NR 508 Week 4 Midterm Exam / NR508 Week 4 Midterm Exam(V4): Chamberlain College of Nursing (2020/21, All Correct)

NR508 Week 4 Midterm Exam / NR 508 Week 4 Midterm Exam (Latest): Chamberlain College of Nursing Chamberlain NR 508 Midterm Exam / Chamberlain NR508 Midterm Exam (Latest) Question 1 A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is still present. The NP should order: continuation of the PPI for 4 to 8 weeks. Correct! a PPI, amoxicillin, and metronidazole for 14 days. a PPI, clarithromycin, and amoxicillin for 14 more days. a PPI, bismuth subsalicylate, tetracycline, and metronidazole. 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. Question 2 A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this patient’s laboratory tests and notes normal renal function, increased triglycerides, and deceased HDL levels. The NP should prescribe: nateglinide (Starlix). glyburide (Micronase). colesevelam (Welchol). Correct! metformin (Glucophage). Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs. Question 3 The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP learns that the patient has decreased renal function and has renal artery stenosis in the right kidney. The NP should: Correct! initiate ACE inhibitor therapy at a low dose. consider a different drug class to treat this patient’s symptoms. give the captopril with a thiazide diuretic to improve renal function. orderlisinopril (Zestril) instead of captopril to avoid increased nephropathy. Patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary to avoid ACE inhibitors with unilateral renal stenosis. Question 4 A woman who has been taking a COCP for 2 months tells the primary care NP that she has had several headaches, breakthrough bleeding, and nausea. The NP should counsel the woman: to change to a progestin-only pill. to stop taking the COCP immediately. to use a backup form of contraception. Correct! that these effects will likely decrease in another month. Breakthrough bleeding, nausea, and headaches are common during the first 3 months of therapy and should improve without intervention. Progestin-only pills are used for lactating women only. Prolonged bleeding and severe headache would warrant discontinuation of the COCP. Backup contraception is not indicated. Question 5 A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: order liver function tests (LFTs). Correct! order a creatine kinase-MM (CK-MM) level. change atorvastatin to twice-daily dosing. add gemfibrozil (Lopid) to the patient’s medication regimen. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. Question 6 An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation therapy. The patient has an INR of 3.5. The primary care NP should consider: lowering the dose of warfarin. Correct! rechecking the INR in 1 week. omitting a dose and resuming at a lower dose. omitting a dose and administering 1 mg of vitamin K. 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. Question 7 Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical cardioversion in 3 weeks. The patient asks the primary care nurse practitioner (NP) why the procedure is necessary. The NP should tell the patient: Correct! this medication prevents clots but does not alter rhythm. if the medication proves effective, the procedure may be canceled. there are no medications that alter the arrhythmia causing AF. to ask the cardiologist if verapamil may be ordered instead of cardioversion. Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks. Warfarin does not alter AF. β-Blockers, calcium channel blockers, and digoxin are sometimes given to alter the rate. Verapamil is not an alternative to cardioversion for patients with persistent AF. Question 8 A patient who has had a previous myocardial infarction has a blood pressure of 135/82 mm Hg. The patient’s body mass index is 28, and the patient has a fasting plasma glucose of 105 mg/dL. The primary care NP should prescribe: Correct! an angiotensin-converting enzyme inhibitor. a thiazide diuretic. lifestyle modifications. a calcium-channel blocker. This patient has prehypertension but has a compelling reason for treatment. Patients who have had a myocardial infarction should be treated with a β-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ARB). Question 9 An 80-year-old female patient with a history of angina has increased TSH and decreased T4. The primary care NP should prescribe _____ mcg of _____. 25; liothyronine 75; liothyronine Correct! 25; levothyroxine 75; levothyroxine Elderly individuals may experience exacerbation of cardiovascular disease and angina with thyroid hormone replacement. It is advisable to start low at 25 mcg and work up as tolerated. Liothyronine is a synthetic T3. Question 10 CRNAs in most states: must have a Drug Enforcement Administration (DEA) number to practice. must have prescriptive authority to practice. Correct! order and administer controlled substances but do not have full prescriptive authority. administer medications, including controlled substances, under direct physician supervision. Only five states grant independent prescriptive authority to CRNAs. CRNAs do not require prescriptive authority because they dispense a drug immediately to a patient and do not prescribe. Without prescriptive authority, they do not need a DEA number. Question 11 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. Correct! reassure the patient that this side effect is common. 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. Question 12 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. Correct! lower the dose of the antispasmodic medication. 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. Question 13 A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP performs a medication history and learns that the patient also takes digoxin. The NP should recommend: decreasing the dose of digoxin. Correct! obtaining a serum digoxin level. changing the PPI to omeprazole. increasing the dose of lansoprazole. Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that require absorption in an acid stomach, including digoxin. It may be necessary to increase the dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so changing to another PPI would not solve the problem. Increasing the dose of lansoprazole would decrease the absorption of digoxin. Question 14 A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness. The NP activates the emergency medical system and should anticipate that this patient will receive: You Answered intravenousalteplase. low-dose aspirin and warfarin. low-molecular-weight heparin (LMWH). Correct Answer unfractionated heparin (UFH) and warfarin. This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy. Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is controversial for treatment of massive PE. Question 15 A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that: a fundoplication will be necessary to correct the cause of GERD. over-the-counter (OTC) antacids can be effective and should be tried first. elevation of the head of the bed at night can relieve most symptoms. Correct! a combination of lifestyle changes, medications, and surgery may be necessary. People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids are sometimes used but are rarely used as first-line treatment. Question 16 A 40-year-old patient is in the clinic for a routine physical examination. The patient has a body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30 mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should: Correct! order a fasting plasma glucose level. consider prescribing metformin (Glucophage). suggest dietary changes and increased exercise. obtain serum insulin and hemoglobin A1c levels. Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Serum insulin level is not indicated. Question 17 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: Correct! 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. 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. Question 18 A patient comes to the clinic reporting dizziness and fatigue associated with nausea and vomiting. The primary care NP suspects anemia and orders a complete blood count. The patient’s hemoglobin is elevated. The NP correctly concludes that the patient is not anemic. The NP has made an error in: context formulation. inappropriate knowledge base. cost-versus-benefit analysis. Correct! hypothesis triggering and information processing. Faulty hypothesis triggering occurs when the clinician fails to consider appropriate initial hypotheses. The patient had nausea and vomiting, which can cause dehydration, leading to orthostatic hypotension and dizziness. The NP made an assumption that the dizziness was caused by anemia and ordered a complete blood count. Faulty information gathering occurs when clinicians fail to order appropriate tests. An error in context formulation occurs when clinicians and patients have different goals. Errors in knowledge base would occur if the practitioner did not perform a complete history and physical, missing important information. An error in cost-versus-benefit analysis could occur if the clinician ordered expensive tests that were not necessary for diagnosis and treatment. Question 19 A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe: Correct! benztropine (Cogentin). cimetidine. an SSRI antidepressant. a TCA. Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg Question 20 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: Correct! 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. 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. Question 21 A patient who takes a calcium channel blocker is in the clinic for an annual physical examination. The cardiovascular examination is normal. As part of routine monitoring for this patient, the primary care NP should evaluate: serum calcium channel blocker level. complete blood count and electrolytes. Correct! liver function tests (LFTs) and renal function. thyroid and insulin levels. Patients who take calcium channel blockers should have periodic renal and LFTs. Question 22 A primary care NP prepares to teach a patient about the management of a chronic condition. The patient says, “I don’t want to know all of that. Just tell me what to take and when.” The NP should initially: Correct! give the patient basic written instructions about medications, follow up visits, and symptoms. ask the patient to describe the disease process and the medications to evaluate understanding. explain to the patient that without mutual cooperation, the treatment regimen will not be effective. ask the patient to explore feelings and fears about having a chronic disease and taking medications. The patient has stated expectations about care and treatment for the condition. The NP should begin by respecting that and providing the amount of information the patient wants. As the therapeutic relationship grows, the NP may elicit more active participation and understanding. Question 23 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. Correct! admit to the hospital for intravenous (IV) rehydration. encourage the patient to take small, frequent sips of Gatorade. 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. Question 24 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: orderdiphenoxylate (Lomotil). prescribealosetron after ruling out pregnancy. Correct! refer her to a gastroenterologist for endoscopy. increase the fiber in her diet to 30 g per day. 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. Question 25 A patient with a history of coronary heart disease develops atrial fibrillation. The primary care NP refers the patient to a cardiologist who performs direct current cardioversion. The NP should expect the patient to begin taking which β-blocker medication? Nadolol (Corgard) Correct! Sotalol (Betapace) Timolol (Blocadren) Propranolol (Inderal) Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with a history of coronary heart disease. Question 26 A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in symptoms. The next response of the primary care NP is to: Correct! add a histamine-2-receptor agonist. increase the dose of the PPI. change to long-term, low-dose PPI therapy. refer the patient to an endocrinologist for endoscopy and further management. If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis. When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist. Question 27 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. Correct! order an electrocardiogram (ECG) and serum electrolytes. change the medication to a thiazide diuretic. question the patient about potassium intake. 