Pharmacology for the Primary Care Provider Edmunds 4th Edition Test Bank

TEST BANK with Complete Questions and Solutions. To clarify, this is the TEST BANK, not the textbook. You get immediate access to download your test bank. You will receive a complete test bank; in other words, all chapters will be there. Test banks come in PDF format; therefore, you do not need specialized software to open them. Exam (elaborations) TEST BANK FOR PHARMACOLOGY FOR PRIMARY PROVIDER 4TH EDITION EDMUNDS 2021 UPDATED ALL CHAPTERS Chapter 01: Prescriptive Authority and Role Implementation: Tradition vs. Change Test Bank MULTIPLE CHOICE 1. Which of the following has influenced an emphasis on primary care education in medical schools? a. Changes in Medicare reimbursement methods recommended in 1992 b. Competition from nonphysicians desiring to meet primary care shortages c. The need for monopolistic control in the marketplace of primary outpatient care d. The recognition that nonphysicians have variable success providing primary care ANS: A 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. DIF: Cognitive Level: Remembering (Knowledge) REF: 2 2. Which of the following statements is true about the prescribing practices of physicians? a. Older physicians tend to prescribe more appropriate medications than younger physicians. b. Antibiotic medications remain in the top five classifications of medications prescribed. c. Most physicians rely on a “therapeutic armamentarium” that consists of less than 100 drug preparations per physician. d. The dominant form of drug information used by primary care physicians continues to be that provided by pharmaceutical companies. ANS: D Even though most physicians claim to place little weight on drug advertisements, pharmaceutical representatives, and patient preference and state that they rely on academic sources for drug information, a study showed that commercial rather than scientific sources of drug information dominated their drug information materials. Younger physicians tend to prescribe fewer and more appropriate drugs. Antibiotics have dropped out of the top five classifications of drugs prescribed. Most physicians have a therapeutic armamentarium of about 144 drugs. DIF: Cognitive Level: Remembering (Knowledge) REF: 3 3. As primary care nurse practitioners (NPs) continue to develop their role as prescribers of medications, it will be important to: a. attain the same level of expertise as physicians who currently prescribe medications. b. learn from the experiences of physicians and develop expertise based on evidencebased practice. c. maintain collaborative and supervisorial relationships with physicians who will oversee prescribing practices. d. develop relationships with pharmaceutical representatives to learn about new medications as they are developed. ANS: B As nonphysicians develop the roles associated with prescriptive authority, it will be important to learn from the past experiences of physicians and to develop prescribing practices based on evidence-based medicine. It is hoped that all prescribers, including physicians and nurse practitioners, will strive to do better than in the past. NPs should work toward prescriptive authority and for practice that is not supervised by another professional. Pharmaceutical representatives provide information that carries some bias. Academic sources are better. DIF: Cognitive Level: Applying (Application) REF: 4 Chapter 02: Historical Review of Prescriptive Authority: The Role of Nurses (NPs, CNMs, CRNAs, and CNSs) and Physician Assistants Test Bank MULTIPLE CHOICE 1. 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: a. without physician supervision in private practice. b. as CRNAs without physician supervision in a hospital setting. c. in any situation but will not be reimbursed for this by government insurers. d. only with physician supervision in both private practice and a hospital setting. ANS: B 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. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 2. CRNAs in most states: a. must have a Drug Enforcement Administration (DEA) number to practice. b. must have prescriptive authority to practice. c. order and administer controlled substances but do not have full prescriptive authority. d. administer medications, including controlled substances, under direct physician supervision. ANS: C 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. DIF: Cognitive Level: Understanding (Comprehension) REF: 9 3. A CNM: a. may treat only women. b. has prescriptive authority in all 50 states. c. may administer only drugs used during labor and delivery. d. may practice only in birthing centers and home birth settings. ANS: B CNMs have prescriptive authority in all 50 states. They