NR 508 Week 4 Mid-Term Exam 2020 with complete solution

NR 508 Week 4 Mid-Term Question 12 pts Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend: ...

NR 508 Week 4 Mid-Term Question 12 pts Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She has a positive family history of breast cancer. The primary care NP should recommend: testosterone therapy. estrogen-only therapy. nonhormonal drugs for osteoporosis. estrogen-progesterone therapy for 1 to 2 years. Flag this Question Question 22 pts 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: aprepitant (Emend). ondansetron (Zofran). scopolamine transdermal. prochlorperazine (Compazine). Flag this Question Question 32 pts 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: thyrotropin. methimazole. levothyroxine. propylthiouracil. Flag this Question Question 42 pts 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: prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. perform a careful cardiovascular physical assessment. counsel the patient about dietary and lifestyle changes. order a urinalysis and creatinine clearance and begin therapy with a β-blocker. Flag this Question Question 52 pts 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: methimazole. liothyronine. levothyroxine. propylthiouracil. Flag this Question Question 62 pts When prescribing a medication for a chronic condition, the primary care NP should tell the patient: to contact the pharmacy whenever refills are needed. that it is necessary to return to the clinic for each monthly refill of the medication. about the frequency of clinic visits necessary for the number of refills authorized. to ask the pharmacist to supply several months’ worth of the medication at a time. Flag this Question Question 72 pts 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: increasing the dose to 90 mcg/day. decreasing the dose to 30 mcg/day. stopping the medication and checking TSH and T4 in 4 weeks. discussing the need for lifetime replacement therapy with the child’s parents. Flag this Question Question 82 pts A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend: 25 g of fiber each day. avoiding gluten and lactose in the diet. increasing water intake to eight to ten glasses per day. beginning aerobic exercise, such as running, every day. Flag this Question Question 92 pts A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and: take one cycle of COCPs. take a home pregnancy test. use condoms for the next 7 days. contact the clinic if she misses a period. Flag this Question Question 102 pts 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: mesalamine (Asacol). dicyclomine (Bentyl). simethicone (Phazyme). metoclopramide (Reglan). Flag this Question Question 112 pts 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: may cause different adverse effects. does not necessarily have the same therapeutic effect. is likely to be less safe than the brand specified in the prescription. may vary in the amount of drug that reaches the site of action in the body. Flag this Question Question 122 pts 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: (PSVT) administer intravenous fluids and obtain serum electrolytes. administer amiodarone in the clinic and observe closely for response. order digoxin and verapamil and ask the patient to return for a follow-up examination in 1 week. send the patient to an emergency department for evaluation and treatment. Flag this Question Question 132 pts An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary care NP that she likes the fact that she won’t have to deal with pills or periods. The primary care NP should tell her that she: should consider another form of contraception after 1 year. may have irregular bleeding, especially in the first month or so. will need to take calcium and vitamin D every day while using this method. will have to take oral contraceptive pills in addition to Depo-Provera when she takes antibiotics. Flag this Question Question 142 pts A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss: changing to amlodipine. ordering renal function tests. increasing the dose of nifedipine. evaluation of left ventricular function. Flag this Question Question 152 pts 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: schedule a treadmill stress test. order genetic testing for this patient. discontinue the trimethoprim-sulfamethoxazole. refer the patient to a cardiologist for further evaluation. Flag this Question Question 162 pts 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 β-blocker. an angiotensin-converting enzyme inhibitor. a thiazide diuretic. dietary and lifestyle changes. Flag this Question Question 172 pts A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to: order LH and FSH levels. order a serum prolactin level. prescribe testosterone replacement. obtain a morning serum testosterone level. Flag this Question Question 182 pts 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: order diphenoxylate (Lomotil). prescribe alosetron after ruling out pregnancy. refer her to a gastroenterologist for endoscopy. increase the fiber in her diet to 30 g per day. Flag this Question Question 192 pts 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. pyloriis still present. The NP should order: continuation of the PPI for 4 to 8 weeks. a PPI, amoxicillin, and metronidazole for 14 days. a PPI, clarithromycin, and amoxicillin for 14 more days. a PPI, bismuth subsalicylate, tetracycline, and metronidazole. Flag this Question Question 202 pts 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: inhibitor. substrate. inducer. metabolizer. Flag this Question Question 212 pts 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: order a β-blocker. add an angiotensin-converting enzyme inhibitor. continue the current drug regimen. change to an aldosterone antagonist medication. Flag this Question Question 222 pts 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: obtain a stool specimen and order vancomycin. order testing for Clostridium difficile and consider metronidazole therapy. prescribe diphenoxylate (Lomotil) to provide symptomatic relief. reassure the patient that diarrhea is a common side effect of antibiotic therapy. Flag this Question Question 232 pts 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: compromise with the parents and order a nasogastric tube for feedings. initiate a discussion with the