Drugs Used in Treating Inflammatory Processes Quiz: NURS 3310 - Hunter College - CUNY | Already Graded A.

Drugs Used in Treating Inflammatory Processes Quiz Q&A + Rationales 100% Graded A+. Question 1. Which finding is consistent with adrenal insufficiency? 1.Hypokalemia in 2.Hypernatremia 3.Hypotension 4.Hyperthermia Rationales Option 1:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hyperkalemia rather than hypokalemia. Option 2:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hyponatremia rather than hypernatremia. Option 3:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hypotension due to decreased fluid volume. Option 4:Adrenal insufficiency may potentially cause hypothermia during times of stress but returns to normal once hormones are replaced and stressors are removed. Question 2. A mother who is breastfeeding asks which medication she can safely take for headaches. Which drug is the drug of choice for this patient? 1.Ibuprofen 2.Naproxen 3.Ketorolac 4.Diclofenac Rationales Option 1:Of the NSAIDs, ibuprofen is the safest during breastfeeding. At doses of 400 mg bid and 400 mg every 6 hours, ibuprofen is not detected in breast milk. Option 2:Naproxen should be avoided due to its long duration of action and potential for harm to the neonate. Option 3:Ketorolac has been detected in breast milk. Option 4:Diclofenac is not the safest during breastfeeding. Question 3. Which pain reliever has the lowest anti-inflammatory effect? 1.A corticosteroid 2.An NSAID 3.Aspirin 4.Acetaminophen Rationales Option 1:Corticosteroids, specifically glucocorticoids, inhibit the inflammatory systems by depressing proliferation of T lymphocytes, decreasing natural killer cell activity, reversing macrophage activity, and suppressing the synthesis, secretion, and actions of chemical mediators involved in inflammatory responses. Option 2:The major mechanism in which NSAIDs decrease inflammation is thought to be by inhibition of the cyclo-oxygenase activity and prostaglandin synthesis. Option 3:Aspirin more potently inhibits prostaglandin synthesis and has a greater antiinflammatory activity than the NSAIDs. Option 4:Acetaminophen, although not an anti-inflammatory drug by chemistry, is often used to treat pain and fever. It is an analgesic and antipyretic with limited anti-inflammatory activity. Question 4. Which patient would be an ideal candidate for corticosteroid therapy? 1.A patient recently diagnosed with cellulitis of the lower extremity 2.A patient with chronic, active hepatitis C 3.A patient recently diagnosed with type II diabetes mellitus 4.A patient with acute heart failure Rationales Option 1:Corticosteroid therapy is contraindicated in the presence of active, untreated infection because it may mask the indications of infection, and new infections may appear during its use. Option 2:Use of corticosteroid therapy has been advocated for in patients with chronic active hepatitis; however, it may be harmful in hepatitis patients positive for hepatitis B surface antigen. Option 3:In patients with diabetes mellitus, corticosteroids may alter the liverâ??s glucose regulation, resulting in difficulty with maintenance of glycemic control. Option 4:Corticosteroids, especially those with high relative mineralocorticoid potency, can cause elevated blood pressure, salt and water retention, and increased excretion of potassium, rendering them problematic for patients with hypertension and cardiovascular disorders, such as heart failure. Question 5. Benzyl alcohol, an additive sometimes used in corticosteroid preparations, has been associated with which symptom in infants? 1.Short stature 2.Gasping syndrome 3.Cleft palate 4.Hypoaldosteronism Rationales Option 1:Short stature is a potential side effect of corticosteroid therapy but not a specific side effect of benzyl alcohol. Option 2:Benzyl alcohol, an additive sometimes used in corticosteroid preparations, has been associated with a fatal "gasping syndrome" in infants. Option 3:Cleft palate is a potential side effect of corticosteroid therapy (if taken during pregnancy) but not a specific side effect of benzyl alcohol. Option 4:Hypoaldosteronism is a potential side effect of corticosteroid therapy (if taken during pregnancy) but not a specific side effect of benzyl alcohol. Question 6. Which laboratory finding is consistent with long-term corticosteroid therapy? 1.Increased serum calcium levels 2.Increased serum phosphorus levels 3.Decreased serum sodium levels 4.Decreased serum potassium levels Rationales Option 1:All corticosteroids increase calcium excretion, which leads to decreased serum calcium levels and creates problems for postmenopausal women and others at risk for osteoporosis. Option 2:Glucocorticoids decrease serum calcium levels, possibly by inhibiting gastrointestinal (GI) absorption of calcium and phosphate. Option 3:Average and large doses of drugs with high relative mineralocorticoid potency (e.g., cortisone and hydrocortisone) can cause salt and water retention, leading to increased serum sodium levels. Sodium restriction may be necessary. Option 4:Average and large doses of drugs with high relative mineralocorticoid potency (e.g., cortisone and hydrocortisone) can cause increased excretion of potassium, leading to decreased serum potassium levels. Potassium supplementation may be necessary. Question 7. When prescribing NSAIDs, how would the APN advise the patient to achieve optimal pain control? 