NR 508 Final Exam Practice Questions and
Answers with Rationale
1. A patient who has diabetes reports intense discomfort when needing to void. A
urinalysis is normal. To treat this, the primary care NP should consider
prescribing: oxybutynin chloride (Ditropan XL).
This patient is describing urge incontinence, or overactive bladder, which occurs when
the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is
full. Urge incontinence is associated with many conditions, including diabetes.
Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity
and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria
associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is
used to treat dysuria.
2. A patient reports difficulty returning to sleep after getting up to go to the bathroom
every night. A physical examination and a sleep hygiene history are noncontributory.
The primary care NP should prescribe: ZolpiMist.
ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the
middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty
with sleep onset. Chloral hydrate is not typically used as outpatient therapy.
3. A 5-year-old child who has no previous history of otitis media is seen in clinic with
a temperature of 100° F. The primary care NP visualizes bilateral erythematous,
nonbulging, intact tympanic membranes. The child is taking fluids well and is
playing with toys in the examination room. The NP should: initiate antibiotic
therapy if the child’s condition worsens.
Signs and symptoms of otitis media that indicate a need for antibiotic treatment include
otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has
a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no
otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin
is the drug of choice.
4. An 80-year-old patient with congestive heart failure has a viral upper respiratory
infection. The patient asks the primary care NP about treating the fever, which is 38.5°
C. The NP should: recommend acetaminophen.
Patients with congestive heart failure may have tachycardia from fever that aggravates
their symptoms, so fever should be treated. High doses should be given with caution in
elderly patients because of possible decreased hepatic function. Antibiotics should not be
given without evidence of bacterial infection.
1
, 5. A patient who takes levodopa and carbidopa for Parkinson’s disease reports
experiencing freezing episodes between doses. The primary care NP should consider
using: apomorphine.
Apomorphine injection is used for acute treatment of immobility known as “freezing.”
6. A patient is being tapered from long-term therapy with prednisolone and reports
weight loss and fatigue. The primary care NP should counsel this patient to: increase
the dose of prednisolone to the most recent amount taken.
Sudden discontinuation or rapid tapering of glucocorticoids in patients who have
developed adrenal suppression can precipitate symptoms of adrenal insufficiency,
including nausea, weakness, depression, anorexia, myalgia, hypotension, and
hypoglycemia. When patients experience these symptoms during a drug taper, the dose
should be increased to the last dose. Vitamin D deficiency is common while taking
glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to
another glucocorticoid is not recommended. Patients should be taught to report the side
effects so that action can be taken and should not be told that they are to be expected.
7. The primary care nurse practitioner (NP) sees a 50-year-old woman who reports
frequent leakage of urine. The NP learns that this occurs when she laughs or sneezes.
She also reports having an increased urge to void even when her bladder is not full.
She is not taking any medications. The NP should: prescribe desmopressin
(DDAVP).
A focused history with a careful physical examination is essential for determining the
cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can
cause incontinence. Medications are prescribed after determining the cause, if any, and
treating underlying conditions. Exercises to strengthen the pelvic muscles are part of
treatment.
8. A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-
child examination, the primary care NP notes a decrease in the child’s linear growth
rate. The NP should consult the child’s asthma specialist about: giving a double dose
of prednisone every other day.
Administration of a double dose of a glucocorticoid every other morning has been found
to cause less suppression of the HPA axis and less growth suppression in children.
Because the child has severe asthma, an oral steroid is necessary. Growth hormone
therapy is not indicated. Twice-daily dosing would not change the HPA axis
suppression.
2
, 9. A patient who is taking isoniazid and rifampin for latent TB is seen by the primary
care NP for a routine follow-up visit. The patient reports having nausea, vomiting,
and a decreased appetite. The NP should: ask about alcohol intake.
Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient
shows signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid
should be taken on an empty stomach.
10. A primary care NP sees a child with asthma to evaluate the child’s response to the
prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose
inhaler as needed. The child’s symptoms are well controlled. The NP notes slowing of
the child’s linear growth on a standardized growth chart. The NP should change this
child’s medication regimen to a: SABA as needed plus a leukotriene modifier once
daily.
A leukotriene modifier may be used as an alternative to ICS for children who experience
systemic side effects of the ICS. This child’s symptoms are well controlled, so there is no
need to step up therapy to include a LABA. Oral corticosteroids should be used only for
severe exacerbations. Ipratropium and albuterol are used for severe exacerbations.
11. A patient is newly diagnosed with Alzheimer’s disease stage 6 on the
Global Deterioration Scale. The primary care NP should prescribe:
memantine (Namenda).
Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine.
12. The primary care NP sees a 12-month-old infant who needs the MMR,
Varivax, influenza, and hepatitis A vaccines. The child’s mother tells the NP
that she is pregnant. The NP should: administer all of these vaccines today.
Although live-virus vaccines should not be administered to mothers during pregnancy,
they may be given to children whose mothers are pregnant.
13. 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: obtain a
serum drug level and consider increasing the drug dose.
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.