parents about the potential outcomes of each possible action. refer the family to a case manager who can help guide the parents to the best decision. understand that the child’s parents have a right to make choices that override those of the medical team. Flag this Question Question 242 pts The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen? “I have to take a pill only every 3 months.” “I should expect to have only four periods each year.” “I will need to use condoms for only 7 more days.” “This type of pill has fewer side effects than other types.” Flag this Question Question 252 pts 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: provide pharmaceutical company samples of the medication for the patient. inform the patient that the drug must be paid for out of pocket because it is not covered. order the closest formulary-approved approximation of the drug and monitor effectiveness. write a letter of medical necessity to the insurer to explain the need for this particular medication. Flag this Question Question 262 pts 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: order LFTs. order CK-MM tests. consider decreasing the dose of the medication. reassure the patient that this side effect is common. Flag this Question Question 272 pts A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary care NP should counsel the patient to: report wheezing and shortness of breath, which may occur with these drugs. take care when getting out of bed or a chair after the first dose of the ACE inhibitor. discuss taking an increased dose of the thiazide diuretic with the cardiologist. minimize fluid intake for several days when beginning therapy with the ACE inhibitor. Flag this Question Question 282 pts A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she is having frequent hot flashes and vaginal dryness. A recent bone density study shows early osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The NP should prescribe: estrogen-only HT now. estrogen-only HT in 5 years. estrogen-progesterone HT now. estrogen-progesterone HT in 5 years. Flag this Question Question 292 pts 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: dissolve atheromatous lesions. relax vascular smooth muscle. prevent catecholamine release. reduce C-reactive protein levels. Flag this Question Question 302 pts 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: obtain a complete blood count and serum electrolytes. prescribe a rectal antiemetic medication. admit to the hospital for intravenous (IV) rehydration. encourage the patient to take small, frequent sips of Gatorade. Flag this Question Question 312 pts 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: prescribe cimetidine (Tagamet). prescribe omeprazole (Prilosec). teach the patient about a bland diet. change the NSAID to a corticosteroid. Flag this Question Question 322 pts 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: obtain an electrocardiogram. administer oxygen at 2 L/minute. give 325 mg of chewable aspirin. call EMS. Flag this Question Question 332 pts 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: decrease the dose of the diuretic to prevent further dehydration. obtain a serum potassium level to assess for hyperkalemia. hold the ACE inhibitor until the patient’s blood pressure stabilizes. obtain a digoxin level before the patient takes the next dose of digoxin. Flag this Question Question 342 pts 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: avoid foods that are high in vitamin K for several days. take a double dose of the medication the next morning. refill the prescription and take today’s dose immediately. skip today’s dose and resume a regular dosing schedule in the morning. Flag this Question Question 352 pts A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10 lb in the first month but reports that the drug does not seem to be suppressing appetite as much as before. The NP should: discontinue the phentermine. increase the dose of phentermine. continue the phentermine at the same dose. change to a combination of phentermine and topiramate. Flag this Question Question 362 pts 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: 30 minutes of aerobic exercise daily. taking 81 to 325 mg of aspirin daily. beginning therapy with a statin medication. starting a thiazide diuretic to treat hypertension. Flag this Question Question 372 pts A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE inhibitor. The primary care NP sees the patient for a routine physical examination and notes a heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should: order serum electrolytes. obtain renal function tests. consider prescribing a β-blocker. call the patient’s cardiologist to discuss adding digoxin to the patient’s regimen. Flag this Question Question 382 pts 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: prescribe a TCA. discontinue the antidiarrheal medication. encourage the patient to increase water intake. lower the dose of the antispasmodic medication. Flag this Question Question 392 pts 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: not curative and may prolong the illness. useful in cases of acute infection with elevated temperature. most beneficial when symptoms persist longer than 2 weeks. useful when other symptoms, such as hematochezia, develop. Flag this Question Question 402 pts 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: amlodipine (Norvasc). isradipine (DynaCirc). verapamil HCl (Calan). short-acting nifedipine (Procardia). Flag this Question Question 412 pts 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: recommend a reduced potassium intake. increase the dose of digoxin to 0.5 mg daily. hold the next dose of digoxin and obtain a serum digoxin level. contact the patient’s pharmacy to ask if generic digoxin was dispensed. Flag this Question Question 422 pts 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: obtain a serum drug level. order an electrocardiogram (ECG) and serum electrolytes. change the medication to a thiazide diuretic. question the patient about potassium intake. Flag this Question Question 432 pts 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: prescribe a thiazide diuretic. consider treatment with an angiotensin-converting enzyme inhibitor. reassure the patient that these findings are normal. counsel the patient about dietary and lifestyle changes. Flag this Question Question 442 pts 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: change the atorvastatin dose to 15 mg twice daily. change the patient’s medication to cholestyramine (Questran). add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. recommend supplements of omega-3 along with the atorvastatin. Flag this Question Question 452 pts The primary care NP is seeing a patient for a hospital follow-up after the patient has had a first myocardial infarction. The patient has a list of the prescribed medications and tells the NP that “no one explained anything about them.” The NP’s initial response should be to: ask the patient to describe the medication regimen. ask the patient to make a list of questions about the medications. determine what the patient understands about coronary artery disease. give the patient information about drug effects and any adverse reactions. Flag this Question Question 462 pts ???? 