Primary Care Nurse Practitioner Prescriptions and Counseling | Exams Nursing | Docsity (2024)

Download Primary Care Nurse Practitioner Prescriptions and Counseling and more Exams Nursing in PDF only on Docsity! 1 NR 508 Final Exam Practice Questions with Answers - Rationale 1. A patient who has diabetes reports intense discomfort when needing to void. A urinalysis is normal. To treat this, the primary care NP should consider prescribing: oxybutynin chloride (Ditropan XL). This patient is describing urge incontinence, or overactive bladder, which occurs when the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is full. Urge incontinence is associated with many conditions, including diabetes. Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor over activity and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is used to treat dysuria. 2. A patient reports difficulty returning to sleep after getting up to go to the bathroom every night. A physical examination and a sleep hygiene history are noncontributory. The primary care NP should prescribe: ZolpiMist. ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty with sleep onset. Chloral hydrate is not typically used as outpatient therapy. 3. A 5-year-old child who has no previous history of otitis media is seen in clinic with a temperature of 100° F. The primary care NP visualizes bilateral erythematous, no bulging, intact tympanic membranes. The child is taking fluids well and is playing with toys in the examination room. The NP should: initiate antibiotic therapy if the child’s condition worsens. Signs and symptoms of otitis media that indicate a need for antibiotic treatment include 2 nostalgia, fever, logorrhea, or a bulging yellow or red tympanic membrane. This child has a low-grade fever, no history of otitis media, a no bulging tympanic membrane, and no logorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is the drug of choice. 4. An 80-year-old patient with congestive heart failure has a viral upper respiratory infection. The patient asks the primary care NP about treating the fever, which is 38.5° C. The NP should: recommend acetaminophen. Patients with congestive heart failure may have tachycardia from fever that aggravates their symptoms, so fever should be treated. High doses should be given with caution in elderly patients because of possible decreased hepatic function. Antibiotics should not be given without evidence of bacterial infection. 5. A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing freezing episodes between doses. The primary care NP should consider using: Apo morphine. Apo morphine injection is used for acute treatment of immobility known as “freezing.” 6. A patient is being tapered from long-term therapy with prednisolone and reports weight loss and fatigue. The primary care NP should counsel this patient to: increase the dose of prednisolone to the most recent amount taken. Sudden discontinuation or rapid tapering of glucocorticoids in patients who have developed adrenal suppression can precipitate symptoms of adrenal insufficiency, including nausea, weakness, depression, anorexia, myalgia, hypotension, and hypoglycemia. When patients experience these symptoms during a drug taper, the dose should be increased to the last dose. Vitamin D deficiency is common while taking glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another glucocorticoid is not recommended. Patients should be taught to report the side effects so that action can be taken and should not be told that they are to be expected. 5 14. An NP orders 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: ask the patient to describe how the medications are taken each day. 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. 15. 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: take the medication at regular intervals and not just when pain is present. Chronic pain requires routine administration of drugs, and patients should take analgesics routinely without waiting for increased pain. 16. A patient tells the primary care NP that he has difficulty getting and maintaining an erection. The NP’s initial response should be to: perform a medication history. 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. Palavering 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. 17. 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: pramipexole. 6 Patients younger than 65 years of age should be started with a dopamine agonist. 18. 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: sumatriptan (MITRE). If the patient is able to take medication at the earliest onset of migraine, ergots are usually effective. Trip tans are more effective when patients have difficulty “catching the headache in time.” Samaritan 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. 19. 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: avoid using antihistamine medications during her first trimester of pregnancy. 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. 20. A patient who has partial seizures has been taking phenytoin (Dilantin). The patient has recently developed thrombocytopenia. The primary care nurse practitioner (NP) should 7 contact the patient’s neurologist to discuss changing the patient’s medication to: 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. 21. 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: 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. 22. 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: 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. 23. A patient has been taking intramuscular (IM) meperidine 75 mg every 6 hours for 3 days 10 each dose of the NSAID with a full glass of water. 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. 30. 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. 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. 31. 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: possible misuse. 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. 32. An elderly patient with dementia exhibits hostility and uncooperativeness. The primary care NP prescribes clozapine (Clozaril) and should counsel the family about: a possible increased risk of heart disease and stroke. Antipsychotics are useful in treating some psychiatric symptoms of dementia and help to 11 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. 33. 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: 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. 34. 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: continue taking the antidepressant. 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. 35. 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: changing to Truvada. 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. 36. 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. 12 A computed tomography scan is normal. The primary care NP should: order physical therapy. 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. 37. 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: prescribe cefixime (Suprax). 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 coliand excellent penetration into body fluids, making it a good choice for empirical treatment of urinary tract infection. 38. 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: prescribe TMP- SMX. 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. 39. 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: cause episodes to be shorter and less frequent. 15 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. 47. 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: expect the patient to sustain permanent liver damage. 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. 16 48. 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: ask the parent about the drug’s use and side effects. 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. 49. 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: benztropine. Anticholinergics, such as benztropine, are used to control drooling. 50. 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: administer the 6-month immunizations at this visit today. Minor upper respiratory infection or gastroenteritis, with or without fever, is not an indication for withholding a scheduled vaccine dose. 51. 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: reassure the patient 17 that complete recovery should occur. 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. 52. A patient has begun treatment for HIV. The primary care NP should monitor the patient’s complete blood count (CBC) at least every months. 3 to 6 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. 20 58. 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: permethrin 5%. 59. 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: ask the patient about any other over- the-counter (OTC) cold medications being used. 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. 60. 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: methotrexate is used to slow disease progression and preserve joint function. Disease-modifying antirheumatic drugs (DMARDs) have anti-inflammatory effects that may slow disease progression and preserve joint function. Acetaminophen and no steroidal anti-inflammatory drugs (NSAIDs) are common adjuncts to therapy to treat pain 61. 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: phenazopyridine (Pyridium). 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 21 adjunct therapy. 62. 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: atomoxetine (Strattera). 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 22 63. 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: use naproxen (Naprosyn) instead of ibuprofen. 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. 64. A patient who takes valproic acid for a seizure disorder is preparing to have surgery. The primary care NP should order: coagulation studies. 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. 65. A patient who has Alzheimer’s disease is taking 10 mg of donepezil daily and reports difficulty sleeping. The primary care NP should recommend: taking the drug in the morning. 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. 66. 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: discontinuing the 4 PM dose. 25 should order: topical miconazole (Monistat). 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 vulvovagin*l 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 vulvovagin*l candidiasis. Another dose of fluconazole would not be effective if resistance is present. 26 72. 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: perform a thorough history and physical examination. 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. 73. 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: ziprasidone (Geodon). 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. 74. 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? Tremor, restlessness, and insomnia b-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. 75. 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: continue the medication for several months and consider adding bupropion (Wellbutrin). 27 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.