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NR508 NR 508 test bank pharmacology.
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NR508 NR 508 test bank pharmacology.
NR 508 test bank pharmacology.
Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs.
Change
Test Bank
MULTIPLE CHOICE
1. Which of the following has influen
...
NR508 NR 508 test bank pharmacology.
NR 508 test bank pharmacology.
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
b. Competition from nonphysicians desiring
to meet primary care shortages
c. The need for monopolistic control in the
marketplace of primary outpatient care
d. 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.
b. Antibiotic medications remain in the top
five classifications of medications
prescribed.
c. Most physicians rely on a ―therapeutic
armamentarium‖ that consists of less than
100 drug preparations per physician.
d. The dominant form of drug information
used by primary care physicians continues
to be that provided by pharmaceuticalcompanies.
ANS: D
Even though most physicians claim to place little weight on drug advertisements,
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.
b. learn from the experiences of physicians
and develop expertise based on evidencebased practice.
c. maintain collaborative and supervisorial
relationships with physicians who will
oversee prescribing practices.
d. develop relationships with pharmaceutical
representatives to learn about new
medications as they are developed.
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 defineshow NPs may write prescriptions:
a. without physician supervision in private
practice.
b. as CRNAs without physician supervision
in a hospital setting.
c. in any situation but will not be reimbursed
for this by government insurers.
d. only with physician supervision in both
private practice and a hospital setting.
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.
b. must have prescriptive authority to
practice.
c. order and administer controlled
substances but do not have full
prescriptive authority.
d. 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.
b. has prescriptive authority in all 50 states.
c. may administer only drugs used during
labor and delivery.
d. may practice only in birthing centers and
home birth settings.
ANS: B
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 todrugs 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.
b. for specified classifications of
medications.
c. without physician-mandated involvement.
d. 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.
b. full prescriptive authority will be granted
to all NPs with doctoral degrees.
c. NPs will be better prepared to meet
emerging health care needs of patients.
d. 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.
b. are not required to follow drug treatment
protocols.
c. may write for all drug categories with
physician co-signatures.
d. 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 AfricanAmerican woman. When selecting a drug and determining the correct dose, the NP
should understand that the knowledge of how age, race, and gender may affect drug
excretion is based on an understanding of:
a. bioavailability.
b. pharmacokinetics.
c. pharmacodynamics.
d. anatomy and physiology.
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.
b. Tylenol.
c. acetaminophen.
d. any over-the-counter pain product.
ANS: C
Providers should use generic drug names when prescribing drugs or recommending them
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.
b. does not necessarily have the same
therapeutic effect.
c. is likely to be less safe than the brand
specified in the prescription.
d. may vary in the amount of drug that
reaches the site of action in the body.
ANS: D
Different formulations of the same drug may have varying degrees of bioavailability, and
it may be important to stick to a particular brand for drugs with narrow therapeutic
ranges. All drugs with similar active ingredients should have the same therapeutic actions
and side effects and should be equally safe.
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
b. Topical
c. Sublingual
d. 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:
a. is absorbed less quickly.
b. has reduced bioavailability.
c. has fewer systemic side effects.
d. 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 theprimary 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.
b. alter drug distribution.
c. lead to drug toxicity.
d. 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.
b. monitor drug levels, actions, and side
effects.
c. teach the patient to increase intake of
protein.
d. 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
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.
b. substrate.
c. inducer.
d. 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 - 279. The primary care NP should understand that a drug is at a therapeutic level when it is:
a. at peak plasma level.
b. past 4 or 5 half-lives.
c. at its steady plasma state.
d. between minimal effective concentration
and toxic levels.
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.
b. administer a much higher initial dose as a
loading dose.
c. monitor creatinine clearance at baseline
and periodically.
d. administer the drug via a route that avoids
the first-pass effect.
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.
b. substrates such as alcohol cannot interfere
with the drug when the patient is
abstaining.
c. food-drug interactions are limited to those
where food enhances or inhibits drug
absorption.
d. a thorough history of diet, alcohol use,
smoking, and over-the-counter and herbal
products is required.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.
b. provide detailed written instructions for
each medication.
c. order medications that can be given on an
empty stomach.
d. 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.
b. ask the patient about problems with
constipation.
c. obtain a baseline creatinine clearance test
before the first dose.
d. perform a thorough evaluation of
cognitive and motor abilities.
ANS: DThe 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.
b. write the initial prescription at the lowest
possible dose.
c. encourage the patient to consume a diet
high in fat and protein.
d. counsel the patient to take the drug with
food to enhance absorption.
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.
b. titrate the patient’s dose upward and
recheck in 1 month.
c. ask the patient about any increased
frequency of bowel movements.
d. 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
b. Naproxen
c. Calcium citrate
d. Calcium channel blocker
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)
b. Hydroxyzine (Vistaril)
c. Diphenhydramine (Benadryl)
d. 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.
b. prescribe a systemic corticosteroid to help
with symptoms.
c. ask the patient to describe how themedications are taken each day.
d. 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
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.
b. estimate the child’s body surface area
(BSA) to calculate the medication dose.
c. divide the recommended adult dose by the
child’s weight in kilograms (kg).
d. 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. 20
b. 10
c. 14
d. 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:
a. 100 mg daily.
b. 100 mg tid.
c. 300 mg daily.
d. 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.
b. to throw away the old medication and get
a new bottle.
c. that she may give 5 to 7.5 mL per dose
every 4 to 6 hours.
d. to find out whether she has a preparation
made for infants or children.
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.b. medications given by this route are not
absorbed well in young children.
c. topical application of an antihistamine
may result in drug toxicity in children.
d. 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
b. Rectal suppository
c. Lipid soluble compound
d. 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 sustainedrelease 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.
b. mix the medication with cereal or
applesauce to improve its taste.
c. administer the medication on an empty
stomach to enhance absorption.
d. use a syringe purchased at the pharmacy
to measure the medication accurately.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
b. Acetaminophen as needed
c. Dextromethorphan for coughing
d. 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.
b. prescribe another medication to treat this
child’s symptoms.
c. discontinue the drug and observe the child
for toxic side effects.
d. 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.
DIF: Cognitive Level: Applying (Application) REF: 62| 66 - 6710. 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
b. 250 mg/5 mL—250 mg PO tid
c. 500 mg/5 mL—375 mg PO bid
d. 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.
b. order serum drug levels to evaluate
toxicity.
c. report the prescribing provider to the Food
and Drug Administration (FDA).
d. 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
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.
b. order nitrofurantoin daily to minimize the
patient’s risk of urinary tract infection late
in her pregnancy.
c. encourage the patient to increase daily
water intake and to wear only cotton
underwear.
d. 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.
b. avoid using antihistamine medications
during her first trimester of pregnancy.
c. discontinue her seizure medications at
least 6 months before becoming pregnant.
d. 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
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.
b. change her antiepileptic drug to
lamotrigine (Lamictal).
c. order prophylactic vitamin K to be given
in the second trimester.
d. recommend that she discontinue taking
the valproic sodium by 12 weeks.
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.
b. give her information about diet and
exercise.
c. begin treating her with daily insulin
injections.
d. 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
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 withmethyldopa.
b. lower her angiotensin converting enzyme
inhibitor dose during the first trimester.
c. counsel her to increase her
antihypertensive medications during
pregnancy.
d. 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.
b. continue taking the antidepressant.
c. change to a monoamine oxidase inhibitor
(MAOI).
d. 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
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.
b. provide smoking cessation information.
c. counsel her to avoid caffeine while
pregnant.
d. 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.
b. most over-the-counter medications are
safe for the breastfed infant.
c. she may need to interrupt breastfeeding
when taking headache medications.
d. she should consider weaning her infant to
formula if her headaches are frequent.
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.
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.
b. suggest using single-ingredient products
to treat each symptom separately.
c. recommend a product containing
antitussive, antipyretic, and decongestant
ingredients.
d. tell the patient that over-the-countermedications 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.
b. safer because over-the-counter doses are
lower than prescription doses of the same
drug.
c. less safe because they are not well
regulated by the Food and Drug
Administration (FDA).
d. not extensively tested, so claims made by
manufacturers cannot be substantiated.
ANS: A
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, overthe-counter 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.
b. ask the parent to identify all of the
ingredients listed on the medication label.
c. calculate the dose for the active ingredient
in the over-the-counter preparation.
d. tell the parent to approximate the dose at
about one third to one half the adult dose.
ANS: BOver-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.
b. not to worry about taking this drug with
any other medications.
c. to avoid taking other drugs that cause
sedation while taking this drug.
d. 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
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.
b. recommend natural vitamin products over
synthetic vitamin products.
c. reassure the patient that vitamins that are
high in folic acid are safe to take.
d. tell the patient that some vitamins, such as
vitamin C, are safe in large doses.
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 B12
deficiency. Vitamin C in high doses can cause dependency.
DIF: Cognitive Level: Applying (Application) REF: 896. A patient reports taking antioxidant supplements to help prevent cancer. The primary care
NP should:
a. review healthy dietary practices with this
patient.
b. make sure that the supplements contain
large doses of vitamin A.
c. tell the patient that antioxidants are
especially important for patients who
smoke.
d. 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.
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.
b. calcium supplements.
c. acid reflux medications.
d. 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.b. creatine has been shown to be an effective
herbal choice to treat back pain.
c. there is no valid research documenting the
efficacy of this treatment for pain.
d. 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
treat various conditions. The NP understands the importance of:
a. learning about the actions, uses, doses,
and toxicities of these agents.
b. prescribing these agents when possible to
ensure safe dosing.
c. counseling patients to stop using herbal
products to avoid toxic side effects.
d. teaching patients that these products are
unregulated and unsafe to use.
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.
b. inform the patient of the risks of toxic side
effects with this supplement.
c. refer the patient to a CAM provider whocan manage this patient’s therapy.
d. 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
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
man-made.
b. not marketed as products that can treat or
cure disease.
c. regulated by the Dietary Supplement
Health and Education Act.
d. 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.
b. echinacea.
c. ginkgo biloba.
d. 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.
b. echinacea.
c. green tea.
d. ginkgo biloba.
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.
b. chondroitin.
c. coenzyme Q.
d. 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.
b. provide education about the medication
actions and adverse effects.
c. stress the importance of taking the
medication exactly as it is prescribed.
d. 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
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.
b. provide written information about her
condition and the medication.
c. administer the medication in the clinic to
ensure that she takes the drug.
d. ask her about her lifestyle, her schedule,
and her understanding of her condition.
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.
b. ask the patient to describe the disease
process and the medications to evaluate
understanding.
c. explain to the patient that without mutual
cooperation, the treatment regimen will
not be effective.
d. 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 patientwants. As the therapeutic relationship grows, the NP may elicit more active participation
and understanding.
