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

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

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 Alzheimer’s disease and elects to take donepezil (Aricept). The patient asks the primary care nurse practitioner (NP) how long the medication will be needed. The NP should tell the patient that donepezil must be taken:
a. until symptoms improve.
b. indefinitely because it is not curative.
c. for 24 weeks, which is when cognitive function improves in most patients.
d. until symptoms worsen, when a switch to memantine (Namenda) will be needed.

 

 

ANS:  B

Cholinesterase (ChE) inhibitor drugs such as donepezil diminish symptoms; when the drug is stopped, the symptoms return. Cognitive function will show improvement at about 24 weeks, but the drug must be continued indefinitely.

 

DIF:    Cognitive Level: Understanding (Comprehension)          REF:   459

 

  1. A patient who has Alzheimer’s disease has been taking donepezil for 1 year. The patient’s spouse reports a worsening of symptoms. The primary care NP should consider:
a. switching to ginkgo biloba.
b. adding an antidepressant medication.
c. changing to galantamine (Razadyne).
d. adding memantine hydrochloride (Namenda).

 

 

ANS:  D

Memantine hydrochloride can be added to therapy when symptoms worsen. Ginkgo biloba may be useful but is not recommended as adjunct therapy. Antidepressants given to patients with Alzheimer’s disease who have depression appear not to be effective and often cause adverse effects or produce unwanted drug interactions. Galantamine is part of first-line therapy but should not be given with donepezil because both are ChE inhibitors.

 

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

 

  1. Early-stage Alzheimer’s disease is diagnosed in a patient, and the primary care NP recommends therapy with a ChE inhibitor. The patient asks why drug treatment is necessary because most functioning is intact. The NP should explain that medication may:
a. delay progression of symptoms.
b. produce temporary disease remission.
c. prevent depressive effects of the disease.
d. reduce the need for adjunct medications later on.

 

 

ANS:  A

Pharmacologic treatment should begin as soon as Alzheimer’s disease is suspected because early treatment can slow disease progression. Medication does not produce disease remission or prevent depression. The disease eventually progresses despite medication, and adjunct therapies are often required.

 

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

 

  1. A patient has a diagnosis of depression and Alzheimer’s disease with mild, intermittent symptoms. The primary care NP should prescribe a(n):
a. antidepressant.
b. ChE inhibitor.
c. antidepressant and ginkgo biloba.
d. antidepressant and a ChE inhibitor.

 

 

ANS:  B

Antidepressants given to patients with Alzheimer’s disease do not appear to be effective and cause adverse effects and unwanted drug interactions.

 

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

 

  1. A patient who has Alzheimer’s disease begins taking donepezil (Aricept). After 3 months of treatment, the patient does not show improvement of symptoms. The primary care NP should:
a. switch to rivastigmine (Exelon).
b. switch to galantamine (Razadyne).
c. switch to memantine (Namenda).
d. continue donepezil and reevaluate in 3 months.

 

 

ANS:  D

Patients should be switched to other medications if initial therapy fails, but switching to another medication should be considered only after a minimum of 6 months of treatment.

 

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

 

  1. A patient is newly diagnosed with Alzheimer’s disease stage 6 on the Global Deterioration Scale. The primary care NP should prescribe:
a. donepezil (Aricept).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. galantamine (Razadyne).

 

 

ANS:  C

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

 

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

 

  1. A patient has been taking donepezil (Aricept) for several months after being diagnosed with Alzheimer’s disease. The patient’s spouse brings the patient to the clinic and reports that the patient seems to be having visual hallucinations. The primary care NP should:
a. increase the dose.
b. decrease the dose.
c. switch to memantine (Namenda).
d. switch to galantamine (Razadyne).

 

 

ANS:  B

Hallucinations may be a sign of drug toxicity. The NP should decrease the dose.

 

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

 

  1. A patient who has Alzheimer’s disease is taking 10 mg of donepezil daily and reports difficulty sleeping. The primary care NP should recommend:
a. decreasing the dose to 5 mg.
b. increasing the dose to 15 mg.
c. taking the drug in the morning.
d. taking the drug in the evening.