1.Take the drug with food. 2.Take the drug only when pain is present. 3.Take the drug around the clock. 4.Take the drug at its highest dose. Rationales Option 1:Taking NSAIDs with food may assist with gastrointestinal (GI) adverse effects and may slow absorption, which may prevent optimal pain control. Option 2:Taking NSAIDs for mild to moderate pain around the clock, rather than as necessary, is most effective. Option 3:Taking NSAIDs for mild to moderate pain around the clock, rather than as necessary, is most effective. Option 4:Taking NSAIDs at their highest dose may exacerbate adverse reactions. Patients should take the lowest effective dose possible to decrease risk for adverse reactions. Question 8. Relief of inflammation that causes increased intracranial pressure is best achieved with which drug? 1.Methylprednisolone 2.Triamcinolone 3.Betamethasone 4.Dexamethasone Rationales Option 1:Methylprednisolone is used as an anti-inflammatory; however, it does have some mineralocorticoid activity that can increase blood pressure and in turn increase intracranial pressure, making it a less ideal choice for patients with increased intracranial pressure. Option 2:Triamcinolone is used as an anti-inflammatory; however, it does have some mineralocorticoid activity that can increase blood pressure and in turn increase intracranial pressure, making it a less ideal choice for patients with increased intracranial pressure. Option 3:Betamethasone is used as an anti-inflammatory and is four to five times more potent than the other corticosteroids; however, it does have some mineralocorticoid activity that can increase blood pressure and in turn increase intracranial pressure, making it a less ideal choice for patients with increased intracranial pressure. Option 4:Dexamethasone is the drug of choice for inflammation that causes increased intracranial pressure because it has extremely low mineralocorticoid activity and limited effects on blood pressure, thus minimizing the risk for inadvertently increasing intracranial pressure. Question 9. Which dose of salicylates is acutely lethal in children? 1.3 gm 2.6 gm 3.10 gm 4.30 gm Rationales Option 1:The acute lethal dose of salicylates in adults is 10 to 30 grams, and in children it is 3 gm. Option 2:The acute lethal dose of salicylates in adults is 10 to 30 grams, and in children it is less than 6 gm. Option 3:The acute lethal dose of salicylates in adults is 10 to 30 grams, and in children it is less than 10 gm. Option 4:The acute lethal dose of salicylates in adults is 10 to 30 grams, and in children it is less than 30 gm. Question 10. Patients with elevated salicylate levels should be advised to avoid which spice? 1.Salt 2.Thyme 3.Paprika 4.Cumin Rationales Option 1:Foods and spices high in salicylate should be avoided in patients with elevated salicylate levels. Salt does not have a high salicylate level. Option 2:Foods and spices high in salicylate should be avoided in patients with elevated salicylate levels. Thyme does not have a high salicylate level. Option 3:Foods and spices high in salicylate include curry, paprika, licorice, Benedictine liqueur, prunes, raisins, tea, and gherkins. These should be avoided in patients with elevated salicylate levels. Option 4:Foods and spices high in salicylate should be avoided in patients with elevated salicylate levels. Cumin does not have a high salicylate level. Question 11. Glucocorticoids increase blood glucose by which mechanism of action? 1.Simulating gluconeogenesis in the liver 2.Increasing uptake of glucose into adipose cells 3.Stimulating protein catabolism in the muscle 4.Increasing uptake of amino acids into hepatic cells Rationales Option 1:Glucocorticoids increase blood glucose concentration by stimulating gluconeogenesis in the liver (synthesis of glucose from nonhexose substrates, such as amino acids and lipids) and by decreasing uptake of glucose into muscle, lymphatic, and adipose cells. Option 2:Glucocorticoids increase blood glucose concentration by decreasing (not increasing) uptake of glucose into muscle, lymphatic, and adipose cells (a mechanism to conserve glucose). Option 3:Glucocorticoids stimulate protein catabolism and may result in muscle atrophy. This protein catabolism does not affect blood glucose. Option 4:Glucocorticoids inhibit, rather than increase, uptake of amino acids into hepatic cells. These amino acids serve as substrates for gluconeogenesis but do not directly increase blood glucose. Question 12. A lower dose of corticosteroid therapy may be needed in patients taking which drug(s)? 