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-thecounter 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)
Chapter 05: Special Populations: Pediatrics
Test Bank
REF: 57 - 58
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 sustained-release 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 Level: Applying (Application)
REF: 62| 66 - 67
10. An NP is prescribing an antibiotic for a child who will need to take a total of 750 mg per day.
Which dosing regimen should the NP prescribe to promote compliance?
a. 250 mg/5 mL—375 mg PO bid
b. 250 mg/5 mL—250 mg PO tid
c. 500 mg/5 mL—375 mg PO bid
d. 500 mg/5 mL—250 mg PO tid
ANS: C
To improve compliance with a drug regimen, convenient dosage forms and dosing schedules
should be chosen when possible. A 500 mg/5 mL preparation means that a smaller volume
can be given to achieve the desired dose. A bid dosing schedule is more likely to be followed
than one that is tid.
DIF: Cognitive Level: Applying (Application)
REF: 69
11. An NP sees a preschooler in clinic for the first time. When obtaining a medication history,
the NP notes that the child is taking a medication for which safety and effectiveness in
children has not been established in drug information literature. The NP should:
a. discontinue the medication.
b. order serum drug levels to evaluate toxicity.
c. report the prescribing provider to the Food and Drug Administration (FDA).
d. ask the parent about the drug’s use and side effects.
ANS: D
Many of the drugs and biologic products most widely used in pediatric patients carry
disclaimers stating that safety and effectiveness in pediatric patients have not been
established. The NP should find out why the drug was prescribed and whether there are
any significant side effects. The medication should not be discontinued unless there are
known toxic effects. Serum drug levels may be warranted if side effects are reported. The NP
would not report the prescribing provider to the FDA unless there are clear, evidence-based
contraindications to prescribing a drug to children.
DIF: Cognitive Level: Applying (Application)
REF: 67 - 69
Chapter 06: Special Populations: Pregnant and Nursing Women
Test Bank
MULTIPLE CHOICE
1. A woman is in the 36th week of pregnancy. The nurse practitioner (NP) providing prenatal
care learns that the woman has a history of two previous urinary tract infections during this
pregnancy. A dipstick urinalysis in the office today is negative for leukocyte esterase and
nitrites. The NP should:
a. prescribe a low-dose sulfonamide antibiotic for urinary tract infection prophylaxis.
b. order nitrofurantoin daily to minimize the patient’s risk of urinary tract infection
late in her pregnancy.
c. encourage the patient to increase daily water intake and to wear only cotton
underwear.
d. order a voiding cystourethrogram to rule out structural anomalies that may cause
urinary tract infection.
ANS: C
For women at risk for recurrent urinary tract infection while pregnant, prevention and
treatment begin with nonpharmacologic therapy: forcing fluids and wearing cotton
underpants. Sulfonamide antibiotics and nitrofurantoin are used for documented urinary tract
infection during pregnancy, but not after the 36th week of gestation. A voiding
cystourethrogram is not indicated and would expose the fetus to radiation.
DIF: Cognitive Level: Applying (Application)
REF: 77 - 78
2. A woman tells a primary care NP that she is considering getting pregnant. During a health
history, the NP learns that the patient has seasonal allergies, asthma, and epilepsy, all of
which are well controlled with a second-generation antihistamine daily, an inhaled steroid
daily with albuterol as needed, and an antiepileptic medication daily. The NP should
counsel this patient to:
a. take her asthma medications only when she is having an acute exacerbation.
b. avoid using antihistamine medications during her first trimester of pregnancy.
c. discontinue her seizure medications at least 6 months before becoming pregnant.
d. use only oral corticosteroids and not inhaled steroids while pregnant for improved
asthma control.
ANS: B
Optimal treatment of asthma during pregnancy includes treatment of comorbid allergic
rhinitis, which can trigger symptoms. Antihistamines are recommended after the first
trimester, if possible. Asthma medications should be continued during pregnancy because
poorly controlled asthma can be detrimental to the fetus; she should continue using her daily
inhaled corticosteroid. Although discontinuing seizure medications is optimal, this must be
done in conjunction with this woman’s neurologist because management of epilepsy during
pregnancy is beyond the scope of the primary care provider. Oral corticosteroids have greater
systemic side effects and greater effects on the fetus and should be used only as necessary.
DIF: Cognitive Level: Applying (Application)
REF: 78 - 79
3. A woman has just learned she is pregnant and is in her 10th gestational week. The woman
reports that she takes valproic sodium (Depakote) for a seizure disorder and has been
seizure-free for several years. The NP should:
a. prescribe folic acid supplements.
b. change her antiepileptic drug to lamotrigine (Lamictal).
c. order prophylactic vitamin K to be given in the second trimester.
d. recommend that she discontinue taking the valproic sodium by 12 weeks.
ANS: A
Maternal folic acid deficiency is induced by anticonvulsants, especially valproic acid, so folic
acid supplements must be given. Although antiepileptic drugs can have consequences for the
developing fetus, once a woman is pregnant, the benefit-risk ratio favors continued use of the
woman’s current antiepileptic medication, so she should not discontinue the medication or
change to lamotrigine. Vitamin K is recommended beginning at 36 weeks of gestation and for
the newborn at birth to counter the possibility of hemorrhagic disease of the newborn.
DIF: Cognitive Level: Applying (Application)
REF: 79
4. A woman who is pregnant develops gestational diabetes. The NP’s initial action is to:
a. prescribe an oral antidiabetic agent.
b. give her information about diet and exercise.
c. begin treating her with daily insulin injections.
d. reassure her that her glucose levels will return to normal after pregnancy.
ANS: B
Patients with gestational diabetes should be treated with diet and exercise, with insulin added
as needed for poor control. There is insufficient evidence to support the use of oral
antidiabetic agents during pregnancy, and some of these are pregnancy category D. Insulin
injections may be used but are not the initial intervention. Although glucose levels will return
to prepregnancy values in the postpartum period, the NP must initiate therapy.
DIF: Cognitive Level: Applying (Application)
REF: 79 - 80
5. A woman who takes an angiotensin converting enzyme inhibitor for hypertension tells her
primary care NP that she is trying to get pregnant. The NP should:
a. consider replacing her angiotensin converting enzyme inhibitor with methyldopa.
b. lower her angiotensin converting enzyme inhibitor dose during the first trimester.
c. counsel her to increase her antihypertensive medications during pregnancy.
d. add an angiotensin receptor blocker (ARB) during the first trimester of her
pregnancy.
ANS: A
Angiotensin converting enzyme inhibitors, ARBs, and statins are contraindicated during the
first trimester of pregnancy and should be discontinued before conception and replaced by
safer alternatives, such as methyldopa. The use of antihypertensives during pregnancy remains
controversial; increasing the dose is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 80
6. A woman who is pregnant tells an NP that she has been taking sertraline for depression for
several years but is worried about the effects of this drug on her fetus. The NP will consult
with this patient’s psychiatrist and will recommend that she:
a. stop taking the sertraline now.
b. continue taking the antidepressant.
c. change to a monoamine oxidase inhibitor (MAOI).
d. discontinue the sertraline a week before delivery.
ANS: B
Many women are taking medication for depression before becoming pregnant. Abrupt
discontinuation is not recommended, and many clinicians suggest that women at high risk for
serious depression during pregnancy might best be served by continuing medication
throughout pregnancy. MAOIs may limit fetal growth and are generally discouraged during
pregnancy. It is not necessary to discontinue the sertraline just before delivery.
DIF: Cognitive Level: Applying (Application)
REF: 80
7. A woman is 4 weeks pregnant. The primary care NP sees her for her first prenatal visit and
obtains a rubella titer, which is negative. The woman tells the NP that she drinks 2 cups of
coffee and smokes 3 to 5 cigarettes each day. She denies alcohol use. The NP should:
a.
b.
c.
d.
administer rubella vaccine.
provide smoking cessation information.
counsel her to avoid caffeine while pregnant.
reassure her that her habits are not likely to cause harm.
ANS: B
Each cigarette smoked decreases maternal blood pressure for up to 15 minutes and
decreases uteroplacental perfusion. The NP should encourage the woman to quit smoking.
Rubella vaccine should be given after the baby is delivered because rubella vaccine is a live
virus, with severe teratogenic effects. There is no conclusive evidence that women who are
pregnant should avoid caffeine completely. Her habits, although not severe, are not harmless.
DIF: Cognitive Level: Applying (Application)
REF: 82 - 83
8. A woman who is breastfeeding her infant asks the primary care NP what she can use for
headaches while she is nursing. The NP tells her:
a. most medications enter breast milk and are not safe.
b. most over-the-counter medications are safe for the breastfed infant.
c. she may need to interrupt breastfeeding when taking headache medications.
d. she should consider weaning her infant to formula if her headaches are frequent.
ANS: B
Most over-the-counter medications are considered safe for the breastfed infant and do not
necessitate a disruption of breastfeeding, even though most medications cross easily into
breast milk. Any interruption of breastfeeding carries a risk of premature weaning and so is
indicated only when the mother must take medications known to cause serious harm to the
baby. It is not recommended that she wean her infant to formula when she needs medications
for her headaches.
DIF: Cognitive Level: Applying (Application)
REF: 85
Chapter 07: Over-the-Counter Medications
Test Bank
MULTIPLE CHOICE
1. A patient asks a primary care nurse practitioner (NP) about using over-the-counter
medications to treat an upper respiratory infection with symptoms of cough, fever, and
nasal congestion. The NP should:
a. recommend a cough preparation that also contains acetaminophen.
b. suggest using single-ingredient products to treat each symptom separately.
c. recommend a product containing antitussive, antipyretic, and decongestant
ingredients.
d. tell the patient that over-the-counter medications are usually not effective in
manufacturer-recommended doses.
ANS: B
A basic principle guiding over-the-counter use is to look at specific symptoms and treat each
separately because some products contain therapeutic doses of one ingredient and
subtherapeutic doses of others. Cough preparations containing acetaminophen often do not
contain therapeutic doses, and patients often overdose when they supplement with
acetaminophen. Over-the-counter medications are effective at recommended doses. Patients
should follow dosing recommendations on the package.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 89| 90
2. A patient asks a primary care NP whether over-the-counter drugs are safer than
prescription drugs. The NP should explain that over-the-counter drugs are:
a. generally safe when label information is understood and followed.
b. safer because over-the-counter doses are lower than prescription doses of the same
drug.
c. less safe because they are not well regulated by the Food and Drug Administration
(FDA).
d. not extensively tested, so claims made by manufacturers cannot be substantiated.
ANS: A
Over-the-counter products have a wider margin of safety because most of these drugs have
undergone rigorous testing before marketing and further refinement through years of over-thecounter use by consumers. When labels are understood and followed, over-the-counter
medications are safe. Over-the-counter medications are regulated by the FDA.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 88
3. A parent calls a clinic for advice about giving an over-the-counter cough medicine to a 6-year-
old child. The parent tells the NP that the medication label does not give instructions about
how much to give a child. The NP should:
a. order a prescription antitussive medication for the child.
b. ask the parent to identify all of the ingredients listed on the medication label.
c. calculate the dose for the active ingredient in the over-the-counter preparation.
d. tell the parent to approximate the dose at about one third to one half the adult dose.
ANS: B
Over-the-counter cough medications often contain dextromethorphan, which can be toxic to
young children. It is important to identify ingredients of an over-the-counter medication
before deciding if it is safe for children. A prescription antitussive is probably not warranted
until the cough is evaluated to determine the cause. Until the ingredients are known, it is not
safe to approximate the child’s dose based on only the active ingredient.
DIF: Cognitive Level: Applying (Application)
REF: 89
4. A primary care NP recommends an over-the-counter medication for a patient who has acid
reflux. When teaching the patient about this drug, the NP should tell the patient:
a. to take the dose recommended by the manufacturer.
b. not to worry about taking this drug with any other medications.
c. to avoid taking other drugs that cause sedation while taking this drug.
d. that over-the-counter acid reflux medications are generally safe to take with other
medications.
ANS: A
Because patients often increase over-the-counter drug doses themselves, it is important to
reinforce the need to follow the manufacturer’s recommendations for dosing. As with any
drug, interactions may occur with other medications. Antacids do not cause sedation, so
patients need not be cautioned to avoid other sedating medications.
DIF: Cognitive Level: Applying (Application)
REF: 89
5. A primary care NP is performing a previsit health history on a new patient. The patient reports
taking vitamins every day. The NP should:
a. ask the patient to bring all vitamin bottles to the clinic appointment.
b. recommend natural vitamin products over synthetic vitamin products.
c. reassure the patient that vitamins that are high in folic acid are safe to take.
d. tell the patient that some vitamins, such as vitamin C, are safe in large doses.
ANS: A
It is important to determine exactly what the patient is taking, so asking patients to bring
vitamin bottles to the clinic is appropriate. There is no evidence that natural products are
better than synthetic products. High doses of folic acid may mask signs of vitamin B12
deficiency. Vitamin C in high doses can cause dependency.
DIF: Cognitive Level: Applying (Application)
REF: 89
6. A patient reports taking antioxidant supplements to help prevent cancer. The primary care
NP should:
a. review healthy dietary practices with this patient.
b. make sure that the supplements contain large doses of vitamin A.
c. tell the patient that antioxidants are especially important for patients who smoke.
d. tell the patient that evidence shows antioxidants to be effective in preventing
cancer.
ANS: A
Epidemiologic evidence indicates that people who eat fruits and vegetables regularly have a
decreased risk of cancer. Although retrospective studies have suggested major benefits from
antioxidants, no intervention studies have determined conclusively that antioxidants prevent
cancer. Large doses of vitamin A can produce a yellow hue to the skin. Antioxidants can be
beneficial, but in certain populations, such as smokers, they may be harmful.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 89
7. 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:
a. antipyretics.
b. calcium supplements.
c. acid reflux medications.
d. antioxidant supplements.
ANS: A
Cold preparations often contain antipyretics such as acetaminophen or aspirin. Patients
should be cautioned about taking additional antipyretics to avoid overdose.
DIF: Cognitive Level: Applying (Application)
REF: 89
Chapter 08: Complementary and Alternative Therapies
Test Bank
MULTIPLE CHOICE
1. A patient with chronic back pain that is unrelieved by prescription analgesic medications
asks a primary care nurse practitioner (NP) about acupuncture treatments. The NP should
tell this patient:
a. biofield therapy has been shown to be more effective than acupuncture.
b. creatine has been shown to be an effective herbal choice to treat back pain.
c. there is no valid research documenting the efficacy of this treatment for pain.
d. most studies that show benefits of alternative therapies are based on observation.
ANS: D
Current literature does not allow definitive conclusions to be drawn regarding the use of
complementary and alternative medicine (CAM) because much of what appears in the
literature continues to be based on observational reports and small studies. Biofield therapy
has not been shown to be more effective than acupuncture. Creatine is used to increase muscle
mass.
DIF: Cognitive Level: Applying (Application)
REF: 93
2. A primary care NP is aware that many patients in the community use herbal remedies to
treat various conditions. The NP understands the importance of:
a. learning about the actions, uses, doses, and toxicities of these agents.
b. prescribing these agents when possible to ensure safe dosing.
c. counseling patients to stop using herbal products to avoid toxic side effects.
d. teaching patients that these products are unregulated and unsafe to use.
ANS: A
It is important for primary care providers to be familiar with these products and their
ingredients so that they can help patients choose the safest product for their ailments. Because
there are few evidence-based recommendations for the use of these products, NPs should
not prescribe them. Counseling patients to stop using the products would probably not be
effective; it is more important to know about the products to assist patients in decision
making. Although it is true that the products are not directly regulated by the Food and Drug
Administration (FDA), there are agencies that maintain safety of the products.
DIF: Cognitive Level: Applying (Application)
REF: 94
3. A patient has been using an herbal supplement for 2 years that the primary care NP knows
may have toxic side effects. The NP should:
a. tell the patient to stop taking the supplement immediately.
b. inform the patient of the risks of toxic side effects with this supplement.
c. refer the patient to a CAM provider who can manage this patient’s therapy.
d. prescribe another herbal drug that has fewer adverse effects than the one the
patient is taking.
ANS: B
It is important for primary care NPs to inform patients of any known risks associated with
herbal supplements. Asking the patient to stop an herbal remedy immediately when the patient
has been using it for 2 years would probably be met with resistance. The NP should realize
that referral to a CAM provider can incur legal liabilities if the CAM provider does not have
proper competencies and licensure. Likewise, unless there is evidence-based documentation
about the safety and efficacy of a product, the NP should not prescribe these therapies.
DIF: Cognitive Level: Applying (Application)
REF: 94
4. A patient asks a primary care NP why herbal supplements are not regulated by the FDA.
The nurse practitioner should tell the patient these products are not regulated by the FDA
because they are:
a. natural, plant-based products and not man-made.
b. not marketed as products that can treat or cure disease.
c. regulated by the Dietary Supplement Health and Education Act.
d. covered by the Hatch-Richardson Bill of 1992, which allows them to make health
claims without FDA approval.
ANS: B
A manufacturer must comply with the rigorous standards of safety and efficacy set forth by
the FDA only when the claim is made that a product can be used to treat or cure an
illness or disease. The Hatch-Richardson Bill of 1992 defines herbal supplements as different
from a food additive or drug. The Dietary Supplement Health and Education Act allows
claims to be made as long as they are substantiated with evidence.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 95
5. A patient is diagnosed with lupus and reports occasional use of herbal supplements. The
primary care NP should caution this patient to avoid:
a. ginseng.
b. echinacea.
c. ginkgo biloba.
d. St. John’s wort.
ANS: B
Patients with lupus who take echinacea may experience an increase in symptoms, even if
the patient is taking immunosuppressants.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 98
6. A patient who takes warfarin (Coumadin) experiences excessive bleeding, even though
serum drug levels are normal. The primary care NP should question this patient about the
use of:
a. feverfew.
b. echinacea.
c. green tea.
d. ginkgo biloba.
ANS: D
Ginkgo biloba decreases blood viscosity and can enhance the effects of warfarin. Feverfew,
echinacea, and green tea do not have this effect.
DIF: Cognitive Level: Applying (Application)
REF: 99
7. A patient develops hepatotoxicity from chronic acetaminophen use. The primary care NP
may recommend:
a. milk thistle.
b. chondroitin.
c. coenzyme Q.
d. glucosamine.
ANS: A
Milk thistle has been shown to protect the liver after exposure to hepatotoxins such as
acetaminophen, ethanol, and halothane. The other supplements listed do not have this
effect.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 100
Chapter 09: Establishing the Therapeutic Relationship
Test Bank
MULTIPLE CHOICE
1. To increase the likelihood of successful pharmacotherapy, when teaching a patient about
using a medication, the primary care nurse practitioner (NP) should:
a. encourage the patient to participate in the choice of the medication.
b. provide education about the medication actions and adverse effects.
c. stress the importance of taking the medication exactly as it is prescribed.
d. give the patient copies of medication package inserts describing the drug use.
ANS: A
It is important that the patient “owns the problem” and has a part in the solution.
Providing education about the medication, stressing the importance of following medication
instructions, and distributing package inserts may be useful, but it is essential that patients
take an active role in their care.
DIF: Cognitive Level: Applying (Application)
REF: 104
2. A patient has recurrent symptoms and tells the primary care NP that she can’t remember to
take her medication all the time. The NP should:
a. give her shortened regimens of the drug to facilitate compliance.
b. provide written information about her condition and the medication.
c. administer the medication in the clinic to ensure that she takes the drug.
d. ask her about her lifestyle, her schedule, and her understanding of her condition.
ANS: D
If the attitude is that the patient has a problem for the health care provider to solve, then the
provider owns the problem and often hastens to solve it. When patients own their problems,
they are more likely to engage in their care and treatment. Giving shortened regimens,
providing written information, and administrating medication in the clinic are examples of the
provider solving the problem for the patient.
DIF: Cognitive Level: Applying (Application)
REF: 104
3. A primary care NP prepares to teach a patient about the management of a chronic condition.
The patient says, “I don’t want to know all of that. Just tell me what to take and when.” The
NP should initially:
a. give the patient basic written instructions about medications, follow up visits, and
symptoms.
b. ask the patient to describe the disease process and the medications to evaluate
understanding.
c. explain to the patient that without mutual cooperation, the treatment regimen will
not be effective.
d. ask the patient to explore feelings and fears about having a chronic disease and
taking medications.
ANS: A
The patient has stated expectations about care and treatment for the condition. The NP should
begin by respecting that and providing the amount of information the patient wants. As the
therapeutic relationship grows, the NP may elicit more active participation and understanding.
DIF: Cognitive Level: Applying (Application)
REF: 104
4. A parent brings a child who has moderate-persistent asthma to the clinic and tells the primary
care NP that none of the child’s medications are working. The parent says, “Everybody tells
me something different. I don’t know what to do.” The NP suspects that the parent is not
administering the medications appropriately. The NP should initially:
a. perform a careful history of the child’s symptoms and the medications that are
given.
b. provide a written asthma action plan and encourage the parent to call when
symptoms are worse.
c. review what other providers have prescribed in the past and explain these
interventions to the parent.
d. explain the different purposes of maintenance and rescue medications and give the
parent a schedule for medication administration.
ANS: A
Clinical providers must refine listening and questioning skills and focus on the patient and the
environment. It is important to begin with a thorough history and to elicit the patient’s
understanding of a disease or a medication to identify potential problems. Providing written
action plans, reviewing past providers’ prescriptions, and explaining medications are useful
only after the NP determines what the problem is.
DIF: Cognitive Level: Applying (Application)
REF: 104
5. A primary care NP sees a 5-year-old child who is morbidly obese. The child has an elevated
hemoglobin A1c and increased lipid levels. Both of the child’s parents are overweight but not
obese, and they tell the NP that they see nothing wrong with their child. They both state that it
is difficult to refuse their child’s requests for soda or ice cream. The NP should:
a. suggest that they give the child diet soda and low-fat frozen yogurt.
b. understand and respect the parents’ beliefs about their child’s self-image.
c. initiate a dialogue with the parents about the implications of the child’s laboratory
values.
d. suggest family counseling to explore ways to improve parenting skills and limits.
ANS: C
In this case, the child is at risk if the parents do not intervene. The NP should help the parents
to see the potential adverse effects so that they can understand the need for treatment. The
other answers are examples of the NP creating solutions. Unless the parents see the problem,
they are not likely to engage in the treatment regimen.
DIF: Cognitive Level: Applying (Application)
REF: 108
6. A patient bursts into tears when the primary care NP diagnoses diabetes. The NP should:
a. ask the patient about past experiences with anyone who has this diagnosis.
b. reassure the patient that the medications and blood tests will become routine.
c. call in a social worker to assist the patient to obtain equipment and supplies.
d. refer the patient to a diabetes educator to provide teaching about the disease.
ANS: A
To help patients participate in their disease management, the NP must have an understanding
of the patient’s concerns and fears. The first step when the patient is obviously upset is to
determine what the patient knows and fears about the disease.
DIF: Cognitive Level: Applying (Application)
REF: 107
7. A primary care NP writes a prescription for an off-label use for a drug. To help ensure
compliance, the NP should:
a. include information about the off-label use on the E-script.
b. provide the patient with written instructions about how to use the medication.
c. tell the patient to let the pharmacist know that the drug is being used for an offlabel use.
d. follow up by phone in several days to see if the patient is using the drug
appropriately.
ANS: A
Effective communication extends beyond just the patient-provider relationship. It is important
to include anyone involved in the patient’s care. The best way in this case is to include the
information on the E-script so that there is a record of the off-label use and to help clarify or
reinforce the provider’s instructions.
DIF: Cognitive Level: Applying (Application)
Chapter 10: Practical Tips on Writing Prescriptions
Test Bank
REF: 111
MULTIPLE CHOICE
1. The primary care nurse practitioner (NP) writes a prescription for an antibiotic using an
electronic drug prescription system. The pharmacist will fill this prescription when:
a. the electronic prescription is received.
b. the patient brings a written copy of the prescription.
c. a copy of the written prescription is faxed to the pharmacy.
d. the pharmacist accesses the patient’s electronic record to verify.
ANS: A
E-sign effectively voids requirements that prescriptions be written on paper or printed as a
hard copy. Some scheduled drugs still require written copies. Faxed copies of this drug would
be allowed but are not necessary for the pharmacist to fill the prescription. The patient’s
electronic medical record stands as evidence of the need for a prescription of a drug but is not
needed for the pharmacist to fill the prescription.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 116
2. When prescribing a medication for a chronic condition, the primary care NP should tell the
patient:
a. to contact the pharmacy whenever refills are needed.
b. that it is necessary to return to the clinic for each monthly refill of the medication.
c. about the frequency of clinic visits necessary for the number of refills authorized.
d. to ask the pharmacist to supply several months’ worth of the medication at a time.
ANS: C
Nonscheduled drugs may be ordered with refills so that the patient does not have to be seen
each time a refill is needed. It is important to determine how closely a patient should be
monitored while taking a drug for a chronic condition and to let the patient know how
frequently he or she needs to be seen. Patients may contact a pharmacy when they still have
authorized refills to pick up, but this is determined by the clinician. Pharmacists usually
cannot dispense more than 30 days’ worth of a medication.
DIF: Cognitive Level: Applying (Application)
REF: 116 - 117
3. The neighbor of a primary care NP asks the NP to write a prescription for an antibiotic. The
NP should tell the neighbor:
a. a prescription will be written one time only.
b. she will ask a colleague to write the prescription.
c. that it is illegal to write prescriptions for friends.
d. that it is best if the neighbor sees a health care provider before obtaining a
prescription.
ANS: D
It is not illegal to prescribe antibiotics for friends, but it is unethical. It is better if patients are
seen and diagnosed appropriately before antibiotics are prescribed. The NP should
recommend that the neighbor see a health care provider.
DIF: Cognitive Level: Applying (Application)
REF: 116 - 117
4. The primary care NP is prescribing a medication for an off-label use. To help prevent a
medication error, the NP should:
a. write “off-label use” on the prescription and provide a rationale.
b. call the pharmacist to explain why the instructions deviate from common use.
c. write the alternative drug regimen on the prescription and send it to the pharmacy.
d. tell the patient to ignore the label directions and follow the verbal instructions
given in the clinic.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 116 - 117
5. The primary care NP sees a patient covered by Medicaid, writes a prescription for a
medication, and is informed by the pharmacist that the medication is “off-formulary.” The NP
should:
a. inform the patient that an out-of-pocket expense will be necessary.
b. write the prescription for a generic drug if it meets the patient’s needs.
c. call the patient’s insurance provider to advocate for this particular drug.
d. contact the pharmaceutical company to see if medication samples are available.
ANS: B
Medicaid often stipulates which medications are or are not covered. Unless the particular drug
is absolutely necessary, the NP should substitute with an acceptable generic drug. Insisting
that the patient pay out of pocket may mean that the prescription is not filled. If the drug is
necessary, the NP may advocate for its use by contacting the third-party payer. Asking for
drug samples is not a long-term solution for the problem.
DIF: Cognitive Level: Applying (Application)
REF: 121
6. A patient who has asthma and who is known to the primary care NP calls the NP after hours
and asks for a refill of an albuterol metered-dose inhaler. The patient has not been seen in the
clinic for more than a year. The NP should:
a. call the pharmacy to order the medication with several refills.
b. send an electronic prescription to the pharmacy for one time only.
c. send the patient to the emergency department for evaluation of symptoms.
d. refill the drug and tell the patient that an office visit is necessary for further refills.
ANS: D
The patient needs the medication and is known to the NP so a refill is not inconsistent with
practice guidelines. However, further refills should not be provided until the patient is seen
and has an updated asthma action plan. The patient should be informed of this; simply
refilling the prescription sends a message that it is acceptable to get refills without being seen.
DIF: Cognitive Level: Applying (Application)
REF: 116
7. A patient who has chronic pain and who takes oxycodone (Percodan) calls the clinic to ask for
a refill of the medication. The primary care NP notes that the medication refill is not due for 2
weeks. The patient tells the NP that the refill is needed because he is going out of town. The
NP should:
a. fill the prescription and document the patient’s explanation of the reason.
b. review the patient’s chart to see if this is a one-time or repeat occurrence.
c. call the patient’s pharmacist and report suspicion of drug-seeking behaviors.
d. confront the patient about misuse of narcotics and refuse to fill the prescription.
ANS: B
When patients fill prescriptions early for drugs that have abuse potential, providers should be
alert to possible abuse. The first step would be to see if this is a one-time occurrence or a
pattern. Providers should do this before refilling the prescription. If this is a pattern, the
pharmacist should be notified. Patients should be confronted if a problem is apparent, and
practitioners should not refill the prescriptions.
DIF: Cognitive Level: Applying (Application)
REF: 121
Chapter 11: Evidence-Based Decision Making and Treatment Guidelines
Test Bank
MULTIPLE CHOICE
1. The primary care nurse practitioner (NP) is using critical thinking skills when:
a. using standardized protocols to guide patient care.
b. adhering to scientific principles to solve a patient problem.
c. following the practices of seasoned mentors when giving care.
d. analyzing current research and synthesizing new approaches to patient care.
ANS: D
Practitioners use critical thinking skills by reviewing and analyzing current knowledge and
synthesizing approaches to apply to unique patient situations. Using standardized protocols,
adhering to scientific principles, and following practices of seasoned mentors may be useful,
but these do not encompass the concept of critical thinking, which requires the practitioner to
use what is known in new situations.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 123 - 124
2. 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:
a. compromise with the parents and order a nasogastric tube for feedings.
b. initiate a discussion with the parents about the potential outcomes of each possible
action.
c. refer the family to a case manager who can help guide the parents to the best
decision.
d. understand that the child’s parents have a right to make choices that override those
of the medical team.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 126
3. The primary care NP prescribes an inhaled corticosteroid for a patient who has asthma. The
third-party payer for this patient denies coverage for the brand that comes in the specific
strength the NP prescribes. The NP should:
a. provide pharmaceutical company samples of the medication for the patient.
b. inform the patient that the drug must be paid for out of pocket because it is not
covered.
c. order the closest formulary-approved approximation of the drug and monitor
effectiveness.
d. write a letter of medical necessity to the insurer to explain the need for this
particular medication.
ANS: C
The second step of medical decision making takes into account benefits versus costs along
with an understanding that it is impossible to do everything because of limited resources. The
NP should prescribe what is covered and evaluate its effectiveness; if it does not work, the
third-party payer may be approached about the need for the other medication. Providing
samples is not always possible, and this practice is being discouraged, so it is not a viable
solution. Asking patients to pay out of pocket ultimately may be necessary but carries risks
that the patient will not obtain the medication. Writing a letter of medical necessity may be
indicated if the available drugs are not effective but is not the initial step.
DIF: Cognitive Level: Applying (Application)
REF: 125
4. A patient takes a cardiac medication that has a very narrow therapeutic range. The primary
care NP learns that the particular brand the patient is taking is no longer covered by the
patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to
brand. The NP should:
a. contact the insurance provider to explain why this particular formulation is
necessary.
b. change the patient’s medication to a different drug class that doesn’t have these
bioavailability variations.
c. accept the situation and monitor the patient closely for drug effects with each
prescription refill.
d. ask the pharmaceutical company that makes the drug for samples so that the
patient does not incur out-of-pocket expense.
ANS: A
In this case, the NP should advocate for the desired drug because changing the drug can have
life-threatening consequences. If this fails, other options may have to be explored.
DIF: Cognitive Level: Applying (Application)
REF: 131
5. A patient comes to the clinic reporting dizziness and fatigue associated with nausea and
vomiting. The primary care NP suspects anemia and orders a complete blood count. The
patient’s hemoglobin is elevated. The NP correctly concludes that the patient is not anemic.
The NP has made an error in:
a. context formulation.
b. inappropriate knowledge base.
c. cost-versus-benefit analysis.
d. hypothesis triggering and information processing.
ANS: D
Faulty hypothesis triggering occurs when the clinician fails to consider appropriate initial
hypotheses. The patient had nausea and vomiting, which can cause dehydration, leading to
orthostatic hypotension and dizziness. The NP made an assumption that the dizziness was
caused by anemia and ordered a complete blood count. Faulty information gathering occurs
when clinicians fail to order appropriate tests. An error in context formulation occurs when
clinicians and patients have different goals. Errors in knowledge base would occur if the
practitioner did not perform a complete history and physical, missing important information.
An error in cost-versus-benefit analysis could occur if the clinician ordered expensive tests
that were not necessary for diagnosis and treatment.
DIF: Cognitive Level: Applying (Application)
REF: 127
6. A patient comes to the clinic with a 2-day history of cough and wheezing. The patient has no
previous history of asthma. The patient reports having heartburn for several months, which
has worsened considerably. The primary care NP makes a diagnosis of asthma and orders oral
steroids and inhaled albuterol. The patient’s condition worsens, and a chest radiograph
obtained 2 days later shows bilateral infiltrates. The NP has failed to:
a. confirm the diagnosis.
b. determine the aggressiveness of therapy.
c. prescribe an adequate dose of medications.
d. allow the drugs an adequate amount of time to work.
ANS: A
This patient had symptoms that could occur with both asthma and aspiration pneumonia. The
NP failed to confirm the diagnosis and prescribed the wrong treatment, leading to worsening
of symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 129 - 131
7. A patient comes to the clinic and asks the primary care NP about using a newly developed
formulation of the drug the patient has been taking for a year. When deciding whether or not
to prescribe this formulation, the NP should:
a. tell the patient that when postmarketing data is available, it will be considered.
b. review the pharmaceutical company promotional materials about the new
medication.
c. prescribe the medication if it is less expensive than the current drug formulation.
d. prescribe the medication if the new drug is available in an extended-release form.
ANS: A
About 6 to 12 months of postmarketing experience can yield information about drug efficacy
and side effects, so patients should be cautioned to wait for these data. Drug company
promotional materials have biased information. Most new drugs are more expensive, and
costs alone should not determine drug choice. Extended-release forms are often more
expensive.
DIF: Cognitive Level: Applying (Application)
REF: 131
8. The primary care NP is reviewing evidence-based recommendations about the off-label use of
a particular drug. Which recommendation should influence the NP’s decision about
prescribing the medication?
a. Data from randomized, experimental studies
b. Patient reports about effectiveness of the drug for this purpose
c. Pharmaceutical company reports using anecdotal evidence
d. Endorsement of this use by a leading practitioner in the field
ANS: A
Randomized, experimental studies yield the best data about use of medications. Patient reports
carry the least weight because bias can occur and other factors can influence outcomes.
Pharmaceutical company reports are biased.
DIF: Cognitive Level: Applying (Application)
REF: 133
9. A primary care NP is developing a clinical practice guideline for management of a patient
population in a midsized suburban hospital. The NP should:
a. use an existing guideline from a leading research hospital.
b. follow the guideline provided by a third-party payer to help ensure reimbursement.
c. review expert opinion and experimental, anecdotal, correlational study data.
d. write the guideline to adhere to long-standing practice protocols already in use.
ANS: C
Clinical guidelines should be written using all available evidence as well as expert opinion.
Existing guidelines from a different type of hospital may not be based on data generalizable to
this population. Third-party payer guidelines are usually weighted toward decreased costs.
Long-standing protocols often do not take into account current knowledge and research.
DIF: Cognitive Level: Applying (Application)
REF: 136 - 137
Chapter 12: Design and Implementation of Patient Education
Test Bank
MULTIPLE CHOICE
1. A patient is diagnosed with asthma. The primary care nurse practitioner (NP) prescribes an
inhaled corticosteroid and an inhaled bronchodilator medication and provides education about
how to use inhalers. At a follow-up visit 2 weeks later, the patient’s pulmonary function tests
are worse. The NP should:
a. provide a detailed written asthma action plan for the patient.
b. ask the patient to describe how the medications have been used.
c. review the symptoms of an acute asthma exacerbation with the patient.
d. teach the patient to use the albuterol more often and order an oral steroid.
ANS: B
Follow-up visits present an opportunity for the NP to evaluate learning. A first step when
symptoms have not improved is to ask the patient to describe what he or she does. A detailed
written plan and a review of asthma symptoms are a part of education but should have been
given at the initial visit along with hands-on instruction and demonstrations. Until it is
determined whether or not the patient understands and follows the prescribed regimen, it is
not correct to change the plan of care.
DIF: Cognitive Level: Applying (Application)
REF: 139
2. A patient who has recently developed prediabetic symptoms is overweight and has a sedentary
lifestyle. The primary care NP has prescribed an oral antidiabetic agent. The patient says, “I
suppose I’ll need insulin like my mother and grandfather did.” To educate this patient about
managing this disease, the NP should initially:
a. determine how the patient feels about using insulin.
b. provide written educational materials about diet and exercise.
c. compare the actions of oral antidiabetic agents with insulin injections.
d. tell the patient that the medication plus exercise may prevent the need for insulin.
ANS: A
When beginning an education program for patients, it is first necessary to determine the
patient’s motivation and desire to learn. Asking this patient about feelings about using insulin
would help the NP understand how this possibility might motivate the patient to learn about
prediabetic management. The other options all are legitimate parts of a teaching plan but
cannot be used effectively until the patient and the provider have negotiated what the patient
wants to know.
DIF: Cognitive Level: Applying (Application)
REF: 139
3. A patient who is newly diagnosed with hypertension is to begin taking two antihypertensive
medications. The primary care NP gives the patient written drug information and starts to
discuss medication side effects. The patient interrupts and says, “I don’t want to know all that.
Just tell me what to take and when.” The NP should:
a. explain that medication side effects can have serious consequences.
b. ask the patient about previous experiences with medication side effects.
c. give the patient a copy of the medication package insert to read at home.
d. refer the patient to a website with information about hypertension drug therapy.
ANS: B
Asking the patient about previous experiences with medication side effects can help the NP to
understand the patient’s motivations to learn and may provide the NP a point of reference to
help make the information more relevant to the patient. Giving the patient information when it
is not wanted would not be effective.
DIF: Cognitive Level: Applying (Application)
REF: 139
4. The primary care NP is seeing a patient for a hospital follow-up after the patient has had a
first myocardial infarction. The patient has a list of the prescribed medications and tells the
NP that “no one explained anything about them.” The NP’s initial response should be to:
a. ask the patient to describe the medication regimen.
b. ask the patient to make a list of questions about the medications.
c. determine what the patient understands about coronary artery disease.
d. give the patient information about drug effects and any adverse reactions.
ANS: C
When a patient is first diagnosed with a medical problem, education must start with
explaining the pathophysiology in terms the patient will understand. When patients
understand what has happened to them, they can move on to consider what to do about it. The
other responses are part of an education plan but are not the initial response.
DIF: Cognitive Level: Applying (Application)
REF: 139 - 140
5. A primary care NP is reviewing written information about a newly prescribed medication with
a patient. To evaluate this patient’s understanding of the information, the NP should ask the
patient to:
a. read the information aloud.
b. describe how the medication will be taken.
c. write down questions about the medication.
d. tell the NP if the information is unclear.
ANS: B
To evaluate a patient’s understanding, the NP should ask the patient to describe in his or her
own words what is taught. Asking a patient to read aloud is sometimes used to assess literacy.
Patients who are not literate may not be able to write down questions and, because of shame,
may not tell the NP that the written information is unclear.
DIF: Cognitive Level: Applying (Application)
REF: 144
6. A primary care NP is developing a handout to give to patients who will begin self-
administering insulin. When developing this handout, the NP should:
a. provide detailed descriptions of each step in the process of injecting insulin.
b. use correct medical terminology when describing insulin self-administration.
c. provide as much factual information as possible about insulin administration.
d. address one or two educational objectives that describe what the patient will learn.
ANS: D
When developing patient education materials, it is important to limit content to one or two
educational objectives and list what the patient will learn and do after reading the material.
Written materials should not be too detailed but rather presented using bulleted points. When
possible, material should use common words and phrases and avoid medical terms.
DIF: Cognitive Level: Applying (Application)
REF: 143
7. 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 “Prism.com.” The NP should tell this patient that:
a. this information is probably from a drug advertisement website.
b. this is factual, evidence-based material with accurate information.
c. the information is from a nonprofit group that will not profit from drug sales.
d. internet information is unreliable because anyone can post information there.
ANS: A
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.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 144
Chapter 13: Dermatologic Agents
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) prescribes a topical cream medication. Which
statement by the patient indicates understanding of proper application of this medication?
a. “I should apply this medication after bathing.”
b. “I need to use a tongue blade to apply this medication.”
c. “I should apply this medication liberally to all affected areas.”
d. “I will apply this medication using circular strokes to ensure absorption.”
ANS: A
For optimal absorption of topical medications, apply them to moist skin either immediately
after bathing or after wet soaks. A tongue blade is used for topicals in paste form. Topical
medications should be applied in a thin layer, not liberally. Topical medications should be
applied using long, downward strokes because back-and-forth strokes can cause irritation.
DIF: Cognitive Level: Applying (Application)
REF: 152 - 153
2. An NP student asks the primary care NP about guidelines for using topical steroids. The NP
should tell the student that:
a. evidence-based guidelines are available for each product.
b. standardized guidelines have been developed for use in children.
c. standardized guidelines may be found for disease-specific conditions.
d. evidence-based studies support limited corticosteroid use in pregnancy.
ANS: C
Standardized guidelines are available for disease-specific conditions; there are no evidencebased studies or standardized guidelines for using topical steroids.
DIF: Cognitive Level: Applying (Application)
REF: 154 - 155
3. A 5-year-old child has atopic dermatitis that is refractory to treatment with hydrocortisone
acetone 2.5% cream. The primary care NP should prescribe:
a. desonide cream 0.01%.
b. triamcinolone acetonide.
c. fluocinolone cream 0.2%.
d. betamethasone dipropionate ointment 0.05%.
ANS: B
An over-the-counter steroid has failed to treat this child’s dermatitis, so the NP should
prescribe something in a higher strength. Triamcinolone is a medium-strength steroid and
should be used. The other three are in groups I and II, which are high-strength steroids and are
not recommended in children.
DIF: Cognitive Level: Applying (Application)
REF: 154| 156
4. A patient has been treated for severe contact dermatitis on both arms with clobetasol
propionate cream. At a follow-up visit, the primary care NP notes that the condition has
cleared. The NP should:
a. prescribe triamcinolone cream for 2 weeks.
b. recommend continuing treatment for 2 more weeks.
c. discontinue the clobetasol and schedule a follow-up visit in 2 weeks.
d. discontinue the clobetasol and recommend prn use for occasional flare-ups.
ANS: A
Treatment should be discontinued when the skin condition has resolved. Tapering the
corticosteroid will prevent recurrence of the skin condition. Tapering is best done by
gradually reducing the potency and dosing frequency at 2-week intervals. This patient was on
a very high potency steroid, so changing to a medium frequency with follow-up in 2 weeks is
an appropriate action. Discontinuing the steroid abruptly can lead to recurrence.
DIF: Cognitive Level: Applying (Application)
REF: 160
5. A primary care NP prescribes fluocinolone cream for a patient who has contact dermatitis. At
a follow-up visit in 2 weeks, the patient reports decreased pruritus but continues to have
excoriated, erythematous areas. The NP should:
a. obtain a culture of the skin to monitor for superinfection.
b. discontinue the fluocinolone and order betamethasone cream.
c. begin gradually tapering the fluocinolone at 2-week intervals.
d. tell the patient to continue using the fluocinolone for 3 to 4 more weeks.
ANS: D
The risk of adverse effects is less if group II steroids are used for less than 6 to 8 weeks. If the
condition is responding to treatment, and there are no signs of adverse effects, the NP should
recommend continuing use. The patient does not have exudative lesions, so a culture is not
necessary.
DIF: Cognitive Level: Applying (Application)
REF: 155
6. A primary care NP is considering using a topical immunosuppressive agent for a patient who
has atopic dermatitis that is refractory to treatment with topical corticosteroids. The NP
should:
a.
b.
c.
d.
begin therapy with pimecrolimus (Elidel).
tell the patient that these agents may be used long-term.
counsel the patient that these agents are more likely to cause skin atrophy.
tell the patient that laboratory monitoring for hypothalamic-pituitary-adrenal
(HPA) suppression will be necessary.
ANS: A
Topical calcineurin agents are considered second-line agents for treating atopic dermatitis and
should be limited to use in patients who have failed treatment with other therapies.
Pimecrolimus permeates skin at a lower rate than tacrolimus and so should be tried first.
These agents are for short-term use only because of the risk of skin cancer. These agents are
less likely than steroids to cause skin atrophy, and HPA suppression is not a risk.
DIF: Cognitive Level: Applying (Application)
REF: 156 - 157
7. A primary care NP sees a child who has honey-crusted lesions with areas of erythema around
the nose and mouth. The child’s parent has been applying Polysporin ointment for 5 days and
reports no improvement in the rash. The NP should prescribe:
a. mupirocin.
b. neomycin.
c. a systemic antibiotic.
d. Polysporin with a corticosteroid.
