NR 508-Pharmacology Mid-term (NR508)

Exam (elaborations) NR 508-Pharmacology Mid-term (NR508) NR 508-Pharmacology Mid-term Question 1 2 / 2 pts A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: a β-blocker. an angiotensin-converting enzyme inhibitor. Correct! a thiazide diuretic. dietary and lifestyle changes. The patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails. Question 2 2 / 2 pts NR 508-Pharmacology Mid-term An African-American patient is taking captopril (Capoten) 25 mg twice daily. When performing a physical examination, the primary care nurse practitioner (NP) learns that the patient continues to have blood pressure readings of 135/90 mm Hg. The NP should: increase the captopril dose to 50 mg twice daily. Correct! add a thiazide diuretic to this patient’s regimen. change the drug to losartan (Cozaar) 50 mg once daily. recommend a low-sodium diet in addition to the medication. Some African-American patients do not appear to respond as well as whites in terms of blood pressure reduction. The addition of a low-dose thiazide diuretic often allows for efficacy in blood pressure lowering that is comparable with that seen in white patients. Increasing the captopril dose is not indicated. Losartan is an angiotensin receptor blocker (ARB) and is not indicated in this case. Question 3 2 / 2 pts A 50-year-old woman reports severe, frequent hot flashes and vaginal dryness. She is having irregular periods. She has no family history of CHD or breast cancer and has no personal risk factors. The primary care NP should recommend: estrogen-only HT. Correct! low-dose oral contraceptive therapy. selective serotonin reuptake inhibitor therapy until menopause begins. estrogen-progesterone HT. Oral contraceptive pills are not approved by the U.S. Food and Drug Administration for management of perimenopausal symptoms except to treat irregular menstrual bleeding. This patient has a low risk for CHD and breast cancer, so oral contraceptive pills are relatively safe. She is also at risk for pregnancy, so oral contraceptive pills can help to prevent that. Question 4 2 / 2 pts The primary care NP is prescribing a medication for an off-label use. To help prevent a medication error, the NP should: Correct! write “off-label use” on the prescription and provide a rationale. call the pharmacist to explain why the instructions deviate from common use. write the alternative drug regimen on the prescription and send it to the pharmacy. tell the patient to ignore the label directions and follow the verbal instructions given in the clinic. When prescribing a drug for an off-label use, the provider should specify this on the written prescription and should provide a rationale so that the pharmacist understands why the prescription is different from the normal use. Calling the pharmacist would not provide written documentation. Merely writing the different instructions can lead to errors if the pharmacist changes the label to conform to usual standards. The patient may forget verbal instructions and follow the usual regimen instead. Question 5 2 / 2 pts The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: prescribe a thiazide diuretic. consider treatment with an angiotensin-converting enzyme inhibitor. reassure the patient that these findings are normal. Correct! counsel the patient about dietary and lifestyle changes. The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. Question 6 2 / 2 pts A patient who has had a new onset of AF the day prior will undergo cardioversion that day. The primary care NP will expect the cardiologist to: give clopidogrel after administering cardioversion. Correct! administer cardioversion without using anticoagulants. give warfarin and aspirin before attempting cardioversion. give low-dose aspirin before administering cardioversion. If the onset of AF has occurred within 48 hours, cardioversion can be done without anticoagulation. Clopidogrel is used in other cases for patients who cannot take aspirin. For patients with rheumatic mitral valve disease and AF or a history of systemic embolism, cardioversion plus aspirin is used. Warfarin is used in patients with one or more risk factors for stroke. Question 7 2 / 2 pts A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is: Correct! the relation of the pain to stools. what time of day the pain occurs. whether the pain is sharp or diffuse. the age of the patient when the pain began. The new Rome II guidelines maintain that irritable bowel syndrome (IBS) of any subtype is characterized by a strong relationship between abdominal pain and defecation because of visceral hypersensitivity to gut-related events. The other characteristics of pain may be assessed to help guide management of IBS, but