DIF: Cognitive Level: Applying (Application) REF: 104
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.
b. provide a written asthma action plan and
encourage the parent to call when
symptoms are worse.
c. review what other providers have
prescribed in the past and explain these
interventions to the parent.
d. 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 A1c 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.
b. understand and respect the parents’ beliefs
about their child’s self-image.
c. initiate a dialogue with the parents about
the implications of the child’s laboratory
values.
d. 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
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.
b. reassure the patient that the medications
and blood tests will become routine.
c. call in a social worker to assist the patient
to obtain equipment and supplies.
d. 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.
b. provide the patient with written
instructions about how to use the
medication.
c. tell the patient to let the pharmacist know
that the drug is being used for an off-label
use.
d. 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: 111Chapter 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.
b. adhering to scientific principles to solve a
patient problem.
c. following the practices of seasoned
mentors when giving care.
d. 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.
b. initiate a discussion with the parents about
the potential outcomes of each possible
action.
c. refer the family to a case manager who
can help guide the parents to the best
decision.
d. understand that the child’s parents have a
right to make choices that override those
of the medical team.
ANS: B
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 thechild, 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.
b. inform the patient that the drug must be
paid for out of pocket because it is not
covered.
c. order the closest formulary-approved
approximation of the drug and monitor
effectiveness.
d. 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.
b. change the patient’s medication to a
different drug class that doesn’t have
these bioavailability variations.
c. accept the situation and monitor the
patient closely for drug effects with eachprescription refill.
d. 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.
b. inappropriate knowledge base.
c. cost-versus-benefit analysis.
d. 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:
a. confirm the diagnosis.
b. determine the aggressiveness of therapy.
c. prescribe an adequate dose of
medications.
d. allow the drugs an adequate amount of
time to work.
ANS: AThis 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.
b. review the pharmaceutical company
promotional materials about the new
medication.
c. prescribe the medication if it is less
expensive than the current drug
formulation.
d. 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
b. Patient reports about effectiveness of the
drug for this purpose
c. Pharmaceutical company reports using
anecdotal evidence
d. 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: 1339. 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.
b. follow the guideline provided by a thirdparty payer to help ensure reimbursement.
c. review expert opinion and experimental,
anecdotal, correlational study data.
d. 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.
b. ask the patient to describe how the
medications have been used.
c. review the symptoms of an acute asthma
exacerbation with the patient.
d. 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: 1392. 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.
b. provide written educational materials
about diet and exercise.
c. compare the actions of oral antidiabetic
agents with insulin injections.
d. 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:
a. explain that medication side effects can
have serious consequences.
b. ask the patient about previous experiences
with medication side effects.
c. give the patient a copy of the medication
package insert to read at home.
d. 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 hada 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.
b. ask the patient to make a list of questions
about the medications.
c. determine what the patient understands
about coronary artery disease.
d. 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.
b. describe how the medication will be
taken.
c. write down questions about the
medication.
d. 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 selfadministering insulin. When developing this handout, the NP should:
a. provide detailed descriptions of each step
in the process of injecting insulin.
b. use correct medical terminology when
describing insulin self-administration.
c. provide as much factual information as
possible about insulin administration.
d. address one or two educational objectivesthat 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.
b. this is factual, evidence-based material
with accurate information.
c. the information is from a nonprofit group
that will not profit from drug sales.
d. internet information is unreliable because
anyone can post information there.
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.‖
b. ―I need to use a tongue blade to apply this
medication.‖
c. ―I should apply this medication liberally
to all affected areas.‖
d. ―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.
b. standardized guidelines have been
developed for use in children.
c. standardized guidelines may be found for
disease-specific conditions.
d. evidence-based studies support limited
corticosteroid use in pregnancy.
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:
a. desonide cream 0.01%.
b. triamcinolone acetonide.
c. fluocinolone cream 0.2%.
d. 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.b. recommend continuing treatment for 2
more weeks.
c. discontinue the clobetasol and schedule a
follow-up visit in 2 weeks.
d. discontinue the clobetasol and recommend
prn use for occasional flare-ups.
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.
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.
b. discontinue the fluocinolone and order
betamethasone cream.
c. begin gradually tapering the fluocinolone
at 2-week intervals.
d. 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).
b. tell the patient that these agents may be
used long-term.
c. counsel the patient that these agents are
more likely to cause skin atrophy.
d. 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
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.
b. neomycin.
c. a systemic antibiotic.
d. 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).
b. oxiconazole (Oxistat).
c. ketoconazole (Nizoral).
d. 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 theprimary care NP notes live bugs on the child’s scalp. The NP should order:
a. lindane.
b. malathion.
c. ivermectin.
d. permethrin 5%.
ANS: D
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.
b. order malathion.
c. re-treat with permethrin.
d. 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.
b. topical tretinoin.
c. oral antibiotics.
d. 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 anappropriate first-line treatment, but because this patient has pustular lesions, topical
antibiotics must be included.
DIF: Cognitive Level: Applying (Application) REF: 165
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.
b. lidocaine with epinephrine.
c. bupivacaine hydrochloride.
d. 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
b. ophthalmic antibiotic
c. sympathomimetic ophthalmic
d. 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.b. refer the patient to an ophthalmologist.
c. prescribe trifluridine ophthalmic eye
drops.
d. 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.‖
b. ―I should put in one drop and wait 5
minutes before putting in the other one.‖
c. ―To make sure the medicine is evenly
distributed, I should blink several times.‖
d. ―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.
b. ciprofloxacin otic drops qid.
c. glycerin oil drops weekly.
d. acetic acid, boric acid, and isopropyl
alcohol solution.
ANS: B
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 nottreat 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.
b. chlorhexidine, 15 mL oral rinse bid.
c. carbamide peroxide, 2 to 3 drops tid.
d. 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)
b. pilocarpine (Isopto)
c. nedocromil (Tilade)
d. 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:
a. that systemic side effects of these
medications may be severe.
b. that the combination of these two drugs
may cause drowsiness.c. to begin an exercise program to improve
cardiovascular health.
d. 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
b. Frequent hand washing
c. Zinc gluconate supplements
d. 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:
a. order a narcotic antitussive to suppress
cough.
b. obtain a thorough history of the patient’s
symptoms.
c. suggest that the patient try a guaifenesinonly over-the-counter product.
d. prescribe an antibiotic to treat theunderlying 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.
b. will not provide maximum relief for a few
weeks.
c. will cause rebound congestion if
withdrawn suddenly.
d. 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)
b. Increased fluids with a teaspoon of honey
c. Over-the-counter pseudoephedrine with
guaifenesin (Sudafed)
d. An antitussive/expectorant combination
such as Robitussin DM
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: 1985. 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.
b. blood pressure.
c. height and weight.
d. 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).
b. triamcinolone (Nasacort AQ).
c. phenylephrine (Neo-Synephrine).
d. 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.
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.
b. monitor for hypertension while taking the
drug.
c. take the antihistamine with a decongestant
for best effect.
d. watch for symptoms of paradoxical
excitation with this medication.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
b. Excessive drowsiness
c. Rebound congestion
d. 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
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 (FEV1) is 80% of the predicted value. The patient’s current medication regimen
is an albuterol metered-dose inhaler, 2 puffs every 4 hours as needed. The NP should
prescribe:
a. montelukast (Singulair) po daily.
b. ipratropium bromide bid with albuterol.
c. a low-dose inhaled corticosteroid (ICS), 2
puffs bid.
d. a long-acting -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 exacerbationbut 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.
b. consider adding theophylline to this
patient’s regimen.
c. continue the current regimen and add
omalizumab daily.
d. 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.
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 FEV1 is 80% of
predicted. Pulse oximetry reveals an oxygen saturation of 97%. The primary care NP
auscultates clear breath sounds. The NP should:
a. reassure the patient that these symptoms
will subside.
b. prescribe a moderate-dose ICS twice
daily.
c. order a long-acting anticholinergic with
albuterol twice daily.
d. 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 FEV1 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
FEV1/forced vital capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe
a(n):
a. oral corticosteroid.
b. long-acting anticholinergic.
c. long-acting oral theophylline.
d. combination ICS/LABA inhaler.
ANS: D
Providers should administer combination inhaled therapies for symptomatic patients with
stable COPD and FEV1 less than 60%. Oral corticosteroids have not been shown to be
effective, even in severe cases of COPD. Long-acting anticholinergic medications may be
used as monotherapy in early stages of COPD. Long-acting theophylline is poorly
tolerated because of side effects.
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
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.
b. short-acting 2-agonist (SABA) with oral
corticosteroids when symptomatic.
c. combination ipratropium/albuterol inhaler
twice daily.
d. 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 patientreports occasional mild exertional dyspnea but is able to sleep well. The patient’s FEV1
in the clinic is 85% of predicted, and oxygen saturation is 96%. The primary care NP
should recommend:
a. a combination LABA/ICS twice daily.
b. influenza and pneumococcal vaccines.
c. ipratropium bromide (Atrovent) twice
daily.
d. 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
trouble sleeping. The primary care NP should:
a. obtain a serum theophylline level.
b. order a creatinine clearance level.
c. prescribe a leukotriene modifier instead of
theophylline.
d. 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.
b. monitor the patient’s renal function at
every visit.
c. order an electrocardiogram to assess for
arrhythmias.
d. order routine chest radiographs to watchfor 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.‖
b. ―A side effect of albuterol may be
shortness of breath.‖
c. ―I should rinse my mouth thoroughly after
using an ICS.‖
d. ―I put the albuterol metered-dose inhaler
in my mouth with my lips sealed around
it.‖
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.
b. consider treatment with an angiotensinconverting enzyme inhibitor.
c. reassure the patient that these findings are
normal.
d. counsel the patient about dietary and
lifestyle changes.
ANS: D
The patient’s blood pressure indicates prehypertension, but the patient does not havecardiovascular 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.
b. perform a careful cardiovascular physical
assessment.
c. counsel the patient about dietary and
lifestyle changes.
d. 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 -blocker.
b. add an angiotensin-converting enzyme
inhibitor.
c. continue the current drug regimen.
d. change to an aldosterone antagonist
medication.
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 medicationsare 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.
b. a thiazide diuretic.
c. lifestyle modifications.
d. 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. a -blocker.
b. an angiotensin-converting enzyme
inhibitor.
c. a thiazide diuretic.
d. dietary and lifestyle changes.
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.
b. prescribe a thiazide diuretic and an
angiotensin-converting enzyme inhibitor.
c. discuss dietary and lifestyle modificationswith the patient.
d. 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
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.
b. restrict fluids to aid with diuresis.
c. take the medication in the morning with
food.
d. 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.‖
b. ―I should take 3 nitroglycerin tablets 5
minutes apart and then call 9-1-1.‖
c. ―I should take aspirin along with the
nitroglycerin when I have chest pain.‖
d. ―I should take nitroglycerin and then restfor 15 minutes before taking the next
dose.‖
ANS: A
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.
b. relax vascular smooth muscle.
c. prevent catecholamine release.
d. 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.
b. change from a sublingual to a transdermal
patch nitroglycerin.
c. discontinue the nitroglycerin and order
ranolazine (Ranexa ER).
d. 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.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.
b. administer oxygen at 2 L/minute.
c. give 325 mg of chewable aspirin.
d. 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.
b. taking 81 to 325 mg of aspirin daily.
c. beginning therapy with a statin
medication.
d. 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
initial dosing of:
a. 60 mg four times daily at 6-hour intervals.
b. 40 mg twice daily 30 minutes beforemeals.
c. 60 mg on awakening and 40 mg 7 hours
later.
d. 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.
b. use the patch as needed for angina pain.
c. use two patches daily and change them
every 12 hours.
d. 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 S3 heart sounds but does not palpate
hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should
consult a cardiologist to discuss prescribing a(n):
a. -blocker.
b. loop diuretic.
c. angiotensin-converting enzyme (ACE)
inhibitor.d. 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.
b. blood glucose levels.
c. serum thyroid levels.
d. 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.‖
b. ―I should eat foods high in potassium.‖
c. ―I need to take a calcium supplement
every day.‖
d. ―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
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 examinationand 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.
b. obtain renal function tests.
c. consider prescribing a -blocker.
d. call the patient’s cardiologist to discuss
adding digoxin to the patient’s regimen.
