her that her glucose levels will return to normal after pregnancy.

ANS: B

Patients with gestational diabetes should be treated with diet and exercise, with insulin

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added as needed for poor control. There is insufficient evidence to support the use of oral antidiabetic agents during pregnancy, and some of these are pregnancy category D. Insulin injections may be used but are not the initial intervention. Although glucose levels will return to prepregnancy values in the postpartum period, the NP must initiate therapy. DIF: Cognitive Level: Applying (Application)

REF: 79 - 80

5. A woman who takes an angiotensin converting enzyme inhibitor for hypertension tells

her primary care NP that she is trying to get pregnant. The NP should: a.

consider replacing her angiotensin converting enzyme inhibitor with methyldopa.

lower her angiotensin converting enzyme inhibitor dose during the first trimester.

counsel her to increase her antihypertensive medications during pregnancy.

add an angiotensin receptor blocker (ARB) during the first trimester of her pregnancy.

ANS: A

Angiotensin converting enzyme inhibitors, ARBs, and statins are contraindicated during the first trimester of pregnancy and should be discontinued before conception and replaced by safer alternatives, such as methyldopa. The use of antihypertensives during pregnancy remains controversial; increasing the dose is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 80

6. A woman who is pregnant tells an NP that she has been taking sertraline for depression

for several years but is worried about the effects of this drug on her fetus. The NP will consult with this patient’s psychiatrist and will recommend that she: a.

stop taking the sertraline now.

continue taking the antidepressant.

change to a monoamine oxidase inhibitor (MAOI).

discontinue the sertraline a week before delivery.

ANS: B

Many women are taking medication for depression before becoming pregnant. Abrupt discontinuation is not recommended, and many clinicians suggest that women at high risk for serious depression during pregnancy might best be served by continuing medication throughout pregnancy. MAOIs may limit fetal growth and are generally discouraged

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during pregnancy. It is not necessary to discontinue the sertraline just before delivery. DIF: Cognitive Level: Applying (Application)

REF: 80

7. A woman is 4 weeks pregnant. The primary care NP sees her for her first prenatal visit

and obtains a rubella titer, which is negative. The woman tells the NP that she drinks 2 cups of coffee and smokes 3 to 5 cigarettes each day. She denies alcohol use. The NP should: a.

administer rubella vaccine.

provide smoking cessation information.

counsel her to avoid caffeine while pregnant.

reassure her that her habits are not likely to cause harm.

ANS: B

Each cigarette smoked decreases maternal blood pressure for up to 15 minutes and decreases uteroplacental perfusion. The NP should encourage the woman to quit smoking. Rubella vaccine should be given after the baby is delivered because rubella vaccine is a live virus, with severe teratogenic effects. There is no conclusive evidence that women who are pregnant should avoid caffeine completely. Her habits, although not severe, are not harmless. DIF: Cognitive Level: Applying (Application)

REF: 82 - 83

8. A woman who is breastfeeding her infant asks the primary care NP what she can use for

headaches while she is nursing. The NP tells her: a.

most medications enter breast milk and are not safe.

most over-the-counter medications are safe for the breastfed infant.

she may need to interrupt breastfeeding when taking headache medications.

she should consider weaning her infant to formula if her headaches are frequent.

ANS: B

Most over-the-counter medications are considered safe for the breastfed infant and do not necessitate a disruption of breastfeeding, even though most medications cross easily into breast milk. Any interruption of breastfeeding carries a risk of premature weaning and so is indicated only when the mother must take medications known to cause serious harm to the baby. It is not recommended that she wean her infant to formula when she needs medications for her headaches.

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DIF: Cognitive Level: Applying (Application)

REF: 85

Chapter 07: Over-the-Counter Medications Test Bank MULTIPLE CHOICE 1. A patient asks a primary care nurse practitioner (NP) about using over-the-counter

medications to treat an upper respiratory infection with symptoms of cough, fever, and nasal congestion. The NP should: a.

recommend a cough preparation that also contains acetaminophen.

suggest using single-ingredient products to treat each symptom separately.

recommend a product containing antitussive, antipyretic, and decongestant ingredients.

tell the patient that over-the-counter medications are usually not effective in manufacturer-recommended doses.

ANS: B

A basic principle guiding over-the-counter use is to look at specific symptoms and treat each separately because some products contain therapeutic doses of one ingredient and subtherapeutic doses of others. Cough preparations containing acetaminophen often do not contain therapeutic doses, and patients often overdose when they supplement with acetaminophen. Over-the-counter medications are effective at recommended doses. Patients should follow dosing recommendations on the package. DIF: Cognitive Level: Understanding (Comprehension)

REF: 89| 90

2. A patient asks a primary care NP whether over-the-counter drugs are safer than

prescription drugs. The NP should explain that over-the-counter drugs are: a.

generally safe when label information is understood and followed.

safer because over-the-counter doses are lower than prescription doses of the same drug.

less safe because they are not well regulated by the Food and Drug Administration (FDA).

not extensively tested, so claims made by manufacturers cannot be substantiated.

ANS: A

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Over-the-counter products have a wider margin of safety because most of these drugs have undergone rigorous testing before marketing and further refinement through years of over-the-counter use by consumers. When labels are understood and followed, over-thecounter medications are safe. Over-the-counter medications are regulated by the FDA. DIF: Cognitive Level: Understanding (Comprehension)

REF: 88

3. A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6-

year-old child. The parent tells the NP that the medication label does not give instructions about how much to give a child. The NP should: a.

order a prescription antitussive medication for the child.

ask the parent to identify all of the ingredients listed on the medication label.

calculate the dose for the active ingredient in the over-the-counter preparation.

tell the parent to approximate the dose at about one third to one half the adult dose.

ANS: B

Over-the-counter cough medications often contain dextromethorphan, which can be toxic to young children. It is important to identify ingredients of an over-the-counter medication before deciding if it is safe for children. A prescription antitussive is probably not warranted until the cough is evaluated to determine the cause. Until the ingredients are known, it is not safe to approximate the child’s dose based on only the active ingredient. DIF: Cognitive Level: Applying (Application)

REF: 89

4. A primary care NP recommends an over-the-counter medication for a patient who has

acid reflux. When teaching the patient about this drug, the NP should tell the patient: a.

to take the dose recommended by the manufacturer.

not to worry about taking this drug with any other medications.

to avoid taking other drugs that cause sedation while taking this drug.

that over-the-counter acid reflux medications are generally safe to take with other medications.

ANS: A

Because patients often increase over-the-counter drug doses themselves, it is important to reinforce the need to follow the manufacturer’s recommendations for dosing. As with any

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drug, interactions may occur with other medications. Antacids do not cause sedation, so patients need not be cautioned to avoid other sedating medications. DIF: Cognitive Level: Applying (Application)

REF: 89

5. A primary care NP is performing a previsit health history on a new patient. The patient

reports taking vitamins every day. The NP should: a.

ask the patient to bring all vitamin bottles to the clinic appointment.

recommend natural vitamin products over synthetic vitamin products.

reassure the patient that vitamins that are high in folic acid are safe to take.

tell the patient that some vitamins, such as vitamin C, are safe in large doses.

ANS: A

It is important to determine exactly what the patient is taking, so asking patients to bring vitamin bottles to the clinic is appropriate. There is no evidence that natural products are better than synthetic products. High doses of folic acid may mask signs of vitamin B 12 deficiency. Vitamin C in high doses can cause dependency. DIF: Cognitive Level: Applying (Application)

REF: 89

6. A patient reports taking antioxidant supplements to help prevent cancer. The primary care

NP should: a.

review healthy dietary practices with this patient.

make sure that the supplements contain large doses of vitamin A.

tell the patient that antioxidants are especially important for patients who smoke.

tell the patient that evidence shows antioxidants to be effective in preventing cancer.

ANS: A

Epidemiologic evidence indicates that people who eat fruits and vegetables regularly have a decreased risk of cancer. Although retrospective studies have suggested major benefits from antioxidants, no intervention studies have determined conclusively that antioxidants prevent cancer. Large doses of vitamin A can produce a yellow hue to the skin. Antioxidants can be beneficial, but in certain populations, such as smokers, they may be harmful.

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DIF: Cognitive Level: Understanding (Comprehension)

REF: 89

7. A patient who has an upper respiratory infection reports using over-the-counter cold

preparations. The primary care NP should counsel this patient to use caution when taking additional over-the-counter medications such as: a.

antipyretics.

calcium supplements.

acid reflux medications.

antioxidant supplements.

ANS: A

Cold preparations often contain antipyretics such as acetaminophen or aspirin. Patients should be cautioned about taking additional antipyretics to avoid overdose. DIF: Cognitive Level: Applying (Application)

REF: 89

Chapter 08: Complementary and Alternative Therapies Test Bank MULTIPLE CHOICE 1. A patient with chronic back pain that is unrelieved by prescription analgesic medications

asks a primary care nurse practitioner (NP) about acupuncture treatments. The NP should tell this patient: a.

biofield therapy has been shown to be more effective than acupuncture.

creatine has been shown to be an effective herbal choice to treat back pain.

there is no valid research documenting the efficacy of this treatment for pain.

most studies that show benefits of alternative therapies are based on observation.

ANS: D

Current literature does not allow definitive conclusions to be drawn regarding the use of complementary and alternative medicine (CAM) because much of what appears in the literature continues to be based on observational reports and small studies. Biofield therapy has not been shown to be more effective than acupuncture. Creatine is used to increase muscle mass. DIF: Cognitive Level: Applying (Application)

REF: 93

2. A primary care NP is aware that many patients in the community use herbal remedies to

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treat various conditions. The NP understands the importance of: a.

learning about the actions, uses, doses, and toxicities of these agents.

prescribing these agents when possible to ensure safe dosing.

counseling patients to stop using herbal products to avoid toxic side effects.

teaching patients that these products are unregulated and unsafe to use.

ANS: A

It is important for primary care providers to be familiar with these products and their ingredients so that they can help patients choose the safest product for their ailments. Because there are few evidence-based recommendations for the use of these products, NPs should not prescribe them. Counseling patients to stop using the products would probably not be effective; it is more important to know about the products to assist patients in decision making. Although it is true that the products are not directly regulated by the Food and Drug Administration (FDA), there are agencies that maintain safety of the products. DIF: Cognitive Level: Applying (Application)

REF: 94

3. A patient has been using an herbal supplement for 2 years that the primary care NP

knows may have toxic side effects. The NP should: a.

tell the patient to stop taking the supplement immediately.

inform the patient of the risks of toxic side effects with this supplement.

refer the patient to a CAM provider who can manage this patient’s therapy.

prescribe another herbal drug that has fewer adverse effects than the one the patient is taking.

ANS: B

It is important for primary care NPs to inform patients of any known risks associated with herbal supplements. Asking the patient to stop an herbal remedy immediately when the patient has been using it for 2 years would probably be met with resistance. The NP should realize that referral to a CAM provider can incur legal liabilities if the CAM provider does not have proper competencies and licensure. Likewise, unless there is evidence-based documentation about the safety and efficacy of a product, the NP should not prescribe these therapies. DIF: Cognitive Level: Applying (Application)

REF: 94

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4. A patient asks a primary care NP why herbal supplements are not regulated by the FDA.

The nurse practitioner should tell the patient these products are not regulated by the FDA because they are: a.

natural, plant-based products and not manmade.

not marketed as products that can treat or cure disease.

regulated by the Dietary Supplement Health and Education Act.

covered by the Hatch-Richardson Bill of 1992, which allows them to make health claims without FDA approval.

ANS: B

A manufacturer must comply with the rigorous standards of safety and efficacy set forth by the FDA only when the claim is made that a product can be used to treat or cure an illness or disease. The Hatch-Richardson Bill of 1992 defines herbal supplements as different from a food additive or drug. The Dietary Supplement Health and Education Act allows claims to be made as long as they are substantiated with evidence. DIF: Cognitive Level: Understanding (Comprehension)

REF: 95

5. A patient is diagnosed with lupus and reports occasional use of herbal supplements. The

primary care NP should caution this patient to avoid: a.

ginseng.

echinacea.

ginkgo biloba.

St. John’s wort.

ANS: B

Patients with lupus who take echinacea may experience an increase in symptoms, even if the patient is taking immunosuppressants. DIF: Cognitive Level: Understanding (Comprehension)

REF: 98

6. A patient who takes warfarin (Coumadin) experiences excessive bleeding, even though

serum drug levels are normal. The primary care NP should question this patient about the use of: a.

feverfew.

echinacea.

green tea.

ginkgo biloba.

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ANS: D

Ginkgo biloba decreases blood viscosity and can enhance the effects of warfarin. Feverfew, echinacea, and green tea do not have this effect. DIF: Cognitive Level: Applying (Application)

REF: 99

7. A patient develops hepatotoxicity from chronic acetaminophen use. The primary care NP

may recommend: a.

milk thistle.

chondroitin.

coenzyme Q.

glucosamine.

ANS: A

Milk thistle has been shown to protect the liver after exposure to hepatotoxins such as acetaminophen, ethanol, and halothane. The other supplements listed do not have this effect. DIF: Cognitive Level: Understanding (Comprehension)

REF: 100

Chapter 09: Establishing the Therapeutic Relationship Test Bank MULTIPLE CHOICE 1. To increase the likelihood of successful pharmacotherapy, when teaching a patient about

using a medication, the primary care nurse practitioner (NP) should: a.

encourage the patient to participate in the choice of the medication.

provide education about the medication actions and adverse effects.

stress the importance of taking the medication exactly as it is prescribed.

give the patient copies of medication package inserts describing the drug use.

ANS: A

It is important that the patient “owns the problem” and has a part in the solution. Providing education about the medication, stressing the importance of following medication instructions, and distributing package inserts may be useful, but it is essential that patients take an active role in their care. DIF: Cognitive Level: Applying (Application)

REF: 104

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2. A patient has recurrent symptoms and tells the primary care NP that she can’t remember

to take her medication all the time. The NP should: a.

give her shortened regimens of the drug to facilitate compliance.

provide written information about her condition and the medication.

administer the medication in the clinic to ensure that she takes the drug.

ask her about her lifestyle, her schedule, and her understanding of her condition.

ANS: D

If the attitude is that the patient has a problem for the health care provider to solve, then the provider owns the problem and often hastens to solve it. When patients own their problems, they are more likely to engage in their care and treatment. Giving shortened regimens, providing written information, and administrating medication in the clinic are examples of the provider solving the problem for the patient. DIF: Cognitive Level: Applying (Application)

REF: 104

3. A primary care NP prepares to teach a patient about the management of a chronic

condition. The patient says, “I don’t want to know all of that. Just tell me what to take and when.” The NP should initially: a.

give the patient basic written instructions about medications, follow up visits, and symptoms.

ask the patient to describe the disease process and the medications to evaluate understanding.

explain to the patient that without mutual cooperation, the treatment regimen will not be effective.

ask the patient to explore feelings and fears about having a chronic disease and taking medications.

ANS: A

The patient has stated expectations about care and treatment for the condition. The NP should begin by respecting that and providing the amount of information the patient wants. As the therapeutic relationship grows, the NP may elicit more active participation and understanding. DIF: Cognitive Level: Applying (Application)

REF: 104

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4. A parent brings a child who has moderate-persistent asthma to the clinic and tells the

primary care NP that none of the child’s medications are working. The parent says, “Everybody tells me something different. I don’t know what to do.” The NP suspects that the parent is not administering the medications appropriately. The NP should initially: a.

perform a careful history of the child’s symptoms and the medications that are given.

provide a written asthma action plan and encourage the parent to call when symptoms are worse.

review what other providers have prescribed in the past and explain these interventions to the parent.

explain the different purposes of maintenance and rescue medications and give the parent a schedule for medication administration.

ANS: A

Clinical providers must refine listening and questioning skills and focus on the patient and the environment. It is important to begin with a thorough history and to elicit the patient’s understanding of a disease or a medication to identify potential problems. Providing written action plans, reviewing past providers’ prescriptions, and explaining medications are useful only after the NP determines what the problem is. DIF: Cognitive Level: Applying (Application)

REF: 104

5. A primary care NP sees a 5-year-old child who is morbidly obese. The child has an

elevated hemoglobin A 1c and increased lipid levels. Both of the child’s parents are overweight but not obese, and they tell the NP that they see nothing wrong with their child. They both state that it is difficult to refuse their child’s requests for soda or ice cream. The NP should: a.

suggest that they give the child diet soda and low-fat frozen yogurt.

understand and respect the parents’ beliefs about their child’s self-image.

initiate a dialogue with the parents about the implications of the child’s laboratory values.

suggest family counseling to explore ways to improve parenting skills and limits.

ANS: C

In this case, the child is at risk if the parents do not intervene. The NP should help the

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parents to see the potential adverse effects so that they can understand the need for treatment. The other answers are examples of the NP creating solutions. Unless the parents see the problem, they are not likely to engage in the treatment regimen. DIF: Cognitive Level: Applying (Application)

REF: 108

6. A patient bursts into tears when the primary care NP diagnoses diabetes. The NP should: a.

ask the patient about past experiences with anyone who has this diagnosis.

reassure the patient that the medications and blood tests will become routine.

call in a social worker to assist the patient to obtain equipment and supplies.

refer the patient to a diabetes educator to provide teaching about the disease.

ANS: A

To help patients participate in their disease management, the NP must have an understanding of the patient’s concerns and fears. The first step when the patient is obviously upset is to determine what the patient knows and fears about the disease. DIF: Cognitive Level: Applying (Application)

REF: 107

7. A primary care NP writes a prescription for an off-label use for a drug. To help ensure

compliance, the NP should: a.

include information about the off-label use on the E-script.

provide the patient with written instructions about how to use the medication.

tell the patient to let the pharmacist know that the drug is being used for an off-label use.

follow up by phone in several days to see if the patient is using the drug appropriately.

ANS: A

Effective communication extends beyond just the patient-provider relationship. It is important to include anyone involved in the patient’s care. The best way in this case is to include the information on the E-script so that there is a record of the off-label use and to help clarify or reinforce the provider’s instructions. DIF: Cognitive Level: Applying (Application)

REF: 111

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Chapter 11: Evidence-Based Decision Making and Treatment Guidelines Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) is using critical thinking skills when: a.

using standardized protocols to guide patient care.

adhering to scientific principles to solve a patient problem.

following the practices of seasoned mentors when giving care.

analyzing current research and synthesizing new approaches to patient care.

ANS: D

Practitioners use critical thinking skills by reviewing and analyzing current knowledge and synthesizing approaches to apply to unique patient situations. Using standardized protocols, adhering to scientific principles, and following practices of seasoned mentors may be useful, but these do not encompass the concept of critical thinking, which requires the practitioner to use what is known in new situations. DIF: Cognitive Level: Understanding (Comprehension)

REF: 123 - 124

2. The primary care NP has referred a child who has significant gastrointestinal reflux

disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: a.

compromise with the parents and order a nasogastric tube for feedings.

initiate a discussion with the parents about the potential outcomes of each possible action.

refer the family to a case manager who can help guide the parents to the best decision.

understand that the child’s parents have a right to make choices that override those of the medical team.

ANS: B

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In general, the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants. Initiating a discussion about outcomes helps parents decide based on end results. A nasogastric tube is not the best choice for the child, and compromising without first exploring options is incorrect. As part of the therapeutic relationship, the NP should be involved with patients’ decisions. Although patients and families have the right to make decisions, the NP has an obligation to ensure that the decisions are informed decisions. DIF: Cognitive Level: Applying (Application)

REF: 126

3. The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma.

The third-party payer for this patient denies coverage for the brand that comes in the specific strength the NP prescribes. The NP should: a.

provide pharmaceutical company samples of the medication for the patient.

inform the patient that the drug must be paid for out of pocket because it is not covered.

order the closest formulary-approved approximation of the drug and monitor effectiveness.

write a letter of medical necessity to the insurer to explain the need for this particular medication.

ANS: C

The second step of medical decision making takes into account benefits versus costs along with an understanding that it is impossible to do everything because of limited resources. The NP should prescribe what is covered and evaluate its effectiveness; if it does not work, the third-party payer may be approached about the need for the other medication. Providing samples is not always possible, and this practice is being discouraged, so it is not a viable solution. Asking patients to pay out of pocket ultimately may be necessary but carries risks that the patient will not obtain the medication. Writing a letter of medical necessity may be indicated if the available drugs are not effective but is not the initial step. DIF: Cognitive Level: Applying (Application)

REF: 125

4. A patient takes a cardiac medication that has a very narrow therapeutic range. The

primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should: a.

contact the insurance provider to explain why this particular formulation is necessary.

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change the patient’s medication to a different drug class that doesn’t have these bioavailability variations.

accept the situation and monitor the patient closely for drug effects with each prescription refill.

ask the pharmaceutical company that makes the drug for samples so that the patient does not incur out-of-pocket expense.

ANS: A

In this case, the NP should advocate for the desired drug because changing the drug can have life-threatening consequences. If this fails, other options may have to be explored. DIF: Cognitive Level: Applying (Application)

REF: 131

5. A patient comes to the clinic reporting dizziness and fatigue associated with nausea and

vomiting. The primary care NP suspects anemia and orders a complete blood count. The patient’s hemoglobin is elevated. The NP correctly concludes that the patient is not anemic. The NP has made an error in: a.

context formulation.

inappropriate knowledge base.

cost-versus-benefit analysis.

hypothesis triggering and information processing.

ANS: D

Faulty hypothesis triggering occurs when the clinician fails to consider appropriate initial hypotheses. The patient had nausea and vomiting, which can cause dehydration, leading to orthostatic hypotension and dizziness. The NP made an assumption that the dizziness was caused by anemia and ordered a complete blood count. Faulty information gathering occurs when clinicians fail to order appropriate tests. An error in context formulation occurs when clinicians and patients have different goals. Errors in knowledge base would occur if the practitioner did not perform a complete history and physical, missing important information. An error in cost-versus-benefit analysis could occur if the clinician ordered expensive tests that were not necessary for diagnosis and treatment. DIF: Cognitive Level: Applying (Application)

REF: 127

6. A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has

no previous history of asthma. The patient reports having heartburn for several months, which has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral steroids and inhaled albuterol. The patient’s condition worsens, and a chest radiograph obtained 2 days later shows bilateral infiltrates. The NP has failed to:

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confirm the diagnosis.

determine the aggressiveness of therapy.

prescribe an adequate dose of medications.

allow the drugs an adequate amount of time to work.

ANS: A

This patient had symptoms that could occur with both asthma and aspiration pneumonia. The NP failed to confirm the diagnosis and prescribed the wrong treatment, leading to worsening of symptoms. DIF: Cognitive Level: Applying (Application)

REF: 129 - 131

7. A patient comes to the clinic and asks the primary care NP about using a newly

developed formulation of the drug the patient has been taking for a year. When deciding whether or not to prescribe this formulation, the NP should: a.

tell the patient that when postmarketing data is available, it will be considered.

review the pharmaceutical company promotional materials about the new medication.

prescribe the medication if it is less expensive than the current drug formulation.

prescribe the medication if the new drug is available in an extended-release form.

ANS: A

About 6 to 12 months of postmarketing experience can yield information about drug efficacy and side effects, so patients should be cautioned to wait for these data. Drug company promotional materials have biased information. Most new drugs are more expensive, and costs alone should not determine drug choice. Extended -release forms are often more expensive. DIF: Cognitive Level: Applying (Application)

REF: 131

8. The primary care NP is reviewing evidence-based recommendations about the off-label

use of a particular drug. Which recommendation should influence the NP’s decision about prescribing the medication? a.

Data from randomized, experimental studies

Patient reports about effectiveness of the

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drug for this purpose c.

Pharmaceutical company reports using anecdotal evidence

Endorsement of this use by a leading practitioner in the field

ANS: A

Randomized, experimental studies yield the best data about use of medications. Patient reports carry the least weight because bias can occur and other factors can influence outcomes. Pharmaceutical company reports are biased. DIF: Cognitive Level: Applying (Application)

REF: 133

9. A primary care NP is developing a clinical practice guideline for management of a patient

population in a midsized suburban hospital. The NP should: a.

use an existing guideline from a leading research hospital.

follow the guideline provided by a thirdparty payer to help ensure reimbursement.

review expert opinion and experimental, anecdotal, correlational study data.

write the guideline to adhere to longstanding practice protocols already in use.

ANS: C

Clinical guidelines should be written using all available evidence as well as expert opinion. Existing guidelines from a different type of hospital may not be based on data generalizable to this population. Third-party payer guidelines are usually weighted toward decreased costs. Long-standing protocols often do not take into account current knowledge and research. DIF: Cognitive Level: Applying (Application)

REF: 136 - 137

Chapter 12: Design and Implementation of Patient Education Test Bank MULTIPLE CHOICE 1. A patient is diagnosed with asthma. The primary care nurse practitioner (NP) prescribes

an inhaled corticosteroid and an inhaled bronchodilator medication and provides education about how to use inhalers. At a follow-up visit 2 weeks later, the patient’s pulmonary function tests are worse. The NP should: a.

provide a detailed written asthma action plan for the patient.

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ask the patient to describe how the medications have been used.

review the symptoms of an acute asthma exacerbation with the patient.

teach the patient to use the albuterol more often and order an oral steroid.

ANS: B

Follow-up visits present an opportunity for the NP to evaluate learning. A first step when symptoms have not improved is to ask the patient to describe what he or she does. A detailed written plan and a review of asthma symptoms are a part of education but should have been given at the initial visit along with hands-on instruction and demonstrations. Until it is determined whether or not the patient understands and follows the prescribed regimen, it is not correct to change the plan of care. DIF: Cognitive Level: Applying (Application)

REF: 139

2. A patient who has recently developed prediabetic symptoms is overweight and has a

sedentary lifestyle. The primary care NP has prescribed an oral antidiabetic agent. The patient says, “I suppose I’ll need insulin like my mother and grandfather did.” To educate this patient about managing this disease, the NP should initially: a.

determine how the patient feels about using insulin.

provide written educational materials about diet and exercise.

compare the actions of oral antidiabetic agents with insulin injections.

tell the patient that the medication plus exercise may prevent the need for insulin.

ANS: A

When beginning an education program for patients, it is first necessary to determine the patient’s motivation and desire to learn. Asking this patient about feelings about using insulin would help the NP understand how this possibility might motivate the patient to learn about prediabetic management. The other options all are legitimate parts of a teaching plan but cannot be used effectively until the patient and the provider have negotiated what the patient wants to know. DIF: Cognitive Level: Applying (Application)

REF: 139

3. A patient who is newly diagnosed with hypertension is to begin taking two

antihypertensive medications. The primary care NP gives the patient written drug information and starts to discuss medication side effects. The patient interrupts and says, “I don’t want to know all that. Just tell me what to take and when.” The NP should:

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explain that medication side effects can have serious consequences.

ask the patient about previous experiences with medication side effects.

give the patient a copy of the medication package insert to read at home.

refer the patient to a website with information about hypertension drug therapy.

ANS: B

Asking the patient about previous experiences with medication side effects can help the NP to understand the patient’s motivations to learn and may provide the NP a point of reference to help make the information more relevant to the patient. Giving the patient information when it is not wanted would not be effective. DIF: Cognitive Level: Applying (Application)

REF: 139

4. The primary care NP is seeing a patient for a hospital follow-up after the patient has had a

first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them.” The NP’s initial response should be to: a.

ask the patient to describe the medication regimen.

ask the patient to make a list of questions about the medications.

determine what the patient understands about coronary artery disease.

give the patient information about drug effects and any adverse reactions.

ANS: C

When a patient is first diagnosed with a medical problem, education must start with explaining the pathophysiology in terms the patient will understand. When patients understand what has happened to them, they can move on to consider what to do about it. The other responses are part of an education plan but are not the initial response. DIF: Cognitive Level: Applying (Application)

REF: 139 - 140

5. A primary care NP is reviewing written information about a newly prescribed medication

with a patient. To evaluate this patient’s understanding of the information, the NP should ask the patient to: a.

read the information aloud.

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describe how the medication will be taken.

write down questions about the medication.

tell the NP if the information is unclear.

ANS: B

To evaluate a patient’s understanding, the NP should ask the patient to describe in his or her own words what is taught. Asking a patient to read aloud is sometimes used to assess literacy. Patients who are not literate may not be able to write down questions and, because of shame, may not tell the NP that the written information is unclear. DIF: Cognitive Level: Applying (Application)

REF: 144

6. A primary care NP is developing a handout to give to patients who will begin self-

administering insulin. When developing this handout, the NP should: a.

provide detailed descriptions of each step in the process of injecting insulin.

use correct medical terminology when describing insulin self-administration.

provide as much factual information as possible about insulin administration.

address one or two educational objectives that describe what the patient will learn.

ANS: D

When developing patient education materials, it is important to limit content to one or two educational objectives and list what the patient will learn and do after reading the material. Written materials should not be too detailed but rather presented using bulleted points. When possible, material should use common words and phrases and avoid medical terms. DIF: Cognitive Level: Applying (Application)

REF: 143

7. A patient brings written information about a medication to a primary care NP about a new

drug called Prism and wants to know if the NP will prescribe it. The NP notes that the information is from an internet site called “Prism.com.” The NP should tell this patient that: a.

this information is probably from a drug advertisement website.

this is factual, evidence-based material with accurate information.

the information is from a nonprofit group that will not profit from drug sales.

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internet information is unreliable because anyone can post information there.

d. ANS: A

Commercial internet sites are identifiable by “com” at the end of their web address. Many provide reliable information, but others may be more interested in selling something. Nonprofit groups use “org” at the end of their web addresses. Internet information is reliable as long as the internet user is aware of how things are posted and by whom. DIF: Cognitive Level: Understanding (Comprehension)

REF: 144

Chapter 13: Dermatologic Agents Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) prescribes a topical cream medication. Which

statement by the patient indicates understanding of proper application of this medication? a.

“I should apply this medication after bathing.”

“I need to use a tongue blade to apply this medication.”

“I should apply this medication liberally to all affected areas.”

“I will apply this medication using circular strokes to ensure absorption.”

ANS: A

For optimal absorption of topical medications, apply them to moist skin either immediately after bathing or after wet soaks. A tongue blade is used for topicals in paste form. Topical medications should be applied in a thin layer, not liberally. Topical medications should be applied using long, downward strokes because back-and-forth strokes can cause irritation. DIF: Cognitive Level: Applying (Application)

REF: 152 - 153

2. An NP student asks the primary care NP about guidelines for using topical steroids. The

NP should tell the student that: a.

evidence-based guidelines are available for each product.

standardized guidelines have been developed for use in children.

standardized guidelines may be found for disease-specific conditions.

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evidence-based studies support limited corticosteroid use in pregnancy.

d. ANS: C

Standardized guidelines are available for disease-specific conditions; there are no evidence-based studies or standardized guidelines for using topical steroids. DIF: Cognitive Level: Applying (Application)

REF: 154 - 155

3. A 5-year-old child has atopic dermatitis that is refractory to treatment with

hydrocortisone acetone 2.5% cream. The primary care NP should prescribe: desonide cream 0.01%. a. b.

triamcinolone acetonide.

fluocinolone cream 0.2%.

betamethasone dipropionate ointment 0.05%.

ANS: B

An over-the-counter steroid has failed to treat this child’s dermatitis, so the NP should prescribe something in a higher strength. Triamcinolone is a medium-strength steroid and should be used. The other three are in groups I and II, which are high-strength steroids and are not recommended in children. DIF: Cognitive Level: Applying (Application)

REF: 154| 156

4. A patient has been treated for severe contact dermatitis on both arms with clobetasol

propionate cream. At a follow-up visit, the primary care NP notes that the condition has cleared. The NP should: a.

prescribe triamcinolone cream for 2 weeks.

recommend continuing treatment for 2 more weeks.

discontinue the clobetasol and schedule a follow-up visit in 2 weeks.

discontinue the clobetasol and recommend prn use for occasional flare-ups.

ANS: A

Treatment should be discontinued when the skin condition has resolved. Tapering the corticosteroid will prevent recurrence of the skin condition. Tapering is best done by gradually reducing the potency and dosing frequency at 2-week intervals. This patient was on a very high potency steroid, so changing to a medium frequency with follow-up in 2 weeks is an appropriate action. Discontinuing the steroid abruptly can lead to recurrence.