ANS: A
Treatment with a topical antiinfective agent should be reevaluated in 3 to 5 days if there is no
improvement. Polysporin ointment is bacteriostatic, not bacteriocidal. Mupirocin is indicated
for impetigo caused by Staphylococcus aureus, which is most common in children. Neomycin
is an aminoglycoside and is not effective against S. aureus. A systemic antibiotic is not
indicated unless the mupirocin fails to treat the infection. Adding a corticosteroid would
increase the likelihood that the infection will worsen.
DIF: Cognitive Level: Applying (Application)
REF: 157
8. A patient is seen by a primary care NP to evaluate a rash. The NP notes three ring-shaped
lesions with elevated, erythematous borders and two smaller, scaly patches on the patient’s
abdomen. The patient has not used any over-the-counter medications on the rash. The NP
should prescribe:
a. terbinafine (Lamisil).
b. oxiconazole (Oxistat).
c. ketoconazole (Nizoral).
d. miconazole (Lotrimin AF).
ANS: D
When initiating treatment for tinea corporis, start with an older agent, such as miconazole,
because this is available over-the-counter and in generic form and is cheaper. Other agents
may be used if the infection does not respond to miconazole or if there are localized side
effects to the product.
DIF: Cognitive Level: Applying (Application)
REF: 158
9. An 18-month-old child who attends day care has head lice and has been treated with
permethrin 1% (Nix). The parent brings the child to the clinic 1 week later, and the primary
care NP notes live bugs on the child’s scalp. The NP should order:
a. lindane.
b. malathion.
c. ivermectin.
d. permethrin 5%.
ANS: D
Permethrin is the first-line drug of choice for treating head lice and is usually effective in one
application. Significant resistance to permethrin 1% has developed, and permethrin 5% is
more effective. In pediculosis, if live lice can be found after 1 week, reapply treatment. This
child may have been reinfected at day care and so should be treated again. Malathion is a
second-line drug and is not recommended in children younger than age 2. Lindane is a thirdline drug. Ivermectin is a fourth-line drug.
DIF: Cognitive Level: Applying (Application)
REF: 161
10. A patient who has scabies has been treated by the primary care NP twice with permethrin
(Elimite). The second application was administered 10 days after the first. The patient returns
to the clinic with mild pruritus and erythema. The NP does not observe new burrows on the
skin. The NP should:
a. order lindane.
b. order malathion.
c. re-treat with permethrin.
d. prescribe triamcinolone 0.1%.
ANS: D
In scabies, pruritus may persist for several weeks after treatment and does not necessarily
indicate the need for re-treatment. Dermatitis may persist for months. Triamcinolone 0.1%
may be used to help with pruritus and dermatitis. Lindane and malathion are not indicated.
Re-treatment is not necessary.
DIF: Cognitive Level: Applying (Application)
REF: 161
11. A primary care NP is performing a well-child checkup on an adolescent patient and notes
approximately 20 papules and comedones and 10 pustules on the patient’s face, chest, and
back. The patient has not tried any over-the-counter products to treat these lesions. The NP
should begin treatment with:
a. salicylic acid.
b. topical tretinoin.
c. oral antibiotics.
d. benzoyl peroxide and topical clindamycin.
ANS: D
Mild acne consists of a lesion count of less than 30 with less than 15 pustules. Benzoyl
peroxide and topical clindamycin are both indicated for treatment of mild to moderate acne
and are first-line choices. Topical tretinoin is used as a second-line or third-line treatment.
Oral antibiotics are used when topical antibiotics fail. Salicylic acid is an appropriate first-line
treatment, but because this patient has pustular lesions, topical antibiotics must be included.
DIF: Cognitive Level: Applying (Application)
REF: 165
12. A primary care NP is preparing to irrigate and suture a laceration on a patient’s thumb. To
anesthetize the site, the NP should use:
a. lidocaine hydrochloride.
b. lidocaine with epinephrine.
c. bupivacaine hydrochloride.
d. bupivacaine with epinephrine.
ANS: B
Vasoconstrictors, such as epinephrine, help to prolong local anesthetic action by decreasing
systemic absorption, but they are not safe to use at the ends of arteries in fingers, toes, the
nose, or the penis. Lidocaine is an intermediate-acting local anesthetic and, when used without
epinephrine, is appropriate to use on a thumb. Bupivacaine is a very long-acting anesthetic
and is not needed for a short procedure.
DIF: Cognitive Level: Applying (Application)
REF: 169
Chapter 14: Eye, Ear, Throat, and Mouth Agents
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) sees a patient who has a 1-week history of watery,
painful eyes with copious amounts of clear discharge and a sore throat. The NP observes
bilateral erythema of the conjunctivae and palpates enlarged preauricular lymph nodes. The
NP should prescribe _____ drops.
a. ganciclovir
b. ophthalmic antibiotic
c. sympathomimetic ophthalmic
d. nonsteroidal antiinflammatory
ANS: B
The patient has symptoms of viral conjunctivitis; clear discharge is characteristic. Antibiotic
drops are often prescribed to prevent a bacterial infection. Ganciclovir drops are antiviral
drops but are reserved for patients with a clinical diagnosis of herpetic keratitis by an
ophthalmologist. Sympathomimetic drops are used to treat glaucoma. Nonsteroidal
antiinflammatory drops are sometimes used for allergic conjunctivitis.
DIF: Cognitive Level: Applying (Application)
REF: 175
2. A primary care NP examines a patient who complains of chronic, intermittent watery eyes and
runny nose. The NP notes cobblestone-like papillae inside the upper eyelid with
nonerythematous conjunctivae. The NP should:
a. prescribe intranasal corticosteroids.
b. refer the patient to an ophthalmologist.
c. prescribe trifluridine ophthalmic eye drops.
d. apply fluorescein dye to examine the cornea.
ANS: A
This patient has symptoms characteristic of allergic conjunctivitis. Any allergic rhinitis should
be treated first. Intranasal corticosteroids are often effective. It is not necessary to refer to an
ophthalmologist. Trifluridine is an antiviral solution used to treat documented herpetic
keratitis. Fluorescein dye is used to assess for corneal abrasions or tears.
DIF: Cognitive Level: Applying (Application)
REF: 175 - 176
3. The primary care NP teaches a patient how to instill eye drops for a prescription that requires
two drops twice daily. Which statement by the patient indicates understanding of the
teaching?
a. “I should gently massage my eyes for 3 to 5 minutes after instilling the drops.”
b. “I should put in one drop and wait 5 minutes before putting in the other one.”
c. “To make sure the medicine is evenly distributed, I should blink several times.”
d. “I may continue wearing my soft contact lenses while I am using this medication.”
ANS: B
One drop of medication is all the eye can retain. If more than one drop is used, teach the
patient to wait 5 minutes before applying the second drop. The eyes should not be rubbed after
instillation of the drops. Patients should look down for a few seconds and then close the eyes.
Soft contact lenses can absorb the medication and should not be worn.
DIF: Cognitive Level: Applying (Application)
REF: 176
4. The primary care NP examines an adolescent who complains of severe right ear pain for the
past 3 days. When retracting the pinna of the right ear to examine the ear, the NP notes
erythema, edema, and pain and a large amount of white exudate in the ear canal. The NP
should prescribe:
a. benzocaine otic drops tid.
b. ciprofloxacin otic drops qid.
c. glycerin oil drops weekly.
d. acetic acid, boric acid, and isopropyl alcohol solution.
ANS: B
This patient has otitis externa. Ciprofloxacin otic drops instilled onto a wick in the ear canal
are indicated to treat this condition. Benzocaine is a local anesthetic and would not treat the
infection. Glycerin oil drops are used to soften cerumen. An acetic acid, boric acid, and
isopropyl alcohol solution is used to prevent, not treat, otitis externa.
DIF: Cognitive Level: Applying (Application)
REF: 181 - 182
5. A parent brings in a 2-month-old infant with a 5-day history of a white coating on the tongue
and decreased oral intake. The primary care NP should prescribe:
a. clotrimazole, one troche tid.
b. chlorhexidine, 15 mL oral rinse bid.
c. carbamide peroxide, 2 to 3 drops tid.
d. nystatin oral suspension, 200,000 units qid.
ANS: D
Nystatin is an antifungal medication and is indicated for treatment of oral candidiasis, or
thrush. Clotrimazole is an antifungal but is not indicated for oral candidiasis in infants because
the patient must be able to allow the troche to dissolve. Chlorhexidine is used to treat
gingivitis. Carbamide peroxide is used to treat minor oral inflammation.
DIF: Cognitive Level: Applying (Application)
REF: 182
6. A patient who has year-round allergic rhinitis uses an intranasal corticosteroid and a daily oral
antihistamine. The patient reports persistent watery and itchy eyes. The primary care NP
observes profuse clear, watery discharge and a cobblestone appearance inside the upper
eyelids, with clear conjunctivae. The patient has tried topical azelastine (Astelin) and topical
diclofenac (Voltaren) without improvement. The NP should prescribe _____ drops.
a. timolol (Timoptic)
b. pilocarpine (Isopto)
c. nedocromil (Tilade)
d. dexamethasone (Decadron)
ANS: C
Topical mast cell stabilizers, such as nedocromil, are good for long-term treatment of allergic
conjunctivitis. Timolol and pilocarpine are used to treat glaucoma. Dexamethasone is
prescribed for severe cases of conjunctivitis but should be prescribed only by an
ophthalmologist.
DIF: Cognitive Level: Applying (Application)
REF: 177 - 178
7. An 80-year-old patient has a diagnosis of glaucoma, and the ophthalmologist has prescribed
timolol (Timoptic) and pilocarpine eye drops. The primary care NP should counsel this
patient:
a. that systemic side effects of these medications may be severe.
b. that the combination of these two drugs may cause drowsiness.
c. to begin an exercise program to improve cardiovascular health.
d. that a higher dose of one or both of these medications may be needed.
ANS: A
Older patients are susceptible to systemic effects of topical eye drops. Timolol can cause
cerebrovascular, central nervous system, and respiratory side effects, and pilocarpine can
cause systemic -blocker effects. The combination does not cause drowsiness. Although there
is some correlation between cardiovascular health and glaucoma, beginning a new exercise
program is not indicated. A higher dose of the medications would increase systemic side
effects.
DIF: Cognitive Level: Applying (Application)
REF: 183
Chapter 15: Upper Respiratory Agents
Test Bank
MULTIPLE CHOICE
1. A patient tells a nurse practitioner (NP) that several coworkers have upper respiratory
infections and asks about the best way to avoid getting sick. The NP should recommend
which of the following?
a.
b.
c.
d.
Echinacea
Frequent hand washing
Zinc gluconate supplements
Normal saline nasal irrigation
ANS: B
Hand washing is the most effective way to prevent the spread of viral upper respiratory illness
(VURI). Echinacea has not been shown to be effective in preventing VURI. Zinc gluconate
may decrease the duration of a VURI if taken within 24 hours of onset, but it does not prevent
infection. Normal saline irrigation is helpful for symptomatic relief after a VURI has begun.
DIF: Cognitive Level: Applying (Application)
REF: 189
2. A patient comes to the clinic with a 3-day history of fever and a severe cough that interferes
with sleep. The patient asks the NP about using a cough suppressant to help with sleep. The
NP should:
a. order a narcotic antitussive to suppress cough.
b. obtain a thorough history of the patient’s symptoms.
c. suggest that the patient try a guaifenesin-only over-the-counter product.
d. prescribe an antibiotic to treat the underlying cause of the patient’s cough.
ANS: B
It is important to determine the underlying disorder that is causing the cough to rule out
serious causes of cough. The NP should obtain a thorough history before prescribing any
treatment. A narcotic antitussive may be used after serious causes are ruled out. Guaifenesin
may be used to make nonproductive coughs more productive. Antibiotics are indicated only
for a proven bacterial infection.
DIF: Cognitive Level: Applying (Application)
REF: 192
3. An NP prescribes azelastine for a patient who has allergic rhinitis. The NP will teach the
patient that this drug:
a. may cause a bitter aftertaste.
b. will not provide maximum relief for a few weeks.
c. will cause rebound congestion if withdrawn suddenly.
d. can cause many systemic side effects such as drowsiness.
ANS: A
Azelastine is a topical antihistamine with few adverse systemic side effects. Patients may
experience relief from symptoms within 30 minutes. Decongestants can cause rebound
congestion if withdrawn suddenly. Topical antihistamines rarely cause systemic side effects.
DIF: Cognitive Level: Applying (Application)
REF: 198
4. A parent asks an NP which over-the-counter medication would be best to give to a 5-year-old
child who has a viral respiratory illness with nasal congestion and a cough. The NP should
recommend which of the following?
a. Diphenhydramine (Benadryl)
b. Increased fluids with a teaspoon of honey
c. Over-the-counter pseudoephedrine with guaifenesin (Sudafed)
d. An antitussive/expectorant combination such as Robitussin DM
ANS: B
Nonpharmacologic treatments are recommended for children younger than 6 years. Adequate
hydration can decrease cough, thin secretions, and hydrate tissues. A teaspoon of honey has
been shown to be effective in reducing cough in small children. Diphenhydramine is an
antihistamine that dries nasal secretions but does not aid in decongestion. Sudafed and
Robitussin are not recommended in children younger than 6 years.
DIF: Cognitive Level: Applying (Application)
REF: 198
5. A child with chronic allergic symptoms uses an intranasal steroid for control of symptoms. At
this child’s annual well-child checkup, the NP should carefully review this child’s:
a. urinalysis.
b. blood pressure.
c. height and weight.
d. liver function tests.
ANS: C
Intranasal corticosteroids can cause growth suppression in children. When using intranasal
steroids in children, the lowest dosage should be used for the shortest period of time
necessary, and growth should be routinely monitored. It is not necessary to evaluate urine,
blood pressure, or liver function because of intranasal steroid use.
DIF: Cognitive Level: Applying (Application)
REF: 191
6. An NP sees a patient who reports persistent seasonal symptoms of rhinorrhea, sneezing, and
nasal itching every spring unrelieved with diphenhydramine (Benadryl). The NP should
prescribe:
a. azelastine (Astelin).
b. triamcinolone (Nasacort AQ).
c. phenylephrine (Neo-Synephrine).
d. cromolyn sodium (Nasalcrom).
ANS: B
According to randomized controlled trials in patients with allergic rhinitis, oral antihistamines
are used first to help control itching, sneezing, rhinorrhea, and stuffiness in most patients.
Intranasal corticosteroids are indicated for patients who do not respond to antihistamines.
Azelastine is a topical antihistamine. Phenylephrine is a decongestant, and this patient does
not have congestion. Cromolyn sodium is less effective than intranasal corticosteroids.
DIF: Cognitive Level: Applying (Application)
REF: 188 - 189
7. A 70-year-old patient asks an NP about using diphenhydramine (Benadryl) to control
intermittent allergic symptoms that include runny nose and sneezing. The NP should counsel
this patient to:
a. take the lowest recommended dose initially.
b. monitor for hypertension while taking the drug.
c. take the antihistamine with a decongestant for best effect.
d. watch for symptoms of paradoxical excitation with this medication.
ANS: A
Antihistamines are more likely to cause excessive sedation, syncope, dizziness, confusion, and
hypotension in elderly patients; a decrease in dose is usually necessary. Hypotension is likely;
there is no need to monitor for hypertension. This patient does not have symptoms of
congestion. Paradoxical excitation occurs in some young children but is not an identified risk
in elderly patients.
DIF: Cognitive Level: Applying (Application)
REF: 191
8. A patient asks an NP about using an oral over-the-counter decongestant medication for nasal
congestion associated with a viral upper respiratory illness. The NP learns that this patient
uses loratadine (Claritin), a -adrenergic blocker, and an intranasal corticosteroid. The NP
would be concerned about which adverse effects?
a. Liver toxicity
b. Excessive drowsiness
c. Rebound congestion
d. Tremor, restlessness, and insomnia
ANS: D
-Adrenergic blockers and monoamine oxidase inhibitors may potentiate the effects of
decongestants, such as tremor, restlessness, and insomnia. Liver toxicity, excessive
drowsiness, and rebound congestion are not known adverse effects of drug interactions.
DIF: Cognitive Level: Analyzing (Analysis)
REF: 195
Chapter 16: Asthma and Chronic Obstructive Pulmonary Disease Medications
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) is evaluating a patient with asthma who reports having
wheezing and coughing 1 or 2 days each week and awakening from sleep three or four times
each month with asthma symptoms. The patient’s forced expiratory volume in 1 second
(FEV1) is 80% of the predicted value. The patient’s current medication regimen is an albuterol
metered-dose inhaler, 2 puffs every 4 hours as needed. The NP should prescribe:
a. montelukast (Singulair) po daily.
b. ipratropium bromide bid with albuterol.
c. a low-dose inhaled corticosteroid (ICS), 2 puffs bid.
d. a long-acting -adrenergic agonist (LABA), 1 puff bid.
ANS: C
This patient has symptoms of mild, persistent asthma. The preferred controller medication in
adults and children with persistent asthma is a low-dose ICS. Montelukast is a leukotriene
modifier, which may be considered as an alternative to a low-dose ICS but is not the first
option to try. Ipratropium is often used during an acute exacerbation but not for long-term
control. LABA medications are used in patients with moderate persistent symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 210
2. A primary care NP sees an adolescent patient for a hospitalization follow-up after an asthma
exacerbation. The patient reports having daily symptoms with nighttime awakening 4 or 5
nights per week and misses school several days each month. The patient currently uses a
salmeterol/fluticasone LABA twice daily and albuterol as needed. The patient requires a refill
of the albuterol prescription once a month. The patient does not have any known allergies.
The NP should:
a. order a high-dose ICS plus a LABA twice daily.
b. consider adding theophylline to this patient’s regimen.
c. continue the current regimen and add omalizumab daily.
d. order a combination product with ipratropium and albuterol.
ANS: A
The patient has moderate persistent asthma not well controlled with the current regimen. The
next step is to prescribe a high-dose ICS to be taken along with the LABA and to refer to an
asthma specialist. Theophylline is recommended in the 5- to 11-year age group. Omalizumab
is indicated if the patient has allergies. Ipratropium is used during acute exacerbations.
DIF: Cognitive Level: Applying (Application)
REF: 210
3. A 50-year-old patient who recently quit smoking reports a frequent morning cough productive
of yellow sputum. A chest x-ray is clear, and the patient’s FEV1 is 80% of predicted. Pulse
oximetry reveals an oxygen saturation of 97%. The primary care NP auscultates clear breath
sounds. The NP should:
a. reassure the patient that these symptoms will subside.
b. prescribe a moderate-dose ICS twice daily.
c. order a long-acting anticholinergic with albuterol twice daily.
d. prescribe an albuterol metered-dose-inhaler, 2 puffs every 4 hours as needed.
ANS: D
For patients with stable COPD having respiratory symptoms with FEV1 between 60% and
80% of predicted, inhaled bronchodilators may be used. COPD is not reversible, and the
symptoms will not subside. ICS therapy or long-acting anticholinergics are recommended
when FEV1 is less than 60%.
DIF: Cognitive Level: Applying (Application)
REF: 212 - 213
4. A primary care NP is evaluating a patient who has COPD. The patient uses a LABA twice
daily. The patient reports having increased exertional dyspnea, a frequent cough, and poor
sleep. The patient also uses a short-acting -adrenergic agonist (SABA) five or six times each
day. Pulse oximetry reveals an oxygen saturation of 92%. The patient’s FEV1/forced vital
capacity is 65, and FEV1 is 55% of predicted. The NP should prescribe a(n):
a. oral corticosteroid.
b. long-acting anticholinergic.
c. long-acting oral theophylline.
d. combination ICS/LABA inhaler.
ANS: D
Providers should administer combination inhaled therapies for symptomatic patients with
stable COPD and FEV1 less than 60%. Oral corticosteroids have not been shown to be
effective, even in severe cases of COPD. Long-acting anticholinergic medications may be
used as monotherapy in early stages of COPD. Long-acting theophylline is poorly tolerated
because of side effects.
DIF: Cognitive Level: Applying (Application)
REF: 213
5. 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:
a. combination ICS/LABA inhaler twice daily.
b. short-acting 2-agonist (SABA) with oral corticosteroids when symptomatic.
c. combination ipratropium/albuterol inhaler twice daily.
d. SABA as needed plus a leukotriene modifier once daily.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 210
6. A patient who was recently diagnosed with COPD comes to the clinic for a follow-up
evaluation after beginning therapy with a SABA as needed for dyspnea. The patient reports
occasional mild exertional dyspnea but is able to sleep well. The patient’s FEV1 in the clinic is
85% of predicted, and oxygen saturation is 96%. The primary care NP should recommend:
a. a combination LABA/ICS twice daily.
b. influenza and pneumococcal vaccines.
c. ipratropium bromide (Atrovent) twice daily.
d. home oxygen therapy as needed for dyspnea.
ANS: B
Influenza and pneumococcal immunizations are recommended to help reduce comorbidity that
will affect respiratory status. This patient is stable with the prescribed medications, so no
additional medications are needed at this time. Home oxygen therapy is used for patients with
severe resting hypoxemia.
DIF: Cognitive Level: Applying (Application)
REF: 213
7. A 70-year-old patient who has COPD takes theophylline daily and uses a SABA for
exacerbation of symptoms. The patient reports using the SABA three or four times each week
when short of breath. The patient reports feeling jittery and nauseated and having trouble
sleeping. The primary care NP should:
a. obtain a serum theophylline level.
b. order a creatinine clearance level.
c. prescribe a leukotriene modifier instead of theophylline.
d. discontinue the SABA and change to ipratropium bromide.
ANS: A
Nausea, vomiting, insomnia, jitteriness, and other symptoms may indicate theophylline
toxicity. Serum concentration monitoring should be done whenever signs of toxicity are
suspected. A serum creatinine clearance level is not indicated. Leukotriene modifiers are not
used for COPD. Ipratropium is used as an adjunct to the SABA during acute exacerbations.
DIF: Cognitive Level: Applying (Application)
REF: 214
8. A 75-year-old patient requires frequent use of corticosteroids to control COPD exacerbations.
To monitor adverse drug effects in this patient, the primary care NP should:
a. order a bone density study.
b. monitor the patient’s renal function at every visit.
c. order an electrocardiogram to assess for arrhythmias.
d. order routine chest radiographs to watch for pneumonia.
ANS: A
High-dose ICSs and oral corticosteroids that are often used in COPD may cause or worsen
osteoporosis in an older adult. The NP should order a bone density study.
DIF: Cognitive Level: Applying (Application)
REF: 215
9. A patient with asthma is given an asthma action plan and returns to the clinic in 2 weeks to
follow up on symptoms. Which statement by the patient indicates a need for further teaching?
a. “I use the ICS as needed when I am wheezing.”
b. “A side effect of albuterol may be shortness of breath.”
c. “I should rinse my mouth thoroughly after using an ICS.”
d. “I put the albuterol metered-dose inhaler in my mouth with my lips sealed around
it.”
ANS: A
ICSs are controller medications and are not used as needed for symptoms, so this statement by
the patient indicates a need for further teaching. The other statements are true.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 210
Chapter 17: Hypertension and Miscellaneous Antihypertensive Medications
Test Bank
MULTIPLE CHOICE
1. 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:
a. prescribe a thiazide diuretic.
b. consider treatment with an angiotensin-converting enzyme inhibitor.
c. reassure the patient that these findings are normal.
d. counsel the patient about dietary and lifestyle changes.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 226| Table 17-2| Table 17-4| Table 17-6
2. A 55-year-old patient with no prior history of hypertension has a blood pressure greater than
140/90 on three separate occasions. The patient does not smoke, has a body mass index of 24,
and exercises regularly. The patient has no known risk factors for cardiovascular disease. The
primary care NP should:
a. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.
b. perform a careful cardiovascular physical assessment.
c. counsel the patient about dietary and lifestyle changes.
d. order a urinalysis and creatinine clearance and begin therapy with a -blocker.
ANS: B
If the patient is younger than 20 or older than 50 years old at the onset of elevated blood
pressure, the NP should look for causes of secondary hypertension. The physical examination
should include a careful cardiovascular assessment. This patient will need pharmacologic
treatment, but not until the underlying cause of hypertension is determined.
DIF: Cognitive Level: Applying (Application)
REF: 227 - 228
3. The primary care NP sees a new patient who has diabetes and hypertension and has been
taking a thiazide diuretic for 6 months. The patient’s blood pressure at the beginning of
treatment was 150/95 mm Hg. The blood pressure today is 138/85 mm Hg. The NP should:
a. order a -blocker.
b. add an angiotensin-converting enzyme inhibitor.
c. continue the current drug regimen.
d. change to an aldosterone antagonist medication.
ANS: B
Evidence-based guidelines suggest that optimal control of hypertension to less than 130/80
mm Hg could prevent 37% of cardiovascular disease in men and 56% in women, so this
patient, although showing improvement, could benefit from the addition of another
medication. An angiotensin-converting enzyme inhibitor is an appropriate drug for patients
who also have diabetes. -Blockers and aldosterone antagonist medications are not
recommended for patients with diabetes.
DIF: Cognitive Level: Applying (Application)
REF: 229| Table 17-6
4. A patient who has had a previous myocardial infarction has a blood pressure of 135/82 mm
Hg. The patient’s body mass index is 28, and the patient has a fasting plasma glucose of 105
mg/dL. The primary care NP should prescribe:
a. an angiotensin-converting enzyme inhibitor.
b. a thiazide diuretic.
c. lifestyle modifications.
d. a calcium-channel blocker.
ANS: A
This patient has prehypertension but has a compelling reason for treatment. Patients who have
had a myocardial infarction should be treated with a -blocker and angiotensin-converting
enzyme inhibitor or angiotensin II receptor blocker (ARB).
DIF: Cognitive Level: Applying (Application)
REF: 229| Table 17-6
5. 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. a -blocker.
b. an angiotensin-converting enzyme inhibitor.
c. a thiazide diuretic.
d. dietary and lifestyle changes.
ANS: C
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.
DIF: Cognitive Level: Applying (Application)
REF: 229
6. The primary care NP sees a new African-American patient who has blood pressure readings of
140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP
learns that the patient has a family history of hypertension. The NP should:
a. initiate monotherapy with a thiazide diuretic.
b. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.
c. discuss dietary and lifestyle modifications with the patient.
d. begin combination therapy with an ARB and a calcium-channel blocker.
ANS: A
African Americans tend to respond better than whites to diuretic monotherapy, so this is an
appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct
medications in African Americans.
DIF: Cognitive Level: Applying (Application)
REF: 232| Table 17-2
7. An 80-year-old male patient will begin taking an -antiadrenergic medication. The primary
care NP should teach this patient to:
a. ask for assistance while bathing.
b. restrict fluids to aid with diuresis.
c. take the medication in the morning with food.
d. be aware that priapism is a common side effect.
ANS: A
All antihypertensives can cause orthostatic hypotension, so patients should be cautioned to
avoid sudden changes in position and to use caution when bathing because a hot bath or
shower may aggravate dizziness. Older patients are at increased risk for falls and should be
cautioned to ask for assistance. Patients taking -antiadrenergics should consume extra fluids
because dehydration can increase the risk of orthostatic hypotension. Patients should take the
medication at bedtime because drowsiness is a common side effect. Priapism is not a side
effect of these drugs.
DIF: Cognitive Level: Applying (Application)
REF: 232 - 233
Chapter 18: Coronary Artery Disease and Antianginal Medications
Test Bank
MULTIPLE CHOICE
1. A patient who has a history of angina has sublingual nitroglycerin tablets to use as needed.
The primary care nurse practitioner (NP) reviews this medication with the patient at the
patient’s annual physical examination. Which statement by the patient indicates understanding
of the medication?
a. “I should call 9-1-1 if chest pain persists 5 minutes after the first dose.”
b. “I should take 3 nitroglycerin tablets 5 minutes apart and then call 9-1-1.”
c. “I should take aspirin along with the nitroglycerin when I have chest pain.”
d. “I should take nitroglycerin and then rest for 15 minutes before taking the next
dose.”
ANS: A
Although the traditional recommendation is for patients to take up to 3 nitroglycerin doses
over 15 minutes before accessing emergency medical services (EMS), more recent guidelines
suggest an alternative strategy to reduce delays in emergency care. These include instructions
to call 9-1-1 immediately if pain persists for 5 minutes after the first dose. Aspirin is
recommended when the patient is being transported to emergency care and is not
recommended as an adjunct to nitroglycerin with each episode of chest pain. The three doses
of nitroglycerin are given 5 minutes apart over 15 minutes.
DIF: Cognitive Level: Applying (Application)
REF: 241
2. A patient who will begin using nitroglycerin for angina asks the primary care NP how the
medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to:
a. dissolve atheromatous lesions.
b. relax vascular smooth muscle.
c. prevent catecholamine release.
d. reduce C-reactive protein levels.
ANS: B
Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine
monophosphate production with the major effect being to reduce myocardial oxygen demand.
Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce Creactive protein levels.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 239 - 240
3. A patient who has angina uses 0.4 mg of sublingual nitroglycerin for angina episodes. The
patient brings a log of angina episodes to an annual physical examination. The primary care
NP notes that the patient has experienced an increase in frequency of episodes in the past
month but no increase in duration or severity of pain. The NP should:
a. increase the nitroglycerin dose to 0.6 mg per dose.
b. change from a sublingual to a transdermal patch nitroglycerin.
c. discontinue the nitroglycerin and order ranolazine (Ranexa ER).
d. contact the patient’s cardiologist to discuss admission to the hospital.
ANS: D
Unstable angina is a change in pattern or pain, such as an increase in frequency, severity, or
duration of pain and fewer precipitating factors. Patients with unstable angina should be
admitted to a coronary care unit. The primary care NP should not change any medications
without consultation with the patient’s cardiologist.
DIF: Cognitive Level: Applying (Application)
REF: 239
4. A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and
begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs
the patient to lie down. The NP’s next action should be to:
a. obtain an electrocardiogram.
b. administer oxygen at 2 L/minute.
c. give 325 mg of chewable aspirin.
d. call EMS.
ANS: B
When a patient experiences an acute attack of angina in the clinic, the primary care NP should
be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered.
An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is
unrelieved and when the patient is being transported to the hospital. EMS should be activated
if there is no pain relief 5 minutes after the first dose of nitroglycerin.
DIF: Cognitive Level: Applying (Application)
REF: 241
5. A 45-year-old patient who has a positive family history but no personal history of coronary
artery disease is seen by the primary care NP for a physical examination. The patient has a
body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal lowdensity lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120
mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend:
a. 30 minutes of aerobic exercise daily.
b. taking 81 to 325 mg of aspirin daily.
c. beginning therapy with a statin medication.
d. starting a thiazide diuretic to treat hypertension.
ANS: A
This patient is overweight but not obese, and blood lipids are within normal limits. Blood
pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because
of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients
older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 240 - 241
6. The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate
SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of:
a. 60 mg four times daily at 6-hour intervals.
b. 40 mg twice daily 30 minutes before meals.
c. 60 mg on awakening and 40 mg 7 hours later.
d. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM.
ANS: B
Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation
is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day.
The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An
appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be
increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later.
The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the
dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point.
DIF: Cognitive Level: Applying (Application)
REF: 241
7. A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a
patient with chronic stable angina. The NP should teach the patient to:
a. change the patch four times daily.
b. use the patch as needed for angina pain.
c. use two patches daily and change them every 12 hours.
d. apply one patch daily in the morning and remove in 12 hours.
ANS: D
To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch
is not changed four times daily or used on a prn basis. The patch is applied once daily.
DIF: Cognitive Level: Applying (Application)
REF: 244
Chapter 19: Heart Failure and Digoxin
Test Bank
MULTIPLE CHOICE
1. A patient comes to the clinic with a recent onset of nocturnal and exertional dyspnea. The
primary care nurse practitioner (NP) auscultates S3 heart sounds but does not palpate
hepatomegaly. The patient has mild peripheral edema of the ankles. The NP should consult a
cardiologist to discuss prescribing a(n):
a. -blocker.
b. loop diuretic.
c. angiotensin-converting enzyme (ACE) inhibitor.
d. angiotensin receptor blocker (ARB).
ANS: B
This patient shows signs of systolic heart failure. Treatment for heart failure should begin with
a loop diuretic, with an ACE inhibitor added after the diuretic has been taken. -Blockers are
used in patients with minimal fluid retention and would be added later. ARBs are used if ACE
inhibitors are not tolerated or are ineffective.
DIF: Cognitive Level: Applying (Application)
REF: 251
2. A patient who has heart failure has been treated with furosemide and an ACE inhibitor. The
patient’s cardiologist has added digoxin to the patient’s medication regimen. The primary care
NP who cares for this patient should expect to monitor:
a. serum electrolytes.
b. blood glucose levels.
c. serum thyroid levels.
d. complete blood counts (CBCs).
ANS: A
Hypokalemia makes the myocardium more sensitive to digoxin. These levels should be
monitored closely in patients taking furosemide, which can deplete potassium. Serum glucose,
thyroid levels, and a CBC should be monitored if indicated by other conditions.
DIF: Cognitive Level: Applying (Application)
REF: 254
3. A patient who takes spironolactone for heart failure has begun taking digoxin (Lanoxin) for
atrial fibrillation. The primary care NP provides teaching for this patient and asks the patient
to repeat back what has been learned. Which statement by the patient indicates understanding
of the teaching?
a. “I should avoid high-sodium foods.”
b. “I should eat foods high in potassium.”
c. “I need to take a calcium supplement every day.”
d. “I should use a salt substitute while taking these medications.”
ANS: A
Patients should be taught to reduce their overall sodium intake by avoiding salty foods and not
adding salt while cooking. Spironolactone is a potassium-sparing diuretic and carries a risk of
hyperkalemia, which can make the myocardium more sensitive to the effects of digoxin.
Hypercalcemia can predispose the patient to digoxin toxicity. Salt substitutes are high in
potassium.
DIF: Cognitive Level: Applying (Application)
REF: 254
4. A patient has heart failure. A recent echocardiogram reveals decreased compliance of the left
ventricle and poor ventricular filling. The patient takes low-dose furosemide and an ACE
inhibitor. The primary care NP sees the patient for a routine physical examination and notes a
heart rate of 92 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. order serum electrolytes.
b. obtain renal function tests.
c. consider prescribing a -blocker.
d. call the patient’s cardiologist to discuss adding digoxin to the patient’s regimen.
ANS: A
Patients with diastolic heart failure are sensitive to fluid depletion, which can cause decreased
preload and stroke volume. This patient has a rapid heart rate and a low blood pressure, which
can indicate dehydration, so serum electrolytes should be obtained. Renal function tests are
not indicated. -Blockers are used in patients who are stable. Digoxin should not be used in
patients with diastolic failure.
DIF: Cognitive Level: Applying (Application)
REF: 251
5. A primary care NP is preparing to order digoxin for an 80-year-old patient who has systolic
heart failure. The NP obtains renal function tests, which are normal. The NP should:
a. prescribe a digoxin 0.125 mg tablet once daily.
b. give an initial dose of 0.5 mg digoxin tablet and then 0.125 mg every 6 hours  4.
c. administer a digoxin 0.6 mg capsule once and then 0.3 mg every 8 hours  3.
d. administer a loading dose of intravenous digoxin in the clinic and then give 0.125
mg once daily.
ANS: A
In primary care settings, slow digitalization rather than a loading dose is generally
recommended because of the risk of toxicity. Digitalization may be achieved within 1 week
with the use of small daily maintenance doses.
DIF: Cognitive Level: Applying (Application)
REF: 245| Table 19-5
6. A primary care NP sees a patient who is being treated for heart failure with digoxin, a loop
diuretic, and an ACE inhibitor. The patient reports having nausea. The NP notes a heart rate of
60 beats per minute and a blood pressure of 100/60 mm Hg. The NP should:
a. decrease the dose of the diuretic to prevent further dehydration.
b. obtain a serum potassium level to assess for hyperkalemia.
c. hold the ACE inhibitor until the patient’s blood pressure stabilizes.
d. obtain a digoxin level before the patient takes the next dose of digoxin.
ANS: D
To monitor for toxicity, the health care provider must be alert to early signs of toxicity and
must obtain a serum level. Nausea is an early sign of toxicity.
DIF: Cognitive Level: Applying (Application)
REF: 253 - 254
7. A patient who has been taking digoxin 0.25 mg daily for 6 months reports that it is not
working as well as it did initially. The primary care NP should:
a. recommend a reduced potassium intake.
b. increase the dose of digoxin to 0.5 mg daily.
c. hold the next dose of digoxin and obtain a serum digoxin level.
d. contact the patient’s pharmacy to ask if generic digoxin was dispensed.
ANS: D
Clinicians should be aware that generic digoxin marketed by different companies may not be
bioequivalent to the branded digoxin (Lanoxin). Patients with hyperkalemia would show
intensified effects, not diminished effects of digoxin. Patients with diminished effects may
have received a generic brand. It is not correct to increase the dose of digoxin without first
obtaining a digoxin level. Because this patient is reporting decreased effects, it is unnecessary
to suspect toxicity.
DIF: Cognitive Level: Applying (Application)
Chapter 20: Beta-Blockers
Test Bank
REF: 254
MULTIPLE CHOICE
1. An 80-year-old patient with chronic stable angina has begun taking nadolol (Corgard) 20 mg
once daily in addition to taking nitroglycerin as needed. After 1 week, the patient reports no
change in frequency of nitroglycerin use. The primary care nurse practitioner (NP) should
change the dose of nadolol to _____ mg _____ daily.
a. 40; once
b. 80; once
c. 20; twice
d. 40; twice
ANS: A
-Blockers are the treatment of choice for chronic stable and unstable angina. Their
therapeutic effect is dose dependent, and drug titration should be based on frequency of
angina symptoms and nitroglycerin use. Nadolol should be started at 20 mg daily for elderly
patients when treating angina and should be increased by 20 mg every 3 to 7 days if
symptoms do not improve. Nadolol is given once daily.
DIF: Cognitive Level: Applying (Application)
REF: 259| Table 20-7
2. A patient is in the clinic for a follow-up examination after a myocardial infarction (MI). The
patient has a history of left ventricular systolic dysfunction. The primary care NP should
expect this patient to be taking:
a. nadolol (Corgard).
b. carvedilol (Coreg).
c. timolol (Blocadren).
d. propranolol (Inderal).
ANS: B
The 2012 guides for prevention of cardiovascular disease recommend that -blocker therapy
should be used in all patients with left ventricular systolic dysfunction with heart failure or
prior MI. Use should be limited to carvedilol, metoprolol succinate, or bisoprolol.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 259
3. An 80-year-old patient has begun taking propranolol (Inderal) and reports feeling tired all of
the time. The primary care NP should:
a. tell the patient to stop taking the medication immediately.
b. recommend that the patient take the medication at bedtime.
c. tell the patient that tolerance to this side effect will occur over time.
d. contact the patient’s cardiologist to discuss decreasing the dose of propranolol.
ANS: D
Elderly patients have described sedation and sleep disturbances with -blockers. Elderly
patients often need lower doses of these drugs. Patients should not be advised to discontinue
the medication abruptly.
DIF: Cognitive Level: Applying (Application)
REF: 260
4. A patient with a history of coronary heart disease develops atrial fibrillation. The primary care
NP refers the patient to a cardiologist who performs direct current cardioversion. The NP
should expect the patient to begin taking which -blocker medication?
a. Nadolol (Corgard)
b. Sotalol (Betapace)
c. Timolol (Blocadren)
d. Propranolol (Inderal)
ANS: B
Sotalol is classified as a class II and III antiarrhythmic and is a preferred agent in patients with
a history of coronary heart disease.
DIF: Cognitive Level: Applying (Application)
REF: 259
5. A patient who has migraine headaches has begun taking timolol and 2 months after beginning
this therapy reports no change in frequency of migraines. The patient’s current dose is 30 mg
once daily. The primary care NP should:
a. change the medication to propranolol.
b. increase the dose to 40 mg once daily.
c. obtain serum drug levels to see if the dose is therapeutic.
d. tell the patient to continue taking the timolol and return in 1 month.
ANS: D
When giving timolol for migraine prophylaxis, the provider should inform the patient that it
may take several weeks for therapy to be effective. The dose should be titrated and maintained
for a minimum of 3 months before the treatment is deemed a failure. It may be necessary to
change to propranolol if the therapy is not effective in 1 month. The maximum dose of timolol
for migraine prophylaxis is 30 mg. Drug effectiveness is determined by patient response, not
serum drug levels.
DIF: Cognitive Level: Applying (Application)
REF: 259 - 260
6. A patient who has been taking propranolol for 6 months reports having nocturnal cough and
shortness of breath. The primary care NP should:
a. tell the patient to stop taking the medication.
b. obtain serum drug levels to monitor for toxicity of this medication.
c. instruct the patient to increase activity and exercise to counter these side effects.
d. contact the patient’s cardiologist to discuss changing to a selective -blocker.
ANS: D
Nocturnal cough and shortness of breath may be a side effect of propranolol, which can cause
bronchospasm because it is a nonselective â-blocker. The NP should discuss a selective blocker with the patient’s cardiologist. â-Blockers should never be stopped abruptly.
Bradycardia and hypotension are signs of toxicity. Increasing activity would not counter these
side effects if bronchospasm is the cause.
DIF: Cognitive Level: Applying (Application)
REF: 260 - 261
7. A patient is in the clinic for an annual physical examination. The primary care NP obtains a
medication history and learns that the patient is taking a -blocker and nitroglycerin. The NP
orders laboratory tests, performs a physical examination, and performs a review of systems.
Which finding may warrant discontinuation of the -blocker in this patient?
a. Increased triglycerides
b. Decreased exercise tolerance
c. Wheezing, dyspnea, and cough
d. Nausea, vomiting, and anorexia
ANS: C
-Blockers may cause bronchospasm in susceptible patients, and discontinuation of the blocker may be required. -Blockers may cause an insignificant increase in serum
triglycerides. Exercise intolerance, fatigue, and gastrointestinal side effects are common.
DIF: Cognitive Level: Applying (Application)
REF: 257
8. A primary care NP provides teaching for a patient who will begin taking propranolol
(Inderal). Which statement by the patient indicates understanding of the teaching?
a. “I should take this medication on an empty stomach.”
b. “I should use caution while driving while taking this medication.”
c. “I should not take the medication if my pulse is less than 60 beats per minute.”
d. “If I have shortness of breath, I should discontinue the medication immediately.”
ANS: B
Because the medication can cause fatigue and drowsiness, patients should be advised to use
caution when driving. The medication should be taken with food. Patients should not take a
dose if the heart rate is less than 50 beats per minute. Patients should be advised to report
shortness of breath but should not abruptly stop taking the medication.
DIF: Cognitive Level: Applying (Application)
REF: 258
Chapter 21: Calcium Channel Blockers
Test Bank
MULTIPLE CHOICE
1. A patient who has stable angina pectoris and a history of previous myocardial infarction takes
nitroglycerin and verapamil. The patient asks the primary care nurse practitioner (NP) why it
is necessary to take verapamil. The NP should tell the patient that verapamil:
a. improves blood flow and oxygen delivery to the heart.
b. increases the rate of contraction of the cardiac muscle.
c. increases the force of contraction of the cardiac muscle.
d. has a positive inotropic effect to increase cardiac output.
ANS: A
Verapamil decreases the force of smooth muscle contraction in the smooth muscle of the
coronary and peripheral vessels; this results in coronary artery dilation, which lowers coronary
resistance and improves blood flow through collateral vessels as well as oxygen delivery to
ischemic areas of the heart. Calcium channel blockers do not increase the rate or force of
contraction of the heart.
DIF: Cognitive Level: Applying (Application)
REF: 265 - 266
2. A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The
primary care NP should contact the patient’s cardiologist to discuss adding:
a. amlodipine (Norvasc).
b. diltiazem (Cardizem).
c. verapamil HCl (Calan).
d. nifedipine (Procardia XL).
ANS: D
Nifedipine and related drugs are potent vasodilators, which makes them more effective for
hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug.
DIF: Cognitive Level: Applying (Application)
REF: 267
3. A patient who has stable angina is taking nitroglycerin and a -blocker. The patient tells the
primary care NP that the cardiologist is considering adding a calcium channel blocker. The
NP should anticipate that the cardiologist will prescribe:
a. isradipine (DynaCirc).
b. nicardipine (Cardene).
c. verapamil HCl (Calan).
d. nifedipine (Procardia XL).
ANS: C
Nitrates and -blockers are first-line therapy for stable angina. Calcium channel blockers
should be reserved for patients who cannot take these agents or patients whose symptoms are
not controlled with these agents. Verapamil is one of the calcium channel blockers that should
be used. The other calcium channel blockers are not recommended for this purpose.
DIF: Cognitive Level: Applying (Application)
REF: 268
4. A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care
NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient
reports lightheadedness associated with standing up. The NP should consult with the patient’s
cardiologist about changing the medication to:
a. amlodipine (Norvasc).
b. isradipine (DynaCirc).
c. verapamil HCl (Calan).
d. short-acting nifedipine (Procardia).
ANS: C
Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related
drugs, such as isradipine and amlodipine.