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. Question 28 An important difference between physician assistants (PAs) and NPs is PAs: Correct! always work under physician supervision. are not required to follow drug treatment protocols. may write for all drug categories with physician co-signatures. have both inpatient and outpatient independent prescriptive authority. PAs commonly have co-signature requirements and work under physician supervision. Question 29 A woman comes to the clinic to talk about weight reduction. The primary care nurse practitioner (NP) calculates a body mass index (BMI) of 28. The woman’s waist measures 34 inches. The woman tells the NP that she would like to lose 20 lb for her daughter’s wedding in 6 months. The NP should: suggest she try over-the-counter (OTC) orlistat. consider prescribing phentermine short-term. Correct! discuss her short-term and long-term weight loss goals. give her information about physical activity and diet modification. This woman’s BMI is in the moderate range for overweight, and her waist circumference is 34, which is not diagnostic for metabolic syndrome. Because her apparent motivation for losing weight is based on an upcoming event, the NP first should determine what her short-term and long-term weight loss goals are before initiating therapy. Orlistat is used long-term and would not be appropriate in this case. Phentermine should be used short-term and, because of serious risks, should be used only as adjunct therapy to lifestyle modifications. The initial intervention for weight loss is physical activity and diet modification. Question 30 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: increase the captopril dose to 50 mg twice daily. Correct! add a thiazide diuretic to this patient’s regimen. change the drug to losartan (Cozaar) 50 mg once daily. recommend a low-sodium diet in addition to the medication. 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. Question 31 A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe: condoms. tubal ligation. monophasic combined oral contraceptive pill (COCP). Correct! low-estrogen COCP. Low-estrogen COCPs are recommended for women older than 40 with or without cardiovascular risk. Monophasic COCPs are recommended for women with migraine headaches. Condoms are more useful for preventing sexually transmitted diseases and not as reliable as contraception. Tubal ligation has surgical risks. Question 32 A patient with a diagnosis of peptic ulcer disease asks the primary care NP about nonpharmacologic treatment. Which statement by the NP is correct? Correct! “You should consume a diet that is high in fiber.” “One or two cups of coffee each day won’t hurt you.” “Alcoholic beverages are strictly prohibited when you have an ulcer.” “Lifestyle changes and proper diet may eliminate the need for medication.” Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine increases acid secretion and should be avoided. Patients may consume alcohol in moderation. Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer disease, they do not eliminate the need for medications. Question 33 The neighbor of a primary care NP asks the NP to write a prescription for an antibiotic. The NP should tell the neighbor: a prescription will be written one time only. she will ask a colleague to write the prescription. that it is illegal to write prescriptions for friends. Correct! that it is best if the neighbor sees a health care provider before obtaining a prescription. It is not illegal to prescribe antibiotics for friends, but it is unethical. It is better if patients are seen and diagnosed appropriately before antibiotics are prescribed. The NP should recommend that the neighbor see a health care provider. Question 34 A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the patient reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats per minute. The NP should: obtain LFTs. decrease the dose of metformin. change metformin to glyburide. Correct! order electrolytes, ketones, and serum glucose. Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should include electrolytes, ketones, and serum glucose. Question 35 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. Correct! obtain a digoxin level before the patient takes the next dose of digoxin. 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. Question 36 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: Correct! prescribe docusate sodium (Colace) and decrease bisacodyl gradually. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead. tell her that long-term use of suppositories is safer than long-term laxative use. counsel the patient to discontinue the laxative and increase fluid and fiber intake. 