1.Oral contraceptives 2.Antiepileptic drugs 3.Ephedrine 4.Rifampin Rationales Option 1:Oral contraceptives decrease the metabolism of corticosteroids, resulting in increased levels in the blood, which may necessitate a lower dose. Option 2:Antiepileptic drugs (specifically phenobarbital and phenytoin) may increase the metabolism of corticosteroids, resulting in reduced levels in the blood, which may necessitate a higher (not lower) dose. Option 3:Ephedrine may increase the metabolism of corticosteroids, resulting in reduced levels in the blood, which may necessitate a higher (not lower) dose. Option 4:Rifampin may increase the metabolism of corticosteroids, resulting in reduced levels in the blood, which may necessitate a higher (not lower) dose. Question 13. Which advantage does aspirin have in treatment of rheumatoid arthritis compared with nonacetylated salicylates? 1.The low incidence of gastrointestinal (GI) intolerance 2.The convenience of taking it only once or twice daily 3.The potent anti-inflammatory effect 4.The short interval in which the drug becomes effective Rationales Option 1:The high incidence (not low incidence) of GI intolerance with aspirin is a main disadvantage. Option 2:The inconvenience of taking four or five daily doses is a main disadvantage of aspirin. Option 3:An advantage to using aspirin is its potent anti-inflammatory effect. Nonacetylated salicylates are less potent anti-inflammatory agents, but they have fewer adverse reactions than aspirin. Option 4:The relatively long (not short) interval (4 to 7 days) before a full anti-inflammatory effect is reached is a main disadvantage of aspirin. Question 14. When oral corticosteroid therapy is required during pregnancy, which of these is the drug of choice? 1.Prednisone 2.Dexamethasone 3.Triamcinolone 4.Hydrocortisone Rationales Option 1:Corticosteroids cross the placenta (prednisone has the slowest transport rate) and may be used cautiously when needed in pregnancy. Option 2:Prednisone has the slowest transport rate and should be the drug of choice if needed during pregnancy. Option 3:Prednisone has the slowest transport rate and should be the drug of choice if needed during pregnancy. Option 4:Prednisone has the slowest transport rate and should be the drug of choice if needed during pregnancy. Question 15. A 68-year-old patient presents for treatment complaining of a rheumatoid arthritis flare-up. His medical history involves rheumatoid arthritis, gout, and depression. Which drug is most appropriate for controlling inflammation in this patient? 1.Ketorolac 2.Indomethacin 3.Nabumetone 4.Aspirin Rationales Option 1:Ketorolac will assist with the inflammation; however, it is cleared more slowly in older adults, making it a less desirable choice in this patient. Option 2:Indomethacin will assist with the inflammation; however, it may aggravate depression or other psychiatric disturbances, so a different NSAID should be chosen based on the patient's history of depression. Option 3:Nabumetone will assist with the inflammation and has shown no difference in overall efficacy and safety between older adults and younger patients, making it the most appropriate choice for this patient. Option 4:Aspirin will assist with the inflammation; however, in low doses it decreases urate excretion and raises serum uric acid levels, increasing this patient's risk for a gout exacerbation, and thus making it a less desirable choice in this patient. Question 16. A patient on aspirin therapy calls the office complaining of impaired hearing. Which information is most appropriate for the APN to provide? 1.The impaired hearing is permanent, and he should continue taking his aspirin as prescribed. 2.The impaired hearing is permanent, and he should discontinue the aspirin immediately to avoid other complications. 3.The impaired hearing loss is temporary, and he should continue taking his aspirin as prescribed. 4.The impaired hearing loss is temporary, and he should discontinue the aspirin immediately to avoid other complications. Rationales Option 1:Salicylates, such as aspirin, are ototoxic at increased blood levels. They should be discontinued (not continued) if dizziness, tinnitus, or impaired hearing develops. The hearing loss is temporary (not permanent) and will resolve gradually once the drug is stopped. Option 2:Salicylates, such as aspirin, are ototoxic at increased blood levels. The hearing loss is temporary (not permanent) and will resolve gradually once the drug is stopped. Option 3:Salicylates, such as aspirin, are ototoxic at increased blood levels. They should be discontinued (not continued) if dizziness, tinnitus, or impaired hearing develops. Option 4:Salicylates, such as aspirin, are ototoxic at increased blood levels. They should be discontinued if dizziness, tinnitus, or impaired hearing develops. The hearing loss is temporary and will resolve gradually once the drug is stopped. Question 17. If rapid analgesia is desired, which NSAID is most appropriate for the APN to prescribe? 