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: suggest that they give the child diet soda and low-fat frozen yogurt. understand and respect the parents’ beliefs about their child’s self-image. initiate a dialogue with the parents about the implications of the child’s laboratory values. suggest family counseling to explore ways to improve parenting skills and limits. Flag this Question Question 472 pts A primary care NP is developing a handout to give to patients who will begin self-administering insulin. When developing this handout, the NP should: provide detailed descriptions of each step in the process of injecting insulin. use correct medical terminology when describing insulin self-administration. provide as much factual information as possible about insulin administration. address one or two educational objectives that describe what the patient will learn. Flag this Question Question 482 pts 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 daily bulk laxative. long-term docusate sodium. a saline laxative as needed. glycerin suppositories as needed. Flag this Question Question 492 pts 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: serum electrolytes. blood glucose levels. serum thyroid levels. complete blood counts (CBCs). Flag this Question Question 502 pts A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should: tell her that starting HT now may reduce her risk of breast cancer. advise a short course of HT now that may decrease her risk for CHD. tell her that HT will not help control her symptoms during postmenopause. recommend herbal supplements for her symptoms to avoid HT side effects. Flag this Question Question 512 pts A primary care NP is performing a previsit health history on a new patient. The patient reports taking vitamins every day. The NP should: ask the patient to bring all vitamin bottles to the clinic appointment. recommend natural vitamin products over synthetic vitamin products. reassure the patient that vitamins that are high in folic acid are safe to take. tell the patient that some vitamins, such as vitamin C, are safe in large doses. Flag this Question Question 522 pts 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: calcium carbonate (Tums). aluminum hydroxide (Amphojel). sodium bicarbonate (Alka-Seltzer). magnesium hydroxide (Milk of Magnesia). Flag this Question Question 532 pts A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve her symptoms. The NP should: prescribe estrogen-only therapy. initiate oral contraceptive pills now. discuss using bioidentical HT. plan to use estrogen-progesterone therapy when menopause begins. Flag this Question Question 542 pts A patient who has breast cancer has been taking toremifene for 2 weeks. She tells her primary care NP that she thinks her tumor has grown larger. The NP should: schedule her for a breast ultrasound. reassure her that this is common and will subside. tell her she may need an increased dose of this medication. contact her oncologist to discuss adding another medication. Flag this Question Question 552 pts 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: meclizine. ondansetron. scopolamine. dimenhydrinate. Flag this Question Question 562 pts 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: albuterol metered-dose inhaler. furosemide (Lasix). spironolactone (Aldactone). chlorthalidone (Zaroxolyn). Flag this Question Question 572 pts A perimenopausal woman tells the primary care NP that she is having hot flashes and increasingly severe mood swings. The woman has had a hysterectomy. The NP should prescribe: estrogen-only HT. low-dose oral contraceptive therapy. selective serotonin reuptake inhibitor therapy until menopause begins. estrogen-progesterone HT. Flag this Question Question 582 pts A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she: is having vomiting or diarrhea. delays taking a pill by 5 or 6 hours. takes nonsteroidal antiinflammatory drugs several days in a row. has recurrent headaches or insomnia. Flag this Question Question 592 pts 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: give clopidogrel after administering cardioversion. administer cardioversion without using anticoagulants. give warfarin and aspirin before attempting cardioversion. give low-dose aspirin before administering cardioversion. Flag this Question Question 602 pts 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: the relation of the pain to stools. what time of day the pain occurs. whether the pain is sharp or diffuse. the age of the patient when the pain began. ANSWER EXPLANATIONS: 1. Although estrogen slows the progression of osteoporosis, it also increases the risk of breast cancer when initiated early in menopause. This woman should receive a nonhormonal treatment for osteoporosis and may receive HT in 5 years if menopausal symptoms persist. Testosterone therapy, estrogen-only therapy, and estrogen-progesterone therapy are not indicated. 2. 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 3. 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. 4. 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. 5. This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a thyroid suppressant. Liothyronine is synthetic T3. Propylthiouracil is a thyroid suppressant. 