the first is necessary for a correct diagnosis. Question 8 2 / 2 pts A 55-year-old woman has a history of myocardial infarction (MI). A lipid profile reveals LDL of 130 mg/dL, HDL of 35 mg/dL, and triglycerides 150 mg/dL. The woman is sedentary with a body mass index of 26. The woman asks the primary care NP about using a statin medication. The NP should: recommend dietary and lifestyle changes first. Correct! begin therapy with atorvastatin 10 mg per day. discuss quality-of-life issues as part of the decision to begin medication. tell her there is no clinical evidence of efficacy of statin medication in her case. This woman would be using a statin medication for secondary prevention because she already has a history of MI, so a statin should be prescribed. Dietary and lifestyle changes should be a part of therapy, but not the only therapy. She is relatively young, and quality-of-life issues are not a concern. There is no clinical evidence to support use of statins as primary prevention in women. Question 9 2 / 2 pts A 2-year-old child has chronic “toddler’s” diarrhea, which has an unknown but benign etiology. The child’s parent asks the primary care NP if a medication can be used to treat the child’s symptoms. The NP should recommend giving: diphenoxylate (Lomotil). attapulgite (Kaopectate). Correct! an electrolyte solution (Pedialyte). bismuth subsalicylate (Pepto-Bismol). Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children. Question 10 2 / 2 pts A patient who has hyperlipidemia has been taking atorvastatin (Lipitor) 60 mg daily for 6 months. The patient’s initial lipid profile showed LDL of 180 mg/dL, HDL of 45 mg/dL, and triglycerides of 160 mg/dL. The primary care NP orders a lipid profile today that shows LDL of 105 mg/dL, HDL of 50 mg/dL, and triglycerides of 120 mg/dL. The patient reports muscle pain and weakness. The NP should: order liver function tests (LFTs). Correct! order a creatine kinase-MM (CK-MM) level. change atorvastatin to twice-daily dosing. add gemfibrozil (Lopid) to the patient’s medication regimen. Hepatotoxicity and muscle toxicity are the two primary adverse effects of greatest concern with statin use. Patients who report muscle discomfort or weakness should have a CK-MM level drawn. LFTs are indicated with signs of hepatotoxicity. It is not correct to change the dosing schedule. Gemfibrozil is not indicated. Question 11 2 / 2 pts A patient brings written information about a medication to a primary care NP about a new drug called Prism and wants to know if the NP will prescribe it. The NP notes that the information is from an internet site called “P.” The NP should tell this patient that: Correct! this information is probably from a drug advertisement website. this is factual, evidence-based material with accurate information. the information is from a nonprofit group that will not profit from drug sales. internet information is unreliable because anyone can post information there. Commercial internet sites are identifiable by “com” at the end of their web address. Many provide reliable information, but others may be more interested in selling something. Nonprofit groups use “org” at the end of their web addresses. Internet information is reliable as long as the internet user is aware of how things are posted and by whom. Question 12 2 / 2 pts A patient who is taking an ACE inhibitor sees the primary care NP for a follow-up visit. The patient reports having a persistent cough. The NP should: Correct! consider changing the medication to an ARB. order a bronchodilator to counter the bronchospasm caused by this drug. ask whether the patient has had any associated facial swelling with this cough. reassure the patient that tolerance to this adverse effect will develop over time. A persistent cough may occur with ACE inhibitors and may warrant discontinuation of the drug. An ARB would be the next drug of choice because it does not have this side effect. The cough is not related to bronchospasm. Angioedema is not related to ACE inhibitor–induced cough. Patients do not develop tolerance to this side effect. Question 13 2 / 2 pts A primary care NP is prescribing a drug for a patient who does not take any other medications. The NP should realize that: CYP450 enzyme reactions will not interfere with this drug’s metabolism. substrates such as alcohol cannot interfere with the drug when the patient is abstaining. food-drug interactions are limited to those where food enhances or inhibits drug absorption. Correct! a thorough history of diet, alcohol use, smoking, and over-the-counter and herbal products is required. 