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.
b. give an initial dose of 0.5 mg digoxin
tablet and then 0.125 mg every 6 hours
4.
c. administer a digoxin 0.6 mg capsule once
and then 0.3 mg every 8 hours 3.
d. 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.
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.
b. obtain a serum potassium level to assess
for hyperkalemia.
c. hold the ACE inhibitor until the patient’s
blood pressure stabilizes.d. 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.
b. increase the dose of digoxin to 0.5 mg
daily.
c. hold the next dose of digoxin and obtain a
serum digoxin level.
d. 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
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.
a. 40; once
b. 80; once
c. 20; twice
d. 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 daysif 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).
b. carvedilol (Coreg).
c. timolol (Blocadren).
d. 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.
b. recommend that the patient take the
medication at bedtime.
c. tell the patient that tolerance to this side
effect will occur over time.
d. contact the patient’s cardiologist to
discuss decreasing the dose of
propranolol.
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)
b. Sotalol (Betapace)
c. Timolol (Blocadren)
d. 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.
b. increase the dose to 40 mg once daily.
c. obtain serum drug levels to see if the dose
is therapeutic.
d. tell the patient to continue taking the
timolol and return in 1 month.
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
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.
b. obtain serum drug levels to monitor for
toxicity of this medication.
c. instruct the patient to increase activity and
exercise to counter these side effects.
d. 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 obtainsa 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
b. Decreased exercise tolerance
c. Wheezing, dyspnea, and cough
d. 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.‖
b. ―I should use caution while driving while
taking this medication.‖
c. ―I should not take the medication if my
pulse is less than 60 beats per minute.‖
d. ―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.
b. increases the rate of contraction of the
cardiac muscle.
c. increases the force of contraction of thecardiac muscle.
d. 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).
b. diltiazem (Cardizem).
c. verapamil HCl (Calan).
d. nifedipine (Procardia XL).
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).
c. verapamil HCl (Calan).
d. 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).
b. isradipine (DynaCirc).
c. verapamil HCl (Calan).
d. 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.
b. -blocker.
c. ACE inhibitor.
d. 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.
b. complete blood count and electrolytes.
c. liver function tests (LFTs) and renal
function.
d. 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.
b. ordering renal function tests.
c. increasing the dose of nifedipine.
d. 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 Inhibitors and Angiotensin Receptor Blockers
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.
b. add a thiazide diuretic to this patient’s
regimen.
c. change the drug to losartan (Cozaar) 50
mg once daily.
d. 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.
b. choose an ARB instead.
c. add a low-dose thiazide diuretic to the
drug regimen.
d. order a renal perfusion study before
starting treatment.
ANS: DACE 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
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:
a. losartan (Cozaar).
b. captopril (Capoten).
c. enalapril maleate (Vasotec).
d. 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.
b. order a bronchodilator to counter the
bronchospasm caused by this drug.
c. ask whether the patient has had any
associated facial swelling with this cough.
d. 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.
b. use a salt substitute when seasoning foods.c. discuss changing the ACE inhibitor to an
ARB with the cardiologist.
d. avoid taking antacids containing
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.
b. take care when getting out of bed or a
chair after the first dose of the ACE
inhibitor.
c. discuss taking an increased dose of the
thiazide diuretic with the cardiologist.
d. 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.
b. consider a different drug class to treat this
patient’s symptoms.
c. give the captopril with a thiazide diuretic
to improve renal function.
d. order lisinopril (Zestril) instead of
captopril to avoid increased nephropathy.
ANS: APatients 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: Antiarrhythmic 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.
b. if the medication proves effective, the
procedure may be canceled.
c. there are no medications that alter the
arrhythmia causing AF.
d. 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).
b. tell the patient that treatment is not
indicated.
c. refer the patient to a cardiologist for
further evaluation.
d. consider using amiodarone if the patient
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.
b. schedule a cardiac stress test and a graded
exercise test.
c. order a complete blood count (CBC) and
electrolytes and consider a trial of
procainamide.
d. 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.
b. administer amiodarone in the clinic and
observe closely for response.
c. order digoxin and verapamil and ask the
patient to return for a follow-up
examination in 1 week.
d. 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.
b. order genetic testing for this patient.
c. discontinue the trimethoprimsulfamethoxazole.
d. 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.
b. reduce stress with yoga and hot baths.
c. ask the cardiologist about an implantable
defibrillator.
d. ask the cardiologist about adding
procainamide to the drug regimen.
ANS: A
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.
b. reassure the patient that this is a
therapeutic drug level.
c. order an ECG, CBC, liver function tests
(LFTs), and renal function tests.
d. 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: Antihyperlipidemic 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).
b. gemfibrozil (Lopid).
c. simvastatin (Zocor).
d. 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
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).
b. gemfibrozil (Lopid).
c. cholestyramine (Questran).d. 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).
b. order a creatine kinase-MM (CK-MM)
level.
c. change atorvastatin to twice-daily dosing.
d. 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.
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.
b. change the patient’s medication to
cholestyramine (Questran).
c. add ezetimibe (Zetia) and lower the
atorvastatin to 10 mg daily.
d. 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 elevatedLDL 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.
b. begin therapy with atorvastatin 10 mg per
day.
c. discuss quality-of-life issues as part of the
decision to begin medication.
d. 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.
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.
b. adding nicotinic acid to the patient’s drug
regimen.
c. changing the medication to
ezetimibe/simvastatin (Vytorin).
d. 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: 2967. 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)
b. Colestipol (Colestid)
c. Cholestyramine (Questran)
d. 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.
b. order CK-MM tests.
c. consider decreasing the dose of the
medication.
d. reassure the patient that this side effect is
common.
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.
b. start dabigatran 7 to 14 days after
discontinuing warfarin.c. begin giving dabigatran 1 week before
discontinuing warfarin.
d. 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.
b. clopidogrel (Plavix) 75 mg once daily.
c. enoxaparin (Lovenox) 30 mg twice daily.
d. warfarin (Coumadin) titrated to achieve an
INR of 3.5.
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.
b. heparin injections as needed based on
activated partial thromboplastin time
levels.
c. lifelong warfarin combined with
enoxaparin as needed.
d. 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: 3124. 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.
b. low-dose aspirin and warfarin.
c. low-molecular-weight heparin (LMWH).
d. 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.
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.
b. LMWH.
c. intravenous alteplase and aspirin.
d. 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.
b. rechecking the INR in 1 week.
c. omitting a dose and resuming at a lower
dose.
d. omitting a dose and administering 1 mg of
vitamin K.
ANS: BThis 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.
b. administer cardioversion without using
anticoagulants.
c. give warfarin and aspirin before
attempting cardioversion.
d. 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)
b. Warfarin (Coumadin)
c. Pentoxifylline (Trental)
d. 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. Aspirinb. Heparin
c. Dabigatran
d. 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.
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.
b. take a double dose of the medication the
next morning.
c. refill the prescription and take today’s
dose immediately.
d. 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.
b. over-the-counter (OTC) antacids can be
effective and should be tried first.
c. elevation of the head of the bed at nightcan relieve most symptoms.
d. 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.
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.
b. do not help reduce symptoms of erosive
esophagitis.
c. neutralize stomach acid as well as proton
pump inhibitors (PPIs).
d. 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.
b. antireflux surgery must be done before the
PPI can be discontinued.
c. the condition may eventually be cured, but
therapy must continue for years.
d. 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 dosebased 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
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.
b. changes in diet to avoid acidic foods.
c. daily treatment with a PPI.
d. 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.
b. increase the dose of the PPI.
c. change to long-term, low-dose PPI
therapy.
d. 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).
b. use magnesium hydroxide (Milk of
Magnesia) instead.
c. continue using sodium bicarbonate (Alka-Seltzer) as needed.
d. take calcium carbonate (Tums) instead of
sodium bicarbonate (Alka-Seltzer).
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).
b. aluminum hydroxide (Amphojel).
c. sodium bicarbonate (Alka-Seltzer).
d. 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).
b. prescribe omeprazole (Prilosec).
c. teach the patient about a bland diet.
d. 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.
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 dietsare 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.
b. a PPI, amoxicillin, and metronidazole for
14 days.
c. a PPI, clarithromycin, and amoxicillin for
14 more days.
d. 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.‖
b. ―One or two cups of coffee each day
won’t hurt you.‖
c. ―Alcoholic beverages are strictly
prohibited when you have an ulcer.‖
d. ―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
follow-up appointment 3 days later, the patient reports no alleviation of symptoms. The
primary care NP should:
a. order cimetidine (Tagamet).
b. add metronidazole to the drug regimen.c. change from ranitidine to omeprazole
(Prilosec).
d. 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.
b. decreased dose of a histamine-2 blocker.
c. normal dose of a PPI.
d. 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.
b. discontinue the histamine-2 blocker.
c. take the antacid and the histamine-2
blocker at the same time.
d. take the histamine-2 blocker 2 hours
before taking the antacid.
ANS: D
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.b. obtaining a serum digoxin level.
c. changing the PPI to omeprazole.
d. 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).
b. omeprazole (Prilosec).
c. esomeprazole (Nexium).
d. 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:
a. increased intake of fluids and fiber.
b. docusate sodium (Colace) as needed.
c. psyllium (Metamucil) on a daily basis.
d. 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: 3412. 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.
b. long-term docusate sodium.
c. a saline laxative as needed.
d. 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. 10
b. 15
c. 20
d. 25
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).
b. docusate sodium (Colace).
c. polyethylene glycol (MiraLAX).
d. 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 andan abdominal radiograph shows an increased stool load in the sigmoid colon and rectum.
The NP should:
a. give magnesium hydroxide (Milk of
Magnesia).
b. start daily methylcellulose (Citrucel) and
increased fluids.
c. order a sodium phosphate enema and
psyllium (Metamucil).
d. 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.
b. suggest she use polyethylene glycol
(MiraLAX) on a daily basis instead.
c. tell her that long-term use of suppositories
is safer than long-term laxative use.
d. 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).
b. polyethylene glycol (MiraLAX) and
bisacodyl (Dulcolax).
c. lactulose (Chronulac) and polyethylene
glycol (MiraLAX).d. 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.
b. change the laxative to docusate sodium
(Colace).
c. take the digoxin 2 hours before taking the
psyllium.
d. ask the cardiologist about taking an
increased dose of digoxin.