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DIF: Cognitive Level: Applying (Application)

REF: 160

5. A primary care NP prescribes fluocinolone cream for a patient who has contact

dermatitis. At a follow-up visit in 2 weeks, the patient reports decreased pruritus but continues to have excoriated, erythematous areas. The NP should: a.

obtain a culture of the skin to monitor for superinfection.

discontinue the fluocinolone and order betamethasone cream.

begin gradually tapering the fluocinolone at 2-week intervals.

tell the patient to continue using the fluocinolone for 3 to 4 more weeks.

ANS: D

The risk of adverse effects is less if group II steroids are used for less than 6 to 8 weeks. If the condition is responding to treatment, and there are no signs of adverse effects, the NP should recommend continuing use. The patient does not have exudative lesions, so a culture is not necessary. DIF: Cognitive Level: Applying (Application)

REF: 155

6. A primary care NP is considering using a topical immunosuppressive agent for a patient

who has atopic dermatitis that is refractory to treatment with topical corticosteroids. The NP should: a.

begin therapy with pimecrolimus (Elidel).

tell the patient that these agents may be used long-term.

counsel the patient that these agents are more likely to cause skin atrophy.

tell the patient that laboratory monitoring for hypothalamic-pituitary-adrenal (HPA) suppression will be necessary.

ANS: A

Topical calcineurin agents are considered second -line agents for treating atopic dermatitis and should be limited to use in patients who have failed treatment with other therapies. Pimecrolimus permeates skin at a lower rate than tacrolimus and so should be tried first. These agents are for short-term use only because of the risk of skin cancer. These agents are less likely than steroids to cause skin atrophy, and HPA suppression is not a risk. DIF: Cognitive Level: Applying (Application)

REF: 156 - 157

7. A primary care NP sees a child who has honey-crusted lesions with areas of erythema

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around the nose and mouth. The child’s parent has been applying Polysporin ointment for 5 days and reports no improvement in the rash. The NP should prescribe: a.

mupirocin.

neomycin.

a systemic antibiotic.

Polysporin with a corticosteroid.

ANS: A

Treatment with a topical antiinfective agent should be reevaluated in 3 to 5 days if there is no improvement. Polysporin ointment is bacteriostatic, not bacteriocidal. Mupirocin is indicated for impetigo caused by Staphylococcus aureus, which is most common in children. Neomycin is an aminoglycoside and is not effective against S. aureus. A systemic antibiotic is not indicated unless the mupirocin fails to treat the infection. Adding a corticosteroid would increase the likelihood that the infection will worsen. DIF: Cognitive Level: Applying (Application)

REF: 157

8. A patient is seen by a primary care NP to evaluate a rash. The NP notes three ring-shaped

lesions with elevated, erythematous borders and two smaller, scaly patches on the patient’s abdomen. The patient has not used any over-the-counter medications on the rash. The NP should prescribe: a.

terbinafine (Lamisil).

oxiconazole (Oxistat).

ketoconazole (Nizoral).

miconazole (Lotrimin AF).

ANS: D

When initiating treatment for tinea corporis, start with an older agent, such as miconazole, because this is available over-the-counter and in generic form and is cheaper. Other agents may be used if the infection does not respond to miconazole or if there are localized side effects to the product. DIF: Cognitive Level: Applying (Application)

REF: 158

9. An 18-month-old child who attends day care has head lice and has been treated with

permethrin 1% (Nix). The parent brings the child to the clinic 1 week later, and the primary care NP notes live bugs on the child’s scalp. The NP should order: a.

lindane.

malathion.

ivermectin.

permethrin 5%.

ANS: D

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Permethrin is the first-line drug of choice for treating head lice and is usually effective in one application. Significant resistance to permethrin 1% has developed, and permethrin 5% is more effective. In pediculosis, if live lice can be found after 1 week, reapply treatment. This child may have been reinfected at day care and so should be treated again. Malathion is a second-line drug and is not recommended in children younger than age 2. Lindane is a third-line drug. Ivermectin is a fourth-line drug. DIF: Cognitive Level: Applying (Application)

REF: 161

10. A patient who has scabies has been treated by the primary care NP twice with permethrin

(Elimite). The second application was administered 10 days after the first. The patient returns to the clinic with mild pruritus and erythema. The NP does not observe new burrows on the skin. The NP should: a.

order lindane.

order malathion.

re-treat with permethrin.

prescribe triamcinolone 0.1%.

ANS: D

In scabies, pruritus may persist for several weeks after treatment and does not necessarily indicate the need for re-treatment. Dermatitis may persist for months. Triamcinolone 0.1% may be used to help with pruritus and dermatitis. Lindane and malathion are not indicated. Re-treatment is not necessary. DIF: Cognitive Level: Applying (Application)

REF: 161

11. A primary care NP is performing a well-child checkup on an adolescent patient and notes

approximately 20 papules and comedones and 10 pustules on the patient’s face, chest, and back. The patient has not tried any over-the-counter products to treat these lesions. The NP should begin treatment with: a.

salicylic acid.

topical tretinoin.

oral antibiotics.

benzoyl peroxide and topical clindamycin.

ANS: D

Mild acne consists of a lesion count of less than 30 with less than 15 pustules. Benzoyl peroxide and topical clindamycin are both indicated for treatment of mild to moderate acne and are first-line choices. Topical tretinoin is used as a second-line or third-line treatment. Oral antibiotics are used when topical antibiotics fail. Salicylic acid is an appropriate first-line treatment, but because this patient has pustular lesions, topical antibiotics must be included. DIF: Cognitive Level: Applying (Application)

REF: 165

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12. A primary care NP is preparing to irrigate and suture a laceration on a patient’s thumb. To

anesthetize the site, the NP should use: a.

lidocaine hydrochloride.

lidocaine with epinephrine.

bupivacaine hydrochloride.

bupivacaine with epinephrine.

ANS: B

Vasoconstrictors, such as epinephrine, help to prolong local anesthetic action by decreasing systemic absorption, but they are not safe to use at the ends of arteries in fingers, toes, the nose, or the penis. Lidocaine is an intermediate-acting local anesthetic and, when used without epinephrine, is appropriate to use on a thumb. Bupivacaine is a very long-acting anesthetic and is not needed for a short procedure. DIF: Cognitive Level: Applying (Application)

REF: 169

Chapter 14: Eye, Ear, Throat, and Mouth Agents Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) sees a patient who has a 1-week history of watery,

painful eyes with copious amounts of clear discharge and a sore throat. The NP observes bilateral erythema of the conjunctivae and palpates enlarged preauricular lymph nodes. The NP should prescribe drops. a.

ganciclovir

ophthalmic antibiotic

sympathomimetic ophthalmic

nonsteroidal antiinflammatory

ANS: B

The patient has symptoms of viral conjunctivitis; clear discharge is characteristic. Antibiotic drops are often prescribed to prevent a bacterial infection. Ganciclovir drops are antiviral drops but are reserved for patients with a clinical diagnosis of herpetic keratitis by an ophthalmologist. Sympathomimetic drops are used to treat glaucoma. Nonsteroidal antiinflammatory drops are sometimes used for allergic conjunctivitis. DIF: Cognitive Level: Applying (Application)

REF: 175

2. A primary care NP examines a patient who complains of chronic, intermittent watery

eyes and runny nose. The NP notes cobblestone-like papillae inside the upper eyelid with nonerythematous conjunctivae. The NP should: a.

prescribe intranasal corticosteroids.

refer the patient to an ophthalmologist.

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prescribe trifluridine ophthalmic eye drops.

apply fluorescein dye to examine the cornea.

ANS: A

This patient has symptoms characteristic of allergic conjunctivitis. Any allergic rhinitis should be treated first. Intranasal corticosteroids are often effective. It is not necessary to refer to an ophthalmologist. Trifluridine is an antiviral solution used to treat documented herpetic keratitis. Fluorescein dye is used to assess for corneal abrasions or tears. DIF: Cognitive Level: Applying (Application)

REF: 175 - 176

3. The primary care NP teaches a patient how to instill eye drops for a prescription that

requires two drops twice daily. Which statement by the patient indicates understanding of the teaching? a.

“I should gently massage my eyes for 3 to 5 minutes after instilling the drops.”

“I should put in one drop and wait 5 minutes before putting in the other one.”

“To make sure the medicine is evenly distributed, I should blink several times.”

“I may continue wearing my soft contact lenses while I am using this medication.”

ANS: B

One drop of medication is all the eye can retain. If more than one drop is used, teach the patient to wait 5 minutes before applying the second drop. The eyes should not be rubbed after instillation of the drops. Patients should look down for a few seconds and then close the eyes. Soft contact lenses can absorb the medication and should not be worn. DIF: Cognitive Level: Applying (Application)

REF: 176

4. The primary care NP examines an adolescent who complains of severe right ear pain for

the past 3 days. When retracting the pinna of the right ear to examine the ear, the NP notes erythema, edema, and pain and a large amount of white exudate in the ear canal. The NP should prescribe: a.

benzocaine otic drops tid.

ciprofloxacin otic drops qid.

glycerin oil drops weekly.

acetic acid, boric acid, and isopropyl alcohol solution.

ANS: B

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This patient has otitis externa. Ciprofloxacin otic drops instilled onto a wick in the ear canal are indicated to treat this condition. Benzocaine is a local anesthetic and would not treat the infection. Glycerin oil drops are used to soften cerumen. An acetic acid, boric acid, and isopropyl alcohol solution is used to prevent, not treat, otitis externa. DIF: Cognitive Level: Applying (Application)

REF: 181 - 182

5. A parent brings in a 2-month-old infant with a 5-day history of a white coating on the

tongue and decreased oral intake. The primary care NP should prescribe: a.

clotrimazole, one troche tid.

chlorhexidine, 15 mL oral rinse bid.

carbamide peroxide, 2 to 3 drops tid.

nystatin oral suspension, 200,000 units qid.

ANS: D

Nystatin is an antifungal medication and is indicated for treatment of oral candidiasis, or thrush. Clotrimazole is an antifungal but is not indicated for oral candidiasis in infants because the patient must be able to allow the troche to dissolve. Chlorhexidine is used to treat gingivitis. Carbamide peroxide is used to treat minor oral inflammation. DIF: Cognitive Level: Applying (Application)

REF: 182

6. A patient who has year-round allergic rhinitis uses an intranasal corticosteroid and a daily

oral antihistamine. The patient reports persistent watery and itchy eyes. The primary care NP observes profuse clear, watery discharge and a cobblestone appearance inside the upper eyelids, with clear conjunctivae. The patient has tried topical azelastine (Astelin) and topical diclofenac (Voltaren) without improvement. The NP should prescribe drops. a.

timolol (Timoptic)

pilocarpine (Isopto)

nedocromil (Tilade)

dexamethasone (Decadron)

ANS: C

Topical mast cell stabilizers, such as nedocromil, are good for long-term treatment of allergic conjunctivitis. Timolol and pilocarpine are used to treat glaucoma. Dexamethasone is prescribed for severe cases of conjunctivitis but should be prescribed only by an ophthalmologist. DIF: Cognitive Level: Applying (Application)

REF: 177 - 178

7. An 80-year-old patient has a diagnosis of glaucoma, and the ophthalmologist has

prescribed timolol (Timoptic) and pilocarpine eye drops. The primary care NP should counsel this patient:

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that systemic side effects of these medications may be severe.

that the combination of these two drugs may cause drowsiness.

to begin an exercise program to improve cardiovascular health.

that a higher dose of one or both of these medications may be needed.

ANS: A

Older patients are susceptible to systemic effects of topical eye drops. Timolol can cause cerebrovascular, central nervous system, and respiratory side effects, and pilocarpine can cause systemic -blocker effects. The combination does not cause drowsiness. Although there is some correlation between cardiovascular health and glaucoma, beginning a new exercise program is not indicated. A higher dose of the medications would increase systemic side effects. DIF: Cognitive Level: Applying (Application)

REF: 183

Chapter 15: Upper Respiratory Agents Test Bank MULTIPLE CHOICE 1. A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory

infections and asks about the best way to avoid getting sick. The NP should recommend which of the following? a.

Echinacea

Frequent hand washing

Zinc gluconate supplements

Normal saline nasal irrigation

ANS: B

Hand washing is the most effective way to prevent the spread of viral upper respiratory illness (VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun. DIF: Cognitive Level: Applying (Application)

REF: 189

2. A patient comes to the clinic with a 3-day history of fever and a severe cough that

interferes with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The NP should:

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order a narcotic antitussive to suppress cough.

obtain a thorough history of the patient’s symptoms.

suggest that the patient try a guaifenesinonly over-the-counter product.

prescribe an antibiotic to treat the underlying cause of the patient’s cough.

ANS: B

It is important to determine the underlying disorder that is causing the cough to rule out serious causes of cough. The NP should obtain a thorough history before prescribing any treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin may be used to make nonproductive coughs more productive. Antibiotics are indicated only for a proven bacterial infection. DIF: Cognitive Level: Applying (Application)

REF: 192

3. An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the

patient that this drug: a.

may cause a bitter aftertaste.

will not provide maximum relief for a few weeks.

will cause rebound congestion if withdrawn suddenly.

can cause many systemic side effects such as drowsiness.

ANS: A

Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may experience relief from symptoms within 30 minutes. Decongestants can cause rebound congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects. DIF: Cognitive Level: Applying (Application)

REF: 198

4. A parent asks an NP which over-the-counter medication would be best to give to a 5-year-

old child who has a viral respiratory illness with nasal congestion and a cough. The NP should recommend which of the following? a.

Diphenhydramine (Benadryl)

Increased fluids with a teaspoon of honey

Over-the-counter pseudoephedrine with guaifenesin (Sudafed)

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An antitussive/expectorant combination such as Robitussin DM

d. ANS: B

Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has been shown to be effective in reducing cough in small children. Diphenhydramine is an antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and Robitussin are not recommended in children younger than 6 years. DIF: Cognitive Level: Applying (Application)

REF: 198

5. A child with chronic allergic symptoms uses an intranasal steroid for control of

symptoms. At this child’s annual well-child checkup, the NP should carefully review this child’s: a.

urinalysis.

blood pressure.

height and weight.

liver function tests.

ANS: C

Intranasal corticosteroids can cause growth suppression in children. When using intranasal steroids in children, the lowest dosage should be used for the shortest period of time necessary, and growth should be routinely monitored. It is not necessary to evaluate urine, blood pressure, or liver function because of intranasal steroid use. DIF: Cognitive Level: Applying (Application)

REF: 191

6. An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing,

and nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should prescribe: a.

azelastine (Astelin).

triamcinolone (Nasacort AQ).

phenylephrine (Neo-Synephrine).

cromolyn sodium (Nasalcrom).

ANS: B

According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients. Intranasal corticosteroids are indicated for patients who do not respond to antihistamines. Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids.

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DIF: Cognitive Level: Applying (Application)

REF: 188 - 189

7. A 70-year-old patient asks an NP about using diphenhydramine (Benadryl) to control

intermittent allergic symptoms that include runny nose and sneezing. The NP should counsel this patient to: a.

take the lowest recommended dose initially.

monitor for hypertension while taking the drug.

take the antihistamine with a decongestant for best effect.

watch for symptoms of paradoxical excitation with this medication.

ANS: A

Antihistamines are more likely to cause excessive sedation, syncope, dizziness, confusion, and hypotension in elderly patients; a decrease in dose is usually necessary. Hypotension is likely; there is no need to monitor for hypertension. This patient does not have symptoms of congestion. Paradoxical excitation occurs in some young children but is not an identified risk in elderly patients. DIF: Cognitive Level: Applying (Application)

REF: 191

8. A patient asks an NP about using an oral over-the-counter decongestant medication for

nasal congestion associated with a viral upper respiratory illness. The NP learns that this patient uses loratadine (Claritin), a -adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects? a.

Liver toxicity

Excessive drowsiness

Rebound congestion

Tremor, restlessness, and insomnia

ANS: D

-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive drowsiness, and rebound congestion are not known adverse effects of drug interactions. DIF: Cognitive Level: Analyzing (Analysis)

REF: 195

Chapter 16: Asthma and Chronic Obstructive Pulmonary Disease Medications Test Bank MULTIPLE CHOICE

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1. A primary care nurse practitioner (NP) is evaluating a patient with asthma who reports

having wheezing and coughing 1 or 2 days each week and awakening from sleep three or four times each month with asthma symptoms. The patient’s forced expiratory volume in 1 second (FEV 1 ) is 80% of the predicted value. The patient’s current medication regimen is an albuterol metered-dose inhaler, 2 puffs every 4 hours as needed. The NP should prescribe: a.

montelukast (Singulair) po daily.

ipratropium bromide bid with albuterol.

a low-dose inhaled corticosteroid (ICS), 2 puffs bid.

a long-acting -adrenergic agonist (LABA), 1 puff bid.

ANS: C

This patient has symptoms of mild, persistent asthma. The preferred controller medication in adults and children with persistent asthma is a low-dose ICS. Montelukast is a leukotriene modifier, which may be considered as an alternative to a low-dose ICS but is not the first option to try. Ipratropium is often used during an acute exacerbation but not for long-term control. LABA medications are used in patients with moderate persistent symptoms. DIF: Cognitive Level: Applying (Application)

REF: 210

2. A primary care NP sees an adolescent patient for a hospitalization follow-up after an

asthma exacerbation. The patient reports having daily symptoms with nighttime awakening 4 or 5 nights per week and misses school several days each month. The patient currently uses a salmeterol/fluticasone LABA twice daily and albuterol as needed. The patient requires a refill of the albuterol prescription once a month. The patient does not have any known allergies. The NP should: a.

order a high-dose ICS plus a LABA twice daily.

consider adding theophylline to this patient’s regimen.

continue the current regimen and add omalizumab daily.

order a combination product with ipratropium and albuterol.

ANS: A

The patient has moderate persistent asthma not well controlled with the current regimen. The next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an asthma specialist. Theophylline is recommended in the 5- to 11-year age group. Omalizumab is indicated if the patient has allergies. Ipratropium is used during acute exacerbations.

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DIF: Cognitive Level: Applying (Application)

REF: 210

3. A 50-year-old patient who recently quit smoking reports a frequent morning cough

productive of yellow sputum. A chest x-ray is clear, and the patient’s FEV 1 is 80% of predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath sounds. The NP should: a.

reassure the patient that these symptoms will subside.

prescribe a moderate-dose ICS twice daily.

order a long-acting anticholinergic with albuterol twice daily.

prescribe an albuterol metered-doseinhaler, 2 puffs every 4 hours as needed.

ANS: D

For patients with stable COPD having respiratory symptoms with FEV1 between 60% and 80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended when FEV 1 is less than 60%. DIF: Cognitive Level: Applying (Application)

REF: 212 - 213

4. A primary care NP is evaluating a patient who has COPD. The patient uses a LABA twice

daily. The patient reports having increased exertional dyspnea, a frequent cough, and poor sleep. The patient also uses a short-acting -adrenergic agonist (SABA) five or six times each day. Pulse oximetry reveals an oxygen saturation of 92%. The patient’s FEV 1 /forced vital capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe a(n): a.

oral corticosteroid.

long-acting anticholinergic.

long-acting oral theophylline.

combination ICS/LABA inhaler.

ANS: D

Providers should administer combination inhaled therapies for symptomatic patients with stable COPD and FEV 1 less than 60%. Oral corticosteroids have not been shown to be effective, even in severe cases of COPD. Long-acting anticholinergic medications may be used as monotherapy in early stages of COPD. Long-acting theophylline is poorly tolerated because of side effects. DIF: Cognitive Level: Applying (Application)

REF: 213

5. A primary care NP sees a child with asthma to evaluate the child’s response to the

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prescribed therapy. The child uses an ICS twice daily and an albuterol metered -dose inhaler as needed. The child’s symptoms are well controlled. The NP notes slowing of the child’s linear growth on a standardized growth chart. The NP should change this child’s medication regimen to a: a.

combination ICS/LABA inhaler twice daily.

short-acting 2 -agonist (SABA) with oral corticosteroids when symptomatic.

combination ipratropium/albuterol inhaler twice daily.

SABA as needed plus a leukotriene modifier once daily.

ANS: D

A leukotriene modifier may be used as an alternative to ICS for children who experience systemic side effects of the ICS. This child’s symptoms are well controlled, so there is no need to step up therapy to include a LABA. Oral corticosteroids should be used only for severe exacerbations. Ipratropium and albuterol are used for severe exacerbations. DIF: Cognitive Level: Applying (Application)

REF: 210

6. A patient who was recently diagnosed with COPD comes to the clinic for a follow-up

evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports occasional mild exertional dyspnea but is able to sleep well. The patient’s FEV 1 in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend: a.

a combination LABA/ICS twice daily.

influenza and pneumococcal vaccines.

ipratropium bromide (Atrovent) twice daily.

home oxygen therapy as needed for dyspnea.

ANS: B

Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that will affect respiratory status. This patient is stable with the prescribed medications, so no additional medications are needed at this time. Home oxygen therapy is used for patients with severe resting hypoxemia. DIF: Cognitive Level: Applying (Application)

REF: 213

7. A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for

exacerbation of symptoms. The patient reports using the SABA three or four times each week when short of breath. The patient reports feeling jittery and nauseated and having

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trouble sleeping. The primary care NP should: a.

obtain a serum theophylline level.

order a creatinine clearance level.

prescribe a leukotriene modifier instead of theophylline.

discontinue the SABA and change to ipratropium bromide.

ANS: A

Nausea, vomiting, insomnia, jitteriness, and other symptoms may indicate theophylline toxicity. Serum concentration monitoring should be done whenever signs of toxicity are suspected. A serum creatinine clearance level is not indicated. Leukotriene modifiers are not used for COPD. Ipratropium is used as an adjunct to the SABA during acute exacerbations. DIF: Cognitive Level: Applying (Application)

REF: 214

8. A 75-year-old patient requires frequent use of corticosteroids to control COPD

exacerbations. To monitor adverse drug effects in this patient, the primary care NP should: a.

order a bone density study.

monitor the patient’s renal function at every visit.

order an electrocardiogram to assess for arrhythmias.

order routine chest radiographs to watch for pneumonia.

ANS: A

High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen osteoporosis in an older adult. The NP should order a bone density study. DIF: Cognitive Level: Applying (Application)

REF: 215

9. A patient with asthma is given an asthma action plan and returns to the clinic in 2 weeks

to follow up on symptoms. Which statement by the patient indicates a need for further teaching? a.

“I use the ICS as needed when I am wheezing.”

“A side effect of albuterol may be shortness of breath.”

“I should rinse my mouth thoroughly after using an ICS.”

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“I put the albuterol metered-dose inhaler in my mouth with my lips sealed around it.”

ANS: A

ICSs are controller medications and are not used as needed for symptoms, so this statement by the patient indicates a need for further teaching. The other statements are true. DIF: Cognitive Level: Understanding (Comprehension)

REF: 210

Chapter 17: Hypertension and Miscellaneous Antihypertensive Medications Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood

pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: a.

prescribe a thiazide diuretic.

consider treatment with an angiotensinconverting enzyme inhibitor.

reassure the patient that these findings are normal.

counsel the patient about dietary and lifestyle changes.

ANS: D

The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. DIF: Cognitive Level: Applying (Application) REF: 226| Table 17-2| Table 17-4| Table 17-6 2. A 55-year-old patient with no prior history of hypertension has a blood pressure greater

than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for cardiovascular disease. The primary care NP should: a.

prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.

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perform a careful cardiovascular physical assessment.

counsel the patient about dietary and lifestyle changes.

order a urinalysis and creatinine clearance and begin therapy with a -blocker.

ANS: B

If the patient is younger than 20 or older than 50 years old at the onset of elevated blood pressure, the NP should look for causes of secondary hypertension. The physical examination should include a careful cardiovascular assessment. This patient will need pharmacologic treatment, but not until the underlying cause of hypertension is determined. DIF: Cognitive Level: Applying (Application)

REF: 227 - 228

3. The primary care NP sees a new patient who has diabetes and hypertension and has been

taking a thiazide diuretic for 6 months. The patient’s blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should: a.

order a

add an angiotensin-converting enzyme inhibitor.

continue the current drug regimen.

change to an aldosterone antagonist medication.

-blocker.

ANS: B

Evidence-based guidelines suggest that optimal control of hypertension to less than 130/80 mm Hg could prevent 37% of cardiovascular disease in men and 56% in women, so this patient, although showing improvement, could benefit from the addition of another medication. An angiotensin-converting enzyme inhibitor is an appropriate drug for patients who also have diabetes. -Blockers and aldosterone antagonist medications are not recommended for patients with diabetes. DIF: Cognitive Level: Applying (Application)

REF: 229| Table 17-6

4. A patient who has had a previous myocardial infarction has a blood pressure of 135/82

mm Hg. The patient’s body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe: a.

an angiotensin-converting enzyme inhibitor.

a thiazide diuretic.

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lifestyle modifications.

a calcium-channel blocker.

ANS: A

This patient has prehypertension but has a compelling reason for treatment. Patients who have had a myocardial infarction should be treated with a -blocker and angiotensinconverting enzyme inhibitor or angiotensin II receptor blocker (ARB). DIF: Cognitive Level: Applying (Application)

REF: 229| Table 17-6

5. A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s

body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: a.

an angiotensin-converting enzyme inhibitor.

a thiazide diuretic.

dietary and lifestyle changes.

-blocker.

ANS: C

The patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails. DIF: Cognitive Level: Applying (Application)

REF: 229

6. The primary care NP sees a new African-American patient who has blood pressure

readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: a.

initiate monotherapy with a thiazide diuretic.

prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.

discuss dietary and lifestyle modifications with the patient.

begin combination therapy with an ARB and a calcium-channel blocker.

ANS: A

African Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as

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adjunct medications in African Americans. DIF: Cognitive Level: Applying (Application)

REF: 232| Table 17-2

7. An 80-year-old male patient will begin taking an -antiadrenergic medication. The

primary care NP should teach this patient to: a.

ask for assistance while bathing.

restrict fluids to aid with diuresis.

take the medication in the morning with food.

be aware that priapism is a common side effect.

ANS: A

All antihypertensives can cause orthostatic hypotension, so patients should be cautioned to avoid sudden changes in position and to use caution when bathing because a hot bath or shower may aggravate dizziness. Older patients are at increased risk for falls and should be cautioned to ask for assistance. Patients taking -antiadrenergics should consume extra fluids because dehydration can increase the risk of orthostatic hypotension. Patients should take the medication at bedtime because drowsiness is a common side effect. Priapism is not a side effect of these drugs. DIF: Cognitive Level: Applying (Application)

REF: 232 - 233

Chapter 18: Coronary Artery Disease and Antianginal Medications Test Bank MULTIPLE CHOICE 1. A patient who has a history of angina has sublingual nitroglycerin tablets to use as

needed. The primary care nurse practitioner (NP) reviews this medication with the patient at the patient’s annual physical examination. Which statement by the patient indicates understanding of the medication? a.

“I should call 9-1-1 if chest pain persists 5 minutes after the first dose.”

“I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1.”

“I should take aspirin along with the nitroglycerin when I have chest pain.”

“I should take nitroglycerin and then rest for 15 minutes before taking the next dose.”

ANS: A

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Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS), more recent guidelines suggest an alternative strategy to reduce delays in emergency care. These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses of nitroglycerin are given 5 minutes apart over 15 minutes. DIF: Cognitive Level: Applying (Application)

REF: 241

2. A patient who will begin using nitroglycerin for angina asks the primary care NP how the

medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: a.

dissolve atheromatous lesions.

relax vascular smooth muscle.

prevent catecholamine release.

reduce C-reactive protein levels.

ANS: B

Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand. Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce C-reactive protein levels. DIF: Cognitive Level: Understanding (Comprehension)

REF: 239 - 240

3. A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes.

The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain. The NP should: a.

increase the nitroglycerin dose to 0.6 mg per dose.

change from a sublingual to a transdermal patch nitroglycerin.

discontinue the nitroglycerin and order ranolazine (Ranexa ER).

contact the patient’s cardiologist to discuss admission to the hospital.

ANS: D

Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or duration of pain and fewer precipitating factors. Patients with unstable angina should be admitted to a coronary care unit. The primary care NP should not change any medications without consultation with the patient’s cardiologist.

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DIF: Cognitive Level: Applying (Application)

REF: 239

4. A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic

and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to: a.

obtain an electrocardiogram.

administer oxygen at 2 L/minute.

give 325 mg of chewable aspirin.

call EMS.

ANS: B

When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin. DIF: Cognitive Level: Applying (Application)

REF: 241

5. A 45-year-old patient who has a positive family history but no personal history of

coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend: a.

30 minutes of aerobic exercise daily.

taking 81 to 325 mg of aspirin daily.

beginning therapy with a statin medication.

starting a thiazide diuretic to treat hypertension.

ANS: A

This patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 240 - 241

6. The primary care NP is preparing to prescribe isosorbide dinitrate sustained release

(Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend

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initial dosing of: a.

60 mg four times daily at 6-hour intervals.

40 mg twice daily 30 minutes before meals.

60 mg on awakening and 40 mg 7 hours later.

80 mg three times daily at 8:00 AM , 1:00 PM , and 6:00 PM.

ANS: B

Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM , 1:00 PM, and 6:00 PM . would be appropriate at that point. DIF: Cognitive Level: Applying (Application)

REF: 241

7. A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for

a patient with chronic stable angina. The NP should teach the patient to: a.

change the patch four times daily.

use the patch as needed for angina pain.

use two patches daily and change them every 12 hours.

apply one patch daily in the morning and remove in 12 hours.

ANS: D

To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily. DIF: Cognitive Level: Applying (Application)

REF: 244

Chapter 19: Heart Failure and Digoxin Test Bank MULTIPLE CHOICE 1. A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The

primary care nurse practitioner (NP) auscultates S 3 heart sounds but does not palpate hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should

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consult a cardiologist to discuss prescribing a(n): a.

-blocker.

loop diuretic.

angiotensin-converting enzyme (ACE) inhibitor.

angiotensin receptor blocker (ARB).

ANS: B

This patient shows signs of systolic heart failure. Treatment for heart failure should begin with a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. Blockers are used in patients with minimal fluid retention and would be added later. ARBs are used if ACE inhibitors are not tolerated or are ineffective. DIF: Cognitive Level: Applying (Application)

REF: 251

2. A patient who has heart failure has been treated with furosemide and an ACE inhibitor.

The patient’s cardiologist has added digoxin to the patient’s medication regimen. The primary care NP who cares for this patient should expect to monitor: a.

serum electrolytes.

blood glucose levels.

serum thyroid levels.

complete blood counts (CBCs).

ANS: A

Hypokalemia makes the myocardium more sensitive to digoxin. These levels should be monitored closely in patients taking furosemide, which can deplete potassium. Serum glucose, thyroid levels, and a CBC should be monitored if indicated by other conditions. DIF: Cognitive Level: Applying (Application)

REF: 254

3. A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin)

for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching? a.

“I should avoid high-sodium foods.”

“I should eat foods high in potassium.”

“I need to take a calcium supplement every day.”

“I should use a salt substitute while taking these medications.”

ANS: A

Patients should be taught to reduce their overall sodium intake by avoiding salty foods

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and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium. DIF: Cognitive Level: Applying (Application)

REF: 254

4. A patient has heart failure. A recent echocardiogram reveals decreased compliance of the

left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a.

order serum electrolytes.

obtain renal function tests.

consider prescribing a

call the patient’s cardiologist to discuss adding digoxin to the patient’s regimen.

-blocker.

ANS: A

Patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are not indicated. -Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure. DIF: Cognitive Level: Applying (Application)

REF: 251

5. A primary care NP is preparing to order digoxin for an 80-year-old patient who has

systolic heart failure. The NP obtains renal function tests, which are normal. The NP should: a.

prescribe a digoxin 0.125 mg tablet once daily.

give an initial dose of 0.5 mg digoxin tablet and then 0.125 mg every 6 hours

administer a digoxin 0.6 mg capsule once and then 0.3 mg every 8 hours 3.

administer a loading dose of intravenous digoxin in the clinic and then give 0.125 mg once daily.

ANS: A

In primary care settings, slow digitalization rather than a loading dose is generally recommended because of the risk of toxicity. Digitalization may be achieved within 1 week with the use of small daily maintenance doses.