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. Question 14 2 / 2 pts A male patient tells the primary care NP he is experiencing decreased libido, lack of energy, and poor concentration. The NP performs an examination and notes increased body fat and gynecomastia. A serum testosterone level is 225 ng/dL. The NP’s next action should be to: order LH and FSH levels. order a serum prolactin level. prescribe testosterone replacement. Correct! obtain a morning serum testosterone level. To diagnose hypogonadism, two serum testosterone levels must be drawn, with serum collected in the morning. LH, FSH, and prolactin levels may be drawn as well. Testosterone replacement should not be prescribed until the diagnosis is definitive. Question 15 2 / 2 pts In every state, prescriptive authority for NPs includes the ability to write prescriptions: for controlled substances. Correct! for specified classifications of medications. without physician-mandated involvement. with full, independent prescriptive authority. 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. Question 16 2 / 2 pts A patient who has an upper respiratory infection reports using over-the-counter cold preparations. The primary care NP should counsel this patient to use caution when taking additional over-the-counter medications such as: Correct! antipyretics. calcium supplements. acid reflux medications. antioxidant supplements. Cold preparations often contain antipyretics such as acetaminophen or aspirin. Patients should be cautioned about taking additional antipyretics to avoid overdose. Question 17 2 / 2 pts The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: compromise with the parents and order a nasogastric tube for feedings. Correct! initiate a discussion with the parents about the potential outcomes of each possible action. refer the family to a case manager who can help guide the parents to the best decision. understand that the child’s parents have a right to make choices that override those of the medical team. In general, the goal of a health care decision maker is to choose an action that is most likely to deliver the outcomes the patient wants. Initiating a discussion about outcomes helps parents decide based on end results. A nasogastric tube is not the best choice for the child, and compromising without first exploring options is incorrect. As part of the therapeutic relationship, the NP should be involved with patients’ decisions. Although patients and families have the right to make decisions, the NP has an obligation to ensure that the decisions are informed decisions. Question 18 2 / 2 pts A patient who has experienced five to seven liquid stools for 3 days is seen in the clinic by the primary care NP. The patient reports having had fever, mucoid stools, and nausea without vomiting. The patient has been drinking Gatorade to stay hydrated. The NP obtains a stool specimen for culture and should prescribe: diphenoxylate (Lomotil). attapulgite (Kaopectate). Correct! bismuth subsalicylate (Pepto-Bismol). loperamide hydrochloride (Imodium). Bismuth reduces symptoms through antidiarrheal and antibacterial properties and can decrease nausea and vomiting. Opioid antidiarrheals should be given after the cause of infectious diarrhea is treated; these can actually prolong symptoms because they slow transit of the causative organisms through the gut. Attapulgite can be used because it binds bacteria and toxins in the gastrointestinal tract, but bismuth is a better choice in this case because it helps to treat nausea. The patient is drinking Gatorade and is getting electrolyte replacement. Question 19 2 / 2 pts A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend: a daily bulk laxative. long-term docusate sodium. Correct! a saline laxative as needed. glycerin suppositories as needed. Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use. Question 20 2 / 2 pts A postpartum woman will begin taking the minipill while she is nursing her infant. The primary care NP should instruct the patient: to use backup contraception while taking the minipill. to continue using the minipill for 6 months after she stops nursing. that irregular periods while taking the minipill may indicate she is pregnant. Correct! that this method does not increase her risk of thromboembolic events. Minipills are used primarily in breastfeeding women. There is no increased risk for thromboembolic events for women taking these pills. It is not necessary to use a backup method of contraception. Women should be advised to contact the provider when they stop nursing so that a COCP can be prescribed. The more disrupted the bleeding pattern, the more likely it is that ovulation is inhibited. Question 21 2 / 2 pts A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend: orlistat (Xenical). surgical intervention. changes in diet and exercise. Correct!