DIF: Cognitive Level: Applying (Application)
REF: 268
5. An African-American patient who is obese has persistent blood pressure readings greater than
150/95 mm Hg despite treatment with a thiazide diuretic. The primary care NP should
consider prescribing a(n):
a. angiotensin receptor blocker.
b. -blocker.
c. ACE inhibitor.
d. calcium channel blocker.
ANS: D
African-American patients are considered good candidates for calcium channel blockers to
treat hypertension. Treatment with calcium channel blockers as monotherapy in AfricanAmerican patients has proved to be more effective than some other classes of antihypertensive
agents.
DIF: Cognitive Level: Applying (Application)
REF: 268
6. A patient who takes a calcium channel blocker is in the clinic for an annual physical
examination. The cardiovascular examination is normal. As part of routine monitoring for this
patient, the primary care NP should evaluate:
a. serum calcium channel blocker level.
b. complete blood count and electrolytes.
c. liver function tests (LFTs) and renal function.
d. thyroid and insulin levels.
ANS: C
Patients who take calcium channel blockers should have periodic renal and LFTs.
DIF: Cognitive Level: Applying (Application)
REF: 268
7. A patient who is taking nifedipine develops mild edema of both feet. The primary care NP
should contact the patient’s cardiologist to discuss:
a. changing to amlodipine.
b. ordering renal function tests.
c. increasing the dose of nifedipine.
d. evaluation of left ventricular function.
ANS: A
Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients;
this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely
to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would
worsen the symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 269
Chapter 22: ACE Inhibitors and Angiotensin Receptor Blockers
Test Bank
MULTIPLE CHOICE
1. 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:
a. increase the captopril dose to 50 mg twice daily.
b. add a thiazide diuretic to this patient’s regimen.
c. change the drug to losartan (Cozaar) 50 mg once daily.
d. recommend a low-sodium diet in addition to the medication.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 275 - 276
2. A patient with a previous history of myocardial infarction (MI) who takes nitroglycerin for
angina develops hypertension. The primary care NP is considering ordering an ACE inhibitor.
Preliminary laboratory tests reveal decreased renal function. The NP should:
a. begin therapy with a low-dose ACE inhibitor.
b. choose an ARB instead.
c. add a low-dose thiazide diuretic to the drug regimen.
d. order a renal perfusion study before starting treatment.
ANS: D
ACE inhibitors are contraindicated in patients with bilateral renal stenosis. Because this
patient has decreased renal function, perfusion studies are indicated. If the patient does not
have bilateral renal stenosis, a low-dose ACE inhibitor may be used. An ARB is indicated if
perfusion studies show bilateral renal stenosis. A thiazide diuretic is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 277
3. A patient who has type 2 diabetes is seen by a primary care NP for a physical examination.
The NP notes a blood pressure of 140/95 mm Hg on three occasions. A urinalysis reveals
macroalbuminuria. The patient’s serum creatinine is 1.9 mg/dL. Adhering to evidence-based
practice, the NP should prescribe:
a. losartan (Cozaar).
b. captopril (Capoten).
c. enalapril maleate (Vasotec).
d. fosinopril sodium (Monopril).
ANS: A
In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency
(serum creatinine >1.5 mg/dL), ARBs have been shown to delay the progression of
nephropathy. Losartan is an ARB. The other medications are ACE inhibitors.
DIF: Cognitive Level: Applying (Application)
REF: 277
4. 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:
a. consider changing the medication to an ARB.
b. order a bronchodilator to counter the bronchospasm caused by this drug.
c. ask whether the patient has had any associated facial swelling with this cough.
d. reassure the patient that tolerance to this adverse effect will develop over time.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 275
5. A patient who takes an ACE inhibitor and a thiazide diuretic for hypertension will begin
taking spironolactone. The primary care NP should counsel this patient to:
a. avoid foods that are high in potassium.
b. use a salt substitute when seasoning foods.
c. discuss changing the ACE inhibitor to an ARB with the cardiologist.
d. avoid taking antacids containing magnesium while taking these drugs.
ANS: A
Use of potassium-sparing diuretics or salt substitutes can induce hyperkalemia when taking
ACE inhibitors, so this patient should be counseled to restrict potassium. Salt substitutes are
high in potassium and are contraindicated. It is not necessary to change to an ARB. Antacids
are not contraindicated.
DIF: Cognitive Level: Applying (Application)
REF: 278
6. A patient who takes a thiazide diuretic will begin taking an ACE inhibitor. The primary care
NP should counsel the patient to:
a. report wheezing and shortness of breath, which may occur with these drugs.
b. take care when getting out of bed or a chair after the first dose of the ACE
inhibitor.
c. discuss taking an increased dose of the thiazide diuretic with the cardiologist.
d. minimize fluid intake for several days when beginning therapy with the ACE
inhibitor.
ANS: B
ACE inhibitors have a first-dose effect that may cause a precipitous symptomatic fall in blood
pressure, particularly in patients receiving diuretics. The patient should be counseled about
rising quickly from sitting or lying down. Wheezing and shortness of breath are unlikely. An
increased dose of diuretic and a reduction in fluid intake are not indicated and may add to
hypotension.
DIF: Cognitive Level: Applying (Application)
REF: 278
7. The primary care NP is considering prescribing captopril (Capoten) for a patient. The NP
learns that the patient has decreased renal function and has renal artery stenosis in the right
kidney. The NP should:
a. initiate ACE inhibitor therapy at a low dose.
b. consider a different drug class to treat this patient’s symptoms.
c. give the captopril with a thiazide diuretic to improve renal function.
d. order lisinopril (Zestril) instead of captopril to avoid increased nephropathy.
ANS: A
Patients with impaired renal function should use low-dose ACE inhibitors. It is not necessary
to avoid ACE inhibitors with unilateral renal stenosis.
DIF: Cognitive Level: Applying (Application)
REF: 278
Chapter 23: Antiarrhythmic Agents
Test Bank
MULTIPLE CHOICE
1. Persistent atrial fibrillation (AF) is diagnosed in a patient who has valvular disease, and the
cardiologist has prescribed warfarin (Coumadin). The patient is scheduled for electrical
cardioversion in 3 weeks. The patient asks the primary care nurse practitioner (NP) why the
procedure is necessary. The NP should tell the patient:
a. this medication prevents clots but does not alter rhythm.
b. if the medication proves effective, the procedure may be canceled.
c. there are no medications that alter the arrhythmia causing AF.
d. to ask the cardiologist if verapamil may be ordered instead of cardioversion.
ANS: A
Persistent AF lasts longer than 7 days and episodes fail to terminate on their own, but episodes
can be terminated by electrical cardioversion after therapeutic warfarin therapy for 3 weeks.
Warfarin does not alter AF. -Blockers, calcium channel blockers, and digoxin are sometimes
given to alter the rate. Verapamil is not an alternative to cardioversion for patients with
persistent AF.
DIF: Cognitive Level: Applying (Application)
REF: 283
2. A patient undergoes a routine electrocardiogram (ECG), which reveals occasional premature
ventricular contractions that are present when the patient is resting and disappear with
exercise. The patient has no previous history of cardiovascular disease, and the cardiovascular
examination is normal. The primary care NP should:
a. prescribe quinidine (Quinidex Extentabs).
b. tell the patient that treatment is not indicated.
c. refer the patient to a cardiologist for further evaluation.
d. consider using amiodarone if the patient develops other symptoms.
ANS: B
The most important factor in determining whether to treat premature ventricular contractions
is the presence of underlying heart disease, such as myocardial ischemia, previous myocardial
infarction, cardiac scarring or hypertrophy, or left ventricular dysfunction. Because of the
risks associated with antiarrhythmic therapy, patients should not be treated unless clear
indications are present. Premature ventricular contractions are not treated if the patient is
asymptomatic, if the patient has a normal heart, if the premature ventricular contractions are
simple, and if they disappear with exercise. Amiodarone is not used to treat acute premature
ventricular contractions but is used for long-term prophylaxis.
DIF: Cognitive Level: Applying (Application)
REF: 283
3. The primary care NP sees a new patient for a routine physical examination. When auscultating
the heart, the NP notes a heart rate of 78 beats per minute with occasional extra beats followed
by a pause. History reveals no past cardiovascular disease, but the patient reports occasional
syncope and shortness of breath. The NP should:
a. order an ECG and refer to a cardiologist.
b. schedule a cardiac stress test and a graded exercise test.
c. order a complete blood count (CBC) and electrolytes and consider a trial of
procainamide.
d. prescribe a -blocker and anticoagulant and order 24-hour Holter monitoring.
ANS: A
Premature ventricular contractions are premature ventricular beats with a compensatory pause.
This patient has no prior history, but does have syncope and shortness of breath. The NP
should order an ECG and refer the patient to a cardiologist for further evaluation. If there were
no other symptoms, the NP could order stress testing. Medications are not indicated without
further testing and without consultation with a cardiologist.
DIF: Cognitive Level: Applying (Application)
REF: 284
4. A patient comes to the clinic with a history of syncope and weakness for 2 to 3 days. The
primary care NP notes thready, rapid pulses and 3-second capillary refill. An ECG reveals a
heart rate of 198 beats per minute with a regular rhythm. The NP should:
a. administer intravenous fluids and obtain serum electrolytes.
b. administer amiodarone in the clinic and observe closely for response.
c. order digoxin and verapamil and ask the patient to return for a follow-up
examination in 1 week.
d. send the patient to an emergency department for evaluation and treatment.
ANS: D
Paroxysmal supraventricular tachycardia (PSVT) is a very fast regular rate and rhythm. This
patient is becoming decompensated and should be referred to the emergency department for
evaluation and treatment. The primary care NP should not treat this in the clinic or as an
outpatient until the patient is stable.
DIF: Cognitive Level: Applying (Application)
REF: 286
5. A patient who is taking trimethoprim-sulfamethoxazole for prophylaxis of urinary tract
infections tells the primary care NP that a sibling recently died from a sudden cardiac arrest,
determined to be from long QT syndrome. The NP should:
a. schedule a treadmill stress test.
b. order genetic testing for this patient.
c. discontinue the trimethoprim-sulfamethoxazole.
d. refer the patient to a cardiologist for further evaluation.
ANS: B
When a family member’s death is found to be from long QT syndrome, the entire family must
undergo testing. Treadmill testing may be normal in many cases. Trimethoprim-sulfamethoxazole
can prolong the QT interval and should not be used in patients at risk, but genetic testing should
be performed to determine this.
DIF: Cognitive Level: Applying (Application)
REF: 286
6. The primary care NP refers a patient to a cardiologist who diagnoses long QT syndrome. The
cardiologist has prescribed propranolol (Inderal). The patient exercises regularly and is not
obese. The patient asks the NP what else can be done to minimize risk of sudden cardiac
arrest. The NP should counsel the patient to:
a. drink extra fluids when exercising.
b. reduce stress with yoga and hot baths.
c. ask the cardiologist about an implantable defibrillator.
d. ask the cardiologist about adding procainamide to the drug regimen.
ANS: A
Patients with long QT syndrome should avoid situations in which they might overheat or get
dehydrated. This patient should be encouraged to drink plenty of fluids while exercising and
should avoid activities such as yoga and hot baths. Implantable cardioverter-defibrillators are
used for high-risk patients. Procainamide can cause long QT syndrome.
DIF: Cognitive Level: Applying (Application)
REF: 287
7. A patient who has been taking quinidine for several years reports lightheadedness, fatigue,
and weakness. The primary care NP notes a heart rate of 110 beats per minute. The serum
quinidine level is 6 g/mL. The NP should:
a. discontinue the medication immediately.
b. reassure the patient that this is a therapeutic drug level.
c. order an ECG, CBC, liver function tests (LFTs), and renal function tests.
d. admit the patient to the hospital and obtain a cardiology consultation.
ANS: C
The therapeutic level for quinidine is 2 to 5 ìg/mL. Some patients have therapeutic responses
at up to 6 g/mL. The NP should order ECG, CBC, LFT, and renal function tests.
DIF: Cognitive Level: Applying (Application)
REF: 287
Chapter 24: Antihyperlipidemic Agents
Test Bank
MULTIPLE CHOICE
1. The primary care nurse practitioner (NP) sees a patient for a physical examination and orders
laboratory tests that reveal low-density lipoprotein (LDL) of 100 mg/dL, high-density
lipoprotein (HDL) of 30 mg/dL, and triglycerides of 350 mg/dL. The patient has no previous
history of coronary heart disease. The NP should consider prescribing:
a. ezetimibe (Zetia).
b. gemfibrozil (Lopid).
c. simvastatin (Zocor).
d. nicotinic acid (Niaspan).
ANS: B
Fibric acid derivatives, such as gemfibrozil, are indicated for reducing the risk that coronary
heart disease may develop in patients without a history of coronary heart disease who have
low HDL cholesterol levels and elevated triglyceride levels. This patient’s LDL is within
normal limits, so a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor,
such as simvastatin, is not indicated. Ezetimibe is a selective cholesterol absorption inhibitor,
used to reduce total and LDL cholesterol. Nicotinic acid is used to treat hyperlipidemia in
patients who have failed dietary therapy.
DIF: Cognitive Level: Applying (Application)
REF: 295
2. A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that
reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient
has no previous history of coronary heart disease, but the patient’s father developed coronary
heart disease at age 55 years. The NP should prescribe:
a. atorvastatin (Lipitor).
b. gemfibrozil (Lopid).
c. cholestyramine (Questran).
d. lovastatin/niacin (Advicor).
ANS: A
HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary
lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive
family history of coronary heart disease before age 55 in a male first-degree relative.
Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid
sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A
combination product is not indicated for first-line therapy.
DIF: Cognitive Level: Applying (Application)
REF: 293
3. 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:
a. order liver function tests (LFTs).
b. order a creatine kinase-MM (CK-MM) level.
c. change atorvastatin to twice-daily dosing.
d. add gemfibrozil (Lopid) to the patient’s medication regimen.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 299
4. A patient who has primary hyperlipidemia and who takes atorvastatin (Lipitor) continues to
have LDL cholesterol of 140 mg/dL after 3 months of therapy. The primary care NP increases
the dose from 10 mg daily to 20 mg daily. The patient reports headache and dizziness a few
weeks after the dose increase. The NP should:
a.
b.
c.
d.
change the atorvastatin dose to 15 mg twice daily.
change the patient’s medication to cholestyramine (Questran).
add ezetimibe (Zetia) and lower the atorvastatin to 10 mg daily.
recommend supplements of omega-3 along with the atorvastatin.
ANS: C
When used in combination with a low-dose statin, ezetimibe has been noted to produce an
additional 18% reduction in LDL. Because this patient continues to have elevated LDL along
with side effects of the statin, the NP should resume the lower dose of the statin and add
ezetimibe. Atorvastatin is given once daily. Cholestyramine and omega-3 supplements are not
indicated.
DIF: Cognitive Level: Applying (Application)
REF: 299
5. 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:
a. recommend dietary and lifestyle changes first.
b. begin therapy with atorvastatin 10 mg per day.
c. discuss quality-of-life issues as part of the decision to begin medication.
d. tell her there is no clinical evidence of efficacy of statin medication in her case.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 296
6. A patient who has diabetes is taking simvastatin (Zocor) 80 mg daily to treat LDL cholesterol
level of 170 mg/dL. The patient has a body mass index of 29. At a follow-up visit, the
patient’s LDL level is 120 mg/dL. The primary care NP should consider:
a. increasing the simvastatin to 80 mg twice daily.
b. adding nicotinic acid to the patient’s drug regimen.
c. changing the medication to ezetimibe/simvastatin (Vytorin).
d. referring the patient to a dietitian for assistance with weight reduction.
ANS: C
Patients with diabetes have a goal LDL of less than 100 mg/dL. If maximum-dose statin is
unable to achieve the goal LDL, a combination product such as a statin plus ezetimibe is
recommended. The maximum recommended dose is 80 mg daily, so increasing the dose to 80
mg twice daily is incorrect.
DIF: Cognitive Level: Applying (Application)
REF: 296
7. A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which
bile acid sequestrant should the primary care NP order?
a. Colesevelam (Welchol)
b. Colestipol (Colestid)
c. Cholestyramine (Questran)
d. Cholestyramine (Questran Light)
ANS: A
All bile acid sequestrants are equally effective. Colesevelam has an additional indication to
improve glycemic control in adults with type 2 diabetes and so should be selected when
prescribing a bile acid sequestrant for this patient.
DIF: Cognitive Level: Applying (Application)
REF: 298
8. A patient with primary hypercholesterolemia is taking an HMG-CoA reductase inhibitor. All
of the patient’s baseline LFTs were normal. At a 6-month follow-up visit, the patient reports
occasional headache. A lipid profile reveals a decrease of 20% in the patient’s LDL
cholesterol. The NP should:
a. order LFTs.
b. order CK-MM tests.
c. consider decreasing the dose of the medication.
d. reassure the patient that this side effect is common.
ANS: D
LFTs should be performed at baseline, 12 weeks after initiation of therapy, and only
periodically thereafter. Headaches are common side effects, but do not raise concern about
hepatotoxicity. CK-MM tests are indicated if patients report muscle pain or weakness. It is not
necessary to decrease the medication.
DIF: Cognitive Level: Applying (Application)
REF: 299
Chapter 25: Agents that Act on Blood
Test Bank
MULTIPLE CHOICE
1. A patient who has atrial fibrillation (AF) has been taking warfarin (Coumadin). The primary
care nurse practitioner (NP) plans to change the patient’s medication to dabigatran (Pradaxa).
To do this safely, the NP should:
a. initiate dabigatran when the patient’s international normalized ratio (INR) is less
than 2.
b. start dabigatran 7 to 14 days after discontinuing warfarin.
c. begin giving dabigatran 1 week before discontinuing warfarin.
d. order frequent monitoring of the patient’s INR after dabigatran therapy begins.
ANS: A
There are no requirements for monitoring the INR or other measures for patients taking
dabigatran. When changing from warfarin, it is recommended that dabigatran be initiated
when the INR is less than 2.
DIF: Cognitive Level: Applying (Application)
REF: 315
2. A patient who is obese is preparing to have surgery. To help prevent venous
thromboembolism (VTE), the primary care NP should prescribe:
a.
b.
c.
d.
low-dose aspirin once daily.
clopidogrel (Plavix) 75 mg once daily.
enoxaparin (Lovenox) 30 mg twice daily.
warfarin (Coumadin) titrated to achieve an INR of 3.5.
ANS: C
The American College of Clinical Pharmacy recommends against the use of aspirin alone for
prophylaxis of VTE. Patients undergoing surgery who are at moderate to high risk for VTE
should receive unfractionated heparin or low-molecular-weight heparin, such as enoxaparin.
Aspirin may be part of the prophylaxis regimen. Clopidogrel and warfarin are not
recommended.
DIF: Cognitive Level: Applying (Application)
REF: 312
3. A patient who will undergo surgery in implant a biosynthetic heart valve asks the primary care
NP whether any medications will be necessary postoperatively. The NP should tell the patient
that it will be necessary to take:
a. daily low-dose aspirin for 1 year.
b. heparin injections as needed based on activated partial thromboplastin time levels.
c. lifelong warfarin combined with enoxaparin as needed.
d. warfarin for 3 months postoperatively plus long-term aspirin.
ANS: D
Patients with biosynthetic valves should receive anticoagulation for 3 months with long-term
aspirin prophylaxis. Patients with biosynthetic valves should receive anticoagulation for 3
months (INR goal, 2 to 3). Long-term prophylaxis for these patients should include
aminosalicylic acid (75 to 100 mg daily), unless AF is present.
DIF: Cognitive Level: Applying (Application)
REF: 312
4. A patient in the clinic develops sudden shortness of breath and tachycardia. The primary care
NP notes thready pulses, poor peripheral perfusion, and a decreased level of consciousness.
The NP activates the emergency medical system and should anticipate that this patient will
receive:
a. intravenous alteplase.
b. low-dose aspirin and warfarin.
c. low-molecular-weight heparin (LMWH).
d. unfractionated heparin (UFH) and warfarin.
ANS: D
This patient has unstable pulmonary embolism (PE) and should receive thrombolytic therapy.
Intravenous alteplase is the preferred agent. UFH and warfarin are recommended for stable
PE. LMWH is beneficial in submassive PE and deep vein thrombosis (DVT) but is
controversial for treatment of massive PE.
DIF: Cognitive Level: Applying (Application)
REF: 312
5. A patient comes to the clinic with a complaint of gradual onset of left-sided weakness. The
primary care NP notes slurring of the patient’s speech. A family member accompanying the
patient tells the NP that these symptoms began 4 or 5 hours ago. The NP will activate the
emergency medical system and expect to administer:
a.
b.
c.
d.
325 mg of chewable aspirin.
LMWH.
intravenous alteplase and aspirin.
warfarin (Coumadin) and aspirin.
ANS: A
Alteplase is used to treat ischemic stroke but is contraindicated if onset of symptoms occurred
3 hours previously. The administration of anticoagulation or antiplatelet agents during the first
24 hours is not recommended. The oral administration of aspirin within 24 to 48 hours after
stroke onset is recommended.
DIF: Cognitive Level: Applying (Application)
REF: 312 - 313
6. An 80-year-old patient who has persistent AF takes warfarin (Coumadin) for anticoagulation
therapy. The patient has an INR of 3.5. The primary care NP should consider:
a. lowering the dose of warfarin.
b. rechecking the INR in 1 week.
c. omitting a dose and resuming at a lower dose.
d. omitting a dose and administering 1 mg of vitamin K.
ANS: B
This patient’s INR is only minimally prolonged, so no dose reduction is required. The NP
should recheck the INR periodically. If the INR becomes more prolonged, lowering the dose
of warfarin is recommended. If the INR approaches 5, omitting a dose and resuming at a
lower dose is recommended. Vitamin K is used for an INR of 9 or greater.
DIF: Cognitive Level: Applying (Application)
REF: 313
7. 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:
a. give clopidogrel after administering cardioversion.
b. administer cardioversion without using anticoagulants.
c. give warfarin and aspirin before attempting cardioversion.
d. give low-dose aspirin before administering cardioversion.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 313
8. A patient who has disabling intermittent claudication is not a candidate for surgery. Which of
the following medications should the primary care NP prescribe to treat this patient?
a. Cilostazol (Pletal)
b. Warfarin (Coumadin)
c. Pentoxifylline (Trental)
d. Low-dose, short-term aspirin
ANS: A
Patients with disabling intermittent claudication who are not candidates for surgery or
catheter-based intervention should be treated with cilostazol rather than pentoxifylline.
Warfarin is not indicated. Patients with chronic limb ischemia are treated with lifelong aspirin
therapy.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 313
9. A patient who is at risk for DVT tells the primary care NP she has just learned she is pregnant.
The NP should expect that this patient will use which of the following anticoagulant
medications?
a. Aspirin
b. Heparin
c. Dabigatran
d. Warfarin
ANS: B
Heparin does not cross the placental barrier and is the drug of choice for anticoagulation
therapy during pregnancy, despite its category C classification. Aspirin is not recommended
during the last 3 months of pregnancy. Dabigatran is not recommended. Warfarin crosses the
placental barrier.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 317
10. A patient who is taking an oral anticoagulant is in the clinic in the late afternoon and reports
having missed the morning dose of the medication because the prescription was not refilled.
The primary care NP should counsel this patient to:
a. avoid foods that are high in vitamin K for several days.
b. take a double dose of the medication the next morning.
c. refill the prescription and take today’s dose immediately.
d. skip today’s dose and resume a regular dosing schedule in the morning.
ANS: D
Consistency is the key to successful warfarin treatment, and the patient should take the
medication at the same time every day. For missed doses, the patient should take the
medication as soon as possible after the missed dose or not at all that day. Because it is late
afternoon, the patient should skip the dose and resume normal scheduling the next day. It is
not necessary to avoid foods high in vitamin K. Patients should not double up the next day.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 317
Chapter 26: Antacids and the Management of GERD
Test Bank
MULTIPLE CHOICE
1. A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which
shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse
practitioner (NP) about treatment options. The NP should tell this patient that:
a. a fundoplication will be necessary to correct the cause of GERD.
b. over-the-counter (OTC) antacids can be effective and should be tried first.
c. elevation of the head of the bed at night can relieve most symptoms.
d. a combination of lifestyle changes, medications, and surgery may be necessary.
ANS: D
People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach
to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids
are sometimes used but are rarely used as first-line treatment.
DIF: Cognitive Level: Applying (Application)
REF: 329
2. A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient
does not have health insurance and asks the primary care NP about using OTC antacids such
as Tums. The NP should tell the patient that Tums:
a. can help to heal erosions in esophageal tissue.
b. do not help reduce symptoms of erosive esophagitis.
c. neutralize stomach acid as well as proton pump inhibitors (PPIs).
d. help reduce symptoms in conjunction with PPIs.
ANS: D
Antacids reduce symptoms but do not have a significant effect on healing of erosions or
esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to
be ineffective, or has experienced erosion that is documented by endoscopy, he or she should
be started on a PPI.
DIF: Cognitive Level: Applying (Application)
REF: 329
3. A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and
reports a decrease in symptoms. The patient asks the primary care NP if the medication may
be discontinued. The NP should tell the patient that:
a. the dose may be decreased for long-term therapy.
b. antireflux surgery must be done before the PPI can be discontinued.
c. the condition may eventually be cured, but therapy must continue for years.
d. once the symptoms have cleared completely, the medication may be discontinued.
ANS: A
Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy
should be continued long-term and titrated down to the lowest effective dose based on
symptom control. PPI therapy is considered safer than surgery and should be tried first before
surgery is performed. GERD is a lifelong syndrome and is not curable.
DIF: Cognitive Level: Applying (Application)
REF: 329
4. A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent
belching, and a constant sour taste. The patient has a normal weight and reports having a highstress job. The primary care NP should recommend:
a. antacid therapy as needed.
b. changes in diet to avoid acidic foods.
c. daily treatment with a PPI.
d. consultation with a gastroenterologist for endoscopy.
ANS: C
This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and
may be started empirically. Antacids are not first-line medications. Changes in diet are not
recommended as treatment but may help with symptoms. Patients with symptoms unrelieved
by PPIs should be referred for possible endoscopy.
DIF: Cognitive Level: Applying (Application)
REF: 328
5. A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in
symptoms. The next response of the primary care NP is to:
a. add a histamine-2-receptor agonist.
b. increase the dose of the PPI.
c. change to long-term, low-dose PPI therapy.
d. refer the patient to an endocrinologist for endoscopy and further management.
ANS: A
If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is
indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for
recurrences of symptoms on a limited basis. When symptoms fail to resolve with
pharmacologic treatments, patients should be referred to an endocrinologist.
DIF: Cognitive Level: Applying (Application)
REF: 329 - 330
6. A patient is taking a low-dose PPI for long-term management of GERD and reports taking
sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP
should tell the patient to:
a. change to aluminum hydroxide (Amphojel).
b. use magnesium hydroxide (Milk of Magnesia) instead.
c. continue using sodium bicarbonate (Alka-Seltzer) as needed.
d. take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer).
ANS: D
Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium
carbonate requires monitoring when used long-term but has the highest acid-neutralizing
capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances.
DIF: Cognitive Level: Applying (Application)
REF: 330
7. An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn.
The NP notes that the patient has a normal complete blood count and normal electrolytes and
a slight elevation in creatinine levels. The NP should recommend:
a. calcium carbonate (Tums).
b. aluminum hydroxide (Amphojel).
c. sodium bicarbonate (Alka-Seltzer).
d. magnesium hydroxide (Milk of Magnesia).
ANS: A
Elderly patients with renal failure should not take antacids containing magnesium because of
the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly
patients. Aluminum hydroxide is not as effective as calcium carbonate.
DIF: Cognitive Level: Applying (Application)
REF: 330
Chapter 27: Histamine-2 Blockers and Proton Pump Inhibitors
Test Bank
MULTIPLE CHOICE
1. A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs
(NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective
NSAID in the past and states that it is not as effective as the current NSAID. The primary care
nurse practitioner (NP) should:
a. prescribe cimetidine (Tagamet).
b. prescribe omeprazole (Prilosec).
c. teach the patient about a bland diet.
d. change the NSAID to a corticosteroid.
ANS: B
Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid
suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a
situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be
a second-line choice, but cimetidine has many serious side effects. Bland diets are not
effective in treating ulcers. Corticosteroids are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 336 - 337
2. A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence
of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before
meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is
still present. The NP should order:
a. continuation of the PPI for 4 to 8 weeks.
b. a PPI, amoxicillin, and metronidazole for 14 days.
c. a PPI, clarithromycin, and amoxicillin for 14 more days.
d. a PPI, bismuth subsalicylate, tetracycline, and metronidazole.
ANS: B
A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolideallergic patients and for re-treatment for 14 days if first-line treatment of choice failed because
of occasional resistance to clarithromycin.
DIF: Cognitive Level: Applying (Application)
REF: 336
3. A patient with a diagnosis of peptic ulcer disease asks the primary care NP about
nonpharmacologic treatment. Which statement by the NP is correct?
a. “You should consume a diet that is high in fiber.”
b. “One or two cups of coffee each day won’t hurt you.”
c. “Alcoholic beverages are strictly prohibited when you have an ulcer.”
d. “Lifestyle changes and proper diet may eliminate the need for medication.”
ANS: A
Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine
increases acid secretion and should be avoided. Patients may consume alcohol in moderation.
Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer
disease, they do not eliminate the need for medications.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 336
4. A patient has NSAID-induced ulcer and has started taking ranitidine (Zantac). At a follow-up
appointment 3 days later, the patient reports no alleviation of symptoms. The primary care NP
should:
a. order cimetidine (Tagamet).
b. add metronidazole to the drug regimen.
c. change from ranitidine to omeprazole (Prilosec).
d. reassure the patient that drug effects take several weeks.
ANS: C
If the patient does not start to see improvement within a few days after initiation of treatment
with a histamine-2 blocker, the provider either should increase the dose of the medication or
should change to a PPI. Cimetidine is a histamine-2 blocker and has many serious side effects.
Metronidazole is used only when H. pylori is known to be present. Patients should start to get
relief within a few days.
DIF: Cognitive Level: Applying (Application)
REF: 337
5. An 80-year-old patient has a history of renal disease and develops a duodenal ulcer. The
primary care NP should order a:
a. normal dose of a histamine-2 blocker.
b. decreased dose of a histamine-2 blocker.
c. normal dose of a PPI.
d. decreased dose of a PPI.
ANS: C
No adjustment of dosage is necessary for older patients taking PPIs. Patients with a history of
renal disease may have decreased elimination of histamine-2 blockers, so the NP should avoid
these if possible.
DIF: Cognitive Level: Applying (Application)
REF: 337
6. A patient with peptic ulcer disease is taking a histamine-2 blocker and tells the primary care
NP that over-the-counter antacid tablets help with the discomfort. The NP should tell this
patient to:
a. discontinue the antacid.
b. discontinue the histamine-2 blocker.
c. take the antacid and the histamine-2 blocker at the same time.
d. take the histamine-2 blocker 2 hours before taking the antacid.
ANS: D
Histamine-2 blockers should not be taken within 2 hours of antacid ingestion because antacids
decrease the action of histamine-2 blockers.
DIF: Cognitive Level: Applying (Application)
REF: 339
7. A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP
performs a medication history and learns that the patient also takes digoxin. The NP should
recommend:
a. decreasing the dose of digoxin.
b. obtaining a serum digoxin level.
c. changing the PPI to omeprazole.
d. increasing the dose of lansoprazole.
ANS: B
Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that
require absorption in an acid stomach, including digoxin. It may be necessary to increase the
dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so
changing to another PPI would not solve the problem. Increasing the dose of lansoprazole
would decrease the absorption of digoxin.
DIF: Cognitive Level: Applying (Application)
REF: 339
8. A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should
prescribe:
a. ranitidine (Zantac).
b. omeprazole (Prilosec).
c. esomeprazole (Nexium).
d. pantoprazole (Protonix).
ANS: A
PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should
begin therapy with a histamine-2 blocker, such as ranitidine.
DIF: Cognitive Level: Applying (Application)
REF: 339
Chapter 28: Laxatives
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) sees a patient who is concerned about constipation.
The NP learns that the patient has three to four bowel movements per week with occasional
hard stools but no straining with defecation. The NP should recommend:
a. increased intake of fluids and fiber.
b. docusate sodium (Colace) as needed.
c. psyllium (Metamucil) on a daily basis.
d. polyethylene glycol (MiraLAX) as needed.
ANS: A
The objective definition of constipation is two or fewer bowel movements per week or
excessive straining. This patient does not meet these criteria, so the NP should recommend
increasing fluids and fiber to help soften stools. Laxatives should not be used unless
constipation is present or is chronic to avoid laxative dependence.
DIF: Cognitive Level: Applying (Application)
REF: 341
2. 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. a daily bulk laxative.
b. long-term docusate sodium.
c. a saline laxative as needed.
d. glycerin suppositories as needed.
ANS: C
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.
DIF: Cognitive Level: Applying (Application)
REF: 344
3. A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative
for long-term management. In addition to pharmacologic therapy, the NP should also
recommend _____ g of fiber per day.
a. 10
b. 15
c. 20
d. 25
ANS: A
Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age.
DIF: Cognitive Level: Applying (Application)
REF: 343
4. A patient who has cerebral palsy is wheelchair dependent and receives enteral nutrition via a
gastrostomy tube. The patient has infrequent, hard bowel movements despite using a highfiber formula and receiving 1500 mL of fluid per day. The NP should order:
a. bisacodyl (Dulcolax).
b. docusate sodium (Colace).
c. polyethylene glycol (MiraLAX).
d. sodium phosphate (Fleets) enema.
ANS: C
Fluids, fiber, and exercise, which help most people, are not applicable to people who are
wheelchair bound. Other individuals with congestive heart failure are unable to tolerate these
mechanisms. Osmotic laxatives, such as polyethylene glycol are used to manage long-term
constipation. It is essential for clinicians to know their patients and assess what is reasonable
for them to do.
DIF: Cognitive Level: Applying (Application)
REF: 345
5. A primary care NP sees a patient who reports having decreased frequency of stools over the
past few months. In the clinic today, the patient has severe abdominal cramping and an
abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP
should:
a. give magnesium hydroxide (Milk of Magnesia).
b. start daily methylcellulose (Citrucel) and increased fluids.
c. order a sodium phosphate enema and psyllium (Metamucil).
d. recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily.
ANS: C
If a patient is severely constipated, an enema is indicated. When there is underlying chronic
constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are
first-line treatments for long-term constipation.
DIF: Cognitive Level: Applying (Application)
REF: 344
6. A female patient who is underweight tells the primary care NP that she has been using
bisacodyl (Dulcolax) daily for several years. The NP should:
a. prescribe docusate sodium (Colace) and decrease bisacodyl gradually.
b. suggest she use polyethylene glycol (MiraLAX) on a daily basis instead.
c. tell her that long-term use of suppositories is safer than long-term laxative use.
d. counsel the patient to discontinue the laxative and increase fluid and fiber intake.
ANS: A
Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances.
These patients should be weaned from their stimulant laxative and placed on safer long-term
laxatives, such as a bulk laxative or stool softener. Polyethylene glycol is a stimulant. Longterm use of suppositories causes rectal irritation. Discontinuing the laxative without a longterm laxative will lead to rebound constipation.
DIF: Cognitive Level: Applying (Application)
REF: 344
7. A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of
acute constipation. The patient reports having an increased frequency of episodes. The
primary care NP should recommend:
a. adding docusate sodium (Colace).
b. polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).
c. lactulose (Chronulac) and polyethylene glycol (MiraLAX).
d. adding nonpharmacologic measures such as biofeedback.
ANS: A
Patients treated for long-term constipation should begin with a bulk laxative. If that is not
effective, the addition of a second laxative may be necessary. Using two laxatives from the
same category is not recommended. A stool softener, such as docusate sodium, is appropriate.
Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same
category.
DIF: Cognitive Level: Applying (Application)
REF: 344| Table 28-2
8. A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each
month for constipation. The primary care NP should counsel this patient to:
a. decrease fluid intake to avoid cardiac overload.
b. change the laxative to docusate sodium (Colace).
c. take the digoxin 2 hours before taking the psyllium.
d. ask the cardiologist about taking an increased dose of digoxin.
ANS: C
Laxatives can affect the absorption of drugs in the intestine by decreasing transit time.
Digoxin is a drug that is affected by decreased transit time. Patients should be counseled to
take the drugs 2 hours apart.
DIF: Cognitive Level: Applying (Application)
REF: 346
Chapter 29: Antidiarrheals
Test Bank
MULTIPLE CHOICE
1. A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea. Her
husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a
temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60
mm Hg. The NP should:
a. prescribe attapulgite to treat her diarrhea.
b. obtain a stool culture and start antibiotic therapy.
c. instruct her to replace lost fluids by drinking Pedialyte.
d. refer her to an emergency department for intravenous (IV) fluids.
ANS: D
Diarrhea in pregnant women can have serious consequences, and the patient may need to be
referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite
is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is
usually viral, and antibiotics are not given unless a stool culture is performed and is positive.
Because the patient is pregnant and has nausea, oral rehydration would not be effective.
DIF: Cognitive Level: Applying (Application)
REF: 351
2. A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the clinic
after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP
should:
a. obtain a stool specimen and order vancomycin.
b. order testing for Clostridium difficile and consider metronidazole therapy.
c. prescribe diphenoxylate (Lomotil) to provide symptomatic relief.
d. reassure the patient that diarrhea is a common side effect of antibiotic therapy.
ANS: B
The guidelines for treatment of diarrhea emphasize comprehensive evaluation before
treatment begins. Antibiotic use points to C. difficile as a possible cause, and metronidazole is
often used to treat mild to moderate infection. Vancomycin is used when C. difficile is severe.
Diphenoxylate can worsen the infection because it slows transit time of the bacteria in the gut.
Prolonged diarrhea during antibiotic therapy should be investigated.
DIF: Cognitive Level: Applying (Application)
REF: 352
3. A patient who has had four to five liquid stools per day for 4 days is seen by the primary care
NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that
antidiarrheal medications are:
a. not curative and may prolong the illness.
b. useful in cases of acute infection with elevated temperature.
c. most beneficial when symptoms persist longer than 2 weeks.
d. useful when other symptoms, such as hematochezia, develop.
ANS: A
Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should
be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea
and are used for comfort and not cure. They should not be used for patients with bloody
diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a
more serious cause, and antidiarrheals should not be used in those cases.
DIF: Cognitive Level: Applying (Application)
REF: 353
4. 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:
a. diphenoxylate (Lomotil).
b. attapulgite (Kaopectate).
c. bismuth subsalicylate (Pepto-Bismol).
d. loperamide hydrochloride (Imodium).
ANS: C
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.
DIF: Cognitive Level: Applying (Application)
REF: 353
5. 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:
a. diphenoxylate (Lomotil).
b. attapulgite (Kaopectate).
c. an electrolyte solution (Pedialyte).
d. bismuth subsalicylate (Pepto-Bismol).
ANS: C
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.
DIF: Cognitive Level: Applying (Application)
REF: 353
6. A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The
patient reports seeing blood and mucus in the stools. The patient has had nausea but no
vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per
minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral
mucous membranes and capillary refill of 4 seconds. The NP’s priority should be to:
a.
b.
c.
d.
obtain stool cultures.
begin rehydration therapy.
consider prescribing metronidazole.
administer opioid antidiarrheal medications.
ANS: B
Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially
bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be
ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present.
Opioid antidiarrheals may prolong symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 353
7. A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family
members have had similar symptoms, which have resolved. The primary care NP should
recommend:
a. diphenoxylate (Lomotil).
b. attapulgite (Kaopectate).
c. an electrolyte solution (Pedialyte).
d. bismuth subsalicylate (Pepto-Bismol).
ANS: C
Antidiarrheals are not generally recommended in children. Bismuth is not recommended in
children younger than 16 years of age with viral illnesses because it can mask symptoms of
Reye’s syndrome. Oral rehydration with electrolyte solution is safe.
DIF: Cognitive Level: Applying (Application)
REF: 354
Chapter 30: Antiemetics
Test Bank
MULTIPLE CHOICE
1. A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner
(NP) that she continues to have severe morning sickness on a daily basis. The NP notes a
weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an
obstetrician and prescribe:
a. aprepitant (Emend).
b. ondansetron (Zofran).
c. scopolamine transdermal.
d. prochlorperazine (Compazine).
ANS: B
No antiemetic drugs should be used for nausea and vomiting during pregnancy unless
approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label)
for hyperemesis gravidum.
DIF: Cognitive Level: Applying (Application)
REF: 359
2. A primary care NP sees a patient who is about to take a cruise and reports having had motion
sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal
patch and should instruct the patient to apply the patch:
a. daily.
b. every 3 days.
c. as needed for nausea.
d. 1 hour before embarking.
ANS: B
The transdermal system allows steady-state plasma levels of scopolamine to be reached
rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch
should be changed every 3 days and left on at all times, not as needed.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 361
3. A primary care NP sees a patient 2 days after an outpatient surgical procedure. The patient
reports using ondansetron for nausea. The NP notes a blood pressure of 88/56 mm Hg, and the
patient reports feeling faint. The NP should suspect:
a. hemorrhage.
b. dehydration.
c. drug toxicity.
d. drug interaction.
ANS: C
Hypotension and faintness are signs of overdose of ondansetron, and drug toxicity is the more
likely cause of this patient’s decrease in blood pressure.
DIF: Cognitive Level: Applying (Application)
REF: 361
4. A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a
sensation of the room spinning when these occur. The primary care NP will refer the patient to
a specialist who, after diagnostic testing, is likely to prescribe:
a. meclizine.
b. ondansetron.
c. scopolamine.
d. dimenhydrinate.
ANS: A
Patients with vertigo may experience whirling or a feeling of the room spinning around. In
true vertigo, the patient can identify the direction in which the room is spinning.
Anticholinergics are the most effective agents in cases of motion sickness or vertigo.
Meclizine has a specific indication to treat vertigo.
DIF: Cognitive Level: Applying (Application)
REF: 357
5. A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days. The
patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats
per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of
greater than 3 seconds. The NP should:
a. obtain a complete blood count and serum electrolytes.
b. prescribe a rectal antiemetic medication.
c. admit to the hospital for intravenous (IV) rehydration.
d. encourage the patient to take small, frequent sips of Gatorade.
ANS: C
If vomiting is not controlled, dehydration may occur. Patients who are dehydrated, as this
patient is, must be treated with IV fluids in a hospital or emergency department setting.
DIF: Cognitive Level: Applying (Application)
REF: 358
6. A patient who is about to begin chemotherapy expresses concern to the primary care NP about
gastrointestinal side effects of the treatments. The NP should reassure the patient that:
a. most newer chemotherapeutic agents do not cause nausea and vomiting.
b. antiemetics will be administered as needed if nausea and vomiting occur.
c. taking ondansetron before chemotherapy decreases nausea and vomiting.
d. a scopolamine patch is an effective way to prevent nausea and vomiting.
ANS: C
In many situations, nausea and vomiting may be anticipated. These situations may involve
motion sickness or chemotherapy. Premedicating the patient with an antiemetic may be
necessary in order for the patient to receive full therapy; this is the current standard of care.
Although most chemotherapeutic agents have emetogenic potential, the use of premedication
with 5-HT3 receptor antagonists significantly decreases the nausea and vomiting experienced
during and after administration The most common agent in this class, ondansetron, is now
available as a generic.
DIF: Cognitive Level: Applying (Application)
REF: 358
7. A primary care NP sees a 3-year-old patient who has been vomiting for several days. The
child has had fewer episodes of vomiting the past day and is now able to take sips of fluids
without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and
pale but warm skin. The child’s blood pressure is 88/46 mm Hg, the heart rate is 110 beats per
minute, and the temperature is 37.2° C. The NP should:
a. prescribe promethazine.
b. prescribe a scopolamine patch.
c. begin oral rehydration therapy.
d. send the child to the hospital for IV fluids.
ANS: C
The use of antiemetics in children is discouraged for cases of uncomplicated vomiting. The
child has compensated, mild dehydration and is now able to tolerate fluids, so oral rehydration
is indicated.
DIF: Cognitive Level: Applying (Application)
REF: 359
Chapter 31: Medications for Irritable Bowel Syndrome and Other Gastrointestinal
Problems
Test Bank
MULTIPLE CHOICE
1. 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:
a. the relation of the pain to stools.
b. what time of day the pain occurs.
c. whether the pain is sharp or diffuse.
d. the age of the patient when the pain began.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 362 - 363
2. A patient has been diagnosed with IBS and tells the primary care NP that symptoms of
diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the
symptoms. The NP should prescribe:
a. mesalamine (Asacol).
b. dicyclomine (Bentyl).
c. simethicone (Phazyme).
d. metoclopramide (Reglan).
ANS: B
Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI)
tract. Both actions help to relieve smooth muscle spasm. Mesalamine is used to treat
ulcerative colitis. Simethicone acts locally to treat symptoms of trapped air and gas.