6. Nonscheduled drugs may be ordered with refills so that the patient does not have to be seen each time a refill is needed. It is important to determine how closely a patient should be monitored while taking a drug for a chronic condition and to let the patient know how frequently he or she needs to be seen. Patients may contact a pharmacy when they still have authorized refills to pick up, but this is determined by the clinician. Pharmacists usually cannot dispense more than 30 days’ worth of a medication. 7. 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. 8. 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. 9. If a transdermal patch has been discovered to be loose or has come off, patients should use a backup method of contraception. It is not necessary to use oral contraceptives. A home pregnancy test is not indicated. 10. Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas. Metoclopramide is used to increase motility. 11. 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. 12. 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. 13. Because of strong progestational effects on the endometrium, irregular bleeding or spotting is common in the early months of use. Because of concerns about the effect of depot medroxyprogesterone acetate on bone density, it is recommended that woman change to another birth control method after 2 years, not 1 year. Calcium and vitamin D supplements have not been shown to prevent bone density loss. It is not necessary to take oral contraceptive pills when taking antibiotics. 14. 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. 15. 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. Trimethoprim-sulfamethoxazole can prolong the QT interval and should not be used in patients at risk, but genetic testing should be performed to determine this. 16. 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. 17. To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive. 18. 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. 19. 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. 20. 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. 21. 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. β-Blockers and aldosterone antagonist medications are not recommended for patients with diabetes. 22. 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. 23. In general, the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants. Initiating a discussion about outcomes helps parents decide based on end results. A nasogastric tube is not the best choice for the child, and compromising without first exploring options is incorrect. As part of the therapeutic relationship, the NP should be involved with patients’ decisions. Although patients and families have the right to make decisions, the NP has an obligation to ensure that the decisions are informed decisions. 24. The extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types. 25. 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. 26. 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. 27. 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. 28. HT relieves symptoms of menopause and prevents osteoporosis. When started soon after menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5 years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only therapy is indicated. 29. 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. 30. 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. 31. 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 diets are not effective in treating ulcers. Corticosteroids are not indicated. 32. 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. 33. 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. 34. 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. 35. Tolerance to the effects of phentermine usually develops within a few weeks of starting therapy. When this occurs, the drug should be discontinued, not increased. Phentermine use is not recommended longer than a few weeks. 36. 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. 37. 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. β-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure. 38. 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. 39. Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases. 40. Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. 41. 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. 42. The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum electrolytes. This should be done before changing the medication. Because hyperkalemia can cause fatal arrhythmias, an ECG is necessary. 43. 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. 44. 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. 45. 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. 46. 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. 47. 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. 48. 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. 49. 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. 50. The current gap hypothesis regarding breast cancer supports initiating HT 5 years or more after menopause. To decrease risk for CHD, HT should begin at the time of menopause. HT will relieve vasomotor symptoms at all stages of menopause. Herbal supplements have estrogenizing effects and carry the same risks as estrogen therapy. 51. 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. 52. 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. 53. The timing hypothesis suggests that initiating HT at or very near to the time of menopause, which begins when a woman has not had a period for 12 months, reduces CHD in postmenopausal women. Estrogen-only therapy is indicated only for women who do not have a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated. 54. Toremifene can cause tumor flare in the first few weeks of therapy, but the tumor later regresses. An ultrasound is unnecessary at this stage. The NP does not need to notify the oncologist unless this continues to worsen. 55. 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. 56. 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. 57. Estrogen-only regimens are used in women without a uterus and may be initiated to treat perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat irregular menstrual bleeding in perimenopausal women. 58. Vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to use backup contraception if they experience these. The other conditions do not lead to oral contraceptive failure. 59. 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. 60. 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.