may treat partners of women for sexually transmitted diseases. They have full prescriptive authority and are not limited to drugs used during childbirth. They practice in many other types of settings. DIF: Cognitive Level: Remembering (Knowledge) REF: 9 4. In every state, prescriptive authority for NPs includes the ability to write prescriptions: a. for controlled substances. b. for specified classifications of medications. c. without physician-mandated involvement. d. with full, independent prescriptive authority. ANS: B All states now have some degree of prescriptive authority granted to NPs, but not all states allow authority to prescribe controlled substances. Many states still require some degree of physician involvement with certain types of drugs. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 5. The current trend toward transitioning NP programs to the doctoral level will mean that: a. NPs licensed in one state may practice in other states. b. full prescriptive authority will be granted to all NPs with doctoral degrees. c. NPs will be better prepared to meet emerging health care needs of patients. d. requirements for physician supervision of NPs will be removed in all states. ANS: C The American Association of Colleges of Nursing has recommended transitioning graduate level NP programs to the doctoral level as a response to changes in health care delivery and emerging health care needs. NPs with doctoral degrees will not necessarily have full prescriptive authority or be freed from requirements about physician supervision because those are subject to individual state laws. NPs will still be required to meet licensure requirements of each state. DIF: Cognitive Level: Understanding (Comprehension) REF: 12 6. An important difference between physician assistants (PAs) and NPs is PAs: a. always work under physician supervision. b. are not required to follow drug treatment protocols. c. may write for all drug categories with physician co-signatures. d. have both inpatient and outpatient independent prescriptive authority. ANS: A PAs commonly have co-signature requirements and work under physician supervision. DIF: Cognitive Level: Understanding (Comprehension) REF: 17 Chapter 03: General Pharmacokinetic and Pharmacodynamic Principles Test Bank MULTIPLE CHOICE 1. A primary care nurse practitioner (NP) prescribes a drug to an 80-year-old African- American woman. When selecting a drug and determining the correct dose, the NP should understand that the knowledge of how age, race, and gender may affect drug excretion is based on an understanding of: a. bioavailability. b. pharmacokinetics. c. pharmacodynamics. d. anatomy and physiology. ANS: B Pharmacokinetics is the study of the action of drugs in the body and may be thought of as what the body does to the drug. Factors such as age, race, and gender may change the way the body acts to metabolize and excrete a drug. Bioavailability refers to the amount of drug available at the site of action. Pharmacodynamics is the study of the effects of drugs on the body. Anatomy and physiology is a basic understanding of how the body functions. DIF: Cognitive Level: Understanding (Comprehension) REF: 21 2. A patient asks the primary care NP which medication to use for mild to moderate pain. The NP should recommend: a. APAP. b. Tylenol. c. acetaminophen. d. any over-the-counter pain product. ANS: C Providers should use generic drug names when prescribing drugs or recommending them to patients, unless a particular brand is essential for some reason. Because acetaminophen can have many trade names, it is important for patients to understand that the drug is the same for all to avoid overdosing on acetaminophen. APAP is a commonly used abbreviation but should not be used when recommending the drug to patients. DIF: Cognitive Level: Applying (Application) REF: 21 3. A patient wants to know why a cheaper version of a drug cannot be used when the primary care NP writes a prescription for a specific brand name of the drug and writes, “Dispense as Written.” The NP should explain that a different brand of this drug: a. may cause different adverse effects. b. does not necessarily have the same therapeutic effect. c. is likely to be less safe than the brand specified in the prescription. d. may vary in the amount of drug that reaches the site of action in the body. ANS: D Different formulations of the same drug may have varying degrees of bioavailability, and it may be important to stick to a particular brand for drugs with narrow therapeutic ranges. All drugs with similar active ingredients should have the same therapeutic actions and side effects and should be equally safe. DIF: Cognitive Level: Applying (Application) REF: 22 