Metoclopramide is used to increase motility.
DIF: Cognitive Level: Applying (Application)
REF: 363
3. A woman with IBS has been taking antispasmodic medications and reports some relief, but
she tells the primary care NP that the disease is interfering with her ability to work because of
increased pain. The NP should consider prescribing:
a. alosetron (Lotronex).
b. misoprostol (Cytotec).
c. simethicone (Phazyme).
d. tricyclic antidepressants (TCAs).
ANS: D
TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce
symptoms and are useful for long-term treatment. Alosetron is ordered by a GI specialist if
symptoms are resistant to all other interventions and has been shown to be effective in women
with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers.
Simethicone acts locally to treat symptoms of trapped air and gas.
DIF: Cognitive Level: Applying (Application)
REF: 363 - 364
4. A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take
medication. The primary care NP should recommend:
a.
b.
c.
d.
25 g of fiber each day.
avoiding gluten and lactose in the diet.
increasing water intake to eight to ten glasses per day.
beginning aerobic exercise, such as running, every day.
ANS: A
A diet with adequate fiber is the cornerstone of treatment, and 25 g per day is recommended.
Unless the patient has a documented gluten or lactose malabsorption, avoiding these
substances is not recommended. Water intake should be six to eight glasses per day. Regular
walking is usually the best exercise.
DIF: Cognitive Level: Applying (Application)
REF: 364
5. A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea
but is now having occasional constipation. The primary care NP should recommend:
a. beginning treatment with an SSRI.
b. beginning therapy with a TCA.
c. over-the-counter (OTC) laxatives as needed when constipated.
d. increasing the amounts of raw fruits and vegetables in the diet.
ANS: C
Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such
as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can
increase the likelihood of bloating.
DIF: Cognitive Level: Applying (Application)
REF: 364
6. A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The
patient comes to the clinic and reports having dry mouth, difficulty urinating, and more
frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP
should:
a. prescribe a TCA.
b. discontinue the antidiarrheal medication.
c. encourage the patient to increase water intake.
d. lower the dose of the antispasmodic medication.
ANS: D
Patients taking antispasmodic medications should be monitored for anticholinergic side
effects, such as increased heart rate, dry mouth, difficulty urinating, and constipation. The NP
should lower the dose if needed. TCAs are used to treat pain long-term. Because the
antidiarrheal medication is used as needed, there is no reason to discontinue it. Increasing
water intake may improve symptoms associated with side effects but would not treat the
underlying cause of these symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 364
7. A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone (Phazyme),
and a TCA. She reports having continued severe diarrhea. The primary care NP should:
a. order diphenoxylate (Lomotil).
b. prescribe alosetron after ruling out pregnancy.
c. refer her to a gastroenterologist for endoscopy.
d. increase the fiber in her diet to 30 g per day.
ANS: C
Alosetron is given only to women with severe chronic diarrhea-predominant IBS and only
after anatomic or biochemical abnormalities of the GI tract have been excluded. Because this
woman’s symptoms are persistent and severe, diphenoxylate and increased dietary fiber are
not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 364
8. A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders
metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal
symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and
should expect to prescribe:
a. benztropine (Cogentin).
b. cimetidine.
c. an SSRI antidepressant.
d. a TCA.
ANS: A
Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The
patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should
EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine
(Cogentin) 1 to 2 mg
DIF: Cognitive Level: Applying (Application)
REF: 365
Chapter 32: Diuretics
Test Bank
MULTIPLE CHOICE
1. A patient develops hypertension. The primary care nurse practitioner (NP) plans to begin
diuretic therapy for this patient. The NP notes clear breath sounds, no organomegaly, and no
peripheral edema. The patient’s serum electrolytes are normal. The NP should prescribe:
a. furosemide (Lasix).
b. triamterene (Dyrenium).
c. acetazolamide (Diamox).
d. hydrochlorothiazide (HydroDIURIL).
ANS: D
Thiazide diuretics are first-line drugs for treating hypertension. The other three drugs are not
thiazide diuretics.
DIF: Cognitive Level: Applying (Application)
REF: 376
2. A patient takes hydrochlorothiazide to treat hypertension and asks the primary care NP why it
is necessary to reduce sodium intake while taking this medication. The NP should explain that
decreasing sodium is necessary to:
a. prevent renal insufficiency.
b. minimize the risk of hypokalemia.
c. prevent postdiuretic sodium retention.
d. increase the likelihood that the drug may be discontinued.
ANS: C
If dietary salt intake is high, the amount of sodium lost in response to the diuretic may be
partially or completely offset by postdiuretic sodium retention. Sodium restriction does not
prevent renal insufficiency or minimize the incidence of hypokalemia. Sodium restriction is
necessary to maintain the drug’s effectiveness but does not increase the chance of
discontinuing the medication.
DIF: Cognitive Level: Applying (Application)
REF: 372
3. A patient with congestive heart failure will begin therapy with a diuretic medication. The
primary care NP orders laboratory tests, which reveal a glomerular filtration rate (GFR) of 25
mL/minute. The initial drug the NP should prescribe is:
a. metolazone.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. hydrochlorothiazide (HydroDIURIL).
ANS: A
Thiazides are the most frequently used and the least expensive drugs administered to treat
hypertension and are considered first-line treatments. In patients with a GFR less than 30
mL/minute, thiazides are relatively ineffective, with the exception of metolazone. Furosemide
may be added as a second-line drug. Potassium-sparing diuretics, such as spironolactone,
should be used with great caution or avoided altogether in patients with renal insufficiency.
DIF: Cognitive Level: Applying (Application)
REF: 372
4. A patient who has congestive heart failure and arthritis has been taking chlorthalidone
(Zaroxolyn) 25 mg daily for 6 months. The primary care NP notes a persistent blood pressure
of 145/90 mm Hg. The NP should:
a. ask the patient which medications are used for pain.
b. add furosemide (Lasix) to the patient’s drug regimen.
c. increase the dose of chlorthalidone to 100 mg daily.
d. recommend that the patient use salt substitutes to season foods.
ANS: A
For diuretic resistance, the NP should evaluate factors such as patient nonadherence,
physiologic causes, and drugs that may increase resistance, including nonsteroidal
antiinflammatory drugs (NSAIDs). This patient has arthritis, and it is likely that NSAID use
may be causing diuretic resistance. A second drug, such as furosemide, should be added after
the cause of diuretic resistance is determined. The maximum daily dose of chlorthalidone is
100 mg per day, but increasing the dose is not recommended to treat diuretic resistance.
Recommending salt substitutes is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 373
5. The primary care NP is preparing to prescribe a diuretic for a patient who has heart failure.
The patient reports having had an allergic reaction to sulfamethoxazole-trimethoprim
(Bactrim) previously. The NP should prescribe:
a.
b.
c.
d.
ethacrynic acid.
furosemide (Lasix).
acetazolamide (Diamox).
hydrochlorothiazide (HydroDIURIL).
ANS: A
Patients who are allergic to sulfa drugs should avoid diuretics that are sulfonamide
derivatives. Ethacrynic acid is the only choice that is not a sulfonamide derivative.
DIF: Cognitive Level: Applying (Application)
REF: 372
6. The primary care NP sees a patient several months after a myocardial infarction (MI). The
patient has been taking furosemide to treat heart failure. The NP notes that the patient has
edema of the hands, feet, and ankles. The NP should add which drug to this patient’s regimen?
a. Ethacrynic acid
b. Chlorothiazide (Lozol)
c. Triamterene (Dyrenium)
d. Spironolactone (Aldactone)
ANS: B
The addition of a thiazide to a loop diuretic along with sodium restriction may be useful in the
treatment of refractory edema in patients with congestive heart failure. Ethacrynic acid is a
loop diuretic. The other two options are potassium-sparing diuretics.
DIF: Cognitive Level: Applying (Application)
REF: 373
7. The primary care NP sees a patient who has a history of hypertension and alcoholism. The
patient is not taking any medications. The NP auscultates crackles in both lungs and palpates
the liver 2 cm below the costal margin. Laboratory tests show an elevated creatinine level.
The NP will refer this patient to a cardiologist and should prescribe:
a. albuterol metered-dose inhaler.
b. furosemide (Lasix).
c. spironolactone (Aldactone).
d. chlorthalidone (Zaroxolyn).
ANS: B
In the treatment of heart failure, loop diuretics relieve the congestive symptoms of pulmonary
and congestive edema. Loop diuretics are also useful to treat states of volume excess in
cirrhosis and renal insufficiency. Because this patient has a history of alcoholism and has an
enlarged liver on examination, furosemide is a good first choice to relieve this patient’s
congestive symptoms. Spironolactone and chlorthalidone are not loop diuretics. Albuterol
might be used for symptomatic treatment only.
DIF: Cognitive Level: Applying (Application)
REF: 373
8. The primary care NP sees a patient who has heart failure following an MI 6 months before
this visit. The patient has been taking an ACE inhibitor, nitroglycerin, furosemide, and
hydrochlorothiazide. The NP auscultates crackles in both lungs and notes pitting edema of
both feet. The NP should prescribe:
a. mannitol.
b. metolazone.
c. acetazolamide (Diamox).
d. spironolactone (Aldactone).
ANS: D
Spironolactone has been shown to be of particular benefit in the treatment of severe
congestive heart failure when added to an ACE inhibitor and a loop diuretic.
DIF: Cognitive Level: Applying (Application)
REF: 374
9. A patient has been taking furosemide 80 mg once daily for 4 weeks and returns for a follow-
up visit. The primary care NP notes a blood pressure of 100/60 mm Hg. The patient’s lungs
are clear, and there is no peripheral edema. The patient’s serum potassium is 3.4 mEq/L. The
NP should:
a. continue furosemide at the current dose.
b. decrease furosemide to 60 mg once daily.
c. increase furosemide to 80 mg twice daily.
d. change furosemide dose the 40 mg twice daily.
ANS: B
The major toxicities related to loop diuretics result from fluid and electrolyte imbalances. This
patient has a low potassium level just under the lower limit, so a reduction in dose is
indicated.
DIF: Cognitive Level: Applying (Application)
REF: 374
10. A patient is taking spironolactone and comes to the clinic complaining of weakness and
tingling of the hands and feet. The primary care NP notes a heart rate of 62 beats per minute
and a blood pressure of 100/58 mm Hg. The NP should:
a. obtain a serum drug level.
b. order an electrocardiogram (ECG) and serum electrolytes.
c. change the medication to a thiazide diuretic.
d. question the patient about potassium intake.
ANS: B
The patient is showing signs of hyperkalemia, so the NP should order an ECG and serum
electrolytes. This should be done before changing the medication. Because hyperkalemia can
cause fatal arrhythmias, an ECG is necessary.
DIF: Cognitive Level: Applying (Application)
REF: 374
Chapter 33: Male Genitourinary Agents
Test Bank
MULTIPLE CHOICE
1. A man who has benign prostatic hypertrophy (BPH), in whom prostate carcinoma has been
ruled out, asks the primary care nurse practitioner (NP) about beginning drug therapy to treat
his symptoms. The NP notes that he consistently has blood pressure readings around 145/90
mm Hg. The NP should prescribe:
a. tadalafil (Cialis).
b. doxazosin (Cardura).
c. tamsulosin (Flomax).
d. finasteride (Proscar).
ANS: B
Doxazosin is a nonspecific -blocker, which also lowers blood pressure and should be
considered to treat BPH in patients who also have hypertension. Tadalafil is used to treat
erectile dysfunction. Tamsulosin is a specific á-blocker and is first-line treatment for patients
with BPH who do not have hypertension. Finasteride is a 5-reductase inhibitor, which is not
a first-line medication.
DIF: Cognitive Level: Applying (Application)
REF: 385 - 386
2. A patient who has BPH is taking tamsulosin and dutasteride and asks the primary care NP
why he needs to take both medications. The NP should tell him:
a. the combination helps reduce the risk of prostate carcinoma.
b. two-drug therapy is required before corrective prostatectomy surgery.
c. both drugs are given so that smaller doses of each drug may be administered.
d. one gives faster symptom relief, whereas the other shrinks the size of the prostate.
ANS: D
A 5-reductase inhibitor is given to shrink the size of the prostate, but maximum benefit is not
achieved until 6 months of therapy. The -blocker is given to provide more rapid relief. The
combination does not decrease the risk of carcinoma. The drug therapy is not a prerequisite to
surgery, although it may be used before surgical intervention. The combination therapy does
not affect the dose of either drug.
DIF: Cognitive Level: Applying (Application)
REF: 385 - 386
3. A patient who has BPH is taking alfuzosin (Uroxatral) and finasteride (Proscar). The patient
has had two urinary tract infections (UTIs) in the past 2 months. A urinalysis in the clinic is
negative for leukocyte esterase but positive for hematuria. The primary care NP should:
a. discontinue finasteride.
b. refer the patient to a urologist.
c. change alfuzosin to tamsulosin.
d. add doxazosin to the drug regimen.
ANS: B
Surgery is indicated for patients who are refractory to treatment with medications or who have
recurrent UTIs or hematuria. The NP should refer the patient to a urologist. All -blockers are
considered equally efficacious, so changing the drug regimen is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 385 - 386
4. A patient who has BPH is taking doxazosin and finasteride. The patient asks the primary care
NP whether he has an increased risk of prostate cancer. The NP should tell him:
a. his overall cancer risk is increased.
b. he has an increased risk of a certain type of cancer.
c. his cancer risk is the same as any other man his age.
d. doxazosin will increase his cancer risk, but only slightly.
ANS: B
There is an overall reduction in prostate cancer risk for patients taking 5-reductase
inhibitors, such as finasteride, but there is an increased risk of high-grade prostate cancer. His
overall cancer risk is less. Doxazosin does not affect cancer risk.
DIF: Cognitive Level: Applying (Application)
REF: 385 - 386
5. A patient tells the primary care NP that he has difficulty getting and maintaining an erection.
The NP’s initial response should be to:
a. prescribe sildenafil (Viagra).
b. perform a medication history.
c. evaluate his cardiovascular status.
d. order a papaverine injection test to screen for erectile dysfunction.
ANS: B
Because the use of multiple medications is associated with a higher prevalence of erectile
dysfunction, a medication history should be performed first to see if any medications have
sexual side effects. A cardiovascular evaluation may be assessed next. Papaverine injection
tests are useful screening tools after a thorough history has been performed. Medications are
prescribed only after a diagnosis is determined and other causes have been ruled out.
DIF: Cognitive Level: Applying (Application)
REF: 389
6. The primary care NP is preparing to prescribe sildenafil for a man who has erectile
dysfunction. The NP should remember to tell this patient:
a. to avoid oral nitrates while taking this medication.
b. that the drug may cause penile aching.
c. to use a condom if his sexual partner is pregnant.
d. dyspepsia may occur and may warrant discontinuation of the drug.
ANS: A
Deaths have been reported in men on concomitant treatment with oral nitrates who are taking
sildenafil. Patients taking alprostadil may experience penile ache. Finasteride, not sildenafil, is
teratogenic, and a man taking finasteride should use condoms if his partner is pregnant.
Dyspepsia is a common but not serious side effect of sildenafil.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 389
7. A man who has cardiovascular disease and takes nitroglycerin for angina pain develops
erectile dysfunction. The primary care NP who cares for this patient should recommend:
a. sildenafil (Viagra).
b. testosterone injections.
c. vascular reconstruction surgery.
d. use of a vacuum constriction device.
ANS: D
Deaths have been reported in men on concomitant treatment with oral nitrates who are taking
sildenafil. Patients with erectile dysfunction should be advised to try nonpharmacologic
treatment, such as a vacuum constriction device. Testosterone injections are used for men with
documented androgen deficiency. Vascular reconstruction surgery may be used for men with
decreased blood flow and should be considered if other treatments are ineffective.
DIF: Cognitive Level: Applying (Application)
REF: 389
8. A patient who has erectile dysfunction wants a medication to use as needed. The primary care
NP should recommend:
a. tadalafil (Cialis).
b. sildenafil (Viagra).
c. avanafil (Stendra).
d. vardenafil (Levitra).
ANS: C
Avanafil is the newest drug on the market and can be used on an as-needed basis because it
has a shorter half-life and shorter onset of action. It may be taken 30 minutes before sexual
activity. The other agents have an onset of action of several hours.
DIF: Cognitive Level: Applying (Application)
REF: 390
Chapter 34: Drugs for Urinary Incontinence and Urinary Analgesia
Test Bank
MULTIPLE CHOICE
1. 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:
a. perform a dipstick urinalysis.
b. prescribe desmopressin (DDAVP).
c. prescribe oxybutynin chloride (Ditropan XL).
d. teach exercises to strengthen the pelvic muscles.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 393
2. 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:
a. flavoxate (Urispas).
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. oxybutynin chloride (Ditropan XL).
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 393
3. A patient reports having urinary frequency and discomfort associated with urination. After a
careful physical examination and history to determine the cause, the NP should prescribe a
medication from which drug class?
a. Cholinergics
b. Antispasmodics
c. Anticholinergics
d. Urinary tract analgesics
ANS: B
Antispasmodics are smooth muscle relaxants. Use of these drugs can produce increased
bladder capacity and exhibit local anesthetic and analgesic actions. Cholinergic agents
increase detrusor muscle tone to improve initiation of voiding and bladder emptying.
Anticholinergics decrease detrusor tone to treat urge incontinence. Urinary tract analgesics are
used to treat pain via a local analgesic effect on urinary tract mucosa and are used in
conjunction with antibiotics to treat UTI.
DIF: Cognitive Level: Applying (Application)
REF: 393 - 394
4. A parent brings an 8-year-old child to the clinic because the child continues to wet the bed
despite using cognitive-behavioral measures and a bed alarm system. The NP should
prescribe:
a. solifenacin (VESIcare).
b. tolterodine (Detrol LA).
c. desmopressin (DDAVP).
d. phenazopyridine (Pyridium).
ANS: C
Desmopressin is used as an antidiuretic and decreases urine output for approximately 6 hours
and is often used to treat nocturia in children. Solifenacin and tolterodine are anticholinergics.
Phenazopyridine is a urinary tract analgesic.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 394
5. A patient has a UTI and will begin treatment with an antibiotic. The patient reports moderate
to severe suprapubic pain. The primary care NP should prescribe:
a. ibuprofen as needed.
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. increased oral fluid intake to dilute urine.
ANS: C
Phenazopyridine is a urinary tract analgesic used to treat pain via a local analgesic effect on
urinary tract mucosa in conjunction with antibiotics to treat UTI. Ibuprofen may be used but
does not have direct effects on the urinary tract mucosa. Bethanechol is used to treat voiding
dysfunction and not pain. Increasing fluid intake should be used as adjunct therapy.
DIF: Cognitive Level: Applying (Application)
REF: 394
6. A primary care NP prescribes oxybutynin chloride for an 80-year-old patient to treat urinary
incontinence. When teaching this patient about this medication, the NP should tell the patient:
a. to increase intake of fluids and fiber.
b. that alcohol may be consumed in moderation.
c. that drowsiness may be a transient adverse effect.
d. that hypertension may occur and to report headaches.
ANS: A
Oxybutynin chloride is an anticholinergic drug and can cause dry mouth and constipation.
Patients should be taught to increase fluids and fiber. Patients should be cautioned to avoid
alcoholic beverages. Drowsiness occurs but does not subside, and elderly patients are at
increased risk for this side effect. Anticholinergics cause hypotension.
DIF: Cognitive Level: Applying (Application)
REF: 395
7. A patient reports dribbling small amounts of urine but also has difficulty initiating a urine
stream. The primary care NP should prescribe:
a. solifenacin (VESIcare).
b. bethanechol (Urecholine).
c. phenazopyridine (Pyridium).
d. oxybutynin chloride (Ditropan XL).
ANS: B
Bethanechol is a cholinergic agonist and is used to treat voiding dysfunction by increasing the
activity of the detrusor muscle. Solifenacin and oxybutynin chloride are anticholinergics.
Phenazopyridine is a urinary tract analgesic.
DIF: Cognitive Level: Applying (Application)
REF: 397
8. A serious side effect associated with desmopressin is:
a. dehydration.
b. hypotension.
c. hyponatremia.
d. urinary retention.
ANS: C
Patients taking desmopressin should be cautioned to limit fluid intake because hyponatremia
and water intoxication may occur.
DIF: Cognitive Level: Remembering (Knowledge)
Chapter 35: Acetaminophen
Test Bank
REF: 394
MULTIPLE CHOICE
1. An adult patient who has a viral upper respiratory infection asks the primary care nurse
practitioner (NP) about taking acetaminophen for fever and muscle aches. To help ensure
against possible drug toxicity, the NP should first:
a. determine the patient’s height and weight.
b. ask the patient how high the temperature has been.
c. tell the patient to take 325 mg initially and increase as needed.
d. ask the patient about any other over-the-counter (OTC) cold medications being
used.
ANS: D
Acetaminophen is present in many other OTC products, so patients should be cautioned about
taking these with acetaminophen to avoid overdose. The adult dose is not based on height and
weight and is not determined by the degree of temperature elevation.
DIF: Cognitive Level: Applying (Application)
REF: 399
2. A parent asks a primary care NP how much acetaminophen to give a 2-year-old child who has
a temperature of 37.5° C. The NP should tell the parent that:
a. acetaminophen is not safe in children younger than 6 years.
b. acetaminophen may mask a fever and prevent treatment of other symptoms.
c. antipyretics are usually not necessary for temperatures less than 37.7° C.
d. antipyretics should be given to prevent seizures, but nonsteroidal antiinflammatory
drugs are a better choice.
ANS: C
Acetaminophen is the drug of choice for treating fever but is generally not indicated for fever
less than 37.7° C. Acetaminophen is safe for children and infants. Treating the fever may
prolong the illness and mask symptoms, but these are not contraindications for giving
antipyretics.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 399
3. 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:
a. recommend acetaminophen.
b. recommend high-dose acetaminophen.
c. tell the patient that antibiotics are needed with a fever that high.
d. tell the patient a fever less than 40° C does not need to be treated.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 400 - 401
4. A patient comes to the clinic and reports breaking out in an urticarial rash 1 hour after taking
acetaminophen for osteoarthritis symptoms. The primary care NP should:
a. order a complete blood count with differential.
b. order liver and renal function tests.
c. suspect Reye’s syndrome and arrange for hospitalization.
d. tell the patient not to take products containing acetaminophen again.
ANS: D
Urticaria is indicative of a hypersensitivity reaction to acetaminophen. Patients who are
hypersensitive should not take the drug again. Laboratory tests are not indicated. An urticarial
rash does not indicate Reye’s syndrome.
DIF: Cognitive Level: Applying (Application)
REF: 402
5. A patient in the clinic reports taking a handful of acetaminophen extra-strength tablets about
12 hours prior. The patient has nausea, vomiting, malaise, and drowsiness. The patient’s
aspartate aminotransferase and alanine aminotransferase are mildly elevated. The primary care
NP should:
a. expect the patient to sustain permanent liver damage.
b. reassure the patient that these symptoms are reversible.
c. tell the patient that acetylcysteine cannot be given this late.
d. administer activated charcoal to remove acetaminophen from the body.
ANS: A
After acetaminophen overdose, if liver enzymes are elevated within 24 hours, irreversible
liver damage is likely. Acetylcysteine may still be given to mitigate the effects. Activated
charcoal is effective only when given immediately.
DIF: Cognitive Level: Applying (Application)
REF: 402
Chapter 36: Aspirin and Nonsteroidal Antiinflammatory Drugs
Test Bank
MULTIPLE CHOICE
1. A patient reports having persistent mild to moderate pain in both knees usually associated
with standing. The patient reports knee stiffness for 15 to 20 minutes each morning. The
primary care nurse practitioner (NP) learns that the patient has used heating pads and
acetaminophen, which no longer relieve the pain. The NP orders an erythrocyte sedimentation
rate, which is normal. The NP should consider prescribing:
a. aspirin.
b. a cyclooxygenase-2 (COX-2) inhibitor.
c. glucosamine and chondroitin.
d. a topical nonsteroidal antiinflammatory drug (NSAID).
ANS: D
Topical NSAIDs, acupuncture, and tramadol are effective for pain relief in knee osteoarthritis.
Treatment for osteoarthritis should begin with nonpharmacologic treatment, and
acetaminophen should be first-line pharmacologic treatment. NSAIDs should be used when
these two measures are no longer effective. COX-2 inhibitors are more expensive and should
be used in the presence of gastrointestinal (GI) side effects or for moderate to severe pain.
Glucosamine and chondroitin do not relieve most osteoarthritis pain.
DIF: Cognitive Level: Applying (Application)
REF: 407
2. A 70-year-old patient describes moderate to severe pain associated with osteoarthritis in
fingers, thumbs, hips, and knees. The patient is currently taking high-dose acetaminophen.
The patient has a strong family history of cardiovascular disease and has been diagnosed with
hypertension. To help alleviate this patient’s pain, the primary care NP should consider
prescribing:
a. a COX-2 inhibitor and low-dose aspirin.
b. ketorolac (Toradol) and 325 mg of aspirin.
c. naproxen (Naprosyn) and low-dose aspirin.
d. indomethacin (Indocin) and 325 mg of aspirin.
ANS: C
Aspirin at the dosage of 325 mg every other day or 81 mg daily is effective in reducing the
incidence of myocardial infarction (MI) and stroke. Concomitant use of an NSAID with
aspirin has been shown to reduce the cardioprotective effects of aspirin. However, naproxen
does not appear to have this risk.
DIF: Cognitive Level: Applying (Application)
REF: 409
3. A patient with mild to moderate osteoarthritis pain has been taking acetaminophen for pain.
The primary care NP prescribes a nonselective NSAID. At a follow-up visit, the patient
reports mild GI side effects. The NP should:
a. order misoprostol to take with the NSAID.
b. discontinue the NSAID and order tramadol.
c. change the medication to a COX-2 inhibitor.
d. change the medication to naproxen (Naprosyn).
ANS: A
If the patient experiences GI distress, coadministration of histamine-2 blockers, proton pump
inhibitors, or misoprostol may be considered. Tramadol is used for severe pain. A COX-2
inhibitor is generally used for long-term therapy. Naproxen is another nonselective NSAID
and would likely have similar GI side effects.
DIF: Cognitive Level: Applying (Application)
REF: 408
4. A patient is taking 81 mg of aspirin daily to decrease MI risk and uses acetaminophen for mild
osteoarthritis symptoms. For flare-ups of osteoarthritis pain, the primary care NP should
prescribe:
a. ibuprofen (Motrin).
b. celecoxib (Celebrex).
c. naproxen (Naprosyn).
d. increasing the dose of aspirin.
ANS: C
Concomitant use of an NSAID with aspirin has been shown to reduce the cardioprotective
effects of aspirin. However, naproxen does not appear to have this risk.
DIF: Cognitive Level: Applying (Application)
REF: 409
5. An 80-year-old patient has been taking naproxen (Naprosyn) for osteoarthritis for 6 months.
The patient reports adequate pain relief but complains of feeling tired. The primary care NP
will order:
a. liver function tests.
b. a serum potassium level.
c. a complete blood count (CBC).
d. a creatinine clearance and urinalysis.
ANS: C
Elderly patients are more susceptible to the adverse effects of NSAIDs, especially slow GI
bleeds leading to anemia (manifested as fatigue, lethargy). Patients complaining of fatigue
should have a CBC to evaluate for anemia.
DIF: Cognitive Level: Applying (Application)
REF: 409
6. A patient who has rheumatoid arthritis begins taking naproxen (Naprosyn) 500 mg once daily
for pain. After 1 week, the patient calls the primary care NP to report no change in
inflammation. The NP should:
a. change the medication to tramadol.
b. change the medication to ketorolac (Toradol).
c. increase the dose of naproxen to 1000 mg daily.
d. counsel the patient that pain relief may not occur for another week.
ANS: D
The analgesic effect of NSAIDs should be noticed within 1 to 4 hours of administration.
However, the full antiinflammatory effect will not be apparent until after a few weeks.
Tramadol and ketorolac are used for severe pain. It is not necessary to increase the dose of
naproxen.
DIF: Cognitive Level: Applying (Application)
REF: 408
7. The primary care NP sees an adolescent who reports moderate to severe dysmenorrhea. The
NP recommends an NSAID and counsels the patient about its use. Which statement by the
patient indicates a need for further teaching?
a. “I should not take this if I think I might be pregnant.”
b. “I should take this medication on a schedule for 2 to 3 days.”
c. “I will begin taking this 1 to 3 days before my period begins.”
d. “I will take this medicine every 4 to 6 hours as needed for pain.”
ANS: D
When treating primary dysmenorrhea, NSAIDs should be started 24 to 72 hours before the
patient starts menstrual bleeding. The medication should be taken on a routine basis for 2 to 3
days. It should not be taken during pregnancy.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 409
8. The primary care NP is performing a medication reconciliation on a patient who takes digoxin
for congestive heart failure and learns that the patient uses ibuprofen as needed for joint pain.
The NP should counsel this patient to:
a. use naproxen (Naprosyn) instead of ibuprofen.
b. increase the dose of digoxin while taking the ibuprofen.
c. use an increased dose of ibuprofen while taking the digoxin.
d. take potassium supplements to minimize the effects of the ibuprofen.
ANS: A
Ibuprofen and indomethacin increase the effects of digoxin, so the NP should recommend
another NSAID, such as naproxen, that does not have this effect. Increasing the dose of
digoxin or the ibuprofen would increase the likelihood of digoxin toxicity further. Potassium
should be monitored while taking NSAIDs long-term, but supplements should not be given
unless there is a potassium deficiency.
DIF: Cognitive Level: Applying (Application)
REF: 413
9. A primary care NP prescribes a nonselective NSAID for a patient who has osteoarthritis. The
patient expresses concerns about possible side effects of this medication. When counseling the
patient about the medication, the NP should tell this patient:
a. to avoid taking antacids while taking the NSAID.
b. to take each dose of the NSAID with a full glass of water.
c. that a few glasses of wine each day are allowed while taking the NSAID.
d. to decrease the dose of the NSAID if GI symptoms occur.
ANS: B
To avoid GI distress associated with NSAIDs, a full glass of water is recommended. Patients
may take NSAIDs with antacids. Patients should avoid alcohol while taking NSAIDs. Patients
should report GI symptoms to their provider.
DIF: Cognitive Level: Applying (Application)
REF: 410
10. A patient who has osteoarthritis is scheduled to have knee surgery. The patient takes aspirin
for MI prophylaxis and naproxen (Naprosyn) for pain and inflammation. Which statement by
the patient to the primary care NP indicates a need for further teaching?
a. “I should stop taking aspirin at least 5 days before surgery.”
b. “I will check with the surgeon to see if I need to stop taking the naproxen.”
c. “I will need to stop taking both medications 1 week before I have surgery.”
d. “Both of these medications interfere with platelet production and may cause blood
clots.”
ANS: C
Although both medications interfere with platelet formation, some NSAIDs may continue to
be taken before surgery, depending on the procedure and the surgeon preference. The patient
should stop taking aspirin 5 days before surgery.
DIF: Cognitive Level: Applying (Application)
REF: 410
Chapter 37: Disease-Modifying Antirheumatic Drugs and Immune Modulators
Test Bank
MULTIPLE CHOICE
1. A patient has recent weight loss, fatigue, and recurrent low-grade fever along with pain and
stiffness of knees and hands. The primary care nurse practitioner (NP) notes symmetric joint
swelling and warmth of these joints. The NP should:
a. refer the patient to a specialist.
b. order erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), and
antinuclear antibody (ANA) tests.
c. begin therapy with methotrexate.
d. order x-rays of the affected joints.
ANS: B
ESR is a very nonspecific but sensitive indication of inflammation. RF is positive in 75% to
85% of patients with rheumatoid arthritis (RA). ANAs are elevated in approximately 20% of
patients with RA. These tests help confirm the diagnosis of RA. Once the diagnosis is more
likely, referral to a specialist is warranted. Drug therapy is not begun until the diagnosis is
confirmed. X-rays are usually the earliest way to detect changes but are not diagnostic in the
early stages of the disease.
DIF: Cognitive Level: Applying (Application)
REF: 416
2. The primary care NP follows a patient who is being treated for RA with methotrexate. The
patient asks the NP why the medication does not seem to alleviate pain. The NP tells the
patient that:
a. an immunomodulator may be needed to control pain.
b. a higher dose of methotrexate may be needed to achieve pain control.
c. if methotrexate does not control pain, an opioid analgesic may be necessary.
d. methotrexate is used to slow disease progression and preserve joint function.
ANS: D
Disease-modifying antirheumatic drugs (DMARDs) have antiinflammatory effects that may
slow disease progression and preserve joint function. Acetaminophen and nonsteroidal
antiinflammatory drugs (NSAIDs) are common adjuncts to therapy to treat pain.
DIF: Cognitive Level: Applying (Application)
REF: 417
3. A patient who is being treated for RA reports having continued pain, which the patient
describes as moderate and persistent. The NP should prescribe:
a. acetaminophen.
b. a cyclooxygenase-2 (COX-2) inhibitor.
c. an opioid analgesic.
d. an NSAID.
ANS: D
NSAIDs are recommended for RA pain because RA is an inflammatory disease.
Acetaminophen may be used for mild pain. COX-2 inhibitors appear to cause more stomach
ulcers and gastrointestinal (GI) bleeds in patients with RA and so should not be used unless
other therapies are ineffective. Opioids should be used for patients with RA when other
medications and nonpharmacologic interventions produce inadequate pain relief and the
patient’s quality of life is affected by pain.
DIF: Cognitive Level: Applying (Application)
REF: 418
4. A patient who has a history of stomach ulcers is taking a nonselective NSAID along with a
DMARD for RA. The primary care NP should:
a. order a glucocorticoid.
b. change to acetaminophen.
c. order a proton pump inhibitor (PPI).
d. change to a selective COX-2 inhibitor.
ANS: C
If GI risk factors are present, a prophylactic PPI should be given along with the nonselective
NSAID. Glucocorticoids make ulcers worse. Acetaminophen is used only for mild pain or as
adjunct pain therapy. A selective COX-2 inhibitor has an increased risk of stomach ulcers.
DIF: Cognitive Level: Applying (Application)
REF: 418
5. A patient who has just been diagnosed with RA is experiencing minimal pain and mild
symptoms. The primary care NP should consult with a rheumatologist and should
recommend:
a. ibuprofen.
b. methotrexate.
c. acetaminophen.
d. herbal remedies.
ANS: A
If the disease is mild, NSAIDs are recommended at full therapeutic doses for the first 2 to 3
months before starting DMARDs such as methotrexate. Acetaminophen and herbal remedies
are not recommended as monotherapy.
DIF: Cognitive Level: Applying (Application)
REF: 418
6. A patient has been taking a COX-2 selective NSAID to treat pain associated with a recent
onset of RA. The patient tells the primary care NP that the pain and joint swelling are
becoming worse. The patient does not have synovitis or extraarticular manifestations of the
disease. The NP will refer the patient to a rheumatologist and should expect the specialist to
prescribe:
a. methotrexate.
b. corticosteroids.
c. opioid analgesics.
d. hydroxychloroquine.
ANS: D
In mild RA disease, patients are given NSAIDs first for 2 to 3 months, and then either
hydroxychloroquine or sulfasalazine is added if the disease does not remit. Methotrexate is a
first-line drug for patients with more aggressive symptoms, such as synovitis or extraarticular
symptoms. Opioid analgesics are used as adjuncts for pain relief along with DMARDs.
DIF: Cognitive Level: Applying (Application)
REF: 419
7. A patient is taking a cytokine immunomodulator to treat RA. The primary care NP caring for
this patient should:
a.
b.
c.
d.
obtain periodic complete blood counts (CBCs) and liver function tests (LFTs).
perform annual tuberculosis (TB) skin testing.
advise the patient of an increased risk of bone cancer.
administer the intranasal live attenuated influenza vaccine (LAIV) each year.
ANS: A
Routine monitoring for patients taking cytokine immunomodulators should include periodic
CBCs and LFTs. TB skin testing should be performed before initiating therapy but is not
indicated annually. Patients taking immunomodulators do not have an increased risk of bone
cancer. Providers should administer the trivalent influenza vaccine intramuscularly and not
the LAIV given intranasally because the LAIV is a live virus, which is contraindicated in
patients who are immunosuppressed.
DIF: Cognitive Level: Applying (Application)
REF: 419
8. A patient who has RA has been taking methotrexate for 6 months and tells the primary care
NP that symptoms seem to be getting worse. The NP refers the patient back to the
rheumatologist and should expect the rheumatologist to:
a. add prednisone to the drug regimen.
b. add adalimumab to the drug regimen.
c. change to a combination of adalimumab and etanercept.
d. discontinue methotrexate because 50% of patients do not respond.
ANS: B
Combination therapy generally is used because it is more effective and provides a more
sustained response. Immunomodulators such as adalimumab are often used with methotrexate.
Prednisone is not indicated. Immunomodulators are generally not used in combination.
DIF: Cognitive Level: Applying (Application)
REF: 417
9. A patient who is taking methotrexate for RA sees the primary care NP for an annual physical
examination. The patient’s alanine aminotransferase (ALT) and AGT are elevated. The NP
should:
a. decrease the dose of methotrexate.
b. recheck ALT and AGT levels in 2 weeks.
c. contact the patient’s rheumatologist to discuss discontinuing the drug.
d. counsel the patient not to take acetaminophen while taking methotrexate.
ANS: B
Liver enzyme elevations are frequent, are usually transient and asymptomatic, and do not
appear predictive of subsequent hepatic disease. A decrease in dose or discontinuation of the
drug is not indicated. Coadministration with acetaminophen is not contraindicated.
DIF: Cognitive Level: Applying (Application)
Chapter 38: Gout Medications
Test Bank
MULTIPLE CHOICE
REF: 420
1. A patient who has hypertension is taking a thiazide diuretic. The patient has a serum uric acid
level of 8 mg/dL. The primary care nurse practitioner (NP) caring for this patient should:
a. prescribe colchicine.
b. discontinue the thiazide diuretic.
c. order a 24-hour urine collection.
d. refer the patient to a rheumatologist.
ANS: C
Patients who have hypertension or who take thiazide diuretics are at increased risk for gout.
An elevated uric acid level alone is not diagnostic, and a 24-hour urine collection should be
ordered. Colchicine should not be prescribed until the diagnosis is confirmed. It is not
necessary to discontinue the thiazide diuretic. A referral to a specialist is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 423
2. A patient comes to the clinic reporting sudden pain and swelling of one knee joint. The
primary care NP suspects gout. When preparing to order diagnostic tests, the most important
initial test the primary care NP should order is:
a. renal function tests.
b. serum uric acid levels.
c. 24-hour urine collection.
d. synovial fluid aspirate for Gram stain and culture.
ANS: D
Although the other tests are part of the diagnostic process, the most important differential
diagnosis to be made in a patient with gout is the exclusion of a septic joint.
DIF: Cognitive Level: Applying (Application)
REF: 423
3. Gout is diagnosed in a patient, and tests show the cause to be an underexcretion of uric acid.
The primary care NP should prescribe:
a. febuxostat (Uloric).
b. colchicine (Colcrys).
c. allopurinol (Zyloprim).
d. probenecid (Benemid).
ANS: D
A uricosuric agent is indicated to increase the excretion of uric acid. Probenecid is a uricosuric
medication. Febuxostat and allopurinol are xanthine oxidase inhibitors. Colchicine is not a
uricosuric agent.
DIF: Cognitive Level: Applying (Application)
REF: 423
4. A primary care NP prescribes probenecid to treat a patient who has gout. The patient comes to
the clinic 2 weeks later with severe flank pain. The NP should:
a. ask the patient about fluid intake.
b. order a urinalysis and urine culture.
c. change the medication to allopurinol.
d. recommend nonsteroidal antiinflammatory drugs (NSAIDs) to treat flank pain.
ANS: A
Uricosuric agents are tubular blocking agents and decrease serum uric acid levels by
increasing urinary excretion of uric acid. During this process, high concentrations of uric acid
develop in the proximal renal tubules and may predispose the patient to the development of
urinary stones. Patients should be encouraged to drink plenty of fluids. The patient who
presents with flank pain should be questioned about fluid intake. If fluid intake is sufficient
and renal stones are ruled out, a urinary tract infection may be considered. Allopurinol is not
indicated. NSAIDs are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 423
5. A patient who is obese and has hypertension is taking a thiazide diuretic and develops gouty
arthritis, which is treated with probenecid. At a follow-up visit, the patient’s serum uric acid
level is 7 mg/dL, and the patient denies any current symptoms. The primary care NP should
discontinue the probenecid and:
a. prescribe colchicine.
b. prescribe febuxostat.
c. tell the patient to use an NSAID if symptoms recur.
d. counsel the patient to report recurrence of symptoms.
ANS: A
Colchicine is a first-line drug for preventing acute attacks. Because this patient has three risk
factors, a preventive medication should be used. Febuxostat is a second-line preventive
medication. The patient should not be treated on an as-needed basis.
DIF: Cognitive Level: Applying (Application)
REF: 424
6. A patient with a history of gouty arthritis comes to the clinic with acute pain and swelling of
the great toe. The patient is not currently taking any medications. The primary care NP should
prescribe:
a. naproxen.
b. colchicine.
c. probenecid.
d. allopurinol.
ANS: A
Naproxen is the first medication given for an attack of acute gouty arthritis to stop the
inflammatory response. Pharmacologic treatment for hyperuricemia must be started after the
acute attack has subsided.
DIF: Cognitive Level: Applying (Application)
REF: 425
7. A patient who is taking colchicine for gout is in the clinic 1 week after beginning the
medication. The patient reports decreased appetite and nausea. The primary care NP should:
a. suspect worsening of gouty arthritis.
b. order vitamin B12 levels to assess for vitamin deficiency.
c. discontinue the colchicine for 48 hours until symptoms subside.
d. reassure the patient that these are common, temporary side effects.
ANS: C
Colchicine toxicity causes nausea, vomiting, and anorexia. When toxicity is suspected, the
medication should be temporarily discontinued and restarted after symptoms subside.
DIF: Cognitive Level: Applying (Application)
REF: 426
8. A patient who has a previous history of renal stones will begin taking probenecid for gout.
The primary care NP should:
a. add colchicine to the patient’s drug regimen.
b. counsel the patient to use high-dose aspirin for pain.
c. teach the patient to drink plenty of acidic fluids such as juice.
d. tell the patient to stop taking the medication when symptoms subside.
ANS: A
Patients at risk for urinary stones may take colchicine along with probenecid to reduce the risk
caused by probenecid. Salicylates and acidic urine increase the risk. The medication must be
tapered 6 months after the last acute attack.
DIF: Cognitive Level: Applying (Application)
REF: 425
Chapter 39: Osteoporosis Treatment
Test Bank
MULTIPLE CHOICE
1. A 55-year-old woman who experienced menopause at age 50 years undergoes central dual-
energy x-ray absorptiometry and has a T-score greater than 2.5. The patient weighs 130 lb and
has a body mass index of 22. She sits at a computer all day at work. The primary care nurse
practitioner (NP) caring for this patient should:
a. prescribe a bisphosphonate.
b. prescribe hormone replacement therapy.
c. counsel the patient about diet and exercise.
d. prescribe a selective estrogen receptor modulator.
ANS: C
The NP should counsel the patient about diet and exercise. Women who are at least 5 years
postmenopausal or who have several risk factors should have bone density testing.
Osteoporosis is defined as a T-score of less than 2.5, and treatment is indicated for women
with T-scores that are 2 or more standard deviations below the normal premenopausal level. It
is not necessary to initiate treatment at this time.
DIF: Cognitive Level: Applying (Application)
REF: 435
2. A 50-year-old white woman who is experiencing menopause asks the primary care NP what
she can do to prevent osteoporosis. She has a negative family history and no risk factors. The
NP should counsel her to:
a. consider bisphosphonate therapy in 5 years.
b. undergo bone density testing every 2 years.
c. avoid high-impact sports that can lead to fractures.
d. take supplemental calcium and vitamin D every day.
ANS: D
Postmenopausal women should consume 1200 mg of calcium and at least 1000 U of vitamin
D each day. Bisphosphonate therapy should be considered for persons with known risk
factors. Bone density testing is indicated for women with risk factors and then routinely after
age 65. Patients should be encouraged to engage in high-impact sports if possible to improve
bone density.
DIF: Cognitive Level: Applying (Application)
REF: 433
3. A 60-year-old woman has a central dual-energy x-ray absorptiometry with a T-score of 1.9. A
health history reveals no risk factors for osteoporosis. The primary care NP should:
a. prescribe alendronate sodium (Fosamax).
b. counsel her to increase her physical activity.
c. prescribe calcitonin (Miacalcin nasal spray).
d. prescribe supplemental calcium and vitamin D.
ANS: A
This woman’s T-score is less than 2.5 and indicates osteoporosis. She should begin treatment
with a bisphosphonate. Increasing physical activity and taking supplemental calcium and
vitamin D are indicated as well but only as part of a medication regimen. Calcitonin is not a
first-line medication.