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DIF: Cognitive Level: Applying (Application)

REF: 245| Table 19-5

6. A primary care NP sees a patient who is being treated for heart failure with digoxin, a

loop diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of 60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: a.

decrease the dose of the diuretic to prevent further dehydration.

obtain a serum potassium level to assess for hyperkalemia.

hold the ACE inhibitor until the patient’s blood pressure stabilizes.

obtain a digoxin level before the patient takes the next dose of digoxin.

ANS: D

To monitor for toxicity, the health care provider must be alert to early signs of toxicity and must obtain a serum level. Nausea is an early sign of toxicity. DIF: Cognitive Level: Applying (Application)

REF: 253 - 254

7. A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not

working as well as it did initially. The primary care NP should: a.

recommend a reduced potassium intake.

increase the dose of digoxin to 0.5 mg daily.

hold the next dose of digoxin and obtain a serum digoxin level.

contact the patient’s pharmacy to ask if generic digoxin was dispensed.

ANS: D

Clinicians should be aware that generic digoxin marketed by different companies may not be bioequivalent to the branded digoxin (Lanoxin). Patients with hyperkalemia would show intensified effects, not diminished effects of digoxin. Patients with diminished effects may have received a generic brand. It is not correct to increase the dose of digoxin without first obtaining a digoxin level. Because this patient is reporting decreased effects, it is unnecessary to suspect toxicity. DIF: Cognitive Level: Applying (Application)

REF: 254

Chapter 20: Beta-Blockers Test Bank MULTIPLE CHOICE

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1. An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20

mg once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should change the dose of nadolol to mg daily. 40; once a. b.

80; once

20; twice

40; twice

ANS: A

-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily. DIF: Cognitive Level: Applying (Application)

REF: 259| Table 20-7

2. A patient is in the clinic for a follow-up examination after a myocardial infarction (MI).

The patient has a history of left ventricular systolic dysfunction. The primary care NP should expect this patient to be taking: a.

nadolol (Corgard).

carvedilol (Coreg).

timolol (Blocadren).

propranolol (Inderal).

ANS: B

The 2012 guides for prevention of cardiovascular disease recommend that -blocker therapy should be used in all patients with left ventricular systolic dysfunction with heart failure or prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol. DIF: Cognitive Level: Understanding (Comprehension)

REF: 259

3. An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all

of the time. The primary care NP should: a.

tell the patient to stop taking the medication immediately.

recommend that the patient take the medication at bedtime.

tell the patient that tolerance to this side effect will occur over time.

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contact the patient’s cardiologist to discuss decreasing the dose of propranolol.

d. ANS: D

Elderly patients have described sedation and sleep disturbances with -blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly. DIF: Cognitive Level: Applying (Application)

REF: 260

4. A patient with a history of coronary heart disease develops atrial fibrillation. The primary

care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which -blocker medication? a.

Nadolol (Corgard)

Sotalol (Betapace)

Timolol (Blocadren)

Propranolol (Inderal)

ANS: B

Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease. DIF: Cognitive Level: Applying (Application)

REF: 259

5. A patient who has migraine headaches has begun taking timolol and 2 months after

beginning this therapy reports no change in frequency of migraines. The patient’s current dose is 30 mg once daily. The primary care NP should: a.

change the medication to propranolol.

increase the dose to 40 mg once daily.

obtain serum drug levels to see if the dose is therapeutic.

tell the patient to continue taking the timolol and return in 1 month.

ANS: D

When giving timolol for migraine prophylaxis, the provider should inform the patient that it may take several weeks for therapy to be effective. The dose should be titrated and maintained for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not serum drug levels. DIF: Cognitive Level: Applying (Application)

REF: 259 - 260

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6. A patient who has been taking propranolol for 6 months reports having nocturnal cough

and shortness of breath. The primary care NP should: a.

tell the patient to stop taking the medication.

obtain serum drug levels to monitor for toxicity of this medication.

instruct the patient to increase activity and exercise to counter these side effects.

contact the patient’s cardiologist to discuss changing to a selective -blocker.

ANS: D

Nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective -blocker with the patient’s cardiologist. â-Blockers should never be stopped abruptly. Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these side effects if bronchospasm is the cause. DIF: Cognitive Level: Applying (Application)

REF: 260 - 261

7. A patient is in the clinic for an annual physical examination. The primary care NP obtains

a medication history and learns that the patient is taking a -blocker and nitroglycerin. The NP orders laboratory tests, performs a physical examination, and performs a review of systems. Which finding may warrant discontinuation of the -blocker in this patient? a.

Increased triglycerides

Decreased exercise tolerance

Wheezing, dyspnea, and cough

Nausea, vomiting, and anorexia

ANS: C

-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the -blocker may be required. -Blockers may cause an insignificant increase in serum triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common. DIF: Cognitive Level: Applying (Application)

REF: 257

8. A primary care NP provides teaching for a patient who will begin taking propranolol

(Inderal). Which statement by the patient indicates understanding of the teaching? a.

“I should take this medication on an empty stomach.”

“I should use caution while driving while taking this medication.”

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“I should not take the medication if my pulse is less than 60 beats per minute.”

“If I have shortness of breath, I should discontinue the medication immediately.”

ANS: B

Because the medication can cause fatigue and drowsiness, patients should be advised to use caution when driving. The medication should be taken with food. Patients should not take a dose if the heart rate is less than 50 beats per minute. Patients should be advised to report shortness of breath but should not abruptly stop taking the medication. DIF: Cognitive Level: Applying (Application)

REF: 258

Chapter 21: Calcium Channel Blockers Test Bank MULTIPLE CHOICE 1. A patient who has stable angina pectoris and a history of previous myocardial infarction

takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil: a.

improves blood flow and oxygen delivery to the heart.

increases the rate of contraction of the cardiac muscle.

increases the force of contraction of the cardiac muscle.

has a positive inotropic effect to increase cardiac output.

ANS: A

Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary resistance and improves blood flow through collateral vessels as well as oxygen delivery to ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of contraction of the heart. DIF: Cognitive Level: Applying (Application)

REF: 265 - 266

2. A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The

primary care NP should contact the patient’s cardiologist to discuss adding: a.

amlodipine (Norvasc).

diltiazem (Cardizem).

verapamil HCl (Calan).

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nifedipine (Procardia XL).

d. ANS: D

Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug. DIF: Cognitive Level: Applying (Application)

REF: 267

3. A patient who has stable angina is taking nitroglycerin and a

-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: a. isradipine (DynaCirc). b.

nicardipine (Cardene).

verapamil HCl (Calan).

nifedipine (Procardia XL).

ANS: C

Nitrates and -blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose. DIF: Cognitive Level: Applying (Application)

REF: 268

4. A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary

care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to: a.

amlodipine (Norvasc).

isradipine (DynaCirc).

verapamil HCl (Calan).

short-acting nifedipine (Procardia).

ANS: C

Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. DIF: Cognitive Level: Applying (Application)

REF: 268

5. An African-American patient who is obese has persistent blood pressure readings greater

than 150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should consider prescribing a(n): a.

angiotensin receptor blocker.

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-blocker.

ACE inhibitor.

calcium channel blocker.

ANS: D

African-American patients are considered good candidates for calcium channel blockers to treat hypertension. Treatment with calcium channel blockers as monotherapy in African-American patients has proved to be more effective than some other classes of antihypertensive agents. DIF: Cognitive Level: Applying (Application)

REF: 268

6. A patient who takes a calcium channel blocker is in the clinic for an annual physical

examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate: a.

serum calcium channel blocker level.

complete blood count and electrolytes.

liver function tests (LFTs) and renal function.

thyroid and insulin levels.

ANS: C

Patients who take calcium channel blockers should have periodic renal and LFTs. DIF: Cognitive Level: Applying (Application)

REF: 268

7. A patient who is taking nifedipine develops mild edema of both feet. The primary care

NP should contact the patient’s cardiologist to discuss: a.

changing to amlodipine.

ordering renal function tests.

increasing the dose of nifedipine.

evaluation of left ventricular function.

ANS: A

Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms. DIF: Cognitive Level: Applying (Application)

REF: 269

Chapter 22: ACE Inhibito rs and Angiotensin Receptor Blockers

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Test Bank MULTIPLE CHOICE 1. An African-American patient is taking captopril (Capoten) 25 mg twice daily. When

performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: a.

increase the captopril dose to 50 mg twice daily.

add a thiazide diuretic to this patient’s regimen.

change the drug to losartan (Cozaar) 50 mg once daily.

recommend a low-sodium diet in addition to the medication.

ANS: B

Some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case. DIF: Cognitive Level: Applying (Application)

REF: 275 - 276

2. A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin

for angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor. Preliminary laboratory tests reveal decreased renal function. The NP should: a.

begin therapy with a low-dose ACE inhibitor.

choose an ARB instead.

add a low-dose thiazide diuretic to the drug regimen.

order a renal perfusion study before starting treatment.

ANS: D

ACE inhibitors are contraindicated in patients with bilateral renal stenosis. Because this patient has decreased renal function, perfusion studies are indicated. If the patient does not have bilateral renal stenosis, a low-dose ACE inhibitor may be used. An ARB is indicated if perfusion studies show bilateral renal stenosis. A thiazide diuretic is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 277

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3. A patient who has type 2 diabetes is seen by a primary care NP for a physical

examination. The NP notes a blood pressure of 140/95 mm Hg on three occasions. A urinalysis reveals macroalbuminuria. The patient’s serum creatinine is 1.9 mg/dL. Adhering to evidence-based practice, the NP should prescribe: losartan (Cozaar). a. b.

captopril (Capoten).

enalapril maleate (Vasotec).

fosinopril sodium (Monopril).

ANS: A

In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dL), ARBs have been shown to delay the progression of nephropathy. Losartan is an ARB. The other medications are ACE inhibitors. DIF: Cognitive Level: Applying (Application)

REF: 277

4. A patient who is taking an ACE inhibitor sees the primary care NP for a follow-up visit.

The patient reports having a persistent cough. The NP should: a.

consider changing the medication to an ARB.

order a bronchodilator to counter the bronchospasm caused by this drug.

ask whether the patient has had any associated facial swelling with this cough.

reassure the patient that tolerance to this adverse effect will develop over time.

ANS: A

A persistent cough may occur with ACE inhibitors and may warrant discontinuation of the drug. An ARB would be the next drug of choice because it does not have this side effect. The cough is not related to bronchospasm. Angioedema is not related to ACE inhibitor–induced cough. Patients do not develop tolerance to this side effect. DIF: Cognitive Level: Applying (Application)

REF: 275

5. A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin

taking spironolactone. The primary care NP should counsel this patient to: a.

avoid foods that are high in potassium.

use a salt substitute when seasoning foods.

discuss changing the ACE inhibitor to an ARB with the cardiologist.

avoid taking antacids containing

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magnesium while taking these drugs. ANS: A

Use of potassium-sparing diuretics or salt substitutes can induce hyperkalemia when taking ACE inhibitors, so this patient should be counseled to restrict potassium. Salt substitutes are high in potassium and are contraindicated. It is not necessary to change to an ARB. Antacids are not contraindicated. DIF: Cognitive Level: Applying (Application)

REF: 278

6. A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary

care NP should counsel the patient to: a.

report wheezing and shortness of breath, which may occur with these drugs.

take care when getting out of bed or a chair after the first dose of the ACE inhibitor.

discuss taking an increased dose of the thiazide diuretic with the cardiologist.

minimize fluid intake for several days when beginning therapy with the ACE inhibitor.

ANS: B

ACE inhibitors have a first-dose effect that may cause a precipitous symptomatic fall in blood pressure, particularly in patients receiving diuretics. The patient should be counseled about rising quickly from sitting or lying down. Wheezing and shortness of breath are unlikely. An increased dose of diuretic and a reduction in fluid intake are not indicated and may add to hypotension. DIF: Cognitive Level: Applying (Application)

REF: 278

7. The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP

learns that the patient has decreased renal function and has renal artery stenosis in the right kidney. The NP should: a.

initiate ACE inhibitor therapy at a low dose.

consider a different drug class to treat this patient’s symptoms.

give the captopril with a thiazide diuretic to improve renal function.

order lisinopril (Zestril) instead of captopril to avoid increased nephropathy.

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ANS: A

Patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary to avoid ACE inhibitors with unilateral renal stenosis. DIF: Cognitive Level: Applying (Application)

REF: 278

Chapter 23: Antiarrhy thmic Agents Test Bank MULTIPLE CHOICE 1. Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and

the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the primary care nurse practitioner (NP) why the procedure is necessary. The NP should tell the patient: a.

this medication prevents clots but does not alter rhythm.

if the medication proves effective, the procedure may be canceled.

there are no medications that alter the arrhythmia causing AF.

to ask the cardiologist if verapamil may be ordered instead of cardioversion.

ANS: A

Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. -Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF. DIF: Cognitive Level: Applying (Application)

REF: 283

2. A patient undergoes a routine electrocardiogram (ECG), which reveals occasional

premature ventricular contractions that are present when the patient is resting and disappear with exercise. The patient has no previous history of cardiovascular disease, and the cardiovascular examination is normal. The primary care NP should: a.

prescribe quinidine (Quinidex Extentabs).

tell the patient that treatment is not indicated.

refer the patient to a cardiologist for further evaluation.

consider using amiodarone if the patient

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develops other symptoms. ANS: B

The most important factor in determining whether to treat premature ventricular contractions is the presence of underlying heart disease, such as myocardial ischemia, previous myocardial infarction, cardiac scarring or hypertrophy, or left ventricular dysfunction. Because of the risks associated with antiarrhythmic therapy, patients should not be treated unless clear indications are present. Premature ventricular contractions are not treated if the patient is asymptomatic, if the patient has a normal heart, if the premature ventricular contractions are simple, and if they disappear with exercise. Amiodarone is not used to treat acute premature ventricular contractions but is used for long-term prophylaxis. DIF: Cognitive Level: Applying (Application)

REF: 283

3. The primary care NP sees a new patient for a routine physical examination. When

auscultating the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed by a pause. History reveals no past cardiovascular disease, but the patient reports occasional syncope and shortness of breath. The NP should: a.

order an ECG and refer to a cardiologist.

schedule a cardiac stress test and a graded exercise test.

order a complete blood count (CBC) and electrolytes and consider a trial of procainamide.

prescribe a -blocker and anticoagulant and order 24-hour Holter monitoring.

ANS: A

Premature ventricular contractions are premature ventricular beats with a compensatory pause. This patient has no prior history, but does have syncope and shortness of breath. The NP should order an ECG and refer the patient to a cardiologist for further evaluation. If there were no other symptoms, the NP could order stress testing. Medications are not indicated without further testing and without consultation with a cardiologist. DIF: Cognitive Level: Applying (Application)

REF: 284

4. A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The

primary care NP notes thready, rapid pulses and 3-second capillary refill. An ECG reveals a heart rate of 198 beats per minute with a regular rhythm. The NP should: a.

administer intravenous fluids and obtain serum electrolytes.

administer amiodarone in the clinic and observe closely for response.

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order digoxin and verapamil and ask the patient to return for a follow-up examination in 1 week.

send the patient to an emergency department for evaluation and treatment.

ANS: D

Paroxysmal supraventricular tachycardia (PSVT) is a very fast regular rate and rhythm. This patient is becoming decompensated and should be referred to the emergency department for evaluation and treatment. The primary care NP should not treat this in the clinic or as an outpatient until the patient is stable. DIF: Cognitive Level: Applying (Application)

REF: 286

5. A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract

infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest, determined to be from long QT syndrome. The NP should: a.

schedule a treadmill stress test.

order genetic testing for this patient.

discontinue the trimethoprimsulfamethoxazole.

refer the patient to a cardiologist for further evaluation.

ANS: B

When a family member’s death is found to be from long QT syndrome, the entire family must undergo testing. Treadmill testing may be normal in many cases. Trimethoprimsulfamethoxazole can prolong the QT interval and should not be used in patients at risk, but genetic testing should be performed to determine this. DIF: Cognitive Level: Applying (Application)

REF: 286

6. The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome.

The cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not obese. The patient asks the NP what else can be done to minimize risk of sudden cardiac arrest. The NP should counsel the patient to: a.

drink extra fluids when exercising.

reduce stress with yoga and hot baths.

ask the cardiologist about an implantable defibrillator.

ask the cardiologist about adding procainamide to the drug regimen.

ANS: A

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Patients with long QT syndrome should avoid situations in which they might overheat or get dehydrated. This patient should be encouraged to drink plenty of fluids while exercising and should avoid activities such as yoga and hot baths. Implantable cardioverter-defibrillators are used for high-risk patients. Procainamide can cause long QT syndrome. DIF: Cognitive Level: Applying (Application)

REF: 287

7. A patient who has been taking quinidine for several years reports lightheadedness,

fatigue, and weakness. The primary care NP notes a heart rate of 110 beats per minute. The serum quinidine level is 6 g/mL. The NP should: a.

discontinue the medication immediately.

reassure the patient that this is a therapeutic drug level.

order an ECG, CBC, liver function tests (LFTs), and renal function tests.

admit the patient to the hospital and obtain a cardiology consultation.

ANS: C

The therapeutic level for quinidine is 2 to 5 ìg/mL. Some patients have therapeutic responses at up to 6 g/mL. The NP should order ECG, CBC, LFT, and renal function tests. DIF: Cognitive Level: Applying (Application)

REF: 287

Chapter 24: Antihy perlipidemic Agents Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) sees a patient for a physical examination and

orders laboratory tests that reveal low-density lipoprotein (LDL) of 100 mg/dL, highdensity lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous history of coronary heart disease. The NP should consider prescribing: a.

ezetimibe (Zetia).

gemfibrozil (Lopid).

simvastatin (Zocor).

nicotinic acid (Niaspan).

ANS: B

Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels. This

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patient’s LDL is within normal limits, so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor, used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy. DIF: Cognitive Level: Applying (Application)

REF: 295

2. A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile

that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient’s father developed coronary heart disease at age 55 years. The NP should prescribe: a.

atorvastatin (Lipitor).

gemfibrozil (Lopid).

cholestyramine (Questran).

lovastatin/niacin (Advicor).

ANS: A

HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male firstdegree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy. DIF: Cognitive Level: Applying (Application)

REF: 293

3. A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6

months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: a.

order liver function tests (LFTs).

order a creatine kinase-MM (CK-MM) level.

change atorvastatin to twice-daily dosing.

add gemfibrozil (Lopid) to the patient’s medication regimen.

ANS: B

Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated.

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DIF: Cognitive Level: Applying (Application)

REF: 299

4. A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues

to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: a.

change the atorvastatin dose to 15 mg twice daily.

change the patient’s medication to cholestyramine (Questran).

add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.

recommend supplements of omega-3 along with the atorvastatin.

ANS: C

When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 299

5. A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals

LDL of 130 mg/dL, HDL of 35 mg/dL, and triglycerides 150 mg/dL. The woman is sedentary with a body mass index of 26. The woman asks the primary care NP about using a statin medication. The NP should: a.

recommend dietary and lifestyle changes first.

begin therapy with atorvastatin 10 mg per day.

discuss quality-of-life issues as part of the decision to begin medication.

tell her there is no clinical evidence of efficacy of statin medication in her case.

ANS: B

This woman would be using a statin medication for secondary prevention because she already has a history of MI, so a statin should be prescribed. Dietary and lifestyle changes should be a part of therapy, but not the only therapy. She is relatively young, and qualityof-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women.

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DIF: Cognitive Level: Applying (Application)

REF: 296

6. A patient who has diabetes is taking simvastatin (Zocor) 80 mg daily to treat LDL

cholesterol level of 170 mg/dL. The patient has a body mass index of 29. At a follow-up visit, the patient’s LDL level is 120 mg/dL. The primary care NP should consider: a.

increasing the simvastatin to 80 mg twice daily.

adding nicotinic acid to the patient’s drug regimen.

changing the medication to ezetimibe/simvastatin (Vytorin).

referring the patient to a dietitian for assistance with weight reduction.

ANS: C

Patients with diabetes have a goal LDL of less than 100 mg/dL. If maximum-dose statin is unable to achieve the goal LDL, a combination product such as a statin plus ezetimibe is recommended. The maximum recommended dose is 80 mg daily, so increasing the dose to 80 mg twice daily is incorrect. DIF: Cognitive Level: Applying (Application)

REF: 296

7. A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant.

Which bile acid sequestrant should the primary care NP order? a.

Colesevelam (Welchol)

Colestipol (Colestid)

Cholestyramine (Questran)

Cholestyramine (Questran Light)

ANS: A

All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient. DIF: Cognitive Level: Applying (Application)

REF: 298

8. A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor.

All of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL cholesterol. The NP should: a.

order LFTs.

order CK-MM tests.

consider decreasing the dose of the

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medication. reassure the patient that this side effect is common.

d. ANS: D

LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only periodically thereafter. Headaches are common side effects, but do not raise concern about hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not necessary to decrease the medication. DIF: Cognitive Level: Applying (Application)

REF: 299

Chapter 25: Agents that Act on Blood Test Bank MULTIPLE CHOICE 1. A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The

primary care nurse practitioner (NP) plans to change the patient’s medication to dabigatran (Pradaxa). To do this safely, the NP should: a.

initiate dabigatran when the patient’s international normalized ratio (INR) is less than 2.

start dabigatran 7 to 14 days after discontinuing warfarin.

begin giving dabigatran 1 week before discontinuing warfarin.

order frequent monitoring of the patient’s INR after dabigatran therapy begins.

ANS: A

There are no requirements for monitoring the INR or other measures for patients taking dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated when the INR is less than 2. DIF: Cognitive Level: Applying (Application)

REF: 315

2. A patient who is obese is preparing to have surgery. To help prevent venous

thromboembolism (VTE), the primary care NP should prescribe: a.

low-dose aspirin once daily.

clopidogrel (Plavix) 75 mg once daily.

enoxaparin (Lovenox) 30 mg twice daily.

warfarin (Coumadin) titrated to achieve an INR of 3.5.

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ANS: C

The American College of Clinical Pharmacy recommends against the use of aspirin alone for prophylaxis of VTE. Patients undergoing surgery who are at moderate to high risk for VTE should receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin. Aspirin may be part of the prophylaxis regimen. Clopidogrel and warfarin are not recommended. DIF: Cognitive Level: Applying (Application)

REF: 312

3. A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary

care NP whether any medications will be necessary postoperatively. The NP should tell the patient that it will be necessary to take: a.

daily low-dose aspirin for 1 year.

heparin injections as needed based on activated partial thromboplastin time levels.

lifelong warfarin combined with enoxaparin as needed.

warfarin for 3 months postoperatively plus long-term aspirin.

ANS: D

Patients with biosynthetic valves should receive anticoagulation for 3 months with longterm aspirin prophylaxis. Patients with biosynthetic valves should receive anticoagulation for 3 months (INR goal, 2 to 3). Long-term prophylaxis for these patients should include aminosalicylic acid (75 to 100 mg daily), unless AF is present. DIF: Cognitive Level: Applying (Application)

REF: 312

4. A patient in the clinic develops sudden shortness of breath and tachycardia. The primary

care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive: a.

intravenous alteplase.

low-dose aspirin and warfarin.

low-molecular-weight heparin (LMWH).

unfractionated heparin (UFH) and warfarin.

ANS: D

This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE.

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DIF: Cognitive Level: Applying (Application)

REF: 312

5. A patient comes to the clinic with a complaint of gradual onset of left-sided weakness.

The primary care NP notes slurring of the patient’s speech. A family member accompanying the patient tells the NP that these symptoms began 4 or 5 hours ago. The NP will activate the emergency medical system and expect to administer: a.

325 mg of chewable aspirin.

LMWH.

intravenous alteplase and aspirin.

warfarin (Coumadin) and aspirin.

ANS: A

Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred 3 hours previously. The administration of anticoagulation or antiplatelet agents during the first 24 hours is not recommended. The oral administration of aspirin within 24 to 48 hours after stroke onset is recommended. DIF: Cognitive Level: Applying (Application)

REF: 312 - 313

6. An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for

anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider: a.

lowering the dose of warfarin.

rechecking the INR in 1 week.

omitting a dose and resuming at a lower dose.

omitting a dose and administering 1 mg of vitamin K.

ANS: B

This patient’s INR is only minimally prolonged, so no dose reduction is required. The NP should recheck the INR periodically. If the INR becomes more prolonged, lowering the dose of warfarin is recommended. If the INR approaches 5, omitting a dose and resuming at a lower dose is recommended. Vitamin K is used for an INR of 9 or greater. DIF: Cognitive Level: Applying (Application)

REF: 313

7. A patient who has had a new onset of AF the day prior will undergo cardioversion that

day. The primary care NP will expect the cardiologist to: a.

give clopidogrel after administering cardioversion.

administer cardioversion without using anticoagulants.

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give warfarin and aspirin before attempting cardioversion.

give low-dose aspirin before administering cardioversion.

ANS: B

If the onset of AF has occurred within 48 hours, cardioversion can be done without anticoagulation. Clopidogrel is used in other cases for patients who cannot take aspirin. For patients with rheumatic mitral valve disease and AF or a history of systemic embolism, cardioversion plus aspirin is used. Warfarin is used in patients with one or more risk factors for stroke. DIF: Cognitive Level: Applying (Application)

REF: 313

8. A patient who has disabling intermittent claudication is not a candidate for surgery.

Which of the following medications should the primary care NP prescribe to treat this patient? a.

Cilostazol (Pletal)

Warfarin (Coumadin)

Pentoxifylline (Trental)

Low-dose, short-term aspirin

ANS: A

Patients with disabling intermittent claudication who are not candidates for surgery or catheter-based intervention should be treated with cilostazol rather than pentoxifylline. Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin therapy. DIF: Cognitive Level: Understanding (Comprehension)

REF: 313

9. A patient who is at risk for DVT tells the primary care NP she has just learned she is

pregnant. The NP should expect that this patient will use which of the following anticoagulant medications? a.

Aspirin

Heparin

Dabigatran

Warfarin

ANS: B

Heparin does not cross the placental barrier and is the drug of choice for anticoagulation therapy during pregnancy, despite its category C classification. Aspirin is not recommended during the last 3 months of pregnancy. Dabigatran is not recommended. Warfarin crosses the placental barrier.

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DIF: Cognitive Level: Understanding (Comprehension)

REF: 317

10. A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and

reports having missed the morning dose of the medication because the prescription was not refilled. The primary care NP should counsel this patient to: a.

avoid foods that are high in vitamin K for several days.

take a double dose of the medication the next morning.

refill the prescription and take today’s dose immediately.

skip today’s dose and resume a regular dosing schedule in the morning.

ANS: D

Consistency is the key to successful warfarin treatment, and the patient should take the medication at the same time every day. For missed doses, the patient should take the medication as soon as possible after the missed dose or not at all that day. Because it is late afternoon, the patient should skip the dose and resume normal scheduling the next day. It is not necessary to avoid foods high in vitamin K. Patients should not double up the next day. DIF: Cognitive Level: Understanding (Comprehension)

REF: 317

Chapter 26: Antacids and the Management of GERD Test Bank MULTIPLE CHOICE 1. A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy,

which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that: a.

a fundoplication will be necessary to correct the cause of GERD.

over-the-counter (OTC) antacids can be effective and should be tried first.

elevation of the head of the bed at night can relieve most symptoms.

a combination of lifestyle changes, medications, and surgery may be necessary.

ANS: D

People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery.

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OTC antacids are sometimes used but are rarely used as first-line treatment. DIF: Cognitive Level: Applying (Application)

REF: 329

2. A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The

patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums: a.

can help to heal erosions in esophageal tissue.

do not help reduce symptoms of erosive esophagitis.

neutralize stomach acid as well as proton pump inhibitors (PPIs).

help reduce symptoms in conjunction with PPIs.

ANS: D

Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI. DIF: Cognitive Level: Applying (Application)

REF: 329

3. A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and

reports a decrease in symptoms. The patient asks the primary care NP if the medication may be discontinued. The NP should tell the patient that: a.

the dose may be decreased for long-term therapy.

antireflux surgery must be done before the PPI can be discontinued.

the condition may eventually be cured, but therapy must continue for years.

once the symptoms have cleared completely, the medication may be discontinued.

ANS: A

Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy should be continued long-term and titrated down to the lowest effective dose based on symptom control. PPI therapy is considered safer than surgery and should be tried first before surgery is performed. GERD is a lifelong syndrome and is not curable. DIF: Cognitive Level: Applying (Application)

REF: 329

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4. A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness,

frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend: a.

antacid therapy as needed.

changes in diet to avoid acidic foods.

daily treatment with a PPI.

consultation with a gastroenterologist for endoscopy.

ANS: C

This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications. Changes in diet are not recommended as treatment but may help with symptoms. Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy. DIF: Cognitive Level: Applying (Application)

REF: 328

5. A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease

in symptoms. The next response of the primary care NP is to: a.

add a histamine-2-receptor agonist.

increase the dose of the PPI.

change to long-term, low-dose PPI therapy.

refer the patient to an endocrinologist for endoscopy and further management.

ANS: A

If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis. When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist. DIF: Cognitive Level: Applying (Application)

REF: 329 - 330

6. A patient is taking a low-dose PPI for long-term management of GERD and reports

taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to: a.

change to aluminum hydroxide (Amphojel).

use magnesium hydroxide (Milk of Magnesia) instead.

continue using sodium bicarbonate (AlkaSeltzer) as needed.

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take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer).

d. ANS: D

Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances. DIF: Cognitive Level: Applying (Application)

REF: 330

7. An 80-year-old patient asks a primary care NP about OTC antacids for occasional

heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend: a.

calcium carbonate (Tums).

aluminum hydroxide (Amphojel).

sodium bicarbonate (Alka-Seltzer).

magnesium hydroxide (Milk of Magnesia).

ANS: A

Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients. Aluminum hydroxide is not as effective as calcium carbonate. DIF: Cognitive Level: Applying (Application)

REF: 330

Chapter 27: Histamine-2 Blockers and Proton Pump Inhibitors Test Bank MULTIPLE CHOICE 1. A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs

(NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should: a.

prescribe cimetidine (Tagamet).

prescribe omeprazole (Prilosec).

teach the patient about a bland diet.

change the NSAID to a corticosteroid.

ANS: B

Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID.

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In a situation such as this, a PPI is indicated. Cimetidine is a histamine -2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 336 - 337

2. A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the

presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is still present. The NP should order: a.

continuation of the PPI for 4 to 8 weeks.

a PPI, amoxicillin, and metronidazole for 14 days.

a PPI, clarithromycin, and amoxicillin for 14 more days.

a PPI, bismuth subsalicylate, tetracycline, and metronidazole.

ANS: B

A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolide-allergic patients and for re-treatment for 14 days if first-line treatment of choice failed because of occasional resistance to clarithromycin. DIF:

Cognitive Level: Applying (Application)

REF: 336

3. A patient with a diagnosis of peptic ulcer disease asks the primary care NP about

nonpharmacologic treatment. Which statement by the NP is correct? a.

“You should consume a diet that is high in fiber.”

“One or two cups of coffee each day won’t hurt you.”

“Alcoholic beverages are strictly prohibited when you have an ulcer.”

“Lifestyle changes and proper diet may eliminate the need for medication.”

ANS: A

Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine increases acid secretion and should be avoided. Patients may consume alcohol in moderation. Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer disease, they do not eliminate the need for medications. DIF: Cognitive Level: Understanding (Comprehension)

REF: 336

4. A patient has NSAID-induced ulcer and has started taking ranitidine (Zantac). At a

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follow-up appointment 3 days later, the patient reports no alleviation of symptoms. The primary care NP should: a.

order cimetidine (Tagamet).

add metronidazole to the drug regimen.

change from ranitidine to omeprazole (Prilosec).

reassure the patient that drug effects take several weeks.

ANS: C

If the patient does not start to see improvement within a few days after initiation of treatment with a histamine-2 blocker, the provider either should increase the dose of the medication or should change to a PPI. Cimetidine is a histamine-2 blocker and has many serious side effects. Metronidazole is used only when H. pylori is known to be present. Patients should start to get relief within a few days. DIF: Cognitive Level: Applying (Application)

REF: 337

5. An 80-year-old patient has a history of renal disease and develops a duodenal ulcer. The

primary care NP should order a: a.

normal dose of a histamine-2 blocker.

decreased dose of a histamine-2 blocker.

normal dose of a PPI.

decreased dose of a PPI.