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. Question 37 A patient who is obese is preparing to have surgery. To help prevent venous thromboembolism (VTE), the primary care NP should prescribe: low-dose aspirin once daily. clopidogrel (Plavix) 75 mg once daily. Correct! enoxaparin (Lovenox) 30 mg twice daily. warfarin (Coumadin) titrated to achieve an INR of 3.5. The American College of Clinical Pharmacy recommends against the use of aspirin alone for prophylaxis of VTE. Patients undergoing surgery who are at moderate to high risk for VTE should receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin. Aspirin may be part of the prophylaxis regimen. Clopidogrel and warfarin are not recommended. Question 38 A man with a BMI of 38 and a waist size of 48 inches is seen in the clinic for an annual well check-up. The primary care NP orders laboratory tests and notes a fasting plasma glucose of 110 mg/dL, triglyceride level of 220 mg/dL, and high-density lipoprotein level of 40 mg/dL. The man’s blood pressure is 160/110 mm Hg. The man has a history of cardiovascular disease and tells the NP he has tried to lose weight numerous times. The NP should consider: Correct! orlistat (Xenical). phentermine (Adipex-P). an oral antidiabetic agent. a strict low-fat, low-sodium diet. This man’s BMI and waist circumference indicate that he is obese, and he has more than three indicators of metabolic syndrome. Because of his history of cardiovascular disease, his past failed attempts to lose weight, and his elevated blood pressure, treatment is indicated. Phentermine would be a good initial choice but carries significant risks in patients with cardiovascular disease and high blood pressure. Orlistat is a safer choice for pharmacologic therapy. An oral antidiabetic agent would be used if insulin resistance were present, but his fasting plasma glucose is normal. A strict change in diet is warranted but in this case should be combined with pharmacologic treatment. Question 39 Which of the following has influenced an emphasis on primary care education in medical schools? Correct! Changes in Medicare reimbursement methods recommended in 1992 Competition from nonphysicians desiring to meet primary care shortages The need for monopolistic control in the marketplace of primary outpatient care The recognition that nonphysicians have variable success providing primary care The Physician Payment Review Commission in 1992 directly increased financial reimbursement to clinicians who provide primary care. Coupled with a shortage of primary care providers, this incentive led medical schools to place greater emphasis on preparing primary care physicians. Competition from nonphysicians increased coincidentally as professionals from other disciplines stepped up to meet the needs. Nonphysicians have had increasing success at providing primary care and have been shown to be safe and effective. Question 40 A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should: order a T4 level today. increase the dose to 100 mcg. Correct! check the TSH level in 1 week. reassure the patient that this will improve in several weeks. Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH level is indicated to evaluate drug effectiveness. The dose should not be increased without first evaluating the patient’s TSH level. Question 41 A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The primary care nurse practitioner (NP) auscultates S3 heart sounds but does not palpate hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should consult a cardiologist to discuss prescribing a(n): β-blocker. Correct! loop diuretic. angiotensin-converting enzyme (ACE) inhibitor. angiotensin receptor blocker (ARB). This patient shows signs of systolic heart failure. Treatment for heart failure should begin with a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. β-Blockers are used in patients with minimal fluid retention and would be added later. ARBs are used if ACE inhibitors are not tolerated or are ineffective. Question 42 A primary care NP will begin practicing in a state in which the governor has opted out of the federal facility reimbursement requirement. The NP should be aware that this defines how NPs may write prescriptions: without physician supervision in private practice. Correct! as CRNAs without physician supervision in a hospital setting. in any situation but will not be reimbursed for this by government insurers. only with physician supervision in both private practice and a hospital setting. In 2001, the Centers for Medicare and Medicaid Services changed the federal physician supervision rule for CRNAs to allow state governors to opt out, allowing CRNAs to write prescriptions and dispense drugs without physician supervision. Question 43 A patient with congestive heart failure will begin therapy with a diuretic medication. The primary care NP orders laboratory tests, which reveal a glomerular filtration rate (GFR) of 25 mL/minute. The initial drug the NP should prescribe is: Correct! metolazone. furosemide (Lasix). spironolactone (Aldactone). hydrochlorothiazide (HydroDIURIL). Thiazides are the most frequently used and the least expensive drugs administered to treat hypertension and are considered first-line treatments. In patients with a GFR less than 30 mL/minute, thiazides are relatively ineffective, with the exception of metolazone. Furosemide may be added as a second-line drug. Potassium-sparing diuretics, such as spironolactone, should be used with great caution or avoided altogether in patients with renal insufficiency. Question 44 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: Correct! 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. 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. Question 45 A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant and tells the primary care NP that she would like to space her children about 2 years apart. The NP should: discontinue the progestin-only pill. Correct! prescribe a COCP and a folic acid supplement. prescribe a progestin-only pill for another 6 months. suggest that she use a barrier method of contraception. Serum folate levels may be decreased by oral contraceptives. Women who become pregnant shortly after stopping oral contraceptive use may have a greater chance of birth defects. This woman should become pregnant in about 6 months if she wants to space her children 2 years apart, so she needs an oral contraceptive. Progestin-only pills are used only during lactation. Question 46 A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to: obtain stool cultures. Correct! begin rehydration therapy. consider prescribing metronidazole. administer opioid antidiarrheal medications. Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms. Question 47 A primary care nurse practitioner (NP) sees a patient who is concerned about constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend: Correct! increased intake of fluids and fiber. docusate sodium (Colace) as needed. psyllium (Metamucil) on a daily basis. polyethylene glycol (MiraLAX) as needed. The objective definition of constipation is two or fewer bowel movements per week or excessive straining. This patient does not meet these criteria, so the NP should recommend increasing fluids and fiber to help soften stools. Laxatives should not be used unless constipation is present or is chronic to avoid laxative dependence. Question 48 A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant. The NP should expect that this patient will use which of the following anticoagulant medications? Aspirin Correct! Heparin Dabigatran Warfarin Heparin does not cross the placental barrier and is the drug of choice for anticoagulation therapy during pregnancy, despite its category C classification. Aspirin is not recommended during the last 3 months of pregnancy. Dabigatran is not recommended. Warfarin crosses the placental barrier. Question 49 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. Correct! methimazole. levothyroxine. propylthiouracil. 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. Question 50 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. Correct! determine what the patient understands about coronary artery disease. give the patient information about drug effects and any adverse reactions. 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. Question 51 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: Correct! 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. 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. Question 52 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. Correct! order testing for Clostridium difficile and consider metronidazole therapy. prescribediphenoxylate (Lomotil) to provide symptomatic relief. reassure the patient that diarrhea is a common side effect of antibiotic therapy. 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. Question 53 A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to: change to aluminum hydroxide (Amphojel). use magnesium hydroxide (Milk of Magnesia) instead. continue using sodium bicarbonate (Alka-Seltzer) as needed. Correct! take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances. Question 54 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: diphenoxylate (Lomotil). attapulgite (Kaopectate). Correct! an electrolyte solution (Pedialyte). bismuth subsalicylate (Pepto-Bismol). 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. Question 55 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. Correct Answer administer oxygen at 2 L/minute. give 325 mg of chewable aspirin. You Answered call EMS. 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. Question 56 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: Correct! discontinue the phentermine. increase the dose of phentermine. continue the phentermine at the same dose. change to a combination of phentermine and topiramate. 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. Question 57 A patient who has hypothyroidism and is obese begins therapy with orlistat. The primary care NP teaches the patient about this drug and then asks the patient to describe its use. Which statement by the patient indicates understanding of the teaching? “I may eat a high-fat diet while taking orlistat.” Correct! “I can expect the most benefit in the first few months.” “I should take fat-soluble vitamins each time I take orlistat.” “I should take an increased dose of levothyroxine while I am taking orlistat.” In long-term studies on the use of orlistat, most of the weight loss occurred during the first months. Patients should not be counseled to eat a high-fat diet; the maximum amount of fat excretion is around 25% to 30%. Patients should take fat-soluble vitamins, but the vitamins should be taken at different times and not with orlistat. Orlistat interferes with levothyroxine absorption, so the two drugs should be taken at different times, and thyroid levels should be monitored with an increase in levothyroxine dose only when indicated by thyroid levels. Question 58 A patient who has an upper respiratory infection reports using over-the-counter cold preparations. The primary care NP should counsel this patient to use caution when taking additional over-the-counter medications such as: Correct! antipyretics. calcium supplements. acid reflux medications. antioxidant supplements. Cold preparations often contain antipyretics such as acetaminophen or aspirin. Patients should be cautioned about taking additional antipyretics to avoid overdose. Question 59 A patient with chronic back pain that is unrelieved by prescription analgesic medications asks a primary care nurse practitioner (NP) about acupuncture treatments. The NP should tell this patient: biofield therapy has been shown to be more effective than acupuncture. creatine has been shown to be an effective herbal choice to treat back pain. there is no valid research documenting the efficacy of this treatment for pain. Correct! most studies that show benefits of alternative therapies are based on observation. Current literature does not allow definitive conclusions to be drawn regarding the use of complementary and alternative medicine (CAM) because much of what appears in the literature continues to be based on observational reports and small studies. Biofield therapy has not been shown to be more effective than acupuncture. Creatine is used to increase muscle mass. Question 60 A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient to repeat back what has been learned. Which statement by the patient indicates understanding of the teaching? Correct! “I should avoid high-sodium foods.” “I should eat foods high in potassium.” “I need to take a calcium supplement every day.” “I should use a salt substitute while taking these medications.” Patients should be taught to reduce their overall sodium intake by avoiding salty foods and not adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin. Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in potassium.