1.Acetaminophen (Tylenol) 2.Naproxen sodium (Naprosyn) 3.Diclofenac sodium (Voltaren) 4.Rofecoxib (Vioxx) Rationales Option 1:Acetaminophen (Tylenol) does have analgesic properties; however, it is not considered an NSAID. Option 2:Naproxen sodium (Naprosyn) is a rapidly absorbed NSAID and is used when rapid analgesia is desired. Option 3:Diclofenac sodium (Voltaren) is released in the higher pH environment of the duodenum and takes more time to effect than many of the other NSAIDs. Option 4:Rofecoxib (Vioxx) was voluntarily removed from the market in 2004 and is no longer available. Question 18. In patients with elevated liver enzymes who are receiving corticosteroid therapy for post-transplant immunosuppression, which of these is the drug of choice? 1.Prednisolone 2.Cortisone 3.Betamethasone 4.Dexamethasone Rationales Option 1:Prednisolone, the active hepatic metabolite of prednisone, is used for post-transplant immunosuppression in patients with hepatic dysfunction. Option 2:Cortisone is used for post-transplant immunosuppression; however, the liver must convert it to its clinically active metabolite prior to clearance, making it a less ideal option for patients with hepatic dysfunction. Option 3:Betamethasone is used for post-transplant immunosuppression; however, the liver must convert it to its clinically active metabolite prior to clearance, making it a less ideal option for patients with hepatic dysfunction. Option 4:Dexamethasone is used for post-transplant immunosuppression; however, the liver must convert it to its clinically active metabolite prior to clearance, making it a less ideal option for patients with hepatic dysfunction. Question 19. Gastrointestinal adverse reactions from NSAIDs are caused by inhibition of which action? 1.Leukotriene synthesis 2.Cyclooxygenase activity 3.Neutrophil aggregation 4.Lysosomal enzyme release Rationales Option 1:NSAIDs inhibit leukotriene synthesis, cyclo-oxygenase activity, neutrophil aggregation, and lysosomal enzyme release. However, the inhibition of leukotriene synthesis does not result in gastrointestinal (GI) adverse effects. Option 2:NSAIDs inhibit leukotriene synthesis, cyclooxygenase activity, neutrophil aggregation, and lysosomal enzyme release. However, it is the inhibition of cyclo-oxygenase activity (more specifically COX-1 as opposed to COX-2), which results in gastrointestinal (GI) adverse effects. COX-1 has a large role in gastric acid secretion and production or protective mucous, especially in the stomach. COX-2 does have some synthesis in the GI tract. Option 3:NSAIDs inhibit leukotriene synthesis, cyclo-oxygenase activity, neutrophil aggregation, and lysosomal enzyme release. However, the inhibition of neutrophil aggregation does not result in gastrointestinal (GI) adverse effects. Option 4:NSAIDs inhibit leukotriene synthesis, cyclo-oxygenase activity, neutrophil aggregation, and lysosomal enzyme release. However, the inhibition of lysosomal enzyme release does not result in gastrointestinal (GI) adverse effects. Question 20. Initial control of inflammation caused by rheumatoid arthritis (RA) is best achieved by using which category of drugs? 1.Disease-modifying antirheumatic drugs (DMARDs) 2.Anti-tumor necrosis factor (anti-TNF) drugs 3.Non-tumor necrosis factor (non-TNF) drugs 4.Oral glucocorticoid drugs Rationales Option 1:DMARDs are used for treatment of RA but may take weeks to months for time to effect, rendering the need for oral glucocorticoids to treat initial acute inflammation. Option 2:Anti-TNF drugs are used for treatment of RA but may take weeks to months for time to effect, rendering the need for oral glucocorticoids to treat initial acute inflammation. Option 3:Non-TNF drugs are used for treatment of RA but may take weeks to months for time to effect rendering the need for oral glucocorticoids to treat initial acute inflammation. Option 4:Oral glucocorticoids are prescribed for moderate to severe RA to gain initial control of inflammation while awaiting response to other agents (disease-modifying antirheumatic drugs [DMARDs], anti-tumor necrosis factor [anti-TNF] drugs, non-tumor necrosis factor [non-TNF] drugs). Question 1. Which main benefit belongs to nonacetylated salicylates as opposed to aspirin? 1.They have fewer gastrointestinal (GI) side effects. 2.Their full anti-inflammatory effect develops rapidly. 3.They are less expensive. 4.They are available for use via intramuscular (IM) route. Rationales Option 1:The main benefit of nonacetylated salicylates as opposed to aspirin is that they have fewer GI side effects. Option 2:The full anti-inflammatory effect of nonacetylated salicylates may take as long as 2 weeks to occur. Option 3:Nonacetylated salicylates are more expensive than aspirin; however, cost may be similar to that of NSAIDs. Option 4:Currently nonacetylated salicylates are available in oral form (not IM). Question 2. A patient with suspected acetaminophen overdose arrives at the emergency department (ED). Serum levels indicate 100 mg/mL. Which treatment option should the APN prescribe? 1.Administer intravenous N-acetylcysteine. 2.Administer dialysis. 3.Initiate seizure precautions. 4.Use supportive care. Rationales Option 1:Oral or intravenous N-acetylcysteine is a specific antidote for acetaminophen toxicity. Option 2:Hepatic damage can occur from a level below 120 mg/mL. There are insufficient clinical data to support dialysis at this time. Option 3:Seizures are not typically seen with acetaminophen overdose. Option 4:Supportive care should be ensured for all patients with acetaminophen overdose; however, it is not the priority. Question 3. Which patient is an inappropriate candidate for analgesia with acetaminophen? 