ANS: C

No adjustment of dosage is necessary for older patients taking PPIs. Patients with a history of renal disease may have decreased elimination of histamine-2 blockers, so the NP should avoid these if possible. DIF: Cognitive Level: Applying (Application)

REF: 337

6. A patient with peptic ulcer disease is taking a histamine-2 blocker and tells the primary

care NP that over-the-counter antacid tablets help with the discomfort. The NP should tell this patient to: a.

discontinue the antacid.

discontinue the histamine-2 blocker.

take the antacid and the histamine-2 blocker at the same time.

take the histamine-2 blocker 2 hours before taking the antacid.

ANS: D

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Histamine-2 blockers should not be taken within 2 hours of antacid ingestion because antacids decrease the action of histamine-2 blockers. DIF: Cognitive Level: Applying (Application)

REF: 339

7. A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP

performs a medication history and learns that the patient also takes digoxin. The NP should recommend: a.

decreasing the dose of digoxin.

obtaining a serum digoxin level.

changing the PPI to omeprazole.

increasing the dose of lansoprazole.

ANS: B

Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that require absorption in an acid stomach, including digoxin. It may be necessary to increase the dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so changing to another PPI would not solve the problem. Increasing the dose of lansoprazole would decrease the absorption of digoxin. DIF: Cognitive Level: Applying (Application)

REF: 339

8. A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should

prescribe: a.

ranitidine (Zantac).

omeprazole (Prilosec).

esomeprazole (Nexium).

pantoprazole (Protonix).

ANS: A

PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine. DIF: Cognitive Level: Applying (Application)

REF: 339

Chapter 28: Laxatives Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) sees a patient who is concerned about

constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend: increased intake of fluids and fiber. a.

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docusate sodium (Colace) as needed.

psyllium (Metamucil) on a daily basis.

polyethylene glycol (MiraLAX) as needed.

ANS: A

The objective definition of constipation is two or fewer bowel movements per week or excessive straining. This patient does not meet these criteria, so the NP should recommend increasing fluids and fiber to help soften stools. Laxatives should not be used unless constipation is present or is chronic to avoid laxative dependence. DIF: Cognitive Level: Applying (Application)

REF: 341

2. A patient reports having occasional acute constipation with large, hard stools and pain

and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend: a.

a daily bulk laxative.

long-term docusate sodium.

a saline laxative as needed.

glycerin suppositories as needed.

ANS: C

Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use. DIF: Cognitive Level: Applying (Application)

REF: 344

3. A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a

laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend g of fiber per day. a.

ANS: A

Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age. DIF: Cognitive Level: Applying (Application)

REF: 343

4. A patient who has cerebral palsy is wheelchair dependent and receives enteral nutrition

via a gastrostomy tube. The patient has infrequent, hard bowel movements despite using a

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high-fiber formula and receiving 1500 mL of fluid per day. The NP should order: a.

bisacodyl (Dulcolax).

docusate sodium (Colace).

polyethylene glycol (MiraLAX).

sodium phosphate (Fleets) enema.

ANS: C

Fluids, fiber, and exercise, which help most people, are not applicable to people who are wheelchair bound. Other individuals with congestive heart failure are unable to tolerate these mechanisms. Osmotic laxatives, such as polyethylene glycol are used to manage long-term constipation. It is essential for clinicians to know their patients and assess what is reasonable for them to do. DIF: Cognitive Level: Applying (Application)

REF: 345

5. A primary care NP sees a patient who reports having decreased frequency of stools over

the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should: a.

give magnesium hydroxide (Milk of Magnesia).

start daily methylcellulose (Citrucel) and increased fluids.

order a sodium phosphate enema and psyllium (Metamucil).

recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily.

ANS: C

If a patient is severely constipated, an enema is indicated. When there is underlying chronic constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are first-line treatments for long-term constipation. DIF: Cognitive Level: Applying (Application)

REF: 344

6. A female patient who is underweight tells the primary care NP that she has been using

bisacodyl (Dulcolax) daily for several years. The NP should: a.

prescribe docusate sodium (Colace) and decrease bisacodyl gradually.

suggest she use polyethylene glycol (MiraLAX) on a daily basis instead.

tell her that long-term use of suppositories is safer than long-term laxative use.

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counsel the patient to discontinue the laxative and increase fluid and fiber intake.

ANS: A

Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer longterm laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation. DIF: Cognitive Level: Applying (Application)

REF: 344

7. A patient who has a history of chronic constipation uses a bulk laxative to prevent

episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend: a.

adding docusate sodium (Colace).

polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).

lactulose (Chronulac) and polyethylene glycol (MiraLAX).

adding nonpharmacologic measures such as biofeedback.

ANS: A

Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category. DIF: Cognitive Level: Applying (Application)

REF: 344| Table 28-2

8. A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each

month for constipation. The primary care NP should counsel this patient to: a.

decrease fluid intake to avoid cardiac overload.

change the laxative to docusate sodium (Colace).

take the digoxin 2 hours before taking the psyllium.

ask the cardiologist about taking an increased dose of digoxin.

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ANS: C

Laxatives can affect the absorption of drugs in the intestine by decreasing transit time. Digoxin is a drug that is affected by decreased transit time. Patients should be counseled to take the drugs 2 hours apart. DIF: Cognitive Level: Applying (Application)

REF: 346

Chapter 28: Laxatives Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) sees a patient who is concerned about

constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend: a.

increased intake of fluids and fiber.

docusate sodium (Colace) as needed.

psyllium (Metamucil) on a daily basis.

polyethylene glycol (MiraLAX) as needed.

ANS: A

REF: 341

2. A patient reports having occasional acute constipation with large, hard stools and pain

a daily bulk laxative.

long-term docusate sodium.

a saline laxative as needed.

glycerin suppositories as needed.

ANS: C

REF: 344

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3. A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a

laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend g of fiber per day. a.

ANS: A

Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age. DIF: Cognitive Level: Applying (Application)

REF: 343

4. A patient who has cerebral palsy is wheelchair dependent and receives enteral nutrition

via a gastrostomy tube. The patient has infrequent, hard bowel movements despite using a high-fiber formula and receiving 1500 mL of fluid per day. The NP should order: a.

bisacodyl (Dulcolax).

docusate sodium (Colace).

polyethylene glycol (MiraLAX).

sodium phosphate (Fleets) enema.

ANS: C

REF: 345

5. A primary care NP sees a patient who reports having decreased frequency of stools over

the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should: a.

give magnesium hydroxide (Milk of Magnesia).

start daily methylcellulose (Citrucel) and increased fluids.

order a sodium phosphate enema and psyllium (Metamucil).

recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily.

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ANS: C

REF: 344

6. A female patient who is underweight tells the primary care NP that she has been using

bisacodyl (Dulcolax) daily for several years. The NP should: a.

prescribe docusate sodium (Colace) and decrease bisacodyl gradually.

suggest she use polyethylene glycol (MiraLAX) on a daily basis instead.

tell her that long-term use of suppositories is safer than long-term laxative use.

counsel the patient to discontinue the laxative and increase fluid and fiber intake.

ANS: A

REF: 344

7. A patient who has a history of chronic constipation uses a bulk laxative to prevent

episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend: a.

adding docusate sodium (Colace).

polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).

lactulose (Chronulac) and polyethylene glycol (MiraLAX).

adding nonpharmacologic measures such as biofeedback.

ANS: A

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are from the same category. DIF: Cognitive Level: Applying (Application)

REF: 344| Table 28-2

8. A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each

month for constipation. The primary care NP should counsel this patient to: a.

decrease fluid intake to avoid cardiac overload.

change the laxative to docusate sodium (Colace).

take the digoxin 2 hours before taking the psyllium.

ask the cardiologist about taking an increased dose of digoxin.

ANS: C

REF: 346

Chapter 29: Antidiarrheals Test Bank MULTIPLE CHOICE 1. A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea.

Her husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60 mm Hg. The NP should: a.

prescribe attapulgite to treat her diarrhea.

obtain a stool culture and start antibiotic therapy.

instruct her to replace lost fluids by drinking Pedialyte.

refer her to an emergency department for intravenous (IV) fluids.

ANS: D

Diarrhea in pregnant women can have serious consequences, and the patient may need to be referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is usually viral, and antibiotics are not given unless a stool culture is performed and is positive. Because the patient is pregnant and has nausea, oral rehydration would

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not be effective. DIF: Cognitive Level: Applying (Application)

REF: 351

2. A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the

clinic after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP should: a.

obtain a stool specimen and order vancomycin.

order testing for Clostridium difficile and consider metronidazole therapy.

prescribe diphenoxylate (Lomotil) to provide symptomatic relief.

reassure the patient that diarrhea is a common side effect of antibiotic therapy.

ANS: B

The guidelines for treatment of diarrhea emphasize comprehensive evaluation before treatment begins. Antibiotic use points to C. difficile as a possible cause, and metronidazole is often used to treat mild to moderate infection. Vancomycin is used when C. difficile is severe. Diphenoxylate can worsen the infection because it slows transit time of the bacteria in the gut. Prolonged diarrhea during antibiotic therapy should be investigated. DIF: Cognitive Level: Applying (Application)

REF: 352

3. A patient who has had four to five liquid stools per day for 4 days is seen by the primary

care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are: a.

not curative and may prolong the illness.

useful in cases of acute infection with elevated temperature.

most beneficial when symptoms persist longer than 2 weeks.

useful when other symptoms, such as hematochezia, develop.

ANS: A

Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases.

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DIF: Cognitive Level: Applying (Application)

REF: 353

4. A patient who has experienced five to seven liquid stools for 3 days is seen in the clinic

by the primary care NP. The patient reports having had fever, mucoid stools, and nausea without vomiting. The patient has been drinking Gatorade to stay hydrated. The NP obtains a stool specimen for culture and should prescribe: a.

diphenoxylate (Lomotil).

attapulgite (Kaopectate).

bismuth subsalicylate (Pepto-Bismol).

loperamide hydrochloride (Imodium).

ANS: C

Bismuth reduces symptoms through antidiarrheal and antibacterial properties and can decrease nausea and vomiting. Opioid antidiarrheals should be given after the cause of infectious diarrhea is treated; these can actually prolong symptoms because they slow transit of the causative organisms through the gut. Attapulgite can be used because it binds bacteria and toxins in the gastrointestinal tract, but bismuth is a better choice in this case because it helps to treat nausea. The patient is drinking Gatorade and is getting electrolyte replacement. DIF: Cognitive Level: Applying (Application)

REF: 353

5. A 2-year-old child has chronic “toddler’s” diarrhea, which has an unknown but benign

etiology. The child’s parent asks the primary care NP if a medication can be used to treat the child’s symptoms. The NP should recommend giving: a.

diphenoxylate (Lomotil).

attapulgite (Kaopectate).

an electrolyte solution (Pedialyte).

bismuth subsalicylate (Pepto-Bismol).

ANS: C

Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children. DIF: Cognitive Level: Applying (Application)

REF: 353

6. A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The

patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to: a.

obtain stool cultures.

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begin rehydration therapy.

consider prescribing metronidazole.

administer opioid antidiarrheal medications.

ANS: B

Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms. DIF: Cognitive Level: Applying (Application)

REF: 353

7. A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family

members have had similar symptoms, which have resolved. The primary care NP should recommend: a.

diphenoxylate (Lomotil).

attapulgite (Kaopectate).

an electrolyte solution (Pedialyte).

bismuth subsalicylate (Pepto-Bismol).

ANS: C

Antidiarrheals are not generally recommended in children. Bismuth is not recommended in children younger than 16 years of age with viral illnesses because it can mask symptoms of Reye’s syndrome. Oral rehydration with electrolyte solution is safe. DIF: Cognitive Level: Applying (Application)

REF: 354

Chapter 30: Antiemetics Test Bank MULTIPLE CHOICE 1. A woman is in her first trimester of pregnancy. She tells the primary care nurse

practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe: a.

aprepitant (Emend).

ondansetron (Zofran).

scopolamine transdermal.

prochlorperazine (Compazine).

ANS: B

No antiemetic drugs should be used for nausea and vomiting during pregnancy unless

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approved by an obstetrician. Ondansetron has been shown to be safe and effective (offlabel) for hyperemesis gravidum. DIF: Cognitive Level: Applying (Application)

REF: 359

2. A primary care NP sees a patient who is about to take a cruise and reports having had

motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch: a.

daily.

every 3 days.

as needed for nausea.

1 hour before embarking.

ANS: B

The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed. DIF: Cognitive Level: Understanding (Comprehension)

REF: 361

3. A primary care NP sees a patient 2 days after an outpatient surgical procedure. The

patient reports using ondansetron for nausea. The NP notes a blood pressure of 88/56 mm Hg, and the patient reports feeling faint. The NP should suspect: a.

hemorrhage.

dehydration.

drug toxicity.

drug interaction.

ANS: C

Hypotension and faintness are signs of overdose of ondansetron, and drug toxicity is the more likely cause of this patient’s decrease in blood pressure. DIF: Cognitive Level: Applying (Application)

REF: 361

4. A patient reports having episodes of dizziness, nausea, and lightheadedness and describes

a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe: a.

meclizine.

ondansetron.

scopolamine.

dimenhydrinate.

ANS: A

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Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo. DIF: Cognitive Level: Applying (Application)

REF: 357

5. A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days.

The patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of greater than 3 seconds. The NP should: a.

obtain a complete blood count and serum electrolytes.

prescribe a rectal antiemetic medication.

admit to the hospital for intravenous (IV) rehydration.

encourage the patient to take small, frequent sips of Gatorade.

ANS: C

If vomiting is not controlled, dehydration may occur. Patients who are dehydrated, as this patient is, must be treated with IV fluids in a hospital or emergency department setting. DIF: Cognitive Level: Applying (Application)

REF: 358

6. A patient who is about to begin chemotherapy expresses concern to the primary care NP

about gastrointestinal side effects of the treatments. The NP should reassure the patient that: a.

most newer chemotherapeutic agents do not cause nausea and vomiting.

antiemetics will be administered as needed if nausea and vomiting occur.

taking ondansetron before chemotherapy decreases nausea and vomiting.

a scopolamine patch is an effective way to prevent nausea and vomiting.

ANS: C

In many situations, nausea and vomiting may be anticipated. These situations may involve motion sickness or chemotherapy. Premedicating the patient with an antiemetic may be necessary in order for the patient to receive full therapy; this is the current standard of care. Although most chemotherapeutic agents have emetogenic potential, the use of premedication with 5-HT3 receptor antagonists significantly decreases the nausea and vomiting experienced during and after administration The most common agent in this

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class, ondansetron, is now available as a generic. DIF: Cognitive Level: Applying (Application)

REF: 358

7. A primary care NP sees a 3-year-old patient who has been vomiting for several days. The

child has had fewer episodes of vomiting the past day and is now able to take sips of fluids without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and pale but warm skin. The child’s blood pressure is 88/46 mm Hg, the heart rate is 110 beats per minute, and the temperature is 37.2° C. The NP should: a.

prescribe promethazine.

prescribe a scopolamine patch.

begin oral rehydration therapy.

send the child to the hospital for IV fluids.

ANS: C

The use of antiemetics in children is discouraged for cases of uncomplicated vomiting. The child has compensated, mild dehydration and is now able to tolerate fluids, so oral rehydration is indicated. DIF: Cognitive Level: Applying (Application)

REF: 359

Chapter 31: Medications for Irritable Bowel Syndrome and Other Gastrointestinal Problems Test Bank MULTIPLE CHOICE 1. A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose

stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is: a.

the relation of the pain to stools.

what time of day the pain occurs.

whether the pain is sharp or diffuse.

the age of the patient when the pain began.

ANS: A

The new Rome II guidelines maintain that irritable bowel syndrome (IBS) of any subtype is characterized by a strong relationship between abdominal pain and defecation because of visceral hypersensitivity to gut-related events. The other characteristics of pain may be assessed to help guide management of IBS, but the first is necessary for a correct diagnosis. DIF: Cognitive Level: Applying (Application)

REF: 362 - 363

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2. A patient has been diagnosed with IBS and tells the primary care NP that symptoms of

diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe: a.

mesalamine (Asacol).

dicyclomine (Bentyl).

simethicone (Phazyme).

metoclopramide (Reglan).

ANS: B

Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas. Metoclopramide is used to increase motility. DIF: Cognitive Level: Applying (Application)

REF: 363

3. A woman with IBS has been taking antispasmodic medications and reports some relief,

but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing: a.

alosetron (Lotronex).

misoprostol (Cytotec).

simethicone (Phazyme).

tricyclic antidepressants (TCAs).

ANS: D

TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms and are useful for long-term treatment. Alosetron is ordered by a GI specialist if symptoms are resistant to all other interventions and has been shown to be effective in women with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers. Simethicone acts locally to treat symptoms of trapped air and gas. DIF: Cognitive Level: Applying (Application)

REF: 363 - 364

4. A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take

medication. The primary care NP should recommend: a.

25 g of fiber each day.

avoiding gluten and lactose in the diet.

increasing water intake to eight to ten glasses per day.

beginning aerobic exercise, such as running, every day.

ANS: A

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A diet with adequate fiber is the cornerstone of treatment, and 25 g per day is recommended. Unless the patient has a documented gluten or lactose malabsorption, avoiding these substances is not recommended. Water intake should be six to eight glasses per day. Regular walking is usually the best exercise. DIF: Cognitive Level: Applying (Application)

REF: 364

5. A patient who has IBS has been taking dicyclomine and reports decreased pain and

diarrhea but is now having occasional constipation. The primary care NP should recommend: a.

beginning treatment with an SSRI.

beginning therapy with a TCA.

over-the-counter (OTC) laxatives as needed when constipated.

increasing the amounts of raw fruits and vegetables in the diet.

ANS: C

Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can increase the likelihood of bloating. DIF: Cognitive Level: Applying (Application)

REF: 364

6. A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS.

The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP should: a.

prescribe a TCA.

discontinue the antidiarrheal medication.

encourage the patient to increase water intake.

lower the dose of the antispasmodic medication.

ANS: D

Patients taking antispasmodic medications should be monitored for anticholinergic side effects, such as increased heart rate, dry mouth, difficulty urinating, and constipation. The NP should lower the dose if needed. TCAs are used to treat pain long-term. Because the antidiarrheal medication is used as needed, there is no reason to discontinue it. Increasing water intake may improve symptoms associated with side effects but would not treat the underlying cause of these symptoms. DIF: Cognitive Level: Applying (Application)

REF: 364

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7. A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone

(Phazyme), and a TCA. She reports having continued severe diarrhea. The primary care NP should: a.

order diphenoxylate (Lomotil).

prescribe alosetron after ruling out pregnancy.

refer her to a gastroenterologist for endoscopy.

increase the fiber in her diet to 30 g per day.

ANS: C

Alosetron is given only to women with severe chronic diarrhea-predominant IBS and only after anatomic or biochemical abnormalities of the GI tract have been excluded. Because this woman’s symptoms are persistent and severe, diphenoxylate and increased dietary fiber are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 364

8. A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders

metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe: a.

benztropine (Cogentin).

cimetidine.

an SSRI antidepressant.

a TCA.

ANS: A

Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg DIF: Cognitive Level: Applying (Application)

REF: 365

Chapter 32: Diuretics Test Bank MULTIPLE CHOICE 1. A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin

diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no peripheral edema. The patient’s serum electrolytes are normal. The NP should prescribe:

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furosemide (Lasix).

triamterene (Dyrenium).

acetazolamide (Diamox).

hydrochlorothiazide (HydroDIURIL).

ANS: D

Thiazide diuretics are first-line drugs for treating hypertension. The other three drugs are not thiazide diuretics. DIF: Cognitive Level: Applying (Application)

REF: 376

2. A patient takes hydrochlorothiazide to treat hypertension and asks the primary care NP

why it is necessary to reduce sodium intake while taking this medication. The NP should explain that decreasing sodium is necessary to: prevent renal insufficiency. a. b.

minimize the risk of hypokalemia.

prevent postdiuretic sodium retention.

increase the likelihood that the drug may be discontinued.

ANS: C

If dietary salt intake is high, the amount of sodium lost in response to the diuretic may be partially or completely offset by postdiuretic sodium retention. Sodium restriction does not prevent renal insufficiency or minimize the incidence of hypokalemia. Sodium restriction is necessary to maintain the drug’s effectiveness but does not increase the chance of discontinuing the medication. DIF: Cognitive Level: Applying (Application)

REF: 372

3. A patient with congestive heart failure will begin therapy with a diuretic medication. The

primary care NP orders laboratory tests, which reveal a glomerular filtration rate (GFR) of 25 mL/minute. The initial drug the NP should prescribe is: a.

metolazone.

furosemide (Lasix).

spironolactone (Aldactone).

hydrochlorothiazide (HydroDIURIL).

ANS: A

Thiazides are the most frequently used and the least expensive drugs administered to treat hypertension and are considered first-line treatments. In patients with a GFR less than 30 mL/minute, thiazides are relatively ineffective, with the exception of metolazone. Furosemide may be added as a second-line drug. Potassium-sparing diuretics, such as spironolactone, should be used with great caution or avoided altogether in patients with

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renal insufficiency. DIF: Cognitive Level: Applying (Application)

REF: 372

4. A patient who has congestive heart failure and arthritis has been taking chlorthalidone

(Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure of 145/90 mm Hg. The NP should: a.

ask the patient which medications are used for pain.

add furosemide (Lasix) to the patient’s drug regimen.

increase the dose of chlorthalidone to 100 mg daily.

recommend that the patient use salt substitutes to season foods.

ANS: A

For diuretic resistance, the NP should evaluate factors such as patient nonadherence, physiologic causes, and drugs that may increase resistance, including nonsteroidal antiinflammatory drugs (NSAIDs). This patient has arthritis, and it is likely that NSAID use may be causing diuretic resistance. A second drug, such as furosemide, should be added after the cause of diuretic resistance is determined. The maximum daily dose of chlorthalidone is 100 mg per day, but increasing the dose is not recommended to treat diuretic resistance. Recommending salt substitutes is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 373

5. The primary care NP is preparing to prescribe a diuretic for a patient who has heart

failure. The patient reports having had an allergic reaction to sulfamethoxazoletrimethoprim (Bactrim) previously. The NP should prescribe: a.

ethacrynic acid.

furosemide (Lasix).

acetazolamide (Diamox).

hydrochlorothiazide (HydroDIURIL).

ANS: A

Patients who are allergic to sulfa drugs should avoid diuretics that are sulfonamide derivatives. Ethacrynic acid is the only choice that is not a sulfonamide derivative. DIF: Cognitive Level: Applying (Application)

REF: 372

6. The primary care NP sees a patient several months after a myocardial infarction (MI).

The patient has been taking furosemide to treat heart failure. The NP notes that the patient has edema of the hands, feet, and ankles. The NP should add which drug to this patient’s regimen?

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Ethacrynic acid

Chlorothiazide (Lozol)

Triamterene (Dyrenium)

Spironolactone (Aldactone)

ANS: B

The addition of a thiazide to a loop diuretic along with sodium restriction may be useful in the treatment of refractory edema in patients with congestive heart failure. Ethacrynic acid is a loop diuretic. The other two options are potassium-sparing diuretics. DIF: Cognitive Level: Applying (Application)

REF: 373

7. The primary care NP sees a patient who has a history of hypertension and alcoholism.

The patient is not taking any medications. The NP auscultates crackles in both lungs and palpates the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level. The NP will refer this patient to a cardiologist and should prescribe: a.

albuterol metered-dose inhaler.

furosemide (Lasix).

spironolactone (Aldactone).

chlorthalidone (Zaroxolyn).

ANS: B

In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary and congestive edema. Loop diuretics are also useful to treat states of volume excess in cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an enlarged liver on examination, furosemide is a good first choice to relieve this patient’s congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol might be used for symptomatic treatment only. DIF: Cognitive Level: Applying (Application)

REF: 373

8. The primary care NP sees a patient who has heart failure following an MI 6 months

before this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of both feet. The NP should prescribe: a.

mannitol.

metolazone.

acetazolamide (Diamox).

spironolactone (Aldactone).

ANS: D

Spironolactone has been shown to be of particular benefit in the treatment of severe congestive heart failure when added to an ACE inhibitor and a loop diuretic.

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DIF: Cognitive Level: Applying (Application)

REF: 374

9. A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a

follow-up visit. The primary care NP notes a blood pressure of 100/60 mm Hg. The patient’s lungs are clear, and there is no peripheral edema. The patient’s serum potassium is 3.4 mEq/L. The NP should: a.

continue furosemide at the current dose.

decrease furosemide to 60 mg once daily.

increase furosemide to 80 mg twice daily.

change furosemide dose the 40 mg twice daily.

ANS: B

The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This patient has a low potassium level just under the lower limit, so a reduction in dose is indicated. DIF: Cognitive Level: Applying (Application)

REF: 374

10. A patient is taking spironolactone and comes to the clinic complaining of weakness and

tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute and a blood pressure of 100/58 mm Hg. The NP should: a.

obtain a serum drug level.

order an electrocardiogram (ECG) and serum electrolytes.

change the medication to a thiazide diuretic.

question the patient about potassium intake.

ANS: B

The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum electrolytes. This should be done before changing the medication. Because hyperkalemia can cause fatal arrhythmias, an ECG is necessary. DIF: Cognitive Level: Applying (Application)

REF: 374

Chapter 41: Medications for Attention-Deficit/Hyperactivity Disorder Test Bank MULTIPLE CHOICE 1. An adult patient reports feeling unfocused all the time, loses things, and has difficulty

completing tasks and says that this is interfering with family relations and work. The

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symptoms have been present as long as the patient can remember, although there is no previous documentation of attention-deficit/hyperactivity disorder (AD/HD) in this patient’s medical history. The primary care nurse practitioner (NP) should: a.

tell the patient that a diagnosis of AD/HD as a child is a prerequisite for diagnosing this in adults.

conduct a thorough evaluation to document behaviors associated with AD/HD and begin treatment if indicated.

suggest that the patient may have a major depressive disorder and refer the patient for psychiatric evaluation and treatment.

prescribe a methylphenidate trial, ask the patient to keep a diary of behaviors and feelings, and reevaluate in 1 to 2 months.

ANS: B

Although childhood AD/HD is a prerequisite for diagnosis in an adult, it is increasingly recognized that many adults have the disorder without having been diagnosed as children. The NP should evaluate the patient’s symptoms and treat if indicated. The patient does not have symptoms of depression. Methylphenidate should not be given unless the patient meets the diagnostic criteria. DIF: Cognitive Level: Applying (Application)

REF: 449

2. A child is taking methylphenidate (Ritalin) for AD/HD. The child’s parent calls the

primary care NP to report increased behavior problems and delusional thinking. The NP should: a.

increase the drug dose.

discontinue the medication.

change to dextroamphetamine.

order methylphenidate SR.

ANS: B

Exacerbation of behavioral and processing symptoms can occur in patients with preexisting psychosis, and manic and behavioral symptoms may occur in patients who do not have an underlying psychiatric disorder. This is true with all stimulant medications, so increasing the dose, switching to another stimulant, or switching to a long-acting form are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 453

3. A primary care NP sees a child for an annual well-child check-up. The child has been

taking methylphenidate for AD/HD for 3 months. The NP should discontinue the

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medication if which symptom is present? a.

Motor tics

Decreased appetite

Occasional headaches

Decreased blood pressure

ANS: A

Methylphenidate is contraindicated in patients who have motor tics or a diagnosis of Tourette’s syndrome. Decreased appetite, occasional headaches, and changes in blood pressure are not concerning. DIF: Cognitive Level: Understanding (Comprehension)

REF: 452

4. A child is diagnosed with AD/HD after being expelled from school for disruptive

behaviors. The child’s parents are reluctant to start medication because of the stigma attached. The primary care NP should suggest: a.

Ritalin.

Concerta.

Adderall.

Dexedrine.

ANS: B

Concerta is a long-acting stimulant, and children taking it can avoid having to take a dose of medication at school. The other choices are shorter acting and may require dosing during school. DIF: Cognitive Level: Applying (Application)

REF: 453

5. A child has been taking methylphenidate 5 mg at 8 AM , 12 PM , and 4 PM for 30 days after

a new diagnosis of AD/HD and comes to the clinic for evaluation. The child’s mother reports that the child exhibits some nervousness and insomnia but is doing much better in school. The primary care NP should suggest: a.

discontinuing the 4 PM dose.

increasing the dose to 10 mg each time.

giving 10 mg at 8 AM and 5 mg at noon.

changing the dosing to 15 mg twice daily.

ANS: A

Nervousness and insomnia are the most common adverse effects and are usually controlled by reducing the dose or omitting the afternoon or evening dose. DIF: Cognitive Level: Applying (Application)

REF: 453

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6. A patient who has recently begun working at night reports having difficulty staying

awake at work. The primary care NP should consider prescribing: a.

caffeine.

modafinil (Provigil).

methylphenidate (Ritalin).

dextroamphetamine (Dexedrine).

ANS: B

Modafinil is approved for day/night shift changes in adults as well as narcolepsy, excessive daytime sleepiness, and sleep apnea. DIF: Cognitive Level: Applying (Application)

REF: 454

7. The parent of a 4-year-old child is concerned that the child may have AD/HD and wants

to know if medications can be given. The primary care NP should tell the parent that: a.

children cannot be diagnosed with AD/HD at this age.

alternative therapies to treat AD/HD are used at this age.

symptoms at this age are more likely due to environmental factors.

most drugs for AD/HD are not approved for children younger than 6 years.

ANS: D

Most AD/HD medications are not approved for use in children younger than 6 years. Children can be diagnosed with AD/HD at age 4. Alternative therapies are not necessarily used. DIF: Cognitive Level: Applying (Application)

REF: 454

8. The parent of an 8-year-old child recently diagnosed with AD/HD verbalizes concerns

about giving the child stimulants. The primary care NP should recommend: a.

modafinil (Provigil).

guanfacine (Intuniv).

bupropion (Wellbutrin).

atomoxetine (Strattera).

ANS: D

Atomoxetine is not a stimulant medication but is thought to be as effective as stimulant medications. It is the only nonstimulant treatment approved by the U.S. Food and Drug Administration for AD/HD that has been shown to be safe, well tolerated, and efficacious in the treatment of children.

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DIF: Cognitive Level: Applying (Application)

REF: 452

Chapter 42: Medications for Dementia Test Bank MULTIPLE CHOICE 1. A patient is identified as having stage 2 Alzheimer’s disease and elects to take donepezil

(Aricept). The patient asks the primary care nurse practitioner (NP) how long the medication will be needed. The NP should tell the patient that donepezil must be taken: a.

until symptoms improve.

indefinitely because it is not curative.

for 24 weeks, which is when cognitive function improves in most patients.

until symptoms worsen, when a switch to memantine (Namenda) will be needed.

ANS: B

Cholinesterase (ChE) inhibitor drugs such as donepezil diminish symptoms; when the drug is stopped, the symptoms return. Cognitive function will show improvement at about 24 weeks, but the drug must be continued indefinitely. DIF: Cognitive Level: Understanding (Comprehension)

REF: 459

2. A patient who has Alzheimer’s disease has been taking donepezil for 1 year. The patient’s

spouse reports a worsening of symptoms. The primary care NP should consider: a.

switching to ginkgo biloba.

adding an antidepressant medication.

changing to galantamine (Razadyne).

adding memantine hydrochloride (Namenda).

ANS: D

Memantine hydrochloride can be added to therapy when symptoms worsen. Ginkgo biloba may be useful but is not recommended as adjunct therapy. Antidepressants given to patients with Alzheimer’s disease who have depression appear not to be effective and often cause adverse effects or produce unwanted drug interactions. Galantamine is part of first-line therapy but should not be given with donepezil because both are ChE inhibitors. DIF: Cognitive Level: Applying (Application)

REF: 459

3. Early-stage Alzheimer’s disease is diagnosed in a patient, and the primary care NP

recommends therapy with a ChE inhibitor. The patient asks why drug treatment is necessary because most functioning is intact. The NP should explain that medication

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may: a.

delay progression of symptoms.

produce temporary disease remission.

prevent depressive effects of the disease.

reduce the need for adjunct medications later on.