3
Answers with Rationale
1. A patient who has diabetes reports intense discomfort when needing to void. A
urinalysis is normal. To treat this, the primary care NP should consider
prescribing: oxybutynin chloride (Ditropan XL).
This patient is describing urge incontinence, or overactive bladder, which occurs when
the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is
full. Urge incontinence is associated with many conditions, including diabetes.
Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity
and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria
associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is
used to treat dysuria.
2. A patient reports difficulty returning to sleep after getting up to go to the bathroom
every night. A physical examination and a sleep hygiene history are noncontributory.
The primary care NP should prescribe: ZolpiMist.
ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the
middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty
with sleep onset. Chloral hydrate is not typically used as outpatient therapy.
3. A 5-year-old child who has no previous history of otitis media is seen in clinic with
a temperature of 100° F. The primary care NP visualizes bilateral erythematous,
nonbulging, intact tympanic membranes. The child is taking fluids well and is
playing with toys in the examination room. The NP should: initiate antibiotic
therapy if the child’s condition worsens.
Signs and symptoms of otitis media that indicate a need for antibiotic treatment include
otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has
a low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no
otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin
is the drug of choice.
4. An 80-year-old patient with congestive heart failure has a viral upper respiratory
infection. The patient asks the primary care NP about treating the fever, which is 38.5°
C. The NP should: recommend acetaminophen.
Patients with congestive heart failure may have tachycardia from fever that aggravates
their symptoms, so fever should be treated. High doses should be given with caution in
elderly patients because of possible decreased hepatic function. Antibiotics should not be
given without evidence of bacterial infection.
1
, 5. A patient who takes levodopa and carbidopa for Parkinson’s disease reports
experiencing freezing episodes between doses. The primary care NP should consider
using: apomorphine.
Apomorphine injection is used for acute treatment of immobility known as “freezing.”
6. A patient is being tapered from long-term therapy with prednisolone and reports
weight loss and fatigue. The primary care NP should counsel this patient to: increase
the dose of prednisolone to the most recent amount taken.
Sudden discontinuation or rapid tapering of glucocorticoids in patients who have
developed adrenal suppression can precipitate symptoms of adrenal insufficiency,
including nausea, weakness, depression, anorexia, myalgia, hypotension, and
hypoglycemia. When patients experience these symptoms during a drug taper, the dose
should be increased to the last dose. Vitamin D deficiency is common while taking
glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to
another glucocorticoid is not recommended. Patients should be taught to report the side
effects so that action can be taken and should not be told that they are to be expected.
7. The primary care nurse practitioner (NP) sees a 50-year-old woman who reports
frequent leakage of urine. The NP learns that this occurs when she laughs or sneezes.
She also reports having an increased urge to void even when her bladder is not full.
She is not taking any medications. The NP should: prescribe desmopressin
(DDAVP).
A focused history with a careful physical examination is essential for determining the
cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can
cause incontinence. Medications are prescribed after determining the cause, if any, and
treating underlying conditions. Exercises to strengthen the pelvic muscles are part of
treatment.
8. A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-
child examination, the primary care NP notes a decrease in the child’s linear growth
rate. The NP should consult the child’s asthma specialist about: giving a double dose
of prednisone every other day.
Administration of a double dose of a glucocorticoid every other morning has been found
to cause less suppression of the HPA axis and less growth suppression in children.
Because the child has severe asthma, an oral steroid is necessary. Growth hormone
therapy is not indicated. Twice-daily dosing would not change the HPA axis
suppression.
2
, 9. A patient who is taking isoniazid and rifampin for latent TB is seen by the primary
care NP for a routine follow-up visit. The patient reports having nausea, vomiting,
and a decreased appetite. The NP should: ask about alcohol intake.
Concomitant use of alcohol with isoniazid increases the risk of hepatitis. This patient
shows signs of hepatitis, so the NP should ask about alcohol consumption. Isoniazid
should be taken on an empty stomach.
10. A primary care NP sees a child with asthma to evaluate the child’s response to the
prescribed therapy. The child uses an ICS twice daily and an albuterol metered-dose
inhaler as needed. The child’s symptoms are well controlled. The NP notes slowing of
the child’s linear growth on a standardized growth chart. The NP should change this
child’s medication regimen to a: SABA as needed plus a leukotriene modifier once
daily.
A leukotriene modifier may be used as an alternative to ICS for children who experience
systemic side effects of the ICS. This child’s symptoms are well controlled, so there is no
need to step up therapy to include a LABA. Oral corticosteroids should be used only for
severe exacerbations. Ipratropium and albuterol are used for severe exacerbations.
11. A patient is newly diagnosed with Alzheimer’s disease stage 6 on the
Global Deterioration Scale. The primary care NP should prescribe:
memantine (Namenda).
Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine.
12. The primary care NP sees a 12-month-old infant who needs the MMR,
Varivax, influenza, and hepatitis A vaccines. The child’s mother tells the NP
that she is pregnant. The NP should: administer all of these vaccines today.
Although live-virus vaccines should not be administered to mothers during pregnancy,
they may be given to children whose mothers are pregnant.
13. 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: obtain a
serum drug level and consider increasing the drug dose.
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.
3