1.A patient with a history of renal stones 2.A patient with a history of psychosis 3.A patient who reports drinking five alcoholic drinks per night 4.A patient who reports smoking one pack of cigarettes per day Rationales Option 1:A history of renal stones does not disqualify a patient for analgesia with acetaminophen. Acetaminophen might be a superior analgesia choice over NSAIDs in patients with renal impairment because it is a relative contraindication for a select few NSAIDs (ketorolac, mefenamic acid, flurbiprofen, and nabumetone). Option 2:A history of psychosis does not disqualify a patient for analgesia with acetaminophen. In these patients, analgesia with acetaminophen might be superior to use of glucocorticoids because they are at risk for steroid psychosis. Option 3:In a patient who reports drinking five alcoholic drinks per night, the clinician should be suspicious of alcoholism and consider an alternative to acetaminophen. For patients with chronic alcoholism, no safe dose has been determined, and acetaminophen should not be used for these patients. Option 4:Smoking does not disqualify a patient for analgesia with acetaminophen. Question 4. Which of these is the earliest sign of salicylate toxicity? 1.Tinnitus 2.Vomiting 3.Tarry stools 4.Dizziness Rationales Option 1:The earliest manifestation of salicylate toxicity is tinnitus or mild deafness. Option 2:Vomiting is associated with salicylate toxicity but occurs later. Option 3:Tarry stools occur as an adverse effect rather than as a sign of toxicity (although it could be a later sign). Option 4:Dizziness is associated with salicylate toxicity but occurs later. Question 5. When advising a mother on treatment of fever in a 3-month-old, the APN should recommend which medication? 1.Ibuprofen 2.Acetaminophen 3.Aspirin 4.Naproxen Rationales Option 1:Ibuprofen is the NSAID of choice for fever in children older than 6 months and adults. Option 2:Acetaminophen is used for children younger than 6 months and patients who do not tolerate ibuprofen. Option 3:Aspirin should not be used in children with acute febrile illness due to risk of Reye syndrome. Additionally, children with dehydration appear more at risk for salicylate toxicity. Option 4:Naproxen is not indicated for treatment of fever nor is it approved for use in infants. Question 6. Use of magnesium salicylates is contraindicated with which laboratory values? 1.Elevated liver enzymes 2.Elevated blood urea nitrogen (BUN) and creatinine 3.Decreased prothrombin time (PT) and partial thromboplastin time (PTT) 4.Decreased urinary pH Rationales Option 1:Liver dysfunction (i.e., elevated liver enzymes) is not a contraindication; however, because salicylates are metabolized in the liver, dosing may need to be adjusted. Option 2:Magnesium salicylates are contraindicated in the presence of renal insufficiency because they cannot eliminate the magnesium, and hypermagnesemia results. Option 3:Decreased PT and PTT are not contraindications for magnesium salicylate therapy. Alternatives may need to be considered if the PT and PTT are increased. Option 4:Decreased urinary pH is not a contraindication for magnesium salicylate therapy but may result in slower excretion of the drug, so lowering the dose might be considered in this patient population. Question 7. Which dose of aspirin is recommended for primary prevention of cardiovascular disease in a 55-year-old patient? 1.75 to 100 mg daily 2.75 to 100 mg twice daily 3.325 mg daily 4.325 mg twice daily Rationales Option 1:The American College of Chest Physicians Guidelines for Primary and Secondary Prevention of Cardiovascular Disease recommend low-dose aspirin (75 to 100 mg daily) in patients (ages 40 to 59 with a risk factor of 10% or higher) with established coronary artery disease, patients with coronary stenosis greater than 50%, and those with evidence of cardiac ischemia. Option 2:The American College of Chest Physicians Guidelines for Primary and Secondary Prevention of Cardiovascular Disease recommend low-dose aspirin (75 to 100 mg daily, not twice daily) in patients (ages 40 to 59 with a risk factor of 10% or higher) with established coronary artery disease, patients with coronary stenosis greater than 50%, and those with evidence of cardiac ischemia. Option 3:325 mg is too high for prevention of cardiovascular disease but could be used to treat acute pain, inflammation, or fever. Option 4:325 mg twice daily is too high for prevention of cardiovascular disease but could be used to treat acute pain, inflammation, or fever. Question 8. A patient who is on a regimen of indomethacin (Indocin) 25 mg twice daily calls the office because he missed his morning dose. Which advice would be most appropriate for the APN to provide? 