Exam (elaborations) NGR 6172 PHARM TEST 3

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. bismuth subsalicylate (Pepto-Bismol). c. attapulgite (Kaopectate). d. an electrolyte solution (Pedialyte). d. an electrolyte solution (Pedialyte). 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. 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. 20 b. 15 c. 10 d. 25 c. 10 Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age. 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. attapulgite (Kaopectate). b. bismuth subsalicylate (Pepto-Bismol). c. an electrolyte solution (Pedialyte). d. diphenoxylate (Lomotil). c. an electrolyte solution (Pedialyte). 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. 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. beginning therapy with a statin medication. c. taking 81 to 325 mg of aspirin daily. d. starting a thiazide diuretic to treat hypertension. a. 30 minutes of aerobic exercise daily. 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. A 50-year-old patient who recently quit smoking reports a frequent morning cough productive of yellow sputum. A chest xray 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. order a long-acting anticholinergic with albuterol twice daily. b. prescribe a moderate-dose ICS twice daily. c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. d. reassure the patient that these symptoms will subside. c. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed. 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%. 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. order a urinalysis and creatinine clearance and begin therapy with a b-blocker. b. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. c. perform a careful cardiovascular physical assessment. d. counsel the patient about dietary and lifestyle changes. c. perform a careful cardiovascular physical assessment. 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. 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. discuss quality-of-life issues as part of the decision to begin medication. c. tell her there is no clinical evidence of efficacy of statin medication in her case. d. begin therapy with atorvastatin 10 mg per day. d. begin therapy with atorvastatin 10 mg per day. 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 quality-of-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women. 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. monitor for hypertension while taking the drug. b. watch for symptoms of paradoxical excitation with this medication. c. take the lowest recommended dose initially. d. take the antihistamine with a decongestant for best effect. c. take the lowest recommended dose initially. 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. 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. prescribe a leukotriene modifier instead of theophylline. c. order a creatinine clearance level. d. discontinue the SABA and change to ipratropium bromide. a. obtain a serum theophylline level. 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. 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 an electrocardiogram to assess for arrhythmias. b. order routine chest radiographs to watch for pneumonia. c. order a bone density study. d. monitor the patient's renal function at every visit. c. order a bone density study. 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. An 80-year-old male patient will begin taking an a-antiadrenergic medication. The primary care NP should teach this patient to: a. ask for assistance while bathing. b. be aware that priapism is a common side effect. c. take the medication in the morning with food. d. restrict fluids to aid with diuresis. a. ask for assistance while bathing. 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 a-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. 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. magnesium hydroxide (Milk of Magnesia). b. aluminum hydroxide (Amphojel). c. sodium bicarbonate (Alka-Seltzer). d. calcium carbonate (Tums). d. calcium carbonate (Tums). 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. An 80-year-old patient has a history of renal disease and develops a duodenal ulcer. The primary care NP should order a: a. decreased dose of a PPI. b. normal dose of a PPI. c. decreased dose of a histamine-2 blocker. d. normal dose of a histamine-2 blocker. b. normal dose of a PPI. 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. 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. d. contact the patient's cardiologist to discuss decreasing the dose of propranolol. Elderly patients have described sedation and sleep disturbances with b-blockers. Elderly patients often need lower doses of these drugs. Patients should not be advised to discontinue the medication abruptly. 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. omitting a dose and resuming at a lower dose. b. omitting a dose and administering 1 mg of vitamin K. c. lowering the dose of warfarin. d. rechecking the INR in 1 week. d. rechecking the INR in 1 week. This patient's INR is only minimally prolonged, so no dose reduction is required. The NP should recheck the INR periodically. If the INR becomes more prolonged, lowering the dose of warfarin is recommended. If the INR approaches 5, omitting a dose and resuming at a lower dose is recommended. Vitamin K is used for an INR of 9 or greater. 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. 20; twice b. 40; twice c. 80; once d. 40; once d. 40; once b-Blockers are the treatment of choice for chronic stable and unstable angina. Their therapeutic effect is dose dependent, and drug titration should be based on frequency of angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly patients when treating angina and should be increased by 20 mg every 3 to 7 days if symptoms do not improve. Nadolol is given once daily. 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. change the drug to losartan (Cozaar) 50 mg once daily. b. increase the captopril dose to 50 mg twice daily. c. add a thiazide diuretic to this patient's regimen. d. recommend a low-sodium diet in addition to the medication c. add a thiazide diuretic to this patient's regimen. 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. 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. b-blocker. b. angiotensin receptor blocker. c. ACE inhibitor. d. calcium channel blocker. d. calcium channel blocker. 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. 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. height and weight. b. blood pressure. c. liver function tests. d. urinalysis. a. height and weight. 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. 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. counsel the patient to discontinue the laxative and increase fluid and fiber intake. b. tell her that long-term use of suppositories is safer than long-term laxative use. c. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. d. prescribe docusate sodium (Colace) and decrease bisacodyl gradually. 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 long-term 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. An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the patient that this drug: a. will cause rebound congestion if withdrawn suddenly. b. can cause many systemic side effects such as drowsiness. c. will not provide maximum relief for a few weeks. d. may cause a bitter aftertaste. d. may cause a bitter aftertaste 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. 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. triamcinolone (Nasacort AQ). b. cromolyn sodium (Nasalcrom). c. azelastine (Astelin). d. phenylephrine (Neo-Synephrine) a. triamcinolone (Nasacort AQ) 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. 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. Increased fluids with a teaspoon of honey b. An antitussive/expectorant combination such as Robitussin DM c. Diphenhydramine (Benadryl) d. Over-the-counter pseudoephedrine with guaifenesin (Sudafed) a. Increased fluids with a teaspoon of honey 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. 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 b-adrenergic blocker, and an intranasal corticosteroid. The NP would be concerned about which adverse effects? a. Rebound congestion b. Liver toxicity c. Excessive drowsiness d. Tremor, restlessness, and insomnia d. Tremor, restlessness, and insomnia b-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. 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. suggest that the patient try a guaifenesin-only over-thecounter product. b. prescribe an antibiotic to treat the underlying cause of the patient's cough. c. order a narcotic antitussive to suppress cough. d. obtain a thorough history of the patient's symptoms. d. obtain a thorough history of the patient's symptoms. 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