4. A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose? a. Rectal b. Topical c. Sublingual d. Intramuscular ANS: C The sublingual route is preferred for quick action because the drug is directly absorbed into the bloodstream and avoids the pass through of the liver, where much of an oral drug is metabolized. Rectal routes have unpredictable absorption rates. Topical routes are the slowest. Intramuscular routes are slow. DIF: Cognitive Level: Remembering (Knowledge) REF: 22 5. A patient receives an inhaled corticosteroid to treat asthma. The patient asks the primary care NP why the drug is given by this route instead of orally. The NP should explain that the inhaled form: a. is absorbed less quickly. b. has reduced bioavailability. c. has fewer systemic side effects. d. provides dosing that is easier to regulate. ANS: C An inhaled corticosteroid goes directly to the site of action and does not have to pass through gastrointestinal tract absorption or the liver to get to the lungs. It is generally well absorbed at this site, although dosing is not necessarily easier to regulate because it is not always clear how much of an inhaled drug gets into the lungs. DIF: Cognitive Level: Applying (Application) REF: 21 6. A patient takes an oral medication that causes gastrointestinal upset. The patient asks the primary care NP why the drug information insert cautions against using antacids while taking the drug. The NP should explain that the antacid may: a. alter drug absorption. b. alter drug distribution. c. lead to drug toxicity. d. increase stomach upset. ANS: A Changing the pH of the gastric mucosa can alter the absorption of the drug. Drug distribution is not affected. It may indirectly cause drug toxicity if a significant amount more of the drug is absorbed. It would decrease stomach upset. DIF: Cognitive Level: Applying (Application) REF: 22 7. A patient will begin taking two drugs that are both protein-bound. The primary care NP should: a. prescribe increased doses of both drugs. b. monitor drug levels, actions, and side effects. c. teach the patient to increase intake of protein. d. stagger the doses of drugs to be given 1 hour apart. ANS: B Protein-bound drugs bind to albumin, and serum albumin levels may affect how drugs are distributed. The provider should monitor drug levels, actions, and side effects and change dosing accordingly. Increasing the dose of both drugs is not recommended unless monitoring indicates. Increasing dietary protein does not affect this. Staggering the drugs will not affect this. DIF: Cognitive Level: Applying (Application) REF: 25 8. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: a. inhibitor. b. substrate. c. inducer. d. metabolizer. ANS: A If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. DIF: Cognitive Level: Applying (Application) REF: 26 - 27 9. The primary care NP should understand that a drug is at a therapeutic level when it is: a. at peak plasma level. b. past 4 or 5 half-lives. c. at its steady plasma state. d. between minimal effective concentration and toxic levels. ANS: D The therapeutic range of a drug is the area between the minimal effective concentration and the toxic concentration. Peak plasma level is the highest level the drug reaches and may be well into the toxic range. Steady state occurs when there is a stable concentration of the drug and generally occurs after 4 or 5 half-lives. DIF: Cognitive Level: Applying (Application) REF: 31 10. A primary care NP is preparing to prescribe a drug and notes that the drug has nonlinear kinetics. The NP should: a. monitor frequently for desired and adverse effects. b. administer a much higher initial dose as a loading dose. c. monitor creatinine clearance at baseline and periodically. d. administer the drug via a route that avoids the first-pass effect. ANS: A Drugs with nonlinear kinetics are not eliminated based on dose or concentration of the drug, and these drugs have a narrow therapeutic window and must be monitored closely for desired effects and toxicity. DIF: Cognitive Level: Applying (Application) REF: 32 11. A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that: a. CYP450 enzyme reactions will not interfere with this drug’s metabolism. b. substrates such as alcohol cannot interfere with the drug when the patient is abstaining. c. food-drug interactions are limited to those where food enhances or inhibits drug absorption. d. a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required. ANS: D Drugs are not the only substances that interfere with drug kinetics and dynamics. The primary care NP should conduct a thorough history of food and alcohol intake, smoking, and over-the-counter and herbal supplements to identify things that might interfere with a drug. All of these may interfere with CYP