1."Do not take the regularly scheduled morning dose and take the regularly scheduled evening dose." 2."Do not take the regularly scheduled morning dose and double the regularly scheduled evening dose." 3."Take the morning dose as soon as possible and take the regularly scheduled evening dose." 4."Double the morning dose and take as soon as possible, but do not take the regularly scheduled evening dose." Rationales Option 1:A missed dose should be taken as soon as the patient remembers unless it is almost time for the next dose. Option 2:Drugs should be taken exactly as prescribed. Doses should not be doubled. Option 3:Drugs should be taken exactly as prescribed. A missed dose should be taken as soon as the patient remembers unless it is almost time for the next dose. For drugs taken more than once daily, ideally the missed dose should be taken within 1 to 2 hours of the time it was scheduled. Doses should not be doubled. Option 4:Drugs should be taken exactly as prescribed. Doses should not be doubled. Question 9. Which NSAID is the most appropriate choice for a patient who is actively vomiting? 1.Naproxen sodium (Naprosyn) 2.Diclofenac potassium (Cataflam) 3.Meloxicam (Mobic) 4.Ketorolac (Toradol) Rationales Option 1:Naproxen sodium (Naprosyn) is available only via oral route and would not be a good option for a patient who is actively vomiting. Option 2:Diclofenac potassium (Cataflam) is available only via oral route and would not be a good option for a patient who is actively vomiting. Option 3:Meloxicam (Mobic) is available only via oral route and would not be a good option for a patient who is actively vomiting. Option 4:Ketorolac (Toradol) is the only NSAID available in an intramuscular route, making it the best option for a patient who is actively vomiting. Question 10. In which patient would adrenal insufficiency be most suspected? 1.A patient who presents with complaints of weakness and fatigue and has a blood pressure of 184/96 mm Hg 2.A patient who presents with complaints of nausea and shortness of breath and has a blood pressure of 84/52 mm Hg 3.A patient who presents with complaints of increased appetite and nervousness with a blood sugar of 62 mg/dL 4.A patient who presents with complaints of anorexia and weakness with a blood sugar of 432 mg/dL Rationales Option 1:Signs of adrenal insufficiency include anorexia, nausea, weakness, fatigue, dyspnea, hypotension, and hypoglycemia. This patient has weakness and fatigue, which are consistent with adrenal insufficiency; however, the elevated blood pressure is not consistent with this diagnosis. Option 2:Signs of adrenal insufficiency include anorexia, nausea, weakness, fatigue, dyspnea, hypotension, and hypoglycemia. This patient has nausea, dyspnea, and hypotension, all of which are consistent with adrenal insufficiency. Option 3:Signs of adrenal insufficiency include anorexia, nausea, weakness, fatigue, dyspnea, hypotension, and hypoglycemia. This patient has hypoglycemia, which is consistent with adrenal insufficiency; however, the increased appetite and nervousness are not consistent with this diagnosis. Option 4:Signs of adrenal insufficiency include anorexia, nausea, weakness, fatigue, dyspnea, hypotension, and hypoglycemia. This patient has anorexia and weakness, which are consistent with adrenal insufficiency; however, the elevated blood sugar is not consistent with this diagnosis. Question 11. Although indomethacin is not approved for use in children, it has shown clinical benefit for which condition in neonates? 1.Patent ductus arteriosus 2.Coarctation of the aorta 3.Tetralogy of Fallot 4.Hypoplastic left heart syndrome Rationales Option 1:Indomethacin is not approved for use in children younger than 14 years, although it is used in neonates to close a patent ductus arteriosus. Option 2:Indomethacin is not used to treat coarctation of the aorta. Treatment is with surgery or balloon angioplasty. Option 3:Indomethacin is not used to treat tetralogy of Fallot. Treatment is with surgery that involves widening or replacing the pulmonary valve and patching the ventricular septal defect. Option 4:Indomethacin is not used to treat hypoplastic left heart syndrome. Treatment involves use of medications (not indomethacin) to strengthen the heart, high caloric intake to assist with failure to thrive, and several surgeries. Question 12. In patients on salicylate therapy, which foods might result in increased serum levels? 1.Plums and peas 2.Cheese and fish 3.Chocolate and beef 4.Prunes and milk Rationales Option 1:All fruits (except cranberries), prunes, plums, all vegetables, and milk alkalinize the urine, which increases excretion of salicylate, resulting in decreased serum levels rather than increased. Option 2:Cheeses, cranberries, eggs, fish, grains, meats, plums, poultry, and prunes acidify the urine, which decreases excretion of salicylate, resulting in increased serum levels. Option 3:Chocolate and beef do not appear to affect the pH of the urine and thus do not affect the excretion and serum levels of salicylates. Option 4:All fruits (except cranberries), prunes, plums, all vegetables, and milk alkalinize the urine, which increases excretion of salicylate, resulting in decreased