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:
- ANSWER administer all of these vaccines today
Although live-virus vaccines should not be administered to mothers during pregnancy, they
may be given to children whose mothers are pregnant.
A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is
normal. To treat this, the primary care NP should consider prescribing: - ANSWER oxy-
butynin chloride (Ditropan XL).
This patient is describing urge incontinence, or overactive bladder, which occurs when the
detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full.
Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chlo-
ride, which is an anticholinergic, acts to decrease detrusor overactivity and is indicated for
treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI.
Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria.
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: - ANSWER ZolpiMist
ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle
of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep
onset. Chloral hydrate is not typically used as outpatient therapy.
A 5-year-old child who has no previous history of otitis media is seen in clinic with a temper-
ature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact
1
,tympanic membranes. The child is taking fluids well and is playing with toys in the examina-
tion room. The NP should: - ANSWER initiate antibiotic therapy if the child's condition
worsens.
Signs and symptoms of otitis media that indicate a need for antibiotic treatment include
otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-
grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea,
so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of
choice.
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: - ANSWER recommend acetaminophen.
tell the patient a fever less than 40° C does not need to be treated.
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 pa-
tients because of possible decreased hepatic function. Antibiotics should not be given with-
out evidence of bacterial infection.
A patient who takes levodopa and carbidopa for Parkinson's disease reports experiencing
freezing episodes between doses. The primary care NP should consider using: - ANSWER
apomorphine.
Apomorphine injection is used for acute treatment of immobility known as "freezing."
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: - ANSWER increase the
dose of prednisolone to the most recent amount taken.
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
2
, experience these symptoms during a drug taper, the dose should be increased to the last
dose
The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent
leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also reports
having an increased urge to void even when her bladder is not full. She is not taking any
medications. The NP should: - ANSWER perform a dipstick urinalysis.
A focused history with a careful physical examination is essential for determining the cause
of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can cause inconti-
nence. Medications are prescribed after determining the cause, if any, and treating underly-
ing conditions. Exercises to strengthen the pelvic muscles are part of treatment.
A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child ex-
amination, the primary care NP notes a decrease in the child's linear growth rate. The NP
should consult the child's asthma specialist about: - ANSWER giving a double dose of
prednisone every other day.
Administration of a double dose of a glucocorticoid every other morning has been found to
cause less suppression of the HPA axis and less growth suppression in children. Because the
child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indi-
cated. Twice-daily dosing would not change the HPA axis suppression.
A patient who is taking isoniazid and rifampin for latent TB is seen by the primary care NP for
a routine follow-up visit. The patient reports having nausea, vomiting, and a decreased ap-
petite. The NP should: - ANSWER ask about alcohol intake.
Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient shows
signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid should be
taken on an empty stomach.
A primary care NP sees a child with asthma to evaluate the child's response to the pre-
scribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as
3
and hepatitis A vaccines. The child's mother tells the NP that she is pregnant. The NP should:
- ANSWER administer all of these vaccines today
Although live-virus vaccines should not be administered to mothers during pregnancy, they
may be given to children whose mothers are pregnant.
A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is
normal. To treat this, the primary care NP should consider prescribing: - ANSWER oxy-
butynin chloride (Ditropan XL).
This patient is describing urge incontinence, or overactive bladder, which occurs when the
detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full.
Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chlo-
ride, which is an anticholinergic, acts to decrease detrusor overactivity and is indicated for
treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI.
Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria.
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: - ANSWER ZolpiMist
ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle
of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep
onset. Chloral hydrate is not typically used as outpatient therapy.
A 5-year-old child who has no previous history of otitis media is seen in clinic with a temper-
ature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact
1
,tympanic membranes. The child is taking fluids well and is playing with toys in the examina-
tion room. The NP should: - ANSWER initiate antibiotic therapy if the child's condition
worsens.
Signs and symptoms of otitis media that indicate a need for antibiotic treatment include
otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a low-
grade fever, no history of otitis media, a nonbulging tympanic membrane, and no otorrhea,
so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of
choice.
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: - ANSWER recommend acetaminophen.
tell the patient a fever less than 40° C does not need to be treated.
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 pa-
tients because of possible decreased hepatic function. Antibiotics should not be given with-
out evidence of bacterial infection.
A patient who takes levodopa and carbidopa for Parkinson's disease reports experiencing
freezing episodes between doses. The primary care NP should consider using: - ANSWER
apomorphine.
Apomorphine injection is used for acute treatment of immobility known as "freezing."
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: - ANSWER increase the
dose of prednisolone to the most recent amount taken.
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
2
, experience these symptoms during a drug taper, the dose should be increased to the last
dose
The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent
leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also reports
having an increased urge to void even when her bladder is not full. She is not taking any
medications. The NP should: - ANSWER perform a dipstick urinalysis.
A focused history with a careful physical examination is essential for determining the cause
of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can cause inconti-
nence. Medications are prescribed after determining the cause, if any, and treating underly-
ing conditions. Exercises to strengthen the pelvic muscles are part of treatment.
A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child ex-
amination, the primary care NP notes a decrease in the child's linear growth rate. The NP
should consult the child's asthma specialist about: - ANSWER giving a double dose of
prednisone every other day.
Administration of a double dose of a glucocorticoid every other morning has been found to
cause less suppression of the HPA axis and less growth suppression in children. Because the
child has severe asthma, an oral steroid is necessary. Growth hormone therapy is not indi-
cated. Twice-daily dosing would not change the HPA axis suppression.
A patient who is taking isoniazid and rifampin for latent TB is seen by the primary care NP for
a routine follow-up visit. The patient reports having nausea, vomiting, and a decreased ap-
petite. The NP should: - ANSWER ask about alcohol intake.
Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient shows
signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid should be
taken on an empty stomach.
A primary care NP sees a child with asthma to evaluate the child's response to the pre-
scribed therapy. The child uses an ICS twice daily and an albuterol metered-dose inhaler as
3
