ANCC FNP review questions
Key Considerations in Pharmacotherapy and
Clinical Practice
1. Thiazide Diuretics
Special Considerations for Thiazides
Preferred Agent: Chlorthalidone is often favored due to its prolonged half-life and proven
efficacy in reducing cardiovascular disease (CVD) risk in clinical trials.
Monitoring:
o Crucially monitor for electrolyte imbalances:
Hyponatremia (low sodium)
Hypokalemia (low potassium)
o Regularly assess uric acid and calcium levels.
Gout: Exercise caution in patients with a history of acute gout, unless they are concurrently
receiving uric acid-lowering therapy.
2. Angiotensin-Converting Enzyme (ACE) Inhibitors
Special Considerations for ACE Inhibitors
Combination Therapy: Avoid using ACE inhibitors in combination with:
o Angiotensin Receptor Blockers (ARBs)
o Direct Renin Inhibitors
Hyperkalemia Risk: Increased risk of hyperkalemia (high potassium), particularly in:
o Patients with Chronic Kidney Disease (CKD)
o Individuals on potassium (K+) supplements or potassium-sparing drugs.
Renal Artery Stenosis: Risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Angioedema: Contraindicated in patients with a history of angioedema associated with previous
ACE inhibitor use.
Cough: ACE inhibitor cough is a common side effect, affecting 5-20% of patients, due to
increased bradykinin production.
Pregnancy: Strictly avoid in pregnant females or females of reproductive age without adequate
contraception due to the risk of fetal harm.
,3. Angiotensin Receptor Blockers (ARBs)
Special Considerations for Angiotensin Receptor Blockers
Combination Therapy: Avoid using ARBs in combination with:
o ACE inhibitors
o Direct Renin Inhibitors
Hyperkalemia Risk: Increased risk of hyperkalemia (high potassium) in:
o Patients with Chronic Kidney Disease (CKD)
o Individuals on potassium (K+) supplements or potassium-sparing drugs.
Renal Artery Stenosis: Risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Angioedema: Contraindicated in patients with a history of angioedema associated with ARB
use.
o Patients with a history of angioedema with an ACE inhibitor can typically receive an ARB
beginning 6 weeks after the ACE inhibitor is discontinued.
Pregnancy: Strictly avoid in pregnant females or females of reproductive age without adequate
contraception due to the risk of fetal harm.
Cough: Lower risk of cough compared to ACE inhibitors.
4. Calcium Channel Blockers (CCBs)
Special Considerations for Calcium Channel Blockers
Pedal Edema: Associated with dose-related pedal edema (swelling in the feet and ankles),
which is more prevalent in females than males.
5. Referral Guidelines for Hypertensive Patients
When to Refer to a Nephrologist or Cardiologist
Consider referral for hypertensive patients exhibiting any of the following:
Signs of end-organ damage.
Evidence of a secondary cause of hypertension (identifiable underlying condition).
Hypertension that remains uncontrolled despite being on one to two medications.
Generally, failure to achieve blood pressure goal in patients who are adhering to full doses
of an appropriate three to four drug regimen that includes a diuretic may warrant referral.
Prior to Referral: Review Potential Contributing Factors
,Before making a referral, clinicians should thoroughly review other potential causes of inadequate
hypertension control:
Improper blood pressure measurement technique.
White coat hypertension (elevated readings in a clinical setting).
Excess sodium intake in the diet.
Medication issues:
o Nonsteroidal anti-inflammatory drugs (NSAIDs)
o Illicit drugs
o Sympathomimetics (e.g., some decongestants)
o Oral contraceptives
Excess alcohol intake.
***Underlying identifiable causes of hypertension (secondary hypertension)***.
6. Research Study Design: Obesity Risk Factors
Case-Control Study
Study Design: The described study, where researchers compare a group with an outcome
(obesity - the cases) to a group without the outcome (non-obese - the controls) to assess prior
exposures (sedentary lifestyle, processed food consumption, family history), is best described as
a Case-control study.
Key Characteristics:
o Retrospective in nature (assessing past exposures).
o Subjects are selected based on outcome.
o Prior exposures are assessed and compared between groups.
Result Interpretation: The result of a case-control study is expressed as an ***odds ratio
(OR)***: $$\text{OR} = \frac{(\text{# exposed with disease / # exposed without
disease})}{(\text{# not exposed with disease / # not exposed without disease})}$$
Causation vs. Association: Case-control studies do not prove causation but demonstrate an
association between exposure and outcome.
Incorrect Answer Explanations:
A. Cross-sectional study: Assesses disease status and risk factors at one point in time.
B. Randomized controlled trial: Involves intervention (treatment) and comparison against a
control group.