enzymes. Alcohol intake can influence this even when the patient is abstaining because of long-term effects on the liver. DIF: Cognitive Level: Understanding (Comprehension) REF: 38-39 Chapter 04: Special Populations: Geriatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is considering a possible drug regimen for an 80-year-old patient who reports being forgetful. To promote adherence to the regimen, the NP should: a. select drugs that can be given once or twice daily. b. provide detailed written instructions for each medication. c. order medications that can be given on an empty stomach. d. instruct the patient to take a lower dose if side effects occur. ANS: A To promote adherence in elderly patients, selecting the smallest number of medications with the simplest dose regimens is recommended, with once-daily dosing preferred. Instructions should be simplified. Drug dosing should be timed with mealtimes to help patients remember to take them. Lower dosing may be necessary with some drugs, but patients should not do this without consulting their provider. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 2. A 75-year-old patient who lives alone will begin taking a narcotic analgesic for pain. To help ensure patient safety, the NP prescribing this medication should: a. assess this patient’s usual sleeping patterns. b. ask the patient about problems with constipation. c. obtain a baseline creatinine clearance test before the first dose. d. perform a thorough evaluation of cognitive and motor abilities. ANS: D The body system most significantly affected by increased receptor sensitivity in elderly patients is the central nervous system, making this population sensitive to numerous drugs. It is important to evaluate motor and cognitive function before beginning drugs that affect the central nervous system to minimize the risk of falls. Assessment of sleeping patterns is important, but not in relation to patient safety. It is not necessary to evaluate stool patterns or renal function. DIF: Cognitive Level: Applying (Application) REF: 50| 55 3. A thin 90-year-old patient who will begin taking warfarin has experienced a recent weight loss of 15 pounds. The NP caring for this patient should: a. obtain a baseline liver function test (LFT) before starting the drug. b. write the initial prescription at the lowest possible dose. c. encourage the patient to consume a diet high in fat and protein. d. counsel the patient to take the drug with food to enhance absorption. ANS: B A common age change that affects the distribution of drugs in older adults is a decrease in serum albumin. Significant changes that may affect drug therapy may be seen in malnourished elderly patients. Warfarin has a high binding affinity with albumin. Significant decreases in albumin may result in a greater free concentration of highly protein-bound drugs. It is important to order the lowest possible dose and titrate upward as needed. A baseline LFT is not indicated. A diet high in fat and protein is not indicated. DIF: Cognitive Level: Applying (Application) REF: 50 - 51 4. An 86-year-old patient is seen in clinic for a scheduled follow-up after starting a new oral medication 1 month prior. The patient reports no change in symptoms, and a laboratory test reveals a subtherapeutic serum drug level. The NP caring for this patient should: a. consider ordering more frequent dosing of the drug. b. titrate the patient’s dose upward and recheck in 1 month. c. ask the patient about any increased frequency of bowel movements. d. determine the number of pills left in the patient’s prescription bottle. ANS: D Because of cost concerns, poor understanding of a drug’s actions, or confusion about how to take a medication, many elderly patients do not comply with drug regimens and may not take drugs as prescribed. Before increasing the frequency or amount of a drug, it is important to assess first whether or not the patient has been taking the drug as ordered. Counting the number of pills in the bottle will help the provider assess whether the patient is taking the drug as ordered. Changes in gastric motility do not generally have major effects on the effectiveness or serum drug levels of medications. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 5. An NP learns that a 90-year-old patient is chronically constipated and has frequent problems with acid reflux. The NP notes a weight loss of 20 pounds in this patient in the previous 6 months. Which of the following drugs that this patient is taking is cause for concern? a. Quinidine b. Naproxen c. Calcium citrate d. Calcium channel blocker ANS: B Naproxen has a high binding affinity for protein, and these drugs can become toxic in patients who may have low serum albumin because of the amount of free drug in serum. Constipation and acid reflux may cause problems with absorption for some drugs, but not the drugs listed. DIF: Cognitive Level: Analyzing (Analysis) REF: 50 - 52 6. An NP is caring for a 70-year-old patient who reports having seasonal allergies with severe rhinorrhea. Using the Beers criteria, which of the following medications should the NP recommend for this patient? a. Loratadine (Claritin) b. Hydroxyzine (Vistaril) c. Diphenhydramine (Benadryl) d. Chlorpheniramine maleate (Chlorphen 12) ANS: A Loratadine is the only nonsedating antihistamine on this list. Older patients are especially susceptible to sedation side effects and should not use these medications if possible. DIF: Cognitive Level: Applying (Application) REF: 57 7. An NP orders an inhaled corticosteroid 2 puffs twice daily and an albuterol metered-dose inhaler 2 puffs every 4 hours as needed for cough or wheezing for a 65-year-old patient with recent onset of reactive airways disease who reports symptoms occurring every 1 or 2 weeks. At a follow-up appointment several months later, the patient reports no change in frequency of symptoms. The NP’s initial action should be to: a. order spirometry to evaluate pulmonary function. b. prescribe a systemic corticosteroid to help with symptoms. c. ask the patient to describe how the medications are taken each day. d. give the patient detailed information about the use of metered-dose inhalers. ANS: C It is essential to explore with the older patient what he or she is actually doing with regard to daily medication use and compare this against the “prescribed” medication regimen before ordering further tests, prescribing any increase in medications, or providing further education. DIF: Cognitive Level: Applying (Application) REF: 57 - 58 Chapter 05: Special Populations: Pediatrics Test Bank MULTIPLE CHOICE 1. A nurse practitioner (NP) is preparing to prescribe a medication for a 5-year-old child. To determine the correct dose for this child, the NP should: a. calculate the dose at one third of the recommended adult dose. b. estimate the child’s body surface area (BSA) to calculate the medication dose. c. divide the recommended adult dose by the child’s weight in kilograms (kg). d. follow the drug manufacturer’s recommendations for medication dosing. ANS: D The package insert provided by the manufacturer is the best source for pediatric dose recommendations. Approximated reduction in the adult dose is not a safe or effective way of calculating pediatric doses of medications, so using a third of the adult dose may not be safe. Errors inherent in determining BSA make this method less reliable than dose based on accurate weights. Dividing the adult dose by the child’s weight is incorrect. DIF: Cognitive Level: Understanding (Comprehension) REF: 64 - 65 2. An NP is prescribing a drug that is known to be safe in children but is unable to find recommendations about drug dosing. The recommended adult dose is 100 mg per dose. The child weighs 14 kg. Using Clark’s rule, the NP should order _____ mg per dose. a. 20 b. 10 c. 14 d. 9.3 ANS: A Clark’s rule suggests dividing the weight of the child in kg by the weight of an adult in kg and multiplying the result by the adult dose to get an approximation of the child’s dose. The average adult weighs 150 lb, or 70 kg. The equation is: 14 kg/70 kg = 0.2. 0.2  100 = 20 mg. DIF: Cognitive Level: Understanding (Comprehension) REF: 65 3. A child who weighs 22 lb, 2 oz needs a medication. The NP learns that the recommended dosing for this drug is 25 to 30 mg per kg per day in three divided doses. The NP should order: a. 100 mg daily. b. 100 mg tid. c. 300 mg daily. d. 300 mg tid. ANS: B The NP should first convert the child’s weight to kg, which is about 10 kg. The dose is then calculated to be 250 to 300 mg per day in three divided doses, which is 83 to 100 mg per dose given tid. DIF: Cognitive Level: Applying (Application) REF: 65 4. The mother of a 3-year-old child who weighs 15 kg tells the NP that she has liquid acetaminophen at home but does not know what dose to give her child. The NP should tell the mother: a. to give 1 teaspoon every 4 to 6 hours as needed. b. to throw away the old medication and get a new bottle. c. that she may give 5 to 7.5 mL per dose every 4 to 6 hours. d. to find out whether she has a preparation made for infants or children. ANS: D Acetaminophen drops for infants are three times as concentrated as the oral liquid for children. The drops have been pulled from the market, but many parents may still have old preparations on hand. The NP should first determine which preparation this mother has before giving dosage recommendations. If the mother has the oral liquid for children, answers A and C would both be acceptable