DIF: Cognitive Level: Applying (Application)
REF: 433
4. A 70-year-old patient who has a high fracture risk has been taking alendronate (Fosamax) and
calcium for 6 months. The primary care NP orders a urine NTx level, which is 42. The NP
should discontinue the alendronate and prescribe:
a. raloxifene (Evista).
b. teriparatide (Forteo).
c. calcitonin (Miacalcin nasal spray).
d. ibandronate sodium (Boniva).
ANS: B
Teriparatide is used in patients with a high fracture risk or in whom bisphosphonate therapy
has failed. Raloxifene and ibandronate are second-line treatments for patients with usual
fracture risks. Calcitonin is a last-line treatment.
DIF: Cognitive Level: Applying (Application)
REF: 436
5. A 60-year-old female patient has begun taking a daily bisphosphonate to prevent osteoporosis
and complains of gastrointestinal (GI) upset and dyspepsia. The primary care NP’s initial
response should be to:
a. prescribe a proton pump inhibitor (PPI).
b. order intravenous (IV) bisphosphonates.
c. suggest that she take the drug with food.
d. review the instructions for taking the drug with the patient.
ANS: D
Oral bisphosphonates must be taken on an empty stomach, and the patient must remain
upright and not eat or drink anything for 30 to 60 minutes. GI upset and dyspepsia are
frequent and can be minimized with correct administration. A PPI is not indicated. IV
bisphosphonates may be indicated if the patient is unable to tolerate the oral drug after correct
administration is confirmed. Bisphosphonates should not be taken with food.
DIF: Cognitive Level: Applying (Application)
REF: 436
6. A 50-year-old woman with osteopenia will begin taking raloxifene (Evista). When counseling
this patient about this drug regimen, the primary care NP should tell her to:
a. go for walks daily.
b. take the medication 1 hour before meals.
c. sit upright for 30 minutes after taking the drug.
d. avoid using diuretics while taking this medication.
ANS: A
Raloxifene is a selective estrogen receptor modulator, and it carries a risk of venous
thromboembolism. Patients should be encouraged to avoid immobilization. The other
instructions are part of medication teaching about bisphosphonates.
DIF: Cognitive Level: Applying (Application)
REF: 436
7. A 60-year-old woman is in the clinic for an annual well-woman examination. She has been
taking alendronate (Fosamax) 10 mg daily for 4 years. Her last bone density test yielded a Tscore of 2.0. Her urine NTx level today is 22. She walks daily. Her fracture risk is low. The
primary care NP should recommend that she:
a. take a 1- to 2-year drug holiday.
b. change to 70 mg of alendronate weekly.
c. decrease the alendronate dose to 5 mg daily.
d. change to ibandronate (Boniva) 3 mg IV every 3 months.
ANS: A
The American Association of Clinical Endocrinologists recommends patients have a “drug
holiday” after 4 to 5 years of bisphosphonate treatment if osteoporosis is mild and the fracture
risk is low. The other options are all viable treatment regimens but are not appropriate in this
case.
DIF: Cognitive Level: Applying (Application)
REF: 436
8. A patient who has several risk factors for osteoporosis has a bone density test that indicates
osteopenia. The primary care NP plans to prescribe a bisphosphonate. Before initiating
treatment, the NP should:
a. order an upper GI x-ray.
b. initiate PPI therapy.
c. order serum calcium and vitamin D levels.
d. prescribe a calcium and vitamin D supplement.
ANS: C
Patients must have adequate nutrition, calcium, and vitamin D. Hypocalcemia and vitamin D
deficiency must be corrected before therapy is initiated. An upper GI x-ray is indicated only if
the patient is symptomatic. Patients at risk for fracture should not take PPIs. Calcium and
vitamin D supplements should be given with bisphosphonate therapy; however, the first action
is to evaluate current serum levels.
DIF: Cognitive Level: Applying (Application)
REF: 438
Chapter 40: Muscle Relaxants
Test Bank
MULTIPLE CHOICE
1. The primary care nurse practitioner (NP) is seeing a patient who reports chronic lower back
pain. The patient reports having difficulty sleeping despite taking ibuprofen at bedtime each
night. The NP should prescribe:
a. diazepam (Valium).
b. metaxalone (Skelaxin).
c. methocarbamol (Robaxin).
d. cyclobenzaprine (Flexeril).
ANS: D
Cyclobenzaprine (Flexeril) is indicated for chronic low back pain and provides an added
benefit of aiding sleep, which is a common problem among patients with back pain. The other
medications are used for acute lower back pain.
DIF: Cognitive Level: Applying (Application)
REF: 443
2. A patient reports having an acute onset of low back pain associated with lifting a heavy object
the day before. Besides advising the patient to rest and apply ice, the primary care NP should
prescribe:
a. an opioid analgesic.
b. metaxalone (Skelaxin)
c. cyclobenzaprine (Flexeril).
d. a nonsteroidal antiinflammatory drug (NSAID).
ANS: D
NSAIDs and acetaminophen are first-line analgesic treatments for low back pain. Opioids are
used for severe low back pain. The other two medications are not first-line treatments.
DIF: Cognitive Level: Applying (Application)
REF: 444
3. A patient who was in a motor vehicle accident has been treated for lower back muscle spasms
with metaxalone (Skelaxin) for 1 week and reports decreased but persistent pain. A computed
tomography scan is normal. The primary care NP should:
a. suggest ice and rest.
b. order physical therapy.
c. prescribe diazepam (Valium).
d. add an opioid analgesic medication.
ANS: B
Physical therapy may be used as an injury begins to heal. This patient is experiencing
improvement of symptoms, so physical therapy may now be helpful. Ice and rest are useful in
the first 24 to 48 hours after injury. Diazepam is used on a short-term basis only. Opioid
analgesics are used for severe pain.
DIF: Cognitive Level: Applying (Application)
REF: 444
4. A patient with lower back pain and right-sided sciatica has taken an NSAID and a TCA for 1
week. The patient reports some decrease in pain but is experiencing increased tingling and
numbness of the right leg. The primary care NP should:
a. order a magnetic resonance imaging (MRI) study.
b. order physical therapy.
c. refer the patient to a neurologist.
d. continue the TCA for 1 more week.
ANS: A
Acute episodes of low back pain should be treated with an analgesic for 1 to 2 weeks. A
muscle relaxant is used to treat spasms. Patients with sciatica should be treated for 6 weeks. If
a neurologic deficit progresses, MRI should be ordered. Physical therapy is not indicated until
serious injury is ruled out. A neurology consultation is necessary in urgent conditions and
conditions with bilateral neurologic findings. The TCA may be continued, but the progression
of symptoms necessitates radiologic evaluation.
DIF: Cognitive Level: Applying (Application)
REF: 444
5. A 70-year-old patient has low back pain and will begin taking metaxalone (Skelaxin). The
primary care NP should counsel this patient to:
a. drink extra fluids.
b. avoid taking NSAIDs.
c. get up from a chair slowly.
d. take care to avoid slips and falls.
ANS: D
Use of any muscle relaxant puts elderly patients at risk for falls, so patients should be advised
to take precautions. It is not necessary to increase fluids or avoid NSAIDs. This drug does not
have hypotensive effects, so it is not necessary to provide the caution to rise out of chairs
slowly.
DIF: Cognitive Level: Applying (Application)
REF: 445
6. A patient comes to the clinic complaining of low back pain unrelieved by NSAIDs. The
patient has a history of angle-closure glaucoma and renal disease. The primary care NP should
prescribe:
a. tizanidine (Zanaflex).
b. metaxalone (Skelaxin).
c. acetaminophen (Tylenol).
d. cyclobenzaprine (Flexeril).
ANS: B
Metaxalone may be taken by patients with angle-closure glaucoma and is metabolized by the
liver, so it is safe for this patient. Tizanidine should not be given to patients with renal disease
because clearance may be reduced by more than 50%. After using NSAIDs with no relief,
recommendations are to change to a muscle relaxant. Cyclobenzaprine is not recommended in
patients with glaucoma.
DIF: Cognitive Level: Applying (Application)
REF: 445
7. A patient has acute low back pain caused by lifting a heavy object. The patient reports having
one or two drinks with meals each day. The primary care NP should prescribe:
a. an NSAID.
b. diazepam (Valium).
c. metaxalone (Skelaxin).
d. acetaminophen (Tylenol).
ANS: A
Skeletal muscle relaxants should not be taken with alcohol because effects are additive.
Acetaminophen has toxic effects on the liver, and patients who consume alcohol regularly
should avoid acetaminophen and diazepam.
DIF: Cognitive Level: Applying (Application)
REF: 445
Chapter 41: Medications for Attention-Deficit/Hyperactivity Disorder
Test Bank
MULTIPLE CHOICE
1. An adult patient reports feeling unfocused all the time, loses things, and has difficulty
completing tasks and says that this is interfering with family relations and work. The
symptoms have been present as long as the patient can remember, although there is no
previous documentation of attention-deficit/hyperactivity disorder (AD/HD) in this patient’s
medical history. The primary care nurse practitioner (NP) should:
a. tell the patient that a diagnosis of AD/HD as a child is a prerequisite for diagnosing
this in adults.
b. conduct a thorough evaluation to document behaviors associated with AD/HD and
begin treatment if indicated.
c. suggest that the patient may have a major depressive disorder and refer the patient
for psychiatric evaluation and treatment.
d. prescribe a methylphenidate trial, ask the patient to keep a diary of behaviors and
feelings, and reevaluate in 1 to 2 months.
ANS: B
Although childhood AD/HD is a prerequisite for diagnosis in an adult, it is increasingly
recognized that many adults have the disorder without having been diagnosed as children. The
NP should evaluate the patient’s symptoms and treat if indicated. The patient does not have
symptoms of depression. Methylphenidate should not be given unless the patient meets the
diagnostic criteria.
DIF: Cognitive Level: Applying (Application)
REF: 449
2. A child is taking methylphenidate (Ritalin) for AD/HD. The child’s parent calls the primary
care NP to report increased behavior problems and delusional thinking. The NP should:
a. increase the drug dose.
b. discontinue the medication.
c. change to dextroamphetamine.
d. order methylphenidate SR.
ANS: B
Exacerbation of behavioral and processing symptoms can occur in patients with preexisting
psychosis, and manic and behavioral symptoms may occur in patients who do not have an
underlying psychiatric disorder. This is true with all stimulant medications, so increasing the
dose, switching to another stimulant, or switching to a long-acting form are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 453
3. A primary care NP sees a child for an annual well-child check-up. The child has been taking
methylphenidate for AD/HD for 3 months. The NP should discontinue the medication if
which symptom is present?
a. Motor tics
b. Decreased appetite
c. Occasional headaches
d. Decreased blood pressure
ANS: A
Methylphenidate is contraindicated in patients who have motor tics or a diagnosis of
Tourette’s syndrome. Decreased appetite, occasional headaches, and changes in blood
pressure are not concerning.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 452
4. A child is diagnosed with AD/HD after being expelled from school for disruptive behaviors.
The child’s parents are reluctant to start medication because of the stigma attached. The
primary care NP should suggest:
a. Ritalin.
b. Concerta.
c. Adderall.
d. Dexedrine.
ANS: B
Concerta is a long-acting stimulant, and children taking it can avoid having to take a dose of
medication at school. The other choices are shorter acting and may require dosing during
school.
DIF: Cognitive Level: Applying (Application)
REF: 453
5. A child has been taking methylphenidate 5 mg at 8 AM, 12 PM, and 4 PM for 30 days after a
new diagnosis of AD/HD and comes to the clinic for evaluation. The child’s mother reports
that the child exhibits some nervousness and insomnia but is doing much better in school. The
primary care NP should suggest:
a. discontinuing the 4 PM dose.
b. increasing the dose to 10 mg each time.
c. giving 10 mg at 8 AM and 5 mg at noon.
d. changing the dosing to 15 mg twice daily.
ANS: A
Nervousness and insomnia are the most common adverse effects and are usually controlled by
reducing the dose or omitting the afternoon or evening dose.
DIF: Cognitive Level: Applying (Application)
REF: 453
6. A patient who has recently begun working at night reports having difficulty staying awake at
work. The primary care NP should consider prescribing:
a. caffeine.
b. modafinil (Provigil).
c. methylphenidate (Ritalin).
d. dextroamphetamine (Dexedrine).
ANS: B
Modafinil is approved for day/night shift changes in adults as well as narcolepsy, excessive
daytime sleepiness, and sleep apnea.
DIF: Cognitive Level: Applying (Application)
REF: 454
7. The parent of a 4-year-old child is concerned that the child may have AD/HD and wants to
know if medications can be given. The primary care NP should tell the parent that:
a. children cannot be diagnosed with AD/HD at this age.
b. alternative therapies to treat AD/HD are used at this age.
c. symptoms at this age are more likely due to environmental factors.
d. most drugs for AD/HD are not approved for children younger than 6 years.
ANS: D
Most AD/HD medications are not approved for use in children younger than 6 years. Children
can be diagnosed with AD/HD at age 4. Alternative therapies are not necessarily used.
DIF: Cognitive Level: Applying (Application)
REF: 454
8. The parent of an 8-year-old child recently diagnosed with AD/HD verbalizes concerns about
giving the child stimulants. The primary care NP should recommend:
a. modafinil (Provigil).
b. guanfacine (Intuniv).
c. bupropion (Wellbutrin).
d. atomoxetine (Strattera).
ANS: D
Atomoxetine is not a stimulant medication but is thought to be as effective as stimulant
medications. It is the only nonstimulant treatment approved by the U.S. Food and Drug
Administration for AD/HD that has been shown to be safe, well tolerated, and efficacious in
the treatment of children.
DIF: Cognitive Level: Applying (Application)
Chapter 42: Medications for Dementia
Test Bank
REF: 452
MULTIPLE CHOICE
1. A patient is identified as having stage 2 Alzheimer’s disease and elects to take donepezil
(Aricept). The patient asks the primary care nurse practitioner (NP) how long the medication
will be needed. The NP should tell the patient that donepezil must be taken:
a. until symptoms improve.
b. indefinitely because it is not curative.
c. for 24 weeks, which is when cognitive function improves in most patients.
d. until symptoms worsen, when a switch to memantine (Namenda) will be needed.
ANS: B
Cholinesterase (ChE) inhibitor drugs such as donepezil diminish symptoms; when the drug is
stopped, the symptoms return. Cognitive function will show improvement at about 24 weeks,
but the drug must be continued indefinitely.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 459
2. A patient who has Alzheimer’s disease has been taking donepezil for 1 year. The patient’s
spouse reports a worsening of symptoms. The primary care NP should consider:
a. switching to ginkgo biloba.
b. adding an antidepressant medication.
c. changing to galantamine (Razadyne).
d. adding memantine hydrochloride (Namenda).
ANS: D
Memantine hydrochloride can be added to therapy when symptoms worsen. Ginkgo biloba
may be useful but is not recommended as adjunct therapy. Antidepressants given to patients
with Alzheimer’s disease who have depression appear not to be effective and often cause
adverse effects or produce unwanted drug interactions. Galantamine is part of first-line
therapy but should not be given with donepezil because both are ChE inhibitors.
DIF: Cognitive Level: Applying (Application)
REF: 459
3. Early-stage Alzheimer’s disease is diagnosed in a patient, and the primary care NP
recommends therapy with a ChE inhibitor. The patient asks why drug treatment is necessary
because most functioning is intact. The NP should explain that medication may:
a. delay progression of symptoms.
b. produce temporary disease remission.
c. prevent depressive effects of the disease.
d. reduce the need for adjunct medications later on.
ANS: A
Pharmacologic treatment should begin as soon as Alzheimer’s disease is suspected because
early treatment can slow disease progression. Medication does not produce disease remission
or prevent depression. The disease eventually progresses despite medication, and adjunct
therapies are often required.
DIF: Cognitive Level: Applying (Application)
REF: 459
4. A patient has a diagnosis of depression and Alzheimer’s disease with mild, intermittent
symptoms. The primary care NP should prescribe a(n):
a. antidepressant.
b. ChE inhibitor.
c. antidepressant and ginkgo biloba.
d. antidepressant and a ChE inhibitor.
ANS: B
Antidepressants given to patients with Alzheimer’s disease do not appear to be effective and
cause adverse effects and unwanted drug interactions.
DIF: Cognitive Level: Applying (Application)
REF: 459
5. A patient who has Alzheimer’s disease begins taking donepezil (Aricept). After 3 months of
treatment, the patient does not show improvement of symptoms. The primary care NP should:
a. switch to rivastigmine (Exelon).
b. switch to galantamine (Razadyne).
c. switch to memantine (Namenda).
d. continue donepezil and reevaluate in 3 months.
ANS: D
Patients should be switched to other medications if initial therapy fails, but switching to
another medication should be considered only after a minimum of 6 months of treatment.
DIF: Cognitive Level: Applying (Application)
REF: 459
6. A patient is newly diagnosed with Alzheimer’s disease stage 6 on the Global Deterioration
Scale. The primary care NP should prescribe:
a. donepezil (Aricept).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. galantamine (Razadyne).
ANS: C
Patients with moderate to severe dementia (stages 5 to 7) may be started on memantine.
DIF: Cognitive Level: Applying (Application)
REF: 459
7. A patient has been taking donepezil (Aricept) for several months after being diagnosed with
Alzheimer’s disease. The patient’s spouse brings the patient to the clinic and reports that the
patient seems to be having visual hallucinations. The primary care NP should:
a. increase the dose.
b. decrease the dose.
c. switch to memantine (Namenda).
d. switch to galantamine (Razadyne).
ANS: B
Hallucinations may be a sign of drug toxicity. The NP should decrease the dose.
DIF: Cognitive Level: Applying (Application)
REF: 459
8. A patient who has Alzheimer’s disease is taking 10 mg of donepezil daily and reports
difficulty sleeping. The primary care NP should recommend:
a. decreasing the dose to 5 mg.
b. increasing the dose to 15 mg.
c. taking the drug in the morning.
d. taking the drug in the evening.
ANS: C
Donepezil is typically taken in the evening just before going to bed; however, in patients
experiencing sleep disturbance, daytime administration is preferred. The dose should not be
increased or decreased.
DIF: Cognitive Level: Applying (Application)
REF: 460
9. A patient who is diagnosed with Alzheimer’s disease experiences visual hallucinations. The
primary care NP should initially prescribe:
a. donepezil (Aricept).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. galantamine (Razadyne).
ANS: B
Patients with dementia with Lewy bodies may show benefit with rivastigmine. Visual
hallucinations are a hallmark feature of Lewy body dementia.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 461
Chapter 43: Analgesia and Pain Management
Test Bank
MULTIPLE CHOICE
1. A patient has been taking an opioid analgesic for chronic pain and tells the primary care nurse
practitioner (NP) that the medication doesn’t work as well anymore. The NP should suspect
drug:
a. addiction.
b. tolerance.
c. modulation.
d. dependence.
ANS: B
Tolerance is characterized by decreasing drug effect over time, meaning that more drug is
needed to achieve the same effect. Addiction is an overwhelming obsession with obtaining
and using a drug for non–medically approved purposes. Dependence is the development of
abstinence syndrome or withdrawal symptoms.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 464 - 465
2. A patient has pain caused by a chronic condition. The patient is reluctant to take opioids
because of a fear of addiction. The primary care NP should tell the patient that opioids:
a. carry a high risk of psychological dependence when used long-term.
b. will help to improve the patient’s functional outcomes and quality of life.
c. will eventually become ineffective for treating pain when used over a long period.
d. may require switching from one type of opioid to another to prevent tolerance over
time.
ANS: B
Chronic pain requires routine administration of drugs, and addiction is generally not a
concern, especially for patients with chronic pain or terminal illness. Opioid analgesics will
help the patient improve function and quality of life. Tolerance may develop, and higher doses
may be required to maintain effectiveness. Randomized, controlled trials are lacking to
support switching opioids to manage tolerance and side effects.
DIF: Cognitive Level: Applying (Application)
REF: 467 - 468
3. A patient is diagnosed with a condition that causes chronic pain. The primary care NP
prescribes an opioid analgesic and should instruct the patient to:
a. wait until the pain is at a moderate level before taking the medication.
b. take the medication at regular intervals and not just when pain is present.
c. start the medication at higher doses initially and taper down gradually.
d. take the minimum amount needed even when pain is severe to avoid dependency.
ANS: B
Chronic pain requires routine administration of drugs, and patients should take analgesics
routinely without waiting for increased pain.
DIF: Cognitive Level: Applying (Application)
REF: 467
4. A patient who is a recovering alcoholic is preparing for surgery and expresses fears about
using opioid analgesics postoperatively for pain. The primary care NP should tell the patient:
a. that opioids should not be used.
b. to take a very low dose of the opioid.
c. that nonsteroidal antiinflammatory drugs will be the only safe option.
d. that opioids are safe when taken as directed.
ANS: D
Fear of drug dependency or addiction does not justify withholding of opiates or inadequate
management of pain. As long as the medication is taken as directed, it is safe.
DIF: Cognitive Level: Applying (Application)
REF: 467
5. A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days after
surgery. When the patient is discharged from the hospital, the primary care NP should expect
the patient to receive a prescription for _____ mg orally every _____ hours.
a. hydrocodone 30; 6
b. hydrocodone 75; 6
c. meperidine 300;12
d. meperidine 75; 6
ANS: A
When patients are switched from one opiate to another, an equianalgesic table should be used
to convert the dosage of the current drug to the equivalent dosage of the new drug. An oral
dose of 30 mg of hydrocodone is equivalent to an IM dose of 75 mg of meperidine.
DIF: Cognitive Level: Applying (Application)
REF: 470
6. A patient has been taking an opioid analgesic for 2 weeks after a minor outpatient procedure.
At a follow-up clinic visit, the patient tells the primary care NP that he took extra doses for the
past 2 days because of increased pain and wants an early refill of the medication. The NP
should suspect:
a. dependence.
b. drug addiction.
c. possible misuse.
d. increasing pain.
ANS: C
Unsanctioned dose increases are a sign of possible drug misuse. Dependence refers to an
abstinence or withdrawal syndrome. Drug addiction is an obsession with obtaining and using
the drug for nonmedical purposes. The patient should not have increased pain at 2 weeks.
DIF: Cognitive Level: Applying (Application)
REF: 469
7. A patient who is taking an antibiotic to treat bronchitis reports moderate rib pain associated
with frequent coughing. The primary care NP should consider prescribing:
a. morphine.
b. hydrocodone.
c. hydromorphone.
d. oxycodone CR.
ANS: B
Hydrocodone is used for cough suppression as well as pain. Morphine can cause profound
respiratory depression.
DIF: Cognitive Level: Applying (Application)
REF: 472
Chapter 44: Migraine Medications
Test Bank
MULTIPLE CHOICE
1. A patient who has migraine headaches takes sumatriptan as abortive therapy. The patient tells
the primary care nurse practitioner (NP) that the sumatriptan is effective for stopping
symptoms but that the episodes are occurring three to four times per month. The NP should
consider the addition of:
a. aspirin.
b. topiramate.
c. ergotamine.
d. opioid analgesics.
ANS: B
Topiramate is an anticonvulsant agent that is approved as a preventive medication for
migraines. The other medications are indicated for abortive therapy.
DIF: Cognitive Level: Applying (Application)
REF: 477
2. A patient comes to the clinic concerned about possible migraine headaches. The primary care
NP conducts a history and physical examination, and the patient describes vise-like pressure
in the back of the head that occurs almost daily during the work week. The NP should
recommend:
a. acetaminophen.
b. topiramate.
c. sumatriptan.
d. ergotamine.
ANS: A
This patient is describing symptoms typical of tension headaches. The NP should recommend
acetaminophen, not migraine medications.
DIF: Cognitive Level: Applying (Application)
REF: 478
3. A patient comes to the clinic and reports recurrent headaches. The patient has a headache
diary, which reveals irritability and food cravings followed the next day by visual
disturbances and unilateral right-sided headache, nausea, and photophobia lasting 2 to 3 days.
The NP should recognize these symptoms as _____ migraine.
a. classic
b. hemiplegic
c. basilar-type
d. ophthalmoplegic
ANS: A
These are symptoms of classic migraine. Hemiplegic migraine is characterized by motor and
sensory symptoms. Basilar-type migraine includes vertigo, diplopia, dysarthria, tinnitus, and
decreased hearing. Ophthalmoplegic migraine affects the third, fourth, or fifth cranial nerve,
causing permanent damage.
DIF: Cognitive Level: Applying (Application)
REF: 478
4. A patient who has migraine headaches tells the primary care NP that drinking coffee and
taking nonsteroidal antiinflammatory drugs (NSAIDs) seems to help with discomfort. The NP
should tell the patient that:
a. this combination can lead to longer lasting headache pain.
b. these substances are not indicated for migraine headaches.
c. doing this can increase the risk of more chronic migraines.
d. an opioid analgesic would be a better choice for migraine pain.
ANS: A
Overuse of pain or migraine medications can cause a transformed migraine, which is a longlasting headache. Following a migraine episode, the patient has rebound headache daily or
nearly daily. NSAIDs, caffeine, opiates, and triptans can cause these rebound headaches.
NSAIDs and caffeine are often used to treat migraines. Narcotics and barbiturates increase the
risk for development of chronic migraine headaches and should not be first-line drugs.
DIF: Cognitive Level: Applying (Application)
REF: 478
5. A patient takes rizatriptan (Maxalt) to abort migraine headaches but tells the primary care NP
that the headaches have become more frequent since a promotion at work. The NP’s initial
response should be to:
a. prescribe topiramate (Topamax).
b. stress the importance of establishing new routines.
c. help the patient identify stressors associated with the new role.
d. add a combination NSAID, aspirin, and caffeine product to the regimen.
ANS: B
Prevention or reduction of episodes of migraine requires healthy regular daily habits.
Regularity of habits, rather than just searching for triggers, is essential for enhancing the
effectiveness of nonpharmacologic approaches. If the increase in migraine episodes remains
chronic after nonpharmacologic measures are taken, topiramate may be used.
DIF: Cognitive Level: Applying (Application)
REF: 481
6. A primary care NP prescribes sumatriptan for abortive treatment of migraine headaches. The
patient returns to the clinic 1 month later to report increased frequency of the headaches. The
NP should:
a. add an opioid analgesic.
b. consider changing to dihydroergotamine (D.H.E. 45).
c. suggest that the patient take sumatriptan with a NSAID.
d. ask the patient how often the sumatriptan is used each week.
ANS: D
It is important that any abortive agent be administered no more often than 2 days per week to
avoid the possibility of rebound headache. Patients should be encouraged to try products for at
least two or three episodes of migraine before they decide they are ineffective, so changing the
drug regimen may not be indicated at this time.
DIF: Cognitive Level: Applying (Application)
REF: 484
7. A patient who has migraine headaches without an aura reports difficulty treating the migraines
in time because they come on so suddenly. The patient has been using over-the-counter
NSAIDs. The primary care NP should prescribe:
a. frovatriptan (Frova).
b. sumatriptan (Imitrex).
c. cyproheptadine (Periactin).
d. dihydroergotamine (D.H.E. 45).
ANS: B
If the patient is able to take medication at the earliest onset of migraine, ergots are usually
effective. Triptans are more effective when patients have difficulty “catching the headache in
time.” Sumatriptan begins to work in 15 minutes and so would be indicated for this patient.
Frovatriptan has a longer half-life. Cyproheptadine is not a first-line migraine treatment.
DIF: Cognitive Level: Applying (Application)
REF: 481 - 482
8. A patient who has mild to moderate migraine headaches has severe nausea and vomiting with
each episode. For the best treatment of this patient, the primary care NP should prescribe:
a. triptan nasal spray.
b. metoclopramide and aspirin.
c. an NSAID and prochlorperazine.
d. sumatriptan and metoclopramide.
ANS: A
Administer triptan migraine medication in nasal spray or injection for patients with severe
nausea and vomiting who have trouble taking oral medications. An antiemetic, such as
prochlorperazine or metoclopramide, may be used, although the latter has serious side effects.
DIF: Cognitive Level: Applying (Application)
REF: 483
9. A patient who has migraine headaches usually has two to three severe migraines each month.
The patient has been using a triptan nasal spray but reports little relief and is concerned about
missing so many days of work. The primary care NP should consider:
a. an oral triptan plus an opioid analgesic.
b. an injectable triptan plus an oral corticosteroid.
c. an intramuscular steroid plus an opioid analgesic.
d. dihydroergotamine hydrochloride plus an opioid analgesic.
ANS: B
For severe migraines, an injectable triptan should be considered along with corticosteroids or
opioids as rescue medications. Oral triptans are not as effective for severe migraines.
Ergotamines may be tried as second-line therapy.
DIF: Cognitive Level: Applying (Application)
REF: 483
10. A patient who experiences migraines characterized by unilateral motor and sensory symptoms
tells the primary care NP that despite abortive therapy with a triptan, the frequency of
episodes has increased to three or four times each month. The NP should:
a. add a selective serotonin reuptake inhibitor (SSRI) antidepressant.
b. change to dihydroergotamine hydrochloride.
c. prescribe a -blocker such as propranolol.
d. prescribe an anticonvulsant such as topiramate.
ANS: D
Topiramate is useful for migraine prophylaxis. SSRI antidepressants are considered secondline treatment for prophylaxis and are less effective than tricyclic antidepressants.
Ergotamines are not used as prophylaxis. -Blockers are commonly used but may aggravate
neurologic symptoms associated with hemiplegic or basilar migraine, which is what this
patient has.
DIF: Cognitive Level: Applying (Application)
REF: 483
11. A patient who is diagnosed with migraine headaches has a history of cardiovascular disease
and hypertension. The NP should prescribe:
a. triptan nasal spray.
b. rizatriptan (Maxalt).
c. cyproheptadine (Periactin).
d. dihydroergotamine (D.H.E. 45).
ANS: C
Triptans and ergotamines are contraindicated in patients with cardiovascular disease or
hypertension. Cyproheptadine is safe for these patients.
DIF: Cognitive Level: Applying (Application)
REF: 487
12. A patient reports frequent headaches to the primary NP. The patient describes the headaches
as unilateral and moderate in intensity, accompanied by nausea, vomiting, and photophobia.
There is no aura, and the headaches generally last 24 to 48 hours. The NP should:
a. prescribe dihydroergotamine (D.H.E. 45).
b. prescribe topiramate (Topamax) as migraine prophylaxis.
c. recognize these as classic migraines and order sumatriptan (Imitrex).
d. suggest treatment with acetaminophen because these are probably tension
headaches.
ANS: C
This patient has symptoms of classic migraine with repeated episodes. Sumatriptan is a firstline medication. Ergotamines are second-line medications. Topiramate is used as migraine
prophylaxis in patients who have increasingly frequent migraine episodes. These symptoms
are not characteristic of tension headaches.
DIF: Cognitive Level: Applying (Application)
REF: 479
Chapter 45: Antiepileptics
Test Bank
MULTIPLE CHOICE
1. A patient who has partial seizures has been taking phenytoin (Dilantin). The patient has
recently developed thrombocytopenia. The primary care nurse practitioner (NP) should
contact the patient’s neurologist to discuss changing the patient’s medication to:
a. topiramate (Topamax).
b. levetiracetam (Keppra).
c. zonisamide (Zonegran).
d. carbamazepine (Tegretol).
ANS: D
Evidence-based recommendations exist showing carbamazepine to be effective as
monotherapy for partial seizures. Because this patient has developed a serious side effect of
phenytoin, changing to carbamazepine may be a good option. The other three drugs may be
added to phenytoin or another first-line drug when drug-resistant seizures occur, but are not
recommended as monotherapy.
DIF: Cognitive Level: Applying (Application)
REF: 491
2. A patient is newly diagnosed with generalized epilepsy. The primary care NP will refer this
patient to a neurologist and should expect this patient to begin taking:
a. phenytoin (Dilantin).
b. topiramate (Topamax).
c. lamotrigine (Lamictal).
d. levetiracetam (Keppra).
ANS: A
There is little good-quality evidence to support the use of newer monotherapy over older
drugs. Phenytoin is the prototype of many seizure medications and is usually tried first. Other
drugs may be used if seizures are resistant to phenytoin or if side effects occur.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 491
3. A patient who takes carbamazepine (Tegretol) has been seizure-free for 2 years and asks the
primary care NP about stopping the medication. The NP should:
a. order an electroencephalogram (EEG).
b. prescribe a tapering regimen of the drug.
c. inform the patient that antiepileptic drug (AED) therapy is lifelong.
d. tell the patient to stop the drug and use only as needed.
ANS: A
Discontinuation of AEDs may be considered in patients who have been seizure-free for longer
than 2 years. An EEG should be obtained before the medication is withdrawn. The drug
should be tapered to prevent status epilepticus, but only after a normal EEG is obtained. AED
therapy is not lifelong in all patients. Patients should not stop AED medications abruptly, and
these drugs are not used on an as-needed basis.
DIF: Cognitive Level: Applying (Application)
REF: 492
4. A 12-month-old child with severe developmental delays was recently treated in an emergency
department for a febrile seizure and is seen by the primary care NP for a follow-up visit. The
child’s parent asks if it is necessary to continue giving the child phenobarbital. The NP should
tell the parent that:
a. the phenobarbital may be used on an as-needed basis.
b. the phenobarbital may be stopped when an EEG is normal.
c. once the febrile illness is past, the phenobarbital may be stopped.
d. their child is at increased risk for seizures and should continue the phenobarbital.
ANS: D
Although the American Academy of Pediatrics has concluded that the risks of long-term
treatment with phenobarbital outweigh the potential benefits in most cases, continued
treatment with this drug is used in children at greatest risk for future neurologic problems,
including children with febrile seizures before 18 months of age and children with neurologic
dysfunction or severe developmental delays.
DIF: Cognitive Level: Applying (Application)
REF: 492
5. A patient who is taking phenytoin (Dilantin) for a newly diagnosed seizure disorder calls the
primary care NP to report a rash. The NP should:
a. order a phenytoin level.
b. reassure the patient that this is a self-limiting adverse effect.
c. recommend that the patient take diphenhydramine to treat this side effect.
d. tell the patient to stop taking the phenytoin and contact the neurologist
immediately.
ANS: D
Phenytoin should be discontinued if skin rash appears because some rashes can be lifethreatening. Rashes are not related to serum drug levels, so a phenytoin level is not indicated.
Although some rashes are self-limiting, the patient should stop taking the drug until serious
rashes are ruled out. Suggesting diphenhydramine is not correct until the severity of the rash is
known.
DIF: Cognitive Level: Applying (Application)
REF: 496
6. A patient who takes valproic acid for a seizure disorder is preparing to have surgery. The
primary care NP should order:
a. coagulation studies.
b. a complete blood count.
c. an EEG.
d. a creatinine clearance test.
ANS: A
Valproic acid may cause thrombocytopenia and inhibition of platelet aggregation. Platelet
counts and coagulation studies should be done before therapy is initiated, at regular intervals,
and before any surgical procedure is performed.
DIF: Cognitive Level: Applying (Application)
REF: 497
7. A 20-kg child takes valproic acid (Depakote) for seizures and has had regular dose increases
with a current dose of 250 mg twice daily. The child continues to have one to two seizures
each week along with significant drowsiness that interferes with school participation. The
primary care NP should contact the child’s neurologist to discuss:
a. obtaining a serum valproic acid level.
b. changing the medication to gabapentin (Neurontin).
c. increasing the valproic acid by 5 mg per kg of weight.
d. adding lamotrigine (Lamictal) to this child’s drug regimen.
ANS: D
Research suggests a combination of lamotrigine and valproate to be the most effective
regimen in patients with refractory epilepsy. Valproic acid dosing may be increased to a
maximum of 60 mg/kg/day unless side effects prevent further increase in dosage. The other
drugs are not recommended.
DIF: Cognitive Level: Applying (Application)
REF: 499
8. A patient who takes carbamazepine (Tegretol) for a seizure disorder is seen by a primary care
NP for a routine physical examination. A complete blood count (CBC) reveals a low white
blood cell (WBC) count. The NP should:
a. order a WBC differential.
b. discontinue the carbamazepine.
c. reassure the patient that this effect is temporary.
d. decrease the carbamazepine dose and recheck the CBC in 2 weeks.
ANS: A
A benign leukopenia associated with carbamazepine is common and is reversible and doserelated. A WBC differential should be performed before changing the drug regimen.
DIF: Cognitive Level: Applying (Application)
REF: 500 - 501
Chapter 46: Antiparkinson Agents
Test Bank
MULTIPLE CHOICE
1. A patient who has Parkinson’s disease takes levodopa and carbidopa. The patient asks the
primary care nurse practitioner (NP) why two drugs are necessary. The NP should explain that
both drugs are needed to:
a. prolong effects of the levodopa.
b. delay progression of the disease.
c. decrease adverse peripheral side effects.
d. enhance passage of both drugs across the blood-brain barrier.
ANS: C
Combining carbidopa with levodopa results in increased concentrations of levodopa in the
central nervous system and decreased conversion of levodopa to dopamine in the periphery,
where it causes adverse effects. Carbidopa does not prolong the effects of levodopa. The
combination does not cause delay in disease progression and does not enhance passage across
the blood-brain barrier.
DIF: Cognitive Level: Applying (Application)
REF: 505
2. A patient who has Parkinson’s disease and who takes levodopa reports that the drug effects
wear off more quickly than before. The primary care NP should:
a. add carbidopa.
b. add amantadine.
c. increase the dose of levodopa.
d. add a monoamine oxidase B inhibitor (MAO-B).
ANS: D
When an MAO-B is given, it appears to enhance and prolong the response to levodopa,
reducing the wearing-off effect. Carbidopa does not alter this effect. Amantadine is not
indicated. Increasing the dose of levodopa is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 505
3. A patient who has Parkinson’s disease takes levodopa and carbidopa. The patient reports
experiencing tremors between doses. The primary care NP should:
a. add entacapone.
b. add amantadine.
c. discontinue the carbidopa.
d. increase the dose of levodopa.
ANS: A
Catecholamine O-methyl transferase inhibitors, such as entacapone, are used to prolong the
effects of levodopa and help prevent breakthrough tremors that occur before the next dose of
levodopa. Amantadine is not indicated. Increasing carbidopa does not have this effect.
Increasing the dose of levodopa does not prolong its effects.
DIF: Cognitive Level: Applying (Application)
REF: 505
4. A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing
freezing episodes between doses. The primary care NP should consider using:
a. selegiline.
b. amantadine.
c. apomorphine.
d. modified-release levodopa.
ANS: C
Apomorphine injection is used for acute treatment of immobility known as “freezing.”
DIF: Cognitive Level: Applying (Application)
REF: 506
5. A patient who has Parkinson’s disease who takes levodopa and carbidopa reports having
drooling episodes that are increasing in frequency. The primary care NP should order:
a. benztropine.
b. amantadine.
c. apomorphine.
d. modified-release levodopa.
ANS: A
Anticholinergics, such as benztropine, are used to control drooling.
DIF: Cognitive Level: Applying (Application)
REF: 506
6. A patient who is diagnosed with Parkinson’s disease will begin taking levodopa and
carbidopa. The patient asks the primary care NP what dietary interventions may be helpful in
improving symptoms. The NP should recommend:
a. consuming a high-calorie diet.
b. consuming a low-carbohydrate diet.
c. avoiding extra fluids during meal times.
d. minimizing intake of high-protein foods during the day.
ANS: D
Some people find that avoiding high-protein foods during the day and “hoarding” them until
the evening improves mobility during the day. Because of decreased activity associated with
the disease, patients should not eat a diet high in calories. A low-carbohydrate diet is not
indicated. Patients should consume plenty of water with food to aid in chewing and
swallowing.
DIF: Cognitive Level: Applying (Application)
REF: 506
7. A 55-year-old patient develops Parkinson’s disease characterized by unilateral tremors only.
The primary care NP will refer the patient to a neurologist and should expect initial treatment
to be:
a. levodopa.
b. carbidopa.
c. pramipexole.
d. carbidopa/levodopa.
ANS: C
Patients younger than 65 years of age should be started with a dopamine agonist.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 507 - 508
8. A 65-year-old patient is diagnosed with Parkinson’s disease. The patient has emphysema and
narrow-angle glaucoma. The primary care NP should consider beginning therapy with:
a. selegiline.
b. benztropine.
c. carbidopa/levodopa.
d. ropinirole hydrochloride.
ANS: A
Selegiline is safe for patients with glaucoma and emphysema. Benztropine is contraindicated
in patients with glaucoma and emphysema. Dopamine precursors, such as
carbidopa/levodopa, are contraindicated in patients with narrow-angle glaucoma and
cautioned in patients with emphysema.
DIF: Cognitive Level: Applying (Application)
REF: 507 - 508
Chapter 47: Antidepressants
Test Bank
MULTIPLE CHOICE
1. A patient reports having feelings of hopelessness and anxiety for the past few months. The
primary care nurse practitioner (NP) performs a history and learns that these feelings occur
almost daily. The patient also reports having headaches and difficulty concentrating at work
along with wanting to sleep all the time. The patient has gained 5 lb in the past 6 months. The
NP should:
a. tell the patient that these symptoms should resolve on their own.
b. reassure the patient that these are symptoms of minor depression.
c. tell the patient that an exercise regimen alone should be effective.
d. assess the patient for alcohol and drug use and for suicidal ideation.
ANS: D
The patient is having symptoms of major depression, but other factors such as drug or alcohol
abuse that may be contributing to the diagnosis must be ruled out first. Patients should be
asked about suicidal ideation so that measures can be taken to prevent a suicide attempt.
Symptoms of major depression require treatment. Exercise should be a part of any plan but
should not be the only intervention.
DIF: Cognitive Level: Applying (Application)
REF: 521
2. A patient reports feelings of sadness and hopelessness along with difficulty sleeping and
weight loss. The primary care NP learns that the patient’s mother died 6 months earlier. The
NP should:
a. offer a referral to a bereavement counselor.
b. begin pharmacologic treatment with fluoxetine.
c. determine whether medications are causing these symptoms.
d. tell the patient that these symptoms will go away in a few months.
ANS: A
Bereavement over the loss of a loved one may be associated with symptoms of major
depression. Although only 17% of these patients receive pharmacologic treatment, 94% of
symptoms have been found to resolve in 13 months or less. Bereavement counseling should
be the first step. Pharmacologic treatment may be warranted if symptoms do not improve.
This patient has a clear cause for depression. It is not enough to reassure the patient that the
symptoms will resolve because this belittles their concerns.
DIF: Cognitive Level: Applying (Application)
REF: 520
3. A patient has been taking paroxetine (Paxil) for major depressive symptoms for 8 months. The
patient tells the primary care NP that these symptoms improved after 2 months of therapy.
The patient is experiencing weight gain and sexual dysfunction and wants to know if the
medication can be discontinued. The NP should:
a. change to a tricyclic antidepressant medication.
b. begin to taper the paroxetine and instruct the patient to call if symptoms increase.
c. tell the patient to stop taking the medication and to call if symptoms get worse.
d. continue the medication for several months and consider adding bupropion
(Wellbutrin).
ANS: D
Once a patient achieves remission, a continuation phase of 16 to 20 weeks followed by a
maintenance phase of 4 to 9 months should be carried out. Some responders, called apathetic
responders, may have a decrease in most symptoms but continue to have lack of pleasure,
decreased libido, and lack of energy. Bupropion can be added to therapy to treat these
symptoms. Patients should not change medications during this phase, should not begin a drug
taper, and should never stop the medication abruptly.
DIF: Cognitive Level: Applying (Application)
REF: 525
4. The primary care NP has prescribed sertraline (Zoloft) for a patient who initially reported
daily symptoms of hopelessness, sadness, insomnia, and weight loss. After several months of
therapy, the patient no longer feels hopeless or sad but continues to have difficulty eating and
sleeping. The NP should contact the patient’s psychiatrist to discuss:
a. adding mirtazapine (Remeron).
b. changing to duloxetine (Cymbalta).
c. adding another selective serotonin reuptake inhibitor (SSRI) antidepressant.
d. an inpatient admission to the hospital.
ANS: A
Mirtazapine may be added to the drug regimen for partial responders who continue to feel
anxious. Changing medications is not recommended. Adding another SSRI is contraindicated
because of the risk of serotonin syndrome. An inpatient hospital admission is not warranted.
DIF: Cognitive Level: Applying (Application)
REF: 525
5. A patient has been taking fluoxetine (Prozac) for depression and comes to the clinic to report
nausea and jitteriness. The primary care NP notes tremors and sees that the patient is
confused. The patient has a heart rate of 95 beats per minute. The NP should:
a. change to bupropion (Wellbutrin).
b. ask the patient about other medications.
c. discontinue the fluoxetine immediately.
d. add mirtazapine (Remeron) to treat anxiety.
ANS: B
Serotonin syndrome is a potentially lethal set of symptoms such as these. The NP should
evaluate whether the patient is taking other SSRIs, monoamine oxidase inhibitors, bupropion,
serotonin-norepinephrine reuptake inhibitors, or other medications that can precipitate this.
