NR 508 Final Exam (NR508)

Exam (elaborations) NR 508 Final Exam (NR508) Question 1 2 / 2 pts 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: flavoxate (Urispas). bethanechol (Urecholine). phenazopyridine (Pyridium). Correct! oxybutynin 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 chloride, 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. Question 2 2 / 2 pts 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: zaleplon. Correct! ZolpiMist. ramelteon. NR 508 Final Exam chloral hydrate. 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. Question 3 2 / 2 pts A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, nonbulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: prescribe azithromycin once daily for 5 days. prescribe amoxicillin twice daily for 10 days. prescribe amoxicillin-clavulanate twice daily for 10 days. Correct! 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. Question 4 2 / 2 pts 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: Correct! recommend acetaminophen. recommend high-dose acetaminophen. tell the patient that antibiotics are needed with a fever that high. tell the patient a fever less than 40° C does not need to be treated. 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. Question 5 2 / 2 pts A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing freezing episodes between doses. The primary care NP should consider using: selegiline. amantadine. Correct! apomorphine. modified-release levodopa. Apomorphine injection is used for acute treatment of immobility known as “freezing.” Question 6 2 / 2 pts 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: consume foods high in vitamin D and calcium. begin taking dexamethasone because it has longer effects. expect these side effects to occur as the medication is tapered. Correct! 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 experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected. Question 7 2 / 2 pts 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: Correct! perform a dipstick urinalysis. prescribe desmopressin (DDAVP). prescribe oxybutynin chloride (Ditropan XL). teach exercises to strengthen the pelvic muscles. 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 incontinence. Medications are prescribed after determining the cause, if any, and treating underlying conditions. Exercises to strengthen the pelvic muscles are part of treatment. Question 8 2 / 2 pts 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: gradually tapering the child off the prednisone. a referral for possible growth hormone therapy. Correct! giving a double dose of prednisone every other day. dividing the prednisone dose into twice-daily dosing. 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. Question 9 2 / 2 pts 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 appetite. The NP should: Correct! ask about alcohol intake. suggest taking the medications with food. reassure the patient that these side effects are common. order liver and renal function tests and serum glucose. 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. Question 10 2 / 2 pts 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: combination ICS/LABA inhaler twice daily. short-acting β2-agonist (SABA) with oral corticosteroids when symptomatic. combination ipratropium/albuterol inhaler twice daily. Correct! SABA as needed plus a leukotriene modifier once daily. 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. Question 11 2 / 2 pts A patient is newly diagnosed with Alzheimer’s disease stage 6 on the Global Deterioration Scale. The primary care NP should prescribe: donepezil (Aricept). rivastigmine (Exelon). Correct! memantine (Namenda). galantamine (Razadyne). Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine. Question 12 2 / 2 pts 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: Correct! administer all of these vaccines today. give the hepatitis A and influenza vaccines. give the Varivax, hepatitis A, and influenza vaccines. withhold all of these vaccines until after the baby is born. Although live-virus vaccines should not be administered to mothers during pregnancy, they may be given to children whose mothers are pregnant. Question 13 2 / 2 pts 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: order renal function tests. prescribe another medication to treat this child’s symptoms. discontinue the drug and observe the child for toxic side effects. Correct! obtain a serum drug level and consider increasing the drug dose. 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. Question 14 2 / 2 pts 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: order spirometry to evaluate pulmonary function. prescribe a systemic corticosteroid to help with symptoms. Correct! ask the patient to describe how the medications are taken each day. give the patient detailed information about the use of metered-dose inhalers. 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. Question 15 2 / 2 pts 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: wait until the pain is at a moderate level before taking the medication. Correct! take the medication at regular intervals and not just when pain is present. start the medication at higher doses initially and taper down gradually. take the minimum amount needed even when pain is severe to avoid dependency. Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain. Question 16 2 / 2 pts A patient tells the primary care NP that he has difficulty getting and maintaining an erection. The NP’s initial response should be to: prescribe sildenafil (Viagra). Correct! perform a medication history. evaluate his cardiovascular status. order a papaverine injection test to screen for erectile dysfunction. Because the use of multiple medications is associated with a higher prevalence of erectile dysfunction, a medication history should be performed first to see if any medications have sexual side effects. A cardiovascular evaluation may be assessed next. Papaverine injection tests are useful screening tools after a thorough history has been performed. Medications are prescribed only after a diagnosis is determined and other causes have been ruled out. Question 17 2 / 2 pts A 55-year-old patient develops Parkinson’s disease characterized by unilateral tremors only. The primary care NP will refer the patient to a neurologist and should expect initial treatment to be: levodopa. carbidopa. Correct! pramipexole. carbidopa/levodopa. Patients younger than 65 years of age should be started with a dopamine agonist. Question 18 2 / 2 pts 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 over-the-counter NSAIDs. The primary care NP should prescribe: frovatriptan (Frova). Correct! sumatriptan (Imitrex). cyproheptadine (Periactin). dihydroergotamine (D.H.E. 45). 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. Question 19 2 / 2 pts 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: take her asthma medications only when she is having an acute exacerbation. Correct! avoid using antihistamine medications during her first trimester of pregnancy. discontinue her seizure medications at least 6 months before becoming pregnant. use only oral corticosteroids and not inhaled steroids while pregnant for improved asthma control. 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. Question 20 2 / 2 pts 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: topiramate (Topamax). levetiracetam (Keppra). zonisamide (Zonegran). Correct! carbamazepine (Tegretol). 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. Question 21 2 / 2 pts A patient is taking dicloxacillin (Dynapen) 500 mg every 6 hours to treat a severe penicillinase-resistant infection. At a 1-week follow-up appointment, the patient reports nausea, vomiting, and epigastric discomfort. The primary care NP should: change the medication to a cephalosporin. decrease the dose to 250 mg every 6 hours. reassure the patient that these are normal adverse effects of this drug. Correct! order blood cultures, a white blood cell (WBC) count with differential, and liver function tests (LFTs). When giving penicillinase-resistant penicillins, it is important to monitor therapy with blood cultures, WBC with differential cell counts, and LFTs before treatment and weekly during treatment. This patient may have typical gastrointestinal side effects, but the symptoms may also indicate hepatic damage. Changing the medication is not indicated, unless serious side effects are present. Decreasing the dose is not indicated. Question 22 2 / 2 pts 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: assess this patient’s usual sleeping patterns. ask the patient about problems with constipation. obtain a baseline creatinine clearance test before the first dose. Correct! perform a thorough evaluation of cognitive and motor abilities. The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. Question 23 2 / 2 pts 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. Correct! hydrocodone 30; 6 hydrocodone 75; 6 meperidine 300;12 meperidine 75; 6 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. Question 24 2 / 2 pts 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: Correct! prescribe colchicine. prescribe febuxostat. tell the patient to use an NSAID if symptoms recur. counsel the patient to report recurrence of symptoms. 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 asneeded basis. Question 25 2 / 2 pts 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: Correct! admit him to the hospital for detoxification. ask him how much he had to drink last night. prescribe lorazepam (Ativan) to help with symptoms. suggest that he talk to a counselor about alcohol abuse. 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. Question 26 2 / 2 pts A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprim-sulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase. The NP sends the urine for culture and should treat this patient empirically with: gemifloxacin. Correct! ciprofloxacin. azithromycin. TMP/SMX. 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. Question 27 2 / 2 pts 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: Correct! order an electroencephalogram (EEG). prescribe a tapering regimen of the drug. inform the patient that antiepileptic drug (AED) therapy is lifelong. tell the patient to stop the drug and use only as needed. Discontinuation of AEDs may be considered in patients who have been seizurefree 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. Question 28 2 / 2 pts 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: discuss the effects of smoking on fetal development. Correct! ask her to write down any factors that triggered her relapses. give her information about the long-term effects of smoking. convince her that taking medication will be essential in her case. 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