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.
b. docusate sodium (Colace) as needed.
c. psyllium (Metamucil) on a daily basis.
d. 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 usedunless 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.
b. long-term docusate sodium.
c. a saline laxative as needed.
d. 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. 10
b. 15
c. 20
d. 25
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).
b. docusate sodium (Colace).
c. polyethylene glycol (MiraLAX).
d. 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).
b. start daily methylcellulose (Citrucel) and
increased fluids.
c. order a sodium phosphate enema and
psyllium (Metamucil).
d. 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.
b. suggest she use polyethylene glycol
(MiraLAX) on a daily basis instead.
c. tell her that long-term use of suppositories
is safer than long-term laxative use.
d. 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).b. polyethylene glycol (MiraLAX) and
bisacodyl (Dulcolax).
c. lactulose (Chronulac) and polyethylene
glycol (MiraLAX).
d. 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.
b. change the laxative to docusate sodium
(Colace).
c. take the digoxin 2 hours before taking the
psyllium.
d. ask the cardiologist about taking an
increased dose of digoxin.
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 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.
b. obtain a stool culture and start antibiotic
therapy.
c. instruct her to replace lost fluids bydrinking Pedialyte.
d. 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
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.
b. order testing for Clostridium difficile and
consider metronidazole therapy.
c. prescribe diphenoxylate (Lomotil) to
provide symptomatic relief.
d. 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.
b. useful in cases of acute infection with
elevated temperature.
c. most beneficial when symptoms persist
longer than 2 weeks.
d. useful when other symptoms, such as
hematochezia, develop.
ANS: ATreatment 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.
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).
b. attapulgite (Kaopectate).
c. bismuth subsalicylate (Pepto-Bismol).
d. 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).
b. attapulgite (Kaopectate).
c. an electrolyte solution (Pedialyte).
d. 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 beatsper 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.
b. begin rehydration therapy.
c. consider prescribing metronidazole.
d. 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).
b. attapulgite (Kaopectate).
c. an electrolyte solution (Pedialyte).
d. 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).
b. ondansetron (Zofran).
c. scopolamine transdermal.
d. prochlorperazine (Compazine).
ANS: B
No antiemetic drugs should be used for nausea and vomiting during pregnancy unless
approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label) 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.
b. every 3 days.
c. as needed for nausea.
d. 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.
b. dehydration.
c. drug toxicity.
d. 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.
b. ondansetron.
c. scopolamine.
d. dimenhydrinate.
ANS: A
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: 3575. 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.
b. prescribe a rectal antiemetic medication.
c. admit to the hospital for intravenous (IV)
rehydration.
d. 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.
b. antiemetics will be administered as
needed if nausea and vomiting occur.
c. taking ondansetron before chemotherapy
decreases nausea and vomiting.
d. 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
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.
b. prescribe a scopolamine patch.
c. begin oral rehydration therapy.
d. 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.
b. what time of day the pain occurs.
c. whether the pain is sharp or diffuse.
d. 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
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).
b. dicyclomine (Bentyl).
c. simethicone (Phazyme).
d. 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 treatulcerative 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).
b. misoprostol (Cytotec).
c. simethicone (Phazyme).
d. 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.
b. avoiding gluten and lactose in the diet.
c. increasing water intake to eight to ten
glasses per day.
d. beginning aerobic exercise, such as
running, every day.
ANS: A
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.
b. beginning therapy with a TCA.
c. over-the-counter (OTC) laxatives as
needed when constipated.
d. increasing the amounts of raw fruits andvegetables 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.
b. discontinue the antidiarrheal medication.
c. encourage the patient to increase water
intake.
d. 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
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).
b. prescribe alosetron after ruling out
pregnancy.
c. refer her to a gastroenterologist for
endoscopy.
d. 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: 3648. 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).
b. cimetidine.
c. an SSRI antidepressant.
d. 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:
a. furosemide (Lasix).
b. triamterene (Dyrenium).
c. acetazolamide (Diamox).
d. 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:
a. prevent renal insufficiency.
b. minimize the risk of hypokalemia.
c. prevent postdiuretic sodium retention.
d. increase the likelihood that the drug may
be discontinued.
ANS: CIf 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.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. 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
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.
b. add furosemide (Lasix) to the patient’s
drug regimen.
c. increase the dose of chlorthalidone to 100
mg daily.
d. 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.
b. furosemide (Lasix).
c. acetazolamide (Diamox).
d. 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?
a. Ethacrynic acid
b. Chlorothiazide (Lozol)
c. Triamterene (Dyrenium)
d. 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.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. 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.
b. metolazone.
c. acetazolamide (Diamox).
d. 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.
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.
b. decrease furosemide to 60 mg once daily.
c. increase furosemide to 80 mg twice daily.
d. 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.
b. order an electrocardiogram (ECG) and
serum electrolytes.
c. change the medication to a thiazide
diuretic.
d. question the patient about potassium
intake.
ANS: B
The patient is showing signs of hyperkalemia, so the NP should order an ECG and serumelectrolytes. 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
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.
b. conduct a thorough evaluation to
document behaviors associated with
AD/HD and begin treatment if indicated.
c. suggest that the patient may have a major
depressive disorder and refer the patient
for psychiatric evaluation and treatment.
d. 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.
b. discontinue the medication.
c. change to dextroamphetamine.
d. 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 donot 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
medication if which symptom is present?
a. Motor tics
b. Decreased appetite
c. Occasional headaches
d. 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.
b. Concerta.
c. Adderall.
d. 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.
b. increasing the dose to 10 mg each time.
c. giving 10 mg at 8 AM and 5 mg at noon.
d. 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
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.
b. modafinil (Provigil).
c. methylphenidate (Ritalin).
d. 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.
b. alternative therapies to treat AD/HD are
used at this age.
c. symptoms at this age are more likely due
to environmental factors.
d. 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).
b. guanfacine (Intuniv).
c. bupropion (Wellbutrin).
d. 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.
DIF: Cognitive Level: Applying (Application) REF: 452Chapter 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.
b. indefinitely because it is not curative.
c. for 24 weeks, which is when cognitive
function improves in most patients.
d. 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.
b. adding an antidepressant medication.
c. changing to galantamine (Razadyne).
d. 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
may:
a. delay progression of symptoms.
b. produce temporary disease remission.
c. prevent depressive effects of the disease.d. 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.
b. ChE inhibitor.
c. antidepressant and ginkgo biloba.
d. 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).
b. switch to galantamine (Razadyne).
c. switch to memantine (Namenda).
d. 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
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).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. 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.
b. decrease the dose.
c. switch to memantine (Namenda).
d. 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.
b. increasing the dose to 15 mg.
c. taking the drug in the morning.
d. 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:
a. donepezil (Aricept).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. 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 CHOICE1. 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).
b. levetiracetam (Keppra).
c. zonisamide (Zonegran).
d. 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).
b. topiramate (Topamax).
c. lamotrigine (Lamictal).
d. 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.
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).
b. prescribe a tapering regimen of the drug.
c. inform the patient that antiepileptic drug
(AED) therapy is lifelong.
d. 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: 4924. 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.
b. the phenobarbital may be stopped when
an EEG is normal.
c. once the febrile illness is past, the
phenobarbital may be stopped.
d. 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:
a. order a phenytoin level.
b. reassure the patient that this is a selflimiting adverse effect.
c. recommend that the patient take
diphenhydramine to treat this side effect.
d. 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.
b. a complete blood count.c. an EEG.
d. 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.
b. changing the medication to gabapentin
(Neurontin).
c. increasing the valproic acid by 5 mg per
kg of weight.
d. adding lamotrigine (Lamictal) to this
child’s drug regimen.
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.
b. discontinue the carbamazepine.
c. reassure the patient that this effect is
temporary.
d. 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 BankMULTIPLE 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.
b. delay progression of the disease.
c. decrease adverse peripheral side effects.
d. 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.
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.
b. add amantadine.
c. increase the dose of levodopa.
d. 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.
b. add amantadine.
c. discontinue the carbidopa.
d. 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 thiseffect. 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.
b. amantadine.
c. apomorphine.
d. modified-release levodopa.
ANS: C
Apomorphine injection is used for acute treatment of immobility known as ―freezing.‖
DIF: Cognitive Level: Applying (Application) REF: 506
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:
a. benztropine.
b. amantadine.
c. apomorphine.
d. 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.
b. consuming a low-carbohydrate diet.
c. avoiding extra fluids during meal times.
d. 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 initialtreatment to be:
a. levodopa.
b. carbidopa.
c. pramipexole.
d. 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
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.
b. benztropine.
c. carbidopa/levodopa.
d. 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.
b. reassure the patient that these are
symptoms of minor depression.
c. tell the patient that an exercise regimen
alone should be effective.
d. 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 oralcohol 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
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.
b. begin pharmacologic treatment with
fluoxetine.
c. determine whether medications are
causing these symptoms.
d. 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.
b. begin to taper the paroxetine and instruct
the patient to call if symptoms increase.
c. tell the patient to stop taking the
medication and to call if symptoms get
worse.
d. 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, calledapathetic 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.
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).
b. changing to duloxetine (Cymbalta).
c. adding another selective serotonin
reuptake inhibitor (SSRI) antidepressant.
d. 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).
b. ask the patient about other medications.
c. discontinue the fluoxetine immediately.
d. 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).
b. duloxetine (Cymbalta).c. bupropion (Wellbutrin).
d. 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
b. trazodone 100; three times
c. mirtazapine 15; at bedtime
d. 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).
b. nortriptyline (Pamelor).
c. tranylcypromine (Parnate).
d. 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.
b. encourage the child to report feelings of
self-harm to a school counselor.
c. contact the patient by phone every 2
weeks to see how the medication isworking.
d. 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.
b. change the medication to bupropion.
c. add trazodone to the patient’s regimen.
d. 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.
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.
b. reassure the patient that these are
symptoms of minor depression.
c. tell the patient that an exercise regimen
alone should be effective.
d. assess the patient for alcohol and drug use
and for suicidal ideation.
ANS: DThe 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
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.
b. begin pharmacologic treatment with
fluoxetine.
c. determine whether medications are
causing these symptoms.
d. 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.
b. begin to taper the paroxetine and instruct
the patient to call if symptoms increase.
c. tell the patient to stop taking the
medication and to call if symptoms get
worse.
d. 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 amaintenance 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.