 

 

ANS:  C

Donepezil is typically taken in the evening just before going to bed; however, in patients experiencing sleep disturbance, daytime administration is preferred. The dose should not be increased or decreased.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   460

 

  1. A patient who is diagnosed with Alzheimer’s disease experiences visual hallucinations. The primary care NP should initially prescribe:
a. donepezil (Aricept).
b. rivastigmine (Exelon).
c. memantine (Namenda).
d. galantamine (Razadyne).

 

 

ANS:  B

Patients with dementia with Lewy bodies may show benefit with rivastigmine. Visual hallucinations are a hallmark feature of Lewy body dementia.

 

DIF:    Cognitive Level: Understanding (Comprehension)          REF:   461

 

 

Chapter 54: Contraceptives

Test Bank

 

MULTIPLE CHOICE

 

  1. A 40-year-old woman tells the primary care nurse practitioner (NP) that she does not want more children and would like a contraceptive. She does not smoke and has no personal or family history of cardiovascular disease. She has frequent tension headaches. For this patient, the NP should prescribe:
a. condoms.
b. tubal ligation.
c. monophasic combined oral contraceptive pill (COCP).
d. low-estrogen COCP.

 

 

ANS:  D

Low-estrogen COCPs are recommended for women older than 40 with or without cardiovascular risk. Monophasic COCPs are recommended for women with migraine headaches. Condoms are more useful for preventing sexually transmitted diseases and not as reliable as contraception. Tubal ligation has surgical risks.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   619

 

  1. A primary care NP prescribes a COCP for a woman who has never taken oral contraceptives before. The woman is in a monogamous relationship, and she and her partner have been using condoms and wish to stop using them. Her last period was 1 week ago. The NP should:
a. perform an in-office pregnancy test before starting a COCP.
b. tell the patient to begin the first pill today and to continue using condoms for 7 days.
c. tell the patient to begin the first pill on the Sunday of or following her next menstrual period.
d. tell the patient to begin the first pill today and to return in 2 weeks for a pregnancy test.

 

 

ANS:  B

To start COCPs using the quick start method, the woman takes the first pill on the day of her office visit and uses a barrier method such as condoms for the first 7 days. The patient should be reasonably sure she is not pregnant; she can take a pregnancy test in 2 to 3 weeks if pregnancy is suspected later. If she is pregnant, taking the COCPs would not negatively affect early pregnancy.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   617

 

  1. A woman who began taking a COCP 2 months ago calls the primary care NP to report having nausea every day. She takes a pill at the same time each morning. The NP should tell her to:
a. try taking the pill in the evening each day.
b. come to the clinic for a urine pregnancy test.
c. take the pill on an empty stomach with water.
d. stop taking the pill for 7 days and then restart.

 

 

ANS:  A

If nausea occurs when taking the pill, patients should be instructed to switch to the opposite time of day or to take with food. A urine pregnancy test is not indicated. If nausea occurs, patients should take the pill with food. Patients stop taking pills for 7 days at the end of each 21-day pack.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   617

 

  1. The primary care NP prescribes an extended-cycle monophasic pill regimen for a young woman who reports having multiple partners. Which statement by the patient indicates she understands the regimen?
a. “I have to take a pill only every 3 months.”
b. “I should expect to have only four periods each year.”
c. “I will need to use condoms for only 7 more days.”
d. “This type of pill has fewer side effects than other types.”

 

 

ANS:  B

The extended-cycle pills have fewer pill-free intervals, so women have only four periods a year. Patients take pills every day. Because this patient has multiple partners, she should continue to use condoms. This type of pill has the same side effects as other types.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   622

 

  1. A woman who uses a transdermal contraceptive calls the primary care NP to report that while dressing that morning she discovered that the patch had come off and she was unable to find the patch. The NP should tell her to apply a new patch and:
a. take one cycle of COCPs.
b. take a home pregnancy test.
c. use condoms for the next 7 days.
d. contact the clinic if she misses a period.

 

 

ANS:  C

If a transdermal patch has been discovered to be loose or has come off, patients should use a backup method of contraception. It is not necessary to use oral contraceptives. A home pregnancy test is not indicated.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   621

 

  1. A woman who has been taking a COCP tells the primary care NP that, because of frequent changes in her work schedule, she has difficulty remembering to take her pills. The woman and the NP decide to change to a vaginal ring. The NP will instruct her to insert the ring:
a. within 7 days after her last active pill.
b. and use a backup contraceptive for 7 days.
c. and continue the COCP for one more cycle.
d. on the same day she stops taking her COCP.