C. Meta-analysis: A statistical analysis of the results of multiple independent studies.
7. Management of Hot Flashes in Breast Cancer Survivors
Pharmacological Treatment for Vasomotor Symptoms
, First-line non-pharmacological treatments (lifestyle changes) should always be attempted
first.
Best Treatment: For a patient with a history of breast cancer experiencing frequent hot flashes
unresponsive to lifestyle changes, the best pharmacological treatment is typically a ***Selective
Serotonin Reuptake Inhibitor (SSRI)***, such as Citalopram.
Citalopram: Has good evidence of efficacy against vasomotor symptoms and is generally well-
tolerated.
Incorrect Answer Explanations:
A. Hormonal therapy with estrogen and progesterone: Contraindicated in women with a
history of breast cancer due to the potential for increased risk of recurrence.
B. Bioidentical hormones: Not supported by evidence and hormone treatment is contraindicated
in this patient population. These are often compounded mixtures with unclear safety profiles.
D. Black cohosh: Has not been demonstrated to be consistently more effective than placebo and
may have potential estrogenic effects on breast tissue, which should be avoided in breast cancer
survivors.
8. Prevalence of Bulimia Nervosa in Female College Students
Epidemiology of Eating Disorders
Prevalence: Bulimia nervosa occurs in approximately 5% of female college students.
Gender Disparity: Female college students are 10 times more likely than male college students
to develop bulimia nervosa.
Anorexia Nervosa: The prevalence of anorexia nervosa is approximately 1.5% in teenage girls
overall.
9. Anabolic Steroid Use: Clinical Presentation
Signs and Symptoms of Anabolic Steroid Abuse
The 16-year-old male's presentation with worsening acne, rapid weight and muscle gain without
appearing overweight, mood swings and increased aggression, and lack of improvement in acne despite
conventional treatment raises suspicion for anabolic steroid use.
Consistent Findings with Anabolic Steroid Use:
Patient's sport (football) and desire to "bulk up" for a scholarship.
Difficulty in lifting his left arm above his head accompanied by pain (can be associated with
muscle imbalances and tendon issues related to rapid muscle growth).
Acne: Anabolic steroids can stimulate sebaceous glands, leading to or worsening acne.
Key Considerations in Pharmacotherapy and
Clinical Practice
1. Thiazide Diuretics
Special Considerations for Thiazides
Preferred Agent: Chlorthalidone is often favored due to its prolonged half-life and proven
efficacy in reducing cardiovascular disease (CVD) risk in clinical trials.
Monitoring:
o Crucially monitor for electrolyte imbalances:
Hyponatremia (low sodium)
Hypokalemia (low potassium)
o Regularly assess uric acid and calcium levels.
Gout: Exercise caution in patients with a history of acute gout, unless they are concurrently
receiving uric acid-lowering therapy.
2. Angiotensin-Converting Enzyme (ACE) Inhibitors
Special Considerations for ACE Inhibitors
Combination Therapy: Avoid using ACE inhibitors in combination with:
o Angiotensin Receptor Blockers (ARBs)
o Direct Renin Inhibitors
Hyperkalemia Risk: Increased risk of hyperkalemia (high potassium), particularly in:
o Patients with Chronic Kidney Disease (CKD)
o Individuals on potassium (K+) supplements or potassium-sparing drugs.
Renal Artery Stenosis: Risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Angioedema: Contraindicated in patients with a history of angioedema associated with previous
ACE inhibitor use.
Cough: ACE inhibitor cough is a common side effect, affecting 5-20% of patients, due to
increased bradykinin production.
Pregnancy: Strictly avoid in pregnant females or females of reproductive age without adequate
contraception due to the risk of fetal harm.
,3. Angiotensin Receptor Blockers (ARBs)
Special Considerations for Angiotensin Receptor Blockers
Combination Therapy: Avoid using ARBs in combination with:
o ACE inhibitors
o Direct Renin Inhibitors
Hyperkalemia Risk: Increased risk of hyperkalemia (high potassium) in:
o Patients with Chronic Kidney Disease (CKD)
o Individuals on potassium (K+) supplements or potassium-sparing drugs.
Renal Artery Stenosis: Risk of acute renal failure in patients with severe bilateral renal artery
stenosis.
Angioedema: Contraindicated in patients with a history of angioedema associated with ARB
use.
o Patients with a history of angioedema with an ACE inhibitor can typically receive an ARB
beginning 6 weeks after the ACE inhibitor is discontinued.