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).
b. changing to duloxetine (Cymbalta).
c. adding another selective serotonin
reuptake inhibitor (SSRI) antidepressant.
d. 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).
b. ask the patient about other medications.
c. discontinue the fluoxetine immediately.
d. 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).b. duloxetine (Cymbalta).
c. bupropion (Wellbutrin).
d. 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
b. trazodone 100; three times
c. mirtazapine 15; at bedtime
d. 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).
b. nortriptyline (Pamelor).
c. tranylcypromine (Parnate).
d. 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.
b. encourage the child to report feelings of
self-harm to a school counselor.
c. contact the patient by phone every 2weeks to see how the medication is
working.
d. 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.
b. change the medication to bupropion.
c. add trazodone to the patient’s regimen.
d. 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 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.
b. melatonin.
c. alprazolam.
d. 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: 5412. 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.
b. prescribe alprazolam.
c. order a selective serotonin reuptake
inhibitor (SSRI) antidepressant.
d. 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.
b. fluoxetine.
c. alprazolam.
d. 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.
b. perform a thorough history and physical
examination.
c. teach about avoiding caffeine and good
sleep hygiene.
d. 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: 5415. 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
b. Buspirone
c. Melatonin
d. 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
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.
b. consider short-term zolpidem.
c. order ramelteon for several weeks.
d. 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.
b. ZolpiMist.
c. ramelteon.
d. 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 difficultywith 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.
b. need to change to thioridazine (Mellaril).
c. have developed neuroleptic malignant
syndrome.
d. 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:
a. fluphenazine (Prolixin).
b. risperidone (Risperdal).
c. chlorpromazine (Thorazine).
d. 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: 5523. 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.
b. begin therapy with a high-potency
antipsychotic.
c. obtain a complete blood count (CBC),
serum lipids, and hemoglobin A1c.
d. 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 A1c 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).
b. olanzapine (Zyprexa).
c. risperidone (Risperdal).
d. 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.
b. decrease the dose of olanzapine.
c. maintain the same dose of olanzapine.
d. change from olanzapine to
chlorpromazine.
ANS: AClinicians 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
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.
b. improved cognitive function.
c. the need for long-term use of the
medication.
d. 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.
b. take 75 mg of clozapine now.
c. wait and take the evening dose at the
usual time.
d. 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:
a. order a CBC with differential.
b. obtain serum lipids and LFTs.
c. obtain a serum clozapine level.
d. assess for orthostatic hypotension.
ANS: AClozapine presents a significant risk for agranulocytosis, and leukocytes should be
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).
b. ziprasidone (Geodon).
c. quetiapine (Seroquel).
d. 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.
b. question her further about her nightly
alcohol consumption—ask what size her
wine glasses are.
c. consider her at high risk for alcoholism.
d. 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.
DIF: Cognitive Level: Applying (Application) REF: 5662. 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.
b. ask him how much he had to drink last
night.
c. prescribe lorazepam (Ativan) to help with
symptoms.
d. 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).
b. diazepam (Valium).
c. acamprosate (Campral).
d. 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
(EMS) and administer oxygen.
b. administer oral methadone (Dolophine).
c. administer intramuscular naltrexone
(ReVia).
d. 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.
b. obtain liver function tests.
c. teach the patient never to take the drug
with alcohol.
d. 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.
b. report a garlic taste in the mouth.
c. stop taking the drug after a few months.
d. 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
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 BankMULTIPLE 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.
b. Nicorette gum.
c. a Nicotrol inhaler.
d. 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).
b. recommend a nicotine transdermal patch.
c. refer the patient to a smoking cessation
program.
d. 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.
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.
b. ask her to write down any factors that
triggered her relapses.
c. give her information about the long-term
effects of smoking.d. 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).
b. nicotine replacement gum or nasal spray.
c. a high-dose 24-hour nicotine patch.
d. 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 followup 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.
b. that the patient has been smoking.
c. hypersensitivity reaction to the nicotine
patch.
d. 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: 7856. 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).
b. prescribe bupropion (Wellbutrin).
c. change to a 21 mg/24 hour nicotine patch.
d. 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.
b. using a low-dose 16-hour patch for 2
weeks.
c. continuing one dose per hour for 2 more
months and then discontinuing.
d. beginning one dose every 2 hours for 1
week and then one dose every 4 hours.
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 bloodpressure 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.
b. consider treatment with an angiotensinconverting enzyme inhibitor.
c. reassure the patient that these findings are
normal.
d. 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.
b. perform a careful cardiovascular physical
assessment.
c. counsel the patient about dietary and
lifestyle changes.
d. 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 NPshould:
a. order a -blocker.
b. add an angiotensin-converting enzyme
inhibitor.
c. continue the current drug regimen.
d. change to an aldosterone antagonist
medication.
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.
b. a thiazide diuretic.
c. lifestyle modifications.
d. 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. a -blocker.
b. an angiotensin-converting enzyme
inhibitor.
c. a thiazide diuretic.
d. dietary and lifestyle changes.
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 forpatients 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.
b. prescribe a thiazide diuretic and an
angiotensin-converting enzyme inhibitor.
c. discuss dietary and lifestyle modifications
with the patient.
d. 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
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.
b. restrict fluids to aid with diuresis.
c. take the medication in the morning with
food.
d. 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 BankMULTIPLE 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.‖
b. ―I should take 3 nitroglycerin tablets 5
minutes apart and then call 9-1-1.‖
c. ―I should take aspirin along with the
nitroglycerin when I have chest pain.‖
d. ―I should take nitroglycerin and then rest
for 15 minutes before taking the next
dose.‖
ANS: A
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.
b. relax vascular smooth muscle.
c. prevent catecholamine release.
d. 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 mgper dose.
b. change from a sublingual to a transdermal
patch nitroglycerin.
c. discontinue the nitroglycerin and order
ranolazine (Ranexa ER).
d. 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.
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.
b. administer oxygen at 2 L/minute.
c. give 325 mg of chewable aspirin.
d. 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.
b. taking 81 to 325 mg of aspirin daily.
c. beginning therapy with a statin
medication.
d. 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
initial dosing of:
a. 60 mg four times daily at 6-hour intervals.
b. 40 mg twice daily 30 minutes before
meals.
c. 60 mg on awakening and 40 mg 7 hours
later.
d. 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.
b. use the patch as needed for angina pain.
c. use two patches daily and change them
every 12 hours.
d. 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: 244Chapter 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.
b. increases the rate of contraction of the
cardiac muscle.
c. increases the force of contraction of the
cardiac muscle.
d. 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).
b. diltiazem (Cardizem).
c. verapamil HCl (Calan).
d. nifedipine (Procardia XL).
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).
c. verapamil HCl (Calan).
d. 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).
b. isradipine (DynaCirc).
c. verapamil HCl (Calan).
d. 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.
b. -blocker.
c. ACE inhibitor.
d. 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.
b. complete blood count and electrolytes.
c. liver function tests (LFTs) and renal
function.d. 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.
b. ordering renal function tests.
c. increasing the dose of nifedipine.
d. 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 24: Antihyperlipidemic 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).
b. gemfibrozil (Lopid).
c. simvastatin (Zocor).
d. 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
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: 2952. 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).
b. gemfibrozil (Lopid).
c. cholestyramine (Questran).
d. 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).
b. order a creatine kinase-MM (CK-MM)
level.
c. change atorvastatin to twice-daily dosing.
d. 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.
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.
b. change the patient’s medication to
cholestyramine (Questran).c. add ezetimibe (Zetia) and lower the
atorvastatin to 10 mg daily.
d. 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.
b. begin therapy with atorvastatin 10 mg per
day.
c. discuss quality-of-life issues as part of the
decision to begin medication.
d. 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.
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.
b. adding nicotinic acid to the patient’s drug
regimen.
c. changing the medication to
ezetimibe/simvastatin (Vytorin).
d. 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)
b. Colestipol (Colestid)
c. Cholestyramine (Questran)
d. 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.
b. order CK-MM tests.
c. consider decreasing the dose of the
medication.
d. reassure the patient that this side effect is
common.
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 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.
b. liothyronine.
c. levothyroxine.
d. 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.
b. increase the dose to 100 mcg.
c. check the TSH level in 1 week.
d. reassure the patient that this will improve
in several weeks.
ANS: C
Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH
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.
b. ask the patient about the use of
medications such as lithium.
c. tell the patient that the results most likely
indicate hypothyroidism.
d. ask an endocrinologist to evaluate for
possible Hashimoto’s thyroiditis.
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: 5854. An 80-year-old female patient with a history of angina has increased TSH and decreased
T4. The primary care NP should prescribe _____ mcg of _____.
a. 25; liothyronine
b. 75; liothyronine
c. 25; levothyroxine
d. 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.
b. decreasing the dose to 30 mcg/day.
c. stopping the medication and checking
TSH and T4 in 4 weeks.
d. discussing the need for lifetime
replacement therapy with the child’s
parents.
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.
b. tell the patient that changing brands of the
medication should be avoided.
c. instruct the patient to stop taking the
medication if signs of thyrotoxicosis
occur.
d. 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 potentialvariability 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.
b. discontinue levothyroxine indefinitely.
c. order propylthiouracil to counter the
increased thyroid levels.
d. order TSH and T4 levels and decrease the
dose to 75 mcg/day.
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.
b. methimazole.
c. levothyroxine.
d. 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.
b. order aspartate aminotransferase, AGT,
and LDH tests.c. decrease the dose of the medication.
d. 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
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.
b. consider prescribing metformin
(Glucophage).
c. suggest dietary changes and increased
exercise.
d. 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).
b. glyburide (Micronase).
c. colesevelam (Welchol).d. 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:
a. pramlintide (Symlin).
b. repaglinide (Prandin).
c. glyburide (Micronase).
d. 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 A1c is 7.3%. The NP should:
a. begin insulin therapy.
b. change to therapy with colesevelam
(Welchol).
c. add a third oral antidiabetic agent to this
patient’s drug regimen.
d. enroll the patient in a weight loss program
to achieve better glycemic control.
ANS: A
The target hemoglobin A1c 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 A1c. Adding a third oral antidiabetic agent is not recommended. A
weight loss program may be a part of this patient’s treatment, but insulin is necessary to
maintain glycemic control.
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 milethree or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth.
Her personal and family histories are noncontributory. The primary care NP should:
a. order metformin (Glucophage).
b. order a lipid profile, complete blood
count, and liver function tests (LFTs).
c. order an oral glucose tolerance test.
d. set a weight loss goal of 10 to 15 lb.
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)
b. Insulin and metformin (Glucophage)
c. Saxagliptin/metformin (Kombiglyze)
d. 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.
b. using insulin during the perioperative and
postoperative periods.
c. that the patient stop taking metformin
several days before surgery.
d. adding a sulfonylurea medication until
recovery from surgery is complete.
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: 5968. A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the
patient reports having abdominal pain and nausea. The primary care NP notes a heart rate
of 92 beats per minute. The NP should:
a. obtain LFTs.
b. decrease the dose of metformin.
c. change metformin to glyburide.
d. order electrolytes, 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).
b. glyburide (Micronase).
c. colesevelam (Welchol).
d. metformin (Glucophage).
ANS: D
Metformin is the only drug listed that is recommended for children.
DIF: Cognitive Level: Understanding (Comprehension) REF: 598
Chapter 35: Acetaminophen
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.
b. ask the patient how high the temperature
has been.
c. tell the patient to take 325 mg initially and
increase as needed.
d. ask the patient about any other over-thecounter (OTC) cold medications being
used.
ANS: D
Acetaminophen is present in many other OTC products, so patients should be cautionedabout 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.
b. acetaminophen may mask a fever and
prevent treatment of other symptoms.
c. antipyretics are usually not necessary for
temperatures less than 37.7° C.
d. antipyretics should be given to prevent
seizures, but nonsteroidal
antiinflammatory drugs are a better
choice.