serum levels rather than increased. Question 13. How frequently should older adults on corticosteroid therapy have their blood glucose and electrolyte levels checked? in 1.Every month 2.Every 6 months 3.Every 12 months 4.Every 24 months Rationales Option 1:Checking blood glucose and electrolyte levels every month is too frequent. Option 2:Older adults on corticosteroid therapy should have their blood glucose and electrolyte levels checked every 6 months. Option 3:Checking blood glucose and electrolyte levels every 12 months is too infrequent. Option 4:Checking blood glucose and electrolyte levels every 24 months is too infrequent. Question 14. Before initiation of long-term NSAID therapy, the APN reviews a patient's laboratory values and notes that the hemoglobin is 9 g/dL and the hematocrit is 34%. Which action is most appropriate? 1.These are extremely low values, and NSAID therapy should not be initiated. A blood transfusion should be ordered. 2.These are low values, and NSAID therapy should not be initiated. Initiate iron supplementation. 3.These are extremely low values. Initiate NSAID therapy and monitor values throughout treatment. 4.These are normal values, and nothing further needs to occur. Initiate NSAID therapy. Rationales Option 1:These values, although low, are not a contraindication for initiation of NSAID therapy. They also do not require a blood transfusion. Option 2:These values, although low, are not a contraindication for initiation of NSAID therapy. Iron supplementation may be warranted. Option 3:These values are low, and in patients with initial hemoglobin levels below 10 g/dL who are to receive long-term therapy, values should be monitored throughout treatment. Option 4:These values are not normal. NSAID therapy may be initiated, but if hemoglobin levels are below 10 g/dL, values should be monitored throughout treatment. Question 15. Which finding is consistent with adrenal insufficiency? 1.Hypokalemia 2.Hypernatremia 3.Hypotension 4.Hyperthermia Rationales Option 1:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hyperkalemia rather than hypokalemia. Option 2:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hyponatremia rather than hypernatremia. Option 3:Mineralocorticoids (predominantly aldosterone) are secreted by the adrenal cortex. The main role is to retain sodium and water and excrete potassium. Thus, adrenal insufficiency could potentially result in hypotension due to decreased fluid volume. Option 4:Adrenal insufficiency may potentially cause hypothermia during times of stress but returns to normal once hormones are replaced and stressors are removed. Question 16. Which salicylate is preferred for inhibition of platelet aggregation? 1.Aspirin 2.Salsalate 3.Choline magnesium trisalicylate 4.Choline salicylate Rationales Option 1:Aspirin irreversibly inhibits platelet aggregation, making it the drug of choice. The nonacetylated salicylates (salsalate [Disalcid], choline magnesium trisalicylate [Arthropan], diflunisal [Dolobid]) are salicylic acid derivatives not metabolized to salicylic acid, are not as potent as aspirin, and do not have the same degree of antiplatelet activity. Option 2:The nonacetylated salicylates, such as salsalate (Disalcid), are salicylic acid derivatives not metabolized to salicylic acid, are not as potent as the drug of choice, and do not have the same degree of antiplatelet activity. Option 3:The nonacetylated salicylates, such as choline magnesium trisalicylate (Arthropan), are salicylic acid derivatives not metabolized to salicylic acid, are not as potent as the drug of choice, and do not have the same degree of antiplatelet activity. Option 4:The nonacetylated salicylates, such as diflunisal (Dolobid), are salicylic acid derivatives not metabolized to salicylic acid, are not as potent as the drug of choice, and do not have the same degree of antiplatelet activity. Question 17. A 35-year-old patient has been taking a trial regimen of 3 g of aspirin daily for 6 days. She has no complaints of adverse effects but states she does not feel like it has helped with the inflammation. Her salicylate level is 15 mg/dL. Her plan of care should include which next step? 1.Discontinuing the aspirin because it does not appear to be effective in 2.Continuing the aspirin at the same dose and reevaluating her response in 1 week 3.Increasing the dose of aspirin to 650 mg per day and reevaluating her response in 1 week 4.Adding 600 mg per day of ibuprofen to the current aspirin therapy and reevaluating her response in 1 week Rationales Option 1:With all patients, a therapy trial of 3 to 4 g per day for 4 to 6 days is recommended (2 to 3 g per day in older adults). If the response and adherence have been good, a salicylate level should be drawn before discontinuing and/or changing the drug. This patient's drug level is not within therapeutic parameters (20 to 25 mg/dL in adults; 15 to 20 mg/dL in older adults) and the patient tolerates the aspirin, so it should not be discontinued. Option 2:With all patients a therapy trial of 3 to 4 g per day for 4 to 6 days is recommended (2 to 3 g per day in