ANS: A

Pharmacologic treatment should begin as soon as Alzheimer’s disease is suspected because early treatment can slow disease progression. Medication does not produce disease remission or prevent depression. The disease eventually progresses despite medication, and adjunct therapies are often required. DIF: Cognitive Level: Applying (Application)

REF: 459

4. A patient has a diagnosis of depression and Alzheimer’s disease with mild, intermittent

symptoms. The primary care NP should prescribe a(n): a.

antidepressant.

ChE inhibitor.

antidepressant and ginkgo biloba.

antidepressant and a ChE inhibitor.

ANS: B

Antidepressants given to patients with Alzheimer’s disease do not appear to be effective and cause adverse effects and unwanted drug interactions. DIF: Cognitive Level: Applying (Application)

REF: 459

5. A patient who has Alzheimer’s disease begins taking donepezil (Aricept). After 3 months

of treatment, the patient does not show improvement of symptoms. The primary care NP should: a.

switch to rivastigmine (Exelon).

switch to galantamine (Razadyne).

switch to memantine (Namenda).

continue donepezil and reevaluate in 3 months.

ANS: D

Patients should be switched to other medications if initial therapy fails, but switching to another medication should be considered only after a minimum of 6 months of treatment. DIF: Cognitive Level: Applying (Application)

REF: 459

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6. A patient is newly diagnosed with Alzheimer’s disease stage 6 on the Global

Deterioration Scale. The primary care NP should prescribe: a.

donepezil (Aricept).

rivastigmine (Exelon).

memantine (Namenda).

galantamine (Razadyne).

ANS: C

Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine. DIF: Cognitive Level: Applying (Application)

REF: 459

7. A patient has been taking donepezil (Aricept) for several months after being diagnosed

with Alzheimer’s disease. The patient’s spouse brings the patient to the clinic and reports that the patient seems to be having visual hallucinations. The primary care NP should: a.

increase the dose.

decrease the dose.

switch to memantine (Namenda).

switch to galantamine (Razadyne).

ANS: B

Hallucinations may be a sign of drug toxicity. The NP should decrease the dose. DIF: Cognitive Level: Applying (Application)

REF: 459

8. A patient who has Alzheimer’s disease is taking 10 mg of donepezil daily and reports

difficulty sleeping. The primary care NP should recommend: a.

decreasing the dose to 5 mg.

increasing the dose to 15 mg.

taking the drug in the morning.

taking the drug in the evening.

ANS: C

Donepezil is typically taken in the evening just before going to bed; however, in patients experiencing sleep disturbance, daytime administration is preferred. The dose should not be increased or decreased. DIF: Cognitive Level: Applying (Application)

REF: 460

9. A patient who is diagnosed with Alzheimer’s disease experiences visual hallucinations.

The primary care NP should initially prescribe: donepezil (Aricept). a.

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rivastigmine (Exelon).

memantine (Namenda).

galantamine (Razadyne).

ANS: B

Patients with dementia with Lewy bodies may show benefit with rivastigmine. Visual hallucinations are a hallmark feature of Lewy body dementia. DIF: Cognitive Level: Understanding (Comprehension)

REF: 461

Chapter 45: Antiepileptics Test Bank MULTIPLE CHOICE 1. A patient who has partial seizures has been taking phenytoin (Dilantin). The patient has

recently developed thrombocytopenia. The primary care nurse practitioner (NP) should contact the patient’s neurologist to discuss changing the patient’s medication to: a.

topiramate (Topamax).

levetiracetam (Keppra).

zonisamide (Zonegran).

carbamazepine (Tegretol).

ANS: D

Evidence-based recommendations exist showing carbamazepine to be effective as monotherapy for partial seizures. Because this patient has developed a serious side effect of phenytoin, changing to carbamazepine may be a good option. The other three drugs may be added to phenytoin or another first-line drug when drug-resistant seizures occur, but are not recommended as monotherapy. DIF: Cognitive Level: Applying (Application)

REF: 491

2. A patient is newly diagnosed with generalized epilepsy. The primary care NP will refer

this patient to a neurologist and should expect this patient to begin taking: a.

phenytoin (Dilantin).

topiramate (Topamax).

lamotrigine (Lamictal).

levetiracetam (Keppra).

ANS: A

There is little good-quality evidence to support the use of newer monotherapy over older drugs. Phenytoin is the prototype of many seizure medications and is usually tried first. Other drugs may be used if seizures are resistant to phenytoin or if side effects occur.

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DIF: Cognitive Level: Understanding (Comprehension)

REF: 491

3. A patient who takes carbamazepine (Tegretol) has been seizure-free for 2 years and asks

the primary care NP about stopping the medication. The NP should: a.

order an electroencephalogram (EEG).

prescribe a tapering regimen of the drug.

inform the patient that antiepileptic drug (AED) therapy is lifelong.

tell the patient to stop the drug and use only as needed.

ANS: A

Discontinuation of AEDs may be considered in patients who have been seizure-free for longer than 2 years. An EEG should be obtained before the medication is withdrawn. The drug should be tapered to prevent status epilepticus, but only after a normal EEG is obtained. AED therapy is not lifelong in all patients. Patients should not stop AED medications abruptly, and these drugs are not used on an as-needed basis. DIF: Cognitive Level: Applying (Application)

REF: 492

4. A 12-month-old child with severe developmental delays was recently treated in an

emergency department for a febrile seizure and is seen by the primary care NP for a follow-up visit. The child’s parent asks if it is necessary to continue giving the child phenobarbital. The NP should tell the parent that: a.

the phenobarbital may be used on an asneeded basis.

the phenobarbital may be stopped when an EEG is normal.

once the febrile illness is past, the phenobarbital may be stopped.

their child is at increased risk for seizures and should continue the phenobarbital.

ANS: D

Although the American Academy of Pediatrics has concluded that the risks of long-term treatment with phenobarbital outweigh the potential benefits in most cases, continued treatment with this drug is used in children at greatest risk for future neurologic problems, including children with febrile seizures before 18 months of age and children with neurologic dysfunction or severe developmental delays. DIF: Cognitive Level: Applying (Application)

REF: 492

5. A patient who is taking phenytoin (Dilantin) for a newly diagnosed seizure disorder calls

the primary care NP to report a rash. The NP should:

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order a phenytoin level.

reassure the patient that this is a selflimiting adverse effect.

recommend that the patient take diphenhydramine to treat this side effect.

tell the patient to stop taking the phenytoin and contact the neurologist immediately.

ANS: D

Phenytoin should be discontinued if skin rash appears because some rashes can be lifethreatening. Rashes are not related to serum drug levels, so a phenytoin level is not indicated. Although some rashes are self-limiting, the patient should stop taking the drug until serious rashes are ruled out. Suggesting diphenhydramine is not correct until the severity of the rash is known. DIF: Cognitive Level: Applying (Application)

REF: 496

6. A patient who takes valproic acid for a seizure disorder is preparing to have surgery. The

primary care NP should order: a.

coagulation studies.

a complete blood count.

an EEG.

a creatinine clearance test.

ANS: A

Valproic acid may cause thrombocytopenia and inhibition of platelet aggregation. Platelet counts and coagulation studies should be done before therapy is initiated, at regular intervals, and before any surgical procedure is performed. DIF: Cognitive Level: Applying (Application)

REF: 497

7. A 20-kg child takes valproic acid (Depakote) for seizures and has had regular dose

increases with a current dose of 250 mg twice daily. The child continues to have one to two seizures each week along with significant drowsiness that interferes with school participation. The primary care NP should contact the child’s neurologist to discuss: a.

obtaining a serum valproic acid level.

changing the medication to gabapentin (Neurontin).

increasing the valproic acid by 5 mg per kg of weight.

adding lamotrigine (Lamictal) to this child’s drug regimen.

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ANS: D

Research suggests a combination of lamotrigine and valproate to be the most effective regimen in patients with refractory epilepsy. Valproic acid dosing may be increased to a maximum of 60 mg/kg/day unless side effects prevent further increase in dosage. The other drugs are not recommended. DIF: Cognitive Level: Applying (Application)

REF: 499

8. A patient who takes carbamazepine (Tegretol) for a seizure disorder is seen by a primary

care NP for a routine physical examination. A complete blood count (CBC) reveals a low white blood cell (WBC) count. The NP should: a.

order a WBC differential.

discontinue the carbamazepine.

reassure the patient that this effect is temporary.

decrease the carbamazepine dose and recheck the CBC in 2 weeks.

ANS: A

A benign leukopenia associated with carbamazepine is common and is reversible and dose-related. A WBC differential should be performed before changing the drug regimen. DIF: Cognitive Level: Applying (Application)

REF: 500 - 501

Chapter 46: Antiparkinson Agents Test Bank MULTIPLE CHOICE 1. A patient who has Parkinson’s disease takes levodopa and carbidopa. The patient asks the

primary care nurse practitioner (NP) why two drugs are necessary. The NP should explain that both drugs are needed to: a.

prolong effects of the levodopa.

delay progression of the disease.

decrease adverse peripheral side effects.

enhance passage of both drugs across the blood-brain barrier.

ANS: C

Combining carbidopa with levodopa results in increased concentrations of levodopa in the central nervous system and decreased conversion of levodopa to dopamine in the periphery, where it causes adverse effects. Carbidopa does not prolong the effects of levodopa. The combination does not cause delay in disease progression and does not enhance passage across the blood-brain barrier.

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DIF: Cognitive Level: Applying (Application)

REF: 505

2. A patient who has Parkinson’s disease and who takes levodopa reports that the drug

effects wear off more quickly than before. The primary care NP should: a.

add carbidopa.

add amantadine.

increase the dose of levodopa.

add a monoamine oxidase B inhibitor (MAO-B).

ANS: D

When an MAO-B is given, it appears to enhance and prolong the response to levodopa, reducing the wearing-off effect. Carbidopa does not alter this effect. Amantadine is not indicated. Increasing the dose of levodopa is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 505

3. A patient who has Parkinson’s disease takes levodopa and carbidopa. The patient reports

experiencing tremors between doses. The primary care NP should: a.

add entacapone.

add amantadine.

discontinue the carbidopa.

increase the dose of levodopa.

ANS: A

Catecholamine O-methyl transferase inhibitors, such as entacapone, are used to prolong the effects of levodopa and help prevent breakthrough tremors that occur before the next dose of levodopa. Amantadine is not indicated. Increasing carbidopa does not have this effect. Increasing the dose of levodopa does not prolong its effects. DIF: Cognitive Level: Applying (Application)

REF: 505

4. A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing

freezing episodes between doses. The primary care NP should consider using: a.

selegiline.

amantadine.

apomorphine.

modified-release levodopa.

ANS: C

Apomorphine injection is used for acute treatment of immobility known as “freezing.” DIF: Cognitive Level: Applying (Application)

REF: 506

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5. A patient who has Parkinson’s disease who takes levodopa and carbidopa reports having

drooling episodes that are increasing in frequency. The primary care NP should order: benztropine. a. b.

amantadine.

apomorphine.

modified-release levodopa.

ANS: A

Anticholinergics, such as benztropine, are used to control drooling. DIF: Cognitive Level: Applying (Application)

REF: 506

6. A patient who is diagnosed with Parkinson’s disease will begin taking levodopa and

carbidopa. The patient asks the primary care NP what dietary interventions may be helpful in improving symptoms. The NP should recommend: a.

consuming a high-calorie diet.

consuming a low-carbohydrate diet.

avoiding extra fluids during meal times.

minimizing intake of high-protein foods during the day.

ANS: D

Some people find that avoiding high-protein foods during the day and “hoarding” them until the evening improves mobility during the day. Because of decreased activity associated with the disease, patients should not eat a diet high in calories. A lowcarbohydrate diet is not indicated. Patients should consume plenty of water with food to aid in chewing and swallowing. DIF: Cognitive Level: Applying (Application)

REF: 506

7. A 55-year-old patient develops Parkinson’s disease characterized by unilateral tremors

only. The primary care NP will refer the patient to a neurologist and should expect initial treatment to be: a.

levodopa.

carbidopa.

pramipexole.

carbidopa/levodopa.

ANS: C

Patients younger than 65 years of age should be started with a dopamine agonist. DIF: Cognitive Level: Understanding (Comprehension)

REF: 507 - 508

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8. A 65-year-old patient is diagnosed with Parkinson’s disease. The patient has emphysema

and narrow-angle glaucoma. The primary care NP should consider beginning therapy with: a.

selegiline.

benztropine.

carbidopa/levodopa.

ropinirole hydrochloride.

ANS: A

Selegiline is safe for patients with glaucoma and emphysema. Benztropine is contraindicated in patients with glaucoma and emphysema. Dopamine precursors, such as carbidopa/levodopa, are contraindicated in patients with narrow-angle glaucoma and cautioned in patients with emphysema. DIF: Cognitive Level: Applying (Application)

REF: 507 - 508

Chapter 47: Antidepressants Test Bank MULTIPLE CHOICE 1. A patient reports having feelings of hopelessness and anxiety for the past few months.

The primary care nurse practitioner (NP) performs a history and learns that these feelings occur almost daily. The patient also reports having headaches and difficulty concentrating at work along with wanting to sleep all the time. The patient has gained 5 lb in the past 6 months. The NP should: a.

tell the patient that these symptoms should resolve on their own.

reassure the patient that these are symptoms of minor depression.

tell the patient that an exercise regimen alone should be effective.

assess the patient for alcohol and drug use and for suicidal ideation.

ANS: D

The patient is having symptoms of major depression, but other factors such as drug or alcohol abuse that may be contributing to the diagnosis must be ruled out first. Patients should be asked about suicidal ideation so that measures can be taken to prevent a suicide attempt. Symptoms of major depression require treatment. Exercise should be a part of any plan but should not be the only intervention. DIF: Cognitive Level: Applying (Application)

REF: 521

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2. A patient reports feelings of sadness and hopelessness along with difficulty sleeping and

weight loss. The primary care NP learns that the patient’s mother died 6 months earlier. The NP should: a.

offer a referral to a bereavement counselor.

begin pharmacologic treatment with fluoxetine.

determine whether medications are causing these symptoms.

tell the patient that these symptoms will go away in a few months.

ANS: A

Bereavement over the loss of a loved one may be associated with symptoms of major depression. Although only 17% of these patients receive pharmacologic treatment, 94% of symptoms have been found to resolve in 13 months or less. Bereavement counseling should be the first step. Pharmacologic treatment may be warranted if symptoms do not improve. This patient has a clear cause for depression. It is not enough to reassure the patient that the symptoms will resolve because this belittles their concerns. DIF: Cognitive Level: Applying (Application)

REF: 520

3. A patient has been taking paroxetine (Paxil) for major depressive symptoms for 8 months.

The patient tells the primary care NP that these symptoms improved after 2 months of therapy. The patient is experiencing weight gain and sexual dysfunction and wants to know if the medication can be discontinued. The NP should: a.

change to a tricyclic antidepressant medication.

begin to taper the paroxetine and instruct the patient to call if symptoms increase.

tell the patient to stop taking the medication and to call if symptoms get worse.

continue the medication for several months and consider adding bupropion (Wellbutrin).

ANS: D

Once a patient achieves remission, a continuation phase of 16 to 20 weeks followed by a maintenance phase of 4 to 9 months should be carried out. Some responders, called apathetic responders, may have a decrease in most symptoms but continue to have lack of pleasure, decreased libido, and lack of energy. Bupropion can be added to therapy to treat these symptoms. Patients should not change medications during this phase, should not begin a drug taper, and should never stop the medication abruptly.

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DIF: Cognitive Level: Applying (Application)

REF: 525

4. The primary care NP has prescribed sertraline (Zoloft) for a patient who initially reported

daily symptoms of hopelessness, sadness, insomnia, and weight loss. After several months of therapy, the patient no longer feels hopeless or sad but continues to have difficulty eating and sleeping. The NP should contact the patient’s psychiatrist to discuss: a.

adding mirtazapine (Remeron).

changing to duloxetine (Cymbalta).

adding another selective serotonin reuptake inhibitor (SSRI) antidepressant.

an inpatient admission to the hospital.

ANS: A

Mirtazapine may be added to the drug regimen for partial responders who continue to feel anxious. Changing medications is not recommended. Adding another SSRI is contraindicated because of the risk of serotonin syndrome. An inpatient hospital admission is not warranted. DIF: Cognitive Level: Applying (Application)

REF: 525

5. A patient has been taking fluoxetine (Prozac) for depression and comes to the clinic to

report nausea and jitteriness. The primary care NP notes tremors and sees that the patient is confused. The patient has a heart rate of 95 beats per minute. The NP should: a.

change to bupropion (Wellbutrin).

ask the patient about other medications.

discontinue the fluoxetine immediately.

add mirtazapine (Remeron) to treat anxiety.

ANS: B

Serotonin syndrome is a potentially lethal set of symptoms such as these. The NP should evaluate whether the patient is taking other SSRIs, monoamine oxidase inhibitors, bupropion, serotonin-norepinephrine reuptake inhibitors, or other medications that can precipitate this. Changing medication is not indicated. Patients should never abruptly discontinue an SSRI. Adding mirtazapine is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 524

6. A patient who has symptoms of depression also reports chronic pain. The primary care

NP should begin therapy with: a.

fluoxetine (Prozac).

duloxetine (Cymbalta).

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bupropion (Wellbutrin).

nortriptyline (Pamelor).

ANS: B

Duloxetine is an antidepressant that also has uses for pain syndromes associated with depression. DIF: Cognitive Level: Applying (Application)

REF: 526 - 527

7. An 80-year-old patient experiences prolonged sadness after the death of a spouse. The

patient reports being unable to sleep or eat. The primary care NP should prescribe mg daily. a.

trazodone 50; three times

trazodone 100; three times

mirtazapine 15; at bedtime

mirtazapine 30; at bedtime

ANS: C

Mirtazapine side effects include sedation and increased appetite, and sedation is more likely with a lower dose. Mirtazapine is often used in nursing homes to stimulate appetite in older adults. DIF: Cognitive Level: Applying (Application)

REF: 527

8. The primary care NP sees a 16-year-old patient who reports feeling hopeless and sad. The

child’s parent reports increased aggression and a decline in school performance. The NP should consider prescribing: a.

fluoxetine (Prozac).

nortriptyline (Pamelor).

tranylcypromine (Parnate).

venlafaxine hydrochloride (Effexor).

ANS: A

Fluoxetine may be used in children 8 years of age and older. Nortriptyline may be used in children 12 years of age and older but is not a first-line drug. The other drugs are not indicated in adolescents younger than 18 years. DIF: Cognitive Level: Applying (Application)

REF: 529

9. A 15-year-old patient who is seeing a psychiatrist began taking an antidepressant 1 week

before a clinic visit with the primary care NP. The NP should: a.

schedule weekly clinic visits to evaluate response to the medication.

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encourage the child to report feelings of self-harm to a school counselor.

contact the patient by phone every 2 weeks to see how the medication is working.

instruct the child’s parents to report changes in behavior to the child’s psychiatrist.

ANS: A

Pediatric patients should have face-to-face contact with a provider at least weekly during the first 4 weeks of treatment to evaluate for clinical worsening, suicidality, or unusual changes in behavior. DIF: Cognitive Level: Applying (Application)

REF: 529

10. A patient has been taking fluoxetine 20 mg every morning for 5 days and calls the

primary care NP to report decreased appetite, nausea, and insomnia. The NP should: a.

suggest taking a sedative at bedtime.

change the medication to bupropion.

add trazodone to the patient’s regimen.

reassure the patient that these effects will subside.

ANS: D

Side effects are seen with the first few doses but resolve in approximately 7 days. Patients should avoid taking sedatives while taking antidepressants. DIF: Cognitive Level: Applying (Application)

REF: 530

Chapter 47: Antidepressants Test Bank MULTIPLE CHOICE 1. A patient reports having feelings of hopelessness and anxiety for the past few months.

tell the patient that these symptoms should resolve on their own.

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reassure the patient that these are symptoms of minor depression.

tell the patient that an exercise regimen alone should be effective.

assess the patient for alcohol and drug use and for suicidal ideation.

ANS: D

REF: 521

2. A patient reports feelings of sadness and hopelessness along with difficulty sleeping and

weight loss. The primary care NP learns that the patient’s mother died 6 months earlier. The NP should: a.

offer a referral to a bereavement counselor.

begin pharmacologic treatment with fluoxetine.

determine whether medications are causing these symptoms.

tell the patient that these symptoms will go away in a few months.

ANS: A

REF: 520

3. A patient has been taking paroxetine (Paxil) for major depressive symptoms for 8 months.

change to a tricyclic antidepressant medication.

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begin to taper the paroxetine and instruct the patient to call if symptoms increase.

tell the patient to stop taking the medication and to call if symptoms get worse.

continue the medication for several months and consider adding bupropion (Wellbutrin).

ANS: D

REF: 525

4. The primary care NP has prescribed sertraline (Zoloft) for a patient who initially reported

adding mirtazapine (Remeron).

changing to duloxetine (Cymbalta).

adding another selective serotonin reuptake inhibitor (SSRI) antidepressant.

an inpatient admission to the hospital.

ANS: A

REF: 525

5. A patient has been taking fluoxetine (Prozac) for depression and comes to the clinic to

report nausea and jitteriness. The primary care NP notes tremors and sees that the patient is confused. The patient has a heart rate of 95 beats per minute. The NP should: a.

change to bupropion (Wellbutrin).

ask the patient about other medications.

discontinue the fluoxetine immediately.

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add mirtazapine (Remeron) to treat anxiety.

d. ANS: B

REF: 524

6. A patient who has symptoms of depression also reports chronic pain. The primary care

NP should begin therapy with: a.

fluoxetine (Prozac).

duloxetine (Cymbalta).

bupropion (Wellbutrin).

nortriptyline (Pamelor).

ANS: B

Duloxetine is an antidepressant that also has uses for pain syndromes associated with depression. DIF: Cognitive Level: Applying (Application)

REF: 526 - 527

7. An 80-year-old patient experiences prolonged sadness after the death of a spouse. The

patient reports being unable to sleep or eat. The primary care NP should prescribe mg daily. a.

trazodone 50; three times

trazodone 100; three times

mirtazapine 15; at bedtime

mirtazapine 30; at bedtime

ANS: C

REF: 527

8. The primary care NP sees a 16-year-old patient who reports feeling hopeless and sad. The

child’s parent reports increased aggression and a decline in school performance. The NP should consider prescribing: a.

fluoxetine (Prozac).

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nortriptyline (Pamelor).

tranylcypromine (Parnate).

venlafaxine hydrochloride (Effexor).

ANS: A

REF: 529

9. A 15-year-old patient who is seeing a psychiatrist began taking an antidepressant 1 week

before a clinic visit with the primary care NP. The NP should: a.

schedule weekly clinic visits to evaluate response to the medication.

encourage the child to report feelings of self-harm to a school counselor.

contact the patient by phone every 2 weeks to see how the medication is working.

instruct the child’s parents to report changes in behavior to the child’s psychiatrist.

ANS: A

REF: 529

10. A patient has been taking fluoxetine 20 mg every morning for 5 days and calls the

primary care NP to report decreased appetite, nausea, and insomnia. The NP should: a.

suggest taking a sedative at bedtime.

change the medication to bupropion.

add trazodone to the patient’s regimen.

reassure the patient that these effects will subside.

ANS: D

Side effects are seen with the first few doses but resolve in approximately 7 days. Patients should avoid taking sedatives while taking antidepressants. DIF: Cognitive Level: Applying (Application)

REF: 530

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Chapter 48: Antianxiety and Insomnia Agents Test Bank MULTIPLE CHOICE 1. A patient comes to the clinic and reports having insomnia that began within the last year.

The primary care nurse practitioner (NP) learns that the patient often lies awake worrying about problems at work. The patient feels fatigued during the day and experiences frequent stomach discomfort. The NP should prescribe: a.

buspirone.

melatonin.

alprazolam.

diphenhydramine.

ANS: A

This patient is having insomnia because of anxiety. Alprazolam has a high abuse potential, so starting therapy with an antianxiety medication is a good choice. Melatonin and diphenhydramine are given for insomnia. DIF: Cognitive Level: Applying (Application)

REF: 541

2. A patient tells the primary care NP about having difficulty giving presentations at work.

The patient experiences anxiety and often feels faint or vomits. The NP should: a.

prescribe buspirone.

prescribe alprazolam.

order a selective serotonin reuptake inhibitor (SSRI) antidepressant.

recommend cognitive-behavioral therapy.

ANS: D

The patient is describing a phobic disorder. Cognitive-behavioral therapy is recommended as first-line treatment, with SSRI medications as adjunct therapy. DIF: Cognitive Level: Applying (Application)

REF: 540 - 541

3. An adolescent patient comes to the clinic and reports anxiety and poor sleep that have

persisted since experiencing a hurricane 8 months prior. The patient has been receiving cognitive-behavioral therapy, which has helped a little. The primary care NP should order: a.

doxepin.

fluoxetine.

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alprazolam.

clonazepam.

ANS: B

This patient has posttraumatic stress disorder. If cognitive-behavioral therapy has not been effective, the patient should be given an SSRI as second-line treatment. Doxepin is a tricyclic antidepressant. The other two choices are benzodiazepines. DIF: Cognitive Level: Applying (Application)

REF: 542

4. A patient reports difficulty falling asleep and staying asleep every night and has difficulty

staying awake during the commute to work every day. The NP should: a.

suggest the patient try diphenhydramine first.

perform a thorough history and physical examination.

teach about avoiding caffeine and good sleep hygiene.

suggest melatonin and consider prescribing Ambien if this is not effective.

ANS: B

Before treating insomnia with drug therapy, it is important first to rule out any physiologic causes of a sleep disorder. The other interventions may be tried if no serious cause of the disorder is found. DIF: Cognitive Level: Applying (Application)

REF: 541

5. A patient is in the clinic with acute symptoms of anxiety. The patient is restless and has

not slept in 3 days. The primary care NP observes that the patient is irritable and has moderate muscle tension. The patient’s spouse reports that similar symptoms have occurred before in varying degrees for several years. The NP should refer the patient to a psychologist and should prescribe which drug for short-term use? a.

Alprazolam

Buspirone

Melatonin

Zolpidem

ANS: A

For acute anxiety, a benzodiazepine should be prescribed. SSRIs or buspirone should be used for long-term treatment. Melatonin and zolpidem are anti-insomnia agents. DIF: Cognitive Level: Applying (Application)

REF: 542

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6. A patient reports going to bed at 10:00 pm every night but often lays awake until

midnight. The primary care NP instructs the patient to practice good sleep hygiene and to avoid caffeine in the evening. After 1 week of this regimen, the patient reports still lying awake until 11:00 PM. The NP should: a.

order a sleep study.

consider short-term zolpidem.

order ramelteon for several weeks.

reassure the patient and re-evaluate in 1 week.

ANS: D

Treatment of patients with insomnia begins with sleep hygiene. It is important that the patient have reasonable expectations and understand that the time of onset of sleep can be moved up only by 15 minutes every 3 or 4 days. This patient is showing improvement, which means the measures are working. When these measures are ineffective, medications may be considered. DIF: Cognitive Level: Applying (Application)

REF: 543

7. A patient reports difficulty returning to sleep after getting up to go to the bathroom every

night. A physical examination and a sleep hygiene history are noncontributory. The primary care NP should prescribe: a.

zaleplon.

ZolpiMist.

ramelteon.

chloral hydrate.

ANS: B

ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep onset. Chloral hydrate is not typically used as outpatient therapy. DIF: Cognitive Level: Applying (Application)

REF: 543

Chapter 49: Antipsychotics Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) is performing a physical examination on a

patient who has been taking mesoridazine (Serentil) for several weeks to treat schizophrenia. The patient is exhibiting rhythmic movements of the face and jaw. The NP should be concerned that the patient may: a.

need a higher dose of mesoridazine.

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need to change to thioridazine (Mellaril).

have developed neuroleptic malignant syndrome.

be exhibiting signs of an irreversible adverse effect.

ANS: D

Tardive dyskinesia, or abnormal involuntary movements characterized by rhythmic involuntary movements of the tongue, face, mouth, or jaw, may be progressive and irreversible. This condition can occur with all antipsychotics, especially the firstgeneration antipsychotics. Increasing the dose may increase the symptoms. Thioridazine is another first-generation antipsychotic with a similar adverse-effect profile. Neuroleptic malignant syndrome occurs weeks after initiation and is characterized by fever, catatonia, muscle rigidity, and autonomic instability. DIF: Cognitive Level: Applying (Application)

REF: 552

2. A patient with a recent diagnosis of schizophrenia is taking thioridazine (Mellaril) to treat

psychotic symptoms. The patient’s family member is concerned that the patient continues to have little interest in activities and has difficulty beginning even simple tasks. The primary care NP should contact the patient’s psychiatrist to discuss changing to: fluphenazine (Prolixin). a. b.

risperidone (Risperdal).

chlorpromazine (Thorazine).

prochlorperazine (Compazine).

ANS: B

First-generation antipsychotics treat positive but not negative symptoms associated with psychotic states. This patient exhibits negative symptoms and should be treated with a second-generation antipsychotic, such as risperidone. The other three drugs are firstgeneration antipsychotics. DIF: Cognitive Level: Applying (Application)

REF: 552

3. A 22-year-old male patient who has dropped out of college has increasingly disorganized

behavior and delusional thinking. His parents report that he lives at home and has no desire to find a job or help around the house. The primary care NP has ruled out organic causes and has referred the patient to a psychiatrist for treatment. To prepare for the referral visit, the NP should: a.

begin therapy with a low-potency antipsychotic.

begin therapy with a high-potency antipsychotic.

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obtain a complete blood count (CBC), serum lipids, and hemoglobin A1c.

order liver function tests (LFTs), a CBC, an electrocardiogram (ECG), and a urinalysis.

ANS: D

Before antipsychotic drugs are initiated, baseline laboratory tests, including LFTs, CBC, ECG, and urinalysis, should be performed. Serum lipids and hemoglobin A 1c may be ordered if the patient has risk factors for diabetes or metabolic syndrome. DIF: Cognitive Level: Applying (Application)

REF: 554

4. A patient who is newly diagnosed with schizophrenia is overweight and has a positive

family history for type 2 diabetes mellitus. The primary care NP should consider initiating antipsychotic therapy with: a.

ziprasidone (Geodon).

olanzapine (Zyprexa).

risperidone (Risperdal).

chlorpromazine (Thorazine).

ANS: A

Many antipsychotics increase the risk of metabolic syndrome in patients. Ziprasidone does not have effects on weight. The other agents all increase the risk of weight gain and metabolic syndrome. DIF: Cognitive Level: Applying (Application)

REF: 564

5. A patient has been taking olanzapine (Zyprexa) for 3 weeks to treat schizophrenia. The

primary care NP notes that the patient has more coherent speech and improved initiative and attentiveness but continues to have delusional ideation. The NP should: a.

increase the dose of olanzapine.

decrease the dose of olanzapine.

maintain the same dose of olanzapine.

change from olanzapine to chlorpromazine.

ANS: A

Clinicians should gradually increase the dose of antipsychotic medication to achieve therapeutic effects, while minimizing side effects. It may take weeks to achieve full therapeutic effects. DIF: Cognitive Level: Applying (Application)

REF: 556

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6. An elderly patient with dementia exhibits hostility and uncooperativeness. The primary

care NP prescribes clozapine (Clozaril) and should counsel the family about: a.

a decreased risk of extrapyramidal symptoms.

improved cognitive function.

the need for long-term use of the medication.

a possible increased risk of heart disease and stroke.

ANS: D

Antipsychotics are useful in treating some psychiatric symptoms of dementia and help to improve quality of life in many patients. They do not improve cognitive function, however. They increase the risk of extrapyramidal symptoms and should be used only on a short-term basis. They increase the risk of heart disease and stroke. DIF: Cognitive Level: Applying (Application)

REF: 557

7. A patient who takes 150 mg of clozapine (Clozaril) twice daily calls the primary care NP

at 10:00 AM one day to report forgetting to take the 8:00 AM dose. The NP should counsel the patient to: a.

take the missed dose now.

take 75 mg of clozapine now.

wait and take the evening dose at the usual time.

take the evening dose 2 hours earlier than usual.

