NR 508 FINAL EXAM

NR 508 FINAL EXAM Question 1 0 / 0 pts A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few weeks after the dose increase. The NP should: change the atorvastatin dose to 15 mg twice daily. change the patient’s medication to cholestyramine (Questran). recommend supplements of omega-3 along with the atorvastatin. Correct! add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily. When used in combination with a low-dose statin, ezetimibe has been noted to produce an additional 18% reduction in LDL. Because this patient continues to have elevated LDL along with side effects of the statin, the NP should resume the lower dose of the statin and add ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not indicated. Question 2 0 / 0 pts 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: lifestyle modifications. a calcium-channel blocker. a thiazide diuretic. Correct! an angiotensin-converting enzyme inhibitor. 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 3 0 / 0 pts A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should: order a lipid profile, complete blood count, and liver function tests (LFTs). order an oral glucose tolerance test. order metformin (Glucophage). Correct! set a weight loss goal of 10 to 15 lb. To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose 5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated. Question 4 0 / 0 pts A patient has been taking levothyroxine 100 mcg daily for several months. The patient comes to the clinic with complaints of insomnia and irritability. The primary care NP notes a heart rate of 92 beats per minute. The NP should: Correct! order TSH and T4 levels and decrease the dose to 75 mcg/day. discontinue levothyroxine indefinitely. change to liothyronine 75 mcg/day. order propylthiouracil to counter the increased thyroid levels. When signs of thyrotoxicosis occur, the drug should be decreased or temporarily discontinued for 5 to 7 days. Liothyronine is not indicated. Propylthiouracil is not indicated. Question 5 0 / 0 pts 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): ACE inhibitor. angiotensin receptor blocker. β-blocker. Correct! 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. Question 6 0 / 0 pts A patient who has stable angina is taking nitroglycerin and a β-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: Correct! verapamil HCl (Calan). nifedipine (Procardia XL). isradipine (DynaCirc). nicardipine (Cardene). Nitrates and β-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose. Question 7 0 / 0 pts A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient’s cardiologist to discuss adding: Correct! nifedipine (Procardia XL). verapamil HCl (Calan). diltiazem (Cardizem). amlodipine (Norvasc). Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug. Question 8 0 / 0 pts 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 _____. Correct! 25; levothyroxine 75; levothyroxine 25; liothyronine 75; liothyronine 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 9 0 / 0 pts The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: reassure the patient that these findings are normal. consider treatment with an angiotensin-converting enzyme inhibitor. prescribe a thiazide diuretic. Correct! counsel the patient about dietary and lifestyle changes. The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. Question 10 0 / 0 pts A patient reports fatigue, weight loss, and dry skin. The primary care nurse practitioner (NP) orders thyroid function tests. The patient’s thyroid stimulating hormone (TSH) is 40 microunits/mL, and T4 is 0.1 ng/mL. The NP should refer the patient to an endocrinologist and prescribe: liothyronine. methimazole. propylthiouracil. Correct! levothyroxine. This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a thyroid suppressant. Liothyronine is synthetic T3. Propylthiouracil is a thyroid suppressant. Question 11 0 / 0 pts A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1c is 7.3%. The NP should: Correct! begin insulin therapy. add a third oral antidiabetic agent to this patient’s drug regimen. change to therapy with colesevelam (Welchol). enroll the patient in a weight loss program to achieve better glycemic control. The target hemoglobin A1c goal for adults is less than 7%. Insulin therapy is indicated if maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the maximum recommended doses of metformin and glyburide. Colesevelam does not decrease hemoglobin A1c. Adding a third oral antidiabetic agent is not recommended. A weight loss program may be a part of this patient’s treatment, but insulin is necessary to maintain glycemic control. Question 12 0 / 0 pts 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: Correct! order electrolytes, ketones, and serum glucose. change metformin to glyburide. obtain LFTs. decrease the dose of metformin. Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should include electrolytes, ketones, and serum glucose. Question 13 0 / 0 pts A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to: Correct! verapamil HCl (Calan). isradipine (DynaCirc). amlodipine (Norvasc). short-acting nifedipine (Procardia). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. Question 14 0 / 0 pts A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient’s father developed coronary heart disease at age 55 years. The NP should prescribe: Correct! atorvastatin (Lipitor). gemfibrozil (Lopid). lovastatin/niacin (Advicor). cholestyramine (Questran). HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male first-degree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy. Question 15 0 / 0 pts 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). add gemfibrozil (Lopid) to the patient’s medication regimen. change atorvastatin to twice-daily dosing. Correct! order a creatine kinase-MM (CK-MM) level. 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 16 0 / 0 pts 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 0 / 0 pts An 80-year-old male patient will begin taking an α-antiadrenergic medication. The primary care NP should teach this patient to: be aware that priapism is a common side effect. restrict fluids to aid with diuresis. take the medication in the morning with food. Correct! 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 α-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. Question 18 0 / 0 pts A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to: give 325 mg of chewable aspirin. call EMS. obtain an electrocardiogram. Correct! administer oxygen at 2 L/minute. 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 19 0 / 0 pts A patient with Graves’ disease is taking methimazole. After 6 months of therapy, the primary care NP notes normal T3 and T4 and elevated TSH. The NP should: add levothyroxine to the patient’s regimen. order aspartate aminotransferase, AGT, and LDH tests. order a complete blood count (CBC) with differential. Correct! decrease the dose of the medication. Once clinical levels of thyrotoxicosis have been resolved, elevated TSH indicates a need to reduce the dosage. A CBC with differential is performed at the beginning of treatment and when signs of infection are present. Liver function tests may be monitored periodically but are not indicated by the current laboratory results. Levothyroxine is not indicated. Question 20 0 / 0 pts A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss: ordering renal function tests. evaluation of left ventricular function. increasing the dose of nifedipine. Correct! changing to amlodipine. Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms. Question 21 0 / 0 pts 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. Correct! check the TSH level in 1 week. reassure the patient that this will improve in several weeks. increase the dose to 100 mcg. 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 22 0 / 0 pts 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: colesevelam (Welchol). Correct! metformin (Glucophage). nateglinide (Starlix). glyburide (Micronase). Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been shown to decrease triglycerides and LDLs. Question 23 0 / 0 pts A patient who has stable angina pectoris and a history of previous myocardial infarction takes nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it is necessary to take verapamil. The NP should tell the patient that verapamil: has a positive inotropic effect to increase cardiac output. increases the force of contraction of the cardiac muscle. Correct! improves blood flow and oxygen delivery to the heart. increases the rate of contraction of the cardiac muscle. Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary resistance and improves blood flow through collateral vessels as well as oxygen delivery to ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of contraction of the heart. Question 24 0 / 0 pts A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed. The primary care nurse practitioner (NP) reviews this medication with the patient at the patient’s annual physical examination. Which statement by the patient indicates understanding of the medication? “I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1.” “I should take nitroglycerin and then rest for 15 minutes before taking the next dose.” “I should take aspirin along with the nitroglycerin when I have chest pain.” Correct! “I should call 9-1-1 if chest pain persists 5 minutes after the first dose.” Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses over 15 minutes before accessing emergency medical services (EMS), more recent guidelines suggest an alternative strategy to reduce delays in emergency care. These include instructions to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is recommended when the patient is being transported to emergency care and is not recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses of nitroglycerin are given 5 minutes apart over 15 minutes. Question 25 0 / 0 pts A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes. The patient brings a log of angina episodes to an annual physical examination. The primary care NP notes that the patient has experienced an increase in frequency of episodes in the past month but no increase in duration or severity of pain. The NP should: increase the nitroglycerin dose to 0.6 mg per dose. Correct! contact the patient’s cardiologist to discuss admission to the hospital. change from a sublingual to a transdermal patch nitroglycerin. discontinue the nitroglycerin and order ranolazine (Ranexa ER). Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or duration of pain and fewer precipitating factors. Patients with unstable angina should be admitted to a coronary care unit. The primary care NP should not change any medications without consultation with the patient’s cardiologist.