NR508 Final Exam 2018

nNR 508
Final Exam

Question 1

2 / 2 pts

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:

flavoxate (Urispas).

bethanechol (Urecholine).

phenazopyridine (Pyridium).

oxybutynin chloride (Ditropan XL).

This patient is describing urge
incontinence, or overactive bladder, which occurs when the detrusor muscle is
hyperactive, causing an intense urge to void before the bladder is full. Urge
incontinence is associated with many conditions, including diabetes. Oxybutynin
chloride, which is an anticholinergic, acts to decrease detrusor overactivity
and is indicated for treatment of urge incontinence. Flavoxate is used to treat
dysuria associated with UTI. Bethanechol is indicated for urinary retention.
Phenazopyridine is used to treat dysuria.

Question 2

2 / 2 pts

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:

zaleplon.

ZolpiMist.

ramelteon.

chloral hydrate.

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.

Question 3

2 / 2 pts

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:

prescribe azithromycin once daily
for 5 days.

prescribe amoxicillin twice daily
for 10 days.

prescribe amoxicillin-clavulanate
twice daily for 10 days.

initiate antibiotic therapy if the
child’s condition worsens.

Signs and symptoms of otitis media
that indicate a need for antibiotic treatment include otalgia, fever, otorrhea,
or a bulging yellow or red tympanic membrane. This child has a low-grade fever,
no history of otitis media, a nonbulging tympanic membrane, and no otorrhea, so
watchful waiting is appropriate. When an antibiotic is started, amoxicillin is
the drug of choice.

Question 4

2 / 2 pts

An 80-year-old patient with
congestive heart failure has a viral upper respiratory infection. The patient
asks the primary care NP about treating the fever, which is 38.5° C. The NP
should:

recommend acetaminophen.

recommend high-dose acetaminophen.

tell the patient that antibiotics
are needed with a fever that high.

tell the patient a fever less than
40° C does not need to be treated.

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.

Question 5

2 / 2 pts

A patient who takes levodopa and
carbidopa for Parkinson’s disease reports experiencing freezing episodes
between doses. The primary care NP should consider using:

selegiline.

amantadine.

apomorphine.

modified-release levodopa.

Apomorphine injection is used for
acute treatment of immobility known as “freezing.”

Question 6

2 / 2 pts

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:

consume foods high in vitamin D and
calcium.

begin taking dexamethasone because
it has longer effects.

expect these side effects to occur
as the medication is tapered.

increase the dose of prednisolone
to the most recent amount taken.

Sudden discontinuation or rapid
tapering of glucocorticoids in patients who have developed adrenal suppression
can precipitate symptoms of adrenal insufficiency, including nausea, weakness,
depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients
experience these symptoms during a drug taper, the dose should be increased to
the last dose. Vitamin D deficiency is common while taking glucocorticoids, but
these are not symptoms of vitamin D deficiency. Changing to another
glucocorticoid is not recommended. Patients should be taught to report the side
effects so that action can be taken and should not be told that they are to be
expected.

Question 7

2 / 2 pts

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:

perform a dipstick urinalysis.

prescribe desmopressin (DDAVP).

prescribe oxybutynin chloride
(Ditropan XL).

teach exercises to strengthen the
pelvic muscles.

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.

Question 8

2 / 2 pts

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:

gradually tapering the child off
the prednisone.

a referral for possible growth
hormone therapy.

giving a double dose of prednisone
every other day.

dividing the prednisone dose into
twice-daily dosing.

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.

Question 9

2 / 2 pts

A patient who is taking isoniazid
and rifampin for latent TB is seen by the primary care NP for a routine
follow-up visit. The patient reports having nausea, vomiting, and a decreased
appetite. The NP should:

ask about alcohol intake.

suggest taking the medications with
food.

reassure the patient that these
side effects are common.

order liver and renal function
tests and serum glucose.

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.