Pregnancy: Strictly avoid in pregnant females or females of reproductive age without adequate
contraception due to the risk of fetal harm.
Cough: Lower risk of cough compared to ACE inhibitors.
4. Calcium Channel Blockers (CCBs)
Special Considerations for Calcium Channel Blockers
Pedal Edema: Associated with dose-related pedal edema (swelling in the feet and ankles),
which is more prevalent in females than males.
5. Referral Guidelines for Hypertensive Patients
When to Refer to a Nephrologist or Cardiologist
Consider referral for hypertensive patients exhibiting any of the following:
Signs of end-organ damage.
Evidence of a secondary cause of hypertension (identifiable underlying condition).
Hypertension that remains uncontrolled despite being on one to two medications.
Generally, failure to achieve blood pressure goal in patients who are adhering to full doses
of an appropriate three to four drug regimen that includes a diuretic may warrant referral.
Prior to Referral: Review Potential Contributing Factors
,Before making a referral, clinicians should thoroughly review other potential causes of inadequate
hypertension control:
Improper blood pressure measurement technique.
White coat hypertension (elevated readings in a clinical setting).
Excess sodium intake in the diet.
Medication issues:
o Nonsteroidal anti-inflammatory drugs (NSAIDs)
o Illicit drugs
o Sympathomimetics (e.g., some decongestants)
o Oral contraceptives
Excess alcohol intake.
***Underlying identifiable causes of hypertension (secondary hypertension)***.
6. Research Study Design: Obesity Risk Factors
Case-Control Study
Study Design: The described study, where researchers compare a group with an outcome
(obesity - the cases) to a group without the outcome (non-obese - the controls) to assess prior
exposures (sedentary lifestyle, processed food consumption, family history), is best described as
a Case-control study.
Key Characteristics:
o Retrospective in nature (assessing past exposures).
o Subjects are selected based on outcome.
o Prior exposures are assessed and compared between groups.
Result Interpretation: The result of a case-control study is expressed as an ***odds ratio
(OR)***: $$\text{OR} = \frac{(\text{# exposed with disease / # exposed without
disease})}{(\text{# not exposed with disease / # not exposed without disease})}$$
Causation vs. Association: Case-control studies do not prove causation but demonstrate an
association between exposure and outcome.
Incorrect Answer Explanations:
A. Cross-sectional study: Assesses disease status and risk factors at one point in time.
B. Randomized controlled trial: Involves intervention (treatment) and comparison against a
control group.
C. Meta-analysis: A statistical analysis of the results of multiple independent studies.
7. Management of Hot Flashes in Breast Cancer Survivors
Pharmacological Treatment for Vasomotor Symptoms
, First-line non-pharmacological treatments (lifestyle changes) should always be attempted
first.
Best Treatment: For a patient with a history of breast cancer experiencing frequent hot flashes
unresponsive to lifestyle changes, the best pharmacological treatment is typically a ***Selective
Serotonin Reuptake Inhibitor (SSRI)***, such as Citalopram.
Citalopram: Has good evidence of efficacy against vasomotor symptoms and is generally well-
tolerated.
Incorrect Answer Explanations:
A. Hormonal therapy with estrogen and progesterone: Contraindicated in women with a
history of breast cancer due to the potential for increased risk of recurrence.
B. Bioidentical hormones: Not supported by evidence and hormone treatment is contraindicated
in this patient population. These are often compounded mixtures with unclear safety profiles.
D. Black cohosh: Has not been demonstrated to be consistently more effective than placebo and
may have potential estrogenic effects on breast tissue, which should be avoided in breast cancer
survivors.
8. Prevalence of Bulimia Nervosa in Female College Students
Epidemiology of Eating Disorders
Prevalence: Bulimia nervosa occurs in approximately 5% of female college students.
Gender Disparity: Female college students are 10 times more likely than male college students
to develop bulimia nervosa.
Anorexia Nervosa: The prevalence of anorexia nervosa is approximately 1.5% in teenage girls
overall.
9. Anabolic Steroid Use: Clinical Presentation
Signs and Symptoms of Anabolic Steroid Abuse
The 16-year-old male's presentation with worsening acne, rapid weight and muscle gain without
appearing overweight, mood swings and increased aggression, and lack of improvement in acne despite
conventional treatment raises suspicion for anabolic steroid use.
Consistent Findings with Anabolic Steroid Use:
Patient's sport (football) and desire to "bulk up" for a scholarship.
Difficulty in lifting his left arm above his head accompanied by pain (can be associated with
muscle imbalances and tendon issues related to rapid muscle growth).
Acne: Anabolic steroids can stimulate sebaceous glands, leading to or worsening acne.