older adults). If the response and adherence have been good, a salicylate level should be drawn before discontinuing and/or changing the drug. The patient's drug level is not within therapeutic parameters (20 to 25 mg/dL in adults; 15 to 20 mg/dL in older adults) and the patient tolerates the aspirin, so the dose should not be continued at the same level. Option 3:With all patients, a therapy trial of 3 to 4 g per day for 4 to 6 days is recommended (2 to 3 g per day in older adults). If the response and adherence have been good, a salicylate level should be drawn before discontinuing and/or changing the drug. If the drug level is not within therapeutic parameters (20 to 25 mg/dL in adults; 15 to 20 mg/dL in older adults) and the patient tolerates the aspirin, the dose should be increased by 325 mg to 650 mg until the desired anti-inflammatory effect is achieved. Option 4:Adding ibuprofen will only increase the patient's risk for gastrointestinal (GI) adverse effects. Question 18. When tapering a patient off a 60-mg dose of prednisone, which regimen is most appropriate? in 1.Week 1: 60 mg per dayWeek 2: 50 mg per dayWeek 3: 40 mg per dayWeek 4: 30 mg per dayWeek 5: 20 mg per dayWeek 6: 10 mg per day 2.Week 1: 60 mg per dayWeek 2: 50 mg per dayWeek 3: 45 mg per dayWeek 4: 40 mg per dayWeek 5: 35 mg per dayWeek 6: 30 mg per day 3.Week 1: 60 mg per dayWeek 2: 50 mg per dayWeek 3: 40 mg per dayWeek 4: 35 mg per dayWeek 5: 30 mg per dayWeek 6: 25 mg per day 4.Week 1: 60 mg per dayWeek 2: 40 mg per dayWeek 3: 20 mg per dayWeek 4: 10 mg per dayWeek 5: 5 mg per dayWeek 6: 0 mg per day Rationales Option 1:Tapering schedule for prednisone: for doses greater than 40 mg, decrease by 10 mg every 1 to 3 weeks. Doses below 40 mg require reductions of 5 mg every 1 to 3 weeks. In this instance, the clinician continued to taper by 10 mg weekly even after reaching a dose of 40 mg. Option 2:Tapering schedule for prednisone: for doses greater than 40 mg, decrease by 10 mg every 1 to 3 weeks. Doses below 40 mg require reductions of 5 mg every 1 to 3 weeks. In this instance, the clinician started to taper by 5 mg weekly before reaching a dose of 40 mg. Option 3:Tapering schedule for prednisone: for doses greater than 40 mg, decrease by 10 mg every 1 to 3 weeks. Doses below 40 mg require reductions of 5 mg every 1 to 3 weeks. Once the physiological dose is reached (5 to 7.5 mg/day), then reduce by 1 mg weekly or biweekly (this is not illustrated here). Option 4:Tapering schedule for prednisone: for doses greater than 40 mg, decrease by 10 mg every 1 to 3 weeks. Doses below 40 mg require reductions of 5 mg every 1 to 3 weeks. In this instance, the clinician tapered by 20 mg weekly, then by 10 mg, then by 5 mg. Question 19. A patient who is breastfeeding asks for advice on how she should take her prednisone to minimize the amount excreted in the breast milk. Which advice from the APN is most appropriate? 1.As long as she is taking less than 40 mg of prednisone per day, the amount excreted in the breast milk is negligible. 2.She should discontinue the prednisone and ask for an alternative corticosteroid. 3.She should take the prednisone with a full glass of milk or food to minimize absorption. 4.She should wait 3 to 4 hours after taking the prednisone before she nurses. Rationales Option 1:Several studies have suggested that taking prednisone in doses of 20 mg (not 40 mg) or less per day results in a negligible amount of drug excreted in the breast milk. Option 2:Prednisone or prednisolone in doses of 20 mg or less per day or methylprednisolone (Medrol) in doses of 8 mg or less per day result in a negligible amount of drug excreted in the breast milk, making prednisone a viable choice for breastfeeding mothers. Option 3:There is no evidence to prove that taking prednisone with milk or food minimizes absorption; however, it may be useful to take with food to minimize gastrointestinal (GI) side effects. Option 4:For mothers who want to nurse, waiting 3 to 4 hours after taking prednisone (with a dose of less than 20 mg per day) should be advised to minimize excretion in the breast milk. Question 20. Patients taking glucocorticoids for longer than 3 months should be prescribed which medication? 1.An antihypertensive agent 2.A hypoglycemic agent 3.A bisphosphonate 4.An antibiotic Rationales Option 1:Although glucocorticoids may increase risk for hypertension due to sodium and fluid retention, it is not recommended to prescribe an antihypertensive agent unless hypertension is diagnosed. Option 2:Although glucocorticoids may increase risk for hyperglycemia due to altered glucose regulation in the liver, it is not recommended to prescribe a hypoglycemic agent unless diabetes is diagnosed. Option 3:The American College of Rheumatology recommends treating patients on long-term (3 months or longer) glucocorticoid therapy with the bisphosphonates alendronate (Fosamax) or risedronate (Actonel) based on a risk assessment algorithm. Option 4:Although glucocorticoids may increase risk for infection, it is not recommended to prescribe an antibiotic unless an active infection is diagnosed.