Changing medication is not indicated. Patients should never abruptly discontinue an SSRI.
Adding mirtazapine is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 524
6. A patient who has symptoms of depression also reports chronic pain. The primary care NP
should begin therapy with:
a. fluoxetine (Prozac).
b. duloxetine (Cymbalta).
c. bupropion (Wellbutrin).
d. nortriptyline (Pamelor).
ANS: B
Duloxetine is an antidepressant that also has uses for pain syndromes associated with
depression.
DIF: Cognitive Level: Applying (Application)
REF: 526 - 527
7. An 80-year-old patient experiences prolonged sadness after the death of a spouse. The patient
reports being unable to sleep or eat. The primary care NP should prescribe _____ mg _____
daily.
a. trazodone 50; three times
b. trazodone 100; three times
c. mirtazapine 15; at bedtime
d. mirtazapine 30; at bedtime
ANS: C
Mirtazapine side effects include sedation and increased appetite, and sedation is more likely
with a lower dose. Mirtazapine is often used in nursing homes to stimulate appetite in older
adults.
DIF: Cognitive Level: Applying (Application)
REF: 527
8. The primary care NP sees a 16-year-old patient who reports feeling hopeless and sad. The
child’s parent reports increased aggression and a decline in school performance. The NP
should consider prescribing:
a. fluoxetine (Prozac).
b. nortriptyline (Pamelor).
c. tranylcypromine (Parnate).
d. venlafaxine hydrochloride (Effexor).
ANS: A
Fluoxetine may be used in children 8 years of age and older. Nortriptyline may be used in
children 12 years of age and older but is not a first-line drug. The other drugs are not indicated
in adolescents younger than 18 years.
DIF: Cognitive Level: Applying (Application)
REF: 529
9. A 15-year-old patient who is seeing a psychiatrist began taking an antidepressant 1 week
before a clinic visit with the primary care NP. The NP should:
a. schedule weekly clinic visits to evaluate response to the medication.
b. encourage the child to report feelings of self-harm to a school counselor.
c. contact the patient by phone every 2 weeks to see how the medication is working.
d. instruct the child’s parents to report changes in behavior to the child’s psychiatrist.
ANS: A
Pediatric patients should have face-to-face contact with a provider at least weekly during the
first 4 weeks of treatment to evaluate for clinical worsening, suicidality, or unusual changes in
behavior.
DIF: Cognitive Level: Applying (Application)
REF: 529
10. A patient has been taking fluoxetine 20 mg every morning for 5 days and calls the primary
care NP to report decreased appetite, nausea, and insomnia. The NP should:
a. suggest taking a sedative at bedtime.
b. change the medication to bupropion.
c. add trazodone to the patient’s regimen.
d. reassure the patient that these effects will subside.
ANS: D
Side effects are seen with the first few doses but resolve in approximately 7 days. Patients
should avoid taking sedatives while taking antidepressants.
DIF: Cognitive Level: Applying (Application)
REF: 530
Chapter 48: Antianxiety and Insomnia Agents
Test Bank
MULTIPLE CHOICE
1. A patient comes to the clinic and reports having insomnia that began within the last year. The
primary care nurse practitioner (NP) learns that the patient often lies awake worrying about
problems at work. The patient feels fatigued during the day and experiences frequent stomach
discomfort. The NP should prescribe:
a. buspirone.
b. melatonin.
c. alprazolam.
d. diphenhydramine.
ANS: A
This patient is having insomnia because of anxiety. Alprazolam has a high abuse potential, so
starting therapy with an antianxiety medication is a good choice. Melatonin and
diphenhydramine are given for insomnia.
DIF: Cognitive Level: Applying (Application)
REF: 541
2. A patient tells the primary care NP about having difficulty giving presentations at work. The
patient experiences anxiety and often feels faint or vomits. The NP should:
a. prescribe buspirone.
b. prescribe alprazolam.
c. order a selective serotonin reuptake inhibitor (SSRI) antidepressant.
d. recommend cognitive-behavioral therapy.
ANS: D
The patient is describing a phobic disorder. Cognitive-behavioral therapy is recommended as
first-line treatment, with SSRI medications as adjunct therapy.
DIF: Cognitive Level: Applying (Application)
REF: 540 - 541
3. An adolescent patient comes to the clinic and reports anxiety and poor sleep that have
persisted since experiencing a hurricane 8 months prior. The patient has been receiving
cognitive-behavioral therapy, which has helped a little. The primary care NP should order:
a. doxepin.
b. fluoxetine.
c. alprazolam.
d. clonazepam.
ANS: B
This patient has posttraumatic stress disorder. If cognitive-behavioral therapy has not been
effective, the patient should be given an SSRI as second-line treatment. Doxepin is a tricyclic
antidepressant. The other two choices are benzodiazepines.
DIF: Cognitive Level: Applying (Application)
REF: 542
4. A patient reports difficulty falling asleep and staying asleep every night and has difficulty
staying awake during the commute to work every day. The NP should:
a. suggest the patient try diphenhydramine first.
b. perform a thorough history and physical examination.
c. teach about avoiding caffeine and good sleep hygiene.
d. suggest melatonin and consider prescribing Ambien if this is not effective.
ANS: B
Before treating insomnia with drug therapy, it is important first to rule out any physiologic
causes of a sleep disorder. The other interventions may be tried if no serious cause of the
disorder is found.
DIF: Cognitive Level: Applying (Application)
REF: 541
5. A patient is in the clinic with acute symptoms of anxiety. The patient is restless and has not
slept in 3 days. The primary care NP observes that the patient is irritable and has moderate
muscle tension. The patient’s spouse reports that similar symptoms have occurred before in
varying degrees for several years. The NP should refer the patient to a psychologist and
should prescribe which drug for short-term use?
a. Alprazolam
b. Buspirone
c. Melatonin
d. Zolpidem
ANS: A
For acute anxiety, a benzodiazepine should be prescribed. SSRIs or buspirone should be used
for long-term treatment. Melatonin and zolpidem are anti-insomnia agents.
DIF: Cognitive Level: Applying (Application)
REF: 542
6. A patient reports going to bed at 10:00 pm every night but often lays awake until midnight.
The primary care NP instructs the patient to practice good sleep hygiene and to avoid caffeine
in the evening. After 1 week of this regimen, the patient reports still lying awake until 11:00
PM. The NP should:
a. order a sleep study.
b. consider short-term zolpidem.
c. order ramelteon for several weeks.
d. reassure the patient and re-evaluate in 1 week.
ANS: D
Treatment of patients with insomnia begins with sleep hygiene. It is important that the patient
have reasonable expectations and understand that the time of onset of sleep can be moved up
only by 15 minutes every 3 or 4 days. This patient is showing improvement, which means the
measures are working. When these measures are ineffective, medications may be considered.
DIF: Cognitive Level: Applying (Application)
REF: 543
7. 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:
a. zaleplon.
b. ZolpiMist.
c. ramelteon.
d. chloral hydrate.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 543
Chapter 49: Antipsychotics
Test Bank
MULTIPLE CHOICE
1. The primary care nurse practitioner (NP) is performing a physical examination on a patient
who has been taking mesoridazine (Serentil) for several weeks to treat schizophrenia. The
patient is exhibiting rhythmic movements of the face and jaw. The NP should be concerned
that the patient may:
a. need a higher dose of mesoridazine.
b. need to change to thioridazine (Mellaril).
c. have developed neuroleptic malignant syndrome.
d. be exhibiting signs of an irreversible adverse effect.
ANS: D
Tardive dyskinesia, or abnormal involuntary movements characterized by rhythmic
involuntary movements of the tongue, face, mouth, or jaw, may be progressive and
irreversible. This condition can occur with all antipsychotics, especially the first-generation
antipsychotics. Increasing the dose may increase the symptoms. Thioridazine is another firstgeneration antipsychotic with a similar adverse-effect profile. Neuroleptic malignant
syndrome occurs weeks after initiation and is characterized by fever, catatonia, muscle
rigidity, and autonomic instability.
DIF: Cognitive Level: Applying (Application)
REF: 552
2. A patient with a recent diagnosis of schizophrenia is taking thioridazine (Mellaril) to treat
psychotic symptoms. The patient’s family member is concerned that the patient continues to
have little interest in activities and has difficulty beginning even simple tasks. The primary
care NP should contact the patient’s psychiatrist to discuss changing to:
a. fluphenazine (Prolixin).
b. risperidone (Risperdal).
c. chlorpromazine (Thorazine).
d. prochlorperazine (Compazine).
ANS: B
First-generation antipsychotics treat positive but not negative symptoms associated with
psychotic states. This patient exhibits negative symptoms and should be treated with a secondgeneration antipsychotic, such as risperidone. The other three drugs are first-generation
antipsychotics.
DIF: Cognitive Level: Applying (Application)
REF: 552
3. A 22-year-old male patient who has dropped out of college has increasingly disorganized
behavior and delusional thinking. His parents report that he lives at home and has no desire to
find a job or help around the house. The primary care NP has ruled out organic causes and has
referred the patient to a psychiatrist for treatment. To prepare for the referral visit, the NP
should:
a. begin therapy with a low-potency antipsychotic.
b. begin therapy with a high-potency antipsychotic.
c. obtain a complete blood count (CBC), serum lipids, and hemoglobin A1c.
d. order liver function tests (LFTs), a CBC, an electrocardiogram (ECG), and a
urinalysis.
ANS: D
Before antipsychotic drugs are initiated, baseline laboratory tests, including LFTs, CBC,
ECG, and urinalysis, should be performed. Serum lipids and hemoglobin A1c may be ordered
if the patient has risk factors for diabetes or metabolic syndrome.
DIF: Cognitive Level: Applying (Application)
REF: 554
4. A patient who is newly diagnosed with schizophrenia is overweight and has a positive family
history for type 2 diabetes mellitus. The primary care NP should consider initiating
antipsychotic therapy with:
a. ziprasidone (Geodon).
b. olanzapine (Zyprexa).
c. risperidone (Risperdal).
d. chlorpromazine (Thorazine).
ANS: A
Many antipsychotics increase the risk of metabolic syndrome in patients. Ziprasidone does not
have effects on weight. The other agents all increase the risk of weight gain and metabolic
syndrome.
DIF: Cognitive Level: Applying (Application)
REF: 564
5. A patient has been taking olanzapine (Zyprexa) for 3 weeks to treat schizophrenia. The
primary care NP notes that the patient has more coherent speech and improved initiative and
attentiveness but continues to have delusional ideation. The NP should:
a. increase the dose of olanzapine.
b. decrease the dose of olanzapine.
c. maintain the same dose of olanzapine.
d. change from olanzapine to chlorpromazine.
ANS: A
Clinicians should gradually increase the dose of antipsychotic medication to achieve
therapeutic effects, while minimizing side effects. It may take weeks to achieve full
therapeutic effects.
DIF: Cognitive Level: Applying (Application)
REF: 556
6. An elderly patient with dementia exhibits hostility and uncooperativeness. The primary care
NP prescribes clozapine (Clozaril) and should counsel the family about:
a. a decreased risk of extrapyramidal symptoms.
b. improved cognitive function.
c. the need for long-term use of the medication.
d. a possible increased risk of heart disease and stroke.
ANS: D
Antipsychotics are useful in treating some psychiatric symptoms of dementia and help to
improve quality of life in many patients. They do not improve cognitive function, however.
They increase the risk of extrapyramidal symptoms and should be used only on a short-term
basis. They increase the risk of heart disease and stroke.
DIF: Cognitive Level: Applying (Application)
REF: 557
7. A patient who takes 150 mg of clozapine (Clozaril) twice daily calls the primary care NP at
10:00 AM one day to report forgetting to take the 8:00 AM dose. The NP should counsel the
patient to:
a. take the missed dose now.
b. take 75 mg of clozapine now.
c. wait and take the evening dose at the usual time.
d. take the evening dose 2 hours earlier than usual.
ANS: C
Advise patients to take missed doses only if remembered within 1 hour after the time the dose
was due.
DIF: Cognitive Level: Applying (Application)
REF: 558
8. A patient comes to the clinic for a physical examination 2 weeks after a last dose of clozapine
(Clozaril). The primary care NP should:
a. order a CBC with differential.
b. obtain serum lipids and LFTs.
c. obtain a serum clozapine level.
d. assess for orthostatic hypotension.
ANS: A
Clozapine presents a significant risk for agranulocytosis, and leukocytes should be monitored
before starting treatment, weekly during treatment, and weekly for at least 4 weeks after
discontinuing treatment.
DIF: Cognitive Level: Applying (Application)
REF: 563
9. A patient who is overweight is diagnosed with schizophrenia. The primary care NP should
consider prescribing:
a. olanzapine (Zyprexa).
b. ziprasidone (Geodon).
c. quetiapine (Seroquel).
d. aripiprazole (Abilify).
ANS: B
Of the four drugs listed, ziprasidone causes the least metabolic side-effect burden of secondgeneration antipsychotics.
DIF: Cognitive Level: Applying (Application)
REF: 564
Chapter 50: Substance Abuse
Test Bank
MULTIPLE CHOICE
1. At an annual well-woman examination, the primary care nurse practitioner (NP) asks a patient
about alcohol consumption. The woman reports she usually consumes six glasses of wine per
week and occasionally will consume three or four glasses at a party. The NP smells alcohol on
the woman’s breath. The woman says she is hung over today. The NP should:
a. order liver function tests (LFTs) and a complete blood count.
b. question her further about her nightly alcohol consumption—ask what size her
wine glasses are.
c. consider her at high risk for alcoholism.
d. refer her to treatment for alcohol abuse.
ANS: B
Patients with alcohol on their breath should be assessed for alcohol abuse. The woman
describes an amount of drinking that would put her at low risk, but alcoholics often minimize
their drinking. A first step would be to get more information about how much she is drinking.
The laboratory work may be indicated when the degree of suspicion is confirmed. Once
alcoholism is diagnosed, she should be referred for treatment.
DIF: Cognitive Level: Applying (Application)
REF: 566
2. A mother brings her a college-age son to the primary care NP and asks the NP to talk to him
about alcohol use. He reports binge drinking on occasion and drinking only beer on weekends.
The NP notes diaphoresis, tachycardia, and an easy startle reflex. The NP should:
a. admit him to the hospital for detoxification.
b. ask him how much he had to drink last night.
c. prescribe lorazepam (Ativan) to help with symptoms.
d. suggest that he talk to a counselor about alcohol abuse.
ANS: A
He is showing signs of alcohol withdrawal and possible delirium tremens and so should be
admitted to the hospital. Asking him about drinking and suggesting outpatient counseling
would be useful for a less emergent condition. The NP should not prescribe a medication to
treat delirium tremens on an outpatient basis.
DIF: Cognitive Level: Applying (Application)
REF: 566
3. A patient who is an alcoholic is seen in the clinic, and the primary care NP admits the patient
to the hospital for acute withdrawal. The patient has elevated liver enzymes. The NP should
expect the inpatient provider to prescribe:
a. lorazepam (Ativan).
b. diazepam (Valium).
c. acamprosate (Campral).
d. chlordiazepoxide (Librium).
ANS: A
Benzodiazepines are used to treat alcohol withdrawal because they demonstrate crosstolerance with alcohol. Short-acting benzodiazepines are used in patients with liver damage.
Lorazepam is a short-acting benzodiazepine. Acamprosate is used to reduce voluntary intake
of alcohol and is not used for withdrawal symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 566
4. A patient is brought to the clinic by a spouse because of increased somnolence and
disorientation. The spouse tells the primary care NP that the patient has been taking
oxycodone for postoperative pain. The NP notes a respiratory rate of 8 to 10 breaths per
minute. The NP should:
a. activate the emergency medical service (EMS) and administer oxygen.
b. administer oral methadone (Dolophine).
c. administer intramuscular naltrexone (ReVia).
d. administer sublingual buprenorphine (Subutex).
ANS: C
The patient shows signs of opiate toxicity. Naltrexone is given to reverse the respiratory
depression caused by opiate toxicity. The NP would activate EMS if the patient’s symptoms
worsen. Methadone is used to assist patients addicted to narcotics to withdraw from the drug.
Buprenorphine is used to aid with withdrawal symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 568
5. The primary care NP is preparing to prescribe acamprosate for a patient who is an alcoholic.
Before initiating treatment with this medication, the NP should:
a. assess renal function.
b. obtain liver function tests.
c. teach the patient never to take the drug with alcohol.
d. tell the patient that this medication is used to treat withdrawal symptoms.
ANS: A
This drug should not be given if patients have severe renal impairment. LFTs are indicated if
signs of liver toxicity occur. Acamprosate does not cause a disulfiram-like reaction and is not
used to treat withdrawal.
DIF: Cognitive Level: Applying (Application)
REF: 568
6. The primary care NP prescribes disulfiram to a patient who has stopped drinking but
continues to have cravings for alcohol. The NP must counsel the patient to:
a. abstain from alcohol completely.
b. report a garlic taste in the mouth.
c. stop taking the drug after a few months.
d. increase the drug dose after several months.
ANS: A
Patients taking disulfiram who consume alcohol experience an uncomfortable and sometimes
life-threatening reaction and may have these symptoms up to 14 days after disulfiram is given.
A garlic taste is a minor side effect. Patients may take the drug for years but do not need to
increase the dose because they can become more sensitive to its effects.
DIF: Cognitive Level: Applying (Application)
REF: 568
Chapter 51: Glucocorticoids
Test Bank
MULTIPLE CHOICE
1. A patient has been taking oral prednisone 60 mg daily for 3 days for an asthma exacerbation,
which has resolved. The patient reports having gastrointestinal (GI) upset. The primary care
nurse practitioner (NP) should:
a. discontinue the prednisone.
b. begin tapering the dose of the prednisone.
c. order a proton pump inhibitor (PPI) to counter the effects of the steroid.
d. change the prednisone dosing to every other day.
ANS: A
The patient’s asthma symptoms have resolved, so the prednisone may be discontinued. If the
patient has been on the medication for a few days, it is not necessary to taper the dose before
the patient stops taking it. If the patient required long-term dosing of the steroid, a PPI could
be used. Every-other-day dosing is used. Alternate-day dosing is sometimes used for longterm therapy to minimize suppression of the hypothalamic-pituitary-adrenal (HPA) axis.
DIF: Cognitive Level: Applying (Application)
REF: 576
2. A patient will require a long course of steroids to treat a chronic inflammatory condition. The
primary care NP expects the specialist to order:
a. prednisone daily.
b. triamcinolone daily.
c. hydrocortisone every other day.
d. dexamethasone every other day.
ANS: C
Hydrocortisone is a short-acting glucocorticoid. The use of a short-acting agent and an
alternate-day dosage regimen should be considered for long-term therapy. Prednisone and
triamcinolone are medium-acting glucocorticoids. Dexamethasone is a long-acting
glucocorticoid.
DIF: Cognitive Level: Applying (Application)
REF: 576
3. 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:
a. gradually tapering the child off the prednisone.
b. a referral for possible growth hormone therapy.
c. giving a double dose of prednisone every other day.
d. dividing the prednisone dose into twice-daily dosing.
ANS: C
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.
DIF: Cognitive Level: Applying (Application)
REF: 576
4. A 70-year-old patient with COPD who is new to the clinic reports taking 10 mg of prednisone
daily for several years. The primary care NP should:
a. tell the patient to take the drug every other day before 9:00 AM.
b. order a serum glucose, potassium level, and bone density testing.
c. perform pulmonary function tests to see if the medication is still needed.
d. begin a gradual taper of the prednisone to wean the patient off the medication.
ANS: B
Serum glucose and potassium levels are part of monitoring for side effects of steroids.
Because elderly patients are more prone to certain potential catabolic adverse effects of
steroid therapy, caution is required. Osteoporosis is often seen with elderly patients, so bone
density testing should be performed. The medication dosing regimen should not be changed
unless there is an indication of adverse effects.
DIF: Cognitive Level: Applying (Application)
REF: 577
5. A primary care NP prescribes an oral steroid to a patient and provides teaching about the
medication. Which statement by the patient indicates a need for further teaching?
a. “I should take this medication with food.”
b. “I will take the medication at 8:00 AM each day.”
c. “I can expect a decreased appetite while I am taking this medication.”
d. “I should not stop taking the medication without consulting my provider.”
ANS: C
Therapeutic administration is least likely to interfere with natural hormone production when
the drug is given at the time of natural peak activity. It is generally recommended to
administer the full daily dose before 9 AM. Oral glucocorticoids usually are given with meals
to limit GI irritation. Common side effects include changes in mood, insomnia, and increased
appetite.
DIF: Cognitive Level: Applying (Application)
REF: 577
6. A patient with ulcerative colitis takes 30 mg of methylprednisolone (Medrol) daily. The
primary care NP sees this patient for bronchitis and orders azithromycin (Zithromax). The NP
should:
a. order intramuscular (IM) methylprednisolone.
b. temporarily decrease the dose of methylprednisolone.
c. change the dosing of methylprednisolone to 15 mg twice a day.
d. stop the methylprednisolone while the patient is taking azithromycin.
ANS: B
When given concurrently with macrolide antibiotics, methylprednisolone clearance is
reduced, so a smaller dose of methylprednisolone is needed. IM administration does not affect
clearance of the drug. Changing the dose to twice-daily dosing is not recommended. Stopping
the drug abruptly is not recommended.
DIF: Cognitive Level: Applying (Application)
REF: 579
7. 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:
a. consume foods high in vitamin D and calcium.
b. begin taking dexamethasone because it has longer effects.
c. expect these side effects to occur as the medication is tapered.
d. increase the dose of prednisolone to the most recent amount taken.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 578
Chapter 52: Thyroid Medications
Test Bank
MULTIPLE CHOICE
1. A patient reports fatigue, weight loss, and dry skin. The primary care nurse practitioner (NP)
orders thyroid function tests. The patient’s thyroid stimulating hormone (TSH) is 40
microunits/mL, and T4 is 0.1 ng/mL. The NP should refer the patient to an endocrinologist
and prescribe:
a. methimazole.
b. liothyronine.
c. levothyroxine.
d. propylthiouracil.
ANS: C
This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a
thyroid suppressant. Liothyronine is synthetic T3. Propylthiouracil is a thyroid suppressant.
DIF: Cognitive Level: Applying (Application)
REF: 582
2. A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks.
The patient reports continued fatigue. The primary care NP should:
a. order a T4 level today.
b. increase the dose to 100 mcg.
c. check the TSH level in 1 week.
d. reassure the patient that this will improve in several weeks.
ANS: C
Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH level
is indicated to evaluate drug effectiveness. The dose should not be increased without first
evaluating the patient’s TSH level.
DIF: Cognitive Level: Applying (Application)
REF: 582
3. A primary care NP orders thyroid function tests. The patient’s TSH is 1.2 microunits/mL, and
T4 is 1.7 ng/mL. The NP should:
a. assess the patient for symptoms of hyperthyroidism.
b. ask the patient about the use of medications such as lithium.
c. tell the patient that the results most likely indicate hypothyroidism.
d. ask an endocrinologist to evaluate for possible Hashimoto’s thyroiditis.
ANS: C
Primary hypothyroidism is the most common form of hypothyroidism. Use of certain drugs,
such as lithium, and diseases such as Hashimoto’s thyroiditis can cause hypothyroidism but
are less likely. The patient does not have signs of hyperthyroidism.
DIF: Cognitive Level: Applying (Application)
REF: 585
4. An 80-year-old female patient with a history of angina has increased TSH and decreased T4.
The primary care NP should prescribe _____ mcg of _____.
a. 25; liothyronine
b. 75; liothyronine
c. 25; levothyroxine
d. 75; levothyroxine
ANS: C
Elderly individuals may experience exacerbation of cardiovascular disease and angina with
thyroid hormone replacement. It is advisable to start low at 25 mcg and work up as tolerated.
Liothyronine is a synthetic T3.
DIF: Cognitive Level: Applying (Application)
REF: 587
5. A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child
weighs 15 kg. The primary care NP sees the child for a 3-year-old check-up. The NP should
consult with a pediatric endocrinologist to discuss:
a. increasing the dose to 90 mcg/day.
b. decreasing the dose to 30 mcg/day.
c. stopping the medication and checking TSH and T4 in 4 weeks.
d. discussing the need for lifetime replacement therapy with the child’s parents.
ANS: C
In congenital hypothyroidism, therapy may be stopped for 2 to 8 weeks after the patient
reaches 3 years of age. If TSH levels remain normal, thyroid supplementation may be
discontinued permanently.
DIF: Cognitive Level: Applying (Application)
REF: 587
6. A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When
teaching this patient about the medication, the NP should:
a. counsel the patient to take the medication with food.
b. tell the patient that changing brands of the medication should be avoided.
c. instruct the patient to stop taking the medication if signs of thyrotoxicosis occur.
d. tell the patient that the drug may be stopped when thyroid function tests stabilize.
ANS: B
Patients should be told not to change brands of the medication; there is potential variability in
the bioequivalence between manufacturers. The medication should be taken at approximately
the same time each day before breakfast or on an empty stomach. Patients should be
instructed to contact the provider if signs of thyrotoxicosis are present. Thyroid replacement
medications are usually given for life.
DIF: Cognitive Level: Applying (Application)
REF: 587
7. A patient has been taking levothyroxine 100 mcg daily for several months. The patient comes
to the clinic with complaints of insomnia and irritability. The primary care NP notes a heart
rate of 92 beats per minute. The NP should:
a. change to liothyronine 75 mcg/day.
b. discontinue levothyroxine indefinitely.
c. order propylthiouracil to counter the increased thyroid levels.
d. order TSH and T4 levels and decrease the dose to 75 mcg/day.
ANS: D
When signs of thyrotoxicosis occur, the drug should be decreased or temporarily discontinued
for 5 to 7 days. Liothyronine is not indicated. Propylthiouracil is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 584
8. A 75-year-old patient who has cardiovascular disease reports insomnia and vomiting for
several weeks. The primary care NP orders thyroid function tests. The tests show TSH is
decreased and T4 is increased. The NP should consult with an endocrinologist and order:
a. thyrotropin.
b. methimazole.
c. levothyroxine.
d. propylthiouracil.
ANS: B
Patients with hyperthyroidism, or Graves’ disease, will require radioactive iodine. Elderly
patients and patients with cardiovascular disease should be pretreated with an antithyroid
medication such as methimazole. Thyrotropin is used to diagnose thyroid cancer.
Levothyroxine is used to treat hypothyroidism. Propylthiouracil is also a thyroid suppressant,
but methimazole is preferred.
DIF: Cognitive Level: Applying (Application)
REF: 586
9. A patient with Graves’ disease is taking methimazole. After 6 months of therapy, the primary
care NP notes normal T3 and T4 and elevated TSH. The NP should:
a. order a complete blood count (CBC) with differential.
b. order aspartate aminotransferase, AGT, and LDH tests.
c. decrease the dose of the medication.
d. add levothyroxine to the patient’s regimen.
ANS: C
Once clinical levels of thyrotoxicosis have been resolved, elevated TSH indicates a need to
reduce the dosage. A CBC with differential is performed at the beginning of treatment and
when signs of infection are present. Liver function tests may be monitored periodically but are
not indicated by the current laboratory results. Levothyroxine is not indicated.
DIF: Cognitive Level: Applying (Application)
Chapter 53: Diabetes Mellitus Agents
Test Bank
MULTIPLE CHOICE
REF: 587
1. A 40-year-old patient is in the clinic for a routine physical examination. The patient has a
body mass index (BMI) of 26. The patient is active and walks a dog daily. A lipid profile
reveals low-density lipoprotein (LDL) of 100 mg/dL, high-density lipoprotein (HDL) of 30
mg/dL, and triglycerides of 250 mg/dL. The primary care nurse practitioner (NP) should:
a. order a fasting plasma glucose level.
b. consider prescribing metformin (Glucophage).
c. suggest dietary changes and increased exercise.
d. obtain serum insulin and hemoglobin A1c levels.
ANS: A
Testing for type 2 diabetes should be considered in all adults with a BMI greater than 25 who
have risk factors such as HDL less than 35 mg/dL or triglycerides greater than 250 mg/dL. A
fasting plasma glucose level greater than 126 mg/dL indicates diabetes. Metformin is not
indicated unless testing is positive. Lifestyle changes may be part of the treatment plan. Serum
insulin level is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 591
2. A patient is newly diagnosed with type 2 diabetes mellitus. The primary care NP reviews this
patient’s laboratory tests and notes normal renal function, increased triglycerides, and
deceased HDL levels. The NP should prescribe:
a. nateglinide (Starlix).
b. glyburide (Micronase).
c. colesevelam (Welchol).
d. metformin (Glucophage).
ANS: D
Metformin is recommended as initial pharmacologic treatment for type 2 diabetes. It has been
shown to decrease triglycerides and LDLs.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 592
3. A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood
glucose within normal limits and has had multiple episodes of both hypoglycemia and
hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should
prescribe:
a. pramlintide (Symlin).
b. repaglinide (Prandin).
c. glyburide (Micronase).
d. metformin (Glucophage).
ANS: A
Pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes
and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning
pancreas to be effective. Glyburide and metformin are first-line oral agents and are not
indicated.
DIF: Cognitive Level: Applying (Application)
REF: 593
4. A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily
and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and
hemoglobin A1c is 7.3%. The NP should:
a. begin insulin therapy.
b. change to therapy with colesevelam (Welchol).
c. add a third oral antidiabetic agent to this patient’s drug regimen.
d. enroll the patient in a weight loss program to achieve better glycemic control.
ANS: A
The target hemoglobin A1c goal for adults is less than 7%. Insulin therapy is indicated if
maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the
maximum recommended doses of metformin and glyburide. Colesevelam does not decrease
hemoglobin A1c. Adding a third oral antidiabetic agent is not recommended. A weight loss
program may be a part of this patient’s treatment, but insulin is necessary to maintain
glycemic control.
DIF: Cognitive Level: Applying (Application)
REF: 596
5. A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical
examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile
three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her
personal and family histories are noncontributory. The primary care NP should:
a. order metformin (Glucophage).
b. order a lipid profile, complete blood count, and liver function tests (LFTs).
c. order an oral glucose tolerance test.
d. set a weight loss goal of 10 to 15 lb.
ANS: D
To prevent or delay onset of diabetes, patients with impaired glucose should be advised to
lose 5% to 10% of body weight. Metformin should be considered in patients with high risk of
developing diabetes. This woman does not have risk factors. Other tests are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 594
6. A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes
in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL.
The patient has normal renal function tests. The primary care NP plans to prescribe a
combination product. Which of the following is indicated for this patient?
a. Metformin/glyburide (Glucovance)
b. Insulin and metformin (Glucophage)
c. Saxagliptin/metformin (Kombiglyze)
d. Metformin/pioglitazone (ACTOplus met)
ANS: A
Obese patients with normal renal function and elevated fasting plasma glucose may be started
on a combination of metformin and a second-generation sulfonylurea.
DIF: Cognitive Level: Applying (Application)
REF: 595 - 596
7. A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells
the primary care NP that he will have surgery in a few weeks. The NP should recommend:
a.
b.
c.
d.
taking the metformin dose as usual the morning of surgery.
using insulin during the perioperative and postoperative periods.
that the patient stop taking metformin several days before surgery.
adding a sulfonylurea medication until recovery from surgery is complete.
ANS: B
Insulin should be considered for patients with diabetes during times of physical stress, such as
illness or surgery.
DIF: Cognitive Level: Applying (Application)
REF: 596
8. A patient who has diabetes is taking metformin 1000 mg daily. At a clinic visit, the patient
reports having abdominal pain and nausea. The primary care NP notes a heart rate of 92 beats
per minute. The NP should:
a. obtain LFTs.
b. decrease the dose of metformin.
c. change metformin to glyburide.
d. order electrolytes, ketones, and serum glucose.
ANS: D
Symptoms of lactic acidosis include nausea, abdominal pain, and tachycardia. Tests should
include electrolytes, ketones, and serum glucose.
DIF: Cognitive Level: Applying (Application)
REF: 598
9. A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP
should order:
a. nateglinide (Starlix).
b. glyburide (Micronase).
c. colesevelam (Welchol).
d. metformin (Glucophage).
ANS: D
Metformin is the only drug listed that is recommended for children.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 598
Chapter 54: Contraceptives
Test Bank
MULTIPLE CHOICE
1. A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want
more children and would like a contraceptive. She does not smoke and has no personal or
family history of cardiovascular disease. She has frequent tension headaches. For this patient,
the NP should prescribe:
a. condoms.
b. tubal ligation.
c. monophasic combined oral contraceptive pill (COCP).
d. low-estrogen COCP.
ANS: D
Low-estrogen COCPs are recommended for women older than 40 with or without
cardiovascular risk. Monophasic COCPs are recommended for women with migraine
headaches. Condoms are more useful for preventing sexually transmitted diseases and not as
reliable as contraception. Tubal ligation has surgical risks.
DIF: Cognitive Level: Applying (Application)
REF: 619
2. A primary care NP prescribes a COCP for a woman who has never taken oral contraceptives
before. The woman is in a monogamous relationship, and she and her partner have been using
condoms and wish to stop using them. Her last period was 1 week ago. The NP should:
a. perform an in-office pregnancy test before starting a COCP.
b. tell the patient to begin the first pill today and to continue using condoms for 7
days.
c. tell the patient to begin the first pill on the Sunday of or following her next
menstrual period.
d. tell the patient to begin the first pill today and to return in 2 weeks for a pregnancy
test.
ANS: B
To start COCPs using the quick start method, the woman takes the first pill on the day of her
office visit and uses a barrier method such as condoms for the first 7 days. The patient should
be reasonably sure she is not pregnant; she can take a pregnancy test in 2 to 3 weeks if
pregnancy is suspected later. If she is pregnant, taking the COCPs would not negatively affect
early pregnancy.
DIF: Cognitive Level: Applying (Application)
REF: 617
3. A woman who began taking a COCP 2 months ago calls the primary care NP to report having
nausea every day. She takes a pill at the same time each morning. The NP should tell her to:
a. try taking the pill in the evening each day.
b. come to the clinic for a urine pregnancy test.
c. take the pill on an empty stomach with water.
d. stop taking the pill for 7 days and then restart.
ANS: A
If nausea occurs when taking the pill, patients should be instructed to switch to the opposite
time of day or to take with food. A urine pregnancy test is not indicated. If nausea occurs,
patients should take the pill with food. Patients stop taking pills for 7 days at the end of each
21-day pack.
DIF: Cognitive Level: Applying (Application)
REF: 617
4. The primary care NP prescribes an extended-cycle monophasic pill regimen for a young
woman who reports having multiple partners. Which statement by the patient indicates she
understands the regimen?
a. “I have to take a pill only every 3 months.”
b. “I should expect to have only four periods each year.”
c. “I will need to use condoms for only 7 more days.”
d. “This type of pill has fewer side effects than other types.”
ANS: B
The extended-cycle pills have fewer pill-free intervals, so women have only four periods a
year. Patients take pills every day. Because this patient has multiple partners, she should
continue to use condoms. This type of pill has the same side effects as other types.
DIF: Cognitive Level: Applying (Application)
REF: 622
5. A woman who uses a transdermal contraceptive calls the primary care NP to report that while
dressing that morning she discovered that the patch had come off and she was unable to find
the patch. The NP should tell her to apply a new patch and:
a. take one cycle of COCPs.
b. take a home pregnancy test.
c. use condoms for the next 7 days.
d. contact the clinic if she misses a period.
ANS: C
If a transdermal patch has been discovered to be loose or has come off, patients should use a
backup method of contraception. It is not necessary to use oral contraceptives. A home
pregnancy test is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 621
6. A woman who has been taking a COCP tells the primary care NP that, because of frequent
changes in her work schedule, she has difficulty remembering to take her pills. The woman
and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring:
a. within 7 days after her last active pill.
b. and use a backup contraceptive for 7 days.
c. and continue the COCP for one more cycle.
d. on the same day she stops taking her COCP.
ANS: A
Patients should be switched from a COCP to a vaginal ring by insertion within 7 days after the
last active pill. No backup method is needed. Patients do not need to continue one more cycle
of COCPs. Women taking progestin-only pills insert the ring on the last day of the pill pack.
DIF: Cognitive Level: Applying (Application)
REF: 621
7. A postpartum woman will begin taking the minipill while she is nursing her infant. The
primary care NP should instruct the patient:
a. to use backup contraception while taking the minipill.
b. to continue using the minipill for 6 months after she stops nursing.
c. that irregular periods while taking the minipill may indicate she is pregnant.
d. that this method does not increase her risk of thromboembolic events.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 621
8. A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant
and tells the primary care NP that she would like to space her children about 2 years apart.
The NP should:
a. discontinue the progestin-only pill.
b. prescribe a COCP and a folic acid supplement.
c. prescribe a progestin-only pill for another 6 months.
d. suggest that she use a barrier method of contraception.
ANS: B
Serum folate levels may be decreased by oral contraceptives. Women who become pregnant
shortly after stopping oral contraceptive use may have a greater chance of birth defects. This
woman should become pregnant in about 6 months if she wants to space her children 2 years
apart, so she needs an oral contraceptive. Progestin-only pills are used only during lactation.
DIF: Cognitive Level: Applying (Application)
REF: 625
9. A primary care NP prescribes a COCP for a woman who is taking them for the first time.
After teaching, the woman should correctly state the need for using a backup form of
contraception if she:
a. is having vomiting or diarrhea.
b. delays taking a pill by 5 or 6 hours.
c. takes nonsteroidal antiinflammatory drugs several days in a row.
d. has recurrent headaches or insomnia.
ANS: A
Vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to
use backup contraception if they experience these. The other conditions do not lead to oral
contraceptive failure.
DIF: Cognitive Level: Applying (Application)
REF: 625
10. A woman who has been taking a COCP for 2 months tells the primary care NP that she has
had several headaches, breakthrough bleeding, and nausea. The NP should counsel the
woman:
a. to change to a progestin-only pill.
b. to stop taking the COCP immediately.
c. to use a backup form of contraception.
d. that these effects will likely decrease in another month.
ANS: D
Breakthrough bleeding, nausea, and headaches are common during the first 3 months of
therapy and should improve without intervention. Progestin-only pills are used for lactating
women only. Prolonged bleeding and severe headache would warrant discontinuation of the
COCP. Backup contraception is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 625
11. An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary
care NP that she likes the fact that she won’t have to deal with pills or periods. The primary
care NP should tell her that she:
a. should consider another form of contraception after 1 year.
b. may have irregular bleeding, especially in the first month or so.
c. will need to take calcium and vitamin D every day while using this method.
d. will have to take oral contraceptive pills in addition to Depo-Provera when she
takes antibiotics.
ANS: B
Because of strong progestational effects on the endometrium, irregular bleeding or spotting is
common in the early months of use. Because of concerns about the effect of depot
medroxyprogesterone acetate on bone density, it is recommended that woman change to
another birth control method after 2 years, not 1 year. Calcium and vitamin D supplements
have not been shown to prevent bone density loss. It is not necessary to take oral
contraceptive pills when taking antibiotics.
DIF: Cognitive Level: Applying (Application)
REF: 627
12. A sexually active patient tells the primary care NP that she has been unable to get her new
COCP pill pack until today and has missed 3 days of pills. The NP should tell her to:
a. use backup contraception and take 2 pills each day for the next 2 days.
b. begin a new pack of pills today and use backup contraception for 7 days.
c. begin a new pack of pills today, take a Plan B pill, and use backup contraception
for 7 days.
d. Take a pregnancy test, begin a new pack of pills today, and use backup
contraception for 7 days.
ANS: C
Patients who miss 2 or more pills at the beginning or end of a pack should use emergency
contraceptive pills, such as the Plan B pill, restart a new pill pack, and use backup
contraception for 7 days.
DIF: Cognitive Level: Applying (Application)
REF: 621
Chapter 55: Hormone Replacement Therapy
Test Bank
MULTIPLE CHOICE
1. A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care
nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has
no family history or risk factors for coronary heart disease (CHD) or breast cancer but is
concerned about these side effects of hormone therapy (HT). The NP should:
a. tell her that starting HT now may reduce her risk of breast cancer.
b. advise a short course of HT now that may decrease her risk for CHD.
c. tell her that HT will not help control her symptoms during postmenopause.
d. recommend herbal supplements for her symptoms to avoid HT side effects.
ANS: A
The current gap hypothesis regarding breast cancer supports initiating HT 5 years or more
after menopause. To decrease risk for CHD, HT should begin at the time of menopause. HT
will relieve vasomotor symptoms at all stages of menopause. Herbal supplements have
estrogenizing effects and carry the same risks as estrogen therapy.
DIF: Cognitive Level: Applying (Application)
REF: 630
2. The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3
years. The NP decreases the dosage, and several weeks later, the woman calls to report having
several hot flashes each day. The NP should:
a. increase the HT dose.
b. discontinue HT.
c. recommend black cohosh to alleviate symptoms.
d. reassure her that these symptoms will diminish over time.
ANS: A
The Women’s Health Initiative results indicate that HT use for 3 to 5 years is safe and
recommend slow weaning after women review HT with their providers at annual visits. If
symptoms recur, the dose should be increased until symptoms improve.
DIF: Cognitive Level: Applying (Application)
REF: 630
3. A 52-year-old woman reports having hot flashes and intense mood swings. After a year of
having irregular menstrual periods, she has not had a period for 6 months. The primary care
NP should diagnose:
a. menopause.
b. dysmenorrhea.
c. perimenopause.
d. postmenopause.
ANS: C
Perimenopause usually occurs between ages 42 and 55 and is characterized by erratic
ovulation and irregular periods, hot flashes, and intensified PMS symptoms. Menopause
begins when periods have been absent for 12 months. Postmenopause describes the 5-year
period after menopause. Dysmenorrhea is painful periods.
DIF: Cognitive Level: Applying (Application)
REF: 630
4. A woman with a family history of breast cancer had her last menstrual period 12 months ago
and is experiencing hot flashes. She has not had a hysterectomy. The primary care NP should
recommend:
a. black cohosh.
b. estrogen-only therapy.
c. progesterone-only therapy.
d. limiting alcohol and caffeine intake.
ANS: D
Hot flashes can be triggered by environmental conditions such as stress, excitement, anxiety,
and alcohol and caffeine consumption. Black cohosh carries the same risks as estrogen.
Estrogen-only therapy is not recommended for women with an intact uterus. Progesterone
therapy is not recommended.
DIF: Cognitive Level: Applying (Application)
REF: 631
5. A 50-year-old woman with a family history of CHD is experiencing occasional hot flashes
and is having periods every 3 to 4 months. She asks the primary care NP about HT to relieve
her symptoms. The NP should:
a. prescribe estrogen-only therapy.
b. initiate oral contraceptive pills now.
c. discuss using bioidentical HT.
d. plan to use estrogen-progesterone therapy when menopause begins.
ANS: D
The timing hypothesis suggests that initiating HT at or very near to the time of menopause,
which begins when a woman has not had a period for 12 months, reduces CHD in
postmenopausal women. Estrogen-only therapy is indicated only for women who do not have
a uterus. Oral contraceptive pills increase the risk of CHD. Bioidentical HT is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 631
6. A thin 52-year-old woman who has recently had a hysterectomy tells the primary care NP she
is having frequent hot flashes and vaginal dryness. A recent bone density study shows early
osteopenia. The woman’s mother had CHD. She has no family history of breast cancer. The
NP should prescribe:
a. estrogen-only HT now.
b. estrogen-only HT in 5 years.
c. estrogen-progesterone HT now.
d. estrogen-progesterone HT in 5 years.
ANS: A
HT relieves symptoms of menopause and prevents osteoporosis. When started soon after
menopause, HT can reduce CHD risk. Breast cancer risk may be decreased if HT is begun 5
years after onset of menopause. This woman has a higher risk of CHD and osteoporosis, so
initiating therapy now is a good option. Because she has had a hysterectomy, estrogen-only
therapy is indicated.
DIF: Cognitive Level: Applying (Application)
REF: 633
7. Osteopenia is diagnosed in a 55-year-old woman who has not had a period in 15 months. She
has a positive family history of breast cancer. The primary care NP should recommend:
a. testosterone therapy.
b. estrogen-only therapy.
c. nonhormonal drugs for osteoporosis.
d. estrogen-progesterone therapy for 1 to 2 years.
ANS: C
Although estrogen slows the progression of osteoporosis, it also increases the risk of breast
cancer when initiated early in menopause. This woman should receive a nonhormonal
treatment for osteoporosis and may receive HT in 5 years if menopausal symptoms persist.
Testosterone therapy, estrogen-only therapy, and estrogen-progesterone therapy are not
indicated.
DIF: Cognitive Level: Applying (Application)
REF: 633
8. 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:
a. estrogen-only HT.
b. low-dose oral contraceptive therapy.
c. selective serotonin reuptake inhibitor therapy until menopause begins.
d. estrogen-progesterone HT.
ANS: B
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.