Question 10

2 / 2 pts

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:

combination ICS/LABA inhaler twice
daily.

short-acting ?2-agonist (SABA) with
oral corticosteroids when symptomatic.

combination ipratropium/albuterol
inhaler twice daily.

SABA as needed plus a leukotriene
modifier once daily.

A leukotriene modifier may be used
as an alternative to ICS for children who experience systemic side effects of
the ICS. This child’s symptoms are well controlled, so there is no need to step
up therapy to include a LABA. Oral corticosteroids should be used only for
severe exacerbations. Ipratropium and albuterol are used for severe
exacerbations.

Question 11

2 / 2 pts

A patient is newly diagnosed with
Alzheimer’s disease stage 6 on the Global Deterioration Scale. The primary care
NP should prescribe:

donepezil (Aricept).

rivastigmine (Exelon).

memantine (Namenda).

galantamine (Razadyne).

Patients with moderate to severe
dementia (stages 5 to 7) may be started on memantine.

Question 12

2 / 2 pts

The primary care NP sees a
12-month-old infant who needs the MMR, Varivax, influenza, and hepatitis A
vaccines. The child’s mother tells the NP that she is pregnant. The NP should:

administer all of these vaccines
today.

give the hepatitis A and influenza
vaccines.

give the Varivax, hepatitis A, and
influenza vaccines.

withhold all of these vaccines
until after the baby is born.

Although live-virus vaccines should
not be administered to mothers during pregnancy, they may be given to children
whose mothers are pregnant.

Question 13

2 / 2 pts

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:

order renal function tests.

prescribe another medication to
treat this child’s symptoms.

discontinue the drug and observe
the child for toxic side effects.

obtain a serum drug level and
consider increasing the drug dose.

By a child’s first birthday, the
liver’s metabolic capabilities are not only mature but also more vigorous than
the adult liver, meaning that certain drugs may need to be given in higher
doses or more often. It is prudent to obtain a serum drug level and then
consider increasing the dose to achieve the desired effect. Renal function
tests are not indicated. Unless the child is experiencing toxic effects, the
drug does not need to be discontinued.

Question 14

2 / 2 pts

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:

order spirometry to evaluate
pulmonary function.

prescribe a systemic corticosteroid
to help with symptoms.

ask the patient to describe how the
medications are taken each day.

give the patient detailed
information about the use of metered-dose inhalers.

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.

Question 15

2 / 2 pts

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:

wait until the pain is at a
moderate level before taking the medication.

take the medication at regular
intervals and not just when pain is present.

start the medication at higher
doses initially and taper down gradually.

take the minimum amount needed even
when pain is severe to avoid dependency.

Chronic pain requires routine
administration of drugs, and patients should take analgesics routinely without
waiting for increased pain.

Question 16

2 / 2 pts

A patient tells the primary care NP
that he has difficulty getting and maintaining an erection. The NP’s initial
response should be to:

prescribe sildenafil (Viagra).

perform a medication history.

evaluate his cardiovascular status.

order a papaverine injection test
to screen for erectile dysfunction.

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.

Question 17

2 / 2 pts

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:

levodopa.

carbidopa.

pramipexole.

carbidopa/levodopa.

Patients younger than 65 years of
age should be started with a dopamine agonist.

Question 18

2 / 2 pts

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:

frovatriptan (Frova).

sumatriptan (Imitrex).

cyproheptadine (Periactin).

dihydroergotamine (D.H.E. 45).

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.

Question 19

2 / 2 pts

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:

take her asthma medications only
when she is having an acute exacerbation.

avoid using antihistamine
medications during her first trimester of pregnancy.

discontinue her seizure medications
at least 6 months before becoming pregnant.

use only oral corticosteroids and
not inhaled steroids while pregnant for improved asthma control.

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.

Question 20

2 / 2 pts

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:

topiramate (Topamax).

levetiracetam (Keppra).

zonisamide (Zonegran).

carbamazepine (Tegretol).

