Pharmacology For the Primary Care Provider 4th Edition by Edmunds Mayhew-Test Bank

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Pharmacology For the Primary Care Provider 4th Edition by Edmunds Mayhew-Test Bank

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WITH ANSWERS
Pharmacology For the Primary Care Provider 4th Edition by Edmunds Mayhew-Test Bank

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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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 b-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 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

 

  1. 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

 

  1. 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

 

  1. 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 high-fiber 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

 

  1. 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

 

  1. 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. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   344

 

  1. 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

 

  1. 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 42: Medications for Dementia

Test Bank

 

MULTIPLE CHOICE

 

  1. A patient is identified as having stage 2 Alzheimers 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

 

  1. A patient who has Alzheimers disease has been taking donepezil for 1 year. The patients 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 Alzheimers 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

 

  1. Early-stage Alzheimers 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 Alzheimers 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

 

  1. A patient has a diagnosis of depression and Alzheimers 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 Alzheimers disease do not appear to be effective and cause adverse effects and unwanted drug interactions.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   459

 

  1. A patient who has Alzheimers 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

 

  1. A patient is newly diagnosed with Alzheimers 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

 

  1. A patient has been taking donepezil (Aricept) for several months after being diagnosed with Alzheimers disease. The patients 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

 

  1. A patient who has Alzheimers 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

 

  1. A patient who is diagnosed with Alzheimers 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 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

 

  1. 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 receptornegative breast cancer. The other medications are antiestrogens and treat estrogen receptorpositive cancer.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   648

 

  1. 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

 

  1. 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

 

  1. 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 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

 

  1. 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

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