DIF: Cognitive Level: Applying (Application)
REF: 634
9. A perimenopausal woman tells the primary care NP that she is having hot flashes and
increasingly severe mood swings. The woman has had a hysterectomy. The NP should
prescribe:
a. estrogen-only HT.
b. low-dose oral contraceptive therapy.
c. selective serotonin reuptake inhibitor therapy until menopause begins.
d. estrogen-progesterone HT.
ANS: A
Estrogen-only regimens are used in women without a uterus and may be initiated to treat
perimenopause symptoms if needed. Low-dose oral contraceptive pills are used to treat
irregular menstrual bleeding in perimenopausal women.
DIF: Cognitive Level: Applying (Application)
REF: 635
10. 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:
a. order LH and FSH levels.
b. order a serum prolactin level.
c. prescribe testosterone replacement.
d. obtain a morning serum testosterone level.
ANS: D
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.
DIF: Cognitive Level: Applying (Application)
REF: 643
11. A man who has secondary hypogonadism associated with pituitary dysfunction will begin
exogenous testosterone therapy. The patient asks the primary care NP about future chances of
fathering children. The NP should tell him that:
a. fertility may improve with testosterone therapy.
b. exogenous testosterone therapy will shut down sperm production.
c. fertility can be restored when testosterone therapy is discontinued.
d. he should store sperm ahead of the initiation of testosterone therapy.
ANS: A
Men with secondary hypogonadism may become fertile with exogenous testosterone.
DIF: Cognitive Level: Applying (Application)
REF: 643
12. A patient who has diabetes mellitus and congestive heart failure takes insulin and warfarin.
The patient will begin taking exogenous testosterone to treat secondary hypogonadism. The
primary care NP should recommend:
a. increasing the dose of warfarin.
b. more frequent blood glucose monitoring.
c. a higher than usual dose of testosterone.
d. increasing insulin doses to prevent hypoglycemia.
ANS: B
Patients with diabetes may require a decrease in insulin dose because of the metabolic effects
of androgens. More frequent blood glucose monitoring should be performed. Warfarin doses
may need to be decreased because androgens increase sensitivity to anticoagulants.
DIF: Cognitive Level: Applying (Application)
REF: 645
Chapter 56: Drugs for Breast Cancer
Test Bank
MULTIPLE CHOICE
1. A woman who is being treated with radiotherapy for breast cancer asks her primary care nurse
practitioner (NP) about using dietary supplements to improve her chance of recovery. The NP
should tell her that:
a. vitamin E is not harmful but has not been shown to change outcomes.
b. no supplements have been shown to alter outcomes or response to therapy.
c. folic acid and other B vitamins may improve ability to tolerate chemotherapy.
d. vitamin C, taken at least 6 days per week, may lower her risk of cancer recurrence.
ANS: D
Women with early-stage breast cancer who took supplements of vitamin C or vitamin E at
least 6 days per week had a lower risk of cancer recurrence with vitamin C but no differences
with vitamin E. B vitamins are not listed as effective.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 647
2. A postmenopausal woman has metastatic breast cancer that is estrogen receptor negative. She
is scheduled to begin chemotherapy the following week and asks her primary care NP what
other medications her oncologist may prescribe to treat her cancer. The NP should expect the
oncologist to prescribe:
a. toremifene (Fareston).
b. tamoxifen (Nolvadex).
c. fulvestrant (Faslodex).
d. anastrozole (Arimidex).
ANS: D
Anastrozole (Arimidex) is a selective aromatase inhibitor and is useful in postmenopausal
women who have estrogen receptor–negative breast cancer. The other medications are
antiestrogens and treat estrogen receptor–positive cancer.
DIF: Cognitive Level: Applying (Application)
REF: 648
3. A primary care NP sees a 60-year-old woman for a physical examination. The woman tells the
NP she is taking tamoxifen for treatment of breast cancer. To monitor her response to this
medication, the NP should order:
a. a chest radiograph.
b. bone mineral density testing.
c. serum bilirubin and creatinine.
d. liver enzymes and a complete blood count (CBC).
ANS: D
Patients taking antiestrogens, such as tamoxifen, should have periodic monitoring of liver
enzymes and a CBC. A chest radiograph is not indicated. Bilirubin, creatinine, and bone
mineral density testing are part of routine testing for patients taking aromatase inhibitors.
DIF: Cognitive Level: Applying (Application)
REF: 648
4. A 50-year-old woman who is postmenopausal is taking an aromatase inhibitor as part of a
breast cancer treatment regimen. She calls her primary care NP to report that she has had hot
flashes and increased vaginal discharge but no bleeding. The NP should:
a. schedule her for a gynecologic examination.
b. recommend that she use a barrier method of contraception.
c. tell her to stop taking the medication and call her oncologist.
d. reassure her that these are normal side effects of the medication.
ANS: A
Any abnormal vaginal discharge should be reported immediately and should be evaluated
with a gynecologic examination to rule out carcinoma. She is not showing signs of ovulation,
so contraception is not necessary. She should not stop taking the medication unless the
gynecologic examination is positive. These are common side effects but are not always
normal.
DIF: Cognitive Level: Applying (Application)
REF: 648
5. A patient who has breast cancer has been taking toremifene for 2 weeks. She tells her primary
care NP that she thinks her tumor has grown larger. The NP should:
a. schedule her for a breast ultrasound.
b. reassure her that this is common and will subside.
c. tell her she may need an increased dose of this medication.
d. contact her oncologist to discuss adding another medication.
ANS: B
Toremifene can cause tumor flare in the first few weeks of therapy, but the tumor later
regresses. An ultrasound is unnecessary at this stage. The NP does not need to notify the
oncologist unless this continues to worsen.
DIF: Cognitive Level: Applying (Application)
REF: 650
Chapter 57: Principles for Prescribing Antiinfectives
Test Bank
MULTIPLE CHOICE
1. A patient comes to the clinic with a history of fever of 102° F for several days, poor appetite,
and cough. A sputum culture is pending, but Gram stain indicates a bacterial infection. The
primary care nurse practitioner (NP) should:
a. begin empirical antibiotic therapy.
b. use a broad-spectrum antibiotic for initial treatment.
c. prescribe an antibiotic when culture and sensitivity results are known.
d. offer symptomatic treatment only unless the patient’s condition worsens.
ANS: A
Patients with signs and symptoms of a bacterial infection may be treated empirically,
especially if Gram stain is positive. The antibiotic may need to be changed when culture and
sensitivity results become available. It is best to use an antibiotic that is specific to the
suspected organism and not a broad-spectrum antibiotic.
DIF: Cognitive Level: Applying (Application)
REF: 653
2. The primary care NP sees a patient who has a 1-week history of nasal congestion; red, watery
eyes; cough; and a temperature ranging from 99.1° F to 100.5° F. The NP notes thin, white
nasal discharge and an erythematous oropharynx without swelling or exudates. The NP
should:
a. begin empiric antibiotic therapy to treat sinusitis.
b. reassure the patient that this is likely a viral infection.
c. prescribe antiviral medications and decongestants.
d. obtain a nasal culture and consider antibiotic therapy.
ANS: B
The patient does not have severe symptoms indicating a bacterial infection. Unless symptoms
worsen, reassurance is indicated. Empiric antibiotic therapy is contraindicated for viral
infections. Antiviral medications are not routinely used. A nasal culture is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 653
3. A patient who has had two recent urinary tract infections is in the clinic with dysuria and
fever. The primary care NP reviews the patient’s chart and notes that in both previous cases
the causative organism and sensitivity were the same. The NP should:
a. treat the patient empirically without a culture.
b. order a microscopic evaluation of the urine and an antibiotic.
c. order a urine culture and treat empirically pending culture results.
d. order a urine culture and sensitivity and wait for results before treating.
ANS: C
Because this patient has had similar infections in the past, treating empirically is acceptable.
The NP must still obtain a culture and sensitivity so that appropriate antibiotic therapy can be
provided, even though it is likely that this is a recurrence of the same organism. A culture
should always be obtained when possible. A microscopic evaluation is used to determine
whether or not a culture should be performed and is not diagnostic.
DIF: Cognitive Level: Applying (Application)
REF: 653
4. A new patient comes to see the primary care NP with fever, mild dehydration, and dysuria
with flank pain. The patient tells the NP that a previous provider always prescribed
trimethoprim-sulfamethoxazole and wonders why a urine culture is necessary because this
antibiotic has worked in the past. The NP should tell this patient that a culture is necessary to
help determine:
a. the correct dose of the antibiotic.
b. whether antibiotic resistance is occurring.
c. whether multiple organisms are causing infection.
d. the length of antibiotic therapy needed to treat the infection.
ANS: B
Antibiotic resistance can occur when bacteria are repeatedly exposed to antibiotic agents.
Even though a particular antibiotic is effective for a certain type of infection, resistance can
occur, and another antibiotic may be necessary. A culture and sensitivity test is essential for
choosing the right antibiotic. The culture and sensitivity test does not help determine the dose
or the length of therapy.
DIF: Cognitive Level: Applying (Application)
REF: 654
5. The primary care NP sees a child in the clinic who has a 5-day history of cough, poor fluid
intake, and fever of 103° F. A chest radiograph shows areas of consolidation in the child’s
lungs. The child’s cough is nonproductive, and the NP is unable to get a sputum specimen.
The NP should:
a. prescribe a broad-spectrum antibiotic to cover any possible causative organism.
b. ask colleagues in the clinic about children they have treated and what they have
prescribed.
c. give the child’s parents a specimen cup and ask that they try to bring in a sputum
specimen for culture.
d. refer the child to a pulmonologist or infectious disease specialist to help determine
the proper treatment.
ANS: B
The child shows signs of a bacterial infection, but getting a sputum culture is not likely. The
NP should ask colleagues about similar cases and treat according to those patterns. Broadspectrum antibiotics increase the incidence of resistance. If this child’s symptoms do not
respond to empiric therapy, referral may be warranted.
DIF: Cognitive Level: Applying (Application)
REF: 654
6. A patient has a sore throat with fever. The primary care NP observes erythematous 4+ tonsils
with white exudate. A rapid antigen strep test is negative, and a culture is pending. The NP
orders amoxicillin as empiric treatment. The patient calls the next day to report a rash. The NP
should suspect:
a.
b.
c.
d.
penicillin drug allergy.
a viral cause for the patient’s symptoms.
a serum sickness reaction to the penicillin.
scarlatiniform rash from the streptococcal infection.
ANS: B
Certain viral infections, such as mononucleosis, increase the frequency of rash in response to
penicillin and is commonly attributed to penicillin allergy.
DIF: Cognitive Level: Applying (Application)
REF: 656
Chapter 58: Treatment of Specific Infections and Miscellaneous Antibiotics
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) sees a child who has several honey-colored crusted
lesions around the nose and mouth. The NP notes that no other lesions are present. The NP
should prescribe:
a. dicloxacillin.
b. clarithromycin.
c. mupirocin topical.
d. trimethoprim-sulfamethoxazole (TMP-SMX).
ANS: C
Although systemic antibiotics are often required to treat impetigo, mupirocin can be used for
topical treatment of mild impetigo. Because this is a localized infection, mupirocin can be
ordered empirically. Dicloxacillin and clarithromycin are used when systemic empirical
treatment is indicated. TMP-SMX is used to treat cellulitis.
DIF: Cognitive Level: Applying (Application)
REF: 658 - 659
2. A patient comes to the clinic several days after an outpatient surgical procedure complaining
of swelling and pain at the surgical site. The primary care NP notes a small area of erythema
but no abscess or induration. The NP should:
a. prescribe TMP-SMX.
b. prescribe topical mupirocin four times daily.
c. suggest that the patient apply warm soaks three times daily.
d. refer the patient to the surgeon for further evaluation.
ANS: A
This patient has cellulitis, so empirical treatment with TMP-SMX is indicated. Topical
mupirocin is used for superficial skin infections, not cellulitis. Warm soaks may be used as an
adjunct to antimicrobial treatment. Unless the cellulitis becomes worse, it is not necessary to
refer the patient to the surgeon.
DIF: Cognitive Level: Applying (Application)
REF: 661
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:
a. prescribe azithromycin once daily for 5 days.
b. prescribe amoxicillin twice daily for 10 days.
c. prescribe amoxicillin-clavulanate twice daily for 10 days.
d. initiate antibiotic therapy if the child’s condition worsens.
ANS: D
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 lowgrade 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.
DIF: Cognitive Level: Applying (Application)
REF: 661
4. A primary care NP sees a patient who reports a 2-week history of nasal congestion and runny
nose. The NP performs a history and learns that the nasal discharge has changed from yellow
to green in the past few days, accompanied by a fever of 102° F and unilateral facial pain. To
treat this patient, the NP should:
a. order azithromycin daily for 5 days.
b. prescribe cefdinir twice daily for 10 days.
c. prescribe amoxicillin-clavulanate twice daily for 10 days.
d. recommend symptomatic treatment because this is probably a viral infection.
ANS: C
Evidence of a bacterial sinus infection includes prolonged symptoms without improvement for
10 to 14 days, fever greater than 102° F, and unilateral pain. A bacterial infection should be
suspected if nasal discharge turns from yellow to green. Amoxicillin-clavulanate is a
recommended first-line drug to treat sinusitis.
DIF: Cognitive Level: Applying (Application)
REF: 661
5. A school-age child comes to the clinic with a 5-day history of cough and low-grade fever. The
primary care NP auscultates crackles and diminished breath sounds bilaterally. The NP
should:
a. order azithromycin.
b. prescribe doxycycline.
c. obtain a sputum culture.
d. recommend symptomatic treatment.
ANS: A
Community-acquired pneumonia in school-age children is commonly caused by Mycoplasma.
Azithromycin is a first-line drug of choice to treat this type of pneumonia.
DIF: Cognitive Level: Applying (Application)
REF: 662
6. A patient has recently returned from travel in Central America and reports having seven to
eight liquid stools each day with severe tenesmus. The primary care NP notes a temperature of
102° F. A stool specimen is Hemoccult positive with leukocytes present. The NP will:
a. order tests for Clostridium difficile.
b. prescribe tinidazole 2000 mg for 3 days.
c. give 750 mg of ciprofloxacin one time only.
d. order a stool culture and begin therapy with a fluoroquinolone.
ANS: D
By history, this patient likely has traveler’s diarrhea. The NP should obtain a culture and
should start a fluoroquinolones antibiotic empirically. C. difficile is suspected in patients who
have been taking antibiotics, which is not true in this case. Tinidazole is used for amebiasis or
giardiasis. Ciprofloxacin may be given as a single dose for mild traveler’s diarrhea.
DIF: Cognitive Level: Applying (Application)
REF: 663
7. A woman has a urinary tract infection (UTI) and has been taking TMP-SMX for 3 days along
with increased fluids. She reports continued dysuria and urinary frequency and has a
consistent, low-grade fever. The primary care NP should:
a. prescribe ciprofloxacin twice daily for 3 days.
b. order doxycycline twice daily for 7 to 14 days.
c. prescribe amoxicillin-clavulanate twice daily for 7 days.
d. order TMP-SMX DS twice daily for 7 days.
ANS: A
Initial treatment of uncomplicated UTI is a 3-day course of TMP-SMX. Ciprofloxacin is used if
the patient is still symptomatic. Doxycycline is a second-line treatment. Amoxicillin-clavulanate
is used to treat pyelonephritis.
DIF: Cognitive Level: Applying (Application)
REF: 663 - 664
8. During a gynecologic examination of a sexually active adolescent girl, the primary care NP
notes mucopurulent cervicitis. A culture is positive for Neisseria gonorrhoeae. The NP
should:
a. give a single dose of 2 g of oral azithromycin.
b. administer benzathine penicillin G 2.4 million units intramuscularly.
c. prescribe oral doxycycline 100 mg daily for 7 days.
d. give intramuscular ceftriaxone and a single dose of 1 g of azithromycin.
ANS: D
Many patients who present with one sexually transmitted disease (STD) have other
concomitant STDs. When gonorrhea or urethritis/cervicitis is diagnosed, the NP should treat
for both N. gonorrhoeae and Chlamydia. A single-dose treatment ensures compliance. A
single, 2-g dose of azithromycin is indicated to treat chancroid. Benzathine penicillin G is
indicated to treat syphilis. A 7-day regimen of doxycycline is used to treat Chlamydia, but not
gonorrhea.
DIF: Cognitive Level: Applying (Application)
REF: 664 - 665
9. A female patient presents with grayish, odorous vaginal discharge. The primary care NP
performs a gynecologic examination and notes vulvar and vaginal erythema. Testing of the
discharge reveals a pH of 5.2 and a fishy odor when mixed with a solution of 10% potassium
hydroxide. The NP should:
a. order topical fluconazole.
b. order metronidazole 500 mg twice daily for 7 days.
c. withhold treatment until culture results are available.
d. prescribe a clotrimazole vaginal suppository for 7 days.
ANS: B
This patient has classic symptoms of bacterial vaginosis. The treatment of choice is
metronidazole. Fluconazole is used to treat fungal infections. Cultures are generally not
helpful in the diagnosis of bacterial vaginosis. Clotrimazole is used to treat Candida
infections.
DIF: Cognitive Level: Applying (Application)
REF: 666
10. A patient has confirmed Rocky Mountain spotted fever, and the infectious disease specialist is
treating the patient with doxycycline 100 mg orally for 7 days. The patient comes to the clinic
for follow-up care with the primary care NP at the end of therapy and reports continued fever,
headache, and myalgia. The NP will consult with the infectious disease specialist and order:
a. 7 more days of doxycycline.
b. erythromycin 250 mg four times daily for 7 days.
c. amoxicillin 500 mg three times daily for 10 to 14 days.
d. hospital admission for intravenous chloramphenicol.
ANS: D
With treatment, the patient’s condition should start to improve in 2 to 3 days. Continued
elevation of the temperature may indicate lack of efficacy or drug fever. Chloramphenicol is
used to treat Rocky Mountain spotted fever. It is not correct to continue therapy with
doxycycline because treatment failure is likely. Erythromycin is used to treat Lyme disease.
Amoxicillin is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 666
Chapter 59: Penicillins
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) sees a 3-year-old child who has a history of recurrent
otitis media. The child’s parent tells the NP that the child is allergic to penicillin. The NP
learns that the child developed an all-over rash 2 days after starting amoxicillin at age 2 years.
The NP should:
a. order a penicillin skin test.
b. use cephalosporins when treating otitis media.
c. order penicillin desensitization so the child can take penicillin when needed.
d. use amoxicillin when needed because actual allergy correlates poorly with patient
report.
ANS: A
Although it is true that patient report correlates poorly with actual allergy, there is a risk of
life-threatening anaphylaxis with a true penicillin allergy. The NP should order a penicillin
skin test to verify allergy. If the skin test is positive, the patient should avoid -lactam
antimicrobials. Penicillin desensitization can be used for penicillin-allergic patients who need
penicillins.
DIF: Cognitive Level: Applying (Application)
REF: 672
2. A patient with group A -hemolytic streptococcal pharyngitis is treated with penicillin V. At a
follow-up visit 2 weeks later, the patient presents with edema of the hands and feet, blood
pressure of 140/85 mm Hg, and cola-colored urine. A urine dipstick shows proteinuria. The
primary care NP should:
a. perform a repeat throat culture.
b. prescribe 10 more days of penicillin V.
c. obtain an ASO titer and creatinine clearance.
d. order oral amoxicillin-clavulanate for 14 days.
ANS: C
A minimum of 10 days of treatment is recommended for any infection caused by group A hemolytic streptococcus to prevent the occurrence of rheumatic fever or acute
glomerulonephritis. This patient shows signs of acute glomerulonephritis, so the NP should
obtain an ASO titer and creatinine clearance to help confirm the diagnosis. It is not necessary
to repeat the throat culture. Treatment involves controlling blood pressure and maintaining
renal function, not giving antibiotics.
DIF: Cognitive Level: Applying (Application)
REF: 673
3. A patient is taking dicloxacillin (Dynapen) 500 mg every 6 hours to treat a severe
penicillinase-resistant infection. At a 1-week follow-up appointment, the patient reports
nausea, vomiting, and epigastric discomfort. The primary care NP should:
a. change the medication to a cephalosporin.
b. decrease the dose to 250 mg every 6 hours.
c. reassure the patient that these are normal adverse effects of this drug.
d. order blood cultures, a white blood cell (WBC) count with differential, and liver
function tests (LFTs).
ANS: D
When giving penicillinase-resistant penicillins, it is important to monitor therapy with blood
cultures, WBC with differential cell counts, and LFTs before treatment and weekly during
treatment. This patient may have typical gastrointestinal side effects, but the symptoms may
also indicate hepatic damage. Changing the medication is not indicated, unless serious side
effects are present. Decreasing the dose is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 673
4. The primary care NP administers penicillin G (Bicillin) to a 75-year-old patient who has
COPD and heart failure. The patient takes digoxin, warfarin, and spironolactone. To help
prevent drug interactions, the NP should order:
a. serum electrolytes.
b. coagulation studies.
c. creatinine clearance.
d. liver transaminases aspartate aminotransferase and alanine aminotransferase.
ANS: A
Penicillin G can cause hyperkalemia, which can increase digoxin toxicity, so serum
electrolytes should be monitored. Penicillin G does not interact with warfarin or
spironolactone. Coagulation studies, creatinine clearance, and LFTs are not indicated in this
circumstance.
DIF: Cognitive Level: Applying (Application)
REF: 673
5. A sexually active woman is being treated for streptococcal pharyngitis. The patient takes oral
contraceptive pills (OCPs). Which penicillin should the primary care NP prescribe for this
patient?
a. Ampicillin
b. Penicillin V
c. Penicillin G
d. Dicloxacillin
ANS: C
Although penicillin V is the drug of choice, ampicillin and penicillin G can be used to treat
streptococcal pharyngitis. Penicillin G is the only penicillin that does not interfere with OCPs.
Dicloxacillin is not recommended to treat streptococcal pharyngitis.
DIF: Cognitive Level: Applying (Application)
REF: 674
6. A patient was seen in a local emergency department and was treated empirically for
pharyngitis with ampicillin and comes to the clinic 2 days later with an urticarial rash. The
patient has no previous history of atopy and does not have respiratory symptoms. The primary
care NP should suspect:
a. scarlatina.
b. mononucleosis.
c. serum sickness.
d. penicillin allergy.
ANS: B
A nonallergic urticarial rash occasionally occurs with ampicillin and is common in patients
with mononucleosis. This patient has pharyngitis, which was not diagnosed by throat culture.
The NP should suspect mononucleosis and a nonallergic rash. Serum sickness and penicillin
allergy are possible but less likely. A scarlatiniform rash is not urticarial.
DIF: Cognitive Level: Applying (Application)
REF: 674
7. A patient with otitis media is treated for 10 days with amoxicillin. At the follow-up visit, the
primary care NP notes bilateral erythematous, bulging tympanic membranes. The NP should
prescribe:
a. intramuscular injection of penicillin G (Bicillin).
b. amoxicillin for 10 more days.
c. oral dicloxacillin (Dynapen) for 10 days.
d. oral amoxicillin-clavulanate (Augmentin) for 10 days.
ANS: D
Antibiotic resistance to penicillins occurs through three mechanisms, the most important
being bacteria producing -lactamase, which breaks down the -lactam ring and renders the
penicillin inactive. Clavulanic acid, used in combination with penicillins, prevents this
inactivation. The NP should prescribe amoxicillin-clavulanate. Giving 10 more days of
amoxicillin would not be effective. Dicloxacillin is used when resistance is caused by
penicillinase-resistant staphylococcal infection. Penicillin G is not used to treat otitis media.
DIF: Cognitive Level: Applying (Application)
REF: 672
Chapter 60: Cephalosporins
Test Bank
MULTIPLE CHOICE
1. An adult patient has cellulitis. The patient is a single parent with health insurance who works
and is attending classes at a local university. To treat this infection, the primary care nurse
practitioner (NP) should prescribe:
a. cefdinir (Omnicef).
b. cephalexin (Keflex).
c. cefadroxil (Duricef).
d. ceftriaxone (Rocephin).
ANS: C
First-generation cephalosporins, such as cephalexin and cefadroxil, are used for skin and soft
tissue infections. Cefadroxil is preferred in this case because it can be given twice daily
instead of four times daily, and this patient will be more likely to comply with the drug
regimen. Cefdinir and ceftriaxone are both third-generation cephalosporins.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 678
2. A primary care NP sees a patient who has dysuria, fever, and urinary frequency. The NP
orders a urine dipstick, which is positive for nitrates and leukocyte esterase, and sends the
urine to the laboratory for a culture. The patient is allergic to sulfa drugs. The NP should:
a. order cefaclor (Ceclor).
b. prescribe cefixime (Suprax).
c. administer intramuscular ceftriaxone (Rocephin).
d. wait for culture results before ordering an antibiotic.
ANS: B
Cephalosporins are useful for empirical treatment of many of the most common infections
seen in primary care. Cefixime is a third-generation cephalosporin, which has greater activity
against Escherichia coli and excellent penetration into body fluids, making it a good choice
for empirical treatment of urinary tract infection.
DIF: Cognitive Level: Applying (Application)
REF: 678
3. A patient is taking cefadroxil (Duricef) and comes to the clinic complaining of loose stools for
several days. The primary care NP notes normal vital signs; warm, pink skin with elastic
turgor; and moist mucous membranes. The NP should:
a. order tests for Clostridium difficile–associated disease (CDAD).
b. discontinue the cefadroxil.
c. reassure the patient that loose stools are common with antibiotics.
d. recommend consuming lactobacillus-containing foods to minimize diarrhea.
ANS: A
The U.S. Food and Drug Administration (FDA) advises that CDAD be considered in all
patients who present with diarrhea after antibiotic use. This patient’s symptoms are mild, so
discontinuation of the drug is not warranted unless CDAD is present.
DIF: Cognitive Level: Applying (Application)
REF: 680 - 681
4. A primary care NP provides teaching to a patient who will begin taking cefadroxil (Duricef).
Which statement by the patient indicates a need for further teaching?
a. “I should report any rash that occurs.”
b. “I will take this medication twice daily.”
c. “I should take this medication with food.”
d. “Gastrointestinal (GI) symptoms are common but not worrisome.”
ANS: D
The FDA advises that CDAD be considered in all patients who present with diarrhea after
antibiotic use. Patients should be taught to report all GI symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 680 - 681
5. A 70-year-old patient will begin taking cefdinir (Omnicef) for an acute exacerbation of
COPD. Before initiating therapy, the primary care NP should order:
a. liver function tests (LFTs).
b. coagulation studies.
c. an electrocardiogram (ECG).
d. a creatinine clearance test.
ANS: D
Geriatric patients may need adjusted doses based on creatinine clearance testing, so obtaining
a creatinine clearance test before initiating therapy is indicated. LFTs, coagulation studies, and
an ECG are not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 681
6. A patient is taking an aminoglycoside and a cephalosporin. The primary care NP should
consider _____ the dose of _____.
a. increasing; cephalosporin
b. decreasing; cephalosporin
c. increasing; aminoglycoside
d. decreasing; aminoglycoside
ANS: D
Cephalosporins can heighten aminoglycoside toxicity, so a decrease in the dose of the
aminoglycoside should be considered.
DIF: Cognitive Level: Applying (Application)
REF: 682
7. A child with a febrile illness is taking a cephalosporin. While in the clinic for a follow-up
visit, the child has a tonic-clonic seizure. The primary care NP should:
a.
b.
c.
d.
administer acetaminophen because this is likely a febrile seizure.
reassure the parent that seizures can occur while taking cephalosporins.
ask the child’s parent how much of the cephalosporin the child has taken.
suspect the development of a secondary central nervous system infection.
ANS: C
Seizures can occur with an overdose of cephalosporins, so the NP should determine whether
this has occurred. It is not correct to assume that the seizure is fever-related or that it is a
normal side effect of the cephalosporin.
DIF: Cognitive Level: Applying (Application)
REF: 682
Chapter 61: Tetracyclines
Test Bank
MULTIPLE CHOICE
1. A woman has a Chlamydia infection. Before initiating treatment with a tetracycline antibiotic,
the primary care nurse practitioner (NP) should:
a. perform a pregnancy test.
b. obtain baseline liver function and renal function tests.
c. check her bilirubin and serum amylase levels.
d. tell her she must stop using oral contraceptive pills.
ANS: A
Tetracycline antibiotics can permanently stain teeth in children and in pregnant women.
Before using a tetracycline in a woman who may be pregnant, the NP should perform a
pregnancy test. Other laboratory tests are not indicated for short-term use. Women taking oral
contraceptive pills should continue to take them.
DIF: Cognitive Level: Applying (Application)
REF: 683
2. A young woman will begin taking minocycline. The primary care NP should tell this patient
to:
a.
b.
c.
d.
avoid taking antacids while taking this drug.
expect headaches while taking this medication.
always take the medication on an empty stomach.
use a backup form of contraception if currently taking oral contraceptive pills.
ANS: D
Tetracyclines may decrease the effects of oral contraceptive pills, so patients should use a
backup form of contraception. Headaches are uncommon. Minocycline may be taken with
food and is not affected by antacids.
DIF: Cognitive Level: Applying (Application)
REF: 684
3. A patient is taking tetracycline for a rickettsial infection and reports having heartburn. The
primary care NP should:
a. ask the patient how the medication is taken.
b. tell the patient to take the medication with food.
c. tell the patient to use antacids when heartburn occurs.
d. recommend drinking milk when taking the medication.
ANS: A
Patients should sit up for at least 30 minutes after taking tetracycline to avoid the risk of
esophageal ulceration. Tetracycline should not be taken with food, antacids, or milk.
DIF: Cognitive Level: Applying (Application)
REF: 684 - 685
4. A patient has urethritis. The primary care NP should prescribe:
a. minocycline.
b. doxycycline.
c. tetracycline.
d. demeclocycline.
ANS: A
Minocycline is indicated to treat urethritis.
DIF: Cognitive Level: Applying (Application)
REF: 685
Chapter 62: Macrolides
Test Bank
MULTIPLE CHOICE
1. A primary care nurse practitioner (NP) is prescribing once-daily azithromycin to a 25-year-old
woman. When teaching her about the drug, the NP should tell her to:
a. take the medication on an empty stomach.
b. use a backup contraception method other than oral contraceptive pills.
c. expect severe gastrointestinal side effects while taking this drug.
d. cut the pill in half and take twice daily if side effects are severe.
ANS: B
Patients who use oral contraceptive pills for birth control should be advised that macrolides
can reduce their efficacy and that they should consider using a backup method of
contraception. Azithromycin can be taken without regard to food. Severe gastrointestinal side
effects are uncommon. The tablets should not be chewed, crushed, or cut.
DIF: Cognitive Level: Applying (Application)
REF: 689
2. A primary care NP is preparing to prescribe a macrolide antibiotic for a patient who has a
history of a prolonged QT interval on electrocardiogram. Which macrolide antibiotic should
the NP prescribe?
a. Erythromycin
b. Azithromycin
c. Clarithromycin
d. Telithromycin
ANS: B
Azithromycin does not cause a prolonged QT interval , unlike the other macrolides, so it
would be safe for this patient. Visual disturbances have been found to occur with the use of
telithromycin. Erythromycin has a wider range of adverse effects and can cause cardiac effects
in patients who have a prolonged QT interval. The Ilosone, E-Mycin, and Erythrocin are all
erythromycins.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 689
3. Which antibiotic requires administration of a loading dose?
a. Ilosone
b. E-Mycin
c. Erythrocin
d. Zithromax
ANS: D
It is important to give a loading dose, without which minimum plasma concentrations may
take 5 to 7 days to reach steady state.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 690
4. A patient has had severe diarrhea for 2 weeks. Laboratory testing reveals Clostridium difficile.
The primary care NP should prescribe:
a. erythromycin.
b. azithromycin.
c. fidaxomicin.
d. clarithromycin.
ANS: C
Fidaxomicin is indicated only for treatment of C. difficile–associated diarrhea. The other
macrolides are not used for this purpose.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 690
5. A primary care NP is planning to order a macrolide antibiotic for a patient who is
experiencing an exacerbation of chronic obstructive pulmonary disease. The patient is taking a
cytochrome (CYP) 3A medication. The NP should order:
a. azithromycin.
b. clarithromycin.
c. erythromycin base.
d. erythromycin estolate.
ANS: A
Azithromycin does not interact with other CYP 3A medications. Erythromycin and
clarithromycin do.
DIF: Cognitive Level: Applying (Application)
REF: 690
6. A primary care NP sees a 6-month-old patient who has a persistent staccato cough. The NP is
aware that there is a pertussis outbreak in the community. The NP should obtain appropriate
cultures and treat empirically with:
a. erythromycin.
b. azithromycin.
c. clarithromycin.
d. telithromycin.
ANS: A
Erythromycin is a first-choice drug for the treatment of pertussis.
DIF: Cognitive Level: Applying (Application)
REF: 688
Chapter 63: Fluoroquinolones
Test Bank
MULTIPLE CHOICE
1. A patient has been taking ciprofloxacin for 3 days and calls the primary care nurse practitioner
(NP) to report having headaches and dizziness. The NP should:
a. change to levofloxacin.
b. decrease the dose of ciprofloxacin.
c. change to an antibiotic in another drug class.
d. reassure the patient that these are common side effects.
ANS: D
Headaches and dizziness are common side effects of fluoroquinolones. It is not necessary to
change to another fluoroquinolone, decrease the dose, or change to another antibiotic class.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 694
2. A primary care NP sees a patient who has fever, flank pain, and dysuria. The patient has a
history of recurrent urinary tract infections (UTIs) and completed a course of trimethoprimsulfamethoxazole (TMP/SMX) the week before. A urine test is positive for leukocyte esterase.
The NP sends the urine for culture and should treat this patient empirically with:
a. gemifloxacin.
b. ciprofloxacin.
c. azithromycin.
d. TMP/SMX.
ANS: B
Fluoroquinolones are effective in treatment of UTIs that are resistant to other antibiotics.
Because this patient recently completed a course of TMP/SMX, the NP can assume that the
bacterium causing the infection is resistant to TMP/SMX. Gemifloxacin is not indicated for
UTI, but ciprofloxacin is. Azithromycin is not a fluoroquinolone.
DIF: Cognitive Level: Applying (Application)
REF: 693
3. A patient is taking levofloxacin to treat sinusitis. The patient calls the primary care NP to
report pain just above the heel of the right foot. The NP should:
a. change to ofloxacin.
b. change to ciprofloxacin.
c. discontinue the levofloxacin.
d. reassure the patient that this is a common side effect.
ANS: C
Warnings have been issued for the fluoroquinolone antibiotics for the increased risk of tendon
ruptures. Ruptures have occurred unilaterally and bilaterally, and have involved the Achilles tendon;
however, ruptures in the shoulder joint, hand, biceps, thumb, and other tendon sites have been
reported. The risk of tendon rupture is further increased in those over age 60, those receiving
concomitant steroid therapy, and in kidney, heart, and lung transplant recipients. Reasons for tendon
ruptures also include physical activity or exercise, kidney failure, and tendon problems in the past.
These ruptures may occur during therapy or up to several months after discontinuation of
drugs.
DIF: Cognitive Level: Applying (Application)
REF: 693
4. A patient who is taking a fluoroquinolone antibiotic for pyelonephritis develops Clostridium
difficile–associated disease (CDAD). The primary care NP should treat for C. difficile and
_____ fluoroquinolone.
a. continue the
b. discontinue the
c. increase the dose of
d. decrease the dose of
ANS: B
Patients who develop CDAD while taking fluoroquinolones should stop taking the drug
immediately
DIF: Cognitive Level: Applying (Application)
REF: 694
5. A primary care NP provides teaching for a patient who is about to begin taking levofloxacin
tablets to treat an infection. Which statement by the patient indicates a need for further
teaching?
a. “I should use sunscreen while taking this medication.”
b. “I should take this medication on an empty stomach.”
c. “I should use caution while driving when taking this medication.”
d. “I should take the tablet 2 hours before taking vitamins or an antacid.”
ANS: B
Levofloxacin tablets may be taken without regard to food, although levofloxacin solution
must be taken on an empty stomach. Patients should be cautioned to use sunscreen and to
avoid situations where drowsiness may impair function. Levofloxacin should not be taken
with antacids or vitamins.
DIF: Cognitive Level: Applying (Application)
REF: 695
6. A patient who has been taking ciprofloxacin for 14 days for treatment of a UTI is seen in the
clinic for a follow-up urinalysis. The urinalysis reveals crystalluria. The primary care NP
should:
a. discontinue the ciprofloxacin.
b. decrease the dose of ciprofloxacin.
c. change the antibiotic to norfloxacin.
d. counsel the patient to increase fluid intake.
ANS: D
Fluoroquinolones can cause renal irritation and urine crystals. Patients should be advised to
maintain proper hydration to avoid this. It is not necessary to discontinue the ciprofloxacin or
to decrease the dose.
DIF: Cognitive Level: Applying (Application)
REF: 695
7. A primary care NP is preparing to prescribe a fluoroquinolone for a patient who has a history
of alcohol abuse that has caused liver damage. The NP should choose:
a. norfloxacin.
b. levofloxacin.
c. gemifloxacin.
d. ciprofloxacin.
ANS: B
Levofloxacin has less risk of hepatic adverse events than other fluoroquinolones.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 696
Chapter 64: Aminoglycosides
Test Bank
MULTIPLE CHOICE
1. A patient who was hospitalized for an infection was treated with an aminoglycoside antibiotic.
The patient asks the primary care nurse practitioner (NP) why outpatient treatment wasn’t an
option. The NP should tell the patient that aminoglycoside antibiotics:
a. are more likely to be toxic.
b. cause serious adverse effects.
c. carry more risk for serious allergic reactions.
d. must be given intramuscularly or intravenously.
ANS: D
Aminoglycoside antibiotics must be given intramuscularly or intravenously when treating
infection. Their side effects may be serious, which is an indication for hospitalization.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 697
2. A primary care NP sees a patient who was recently hospitalized for infection and treated with
gentamicin for 10 days. The patient tells the NP that the drug was discontinued early because
“my blood level was too high.” The NP should order:
a. a serial audiometric test.
b. a serum blood urea nitrogen (BUN) and creatinine.
c. a urinalysis and complete blood count.
d. serum calcium, magnesium, and sodium.
ANS: A
Aminoglycosides are associated with ototoxicity and nephrotoxicity. Recovery of renal
function occurs if the drug is stopped at the first sign of renal impairment. The NP should
evaluate the possibility of ototoxicity with a serial audiometric test.
DIF: Cognitive Level: Applying (Application)
REF: 699
3. A patient who was recently hospitalized and treated with gentamicin tells the primary care
NP, “My kidney function test was abnormal and they stopped the medication.” The patient is
worried about long-term effects. The NP should:
a. monitor renal function for several months.
b. reassure the patient that complete recovery should occur.
c. refer the patient to a nephrologist for follow-up evaluation.
d. monitor serum electrolytes and serum creatinine and BUN.
ANS: B
Recovery of renal function occurs if the drug is stopped at the first sign of renal impairment. It
is necessary to monitor blood values during therapy to ensure effectiveness and prevent
toxicity.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 699
4. While a patient is receiving an aminoglycoside medication by intramuscular injection, the
provider should instruct the patient to expect:
a. discomfort to the injection site, which can be treated with warm moist heat.
b. development of localized infection, which can be treated with an occlusive
dressing.
c. discomfort to the injection site, which can best be relieved with narcotic
analgesics.
d. development of localized bleeding, which may require the application of an
occlusive dressing.
ANS: A
The administration of aminoglycosides by intramuscular injection may cause discomfort to
the injection site, which can be treated with warm moist heat and mild analgesics.
DIF: Cognitive Level: Applying (Application)
REF: 697
Chapter 65: Sulfonamides
Test Bank
MULTIPLE CHOICE
1. A patient has been taking trimethoprim-sulfamethoxazole (TMP/SMX) for 14 days. The
patient calls the primary care nurse practitioner (NP) to report fever, rash, and enlarged lymph
nodes. The NP should suspect:
a. serum sickness reaction.
b. immediate sensitivity reaction.
c. cytotoxic hypersensitivity reaction.
d. cell-mediated hypersensitivity reaction.
ANS: A
Serum sickness reaction can occur days to weeks after administration of the drug and is
characterized by fever, rash, and lymphadenopathy. Immediate sensitivity reaction includes
anaphylaxis, urticaria, and angioedema and occurs within 30 minutes of drug administration.
Cytotoxic hypersensitivity reaction causes hemolytic anemia, neutropenia, and
thrombocytopenia and develops 7 to 14 days after drug administration. Cell-mediated
hypersensitivity reaction causes maculopapular rash, Stevens-Johnson syndrome, and toxic
epidermal necrolysis and takes 48 to 72 hours to develop.
DIF: Cognitive Level: Applying (Application)
REF: 702
2. An 80-year-old patient who has COPD takes TMP/SMX for acute exacerbations, which occur
three or four times each year. To monitor this patient for adverse drug reactions, the primary
care NP should order:
a. liver function tests.
b. blood urea nitrogen and creatinine.
c. serum bilirubin levels.
d. a complete blood count (CBC) with differential.
ANS: D
The most frequently reported severe adverse reactions in elderly patients include bone marrow
depression and decreased platelets. A CBC with differential is indicated to monitor for this.
Evaluation of liver and renal function should be performed before beginning treatment
because adverse effects are more common in patients with decreased renal and liver function.
DIF: Cognitive Level: Applying (Application)
REF: 703
3. The primary care NP teaches a patient about TMP/SMX before prescribing it to treat a urinary
tract infection (UTI). Which statement by the patient indicates a need for further teaching?
a. “I will take this medication with food.”
b. “I should drink a full glass of water with each dose.”
c. “I should stay out of direct sunlight and use sunscreen.”
d. “I should report any ringing in my ears or a sore throat.”
ANS: A
TMP/SMX should be taken on an empty stomach, so this statement is incorrect and indicates
the need for further teaching. The other statements all are correct.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 703
4. A primary care NP prescribes TMP/SMX for a patient who is experiencing an exacerbation of
COPD. The patient calls the NP 2 days later to report increased fever, cough, and shortness of
breath. The NP should tell the patient:
a. to stop taking the medication.
b. that symptoms such as sore throat and arthralgia are more worrisome.
c. to continue the medication because these are signs of the disease process.
d. that sulfisoxazole (Gantrisin) will be prescribed instead to minimize side effects.
ANS: A
Fever, cough, and shortness of breath are included on a list of symptoms that may be early
signs of serious reactions. Patients experiencing these symptoms should stop taking the
medication immediately. Sore throat and arthralgia should also be reported but are not more
worrisome than the symptoms this patient is experiencing. The patient should not continue the
medication. Changing to another sulfonamide is incorrect because similar symptoms would
occur.
DIF: Cognitive Level: Applying (Application)
REF: 703
5. A patient is seen in the clinic with a 1-week history of frequent watery stools. The primary
care NP learns that a family member had gastroenteritis a week prior. The patient was treated
for a UTI with a sulfonamide antibiotic 2 months prior. The NP should suspect:
a. Clostridium difficile–associated disease (CDAD).
b. viral gastroenteritis.
c. serum sickness reaction.
d. recurrence of the UTI.
ANS: A
Cases of CDAD have been reported 2 months after a course of antibiotics, and CDAD should
be suspected in all patients who present with diarrhea after antibiotic use. Viral gastroenteritis
is possible, but the possibility of CDAD must be investigated. Serum sickness reaction is not
usually associated with diarrhea and generally occurs within weeks of drug administration.
DIF: Cognitive Level: Applying (Application)
REF: 703
6. When prescribing TMP/SMX to children, the primary care NP should recall that:
a. dosing is based on the trimethoprim component of the drug.
b. TMP/SMX should not be prescribed for children younger than 2 years.
c. folic acid supplements must be given to children who take this medication.
d. the medication should be given three or four times per day because of rapid
metabolism.
ANS: A
When determining the dose of TMP/SMX, the dose is based on the trimethoprim component
of the drug. Children older than 2 months of age may take this medication. Folic acid
supplements are not indicated. The medication is given twice daily in all age groups.
DIF: Cognitive Level: Applying (Application)
REF: 702
7. A patient is taking sulfisoxazole. The patient calls the primary care NP to report abdominal
pain, nausea, and insomnia. The NP should:
a. change to TMP/SMX.
b. tell the patient to stop taking the drug immediately.
c. reassure the patient that these are minor adverse effects of this drug.
d. order a CBC with differential, platelets, and a stool culture.
ANS: C
These side effects are considered common minor side effects of sulfonamide medications.
They occur with all drugs in this class, so changing to TMP/SMX is not indicated. The patient
should continue taking the medication. It is not necessary to perform laboratory tests.
DIF: Cognitive Level: Applying (Application)
REF: 704
Chapter 66: Antitubercular Agents
Test Bank
MULTIPLE CHOICE
1. A patient receives a Mantoux tuberculin skin test as part of screening for a new job. The test is
administered on a Friday, and the patient returns to the clinic the following Wednesday. The
primary care nurse practitioner (NP) notes a 3-mm area of induration. The patient has no risk
factors for tuberculosis (TB). The NP should:
a. repeat the test.
b. record the test as positive.
c. record the test as negative.
d. ask about previous TB exposure.