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.
b. recommend high-dose acetaminophen.
c. tell the patient that antibiotics are needed
with a fever that high.
d. tell the patient a fever less than 40° C does
not need to be treated.
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
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 withdifferential.
b. order liver and renal function tests.
c. suspect Reye’s syndrome and arrange for
hospitalization.
d. tell the patient not to take products
containing acetaminophen again.
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.
b. reassure the patient that these symptoms
are reversible.
c. tell the patient that acetylcysteine cannot
be given this late.
d. administer activated charcoal to remove
acetaminophen from the body.
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
acetaminophen, which no longer relieve the pain. The NP orders an erythrocyte
sedimentation rate, which is normal. The NP should consider prescribing:
a. aspirin.
b. a cyclooxygenase-2 (COX-2) inhibitor.
c. glucosamine and chondroitin.d. a topical nonsteroidal antiinflammatory
drug (NSAID).
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.
b. ketorolac (Toradol) and 325 mg of aspirin.
c. naproxen (Naprosyn) and low-dose
aspirin.
d. 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.
b. discontinue the NSAID and order
tramadol.
c. change the medication to a COX-2
inhibitor.
d. 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. ACOX-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).
b. celecoxib (Celebrex).
c. naproxen (Naprosyn).
d. 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.
b. a serum potassium level.
c. a complete blood count (CBC).
d. 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
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.
b. change the medication to ketorolac
(Toradol).
c. increase the dose of naproxen to 1000 mg
daily.
d. counsel the patient that pain relief may not
occur for another week.
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.‖
b. ―I should take this medication on a
schedule for 2 to 3 days.‖
c. ―I will begin taking this 1 to 3 days before
my period begins.‖
d. ―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.
b. increase the dose of digoxin while taking
the ibuprofen.
c. use an increased dose of ibuprofen while
taking the digoxin.
d. take potassium supplements to minimize
the effects of the ibuprofen.
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. Whencounseling the patient about the medication, the NP should tell this patient:
a. to avoid taking antacids while taking the
NSAID.
b. to take each dose of the NSAID with a full
glass of water.
c. that a few glasses of wine each day are
allowed while taking the NSAID.
d. to decrease the dose of the NSAID if GI
symptoms occur.
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.‖
b. ―I will check with the surgeon to see if I
need to stop taking the naproxen.‖
c. ―I will need to stop taking both
medications 1 week before I have
surgery.‖
d. ―Both of these medications interfere with
platelet production and may cause blood
clots.‖
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.
b. order erythrocyte sedimentation rate
(ESR), rheumatoid factor (RF), and
antinuclear antibody (ANA) tests.
c. begin therapy with methotrexate.
d. 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.
b. a higher dose of methotrexate may be
needed to achieve pain control.
c. if methotrexate does not control pain, an
opioid analgesic may be necessary.
d. 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.
b. a cyclooxygenase-2 (COX-2) inhibitor.
c. an opioid analgesic.
d. 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 morestomach 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.
b. change to acetaminophen.
c. order a proton pump inhibitor (PPI).
d. 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
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.
b. methotrexate.
c. acetaminophen.
d. 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.
b. corticosteroids.
c. opioid analgesics.
d. hydroxychloroquine.
ANS: DIn 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).
b. perform annual tuberculosis (TB) skin
testing.
c. advise the patient of an increased risk of
bone cancer.
d. 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.
b. add adalimumab to the drug regimen.
c. change to a combination of adalimumab
and etanercept.
d. 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: 4179. 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.
b. recheck ALT and AGT levels in 2 weeks.
c. contact the patient’s rheumatologist to
discuss discontinuing the drug.
d. counsel the patient not to take
acetaminophen while taking methotrexate.
ANS: B
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.
b. discontinue the thiazide diuretic.
c. order a 24-hour urine collection.
d. 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.
b. serum uric acid levels.
c. 24-hour urine collection.
d. 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:
a. febuxostat (Uloric).
b. colchicine (Colcrys).
c. allopurinol (Zyloprim).
d. 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:
a. ask the patient about fluid intake.
b. order a urinalysis and urine culture.
c. change the medication to allopurinol.
d. 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.
b. prescribe febuxostat.
c. tell the patient to use an NSAID ifsymptoms recur.
d. counsel the patient to report recurrence of
symptoms.
ANS: A
Colchicine is a first-line drug for preventing acute attacks. Because this patient has three
risk factors, a preventive medication should be used. Febuxostat is a second-line
preventive medication. The patient should not be treated on an as-needed basis.
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.
b. colchicine.
c. probenecid.
d. 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.
b. order vitamin B12 levels to assess for
vitamin deficiency.
c. discontinue the colchicine for 48 hours
until symptoms subside.
d. reassure the patient that these are
common, temporary side effects.
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.
b. counsel the patient to use high-doseaspirin for pain.
c. teach the patient to drink plenty of acidic
fluids such as juice.
d. tell the patient to stop taking the
medication when symptoms subside.
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.
b. prescribe hormone replacement therapy.
c. counsel the patient about diet and
exercise.
d. 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.
b. undergo bone density testing every 2
years.
c. avoid high-impact sports that can lead to
fractures.d. 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).
b. counsel her to increase her physical
activity.
c. prescribe calcitonin (Miacalcin nasal
spray).
d. 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).
b. teriparatide (Forteo).
c. calcitonin (Miacalcin nasal spray).
d. 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.
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 primarycare NP’s initial response should be to:
a. prescribe a proton pump inhibitor (PPI).
b. order intravenous (IV) bisphosphonates.
c. suggest that she take the drug with food.
d. 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.
b. take the medication 1 hour before meals.
c. sit upright for 30 minutes after taking the
drug.
d. 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.
b. change to 70 mg of alendronate weekly.
c. decrease the alendronate dose to 5 mg
daily.
d. 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 notappropriate 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.
b. initiate PPI therapy.
c. order serum calcium and vitamin D levels.
d. 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: 438Chapter 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).
b. metaxalone (Skelaxin).
c. methocarbamol (Robaxin).
d. cyclobenzaprine (Flexeril).
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.
b. metaxalone (Skelaxin)c. cyclobenzaprine (Flexeril).
d. 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.
b. order physical therapy.
c. prescribe diazepam (Valium).
d. 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.
b. order physical therapy.
c. refer the patient to a neurologist.
d. 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.b. avoid taking NSAIDs.
c. get up from a chair slowly.
d. 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).
b. metaxalone (Skelaxin).
c. acetaminophen (Tylenol).
d. 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
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:
a. an NSAID.
b. diazepam (Valium).
c. metaxalone (Skelaxin).
d. 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 CHOICE1. A patient has been taking an opioid analgesic for chronic pain and tells the primary care
nurse practitioner (NP) that the medication doesn’t work as well anymore. The NP should
suspect drug:
a. addiction.
b. tolerance.
c. modulation.
d. dependence.
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.
b. will help to improve the patient’s
functional outcomes and quality of life.
c. will eventually become ineffective for
treating pain when used over a long
period.
d. may require switching from one type of
opioid to another to prevent tolerance over
time.
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.
b. take the medication at regular intervals
and not just when pain is present.
c. start the medication at higher doses
initially and taper down gradually.
d. take the minimum amount needed evenwhen 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.
b. to take a very low dose of the opioid.
c. that nonsteroidal antiinflammatory drugs
will be the only safe option.
d. that opioids are safe when taken as
directed.
ANS: D
Fear of drug dependency or addiction does not justify withholding of opiates or
inadequate management of pain. As long as the medication is taken as directed, it is safe.
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
b. hydrocodone 75; 6
c. meperidine 300;12
d. 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.
b. drug addiction.
c. possible misuse.d. 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.
b. hydrocodone.
c. hydromorphone.
d. oxycodone CR.
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.
b. topiramate.
c. ergotamine.
d. 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.
b. topiramate.
c. sumatriptan.
d. 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
diary, which reveals irritability and food cravings followed the next day by visual
disturbances and unilateral right-sided headache, nausea, and photophobia lasting 2 to 3
days. The NP should recognize these symptoms as _____ migraine.
a. classic
b. hemiplegic
c. basilar-type
d. ophthalmoplegic
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.
b. these substances are not indicated for
migraine headaches.
c. doing this can increase the risk of more
chronic migraines.
d. an opioid analgesic would be a better
choice for migraine pain.
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).
b. stress the importance of establishing new
routines.
c. help the patient identify stressors
associated with the new role.
d. add a combination NSAID, aspirin, and
caffeine product to the regimen.
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.
b. consider changing to dihydroergotamine
(D.H.E. 45).
c. suggest that the patient take sumatriptan
with a NSAID.
d. ask the patient how often the sumatriptan
is used each week.
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).
b. sumatriptan (Imitrex).
c. cyproheptadine (Periactin).d. dihydroergotamine (D.H.E. 45).
ANS: B
If the patient is able to take medication at the earliest onset of migraine, ergots are usually
effective. Triptans are more effective when patients have difficulty ―catching the
headache in time.‖ Sumatriptan begins to work in 15 minutes and so would be indicated
for this patient. Frovatriptan has a longer half-life. Cyproheptadine is not a first-line
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.
b. metoclopramide and aspirin.
c. an NSAID and prochlorperazine.
d. 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.
b. an injectable triptan plus an oral
corticosteroid.
c. an intramuscular steroid plus an opioid
analgesic.
d. 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:a. add a selective serotonin reuptake
inhibitor (SSRI) antidepressant.
b. change to dihydroergotamine
hydrochloride.
c. prescribe a -blocker such as propranolol.
d. prescribe an anticonvulsant such as
topiramate.
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.
b. rizatriptan (Maxalt).
c. cyproheptadine (Periactin).
d. 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).
b. prescribe topiramate (Topamax) as
migraine prophylaxis.
c. recognize these as classic migraines and
order sumatriptan (Imitrex).
d. suggest treatment with acetaminophen
because these are probably tension
headaches.
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.
c. order a proton pump inhibitor (PPI) to
counter the effects of the steroid.
d. 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.
b. triamcinolone daily.
c. hydrocortisone every other day.
d. 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.
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 theprednisone.
b. a referral for possible growth hormone
therapy.
c. giving a double dose of prednisone every
other day.
d. 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.
b. order a serum glucose, potassium level,
and bone density testing.
c. perform pulmonary function tests to see if
the medication is still needed.
d. begin a gradual taper of the prednisone to
wean the patient off the medication.
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?
a. ―I should take this medication with food.‖
b. ―I will take the medication at 8:00 AM
each day.‖
c. ―I can expect a decreased appetite while I
am taking this medication.‖
d. ―I should not stop taking the medication
without consulting my provider.‖
ANS: CTherapeutic 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.
b. temporarily decrease the dose of
methylprednisolone.
c. change the dosing of methylprednisolone
to 15 mg twice a day.
d. 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.
b. begin taking dexamethasone because it
has longer effects.
c. expect these side effects to occur as the
medication is tapered.
d. increase the dose of prednisolone to the
most recent amount 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 sideeffects 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).
b. cephalexin (Keflex).
c. cefadroxil (Duricef).
d. 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).
b. prescribe cefixime (Suprax).
c. administer intramuscular ceftriaxone
(Rocephin).
d. wait for culture results before ordering an
antibiotic.