ANS: C

Advise patients to take missed doses only if remembered within 1 hour after the time the dose was due. DIF: Cognitive Level: Applying (Application)

REF: 558

8. A patient comes to the clinic for a physical examination 2 weeks after a last dose of

clozapine (Clozaril). The primary care NP should: order a CBC with differential. a. b.

obtain serum lipids and LFTs.

obtain a serum clozapine level.

assess for orthostatic hypotension.

ANS: A

Clozapine presents a significant risk for agranulocytosis, and leukocytes should be

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monitored before starting treatment, weekly during treatment, and weekly for at least 4 weeks after discontinuing treatment. DIF: Cognitive Level: Applying (Application)

REF: 563

9. A patient who is overweight is diagnosed with schizophrenia. The primary care NP

should consider prescribing: a.

olanzapine (Zyprexa).

ziprasidone (Geodon).

quetiapine (Seroquel).

aripiprazole (Abilify).

ANS: B

Of the four drugs listed, ziprasidone causes the least metabolic side-effect burden of second-generation antipsychotics. DIF: Cognitive Level: Applying (Application)

REF: 564

Chapter 50: Substance Abuse Test Bank MULTIPLE CHOICE 1. At an annual well-woman examination, the primary care nurse practitioner (NP) asks a

patient about alcohol consumption. The woman reports she usually consumes six glasses of wine per week and occasionally will consume three or four glasses at a party. The NP smells alcohol on the woman’s breath. The woman says she is hung over today. The NP should: a.

order liver function tests (LFTs) and a complete blood count.

question her further about her nightly alcohol consumption—ask what size her wine glasses are.

consider her at high risk for alcoholism.

refer her to treatment for alcohol abuse.

ANS: B

Patients with alcohol on their breath should be assessed for alcohol abuse. The woman describes an amount of drinking that would put her at low risk, but alcoholics often minimize their drinking. A first step would be to get more information about how much she is drinking. The laboratory work may be indicated when the degree of suspicion is confirmed. Once alcoholism is diagnosed, she should be referred for treatment.

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DIF: Cognitive Level: Applying (Application)

REF: 566

2. A mother brings her a college-age son to the primary care NP and asks the NP to talk to

him about alcohol use. He reports binge drinking on occasion and drinking only beer on weekends. The NP notes diaphoresis, tachycardia, and an easy startle reflex. The NP should: a.

admit him to the hospital for detoxification.

ask him how much he had to drink last night.

prescribe lorazepam (Ativan) to help with symptoms.

suggest that he talk to a counselor about alcohol abuse.

ANS: A

He is showing signs of alcohol withdrawal and possible delirium tremens and so should be admitted to the hospital. Asking him about drinking and suggesting outpatient counseling would be useful for a less emergent condition. The NP should not prescribe a medication to treat delirium tremens on an outpatient basis. DIF: Cognitive Level: Applying (Application)

REF: 566

3. A patient who is an alcoholic is seen in the clinic, and the primary care NP admits the

patient to the hospital for acute withdrawal. The patient has elevated liver enzymes. The NP should expect the inpatient provider to prescribe: a.

lorazepam (Ativan).

diazepam (Valium).

acamprosate (Campral).

chlordiazepoxide (Librium).

ANS: A

Benzodiazepines are used to treat alcohol withdrawal because they demonstrate crosstolerance with alcohol. Short-acting benzodiazepines are used in patients with liver damage. Lorazepam is a short-acting benzodiazepine. Acamprosate is used to reduce voluntary intake of alcohol and is not used for withdrawal symptoms. DIF: Cognitive Level: Applying (Application)

REF: 566

4. A patient is brought to the clinic by a spouse because of increased somnolence and

disorientation. The spouse tells the primary care NP that the patient has been taking oxycodone for postoperative pain. The NP notes a respiratory rate of 8 to 10 breaths per minute. The NP should: a.

activate the emergency medical service

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(EMS) and administer oxygen. b.

administer oral methadone (Dolophine).

administer intramuscular naltrexone (ReVia).

administer sublingual buprenorphine (Subutex).

ANS: C

The patient shows signs of opiate toxicity. Naltrexone is given to reverse the respiratory depression caused by opiate toxicity. The NP would activate EMS if the patient’s symptoms worsen. Methadone is used to assist patients addicted to narcotics to withdraw from the drug. Buprenorphine is used to aid with withdrawal symptoms. DIF: Cognitive Level: Applying (Application)

REF: 568

5. The primary care NP is preparing to prescribe acamprosate for a patient who is an

alcoholic. Before initiating treatment with this medication, the NP should: a.

assess renal function.

obtain liver function tests.

teach the patient never to take the drug with alcohol.

tell the patient that this medication is used to treat withdrawal symptoms.

ANS: A

This drug should not be given if patients have severe renal impairment. LFTs are indicated if signs of liver toxicity occur. Acamprosate does not cause a disulfiram-like reaction and is not used to treat withdrawal. DIF: Cognitive Level: Applying (Application)

REF: 568

6. The primary care NP prescribes disulfiram to a patient who has stopped drinking but

continues to have cravings for alcohol. The NP must counsel the patient to: a.

abstain from alcohol completely.

report a garlic taste in the mouth.

stop taking the drug after a few months.

increase the drug dose after several months.

ANS: A

Patients taking disulfiram who consume alcohol experience an uncomfortable and sometimes life-threatening reaction and may have these symptoms up to 14 days after disulfiram is given. A garlic taste is a minor side effect. Patients may take the drug for

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years but do not need to increase the dose because they can become more sensitive to its effects. DIF: Cognitive Level: Applying (Application)

REF: 568

Chapter 72: Smoking Cessation Test Bank MULTIPLE CHOICE 1. A patient who smokes reports repeated attempts to quit smoking using a nicotine

replacement patch. The patient says, “I always do well for a few weeks and then I just start smoking again.” The primary care nurse practitioner (NP) should prescribe: a.

nortriptyline.

Nicorette gum.

a Nicotrol inhaler.

varenicline (Chantix).

ANS: D

Varenicline interferes with the enjoyment of nicotine so that smokers do not get pleasure when they smoke. Nicotine replacement medications do not improve relapse rates, and this patient has relapsed several times. Nortriptyline is not a first-line smoking cessation medication. DIF: Cognitive Level: Applying (Application)

REF: 780

2. An adolescent patient has recently begun smoking and reports a habit of fewer than five

or six cigarettes per day. The patient does not want to quit smoking now but plans to do so after college. The primary care nurse practitioner should: a.

prescribe varenicline (Chantix).

recommend a nicotine transdermal patch.

refer the patient to a smoking cessation program.

begin a discussion about the negative effects of smoking.

ANS: D

For all patients who smoke, the provider should assess their willingness to quit. For patients unwilling to quit, the provider should focus on motivational issues. Chantix, nicotine transdermal patches, and smoking cessation programs are treatments for smoking, but if they are used by a patient who is unwilling to quit, they will be ineffective.

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DIF: Cognitive Level: Applying (Application)

REF: 782

3. A primary care NP has been working with a young woman who wants to quit smoking

before she begins having children. She has made several attempts to quit using nicotine replacement therapy and is feeling discouraged. She does not want to take medication at this time. The NP should: a.

discuss the effects of smoking on fetal development.

ask her to write down any factors that triggered her relapses.

give her information about the long-term effects of smoking.

convince her that taking medication will be essential in her case.

ANS: B

Each attempt to quit smoking should not be seen as a failure but as a trial for the next attempt. Asking a patient who is motivated to quit to write down things that may have contributed to the relapse will help the patient learn from the previous attempts. The patient already knows about the effects of smoking on fetal development because that is her motivation for quitting. Offering medication may be necessary, but only if the patient desires it. DIF: Cognitive Level: Applying (Application)

REF: 781

4. A patient reports smoking two or more packs of cigarettes per day and expresses a desire

to quit smoking. The primary care NP learns that the patient smokes heavily during breaks at work and during the evening but with no established schedule. The NP should recommend: a.

bupropion (Wellbutrin).

nicotine replacement gum or nasal spray.

a high-dose 24-hour nicotine patch.

intensive smoking cessation counseling.

ANS: B

Nicotine replacement gum and nasal spray both can be used when patients have cravings and are especially useful for patients who do not smoke at particular times. The patch is useful when patients smoke consistently throughout the day. Bupropion is not indicated. Intensive counseling is often necessary for patients who have difficulty stopping and have failed several times. DIF: Cognitive Level: Applying (Application)

REF: 782

5. A patient who is using a nicotine patch for smoking cessation is in the clinic for a follow-

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up examination. The primary care NP notes a heart rate of 96 beats per minute and a blood pressure of 140/90 mm Hg. The patient reports feeling dizzy and complains of ringing in both ears. The NP should suspect: a.

nicotine withdrawal symptoms.

that the patient has been smoking.

hypersensitivity reaction to the nicotine patch.

minor cardiovascular effects of the nicotine patch.

ANS: B

Patients who are using the patch should be cautioned not to smoke while using it because of the risk of nicotine overdose. This patient is not having symptoms of nicotine withdrawal or of hypersensitivity of the patch or of minor cardiovascular effects. DIF: Cognitive Level: Analyzing (Analysis)

REF: 785

6. A patient has been using a nicotine patch for several weeks and uses the 15 mg/16 hour

patch. The patient reports having frequent continual cravings for cigarettes, especially on awakening in the morning. The primary care NP should: a.

prescribe varenicline (Chantix).

prescribe bupropion (Wellbutrin).

change to a 21 mg/24 hour nicotine patch.

suggest adding nicotine nasal spray for cravings.

ANS: C

It is important to begin therapy with a dose sufficient to deliver enough nicotine so that patients will not want to smoke. Patients who awaken with nicotine cravings should wear a 24-hour patch. Prescribing varenicline or bupropion may be necessary if the patch fails after appropriate dosing is established. Whichever nicotine replacement method is chosen, the patient should use only one particular product to avoid nicotine toxicity. DIF: Cognitive Level: Applying (Application)

REF: 785

7. A patient has been using a nicotine nasal spray for 4 months, one to two doses every hour

while awake and as needed for cravings. The patient reports that the cravings have stopped and that one dose per hour is generally sufficient. The primary care NP should recommend: a.

changing to Nicorette gum as needed.

using a low-dose 16-hour patch for 2 weeks.

continuing one dose per hour for 2 more

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months and then discontinuing. beginning one dose every 2 hours for 1 week and then one dose every 4 hours.

d. ANS: D

Once the patient is showing improvement, the nasal spray should be tapered by halving the number of doses used each week. Patients should not switch products, so nicotine replacement gum or the patch is not indicated. Tapering is recommended rather than an abrupt discontinuation to prevent acute withdrawal symptoms, which may contribute to relapse. DIF: Cognitive Level: Applying (Application)

REF: 785

Chapter 17: Hypertension and Miscellaneous Antihypertensive Medications Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood

prescribe a thiazide diuretic.

consider treatment with an angiotensinconverting enzyme inhibitor.

reassure the patient that these findings are normal.

counsel the patient about dietary and lifestyle changes.

ANS: D

than 140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24, and exercises regularly. The patient has no known risk factors for

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cardiovascular disease. The primary care NP should: a.

prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.

perform a careful cardiovascular physical assessment.

counsel the patient about dietary and lifestyle changes.

order a urinalysis and creatinine clearance and begin therapy with a -blocker.

ANS: B

REF: 227 - 228

3. The primary care NP sees a new patient who has diabetes and hypertension and has been

taking a thiazide diuretic for 6 months. The patient’s blood pressure at the beginning of treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should: a.

order a

add an angiotensin-converting enzyme inhibitor.

continue the current drug regimen.

change to an aldosterone antagonist medication.

-blocker.

ANS: B

REF: 229| Table 17-6

4. A patient who has had a previous myocardial infarction has a blood pressure of 135/82

mm Hg. The patient’s body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe:

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an angiotensin-converting enzyme inhibitor.

a thiazide diuretic.

lifestyle modifications.

a calcium-channel blocker.

ANS: A

REF: 229| Table 17-6

5. A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s

body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: a.

an angiotensin-converting enzyme inhibitor.

a thiazide diuretic.

dietary and lifestyle changes.

-blocker.

ANS: C

REF: 229

6. The primary care NP sees a new African-American patient who has blood pressure

readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: a.

initiate monotherapy with a thiazide diuretic.

prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.

discuss dietary and lifestyle modifications with the patient.

begin combination therapy with an ARB

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and a calcium-channel blocker. ANS: A

African Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans. DIF: Cognitive Level: Applying (Application)

REF: 232| Table 17-2

7. An 80-year-old male patient will begin taking an -antiadrenergic medication. The

primary care NP should teach this patient to: a.

ask for assistance while bathing.

restrict fluids to aid with diuresis.

take the medication in the morning with food.

be aware that priapism is a common side effect.

ANS: A

REF: 232 - 233

Chapter 18: Coronary Artery Disease and Antianginal Medications Test Bank MULTIPLE CHOICE 1. A patient who has a history of angina has sublingual nitroglycerin tablets to use as

“I should call 9-1-1 if chest pain persists 5 minutes after the first dose.”

“I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1.”

“I should take aspirin along with the nitroglycerin when I have chest pain.”

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“I should take nitroglycerin and then rest for 15 minutes before taking the next dose.”

ANS: A

REF: 241

2. A patient who will begin using nitroglycerin for angina asks the primary care NP how the

medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: a.

dissolve atheromatous lesions.

relax vascular smooth muscle.

prevent catecholamine release.

reduce C-reactive protein levels.

ANS: B

REF: 239 - 240

3. A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes.

increase the nitroglycerin dose to 0.6 mg per dose.

change from a sublingual to a transdermal patch nitroglycerin.

discontinue the nitroglycerin and order ranolazine (Ranexa ER).

contact the patient’s cardiologist to discuss admission to the hospital.

ANS: D

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REF: 239

4. A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic

and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to: a.

obtain an electrocardiogram.

administer oxygen at 2 L/minute.

give 325 mg of chewable aspirin.

call EMS.

ANS: B

REF: 241

5. A 45-year-old patient who has a positive family history but no personal history of

30 minutes of aerobic exercise daily.

taking 81 to 325 mg of aspirin daily.

beginning therapy with a statin medication.

starting a thiazide diuretic to treat hypertension.

ANS: A

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DIF: Cognitive Level: Applying (Application)

REF: 240 - 241

6. The primary care NP is preparing to prescribe isosorbide dinitrate sustained release

(Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: a.

60 mg four times daily at 6-hour intervals.

40 mg twice daily 30 minutes before meals.

60 mg on awakening and 40 mg 7 hours later.

80 mg three times daily at 8:00 AM , 1:00 PM , and 6:00 PM.

ANS: B

REF: 241

7. A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for

a patient with chronic stable angina. The NP should teach the patient to: a.

change the patch four times daily.

use the patch as needed for angina pain.

use two patches daily and change them every 12 hours.

apply one patch daily in the morning and remove in 12 hours.

ANS: D

REF: 244

Chapter 21: Calcium Channel Blockers Test Bank

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MULTIPLE CHOICE 1. A patient who has stable angina pectoris and a history of previous myocardial infarction

takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil: a.

improves blood flow and oxygen delivery to the heart.

increases the rate of contraction of the cardiac muscle.

increases the force of contraction of the cardiac muscle.

has a positive inotropic effect to increase cardiac output.

ANS: A

REF: 265 - 266

2. A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The

primary care NP should contact the patient’s cardiologist to discuss adding: a.

amlodipine (Norvasc).

diltiazem (Cardizem).

verapamil HCl (Calan).

nifedipine (Procardia XL).

ANS: D

REF: 267

3. A patient who has stable angina is taking nitroglycerin and a

-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: a.

isradipine (DynaCirc).

nicardipine (Cardene).

verapamil HCl (Calan).

nifedipine (Procardia XL).

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ANS: C

REF: 268

4. A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary

amlodipine (Norvasc).

isradipine (DynaCirc).

verapamil HCl (Calan).

short-acting nifedipine (Procardia).

ANS: C

Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. DIF: Cognitive Level: Applying (Application)

REF: 268

5. An African-American patient who is obese has persistent blood pressure readings greater

than 150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should consider prescribing a(n): angiotensin receptor blocker.

a. b.

-blocker.

ACE inhibitor.

calcium channel blocker.

ANS: D

REF: 268

6. A patient who takes a calcium channel blocker is in the clinic for an annual physical

examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate:

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serum calcium channel blocker level.

complete blood count and electrolytes.

liver function tests (LFTs) and renal function.

thyroid and insulin levels.

ANS: C

Patients who take calcium channel blockers should have periodic renal and LFTs. DIF: Cognitive Level: Applying (Application)

REF: 268

7. A patient who is taking nifedipine develops mild edema of both feet. The primary care

NP should contact the patient’s cardiologist to discuss: a.

changing to amlodipine.

ordering renal function tests.

increasing the dose of nifedipine.

evaluation of left ventricular function.

ANS: A

REF: 269

Chapter 24: Antihy perlipidemic Agents Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) sees a patient for a physical examination and

ezetimibe (Zetia).

gemfibrozil (Lopid).

simvastatin (Zocor).

nicotinic acid (Niaspan).

ANS: B

Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that

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coronary heart disease may develop in patients without a history of coronary heart disease who have low HDL cholesterol levels and elevated triglyceride levels. This patient’s LDL is within normal limits, so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor, used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in patients who have failed dietary therapy. DIF: Cognitive Level: Applying (Application)

REF: 295

2. A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile

atorvastatin (Lipitor).

gemfibrozil (Lopid).

cholestyramine (Questran).

lovastatin/niacin (Advicor).

ANS: A

REF: 293

3. A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6

order liver function tests (LFTs).

order a creatine kinase-MM (CK-MM) level.

change atorvastatin to twice-daily dosing.

add gemfibrozil (Lopid) to the patient’s medication regimen.

ANS: B

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to change the dosing schedule. Gemfibrozil is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 299

4. A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues

change the atorvastatin dose to 15 mg twice daily.

change the patient’s medication to cholestyramine (Questran).

add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.

recommend supplements of omega-3 along with the atorvastatin.

ANS: C

REF: 299

5. A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals

recommend dietary and lifestyle changes first.

begin therapy with atorvastatin 10 mg per day.

discuss quality-of-life issues as part of the decision to begin medication.

tell her there is no clinical evidence of efficacy of statin medication in her case.

ANS: B

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primary prevention in women. DIF: Cognitive Level: Applying (Application)

REF: 296

6. A patient who has diabetes is taking simvastatin (Zocor) 80 mg daily to treat LDL

cholesterol level of 170 mg/dL. The patient has a body mass index of 29. At a follow-up visit, the patient’s LDL level is 120 mg/dL. The primary care NP should consider: a.

increasing the simvastatin to 80 mg twice daily.

adding nicotinic acid to the patient’s drug regimen.

changing the medication to ezetimibe/simvastatin (Vytorin).

referring the patient to a dietitian for assistance with weight reduction.

ANS: C

REF: 296

7. A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant.

Which bile acid sequestrant should the primary care NP order? a.

Colesevelam (Welchol)

Colestipol (Colestid)

Cholestyramine (Questran)

Cholestyramine (Questran Light)

ANS: A

REF: 298

8. A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor.

order LFTs.

order CK-MM tests.

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consider decreasing the dose of the medication.

reassure the patient that this side effect is common.

ANS: D

REF: 299

Chapter 52: Thyroid Medications Test Bank MULTIPLE CHOICE 1. A patient reports fatigue, weight loss, and dry skin. The primary care nurse practitioner

(NP) orders thyroid function tests. The patient’s thyroid stimulating hormone (TSH) is 40 microunits/mL, and T4 is 0.1 ng/mL. The NP should refer the patient to an endocrinologist and prescribe: a.

methimazole.

liothyronine.

levothyroxine.

propylthiouracil.

ANS: C

This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a thyroid suppressant. Liothyronine is synthetic T3 . Propylthiouracil is a thyroid suppressant. DIF: Cognitive Level: Applying (Application)

REF: 582

2. A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2

weeks. The patient reports continued fatigue. The primary care NP should: a.

order a T4 level today.

increase the dose to 100 mcg.

check the TSH level in 1 week.

reassure the patient that this will improve in several weeks.

ANS: C

Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH

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level is indicated to evaluate drug effectiveness. The dose should not be increased without first evaluating the patient’s TSH level. DIF: Cognitive Level: Applying (Application)

REF: 582

3. A primary care NP orders thyroid function tests. The patient’s TSH is 1.2 microunits/mL,

and T4 is 1.7 ng/mL. The NP should: a.

assess the patient for symptoms of hyperthyroidism.

ask the patient about the use of medications such as lithium.

tell the patient that the results most likely indicate hypothyroidism.

ask an endocrinologist to evaluate for possible Hashimoto’s thyroiditis.

ANS: C

Primary hypothyroidism is the most common form of hypothyroidism. Use of certain drugs, such as lithium, and diseases such as Hashimoto’s thyroiditis can cause hypothyroidism but are less likely. The patient does not have signs of hyperthyroidism. DIF: Cognitive Level: Applying (Application)

REF: 585

4. An 80-year-old female patient with a history of angina has increased TSH and decreased

T4 . The primary care NP should prescribe a.

mcg of . 25; liothyronine

75; liothyronine

25; levothyroxine

75; levothyroxine

ANS: C

Elderly individuals may experience exacerbation of cardiovascular disease and angina with thyroid hormone replacement. It is advisable to start low at 25 mcg and work up as tolerated. Liothyronine is a synthetic T3 . DIF: Cognitive Level: Applying (Application)

REF: 587

5. A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child

weighs 15 kg. The primary care NP sees the child for a 3-year-old check-up. The NP should consult with a pediatric endocrinologist to discuss: a.

increasing the dose to 90 mcg/day.

decreasing the dose to 30 mcg/day.

stopping the medication and checking

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TSH and T4 in 4 weeks. discussing the need for lifetime replacement therapy with the child’s parents.

ANS: C

In congenital hypothyroidism, therapy may be stopped for 2 to 8 weeks after the patient reaches 3 years of age. If TSH levels remain normal, thyroid supplementation may be discontinued permanently. DIF: Cognitive Level: Applying (Application)

REF: 587

6. A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency.

When teaching this patient about the medication, the NP should: a.

counsel the patient to take the medication with food.

tell the patient that changing brands of the medication should be avoided.

instruct the patient to stop taking the medication if signs of thyrotoxicosis occur.

tell the patient that the drug may be stopped when thyroid function tests stabilize.

ANS: B

Patients should be told not to change brands of the medication; there is potential variability in the bioequivalence between manufacturers. The medication should be taken at approximately the same time each day before breakfast or on an empty stomach. Patients should be instructed to contact the provider if signs of thyrotoxicosis are present. Thyroid replacement medications are usually given for life. DIF: Cognitive Level: Applying (Application)

REF: 587

7. A patient has been taking levothyroxine 100 mcg daily for several months. The patient

comes to the clinic with complaints of insomnia and irritability. The primary care NP notes a heart rate of 92 beats per minute. The NP should: a.

change to liothyronine 75 mcg/day.

discontinue levothyroxine indefinitely.

order propylthiouracil to counter the increased thyroid levels.

order TSH and T4 levels and decrease the dose to 75 mcg/day.

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ANS: D

When signs of thyrotoxicosis occur, the drug should be decreased or temporarily discontinued for 5 to 7 days. Liothyronine is not indicated. Propylthiouracil is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 584

8. A 75-year-old patient who has cardiovascular disease reports insomnia and vomiting for

several weeks. The primary care NP orders thyroid function tests. The tests show TSH is decreased and T4 is increased. The NP should consult with an endocrinologist and order: a.

thyrotropin.

methimazole.

levothyroxine.

propylthiouracil.

ANS: B

Patients with hyperthyroidism, or Graves’ disease, will require radioactive iodine. Elderly patients and patients with cardiovascular disease should be pretreated with an antithyroid medication such as methimazole. Thyrotropin is used to diagnose thyroid cancer. Levothyroxine is used to treat hypothyroidism. Propylthiouracil is also a thyroid suppressant, but methimazole is preferred. DIF: Cognitive Level: Applying (Application)

REF: 586

9. A patient with Graves’ disease is taking methimazole. After 6 months of therapy, the

primary care NP notes normal T3 and T4 and elevated TSH. The NP should: a.

order a complete blood count (CBC) with differential.

order aspartate aminotransferase, AGT, and LDH tests.

decrease the dose of the medication.

add levothyroxine to the patient’s regimen.

ANS: C

Once clinical levels of thyrotoxicosis have been resolved, elevated TSH indicates a need to reduce the dosage. A CBC with differential is performed at the beginning of treatment and when signs of infection are present. Liver function tests may be monitored periodically but are not indicated by the current laboratory results. Levothyroxine is not indicated. DIF: Cognitive Level: Applying (Application)

REF: 587

Chapter 53: Diabetes Mellitus Agents

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Test Bank MULTIPLE CHOICE 1. A 40-year-old patient is in the clinic for a routine physical examination. The patient has a

body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should: a.

order a fasting plasma glucose level.

consider prescribing metformin (Glucophage).

suggest dietary changes and increased exercise.

obtain serum insulin and hemoglobin A1c levels.

ANS: A

Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Serum insulin level is not indicated. DIF:

Cognitive Level: Applying (Application)

REF: 591

2. A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews

this patient’s laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe: a.

nateglinide (Starlix).

glyburide (Micronase).

colesevelam (Welchol).

metformin (Glucophage).

ANS: D

Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs. DIF: Cognitive Level: Understanding (Comprehension)

REF: 592

3. A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping

blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe:

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pramlintide (Symlin).

repaglinide (Prandin).

glyburide (Micronase).

metformin (Glucophage).

ANS: A

Pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 593

4. A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice

daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A 1c is 7.3%. The NP should: a. begin insulin therapy. b.

change to therapy with colesevelam (Welchol).

add a third oral antidiabetic agent to this patient’s drug regimen.

enroll the patient in a weight loss program to achieve better glycemic control.

ANS: A

The target hemoglobin A 1c goal for adults is less than 7%. Insulin therapy is indicated if maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the maximum recommended doses of metformin and glyburide. Colesevelam does not decrease hemoglobin A 1c. Adding a third oral antidiabetic agent is not recommended. A weight loss program may be a part of this patient’s treatment, but insulin is necessary to maintain glycemic control. DIF: Cognitive Level: Applying (Application)

REF: 596

5. A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical

examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should: a.

order metformin (Glucophage).

order a lipid profile, complete blood count, and liver function tests (LFTs).

order an oral glucose tolerance test.

set a weight loss goal of 10 to 15 lb.

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ANS: D

To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose 5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 594

6. A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to

changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? a.

Metformin/glyburide (Glucovance)

Insulin and metformin (Glucophage)

Saxagliptin/metformin (Kombiglyze)

Metformin/pioglitazone (ACTOplus met)

ANS: A

Obese patients with normal renal function and elevated fasting plasma glucose may be started on a combination of metformin and a second-generation sulfonylurea. DIF: Cognitive Level: Applying (Application)

REF: 595 - 596

7. A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient

tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: a.

taking the metformin dose as usual the morning of surgery.

using insulin during the perioperative and postoperative periods.

that the patient stop taking metformin several days before surgery.

adding a sulfonylurea medication until recovery from surgery is complete.

ANS: B

Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery. DIF: Cognitive Level: Applying (Application)

REF: 596

8. A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the

patient reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats per minute. The NP should:

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obtain LFTs.

decrease the dose of metformin.

change metformin to glyburide.

order electrolytes, ketones, and serum glucose.

ANS: D

Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should include electrolytes, ketones, and serum glucose. DIF: Cognitive Level: Applying (Application)

REF: 598

9. A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care

NP should order: a.

nateglinide (Starlix).

glyburide (Micronase).

colesevelam (Welchol).

metformin (Glucophage).

ANS: D

Metformin is the only drug listed that is recommended for children. DIF: Cognitive Level: Understanding (Comprehension)

REF: 598

Chapter 35: Acetamino phen Test Bank MULTIPLE CHOICE 1. An adult patient who has a viral upper respiratory infection asks the primary care nurse

practitioner (NP) about taking acetaminophen for fever and muscle aches. To help ensure against possible drug toxicity, the NP should first: a.

determine the patient’s height and weight.

ask the patient how high the temperature has been.

tell the patient to take 325 mg initially and increase as needed.

ask the patient about any other over-thecounter (OTC) cold medications being used.

ANS: D

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Acetaminophen is present in many other OTC products, so patients should be cautioned about taking these with acetaminophen to avoid overdose. The adult dose is not based on height and weight and is not determined by the degree of temperature elevation. DIF: Cognitive Level: Applying (Application)

REF: 399

2. A parent asks a primary care NP how much acetaminophen to give a 2-year-old child who

has a temperature of 37.5° C. The NP should tell the parent that: a.

acetaminophen is not safe in children younger than 6 years.

acetaminophen may mask a fever and prevent treatment of other symptoms.

antipyretics are usually not necessary for temperatures less than 37.7° C.

antipyretics should be given to prevent seizures, but nonsteroidal antiinflammatory drugs are a better choice.

ANS: C

Acetaminophen is the drug of choice for treating fever but is generally not indicated for fever less than 37.7° C. Acetaminophen is safe for children and infants. Treating the fever may prolong the illness and mask symptoms, but these are not contraindications for giving antipyretics. DIF: Cognitive Level: Understanding (Comprehension)

REF: 399

3. An 80-year-old patient with congestive heart failure has a viral upper respiratory

infection. The patient asks the primary care NP about treating the fever, which is 38.5° C. The NP should: a.

recommend acetaminophen.

recommend high-dose acetaminophen.

tell the patient that antibiotics are needed with a fever that high.

tell the patient a fever less than 40° C does not need to be treated.

ANS: A

Patients with congestive heart failure may have tachycardia from fever that aggravates their symptoms, so fever should be treated. High doses should be given with caution in elderly patients because of possible decreased hepatic function. Antibiotics should not be given without evidence of bacterial infection. DIF: Cognitive Level: Applying (Application)

REF: 400 - 401

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4. A patient comes to the clinic and reports breaking out in an urticarial rash 1 hour after

taking acetaminophen for osteoarthritis symptoms. The primary care NP should: a.

order a complete blood count with differential.

order liver and renal function tests.

suspect Reye’s syndrome and arrange for hospitalization.

tell the patient not to take products containing acetaminophen again.

ANS: D

Urticaria is indicative of a hypersensitivity reaction to acetaminophen. Patients who are hypersensitive should not take the drug again. Laboratory tests are not indicated. An urticarial rash does not indicate Reye’s syndrome. DIF: Cognitive Level: Applying (Application)

REF: 402

5. A patient in the clinic reports taking a handful of acetaminophen extra-strength tablets

about 12 hours prior. The patient has nausea, vomiting, malaise, and drowsiness. The patient’s aspartate aminotransferase and alanine aminotransferase are mildly elevated. The primary care NP should: a.

expect the patient to sustain permanent liver damage.

reassure the patient that these symptoms are reversible.

tell the patient that acetylcysteine cannot be given this late.

administer activated charcoal to remove acetaminophen from the body.

ANS: A

After acetaminophen overdose, if liver enzymes are elevated within 24 hours, irreversible liver damage is likely. Acetylcysteine may still be given to mitigate the effects. Activated charcoal is effective only when given immediately. DIF: Cognitive Level: Applying (Application)

REF: 402

Chapter 36: Aspirin and Nonsteroidal Antiinflammatory Drugs Test Bank MULTIPLE CHOICE 1. A patient reports having persistent mild to moderate pain in both knees usually associated

with standing. The patient reports knee stiffness for 15 to 20 minutes each morning. The primary care nurse practitioner (NP) learns that the patient has used heating pads and

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acetaminophen, which no longer relieve the pain. The NP orders an erythrocyte sedimentation rate, which is normal. The NP should consider prescribing: a.

aspirin.

a cyclooxygenase-2 (COX-2) inhibitor.

glucosamine and chondroitin.

a topical nonsteroidal antiinflammatory drug (NSAID).