ANS: A
If the patient returns after more than 3 days and the results appear negative, the test should be
repeated.
DIF: Cognitive Level: Applying (Application)
REF: 706
2. A patient comes to the clinic to have a Mantoux tuberculin skin test read after 48 hours. The
primary care NP notes a 6-mm area of induration. The patient is a young adult with no known
contacts and has never traveled abroad. The NP should:
a. repeat the test.
b. order a chest radiograph.
c. tell the patient the test is negative.
d. refer to an infectious disease specialist.
ANS: B
A chest x-ray should be obtained on all patients who have a positive purified protein
derivative tuberculin test (PPD). The test was read in the appropriate time frame, so repeating
the test is not necessary. This patient has a positive PPD. Referral to an infectious disease
specialist should be made when the diagnosis is confirmed.
DIF: Cognitive Level: Applying (Application)
REF: 707
3. A primary care NP sees a 5-year-old child for a tuberculin skin test. The child lives in a high-
risk community, and a grandparent who babysits has active TB. The PPD shows a 6-mm area
of induration. A chest radiograph is normal. The NP will refer this patient to an infectious
disease specialist and should expect the patient to be on _____ for _____ months.
a. isoniazid; 6
b. ethambutol; 3
c. isoniazid and rifapentine; 3
d. ethambutol and amikacin; 6
ANS: C
This child has a positive PPD with no pulmonary signs, so a 3-month course of isoniazid and
rifapentine is indicated. Ethambutol is not recommended in children younger than 13 years.
DIF: Cognitive Level: Applying (Application)
REF: 708
4. A patient has a Mantoux tuberculin skin test with a 12-mm area of induration. The patient has
a cough, and a chest radiograph is positive. The primary care NP should refer this patient to an
infectious disease specialist and should plan to monitor a regimen of:
a. isoniazid for 6 months.
b. isoniazid and rifapentine.
c. isoniazid, rifapentine, and ethambutol.
d. isoniazid, rifampin, pyrazinamide, and ethambutol.
ANS: D
Newly diagnosed patients with active disease should be started on a four-drug regimen.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 708
5. A patient is taking isoniazid, pyrazinamide, rifampin, and streptomycin to treat TB. The
primary care NP should routinely perform:
a. serum glucose and liver function tests (LFTs).
b. bone marrow density and ophthalmologic tests.
c. ophthalmologic, hearing, and serum glucose tests.
d. color vision, serum glucose, and LFTs.
ANS: C
For patients taking isoniazid, obtain periodic ophthalmologic examinations; for patients taking
pyrazinamide, perform blood glucose tests.
DIF: Cognitive Level: Applying (Application)
REF: 709
6. A patient who takes isoniazid and rifampin for latent TB comes to the clinic with a new-onset
cough and night sweats. The primary care NP should evaluate these findings by ordering:
a. a sputum culture.
b. LFTs.
c. renal function tests.
d. tuberculin skin test.
ANS: A
Patients with latent TB who develop symptoms while being treated should have a sputum
culture.
DIF: Cognitive Level: Applying (Application)
REF: 709
7. 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:
a. ask about alcohol intake.
b. suggest taking the medications with food.
c. reassure the patient that these side effects are common.
d. order liver and renal function tests and serum glucose.
ANS: A
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.
DIF: Cognitive Level: Applying (Application)
REF: 710
8. A patient who has been taking medications to treat TB tells the primary care NP that the
infectious disease specialist has added ethambutol to the drug regimen. The patient asks the
NP for information about this drug. The NP should explain that this drug:
a. should be taken 1 hour before or 2 hours after a meal.
b. should not be taken by patients who have renal impairment.
c. requires more frequent monitoring of LFTs.
d. means the patient will need regular vision examinations and evaluation of color
vision.
ANS: D
Ethambutol can cause changes in vision, including red-green color blindness. It should be
taken with food. It may be taken by patients with renal impairment with adjustment of doses.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 714
Chapter 67: Antifungals
Test Bank
MULTIPLE CHOICE
1. A patient was diagnosed with tinea corporis and given topical ketoconazole. The patient tells
the primary care nurse practitioner (NP) that the infection is not getting better. The NP should:
a. prescribe griseofulvin.
b. prescribe oral ketoconazole.
c. obtain a culture of the infection site.
d. recommend 3 more weeks of treatment with the topical medication.
ANS: C
If infection is unresponsive to empirical therapy, cultures must be obtained to confirm the
diagnosis and rule out resistant organisms. This should be done before changing treatment.
DIF: Cognitive Level: Applying (Application)
REF: 719
2. A female patient has vaginal candidiasis and has taken a single dose of fluconazole without
resolution of the infection. The primary care NP obtains a culture and should order:
a. oral ketoconazole.
b. griseofulvin for 4 weeks.
c. another dose of fluconazole.
d. topical miconazole (Monistat).
ANS: D
Topical miconazole is still recommended as the drug of first choice and should be given when
oral fluconazole has failed. Fluconazole has been approved for single-dose treatment of
vulvovaginal candidiasis, although the Centers for Disease Control and Prevention continues
to recommend topical therapy with an imidazole derivative because of fluconazole-resistant
candidiasis. Ketoconazole and griseofulvin are not recommended first-line treatments for
vulvovaginal candidiasis. Another dose of fluconazole would not be effective if resistance is
present.
DIF: Cognitive Level: Applying (Application)
REF: 718 - 719
3. A parent brings a 6-year-old child to the clinic for evaluation of a rash. The primary care NP
notes three annular lesions with elevated borders and central clearing on the child’s face and a
similar lesion on the back of the neck that extends above the hairline. The NP should
prescribe:
a. fluconazole.
b. griseofulvin.
c. oral ketoconazole.
d. topical ketoconazole.
ANS: B
Griseofulvin is used for tinea infections of the skin, hair, and nails that are not responsive to
topical therapy. Topical treatment of tinea capitis is usually ineffective because the fungus
invades the hair shaft. Fluconazole is not indicated for tinea infections.
DIF: Cognitive Level: Applying (Application)
REF: 719
4. A woman who takes oral contraceptive pills develops vaginal candidiasis. The primary care
NP prescribes a single dose of fluconazole. When counseling the patient about this drug, the
NP should tell her:
a. that the drug is safe if she were to become pregnant.
b. that she may consume alcohol while taking this medication.
c. to use a backup contraceptive method for the next 2 months.
d. that she may need a lower dose of fluconazole because she takes oral contraceptive
pills.
ANS: C
Women using oral contraception who take antifungals should be advised to use supplemental
contraception during and for 2 months after antifungal therapy. Antifungals have teratogenic
effects and are not safe during pregnancy. Patients should not consume alcohol while taking
antifungal medications. It is not necessary to lower the antifungal dose in women taking oral
contraceptive pills.
DIF: Cognitive Level: Applying (Application)
REF: 719 - 720
5. A patient is diagnosed with onychomycosis. The primary care NP notes that the patient takes
quinidine. The NP should prescribe:
a. terbinafine (Lamisil).
b. fluconazole (Diflucan).
c. itraconazole (Sporanox).
d. griseofulvin (Gris-PEG).
ANS: A
Sporanox and terbinafine are both indicated to treat onychomycosis. Sporanox is not indicated
in patients taking quinidine because of the risk of cardiac arrhythmias. Fluconazole and
griseofulvin are not indicated to treat onychomycosis.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 718
6. A patient has been taking griseofulvin for 4 weeks to treat a tineal capitis infection. The
primary care NP notes improvement but not complete cure. The NP should:
a. obtain a culture and change to ketoconazole.
b. add a topical antifungal cream and refill the griseofulvin prescription for 2 weeks.
c. renew the prescription after obtaining renal, liver, and hematopoietic tests.
d. prescribe griseofulvin for 4 more weeks and then re-evaluate the infection.
ANS: C
Tineal infections may take 6 weeks to respond to griseofulvin. Patients taking griseofulvin
longer than 4 weeks should have renal, hepatic, and hematopoietic functions monitored
periodically. Topical antifungals typically are not effective for tinea capitis. Ketoconazole is
usually not effective for tinea capitis.
DIF: Cognitive Level: Applying (Application)
REF: 724
Chapter 68: Antiretroviral Medications
Test Bank
MULTIPLE CHOICE
1. A female patient who is 8 weeks pregnant is seen by a primary care nurse practitioner (NP)
after a routine prenatal screen was positive for human immunodeficiency virus (HIV). A CD4
cell count is 750 cells/mm. The NP should:
a. begin immediate therapy with zidovudine and lamivudine.
b. begin therapy with zidovudine when she is in her second trimester.
c. delay treatment with antiretroviral medications until after her pregnancy.
d. initiate therapy with zidovudine if her CD4 cell count decreases to 500 cells/mm.
ANS: B
Patients who are HIV positive and who are pregnant should be treated with antiretroviral
medications, but treatment should be avoided during the first trimester if possible. Zidovudine
is recommended and has been shown to reduce the risk of transmission to the fetus from 25%
to 8%.
DIF: Cognitive Level: Applying (Application)
REF: 732
2. A patient who has HIV has been receiving a two-drug combination therapy for 6 months. At
an annual physical examination, the primary care NP notes that the patient has a viral load of
60 copies/mL and a CD4 cell count of 350 cells/mm. The NP should contact the patient’s
infectious disease specialist to discuss:
a. changing one of the medications.
b. changing both of the medications.
c. increasing the dose of both medications.
d. discontinuing the medications for a short period.
ANS: B
This patient has a high viral load and a low cell count. When changing medications, both
medications should be changed.
DIF: Cognitive Level: Applying (Application)
REF: 730
3. A primary care NP provides primary care for a woman who has HIV. The woman asks the NP
if she will ever be able to have children. The NP should tell her:
a. none of the antiretroviral medications are safe to take during pregnancy.
b. she will need to take medications throughout her pregnancy and lactation.
c. there is no risk of disease transmission to a fetus if she complies with therapy.
d. strict adherence to antiretroviral therapy decreases her risk of transmitting HIV to
the fetus.
ANS: D
Antiretroviral therapy reduces, but does not eliminate, the risk of transmitting HIV to the
fetus. Antiretroviral therapy medications may be taken during pregnancy. Women with HIV
should not breastfeed because of the high risk of transmission.
DIF: Cognitive Level: Applying (Application)
REF: 732
4. A patient who has HIV frequently expresses concerns about the costs of treatment. The
primary care NP should:
a. discuss the risks associated with underdosing of antiretroviral therapies.
b. suggest taking half doses of the medications on a regular basis.
c. suggest the patient limit therapy to a one- or two-drug regimen.
d. recommend an occasional “drug holiday” when cell and viral counts are good.
ANS: A
Antiretroviral therapy should include three fully active agents. Patients should be cautioned
that underdosing may be worse than not taking drugs at all because resistant strains will be
developed. Taking half doses, having drug holidays, or limiting therapy to one to two drugs
are not recommended.
DIF: Cognitive Level: Applying (Application)
REF: 734
5. A patient has begun treatment for HIV. The primary care NP should monitor the patient’s
complete blood count (CBC) at least every _____ months.
a. 1 to 3
b. 3 to 6
c. 6 to 9
d. 9 to 12
ANS: B
The patient’s CBC should be monitored at least every 3 to 6 months and more frequently if
values are low and bone marrow toxicity is present.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 732
6. A patient who has HIV is being treated with Emtriva. The patient develops hepatitis B. The
primary care NP should contact the patient’s infectious disease specialist to discuss:
a.
b.
c.
d.
adding zidovudine.
changing to Truvada.
changing to tenofovir.
ordering Combivir and tenofovir.
ANS: B
Truvada contains the antiretroviral therapies in Emtriva plus tenofovir. Tenofovir is effective
against hepatitis B and is used in combination with emtricitabine as a preferred first-line
choice.
DIF: Cognitive Level: Applying (Application)
REF: 736
Chapter 69: Antiviral and Antiprotozoal Agents
Test Bank
MULTIPLE CHOICE
1. A patient refuses an influenza vaccine and asks the primary care nurse practitioner (NP) if the
influenza medications will prevent him from getting influenza. The NP should tell the patient
that although the influenza vaccine remains the best protection against influenza:
a. amantadine may be given prophylactically.
b. rimantadine is curative if given early after exposure.
c. zanamivir can be used before or after exposure to influenza A or B.
d. the influenza vaccine is unnecessary because antiviral medications are so effective.
ANS: C
Zanamivir has been shown to be 70% to 90% effective for prophylaxis before or after
exposure to influenza A or B. Amantadine and rimantadine are not recommended for
prophylaxis of seasonal influenza, and many strains have developed resistance to both of these
drugs.
DIF: Cognitive Level: Applying (Application)
REF: 741
2. A patient who is currently not sexually active has an outbreak of genital herpes. The patient
asks the primary care NP how this could have occurred without active infection since being
treated more than 2 years ago. The NP should tell the patient that:
a. the infection must be due to a resistant herpes simplex virus (HSV) strain.
b. the original infection may have been partially treated.
c. the current infection may be from contact with a toilet seat.
d. successful treatment won’t prevent future outbreaks of active infection.
ANS: D
Treatment of acute infection does not eliminate chronic infection, and outbreaks can occur at
any time. Latency and outbreaks are not necessarily caused by resistant HSV strains. The
current infection is not caused by contact with a toilet seat.
DIF: Cognitive Level: Applying (Application)
REF: 741
3. A patient who has genital herpes has frequent outbreaks. The patient asks the primary care NP
why it is necessary to take oral acyclovir all the time and not just for acute outbreaks. The NP
should explain that oral acyclovir may:
a.
b.
c.
d.
prevent the virus from developing resistance.
cause episodes to be shorter and less frequent.
actually eradicate the virus and cure the disease.
reduce the chance of transmitting the virus to others.
ANS: B
Oral acyclovir has prevented or reduced the frequency of severity of recurrences in more than
95% of patients and so should be given to patients with recurrent episodes. It does not affect
resistance. The antiviral medication does not eradicate the virus; it prevents replication. The
disease is transmitted even without symptoms.
DIF: Cognitive Level: Applying (Application)
REF: 741
4. A 60-year-old patient comes to the clinic reporting a sudden onset of a painful rash that began
the day before. The primary care NP notes a vesicular rash along a dermatome on one side of
the patient’s back. The patient has a low-grade fever. The NP will prescribe:
a. varicella vaccine.
b. acyclovir (Zovirax).
c. metronidazole (Flagyl).
d. amantadine (Symmetrel).
ANS: B
Acyclovir is effective against herpes viruses including the varicella-zoster virus that causes
shingles. Varicella vaccine is given to prevent shingles in older patients. Metronidazole is an
antiprotozoal. Amantadine is given to treat influenza.
DIF: Cognitive Level: Applying (Application)
REF: 740
5. A patient is taking amantadine to treat a viral infection. The patient calls the primary care NP
to report having blurred vision. The NP should:
a. question the patient about suicidal ideation.
b. tell the patient to stop the medication immediately.
c. counsel the patient to avoid driving until this subsides.
d. tell the patient to come to the clinic for an electroencephalogram.
ANS: C
Blurred vision or impaired mental acuity may result from the use of amantadine. Patients with
a history of psychiatric illness may develop suicidal ideation, but this is not associated with
blurred vision. It is not necessary to stop the medication. Patients with a history of seizures
may have seizures with this drug, but this is not associated with blurred vision.
DIF: Cognitive Level: Applying (Application)
REF: 744
6. A patient comes to the clinic before a trip to an area where malaria is endemic. The primary
care NP will prescribe:
a. tinidazole (Tindamax).
b. metronidazole (Flagyl).
c. chloroquine (Plaquenil).
d. amantadine (Symmetrel).
ANS: C
Chloroquine is used as malaria prophylaxis.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 748
7. The primary care NP sees a female patient and makes a diagnosis of Trichomonas vaginalis.
The patient does not want to tell her partner she has it because she thinks she may have
contracted it from someone else. The NP will tell her:
a. as long as she takes the antibiotic for 7 days, the infection will be cured.
b. she and all of her partners must be treated, or the infection will not be cured.
c. she can be treated, but if the infection recurs, she will have to tell both partners.
d. she and the person who infected her will need one-time doses of metronidazole.
ANS: B
Because this is a sexually transmitted disease, both partners have to be treated for a cure to be
achieved.
DIF: Cognitive Level: Applying (Application)
REF: 742
8. A patient who is taking metronidazole calls the primary care NP to report severe nausea and
vomiting along with heart palpitations. The NP should:
a. counsel the patient to take the medication with food.
b. ask the patient about any recent alcohol consumption.
c. reassure the patient that these symptoms will subside.
d. instruct the patient to go to an emergency department for intravenous fluids.
ANS: B
Metronidazole can cause a disulfiram-like reaction if taken with alcohol. Mild gastrointestinal
upset may be prevented by taking the medication with food. The patient needs to be told not
to drink alcohol with this drug to prevent this severe reaction. If the symptoms persist, it may
be recommended that the patient go to the emergency department.
DIF: Cognitive Level: Applying (Application)
REF: 743
Chapter 70: The Immune System and Immunizations
Test Bank
MULTIPLE CHOICE
1. The parents of a 2-month-old infant ask the primary care nurse practitioner (NP) if they can
immunize their child by giving one or two immunizations per month instead of following the
recommended immunization schedule for vaccines at 2, 4, 6, 12, and 15 months of age. The
NP should:
a. respect the parents’ wishes and agree to the revised schedule for immunizations.
b. explain that prolonging the vaccine regimen will lead to a decrease in final
antibody concentrations.
c. tell the parents that protection from diseases may be delayed until all
immunizations have been given.
d. inform the parents that a prolonged interval between some vaccines may require
restarting the series for those vaccines.
ANS: C
Young infants are the most vulnerable to serious outcomes of vaccine-preventable disease.
Vaccination providers should adhere as closely as possible to recommended vaccination
schedules. Protection may not occur until all doses have been given. Parents should be
counseled about the risks and benefits of vaccines. Longer than recommended intervals
between doses do not reduce final antibody concentrations. With the exception of oral
typhoid, an interruption in the schedule does not require restarting the entire series.
DIF: Cognitive Level: Applying (Application)
REF: 756
2. The primary care NP sees a 5-year-old child for a prekindergarten physical examination. The
child’s parents do not have immunization records, and a local record search does not provide
proof of vaccinations, although the parent thinks the child may have had some vaccines
several years ago. The NP’s initial action will be to:
a. perform serologic tests for measles, rubella, and tetanus antigens.
b. administer TdaP, MMR, Varivax, PCV13, hepatitis A, hepatitis B, and IPV
vaccines.
c. administer DTaP, Hib, hepatitis A, hepatitis B, MMR, Varivax, IPV, RV, and
PCV13 vaccines.
d. ask the parent to look for immunization records and schedule an appointment for
vaccines when those are found.
ANS: B
Persons without documentation of vaccine receipt should be considered nonimmunized if a
reasonable effort to locate records is unsuccessful and should be started on age-appropriate
vaccines. The Hib and rotavirus vaccines are not given after age 5, or 60 months of age.
Serologic testing for immunity may be done for certain antigens, but this does not include
tetanus.
DIF: Cognitive Level: Applying (Application)
REF: 756
3. The primary care NP sees a 6-month-old infant for a routine physical examination and notes
that the infant has a runny nose and a cough. The parents report a 2-day history of a
temperature of 99° F to 100° F and two to three loose stools per day. Other family members
have similar symptoms. The infant has had two sets of immunizations at 2 and 4 months of
age. The NP should:
a. administer the 6-month immunizations at this visit today.
b. schedule an appointment in 2 weeks for 6-month immunizations.
c. administer DTaP, Hib, IPV, hepatitis B, and PCV13 today and RV in 2 weeks.
d. withhold all immunizations until the infant’s temperature returns to normal and the
cough is gone.
ANS: A
Minor upper respiratory infection or gastroenteritis, with or without fever, is not an indication
for withholding a scheduled vaccine dose.
DIF: Cognitive Level: Applying (Application)
REF: 757
4. A woman who is pregnant and is planning to breastfeed tells the primary care NP that she has
never had chickenpox. The NP should:
a. administer the Varivax vaccine today.
b. administer the varicella-zoster immune globulin.
c. recommend the Varivax vaccine as soon as possible after her baby is born.
d. instruct her to receive the Varivax vaccine after her baby has been weaned.
ANS: C
Live vaccines are usually contraindicated in pregnancy but are usually safe when the mother is
breastfeeding.
DIF: Cognitive Level: Applying (Application)
REF: 758
5. The primary care NP is performing a physical examination on a 6-month-old infant with
cerebral palsy who has not had previous immunizations. The NP plans to begin vaccinations
and should include:
a. DTaP vaccine.
b. TdaP vaccine.
c. TD vaccine only.
d. tetanus vaccine only.
ANS: A
Infants with stable neurologic disorders, including cerebral palsy, may receive the pertussis
vaccine and should receive the DTaP series as infants.
DIF: Cognitive Level: Applying (Application)
REF: 759
6. A parent whose child received a fourth DTaP at a recent 15-month visit calls the primary care
NP to report that the child is fussy, has a temperature of 38.3° C, and has redness and swelling
at the injection site. The NP should:
a. admit the child to the hospital for observation of developing symptoms.
b. flag the child’s chart to avoid administration of pertussis vaccine in the future.
c. report these adverse reactions to the Vaccine Adverse Event Reporting System
(VAERS).
d. instruct the parent to give the child acetaminophen as needed for fever or localized
discomfort.
ANS: D
Temperatures between 38° C and 40° C are common and self-limited, as are fussiness and
localized swelling and erythema. Parents should be advised to provide symptomatic care.
Unless the child experiences a severe reaction, admission to a hospital is not indicated. Mild
reactions are not contraindications to future vaccines. This reaction is not severe, and
reporting to VAERS is not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 760
7. The primary care NP sees an 11-month-old infant for the first time and notes that the infant
has not received the Hib vaccine. The NP should:
a. give the Hib vaccine now with no boosters.
b. give the Hib vaccine now and booster in 2 to 3 months.
c. give the Hib vaccine now and booster at age 4 to 6 years.
d. tell the parents that the child is too old to begin receiving the Hib vaccine.
ANS: B
Children 12 to 14 months old require at least two doses, so this infant should be immunized
today with a booster in 2 to 3 months.
DIF: Cognitive Level: Applying (Application)
REF: 761
8. 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:
a. administer all of these vaccines today.
b. give the hepatitis A and influenza vaccines.
c. give the Varivax, hepatitis A, and influenza vaccines.
d. withhold all of these vaccines until after the baby is born.
ANS: A
Although live-virus vaccines should not be administered to mothers during pregnancy, they
may be given to children whose mothers are pregnant.
DIF: Cognitive Level: Applying (Application)
REF: 762
9. The primary care NP performs a physical examination on an 89-year-old patient who is about
to enter a skilled nursing facility. The patient reports having had chickenpox as a child. The
NP should:
a. obtain a varicella titer.
b. administer the Varivax vaccine.
c. give the patient the Zostavax vaccine.
d. plan to prescribe Zovirax if the patient is exposed to shingles.
ANS: C
The Advisory Committee on Immunization Practices has recommended that a single dose of
herpes zoster vaccine (Zostavax) be given to adults 60 years of age or older. This is
recommended whether or not the patient reports a prior episode of herpes zoster. Varivax is
not recommended to prevent shingles.
DIF: Cognitive Level: Applying (Application)
REF: 763
10. The primary care NP sees a 4-year-old child who has persistent asthma episodes for a well-
child visit in October. The child recently completed a 7-day course of oral steroids. The NP
plans to give the child flu vaccine and should:
a. administer LAIV today.
b. administer 0.5 mg TIV today.
c. wait 4 weeks and administer LAIV.
d. wait 4 weeks and administer 0.5 mg TIV.
ANS: B
U.S. Food and Drug Administration licensure of LAIV excludes children ages 2 to 4 years
with a history of asthma. Steroid therapy should not delay the administration of influenza
vaccine, especially in patients for whom influenza infection would be particularly severe. This
child should receive TIV and may receive it today.
DIF: Cognitive Level: Applying (Application)
REF: 764
11. The primary care NP sees a 4-year-old child who has received four doses of PCV 7 in the first
15 months of life. The NP should administer:
a. PCV 7.
b. PCV 13.
c. PPV 23.
d. no PCV.
ANS: B
Children who have completed the PCV series with PCV 7 and are younger than 5 years
should receive a single dose of PCV 13.
DIF: Cognitive Level: Applying (Application)
REF: 765
12. The primary care NP sees a 65-year-old patient in October. The patient has a history of COPD
and has not had any vaccines for more than 20 years. The NP should administer:
a. influenza and Td vaccines.
b. PCV 13 and influenza vaccines.
c. PPV 23, Td, and influenza vaccines.
d. PPV 23, influenza, and TdaP vaccines.
ANS: D
Persons older than age 65 and patients with chronic illnesses associated with increased risk
from pneumococcal infection should receive the PPV 23. All persons should receive annual
influenza vaccine. TdaP is the recommended vaccine for adults, unless there is a specific
contraindication for the pertussis component; this vaccine is given every 10 years.
DIF: Cognitive Level: Applying (Application)
REF: 765
13. The primary care NP sees a 2-month-old infant for a well-baby examination in late November.
The infant was born at 34 weeks’ gestation, does not have underlying cardiac or pulmonary
conditions, and does not attend daycare. The NP should recommend:
a. one dose of palivizumab (Synagis) today.
b. no respiratory syncytial virus prophylaxis.
c. three monthly doses of palivizumab (Synagis).
d. monthly doses of palivizumab (Synagis) until April.
ANS: C
Infants born at 32 to 35 weeks’ gestation who are younger than 3 months of age at the start of
respiratory syncytial virus season should receive a maximum of three doses of Synagis.
DIF: Cognitive Level: Applying (Application)
REF: 765 - 766
14. A 23-year-old woman who is sexually active has an abnormal Pap smear. She asks the
primary care NP about the human papillomavirus vaccine (HPV). The NP should recommend:
a. no HPV vaccine.
b. a single HPV vaccine.
c. a three-vaccine series of HPV.
d. HPV vaccine for her partner.
ANS: C
A catch-up vaccination may be given for women 13 to 26 years old and should be given even
to women with a history of genital warts, a positive HPV test, or an abnormal pap smear.
DIF: Cognitive Level: Applying (Application)
REF: 768
15. A patient receives a hepatitis A vaccine and 4 weeks later develops symptoms of hepatitis.
The patient has no history of exposure to blood or body fluids. The primary care NP should
tell the patient that:
a. the symptoms are most likely caused by hepatitis B or C.
b. these symptoms are common adverse effects of the vaccine.
c. a prevaccine exposure to hepatitis A could be causing symptoms.
d. the vaccine is effective only after the second dose of hepatitis A vaccine.
ANS: C
Because hepatitis A has a long incubation period of 15 to 50 days, the vaccine may not
prevent hepatitis A infection in patients who have an unrecognized hepatitis A infection at the
time of vaccination. The patient has no history of exposure to blood or body fluids, which are
the methods of transmission of hepatitis B or C. Side effects of the hepatitis A vaccine are
generally mild.
DIF: Cognitive Level: Applying (Application)
REF: 766 - 767
16. The parent of a 2-month-old infant who will soon begin daycare refuses the rotavirus vaccine
(RV) because of fears of intussusception. The parent tells the primary care NP that the daycare
is strict about preventing infants who have fever or gastrointestinal symptoms from attending.
The NP should tell the parent that:
a. herd immunity will protect the infant from infection.
b. asymptomatic children can spread rotavirus infection.
c. the risk of intussusception is nonexistent with the newer vaccine.
d. the infant can be treated with antibiotics if rotavirus infection occurs.
ANS: B
Asymptomatic infection with spread to nonimmune children can occur. The risk of
intussusception is less with the newer rotavirus vaccine but is still present. Rotavirus cannot
be treated with antibiotics.
DIF: Cognitive Level: Applying (Application)
REF: 767
Chapter 71: Weight Management
Test Bank
MULTIPLE CHOICE
1. A woman comes to the clinic to talk about weight reduction. The primary care nurse
practitioner (NP) calculates a body mass index (BMI) of 28. The woman’s waist measures 34
inches. The woman tells the NP that she would like to lose 20 lb for her daughter’s wedding in
6 months. The NP should:
a. suggest she try over-the-counter (OTC) orlistat.
b. consider prescribing phentermine short-term.
c. discuss her short-term and long-term weight loss goals.
d. give her information about physical activity and diet modification.
ANS: C
This woman’s BMI is in the moderate range for overweight, and her waist circumference is
34, which is not diagnostic for metabolic syndrome. Because her apparent motivation for
losing weight is based on an upcoming event, the NP first should determine what her shortterm and long-term weight loss goals are before initiating therapy. Orlistat is used long-term
and would not be appropriate in this case. Phentermine should be used short-term and,
because of serious risks, should be used only as adjunct therapy to lifestyle modifications. The
initial intervention for weight loss is physical activity and diet modification.
DIF: Cognitive Level: Applying (Application)
REF: 774
2. A man with a BMI of 38 and a waist size of 48 inches is seen in the clinic for an annual well
check-up. The primary care NP orders laboratory tests and notes a fasting plasma glucose of
110 mg/dL, triglyceride level of 220 mg/dL, and high-density lipoprotein level of 40 mg/dL.
The man’s blood pressure is 160/110 mm Hg. The man has a history of cardiovascular disease
and tells the NP he has tried to lose weight numerous times. The NP should consider:
a. orlistat (Xenical).
b. phentermine (Adipex-P).
c. an oral antidiabetic agent.
d. a strict low-fat, low-sodium diet.
ANS: A
This man’s BMI and waist circumference indicate that he is obese, and he has more than three
indicators of metabolic syndrome. Because of his history of cardiovascular disease, his past
failed attempts to lose weight, and his elevated blood pressure, treatment is indicated.
Phentermine would be a good initial choice but carries significant risks in patients with
cardiovascular disease and high blood pressure. Orlistat is a safer choice for pharmacologic
therapy. An oral antidiabetic agent would be used if insulin resistance were present, but his
fasting plasma glucose is normal. A strict change in diet is warranted but in this case should
be combined with pharmacologic treatment.
DIF: Cognitive Level: Applying (Application)
REF: 774
3. A patient who weighs 170 lb wishes to lose weight, with a target weight goal of 125 lb. To
initiate a program that will result in a loss of 1 lb per week, the primary care NP should
recommend a dietary intake of _____ kcal.
a. 1000
b. 1200
c. 1700
d. 2000
ANS: B
To lose weight, a patient must decrease intake to below the level needed to maintain weight.
The patient must decrease daily calorie consumption by 500 kcal for each pound he or she
wishes to lose weekly. Because it takes approximately 10 kcal per pound to maintain weight,
the NP can assume that the patient currently takes in 1700 kcal/day and should recommend a
diet of 1200 kcal/day for weight loss.
DIF: Cognitive Level: Applying (Application)
REF: 755
4. 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:
a. orlistat (Xenical).
b. surgical intervention.
c. changes in diet and exercise.
d. changes in diet and exercise along with short-term phentermine.
ANS: D
This patient is grade 2 overweight (obese), so a short-term course of phentermine is useful,
especially as there are no cardiovascular risk factors. Orlistat is a second-line drug. Surgical
intervention is indicated when other therapies fail. Changes in diet and physical activity alone
do not bring immediate results, and patients often get discouraged.
DIF: Cognitive Level: Applying (Application)
REF: 776
5. A patient who has hypothyroidism and is obese begins therapy with orlistat. The primary care
NP teaches the patient about this drug and then asks the patient to describe its use. Which
statement by the patient indicates understanding of the teaching?
a. “I may eat a high-fat diet while taking orlistat.”
b. “I can expect the most benefit in the first few months.”
c. “I should take fat-soluble vitamins each time I take orlistat.”
d. “I should take an increased dose of levothyroxine while I am taking orlistat.”
ANS: B
In long-term studies on the use of orlistat, most of the weight loss occurred during the first
months. Patients should not be counseled to eat a high-fat diet; the maximum amount of fat
excretion is around 25% to 30%. Patients should take fat-soluble vitamins, but the vitamins
should be taken at different times and not with orlistat. Orlistat interferes with levothyroxine
absorption, so the two drugs should be taken at different times, and thyroid levels should be
monitored with an increase in levothyroxine dose only when indicated by thyroid levels.
DIF: Cognitive Level: Applying (Application)
REF: 776
6. A primary care NP has prescribed phentermine for a patient who is obese. The patient loses 10
lb in the first month but reports that the drug does not seem to be suppressing appetite as
much as before. The NP should:
a. discontinue the phentermine.
b. increase the dose of phentermine.
c. continue the phentermine at the same dose.
d. change to a combination of phentermine and topiramate.
ANS: A
Tolerance to the effects of phentermine usually develops within a few weeks of starting
therapy. When this occurs, the drug should be discontinued, not increased. Phentermine use is
not recommended longer than a few weeks.
DIF: Cognitive Level: Applying (Application)
REF: 776
7. A patient has a BMI of 35, a fasting plasma glucose of 120 mg/dL, elevated triglycerides, and
a history of myocardial infarction. The primary care NP plans to initiate dietary and lifestyle
counseling and should consider prescribing:
a. ephedra.
b. orlistat (Xenical).
c. phentermine (Adipex-P).
d. phentermine and topiramate (Onexa).
ANS: D
Patients who take Onexa have shown improvement in blood glucose levels and triglyceride
levels, so this combination is a good choice for this patient.
DIF: Cognitive Level: Applying (Application)
REF: 776
Chapter 72: Smoking Cessation
Test Bank
MULTIPLE CHOICE
1. A patient who smokes reports repeated attempts to quit smoking using a nicotine replacement
patch. The patient says, “I always do well for a few weeks and then I just start smoking
again.” The primary care nurse practitioner (NP) should prescribe:
a. nortriptyline.
b. Nicorette gum.
c. a Nicotrol inhaler.
d. varenicline (Chantix).
ANS: D
Varenicline interferes with the enjoyment of nicotine so that smokers do not get pleasure
when they smoke. Nicotine replacement medications do not improve relapse rates, and this
patient has relapsed several times. Nortriptyline is not a first-line smoking cessation
medication.
DIF: Cognitive Level: Applying (Application)
REF: 780
2. An adolescent patient has recently begun smoking and reports a habit of fewer than five or six
cigarettes per day. The patient does not want to quit smoking now but plans to do so after
college. The primary care nurse practitioner should:
a. prescribe varenicline (Chantix).
b. recommend a nicotine transdermal patch.
c. refer the patient to a smoking cessation program.
d. begin a discussion about the negative effects of smoking.
ANS: D
For all patients who smoke, the provider should assess their willingness to quit. For patients
unwilling to quit, the provider should focus on motivational issues. Chantix, nicotine
transdermal patches, and smoking cessation programs are treatments for smoking, but if they
are used by a patient who is unwilling to quit, they will be ineffective.
DIF: Cognitive Level: Applying (Application)
REF: 782
3. A primary care NP has been working with a young woman who wants to quit smoking before
she begins having children. She has made several attempts to quit using nicotine replacement
therapy and is feeling discouraged. She does not want to take medication at this time. The NP
should:
a. discuss the effects of smoking on fetal development.
b. ask her to write down any factors that triggered her relapses.
c. give her information about the long-term effects of smoking.
d. convince her that taking medication will be essential in her case.
ANS: B
Each attempt to quit smoking should not be seen as a failure but as a trial for the next attempt.
Asking a patient who is motivated to quit to write down things that may have contributed to
the relapse will help the patient learn from the previous attempts. The patient already knows
about the effects of smoking on fetal development because that is her motivation for quitting.
Offering medication may be necessary, but only if the patient desires it.
DIF: Cognitive Level: Applying (Application)
REF: 781
4. A patient reports smoking two or more packs of cigarettes per day and expresses a desire to
quit smoking. The primary care NP learns that the patient smokes heavily during breaks at
work and during the evening but with no established schedule. The NP should recommend:
a. bupropion (Wellbutrin).
b. nicotine replacement gum or nasal spray.
c. a high-dose 24-hour nicotine patch.
d. intensive smoking cessation counseling.
ANS: B
Nicotine replacement gum and nasal spray both can be used when patients have cravings and
are especially useful for patients who do not smoke at particular times. The patch is useful
when patients smoke consistently throughout the day. Bupropion is not indicated. Intensive
counseling is often necessary for patients who have difficulty stopping and have failed several
times.
DIF: Cognitive Level: Applying (Application)
REF: 782
5. A patient who is using a nicotine patch for smoking cessation is in the clinic for a follow-up
examination. The primary care NP notes a heart rate of 96 beats per minute and a blood
pressure of 140/90 mm Hg. The patient reports feeling dizzy and complains of ringing in both
ears. The NP should suspect:
a. nicotine withdrawal symptoms.
b. that the patient has been smoking.
c. hypersensitivity reaction to the nicotine patch.
d. minor cardiovascular effects of the nicotine patch.
ANS: B
Patients who are using the patch should be cautioned not to smoke while using it because of
the risk of nicotine overdose. This patient is not having symptoms of nicotine withdrawal or
of hypersensitivity of the patch or of minor cardiovascular effects.
DIF: Cognitive Level: Analyzing (Analysis)
REF: 785
6. A patient has been using a nicotine patch for several weeks and uses the 15 mg/16 hour patch.
The patient reports having frequent continual cravings for cigarettes, especially on awakening
in the morning. The primary care NP should:
a. prescribe varenicline (Chantix).
b. prescribe bupropion (Wellbutrin).
c. change to a 21 mg/24 hour nicotine patch.
d. suggest adding nicotine nasal spray for cravings.
ANS: C
It is important to begin therapy with a dose sufficient to deliver enough nicotine so that
patients will not want to smoke. Patients who awaken with nicotine cravings should wear a
24-hour patch. Prescribing varenicline or bupropion may be necessary if the patch fails after
appropriate dosing is established. Whichever nicotine replacement method is chosen, the
patient should use only one particular product to avoid nicotine toxicity.
DIF: Cognitive Level: Applying (Application)
REF: 785
7. A patient has been using a nicotine nasal spray for 4 months, one to two doses every hour
while awake and as needed for cravings. The patient reports that the cravings have stopped
and that one dose per hour is generally sufficient. The primary care NP should recommend:
a. changing to Nicorette gum as needed.
b. using a low-dose 16-hour patch for 2 weeks.
c. continuing one dose per hour for 2 more months and then discontinuing.
d. beginning one dose every 2 hours for 1 week and then one dose every 4 hours.
ANS: D
Once the patient is showing improvement, the nasal spray should be tapered by halving the
number of doses used each week. Patients should not switch products, so nicotine replacement
gum or the patch is not indicated. Tapering is recommended rather than an abrupt
discontinuation to prevent acute withdrawal symptoms, which may contribute to relapse.
DIF: Cognitive Level: Applying (Application)
REF: 785
Chapter 73: Vitamins and Minerals
Test Bank
MULTIPLE CHOICE
1. An 80-year-old woman has chronically low hemoglobin despite a diet high in iron. The
primary care nurse practitioner (NP) will perform laboratory tests to confirm a diagnosis and
should suspect the patient will need:
a. omega-3 supplements.
b. a folic acid supplement.
c. a daily multivitamin with iron.
d. a diet high in green, leafy vegetables.
ANS: B
Women and elderly adults are often at risk for folic acid deficiency leading to anemia because
folic acid is necessary for synthesis of hemoglobin. Folic acid supplements are indicated.
Omega-3 supplements are not indicated for anemia. If anemia is caused by iron deficiency
alone, iron supplements must be used, which have more iron than a multivitamin with iron.
Folic acid supplements are more effective than dietary folic acid.
DIF: Cognitive Level: Applying (Application)
REF: 809
2. The parent of a 3-year-old is concerned that the child’s legs are not straight. The primary care
NP notes marked bowing of the child’s lower extremities. Radiologic studies show decreased
ossification of the child’s bones. The NP should:
a. prescribe vitamin D supplements.
b. recommend calcium supplements.
c. counsel the parent to increase the child’s milk intake.
d. ensure that the parent is buying vitamin D–fortified milk.
ANS: A
Children who do not get enough vitamin D can have abnormalities in bone ossification
leading to rickets, which is characterized by bowing of the legs. The NP should prescribe
vitamin D. Calcium supplements or increased milk intake would not be helpful. Without
vitamin D, the body cannot use calcium for bone ossification. The amount of vitamin D in
fortified milk is not sufficient to overcome vitamin D deficiency.
DIF: Cognitive Level: Applying (Application)
REF: 803
3. An adolescent girl reports having heavy menstrual periods. Her hemoglobin is consistently on
the low end of the normal range. The primary care NP should prescribe:
a. iron supplements.
b. a folic acid supplement.
c. oral contraceptive pills.
d. increased red meats in her diet.
ANS: C
Women are at risk for iron-deficiency anemia from menstrual blood loss. Taking oral
contraceptives reduces this risk by moderating periods. Iron would be indicated if anemia
actually occurs, but this patient is just at risk. Folic acid supplements are not indicated to
prevent iron-deficiency anemia. Dietary iron usually is not sufficient for replacing iron losses.
DIF: Cognitive Level: Applying (Application)
REF: 803
4. The parents of a 3-year-old child tell the primary care NP that their child is a very picky eater
and they are worried about the child’s nutrition. The NP should recommend:
a. giving the child a daily multivitamin containing iron.
b. providing small portions of a variety of foods at each meal.
c. disciplining the child at mealtimes to ensure proper nutrition.
d. making sure the child’s cereals are fortified with vitamins and minerals.
ANS: B
Children often develop strong food preferences as they start to eat solid foods. Parents should
be taught that balance over time is important and should provide small portions of a variety of
foods at every meal. Not every meal has to include every nutrient. Vitamin supplementation
may be necessary for children who refuse to eat a variety of foods.
DIF: Cognitive Level: Applying (Application)
REF: 803
5. A patient exhibits keratin deposits around hair follicles and has hardened pigmented “goose
bump” lesions on all extremities. The primary care NP should consider prescribing:
a. thiamine.
b. vitamin A.
c. beta carotene.
d. ascorbic acid.
ANS: C
The patient is exhibiting signs of early vitamin A deficiency. Beta carotene is recommended
to avoid vitamin A toxicity because beta carotene is converted to vitamin A as needed and
there is no need to monitor intake levels as with vitamin A. Thiamine and ascorbic acid are
not indicated.
DIF: Cognitive Level: Applying (Application)
REF: 804 - 805
6. The primary care NP sees a patient for an annual physical examination. The patient reports
chronic alcohol abuse. The NP should refer the patient for treatment and should prescribe:
a. niacin.
b. thiamine.
c. folic acid.
d. vitamin B6.
ANS: B
Patients who are alcohol abusers are prone to thiamine deficiency.
DIF: Cognitive Level: Applying (Application)
REF: 807
7. As patients age, it becomes particularly important to increase their intake of:
a. iron.
b. omega 3.
c. vitamin C.
d. B vitamins.
ANS: D
Elderly patients are especially prone to deficiencies of B vitamins, generally because of poor
dietary intake.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 803
8. A 40-year-old woman asks the primary care NP what she can do to minimize her risk of
osteoporosis. She takes 800 mg of calcium and drinks 2 cups of skim milk each day. The NP
should recommend that she:
a. decrease dietary fat.
b. limit her caffeine intake.
c. consume a high-protein diet.
d. drink diet instead of sugary sodas.
ANS: B
Large amounts of caffeine decrease calcium absorption. Calcium absorption is improved with
fat and decreased with high protein intake. All sodas contain phosphorus, which decreases
calcium levels.
DIF: Cognitive Level: Applying (Application)
REF: 811
9. A 13-month-old child drinks 40 to 48 ounces of milk every day. The parents report that the
toddler eats a variety of baby fruits and vegetables but refuses meats and cereals. The primary
care NP should order a:
a. complete blood count (CBC).
b. ferritin level.
c. vitamin D level.
d. serum calcium level.
ANS: A
This child is consuming a diet low in iron. The NP should order a CBC to check this child’s
hemoglobin.
DIF: Cognitive Level: Applying (Application)
REF: 813
10. A patient reports fatigue and increased frequency of stools over the past week and reports
having just begun a regimen of dietary changes to prevent hypertension. The primary care NP
notes a rapid, irregular heart rate and a blood pressure of 92/58 mm Hg. The NP should
question the patient about:
a. caffeine intake.
b. B vitamin intake.
c. fat-soluble vitamins.
d. use of salt substitutes.
ANS: D
The patient exhibits signs of potassium toxicity. Patients who use salt substitutes often
consume excessive potassium.
DIF: Cognitive Level: Applying (Application)
REF: 815
11. An adolescent girl has decided to become a vegetarian. The primary care NP should counsel
her about iron intake and considering a vitamin containing:
a. zinc.
b. vitamin A.
c. vitamin C.
d. potassium.
ANS: A
Patients who are vegetarians often do not consume adequate amounts of zinc.
DIF: Cognitive Level: Understanding (Comprehension)
REF: 816