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).b. discontinue the cefadroxil.
c. reassure the patient that loose stools are
common with antibiotics.
d. 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.‖
b. ―I will take this medication twice daily.‖
c. ―I should take this medication with food.‖
d. ―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
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).
b. coagulation studies.
c. an electrocardiogram (ECG).
d. 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 _____.
a. increasing; cephalosporin
b. decreasing; cephalosporin
c. increasing; aminoglycoside
d. decreasing; aminoglycosideANS: 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.
b. reassure the parent that seizures can occur
while taking cephalosporins.
c. ask the child’s parent how much of the
cephalosporin the child has taken.
d. 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.
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.
b. use a backup contraception method other
than oral contraceptive pills.
c. expect severe gastrointestinal side effects
while taking this drug.
d. 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: 6892. 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
b. Azithromycin
c. Clarithromycin
d. 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?
a. Ilosone
b. E-Mycin
c. Erythrocin
d. 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.
b. azithromycin.
c. fidaxomicin.
d. 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.b. clarithromycin.
c. erythromycin base.
d. 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.
b. azithromycin.
c. clarithromycin.
d. 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.
b. decrease the dose of ciprofloxacin.
c. change to an antibiotic in another drug
class.
d. 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 patientempirically with:
a. gemifloxacin.
b. ciprofloxacin.
c. azithromycin.
d. 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
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.
b. change to ciprofloxacin.
c. discontinue the levofloxacin.
d. 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
b. discontinue the
c. increase the dose of
d. 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: 6945. 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.‖
b. ―I should take this medication on an
empty stomach.‖
c. ―I should use caution while driving when
taking this medication.‖
d. ―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.
b. decrease the dose of ciprofloxacin.
c. change the antibiotic to norfloxacin.
d. 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.
b. levofloxacin.
c. gemifloxacin.
d. ciprofloxacin.
ANS: B
Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones.
DIF: Cognitive Level: Understanding (Comprehension) REF: 696Chapter 68: Antiretroviral Medications
Test Bank
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.
b. begin therapy with zidovudine when she
is in her second trimester.
c. delay treatment with antiretroviral
medications until after her pregnancy.
d. 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.
b. changing both of the medications.
c. increasing the dose of both medications.
d. 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.
b. she will need to take medications
throughout her pregnancy and lactation.c. there is no risk of disease transmission to
a fetus if she complies with therapy.
d. 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.
b. suggest taking half doses of the
medications on a regular basis.
c. suggest the patient limit therapy to a oneor two-drug regimen.
d. 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.
a. 1 to 3
b. 3 to 6
c. 6 to 9
d. 9 to 12
ANS: B
The patient’s CBC should be monitored at least every 3 to 6 months and more frequently
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.b. changing to Truvada.
c. changing to tenofovir.
d. 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.
b. immediate sensitivity reaction.
c. cytotoxic hypersensitivity reaction.
d. 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.
b. blood urea nitrogen and creatinine.
c. serum bilirubin levels.
d. 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.‖
b. ―I should drink a full glass of water with
each dose.‖
c. ―I should stay out of direct sunlight and
use sunscreen.‖
d. ―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.
b. that symptoms such as sore throat and
arthralgia are more worrisome.
c. to continue the medication because these
are signs of the disease process.
d. that sulfisoxazole (Gantrisin) will be
prescribed instead to minimize side
effects.
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).
b. viral gastroenteritis.
c. serum sickness reaction.
d. 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.
b. TMP/SMX should not be prescribed for
children younger than 2 years.
c. folic acid supplements must be given to
children who take this medication.
d. 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
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.
b. tell the patient to stop taking the drug
immediately.
c. reassure the patient that these are minor
adverse effects of this drug.
d. 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 laboratorytests.
DIF: Cognitive Level: Applying (Application) REF: 704
DIF: Cognitive Level: Applying (Application) REF: 736
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.
b. creatine has been shown to be an effective
herbal choice to treat back pain.
c. there is no valid research documenting the
efficacy of this treatment for pain.
d. 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
treat various conditions. The NP understands the importance of:
a. learning about the actions, uses, doses,
and toxicities of these agents.
b. prescribing these agents when possible to
ensure safe dosing.
c. counseling patients to stop using herbal
products to avoid toxic side effects.
d. teaching patients that these products are
unregulated and unsafe to use.
ANS: AIt 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.
b. inform the patient of the risks of toxic side
effects with this supplement.
c. refer the patient to a CAM provider who
can manage this patient’s therapy.
d. 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
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
man-made.
b. not marketed as products that can treat or
cure disease.
c. regulated by the Dietary Supplement
Health and Education Act.
d. 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.
b. echinacea.
c. ginkgo biloba.
d. 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.
b. echinacea.
c. green tea.
d. ginkgo biloba.
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.
b. chondroitin.
c. coenzyme Q.
d. 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 70: The Immune System and Immunizations
Test Bank
MULTIPLE CHOICE
1. The parents of a 2-month-old infant ask the primary care nurse practitioner (NP) if they
can immunize their child by giving one or two immunizations per month instead of
following the recommended immunization schedule for vaccines at 2, 4, 6, 12, and 15
months of age. The NP should:
a. respect the parents’ wishes and agree to
the revised schedule for immunizations.
b. explain that prolonging the vaccine
regimen will lead to a decrease in final
antibody concentrations.
c. tell the parents that protection from
diseases may be delayed until all
immunizations have been given.
d. inform the parents that a prolonged
interval between some vaccines may
require restarting the series for those
vaccines.
ANS: C
Young infants are the most vulnerable to serious outcomes of vaccine-preventable
disease. Vaccination providers should adhere as closely as possible to recommended
vaccination schedules. Protection may not occur until all doses have been given. Parents
should be counseled about the risks and benefits of vaccines. Longer than recommended
intervals between doses do not reduce final antibody concentrations. With the exception
of oral typhoid, an interruption in the schedule does not require restarting the entire
series.
DIF: Cognitive Level: Applying (Application) REF: 756
2. The primary care NP sees a 5-year-old child for a prekindergarten physical examination.
The child’s parents do not have immunization records, and a local record search does not
provide proof of vaccinations, although the parent thinks the child may have had some
vaccines several years ago. The NP’s initial action will be to:
a. perform serologic tests for measles,
rubella, and tetanus antigens.
b. administer TdaP, MMR, Varivax, PCV13,
hepatitis A, hepatitis B, and IPV vaccines.
c. administer DTaP, Hib, hepatitis A,
hepatitis B, MMR, Varivax, IPV, RV, and
PCV13 vaccines.d. ask the parent to look for immunization
records and schedule an appointment for
vaccines when those are found.
ANS: B
Persons without documentation of vaccine receipt should be considered nonimmunized if
a reasonable effort to locate records is unsuccessful and should be started on ageappropriate vaccines. The Hib and rotavirus vaccines are not given after age 5, or 60
months of age. Serologic testing for immunity may be done for certain antigens, but this
does not include tetanus.
DIF: Cognitive Level: Applying (Application) REF: 756
3. The primary care NP sees a 6-month-old infant for a routine physical examination and
notes that the infant has a runny nose and a cough. The parents report a 2-day history of a
temperature of 99° F to 100° F and two to three loose stools per day. Other family
members have similar symptoms. The infant has had two sets of immunizations at 2 and
4 months of age. The NP should:
a. administer the 6-month immunizations at
this visit today.
b. schedule an appointment in 2 weeks for 6-
month immunizations.
c. administer DTaP, Hib, IPV, hepatitis B,
and PCV13 today and RV in 2 weeks.
d. withhold all immunizations until the
infant’s temperature returns to normal and
the cough is gone.
ANS: A
Minor upper respiratory infection or gastroenteritis, with or without fever, is not an
indication for withholding a scheduled vaccine dose.
DIF: Cognitive Level: Applying (Application) REF: 757
4. A woman who is pregnant and is planning to breastfeed tells the primary care NP that she
has never had chickenpox. The NP should:
a. administer the Varivax vaccine today.
b. administer the varicella-zoster immune
globulin.
c. recommend the Varivax vaccine as soon
as possible after her baby is born.
d. instruct her to receive the Varivax vaccine
after her baby has been weaned.
ANS: C
Live vaccines are usually contraindicated in pregnancy but are usually safe when the
mother is breastfeeding.DIF: Cognitive Level: Applying (Application) REF: 758
5. The primary care NP is performing a physical examination on a 6-month-old infant with
cerebral palsy who has not had previous immunizations. The NP plans to begin
vaccinations and should include:
a. DTaP vaccine.
b. TdaP vaccine.
c. TD vaccine only.
d. tetanus vaccine only.
ANS: A
Infants with stable neurologic disorders, including cerebral palsy, may receive the
pertussis vaccine and should receive the DTaP series as infants.
DIF: Cognitive Level: Applying (Application) REF: 759
6. A parent whose child received a fourth DTaP at a recent 15-month visit calls the primary
care NP to report that the child is fussy, has a temperature of 38.3° C, and has redness
and swelling at the injection site. The NP should:
a. admit the child to the hospital for
observation of developing symptoms.
b. flag the child’s chart to avoid
administration of pertussis vaccine in the
future.
c. report these adverse reactions to the
Vaccine Adverse Event Reporting System
(VAERS).
d. instruct the parent to give the child
acetaminophen as needed for fever or
localized discomfort.
ANS: D
Temperatures between 38° C and 40° C are common and self-limited, as are fussiness
and localized swelling and erythema. Parents should be advised to provide symptomatic
care. Unless the child experiences a severe reaction, admission to a hospital is not
indicated. Mild reactions are not contraindications to future vaccines. This reaction is not
severe, and reporting to VAERS is not indicated.
DIF: Cognitive Level: Applying (Application) REF: 760
7. The primary care NP sees an 11-month-old infant for the first time and notes that the
infant has not received the Hib vaccine. The NP should:
a. give the Hib vaccine now with no
boosters.
b. give the Hib vaccine now and booster in 2
to 3 months.
c. give the Hib vaccine now and booster atage 4 to 6 years.
d. tell the parents that the child is too old to
begin receiving the Hib vaccine.
ANS: B
Children 12 to 14 months old require at least two doses, so this infant should be
immunized today with a booster in 2 to 3 months.
DIF: Cognitive Level: Applying (Application) REF: 761
8. The primary care NP sees a 12-month-old infant who needs the MMR, Varivax,
influenza, and hepatitis A vaccines. The child’s mother tells the NP that she is pregnant.
The NP should:
a. administer all of these vaccines today.
b. give the hepatitis A and influenza
vaccines.
c. give the Varivax, hepatitis A, and
influenza vaccines.
d. withhold all of these vaccines until after
the baby is born.
ANS: A
Although live-virus vaccines should not be administered to mothers during pregnancy,
they may be given to children whose mothers are pregnant.