ANS: D

Topical NSAIDs, acupuncture, and tramadol are effective for pain relief in knee osteoarthritis. Treatment for osteoarthritis should begin with nonpharmacologic treatment, and acetaminophen should be first-line pharmacologic treatment. NSAIDs should be used when these two measures are no longer effective. COX-2 inhibitors are more expensive and should be used in the presence of gastrointestinal (GI) side effects or for moderate to severe pain. Glucosamine and chondroitin do not relieve most osteoarthritis pain. DIF: Cognitive Level: Applying (Application)

REF: 407

2. A 70-year-old patient describes moderate to severe pain associated with osteoarthritis in

fingers, thumbs, hips, and knees. The patient is currently taking high-dose acetaminophen. The patient has a strong family history of cardiovascular disease and has been diagnosed with hypertension. To help alleviate this patient’s pain, the primary care NP should consider prescribing: a.

a COX-2 inhibitor and low-dose aspirin.

ketorolac (Toradol) and 325 mg of aspirin.

naproxen (Naprosyn) and low-dose aspirin.

indomethacin (Indocin) and 325 mg of aspirin.

ANS: C

Aspirin at the dosage of 325 mg every other day or 81 mg daily is effective in reducing the incidence of myocardial infarction (MI) and stroke. Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk. DIF: Cognitive Level: Applying (Application)

REF: 409

3. A patient with mild to moderate osteoarthritis pain has been taking acetaminophen for

pain. The primary care NP prescribes a nonselective NSAID. At a follow-up visit, the patient reports mild GI side effects. The NP should: a.

order misoprostol to take with the NSAID.

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discontinue the NSAID and order tramadol.

change the medication to a COX-2 inhibitor.

change the medication to naproxen (Naprosyn).

ANS: A

If the patient experiences GI distress, coadministration of histamine-2 blockers, proton pump inhibitors, or misoprostol may be considered. Tramadol is used for severe pain. A COX-2 inhibitor is generally used for long-term therapy. Naproxen is another nonselective NSAID and would likely have similar GI side effects. DIF: Cognitive Level: Applying (Application)

REF: 408

4. A patient is taking 81 mg of aspirin daily to decrease MI risk and uses acetaminophen for

mild osteoarthritis symptoms. For flare-ups of osteoarthritis pain, the primary care NP should prescribe: a.

ibuprofen (Motrin).

celecoxib (Celebrex).

naproxen (Naprosyn).

increasing the dose of aspirin.

ANS: C

Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen does not appear to have this risk. DIF: Cognitive Level: Applying (Application)

REF: 409

5. An 80-year-old patient has been taking naproxen (Naprosyn) for osteoarthritis for 6

months. The patient reports adequate pain relief but complains of feeling tired. The primary care NP will order: a.

liver function tests.

a serum potassium level.

a complete blood count (CBC).

a creatinine clearance and urinalysis.

ANS: C

Elderly patients are more susceptible to the adverse effects of NSAIDs, especially slow GI bleeds leading to anemia (manifested as fatigue, lethargy). Patients complaining of fatigue should have a CBC to evaluate for anemia. DIF: Cognitive Level: Applying (Application)

REF: 409

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6. A patient who has rheumatoid arthritis begins taking naproxen (Naprosyn) 500 mg once

daily for pain. After 1 week, the patient calls the primary care NP to report no change in inflammation. The NP should: a.

change the medication to tramadol.

change the medication to ketorolac (Toradol).

increase the dose of naproxen to 1000 mg daily.

counsel the patient that pain relief may not occur for another week.

ANS: D

The analgesic effect of NSAIDs should be noticed within 1 to 4 hours of administration. However, the full antiinflammatory effect will not be apparent until after a few weeks. Tramadol and ketorolac are used for severe pain. It is not necessary to increase the dose of naproxen. DIF: Cognitive Level: Applying (Application)

REF: 408

7. The primary care NP sees an adolescent who reports moderate to severe dysmenorrhea.

The NP recommends an NSAID and counsels the patient about its use. Which statement by the patient indicates a need for further teaching? a.

“I should not take this if I think I might be pregnant.”

“I should take this medication on a schedule for 2 to 3 days.”

“I will begin taking this 1 to 3 days before my period begins.”

“I will take this medicine every 4 to 6 hours as needed for pain.”

ANS: D

When treating primary dysmenorrhea, NSAIDs should be started 24 to 72 hours before the patient starts menstrual bleeding. The medication should be taken on a routine basis for 2 to 3 days. It should not be taken during pregnancy. DIF: Cognitive Level: Understanding (Comprehension)

REF: 409

8. The primary care NP is performing a medication reconciliation on a patient who takes

digoxin for congestive heart failure and learns that the patient uses ibuprofen as needed for joint pain. The NP should counsel this patient to: a.

use naproxen (Naprosyn) instead of ibuprofen.

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increase the dose of digoxin while taking the ibuprofen.

use an increased dose of ibuprofen while taking the digoxin.

take potassium supplements to minimize the effects of the ibuprofen.

ANS: A

Ibuprofen and indomethacin increase the effects of digoxin, so the NP should recommend another NSAID, such as naproxen, that does not have this effect. Increasing the dose of digoxin or the ibuprofen would increase the likelihood of digoxin toxicity further. Potassium should be monitored while taking NSAIDs long-term, but supplements should not be given unless there is a potassium deficiency. DIF: Cognitive Level: Applying (Application)

REF: 413

9. A primary care NP prescribes a nonselective NSAID for a patient who has osteoarthritis.

The patient expresses concerns about possible side effects of this medication. When counseling the patient about the medication, the NP should tell this patient: a.

to avoid taking antacids while taking the NSAID.

to take each dose of the NSAID with a full glass of water.

that a few glasses of wine each day are allowed while taking the NSAID.

to decrease the dose of the NSAID if GI symptoms occur.

ANS: B

To avoid GI distress associated with NSAIDs, a full glass of water is recommended. Patients may take NSAIDs with antacids. Patients should avoid alcohol while taking NSAIDs. Patients should report GI symptoms to their provider. DIF: Cognitive Level: Applying (Application)

REF: 410

10. A patient who has osteoarthritis is scheduled to have knee surgery. The patient takes

aspirin for MI prophylaxis and naproxen (Naprosyn) for pain and inflammation. Which statement by the patient to the primary care NP indicates a need for further teaching? a.

“I should stop taking aspirin at least 5 days before surgery.”

“I will check with the surgeon to see if I need to stop taking the naproxen.”

“I will need to stop taking both

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medications 1 week before I have surgery.” “Both of these medications interfere with platelet production and may cause blood clots.”

ANS: C

Although both medications interfere with platelet formation, some NSAIDs may continue to be taken before surgery, depending on the procedure and the surgeon preference. The patient should stop taking aspirin 5 days before surgery. DIF: Cognitive Level: Applying (Application)

REF: 410

Chapter 37: Disease-Modifying Antirheumatic Drugs and Immune Modulators Test Bank MULTIPLE CHOICE 1. A patient has recent weight loss, fatigue, and recurrent low-grade fever along with pain

and stiffness of knees and hands. The primary care nurse practitioner (NP) notes symmetric joint swelling and warmth of these joints. The NP should: a.

refer the patient to a specialist.

order erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), and antinuclear antibody (ANA) tests.

begin therapy with methotrexate.

order x-rays of the affected joints.

ANS: B

ESR is a very nonspecific but sensitive indication of inflammation. RF is positive in 75% to 85% of patients with rheumatoid arthritis (RA). ANAs are elevated in approximately 20% of patients with RA. These tests help confirm the diagnosis of RA. Once the diagnosis is more likely, referral to a specialist is warranted. Drug therapy is not begun until the diagnosis is confirmed. X-rays are usually the earliest way to detect changes but are not diagnostic in the early stages of the disease. DIF: Cognitive Level: Applying (Application)

REF: 416

2. The primary care NP follows a patient who is being treated for RA with methotrexate.

The patient asks the NP why the medication does not seem to alleviate pain. The NP tells the patient that: a.

an immunomodulator may be needed to control pain.

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a higher dose of methotrexate may be needed to achieve pain control.

if methotrexate does not control pain, an opioid analgesic may be necessary.

methotrexate is used to slow disease progression and preserve joint function.

ANS: D

Disease-modifying antirheumatic drugs (DMARDs) have antiinflammatory effects that may slow disease progression and preserve joint function. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) are common adjuncts to therapy to treat pain. DIF: Cognitive Level: Applying (Application)

REF: 417

3. A patient who is being treated for RA reports having continued pain, which the patient

describes as moderate and persistent. The NP should prescribe: a.

acetaminophen.

a cyclooxygenase-2 (COX-2) inhibitor.

an opioid analgesic.

an NSAID.

ANS: D

NSAIDs are recommended for RA pain because RA is an inflammatory disease. Acetaminophen may be used for mild pain. COX-2 inhibitors appear to cause more stomach ulcers and gastrointestinal (GI) bleeds in patients with RA and so should not be used unless other therapies are ineffective. Opioids should be used for patients with RA when other medications and nonpharmacologic interventions produce inadequate pain relief and the patient’s quality of life is affected by pain. DIF: Cognitive Level: Applying (Application)

REF: 418

4. A patient who has a history of stomach ulcers is taking a nonselective NSAID along with

a DMARD for RA. The primary care NP should: a.

order a glucocorticoid.

change to acetaminophen.

order a proton pump inhibitor (PPI).

change to a selective COX-2 inhibitor.

ANS: C

If GI risk factors are present, a prophylactic PPI should be given along with the nonselective NSAID. Glucocorticoids make ulcers worse. Acetaminophen is used only for mild pain or as adjunct pain therapy. A selective COX-2 inhibitor has an increased

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risk of stomach ulcers. DIF: Cognitive Level: Applying (Application)

REF: 418

5. A patient who has just been diagnosed with RA is experiencing minimal pain and mild

symptoms. The primary care NP should consult with a rheumatologist and should recommend: a.

ibuprofen.

methotrexate.

acetaminophen.

herbal remedies.

ANS: A

If the disease is mild, NSAIDs are recommended at full therapeutic doses for the first 2 to 3 months before starting DMARDs such as methotrexate. Acetaminophen and herbal remedies are not recommended as monotherapy. DIF: Cognitive Level: Applying (Application)

REF: 418

6. A patient has been taking a COX-2 selective NSAID to treat pain associated with a recent

onset of RA. The patient tells the primary care NP that the pain and joint swelling are becoming worse. The patient does not have synovitis or extraarticular manifestations of the disease. The NP will refer the patient to a rheumatologist and should expect the specialist to prescribe: a.

methotrexate.

corticosteroids.

opioid analgesics.

hydroxychloroquine.

ANS: D

In mild RA disease, patients are given NSAIDs first for 2 to 3 months, and then either hydroxychloroquine or sulfasalazine is added if the disease does not remit. Methotrexate is a first-line drug for patients with more aggressive symptoms, such as synovitis or extraarticular symptoms. Opioid analgesics are used as adjuncts for pain relief along with DMARDs. DIF: Cognitive Level: Applying (Application)

REF: 419

7. A patient is taking a cytokine immunomodulator to treat RA. The primary care NP caring

for this patient should: a.

obtain periodic complete blood counts (CBCs) and liver function tests (LFTs).

perform annual tuberculosis (TB) skin testing.

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advise the patient of an increased risk of bone cancer.

administer the intranasal live attenuated influenza vaccine (LAIV) each year.

ANS: A

Routine monitoring for patients taking cytokine immunomodulators should include periodic CBCs and LFTs. TB skin testing should be performed before initiating therapy but is not indicated annually. Patients taking immunomodulators do not have an increased risk of bone cancer. Providers should administer the trivalent influenza vaccine intramuscularly and not the LAIV given intranasally because the LAIV is a live virus, which is contraindicated in patients who are immunosuppressed. DIF: Cognitive Level: Applying (Application)

REF: 419

8. A patient who has RA has been taking methotrexate for 6 months and tells the primary

care NP that symptoms seem to be getting worse. The NP refers the patient back to the rheumatologist and should expect the rheumatologist to: a.

add prednisone to the drug regimen.

add adalimumab to the drug regimen.

change to a combination of adalimumab and etanercept.

discontinue methotrexate because 50% of patients do not respond.

ANS: B

Combination therapy generally is used because it is more effective and provides a more sustained response. Immunomodulators such as adalimumab are often used with methotrexate. Prednisone is not indicated. Immunomodulators are generally not used in combination. DIF: Cognitive Level: Applying (Application)

REF: 417

9. A patient who is taking methotrexate for RA sees the primary care NP for an annual

physical examination. The patient’s alanine aminotransferase (ALT) and AGT are elevated. The NP should: a.

decrease the dose of methotrexate.

recheck ALT and AGT levels in 2 weeks.

contact the patient’s rheumatologist to discuss discontinuing the drug.

counsel the patient not to take acetaminophen while taking methotrexate.

ANS: B

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Liver enzyme elevations are frequent, are usually transient and asymptomatic, and do not appear predictive of subsequent hepatic disease. A decrease in dose or discontinuation of the drug is not indicated. Coadministration with acetaminophen is not contraindicated. DIF: Cognitive Level: Applying (Application)

REF: 420

Chapter 38: Gout Medications Test Bank MULTIPLE CHOICE 1. A patient who has hypertension is taking a thiazide diuretic. The patient has a serum uric

acid level of 8 mg/dL. The primary care nurse practitioner (NP) caring for this patient should: a.

prescribe colchicine.

discontinue the thiazide diuretic.

order a 24-hour urine collection.

refer the patient to a rheumatologist.

ANS: C

Patients who have hypertension or who take thiazide diuretics are at increased risk for gout. An elevated uric acid level alone is not diagnostic, and a 24-hour urine collection should be ordered. Colchicine should not be prescribed until the diagnosis is confirmed. It is not necessary to discontinue the thiazide diuretic. A referral to a specialist is not indicated. DIF:

Cognitive Level: Applying (Application)

REF: 423

2. A patient comes to the clinic reporting sudden pain and swelling of one knee joint. The

primary care NP suspects gout. When preparing to order diagnostic tests, the most important initial test the primary care NP should order is: a.

renal function tests.

serum uric acid levels.

24-hour urine collection.

synovial fluid aspirate for Gram stain and culture.

ANS: D

Although the other tests are part of the diagnostic process, the most important differential diagnosis to be made in a patient with gout is the exclusion of a septic joint. DIF:

Cognitive Level: Applying (Application)

REF: 423

3. Gout is diagnosed in a patient, and tests show the cause to be an underexcretion of uric

acid. The primary care NP should prescribe:

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febuxostat (Uloric).

colchicine (Colcrys).

allopurinol (Zyloprim).

probenecid (Benemid).

ANS: D

A uricosuric agent is indicated to increase the excretion of uric acid. Probenecid is a uricosuric medication. Febuxostat and allopurinol are xanthine oxidase inhibitors. Colchicine is not a uricosuric agent. DIF: Cognitive Level: Applying (Application)

REF: 423

4. A primary care NP prescribes probenecid to treat a patient who has gout. The patient

comes to the clinic 2 weeks later with severe flank pain. The NP should: ask the patient about fluid intake. a. b.

order a urinalysis and urine culture.

change the medication to allopurinol.

recommend nonsteroidal antiinflammatory drugs (NSAIDs) to treat flank pain.

ANS: A

Uricosuric agents are tubular blocking agents and decrease serum uric acid levels by increasing urinary excretion of uric acid. During this process, high concentrations of uric acid develop in the proximal renal tubules and may predispose the patient to the development of urinary stones. Patients should be encouraged to drink plenty of fluids. The patient who presents with flank pain should be questioned about fluid intake. If fluid intake is sufficient and renal stones are ruled out, a urinary tract infection may be considered. Allopurinol is not indicated. NSAIDs are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 423

5. A patient who is obese and has hypertension is taking a thiazide diuretic and develops

gouty arthritis, which is treated with probenecid. At a follow-up visit, the patient’s serum uric acid level is 7 mg/dL, and the patient denies any current symptoms. The primary care NP should discontinue the probenecid and: a.

prescribe colchicine.

prescribe febuxostat.

tell the patient to use an NSAID if symptoms recur.

counsel the patient to report recurrence of symptoms.

ANS: A

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Colchicine is a first-line drug for preventing acute attacks. Because this patient has three risk factors, a preventive medication should be used. Febuxostat is a second -line preventive medication. The patient should not be treated on an as-needed basis. DIF: Cognitive Level: Applying (Application)

REF: 424

6. A patient with a history of gouty arthritis comes to the clinic with acute pain and swelling

of the great toe. The patient is not currently taking any medications. The primary care NP should prescribe: a.

naproxen.

colchicine.

probenecid.

allopurinol.

ANS: A

Naproxen is the first medication given for an attack of acute gouty arthritis to stop the inflammatory response. Pharmacologic treatment for hyperuricemia must be started after the acute attack has subsided. DIF: Cognitive Level: Applying (Application)

REF: 425

7. A patient who is taking colchicine for gout is in the clinic 1 week after beginning the

medication. The patient reports decreased appetite and nausea. The primary care NP should: a.

suspect worsening of gouty arthritis.

order vitamin B12 levels to assess for vitamin deficiency.

discontinue the colchicine for 48 hours until symptoms subside.

reassure the patient that these are common, temporary side effects.

ANS: C

Colchicine toxicity causes nausea, vomiting, and anorexia. When toxicity is suspected, the medication should be temporarily discontinued and restarted after symptoms subside. DIF: Cognitive Level: Applying (Application)

REF: 426

8. A patient who has a previous history of renal stones will begin taking probenecid for

gout. The primary care NP should: a.

add colchicine to the patient’s drug regimen.

counsel the patient to use high-dose aspirin for pain.

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teach the patient to drink plenty of acidic fluids such as juice.

tell the patient to stop taking the medication when symptoms subside.

ANS: A

Patients at risk for urinary stones may take colchicine along with probenecid to reduce the risk caused by probenecid. Salicylates and acidic urine increase the risk. The medication must be tapered 6 months after the last acute attack. DIF: Cognitive Level: Applying (Application)

REF: 425

Chapter 39: Osteoporosis Treatment Test Bank MULTIPLE CHOICE 1. A 55-year-old woman who experienced menopause at age 50 years undergoes central

dual-energy x-ray absorptiometry and has a T-score greater than 2.5. The patient weighs 130 lb and has a body mass index of 22. She sits at a computer all day at work. The primary care nurse practitioner (NP) caring for this patient should: a.

prescribe a bisphosphonate.

prescribe hormone replacement therapy.

counsel the patient about diet and exercise.

prescribe a selective estrogen receptor modulator.

ANS: C

The NP should counsel the patient about diet and exercise. Women who are at least 5 years postmenopausal or who have several risk factors should have bone density testing. Osteoporosis is defined as a T-score of less than 2.5, and treatment is indicated for women with T-scores that are 2 or more standard deviations below the normal premenopausal level. It is not necessary to initiate treatment at this time. DIF: Cognitive Level: Applying (Application)

REF: 435

2. A 50-year-old white woman who is experiencing menopause asks the primary care NP

what she can do to prevent osteoporosis. She has a negative family history and no risk factors. The NP should counsel her to: a.

consider bisphosphonate therapy in 5 years.

undergo bone density testing every 2 years.

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avoid high-impact sports that can lead to fractures.

take supplemental calcium and vitamin D every day.

ANS: D

Postmenopausal women should consume 1200 mg of calcium and at least 1000 U of vitamin D each day. Bisphosphonate therapy should be considered for persons with known risk factors. Bone density testing is indicated for women with risk factors and then routinely after age 65. Patients should be encouraged to engage in high-impact sports if possible to improve bone density. DIF: Cognitive Level: Applying (Application)

REF: 433

3. A 60-year-old woman has a central dual-energy x-ray absorptiometry with a T-score of

1.9. A health history reveals no risk factors for osteoporosis. The primary care NP should: a.

prescribe alendronate sodium (Fosamax).

counsel her to increase her physical activity.

prescribe calcitonin (Miacalcin nasal spray).

prescribe supplemental calcium and vitamin D.

ANS: A

This woman’s T-score is less than 2.5 and indicates osteoporosis. She should begin treatment with a bisphosphonate. Increasing physical activity and taking supplemental calcium and vitamin D are indicated as well but only as part of a medication regimen. Calcitonin is not a first-line medication. DIF: Cognitive Level: Applying (Application)

REF: 433

4. A 70-year-old patient who has a high fracture risk has been taking alendronate (Fosamax)

and calcium for 6 months. The primary care NP orders a urine NTx level, which is 42. The NP should discontinue the alendronate and prescribe: a.

raloxifene (Evista).

teriparatide (Forteo).

calcitonin (Miacalcin nasal spray).

ibandronate sodium (Boniva).

ANS: B

Teriparatide is used in patients with a high fracture risk or in whom bisphosphonate therapy has failed. Raloxifene and ibandronate are second -line treatments for patients with usual fracture risks. Calcitonin is a last-line treatment.

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DIF: Cognitive Level: Applying (Application)

REF: 436

5. A 60-year-old female patient has begun taking a daily bisphosphonate to prevent

osteoporosis and complains of gastrointestinal (GI) upset and dyspepsia. The primary care NP’s initial response should be to: a.

prescribe a proton pump inhibitor (PPI).

order intravenous (IV) bisphosphonates.

suggest that she take the drug with food.

review the instructions for taking the drug with the patient.

ANS: D

Oral bisphosphonates must be taken on an empty stomach, and the patient must remain upright and not eat or drink anything for 30 to 60 minutes. GI upset and dyspepsia are frequent and can be minimized with correct administration. A PPI is not indicated. IV bisphosphonates may be indicated if the patient is unable to tolerate the oral drug after correct administration is confirmed. Bisphosphonates should not be taken with food. DIF: Cognitive Level: Applying (Application)

REF: 436

6. A 50-year-old woman with osteopenia will begin taking raloxifene (Evista). When

counseling this patient about this drug regimen, the primary care NP should tell her to: a.

go for walks daily.

take the medication 1 hour before meals.

sit upright for 30 minutes after taking the drug.

avoid using diuretics while taking this medication.

ANS: A

Raloxifene is a selective estrogen receptor modulator, and it carries a risk of venous thromboembolism. Patients should be encouraged to avoid immobilization. The other instructions are part of medication teaching about bisphosphonates. DIF: Cognitive Level: Applying (Application)

REF: 436

7. A 60-year-old woman is in the clinic for an annual well-woman examination. She has

been taking alendronate (Fosamax) 10 mg daily for 4 years. Her last bone density test yielded a T-score of 2.0. Her urine NTx level today is 22. She walks daily. Her fracture risk is low. The primary care NP should recommend that she: a.

take a 1- to 2-year drug holiday.

change to 70 mg of alendronate weekly.

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decrease the alendronate dose to 5 mg daily.

change to ibandronate (Boniva) 3 mg IV every 3 months.

ANS: A

The American Association of Clinical Endocrinologists recommends patients have a “drug holiday” after 4 to 5 years of bisphosphonate treatment if osteoporosis is mild and the fracture risk is low. The other options are all viable treatment regimens but are not appropriate in this case. DIF: Cognitive Level: Applying (Application)

REF: 436

8. A patient who has several risk factors for osteoporosis has a bone density test that

indicates osteopenia. The primary care NP plans to prescribe a bisphosphonate. Before initiating treatment, the NP should: a.

order an upper GI x-ray.

initiate PPI therapy.

order serum calcium and vitamin D levels.

prescribe a calcium and vitamin D supplement.

ANS: C

Patients must have adequate nutrition, calcium, and vitamin D. Hypocalcemia and vitamin D deficiency must be corrected before therapy is initiated. An upper GI x-ray is indicated only if the patient is symptomatic. Patients at risk for fracture should not take PPIs. Calcium and vitamin D supplements should be given with bisphosphonate therapy; however, the first action is to evaluate current serum levels. DIF: Cognitive Level: Applying (Application)

REF:

438 Chapter 40: Muscle

Relaxants Test Bank MULTIPLE CHOICE 1. The primary care nurse practitioner (NP) is seeing a patient who reports chronic lower

back pain. The patient reports having difficulty sleeping despite taking ibuprofen at bedtime each night. The NP should prescribe: a.

diazepam (Valium).

metaxalone (Skelaxin).

methocarbamol (Robaxin).

cyclobenzaprine (Flexeril).

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ANS: D

Cyclobenzaprine (Flexeril) is indicated for chronic low back pain and provides an added benefit of aiding sleep, which is a common problem among patients with back pain. The other medications are used for acute lower back pain. DIF: Cognitive Level: Applying (Application)

REF: 443

2. A patient reports having an acute onset of low back pain associated with lifting a heavy

object the day before. Besides advising the patient to rest and apply ice, the primary care NP should prescribe: a.

an opioid analgesic.

metaxalone (Skelaxin)

cyclobenzaprine (Flexeril).

a nonsteroidal antiinflammatory drug (NSAID).

ANS: D

NSAIDs and acetaminophen are first-line analgesic treatments for low back pain. Opioids are used for severe low back pain. The other two medications are not first-line treatments. DIF: Cognitive Level: Applying (Application)

REF: 444

3. A patient who was in a motor vehicle accident has been treated for lower back muscle

spasms with metaxalone (Skelaxin) for 1 week and reports decreased but persistent pain. A computed tomography scan is normal. The primary care NP should: a.

suggest ice and rest.

order physical therapy.

prescribe diazepam (Valium).

add an opioid analgesic medication.

ANS: B

Physical therapy may be used as an injury begins to heal. This patient is experiencing improvement of symptoms, so physical therapy may now be helpful. Ice and rest are useful in the first 24 to 48 hours after injury. Diazepam is used on a short-term basis only. Opioid analgesics are used for severe pain. DIF: Cognitive Level: Applying (Application)

REF: 444

4. A patient with lower back pain and right-sided sciatica has taken an NSAID and a TCA

for 1 week. The patient reports some decrease in pain but is experiencing increased tingling and numbness of the right leg. The primary care NP should: a.

order a magnetic resonance imaging (MRI) study.

order physical therapy.

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refer the patient to a neurologist.

continue the TCA for 1 more week.

ANS: A

Acute episodes of low back pain should be treated with an analgesic for 1 to 2 weeks. A muscle relaxant is used to treat spasms. Patients with sciatica should be treated for 6 weeks. If a neurologic deficit progresses, MRI should be ordered. Physical therapy is not indicated until serious injury is ruled out. A neurology consultation is necessary in urgent conditions and conditions with bilateral neurologic findings. The TCA may be continued, but the progression of symptoms necessitates radiologic evaluation. DIF: Cognitive Level: Applying (Application)

REF: 444

5. A 70-year-old patient has low back pain and will begin taking metaxalone (Skelaxin).

The primary care NP should counsel this patient to: a.

drink extra fluids.

avoid taking NSAIDs.

get up from a chair slowly.

take care to avoid slips and falls.

ANS: D

Use of any muscle relaxant puts elderly patients at risk for falls, so patients should be advised to take precautions. It is not necessary to increase fluids or avoid NSAIDs. This drug does not have hypotensive effects, so it is not necessary to provide the caution to rise out of chairs slowly. DIF: Cognitive Level: Applying (Application)

REF: 445

6. A patient comes to the clinic complaining of low back pain unrelieved by NSAIDs. The

patient has a history of angle-closure glaucoma and renal disease. The primary care NP should prescribe: a.

tizanidine (Zanaflex).

metaxalone (Skelaxin).

acetaminophen (Tylenol).

cyclobenzaprine (Flexeril).

ANS: B

Metaxalone may be taken by patients with angle-closure glaucoma and is metabolized by the liver, so it is safe for this patient. Tizanidine should not be given to patients with renal disease because clearance may be reduced by more than 50%. After using NSAIDs with no relief, recommendations are to change to a muscle relaxant. Cyclobenzaprine is not recommended in patients with glaucoma. DIF: Cognitive Level: Applying (Application)

REF: 445

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7. A patient has acute low back pain caused by lifting a heavy object. The patient reports

having one or two drinks with meals each day. The primary care NP should prescribe: an NSAID. a. b.

diazepam (Valium).

metaxalone (Skelaxin).

acetaminophen (Tylenol).

ANS: A

Skeletal muscle relaxants should not be taken with alcohol because effects are additive. Acetaminophen has toxic effects on the liver, and patients who consume alcohol regularly should avoid acetaminophen and diazepam. DIF: Cognitive Level: Applying (Application)

REF: 445

Chapter 43: Analgesia and Pain Management Test Bank MULTIPLE CHOICE 1. A patient has been taking an opioid analgesic for chronic pain and tells the primary care

nurse practitioner (NP) that the medication doesn’t work as well anymore. The NP should suspect drug: a.

addiction.

tolerance.

modulation.

dependence.

ANS: B

Tolerance is characterized by decreasing drug effect over time, meaning that more drug is needed to achieve the same effect. Addiction is an overwhelming obsession with obtaining and using a drug for non–medically approved purposes. Dependence is the development of abstinence syndrome or withdrawal symptoms. DIF: Cognitive Level: Understanding (Comprehension)

REF: 464 - 465

2. A patient has pain caused by a chronic condition. The patient is reluctant to take opioids

because of a fear of addiction. The primary care NP should tell the patient that opioids: a.

carry a high risk of psychological dependence when used long-term.

will help to improve the patient’s functional outcomes and quality of life.

will eventually become ineffective for

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treating pain when used over a long period. d.

may require switching from one type of opioid to another to prevent tolerance over time.

ANS: B

Chronic pain requires routine administration of drugs, and addiction is generally not a concern, especially for patients with chronic pain or terminal illness. Opioid analgesics will help the patient improve function and quality of life. Tolerance may develop, and higher doses may be required to maintain effectiveness. Randomized, controlled trials are lacking to support switching opioids to manage tolerance and side effects. DIF: Cognitive Level: Applying (Application)

REF: 467 - 468

3. A patient is diagnosed with a condition that causes chronic pain. The primary care NP

prescribes an opioid analgesic and should instruct the patient to: a.

wait until the pain is at a moderate level before taking the medication.

take the medication at regular intervals and not just when pain is present.

start the medication at higher doses initially and taper down gradually.

take the minimum amount needed even when pain is severe to avoid dependency.

ANS: B

Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain. DIF: Cognitive Level: Applying (Application)

REF: 467

4. A patient who is a recovering alcoholic is preparing for surgery and expresses fears about

using opioid analgesics postoperatively for pain. The primary care NP should tell the patient: a.

that opioids should not be used.

to take a very low dose of the opioid.

that nonsteroidal antiinflammatory drugs will be the only safe option.

that opioids are safe when taken as directed.

ANS: D

Fear of drug dependency or addiction does not justify withholding of opiates or

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inadequate management of pain. As long as the medication is taken as directed, it is safe. DIF: Cognitive Level: Applying (Application)

REF: 467

5. A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days

after surgery. When the patient is discharged from the hospital, the primary care NP should expect the patient to receive a prescription for mg orally every hours. a.

hydrocodone 30; 6

hydrocodone 75; 6

meperidine 300;12

meperidine 75; 6

ANS: A

When patients are switched from one opiate to another, an equianalgesic table should be used to convert the dosage of the current drug to the equivalent dosage of the new drug. An oral dose of 30 mg of hydrocodone is equivalent to an IM dose of 75 mg of meperidine. DIF: Cognitive Level: Applying (Application)

REF: 470

6. A patient has been taking an opioid analgesic for 2 weeks after a minor outpatient

procedure. At a follow-up clinic visit, the patient tells the primary care NP that he took extra doses for the past 2 days because of increased pain and wants an early refill of the medication. The NP should suspect: a.

dependence.

drug addiction.

possible misuse.

increasing pain.

ANS: C

Unsanctioned dose increases are a sign of possible drug misuse. Dependence refers to an abstinence or withdrawal syndrome. Drug addiction is an obsession with obtaining and using the drug for nonmedical purposes. The patient should not have increased pain at 2 weeks. DIF: Cognitive Level: Applying (Application)

REF: 469

7. A patient who is taking an antibiotic to treat bronchitis reports moderate rib pain

associated with frequent coughing. The primary care NP should consider prescribing: a.

morphine.

hydrocodone.

hydromorphone.

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oxycodone CR.

d. ANS: B

Hydrocodone is used for cough suppression as well as pain. Morphine can cause profound respiratory depression. DIF: Cognitive Level: Applying (Application)

REF: 472

Chapter 44: Migraine Medications Test Bank MULTIPLE CHOICE 1. A patient who has migraine headaches takes sumatriptan as abortive therapy. The patient

tells the primary care nurse practitioner (NP) that the sumatriptan is effective for stopping symptoms but that the episodes are occurring three to four times per month. The NP should consider the addition of: a.

aspirin.

topiramate.

ergotamine.

opioid analgesics.