because the concentration is 160 mg per 5 mL. The mother should not be counseled to throw away the medication until the NP has more information. DIF: Cognitive Level: Applying (Application) REF: 65 5. The parent of a toddler asks the NP about using a topical antihistamine to treat the child’s atopic dermatitis symptoms. The NP should tell the parent that: a. topical medications have fewer side effects in children. b. medications given by this route are not absorbed well in young children. c. topical application of an antihistamine may result in drug toxicity in children. d. it is important to apply topical medications liberally over a large surface area. ANS: C Children have the potential for increased absorption through the skin because their skin is thinner and more sensitive, increasing their risk for drug toxicity. Topical medications have enhanced side effects in children. Topical medications are readily absorbed by children. Applying topical medications liberally over a large surface area would increase the risk of toxicity. DIF: Cognitive Level: Understanding (Comprehension) REF: 67 - 68 6. An NP is prescribing a medication for a 6-month-old infant. The medication comes in the following formulations. Which one should the NP select to improve absorption and distribution of the medication? a. Oral elixir b. Rectal suppository c. Lipid soluble compound d. Sustained-release capsule ANS: A An elixir is a solution in which the drug molecules are dissolved and evenly distributed. Most oral drugs in soluble solutions are readily absorbed from the gastrointestinal tract, and the fact that the drug is evenly distributed helps to ensure that each dose will have equal amounts of the drug. Rectal suppositories generally should be avoided for drug administration, primarily because children may not retain the dosage form long enough to receive the entire dose. Drugs that are lipid soluble may not distribute well in infants. Drugs may pass quickly through the gastrointestinal tract in infants, making sustainedrelease preparations less well absorbed. DIF: Cognitive Level: Understanding (Comprehension) REF: 60| 61| 66 7. An NP prescribes an oral elixir medication for a child who is to take 1 tsp PO bid. When counseling the child’s parents about administering this drug, the NP should tell them to: a. shake the medication well before giving each dose. b. mix the medication with cereal or applesauce to improve its taste. c. administer the medication on an empty stomach to enhance absorption. d. use a syringe purchased at the pharmacy to measure the medication accurately. ANS: D Because the measured volume of “teaspoons” ranges from 2.5 to 7.8 mL, parents should obtain a calibrated medicine spoon or syringe from the pharmacy for dosing small children. Elixirs are solutions in which the drug molecules are dissolved and evenly distributed, so there is no need to shake the drug before each dose. Mixing a drug with food can be problematic if the child does not eat all of the food. An elixir does not need to be administered on an empty stomach. DIF: Cognitive Level: Understanding (Comprehension) REF: 66 - 67| 69 8. A 4-month-old infant has a viral illness with high fever and cough. The infant’s parent asks the NP about what to give the infant to help with symptoms. The NP should prescribe which of the following? a. Aspirin to treat the fever b. Acetaminophen as needed c. Dextromethorphan for coughing d. An antibiotic to prevent increased infection ANS: B Infants should not be given aspirin, which carries a risk of Reye’s syndrome, or dextromethorphan, which has an increased risk of respiratory depression in infants. An antibiotic is not indicated unless there is a known bacterial infection. Acetaminophen is safe for infants. DIF: Cognitive Level: Applying (Application) REF: 64 9. A parent brings a 5-year-old child to a clinic for a hospital follow-up appointment. The child is taking a medication at a dose equal to an adult dose. The parent reports that the medication is not producing the desired effects. The NP should: a. order renal function tests. b. prescribe another medication to treat this child’s symptoms. c. discontinue the drug and observe the child for toxic side effects. d. obtain a serum drug level and consider increasing the drug dose. ANS: D By a child’s first birthday, the liver’s metabolic capabilities are not only mature but also more vigorous than the adult liver, meaning that certain drugs may need to be given in higher doses or more often. It is prudent to obtain a serum drug level and then consider increasing the dose to achieve the desired effect. Renal function tests are not indicated. Unless the child is experiencing toxic effects, the drug does not need to be discontinued. DIF: Cognitive