DIF: Cognitive Level: Applying (Application) REF: 762
9. The primary care NP performs a physical examination on an 89-year-old patient who is
about to enter a skilled nursing facility. The patient reports having had chickenpox as a
child. The NP should:
a. obtain a varicella titer.
b. administer the Varivax vaccine.
c. give the patient the Zostavax vaccine.
d. plan to prescribe Zovirax if the patient is
exposed to shingles.
ANS: C
The Advisory Committee on Immunization Practices has recommended that a single dose
of herpes zoster vaccine (Zostavax) be given to adults 60 years of age or older. This is
recommended whether or not the patient reports a prior episode of herpes zoster. Varivax
is not recommended to prevent shingles.
DIF: Cognitive Level: Applying (Application) REF: 763
10. The primary care NP sees a 4-year-old child who has persistent asthma episodes for a
well-child visit in October. The child recently completed a 7-day course of oral steroids.
The NP plans to give the child flu vaccine and should:
a. administer LAIV today.b. administer 0.5 mg TIV today.
c. wait 4 weeks and administer LAIV.
d. wait 4 weeks and administer 0.5 mg TIV.
ANS: B
U.S. Food and Drug Administration licensure of LAIV excludes children ages 2 to 4
years with a history of asthma. Steroid therapy should not delay the administration of
influenza vaccine, especially in patients for whom influenza infection would be
particularly severe. This child should receive TIV and may receive it today.
DIF: Cognitive Level: Applying (Application) REF: 764
11. The primary care NP sees a 4-year-old child who has received four doses of PCV 7 in the
first 15 months of life. The NP should administer:
a. PCV 7.
b. PCV 13.
c. PPV 23.
d. no PCV.
ANS: B
Children who have completed the PCV series with PCV 7 and are younger than 5 years
should receive a single dose of PCV 13.
DIF: Cognitive Level: Applying (Application) REF: 765
12. The primary care NP sees a 65-year-old patient in October. The patient has a history of
COPD and has not had any vaccines for more than 20 years. The NP should administer:
a. influenza and Td vaccines.
b. PCV 13 and influenza vaccines.
c. PPV 23, Td, and influenza vaccines.
d. PPV 23, influenza, and TdaP vaccines.
ANS: D
Persons older than age 65 and patients with chronic illnesses associated with increased
risk from pneumococcal infection should receive the PPV 23. All persons should receive
annual influenza vaccine. TdaP is the recommended vaccine for adults, unless there is a
specific contraindication for the pertussis component; this vaccine is given every 10
years.
DIF: Cognitive Level: Applying (Application) REF: 765
13. The primary care NP sees a 2-month-old infant for a well-baby examination in late
November. The infant was born at 34 weeks’ gestation, does not have underlying cardiac
or pulmonary conditions, and does not attend daycare. The NP should recommend:
a. one dose of palivizumab (Synagis) today.
b. no respiratory syncytial virus prophylaxis.
c. three monthly doses of palivizumab(Synagis).
d. monthly doses of palivizumab (Synagis)
until April.
ANS: C
Infants born at 32 to 35 weeks’ gestation who are younger than 3 months of age at the
start of respiratory syncytial virus season should receive a maximum of three doses of
Synagis.
DIF: Cognitive Level: Applying (Application) REF: 765 - 766
14. A 23-year-old woman who is sexually active has an abnormal Pap smear. She asks the
primary care NP about the human papillomavirus vaccine (HPV). The NP should
recommend:
a. no HPV vaccine.
b. a single HPV vaccine.
c. a three-vaccine series of HPV.
d. HPV vaccine for her partner.
ANS: C
A catch-up vaccination may be given for women 13 to 26 years old and should be given
even to women with a history of genital warts, a positive HPV test, or an abnormal pap
smear.
DIF: Cognitive Level: Applying (Application) REF: 768
15. A patient receives a hepatitis A vaccine and 4 weeks later develops symptoms of
hepatitis. The patient has no history of exposure to blood or body fluids. The primary
care NP should tell the patient that:
a. the symptoms are most likely caused by
hepatitis B or C.
b. these symptoms are common adverse
effects of the vaccine.
c. a prevaccine exposure to hepatitis A could
be causing symptoms.
d. the vaccine is effective only after the
second dose of hepatitis A vaccine.
ANS: C
Because hepatitis A has a long incubation period of 15 to 50 days, the vaccine may not
prevent hepatitis A infection in patients who have an unrecognized hepatitis A infection
at the time of vaccination. The patient has no history of exposure to blood or body fluids,
which are the methods of transmission of hepatitis B or C. Side effects of the hepatitis A
vaccine are generally mild.
DIF: Cognitive Level: Applying (Application) REF: 766 - 767
16. The parent of a 2-month-old infant who will soon begin daycare refuses the rotavirusvaccine (RV) because of fears of intussusception. The parent tells the primary care NP
that the daycare is strict about preventing infants who have fever or gastrointestinal
symptoms from attending. The NP should tell the parent that:
a. herd immunity will protect the infant from
infection.
b. asymptomatic children can spread
rotavirus infection.
c. the risk of intussusception is nonexistent
with the newer vaccine.
d. the infant can be treated with antibiotics if
rotavirus infection occurs.
ANS: B
Asymptomatic infection with spread to nonimmune children can occur. The risk of
intussusception is less with the newer rotavirus vaccine but is still present. Rotavirus
cannot be treated with antibiotics.
DIF: Cognitive Level: Applying (Application) REF: 767
Chapter 73: Vitamins and Minerals
Test Bank
MULTIPLE CHOICE
1. An 80-year-old woman has chronically low hemoglobin despite a diet high in iron. The
primary care nurse practitioner (NP) will perform laboratory tests to confirm a diagnosis
and should suspect the patient will need:
a. omega-3 supplements.
b. a folic acid supplement.
c. a daily multivitamin with iron.
d. a diet high in green, leafy vegetables.
ANS: B
Women and elderly adults are often at risk for folic acid deficiency leading to anemia
because folic acid is necessary for synthesis of hemoglobin. Folic acid supplements are
indicated. Omega-3 supplements are not indicated for anemia. If anemia is caused by iron
deficiency alone, iron supplements must be used, which have more iron than a
multivitamin with iron. Folic acid supplements are more effective than dietary folic acid.
DIF: Cognitive Level: Applying (Application) REF: 809
2. The parent of a 3-year-old is concerned that the child’s legs are not straight. The primary
care NP notes marked bowing of the child’s lower extremities. Radiologic studies show
decreased ossification of the child’s bones. The NP should:
a. prescribe vitamin D supplements.
b. recommend calcium supplements.
c. counsel the parent to increase the child’smilk intake.
d. ensure that the parent is buying vitamin
D–fortified milk.
ANS: A
Children who do not get enough vitamin D can have abnormalities in bone ossification
leading to rickets, which is characterized by bowing of the legs. The NP should prescribe
vitamin D. Calcium supplements or increased milk intake would not be helpful. Without
vitamin D, the body cannot use calcium for bone ossification. The amount of vitamin D
in fortified milk is not sufficient to overcome vitamin D deficiency.
DIF: Cognitive Level: Applying (Application) REF: 803
3. An adolescent girl reports having heavy menstrual periods. Her hemoglobin is
consistently on the low end of the normal range. The primary care NP should prescribe:
a. iron supplements.
b. a folic acid supplement.
c. oral contraceptive pills.
d. increased red meats in her diet.
ANS: C
Women are at risk for iron-deficiency anemia from menstrual blood loss. Taking oral
contraceptives reduces this risk by moderating periods. Iron would be indicated if anemia
actually occurs, but this patient is just at risk. Folic acid supplements are not indicated to
prevent iron-deficiency anemia. Dietary iron usually is not sufficient for replacing iron
losses.
DIF: Cognitive Level: Applying (Application) REF: 803
4. The parents of a 3-year-old child tell the primary care NP that their child is a very picky
eater and they are worried about the child’s nutrition. The NP should recommend:
a. giving the child a daily multivitamin
containing iron.
b. providing small portions of a variety of
foods at each meal.
c. disciplining the child at mealtimes to
ensure proper nutrition.
d. making sure the child’s cereals are
fortified with vitamins and minerals.
ANS: B
Children often develop strong food preferences as they start to eat solid foods. Parents
should be taught that balance over time is important and should provide small portions of
a variety of foods at every meal. Not every meal has to include every nutrient. Vitamin
supplementation may be necessary for children who refuse to eat a variety of foods.
DIF: Cognitive Level: Applying (Application) REF: 8035. A patient exhibits keratin deposits around hair follicles and has hardened pigmented
―goose bump‖ lesions on all extremities. The primary care NP should consider
prescribing:
a. thiamine.
b. vitamin A.
c. beta carotene.
d. ascorbic acid.
ANS: C
The patient is exhibiting signs of early vitamin A deficiency. Beta carotene is
recommended to avoid vitamin A toxicity because beta carotene is converted to vitamin
A as needed and there is no need to monitor intake levels as with vitamin A. Thiamine
and ascorbic acid are not indicated.
DIF: Cognitive Level: Applying (Application) REF: 804 - 805
6. The primary care NP sees a patient for an annual physical examination. The patient
reports chronic alcohol abuse. The NP should refer the patient for treatment and should
prescribe:
a. niacin.
b. thiamine.
c. folic acid.
d. vitamin B6.
ANS: B
Patients who are alcohol abusers are prone to thiamine deficiency.
DIF: Cognitive Level: Applying (Application) REF: 807
7. As patients age, it becomes particularly important to increase their intake of:
a. iron.
b. omega 3.
c. vitamin C.
d. B vitamins.
ANS: D
Elderly patients are especially prone to deficiencies of B vitamins, generally because of
poor dietary intake.
DIF: Cognitive Level: Understanding (Comprehension) REF: 803
8. A 40-year-old woman asks the primary care NP what she can do to minimize her risk of
osteoporosis. She takes 800 mg of calcium and drinks 2 cups of skim milk each day. The
NP should recommend that she:
a. decrease dietary fat.
b. limit her caffeine intake.
c. consume a high-protein diet.d. drink diet instead of sugary sodas.
ANS: B
Large amounts of caffeine decrease calcium absorption. Calcium absorption is improved
with fat and decreased with high protein intake. All sodas contain phosphorus, which
decreases calcium levels.
DIF: Cognitive Level: Applying (Application) REF: 811
9. A 13-month-old child drinks 40 to 48 ounces of milk every day. The parents report that
the toddler eats a variety of baby fruits and vegetables but refuses meats and cereals. The
primary care NP should order a:
a. complete blood count (CBC).
b. ferritin level.
c. vitamin D level.
d. serum calcium level.
ANS: A
This child is consuming a diet low in iron. The NP should order a CBC to check this
child’s hemoglobin.
DIF: Cognitive Level: Applying (Application) REF: 813
10. A patient reports fatigue and increased frequency of stools over the past week and reports
having just begun a regimen of dietary changes to prevent hypertension. The primary care
NP notes a rapid, irregular heart rate and a blood pressure of 92/58 mm Hg. The NP
should question the patient about:
a. caffeine intake.
b. B vitamin intake.
c. fat-soluble vitamins.
d. use of salt substitutes.
ANS: D
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