 

 

ANS:  A

Patients should be switched from a COCP to a vaginal ring by insertion within 7 days after the last active pill. No backup method is needed. Patients do not need to continue one more cycle of COCPs. Women taking progestin-only pills insert the ring on the last day of the pill pack.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   621

 

  1. A postpartum woman will begin taking the minipill while she is nursing her infant. The primary care NP should instruct the patient:
a. to use backup contraception while taking the minipill.
b. to continue using the minipill for 6 months after she stops nursing.
c. that irregular periods while taking the minipill may indicate she is pregnant.
d. that this method does not increase her risk of thromboembolic events.

 

 

ANS:  D

Minipills are used primarily in breastfeeding women. There is no increased risk for thromboembolic events for women taking these pills. It is not necessary to use a backup method of contraception. Women should be advised to contact the provider when they stop nursing so that a COCP can be prescribed. The more disrupted the bleeding pattern, the more likely it is that ovulation is inhibited.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   621

 

  1. A woman who is taking a progestin-only pill has just stopped nursing her 9-month-old infant and tells the primary care NP that she would like to space her children about 2 years apart. The NP should:
a. discontinue the progestin-only pill.
b. prescribe a COCP and a folic acid supplement.
c. prescribe a progestin-only pill for another 6 months.
d. suggest that she use a barrier method of contraception.

 

 

ANS:  B

Serum folate levels may be decreased by oral contraceptives. Women who become pregnant shortly after stopping oral contraceptive use may have a greater chance of birth defects. This woman should become pregnant in about 6 months if she wants to space her children 2 years apart, so she needs an oral contraceptive. Progestin-only pills are used only during lactation.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   625

 

  1. A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she:
a. is having vomiting or diarrhea.
b. delays taking a pill by 5 or 6 hours.
c. takes nonsteroidal antiinflammatory drugs several days in a row.
d. has recurrent headaches or insomnia.

 

 

ANS:  A

Vomiting and diarrhea may cause oral contraceptive failure, so women should be advised to use backup contraception if they experience these. The other conditions do not lead to oral contraceptive failure.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   625

 

  1. A woman who has been taking a COCP for 2 months tells the primary care NP that she has had several headaches, breakthrough bleeding, and nausea. The NP should counsel the woman:
a. to change to a progestin-only pill.
b. to stop taking the COCP immediately.
c. to use a backup form of contraception.
d. that these effects will likely decrease in another month.

 

 

ANS:  D

Breakthrough bleeding, nausea, and headaches are common during the first 3 months of therapy and should improve without intervention. Progestin-only pills are used for lactating women only. Prolonged bleeding and severe headache would warrant discontinuation of the COCP. Backup contraception is not indicated.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   625

 

  1. An adolescent girl has chosen Depo-Provera as a contraceptive method and tells the primary care NP that she likes the fact that she won’t have to deal with pills or periods. The primary care NP should tell her that she:
a. should consider another form of contraception after 1 year.
b. may have irregular bleeding, especially in the first month or so.
c. will need to take calcium and vitamin D every day while using this method.
d. will have to take oral contraceptive pills in addition to Depo-Provera when she takes antibiotics.

 

 

ANS:  B

Because of strong progestational effects on the endometrium, irregular bleeding or spotting is common in the early months of use. Because of concerns about the effect of depot medroxyprogesterone acetate on bone density, it is recommended that woman change to another birth control method after 2 years, not 1 year. Calcium and vitamin D supplements have not been shown to prevent bone density loss. It is not necessary to take oral contraceptive pills when taking antibiotics.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   627

 

  1. A sexually active patient tells the primary care NP that she has been unable to get her new COCP pill pack until today and has missed 3 days of pills. The NP should tell her to:
a. use backup contraception and take 2 pills each day for the next 2 days.
b. begin a new pack of pills today and use backup contraception for 7 days.
c. begin a new pack of pills today, take a Plan B pill, and use backup contraception for 7 days.
d. Take a pregnancy test, begin a new pack of pills today, and use backup contraception for 7 days.

 

 

ANS:  C

Patients who miss 2 or more pills at the beginning or end of a pack should use emergency contraceptive pills, such as the Plan B pill, restart a new pill pack, and use backup contraception for 7 days.

 

DIF:    Cognitive Level: Applying (Application)                         REF:   621

 

 

Chapter 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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