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.

Question 21

2 / 2 pts

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:

change the medication to a
cephalosporin.

decrease the dose to 250 mg every 6
hours.

reassure the patient that these are
normal adverse effects of this drug.

order blood cultures, a white blood
cell (WBC) count with differential, and liver function tests (LFTs).

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.

Question 22

2 / 2 pts

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:

assess this patient’s usual
sleeping patterns.

ask the patient about problems with
constipation.

obtain a baseline creatinine
clearance test before the first dose.

perform a thorough evaluation of
cognitive and motor abilities.

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.

Question 23

2 / 2 pts

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.

hydrocodone 30; 6

hydrocodone 75; 6

meperidine 300;12

meperidine 75; 6

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.

Question 24

2 / 2 pts

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:

prescribe colchicine.

prescribe febuxostat.

tell the patient to use an NSAID if
symptoms recur.

counsel the patient to report
recurrence of symptoms.

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.

Question 25

2 / 2 pts

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:

admit him to the hospital for
detoxification.

ask him how much he had to drink
last night.

prescribe lorazepam (Ativan) to
help with symptoms.

suggest that he talk to a counselor
about alcohol abuse.

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.

Question 26

2 / 2 pts

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 trimethoprim-sulfamethoxazole
(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:

gemifloxacin.

ciprofloxacin.

azithromycin.

TMP/SMX.

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.

Question 27

2 / 2 pts

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:

order an electroencephalogram
(EEG).

prescribe a tapering regimen of the
drug.

inform the patient that
antiepileptic drug (AED) therapy is lifelong.

tell the patient to stop the drug
and use only as needed.

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.

Question 28

2 / 2 pts

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:

discuss the effects of smoking on
fetal development.

ask her to write down any factors
that triggered her relapses.

give her information about the
long-term effects of smoking.

convince her that taking medication
will be essential in her case.

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.

Question 29

2 / 2 pts

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:

to avoid taking antacids while
taking the NSAID.

to take each dose of the NSAID with
a full glass of water.

that a few glasses of wine each day
are allowed while taking the NSAID.

to decrease the dose of the NSAID
if GI symptoms occur.

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.

Question 30

2 / 2 pts

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:

methotrexate.

corticosteroids.

opioid analgesics.

hydroxychloroquine.

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.

Question 31

2 / 2 pts

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:

dependence.

drug addiction.

possible misuse.

increasing pain.

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.

Question 32

2 / 2 pts

An elderly patient with dementia
exhibits hostility and uncooperativeness. The primary care NP prescribes
clozapine (Clozaril) and should counsel the family about:

a decreased risk of extrapyramidal
symptoms.

improved cognitive function.

the need for long-term use of the
medication.

a possible increased risk of heart
disease and stroke.

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.

Question 33

2 / 2 pts

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:

are more likely to be toxic.

cause serious adverse effects.

carry more risk for serious
allergic reactions.

must be given intramuscularly or
intravenously.

Aminoglycoside antibiotics must be
given intramuscularly or intravenously when treating infection. Their side
effects may be serious, which is an indication for hospitalization.

Question 34

2 / 2 pts

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:

stop taking the sertraline now.

continue taking the antidepressant.

change to a monoamine oxidase
inhibitor (MAOI).

discontinue the sertraline a week
before delivery.

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.

Question 35

2 / 2 pts

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:

adding zidovudine.

changing to Truvada.

changing to tenofovir.

ordering Combivir and tenofovir.

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.

Question 36

2 / 2 pts

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:

suggest ice and rest.

order physical therapy.

prescribe diazepam (Valium).

add an opioid analgesic medication.

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.

Question 37

2 / 2 pts

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:

order cefaclor (Ceclor).

prescribe cefixime (Suprax).

administer intramuscular
ceftriaxone (Rocephin).

wait for culture results before
ordering an antibiotic.

Cephalos

Explanation & Answer

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