Exam

NR 508 MIDTEM EXAM 2023 (QUESTIONS AND ANSWERS)

ANSWER EXPLANATIONS: 1. Although estrogen slows the progression of osteoporosis, it also increases the risk of breast cancer when initiated early in... [Show More] 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. 2. 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 3. 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. 4. 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. 5. This patient has hypothyroidism and should be treated with levothyroxine. Methimazole is a thyroid suppressant. Liothyronine is synthetic T3. Propylthiouracil is a thyroid suppressant. 6. 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. 7. 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. 8. 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. 9. 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. 10. 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. 11. 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. 12. 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. 13. 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. 14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolide-allergic patients and for re-treatment for 14 days if first-line treatment of choice failed because of occasional resistance to clarithromycin. 20. 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. 21. 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. β-Blockers and aldosterone antagonist medications are not recommended for patients with diabetes. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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. 27. 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. 28. 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. 29. 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 C-reactive protein levels. 30. 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. 31. 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. 32. 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. 33. 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. 34. 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. 35. 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. 36. 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. 37. 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. β-Blockers are used in patients who are stable. Digoxin should not be used in patients with diastolic failure. 38. 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. 39. 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. 40. Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. 41. 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. 42. 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. 43. 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. 44. 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. 45. 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. 46. 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. 47. 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. 48. 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. 49. 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. 50. 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. 51. 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. 52. 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. 53. 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. 54. 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. 55. 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. 56. 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. 57. 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. 58. 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. 59. 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. 60. 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. [Show Less]

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