ANS: B

Topiramate is an anticonvulsant agent that is approved as a preventive medication for migraines. The other medications are indicated for abortive therapy. DIF: Cognitive Level: Applying (Application)

REF: 477

2. A patient comes to the clinic concerned about possible migraine headaches. The primary

care NP conducts a history and physical examination, and the patient describes vise-like pressure in the back of the head that occurs almost daily during the work week. The NP should recommend: a.

acetaminophen.

topiramate.

sumatriptan.

ergotamine.

ANS: A

This patient is describing symptoms typical of tension headaches. The NP should recommend acetaminophen, not migraine medications. DIF: Cognitive Level: Applying (Application)

REF: 478

3. A patient comes to the clinic and reports recurrent headaches. The patient has a headache

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diary, which reveals irritability and food cravings followed the next day by visual disturbances and unilateral right-sided headache, nausea, and photophobia lasting 2 to 3 days. The NP should recognize these symptoms as migraine. a.

classic

hemiplegic

basilar-type

ophthalmoplegic

ANS: A

These are symptoms of classic migraine. Hemiplegic migraine is characterized by motor and sensory symptoms. Basilar-type migraine includes vertigo, diplopia, dysarthria, tinnitus, and decreased hearing. Ophthalmoplegic migraine affects the third, fourth, or fifth cranial nerve, causing permanent damage. DIF: Cognitive Level: Applying (Application)

REF: 478

4. A patient who has migraine headaches tells the primary care NP that drinking coffee and

taking nonsteroidal antiinflammatory drugs (NSAIDs) seems to help with discomfort. The NP should tell the patient that: a.

this combination can lead to longer lasting headache pain.

these substances are not indicated for migraine headaches.

doing this can increase the risk of more chronic migraines.

an opioid analgesic would be a better choice for migraine pain.

ANS: A

Overuse of pain or migraine medications can cause a transformed migraine, which is a long-lasting headache. Following a migraine episode, the patient has rebound headache daily or nearly daily. NSAIDs, caffeine, opiates, and triptans can cause these rebound headaches. NSAIDs and caffeine are often used to treat migraines. Narcotics and barbiturates increase the risk for development of chronic migraine headaches and should not be first-line drugs. DIF: Cognitive Level: Applying (Application)

REF: 478

5. A patient takes rizatriptan (Maxalt) to abort migraine headaches but tells the primary care

NP that the headaches have become more frequent since a promotion at work. The NP’s initial response should be to: a.

prescribe topiramate (Topamax).

stress the importance of establishing new

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routines. c.

help the patient identify stressors associated with the new role.

add a combination NSAID, aspirin, and caffeine product to the regimen.

ANS: B

Prevention or reduction of episodes of migraine requires healthy regular daily habits. Regularity of habits, rather than just searching for triggers, is essential for enhancing the effectiveness of nonpharmacologic approaches. If the increase in migraine episodes remains chronic after nonpharmacologic measures are taken, topiramate may be used. DIF: Cognitive Level: Applying (Application)

REF: 481

6. A primary care NP prescribes sumatriptan for abortive treatment of migraine headaches.

The patient returns to the clinic 1 month later to report increased frequency of the headaches. The NP should: a.

add an opioid analgesic.

consider changing to dihydroergotamine (D.H.E. 45).

suggest that the patient take sumatriptan with a NSAID.

ask the patient how often the sumatriptan is used each week.

ANS: D

It is important that any abortive agent be administered no more often than 2 days per week to avoid the possibility of rebound headache. Patients should be encouraged to try products for at least two or three episodes of migraine before they decide they are ineffective, so changing the drug regimen may not be indicated at this time. DIF: Cognitive Level: Applying (Application)

REF: 484

7. A patient who has migraine headaches without an aura reports difficulty treating the

migraines in time because they come on so suddenly. The patient has been using overthe-counter NSAIDs. The primary care NP should prescribe: a.

frovatriptan (Frova).

sumatriptan (Imitrex).

cyproheptadine (Periactin).

dihydroergotamine (D.H.E. 45).

ANS: B

If the patient is able to take medication at the earliest onset of migraine, ergots are usually

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effective. Triptans are more effective when patients have difficulty “catching the headache in time.” Sumatriptan begins to work in 15 minutes and so would be indicated for this patient. Frovatriptan has a longer half-life. Cyproheptadine is not a first-line migraine treatment. DIF: Cognitive Level: Applying (Application)

REF: 481 - 482

8. A patient who has mild to moderate migraine headaches has severe nausea and vomiting

with each episode. For the best treatment of this patient, the primary care NP should prescribe: a.

triptan nasal spray.

metoclopramide and aspirin.

an NSAID and prochlorperazine.

sumatriptan and metoclopramide.

ANS: A

Administer triptan migraine medication in nasal spray or injection for patients with severe nausea and vomiting who have trouble taking oral medications. An antiemetic, such as prochlorperazine or metoclopramide, may be used, although the latter has serious side effects. DIF: Cognitive Level: Applying (Application)

REF: 483

9. A patient who has migraine headaches usually has two to three severe migraines each

month. The patient has been using a triptan nasal spray but reports little relief and is concerned about missing so many days of work. The primary care NP should consider: a.

an oral triptan plus an opioid analgesic.

an injectable triptan plus an oral corticosteroid.

an intramuscular steroid plus an opioid analgesic.

dihydroergotamine hydrochloride plus an opioid analgesic.

ANS: B

For severe migraines, an injectable triptan should be considered along with corticosteroids or opioids as rescue medications. Oral triptans are not as effective for severe migraines. Ergotamines may be tried as second-line therapy. DIF: Cognitive Level: Applying (Application)

REF: 483

10. A patient who experiences migraines characterized by unilateral motor and sensory

symptoms tells the primary care NP that despite abortive therapy with a triptan, the frequency of episodes has increased to three or four times each month. The NP should:

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add a selective serotonin reuptake inhibitor (SSRI) antidepressant.

change to dihydroergotamine hydrochloride.

prescribe a

prescribe an anticonvulsant such as topiramate.

-blocker such as propranolol.

ANS: D

Topiramate is useful for migraine prophylaxis. SSRI antidepressants are considered second-line treatment for prophylaxis and are less effective than tricyclic antidepressants. Ergotamines are not used as prophylaxis. -Blockers are commonly used but may aggravate neurologic symptoms associated with hemiplegic or basilar migraine, which is what this patient has. DIF: Cognitive Level: Applying (Application)

REF: 483

11. A patient who is diagnosed with migraine headaches has a history of cardiovascular

disease and hypertension. The NP should prescribe: a.

triptan nasal spray.

rizatriptan (Maxalt).

cyproheptadine (Periactin).

dihydroergotamine (D.H.E. 45).

ANS: C

Triptans and ergotamines are contraindicated in patients with cardiovascular disease or hypertension. Cyproheptadine is safe for these patients. DIF: Cognitive Level: Applying (Application)

REF: 487

12. A patient reports frequent headaches to the primary NP. The patient describes the

headaches as unilateral and moderate in intensity, accompanied by nausea, vomiting, and photophobia. There is no aura, and the headaches generally last 24 to 48 hours. The NP should: a.

prescribe dihydroergotamine (D.H.E. 45).

prescribe topiramate (Topamax) as migraine prophylaxis.

recognize these as classic migraines and order sumatriptan (Imitrex).

suggest treatment with acetaminophen because these are probably tension headaches.

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ANS: C

This patient has symptoms of classic migraine with repeated episodes. Sumatriptan is a first-line medication. Ergotamines are second-line medications. Topiramate is used as migraine prophylaxis in patients who have increasingly frequent migraine episodes. These symptoms are not characteristic of tension headaches. DIF: Cognitive Level: Applying (Application)

REF: 479

Chapter 51: Glucocorticoids Test Bank MULTIPLE CHOICE 1. A patient has been taking oral prednisone 60 mg daily for 3 days for an asthma

exacerbation, which has resolved. The patient reports having gastrointestinal (GI) upset. The primary care nurse practitioner (NP) should: a. discontinue the prednisone. b.

begin tapering the dose of the prednisone.

order a proton pump inhibitor (PPI) to counter the effects of the steroid.

change the prednisone dosing to every other day.

ANS: A

The patient’s asthma symptoms have resolved, so the prednisone may be discontinued. If the patient has been on the medication for a few days, it is not necessary to taper the dose before the patient stops taking it. If the patient required long-term dosing of the steroid, a PPI could be used. Every-other-day dosing is used. Alternate-day dosing is sometimes used for long-term therapy to minimize suppression of the hypothalamic-pituitary-adrenal (HPA) axis. DIF: Cognitive Level: Applying (Application)

REF: 576

2. A patient will require a long course of steroids to treat a chronic inflammatory condition.

The primary care NP expects the specialist to order: a.

prednisone daily.

triamcinolone daily.

hydrocortisone every other day.

dexamethasone every other day.

ANS: C

Hydrocortisone is a short-acting glucocorticoid. The use of a short-acting agent and an alternate-day dosage regimen should be considered for long-term therapy. Prednisone and triamcinolone are medium-acting glucocorticoids. Dexamethasone is a long-acting glucocorticoid.

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DIF: Cognitive Level: Applying (Application)

REF: 576

3. A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child

examination, the primary care NP notes a decrease in the child’s linear growth rate. The NP should consult the child’s asthma specialist about: a.

gradually tapering the child off the prednisone.

a referral for possible growth hormone therapy.

giving a double dose of prednisone every other day.

dividing the prednisone dose into twicedaily dosing.

ANS: C

Administration of a double dose of a glucocorticoid every other morning has been found to cause less suppression of the HPA axis and less growth suppression in children. Because the child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indicated. Twice-daily dosing would not change the HPA axis suppression. DIF: Cognitive Level: Applying (Application)

REF: 576

4. A 70-year-old patient with COPD who is new to the clinic reports taking 10 mg of

prednisone daily for several years. The primary care NP should: a.

tell the patient to take the drug every other day before 9:00 AM.

order a serum glucose, potassium level, and bone density testing.

perform pulmonary function tests to see if the medication is still needed.

begin a gradual taper of the prednisone to wean the patient off the medication.

ANS: B

Serum glucose and potassium levels are part of monitoring for side effects of steroids. Because elderly patients are more prone to certain potential catabolic adverse effects of steroid therapy, caution is required. Osteoporosis is often seen with elderly patients, so bone density testing should be performed. The medication dosing regimen should not be changed unless there is an indication of adverse effects. DIF: Cognitive Level: Applying (Application)

REF: 577

5. A primary care NP prescribes an oral steroid to a patient and provides teaching about the

medication. Which statement by the patient indicates a need for further teaching?

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“I should take this medication with food.”

“I will take the medication at 8:00 AM each day.”

“I can expect a decreased appetite while I am taking this medication.”

“I should not stop taking the medication without consulting my provider.”

ANS: C

Therapeutic administration is least likely to interfere with natural hormone production when the drug is given at the time of natural peak activity. It is generally recommended to administer the full daily dose before 9 AM . Oral glucocorticoids usually are given with meals to limit GI irritation. Common side effects include changes in mood, insomnia, and increased appetite. DIF: Cognitive Level: Applying (Application)

REF: 577

6. A patient with ulcerative colitis takes 30 mg of methylprednisolone (Medrol) daily. The

primary care NP sees this patient for bronchitis and orders azithromycin (Zithromax). The NP should: a.

order intramuscular (IM) methylprednisolone.

temporarily decrease the dose of methylprednisolone.

change the dosing of methylprednisolone to 15 mg twice a day.

stop the methylprednisolone while the patient is taking azithromycin.

ANS: B

When given concurrently with macrolide antibiotics, methylprednisolone clearance is reduced, so a smaller dose of methylprednisolone is needed. IM administration does not affect clearance of the drug. Changing the dose to twice-daily dosing is not recommended. Stopping the drug abruptly is not recommended. DIF: Cognitive Level: Applying (Application)

REF: 579

7. A patient is being tapered from long-term therapy with prednisolone and reports weight

loss and fatigue. The primary care NP should counsel this patient to: a.

consume foods high in vitamin D and calcium.

begin taking dexamethasone because it has longer effects.

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expect these side effects to occur as the medication is tapered.

increase the dose of prednisolone to the most recent amount taken.

ANS: D

Sudden discontinuation or rapid tapering of glucocorticoids in patients who have developed adrenal suppression can precipitate symptoms of adrenal insufficiency, including nausea, weakness, depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected. DIF: Cognitive Level: Applying (Application)

REF: 578

Chapter 60: Cephalosporins Test Bank MULTIPLE CHOICE 1. An adult patient has cellulitis. The patient is a single parent with health insurance who

works and is attending classes at a local university. To treat this infection, the primary care nurse practitioner (NP) should prescribe: a.

cefdinir (Omnicef).

cephalexin (Keflex).

cefadroxil (Duricef).

ceftriaxone (Rocephin).

ANS: C

First-generation cephalosporins, such as cephalexin and cefadroxil, are used for skin and soft tissue infections. Cefadroxil is preferred in this case because it can be given twice daily instead of four times daily, and this patient will be more likely to comply with the drug regimen. Cefdinir and ceftriaxone are both third-generation cephalosporins. DIF: Cognitive Level: Understanding (Comprehension)

REF: 678

2. A primary care NP sees a patient who has dysuria, fever, and urinary frequency. The NP

orders a urine dipstick, which is positive for nitrates and leukocyte esterase, and sends the urine to the laboratory for a culture. The patient is allergic to sulfa drugs. The NP should: a.

order cefaclor (Ceclor).

prescribe cefixime (Suprax).

administer intramuscular ceftriaxone

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(Rocephin). wait for culture results before ordering an antibiotic.

d. ANS: B

Cephalosporins are useful for empirical treatment of many of the most common infections seen in primary care. Cefixime is a third -generation cephalosporin, which has greater activity against Escherichia coli and excellent penetration into body fluids, making it a good choice for empirical treatment of urinary tract infection. DIF: Cognitive Level: Applying (Application)

REF: 678

3. A patient is taking cefadroxil (Duricef) and comes to the clinic complaining of loose

stools for several days. The primary care NP notes normal vital signs; warm, pink skin with elastic turgor; and moist mucous membranes. The NP should: a.

order tests for Clostridium difficile– associated disease (CDAD).

discontinue the cefadroxil.

reassure the patient that loose stools are common with antibiotics.

recommend consuming lactobacilluscontaining foods to minimize diarrhea.

ANS: A

The U.S. Food and Drug Administration (FDA) advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. This patient’s symptoms are mild, so discontinuation of the drug is not warranted unless CDAD is present. DIF:

Cognitive Level: Applying (Application)

REF: 680 - 681

4. A primary care NP provides teaching to a patient who will begin taking cefadroxil

(Duricef). Which statement by the patient indicates a need for further teaching? a.

“I should report any rash that occurs.”

“I will take this medication twice daily.”

“I should take this medication with food.”

“Gastrointestinal (GI) symptoms are common but not worrisome.”

ANS: D

The FDA advises that CDAD be considered in all patients who present with diarrhea after antibiotic use. Patients should be taught to report all GI symptoms. DIF:

Cognitive Level: Applying (Application)

REF: 680 - 681

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5. A 70-year-old patient will begin taking cefdinir (Omnicef) for an acute exacerbation of

COPD. Before initiating therapy, the primary care NP should order: a.

liver function tests (LFTs).

coagulation studies.

an electrocardiogram (ECG).

a creatinine clearance test.

ANS: D

Geriatric patients may need adjusted doses based on creatinine clearance testing, so obtaining a creatinine clearance test before initiating therapy is indicated. LFTs, coagulation studies, and an ECG are not indicated. DIF: Cognitive Level: Applying (Application)

REF: 681

6. A patient is taking an aminoglycoside and a cephalosporin. The primary care NP should

consider

the dose of

increasing; cephalosporin

decreasing; cephalosporin

increasing; aminoglycoside

decreasing; aminoglycoside

ANS: D

Cephalosporins can heighten aminoglycoside toxicity, so a decrease in the dose of the aminoglycoside should be considered. DIF: Cognitive Level: Applying (Application)

REF: 682

7. A child with a febrile illness is taking a cephalosporin. While in the clinic for a follow-up

visit, the child has a tonic-clonic seizure. The primary care NP should: a.

administer acetaminophen because this is likely a febrile seizure.

reassure the parent that seizures can occur while taking cephalosporins.

ask the child’s parent how much of the cephalosporin the child has taken.

suspect the development of a secondary central nervous system infection.

ANS: C

Seizures can occur with an overdose of cephalosporins, so the NP should determine whether this has occurred. It is not correct to assume that the seizure is fever-related or that it is a normal side effect of the cephalosporin.

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DIF: Cognitive Level: Applying (Application)

REF: 682

Chapter 62: Macrolides Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) is prescribing once-daily azithromycin to a 25-

year-old woman. When teaching her about the drug, the NP should tell her to: a.

take the medication on an empty stomach.

use a backup contraception method other than oral contraceptive pills.

expect severe gastrointestinal side effects while taking this drug.

cut the pill in half and take twice daily if side effects are severe.

ANS: B

Patients who use oral contraceptive pills for birth control should be advised that macrolides can reduce their efficacy and that they should consider using a backup method of contraception. Azithromycin can be taken without regard to food. Severe gastrointestinal side effects are uncommon. The tablets should not be chewed, crushed, or cut. DIF: Cognitive Level: Applying (Application)

REF: 689

2. A primary care NP is preparing to prescribe a macrolide antibiotic for a patient who has a

history of a prolonged QT interval on electrocardiogram. Which macrolide antibiotic should the NP prescribe? a.

Erythromycin

Azithromycin

Clarithromycin

Telithromycin

ANS: B

Azithromycin does not cause a prolonged QT interval , unlike the other macrolides, so it would be safe for this patient. Visual disturbances have been found to occur with the use of telithromycin. Erythromycin has a wider range of adverse effects and can cause cardiac effects in patients who have a prolonged QT interval. The Ilosone, E-Mycin, and Erythrocin are all erythromycins. DIF: Cognitive Level: Understanding (Comprehension)

REF: 689

3. Which antibiotic requires administration of a loading dose?

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Ilosone

E-Mycin

Erythrocin

Zithromax

ANS: D

It is important to give a loading dose, without which minimum plasma concentrations may take 5 to 7 days to reach steady state. DIF: Cognitive Level: Understanding (Comprehension)

REF: 690

4. A patient has had severe diarrhea for 2 weeks. Laboratory testing reveals Clostridium

difficile. The primary care NP should prescribe: a.

erythromycin.

azithromycin.

fidaxomicin.

clarithromycin.

ANS: C

Fidaxomicin is indicated only for treatment of C. difficile–associated diarrhea. The other macrolides are not used for this purpose. DIF: Cognitive Level: Understanding (Comprehension)

REF: 690

5. A primary care NP is planning to order a macrolide antibiotic for a patient who is

experiencing an exacerbation of chronic obstructive pulmonary disease. The patient is taking a cytochrome (CYP) 3A medication. The NP should order: a.

azithromycin.

clarithromycin.

erythromycin base.

erythromycin estolate.

ANS: A

Azithromycin does not interact with other CYP 3A medications. Erythromycin and clarithromycin do. DIF: Cognitive Level: Applying (Application)

REF: 690

6. A primary care NP sees a 6-month-old patient who has a persistent staccato cough. The

NP is aware that there is a pertussis outbreak in the community. The NP should obtain appropriate cultures and treat empirically with: a.

erythromycin.

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azithromycin.

clarithromycin.

telithromycin.

ANS: A

Erythromycin is a first-choice drug for the treatment of pertussis. DIF: Cognitive Level: Applying (Application)

REF: 688

Chapter 63: Fluoroquinolones Test Bank MULTIPLE CHOICE 1. A patient has been taking ciprofloxacin for 3 days and calls the primary care nurse

practitioner (NP) to report having headaches and dizziness. The NP should: a.

change to levofloxacin.

decrease the dose of ciprofloxacin.

change to an antibiotic in another drug class.

reassure the patient that these are common side effects.

ANS: D

Headaches and dizziness are common side effects of fluoroquinolones. It is not necessary to change to another fluoroquinolone, decrease the dose, or change to another antibiotic class. DIF: Cognitive Level: Understanding (Comprehension)

REF: 694

2. A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a

history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprim-sulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase. The NP sends the urine for culture and should treat this patient empirically with: gemifloxacin. a. b.

ciprofloxacin.

azithromycin.

TMP/SMX.

ANS: B

Fluoroquinolones are effective in treatment of UTIs that are resistant to other antibiotics. Because this patient recently completed a course of TMP/SMX, the NP can assume that the bacterium causing the infection is resistant to TMP/SMX. Gemifloxacin is not

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indicated for UTI, but ciprofloxacin is. Azithromycin is not a fluoroquinolone. DIF: Cognitive Level: Applying (Application)

REF: 693

3. A patient is taking levofloxacin to treat sinusitis. The patient calls the primary care NP to

report pain just above the heel of the right foot. The NP should: a.

change to ofloxacin.

change to ciprofloxacin.

discontinue the levofloxacin.

reassure the patient that this is a common side effect.

ANS: C

Warnings have been issued for the fluoroquinolone antibiotics for the increased risk of tendon ruptures. Ruptures have occurred unilaterally and bilaterally, and have involved the Achilles tendon; however, ruptures in the shoulder joint, hand, biceps, thumb, and other tendon sites have been reported. The risk of tendon rupture is further increased in those over age 60, those receiving concomitant steroid therapy, and in kidney, heart, and lung transplant recipients. Reasons for tendon ruptures also include physical activity or exercise, kidney failure, and tendon problems in the past. These ruptures may occur during therapy or up to several months

after discontinuation of drugs. DIF: Cognitive Level: Applying (Application)

REF: 693

4. A patient who is taking a fluoroquinolone antibiotic for pyelonephritis develops

Clostridium difficile–associated disease (CDAD). The primary care NP should treat for C. difficile and fluoroquinolone. a.

continue the

discontinue the

increase the dose of

decrease the dose of

ANS: B

Patients who develop CDAD while taking fluoroquinolones should stop taking the drug immediately DIF: Cognitive Level: Applying (Application)

REF: 694

5. A primary care NP provides teaching for a patient who is about to begin taking

levofloxacin tablets to treat an infection. Which statement by the patient indicates a need for further teaching? a.

“I should use sunscreen while taking this medication.”

“I should take this medication on an

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empty stomach.” c.

“I should use caution while driving when taking this medication.”

“I should take the tablet 2 hours before taking vitamins or an antacid.”

ANS: B

Levofloxacin tablets may be taken without regard to food, although levofloxacin solution must be taken on an empty stomach. Patients should be cautioned to use sunscreen and to avoid situations where drowsiness may impair function. Levofloxacin should not be taken with antacids or vitamins. DIF: Cognitive Level: Applying (Application)

REF: 695

6. A patient who has been taking ciprofloxacin for 14 days for treatment of a UTI is seen in

the clinic for a follow-up urinalysis. The urinalysis reveals crystalluria. The primary care NP should: a.

discontinue the ciprofloxacin.

decrease the dose of ciprofloxacin.

change the antibiotic to norfloxacin.

counsel the patient to increase fluid intake.

ANS: D

Fluoroquinolones can cause renal irritation and urine crystals. Patients should be advised to maintain proper hydration to avoid this. It is not necessary to discontinue the ciprofloxacin or to decrease the dose. DIF:

Cognitive Level: Applying (Application)

REF: 695

7. A primary care NP is preparing to prescribe a fluoroquinolone for a patient who has a

history of alcohol abuse that has caused liver damage. The NP should choose: a.

norfloxacin.

levofloxacin.

gemifloxacin.

ciprofloxacin.

ANS: B

Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones. DIF: Cognitive Level: Understanding (Comprehension)

REF: 696

Chapter 68: Antiretroviral Medications Test Bank

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MULTIPLE CHOICE 1. A female patient who is 8 weeks pregnant is seen by a primary care nurse practitioner

(NP) after a routine prenatal screen was positive for human immunodeficiency virus (HIV). A CD4 cell count is 750 cells/mm. The NP should: a.

begin immediate therapy with zidovudine and lamivudine.

begin therapy with zidovudine when she is in her second trimester.

delay treatment with antiretroviral medications until after her pregnancy.

initiate therapy with zidovudine if her CD4 cell count decreases to 500 cells/mm.

ANS: B

Patients who are HIV positive and who are pregnant should be treated with antiretroviral medications, but treatment should be avoided during the first trimester if possible. Zidovudine is recommended and has been shown to reduce the risk of transmission to the fetus from 25% to 8%. DIF: Cognitive Level: Applying (Application)

REF: 732

2. A patient who has HIV has been receiving a two-drug combination therapy for 6 months.

At an annual physical examination, the primary care NP notes that the patient has a viral load of 60 copies/mL and a CD4 cell count of 350 cells/mm. The NP should contact the patient’s infectious disease specialist to discuss: a.

changing one of the medications.

changing both of the medications.

increasing the dose of both medications.

discontinuing the medications for a short period.

ANS: B

This patient has a high viral load and a low cell count. When changing medications, both medications should be changed. DIF: Cognitive Level: Applying (Application)

REF: 730

3. A primary care NP provides primary care for a woman who has HIV. The woman asks the

NP if she will ever be able to have children. The NP should tell her: a.

none of the antiretroviral medications are safe to take during pregnancy.

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she will need to take medications throughout her pregnancy and lactation.

there is no risk of disease transmission to a fetus if she complies with therapy.

strict adherence to antiretroviral therapy decreases her risk of transmitting HIV to the fetus.

ANS: D

Antiretroviral therapy reduces, but does not eliminate, the risk of transmitting HIV to the fetus. Antiretroviral therapy medications may be taken during pregnancy. Women with HIV should not breastfeed because of the high risk of transmission. DIF: Cognitive Level: Applying (Application)

REF: 732

4. A patient who has HIV frequently expresses concerns about the costs of treatment. The

primary care NP should: a.

discuss the risks associated with underdosing of antiretroviral therapies.

suggest taking half doses of the medications on a regular basis.

suggest the patient limit therapy to a oneor two-drug regimen.

recommend an occasional “drug holiday” when cell and viral counts are good.

ANS: A

Antiretroviral therapy should include three fully active agents. Patients should be cautioned that underdosing may be worse than not taking drugs at all because resistant strains will be developed. Taking half doses, having drug holidays, or limiting therapy to one to two drugs are not recommended. DIF: Cognitive Level: Applying (Application)

REF: 734

5. A patient has begun treatment for HIV. The primary care NP should monitor the patient’s

complete blood count (CBC) at least every

months.

1 to 3

3 to 6

6 to 9

9 to 12

ANS: B

The patient’s CBC should be monitored at least every 3 to 6 months and more frequently

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if values are low and bone marrow toxicity is present. DIF: Cognitive Level: Understanding (Comprehension)

REF: 732

6. A patient who has HIV is being treated with Emtriva. The patient develops hepatitis B.

The primary care NP should contact the patient’s infectious disease specialist to discuss: a.

adding zidovudine.

changing to Truvada.

changing to tenofovir.

ordering Combivir and tenofovir.

ANS: B

Truvada contains the antiretroviral therapies in Emtriva plus tenofovir. Tenofovir is effective against hepatitis B and is used in combination with emtricitabine as a preferred first-line choice.

Chapter 65: Sulfonamides Test Bank MULTIPLE CHOICE 1. A patient has been taking trimethoprim-sulfamethoxazole (TMP/SMX) for 14 days. The

patient calls the primary care nurse practitioner (NP) to report fever, rash, and enlarged lymph nodes. The NP should suspect: a.

serum sickness reaction.

immediate sensitivity reaction.

cytotoxic hypersensitivity reaction.

cell-mediated hypersensitivity reaction.

ANS: A

Serum sickness reaction can occur days to weeks after administration of the drug and is characterized by fever, rash, and lymphadenopathy. Immediate sensitivity reaction includes anaphylaxis, urticaria, and angioedema and occurs within 30 minutes of drug administration. Cytotoxic hypersensitivity reaction causes hemolytic anemia, neutropenia, and thrombocytopenia and develops 7 to 14 days after drug administration. Cell-mediated hypersensitivity reaction causes maculopapular rash, Stevens-Johnson syndrome, and toxic epidermal necrolysis and takes 48 to 72 hours to develop. DIF: Cognitive Level: Applying (Application)

REF: 702

2. An 80-year-old patient who has COPD takes TMP/SMX for acute exacerbations, which

occur three or four times each year. To monitor this patient for adverse drug reactions, the primary care NP should order: a.

liver function tests.

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blood urea nitrogen and creatinine.

serum bilirubin levels.

a complete blood count (CBC) with differential.

ANS: D

The most frequently reported severe adverse reactions in elderly patients include bone marrow depression and decreased platelets. A CBC with differential is indicated to monitor for this. Evaluation of liver and renal function should be performed before beginning treatment because adverse effects are more common in patients with decreased renal and liver function. DIF: Cognitive Level: Applying (Application)

REF: 703

3. The primary care NP teaches a patient about TMP/SMX before prescribing it to treat a

urinary tract infection (UTI). Which statement by the patient indicates a need for further teaching? a.

“I will take this medication with food.”

“I should drink a full glass of water with each dose.”

“I should stay out of direct sunlight and use sunscreen.”

“I should report any ringing in my ears or a sore throat.”

ANS: A

TMP/SMX should be taken on an empty stomach, so this statement is incorrect and indicates the need for further teaching. The other statements all are correct. DIF: Cognitive Level: Understanding (Comprehension)

REF: 703

4. A primary care NP prescribes TMP/SMX for a patient who is experiencing an

exacerbation of COPD. The patient calls the NP 2 days later to report increased fever, cough, and shortness of breath. The NP should tell the patient: a.

to stop taking the medication.

that symptoms such as sore throat and arthralgia are more worrisome.

to continue the medication because these are signs of the disease process.

that sulfisoxazole (Gantrisin) will be prescribed instead to minimize side effects.

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ANS: A

Fever, cough, and shortness of breath are included on a list of symptoms that may be early signs of serious reactions. Patients experiencing these symptoms should stop taking the medication immediately. Sore throat and arthralgia should also be reported but are not more worrisome than the symptoms this patient is experiencing. The patient should not continue the medication. Changing to another sulfonamide is incorrect because similar symptoms would occur. DIF: Cognitive Level: Applying (Application)

REF: 703

5. A patient is seen in the clinic with a 1-week history of frequent watery stools. The

primary care NP learns that a family member had gastroenteritis a week prior. The patient was treated for a UTI with a sulfonamide antibiotic 2 months prior. The NP should suspect: a.

Clostridium difficile–associated disease (CDAD).

viral gastroenteritis.

serum sickness reaction.

recurrence of the UTI.

ANS: A

Cases of CDAD have been reported 2 months after a course of antibiotics, and CDAD should be suspected in all patients who present with diarrhea after antibiotic use. Viral gastroenteritis is possible, but the possibility of CDAD must be investigated. Serum sickness reaction is not usually associated with diarrhea and generally occurs within weeks of drug administration. DIF: Cognitive Level: Applying (Application)

REF: 703

6. When prescribing TMP/SMX to children, the primary care NP should recall that: a.

dosing is based on the trimethoprim component of the drug.

TMP/SMX should not be prescribed for children younger than 2 years.

folic acid supplements must be given to children who take this medication.

the medication should be given three or four times per day because of rapid metabolism.

ANS: A

When determining the dose of TMP/SMX, the dose is based on the trimethoprim component of the drug. Children older than 2 months of age may take this medication. Folic acid supplements are not indicated. The medication is given twice daily in all age

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groups. DIF: Cognitive Level: Applying (Application)

REF: 702

7. A patient is taking sulfisoxazole. The patient calls the primary care NP to report

abdominal pain, nausea, and insomnia. The NP should: a.

change to TMP/SMX.

tell the patient to stop taking the drug immediately.

reassure the patient that these are minor adverse effects of this drug.

order a CBC with differential, platelets, and a stool culture.

ANS: C

These side effects are considered common minor side effects of sulfonamide medications. They occur with all drugs in this class, so changing to TMP/SMX is not indicated. The patient should continue taking the medication. It is not necessary to perform laboratory tests. DIF: Cognitive Level: Applying (Application)

REF: 704

DIF: Cognitive Level: Applying (Application)

REF: 736