CHAMBERLAIN NR 508 WEEK 2 QUIZ

CHAMBERLAIN NR 508 WEEK 2 QUIZ

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Question 1.1. A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to: (Points : 2) amlodipine (Norvasc). isradipine (DynaCirc). verapamil HCl (Calan). short-acting nifedipine (Procardia). b. verapamil HCl (Calan). Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine.

Question 2.2. A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: (Points : 2) dissolve atheromatous lesions. relax vascular smooth muscle. prevent catecholamine release. reduce C-reactive protein levels. relax vascular smooth muscle. Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand. Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce C-reactive protein levels.

Question 3.3. A patient with Graves’ disease is taking methimazole. After 6 months of therapy, the primary care NP notes normal T3 and T4 and elevated TSH. The NP should: (Points : 2) order a complete blood count (CBC) with differential. order aspartate aminotransferase, AGT, and LDH tests. decrease the dose of the medication. add levothyroxine to the patient’s regimen. c. decrease the dose of methimazole

Question 4.4. The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: (Points : 2) prescribe a thiazide diuretic. consider treatment with an angiotensin-converting enzyme inhibitor. reassure the patient that these findings are normal. counsel the patient about dietary and lifestyle changes. d. counsel the patient about dietary and lifestyle changes. The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise.

Question 5.5. A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend: (Points : 2) 30 minutes of aerobic exercise daily. taking 81 to 325 mg of aspirin daily. beginning therapy with a statin medication. starting a thiazide diuretic to treat hypertension. 30 minutes of aerobic exercise daily. This patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated.

Question 6.6. A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: (Points : 2) a b-blocker. an angiotensin-converting enzyme inhibitor. a thiazide diuretic. dietary and lifestyle changes. C. a thiazide diuretic. The patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails

Question 7.7. An 80-year-old male patient will begin taking an a-antiadrenergic medication. The primary care NP should teach this patient to: (Points : 2) ask for assistance while bathing. restrict fluids to aid with diuresis. take the medication in the morning with food. be aware that priapism is a common side effect.   a.     ask for assistance while bathing. All antihypertensives can cause orthostatic hypotension, so patients should be cautioned to avoid sudden changes in position and to use caution when bathing because a hot bath or shower may aggravate dizziness. Older patients are at increased risk for falls and should be cautioned to ask for assistance. Patients taking a-antiadrenergics should consume extra fluids because dehydration can increase the risk of orthostatic hypotension. Patients should take the medication at bedtime because drowsiness is a common side effect. Priapism is not a side effect of these drugs.

Question 8.8. A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss: (Points : 2) changing to amlodipine. ordering renal function tests. increasing the dose of nifedipine. evaluation of left ventricular function.   d. changing to amlodipine. Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms.

Question 9.9. A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient’s father developed coronary heart disease at age 55 years. The NP should prescribe: (Points : 2) atorvastatin (Lipitor). gemfibrozil (Lopid). cholestyramine (Questran). lovastatin/niacin (Advicor). d. atorvastatin (Lipitor). HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male first-degree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy.

Question 10.10. A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1c is 7.3%. The NP should: (Points : 2) begin insulin therapy. change to therapy with colesevelam (Welchol). add a third oral antidiabetic agent to this patient’s drug regimen. enroll the patient in a weight loss program to achieve better glycemic control. a.     begin insulin therapy

Question 11.11. A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? (Points : 2) Metformin/glyburide (Glucovance) Insulin and metformin (Glucophage) Saxagliptin/metformin (Kombiglyze) Metformin/pioglitazone (ACTOplus met) a.     Metformin/glyburide (Glucovance)

Question 12.12. A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: (Points : 2) taking the metformin dose as usual the morning of surgery. using insulin during the perioperative and postoperative periods. that the patient stop taking metformin several days before surgery. adding a sulfonylurea medication until recovery from surgery is complete. b.     using insulin during the perioperative and postoperative periods. Response Feedback: Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery.

Question 13.13. The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: (Points : 2) initiate monotherapy with a thiazide diuretic. prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor. discuss dietary and lifestyle modifications with the patient. begin combination therapy with an ARB and a calcium-channel blocker.   a.     initiate monotherapy with a thiazide diuretic. African Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans.

Question 14.14. A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child weighs 15 kg. The primary care NP sees the child for a 3-year-old check-up. The NP should consult with a pediatric endocrinologist to discuss: (Points : 2) increasing the dose to 90 mcg/day. decreasing the dose to 30 mcg/day. stopping the medication and checking TSH and T4 in 4 weeks. discussing the need for lifetime replacement therapy with the child’s parents. c.     Stopping the medication and checking TSH and T4 in 4 weeks

Question 15.15. A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe: (Points : 2) pramlintide (Symlin). repaglinide (Prandin). glyburide (Micronase). metformin (Glucophage). a.      pramlintide (symlin) Response Feedback: Pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated.

Question 16.16. A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to: (Points : 2) change the patch four times daily. use the patch as needed for angina pain. use two patches daily and change them every 12 hours. apply one patch daily in the morning and remove in 12 hours. d.     apply one patch daily in the morning and remove in 12 hours. To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily.

Question 17.17. A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to: (Points : 2) obtain an electrocardiogram. administer oxygen at 2 L/minute. give 325 mg of chewable aspirin. call EMS. b.     administer oxygen at 2 L/minute. When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin.

Question 18.18. A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP should order: (Points : 2) nateglinide (Starlix). glyburide (Micronase). colesevelam (Welchol). metformin (Glucophage). c.     Glucophage

Question 19.19. A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should: (Points : 2) counsel the patient to take the medication with food. tell the patient that changing brands of the medication should be avoided. instruct the patient to stop taking the medication if signs of thyrotoxicosis occur. tell the patient that the drug may be stopped when thyroid function tests stabilize. b.    tell the patient that changing brands of the medication should be avoided. Patients should be told not to change brands of the medication; there ispotential variability in the bioequivalence between manufacturers. Themedication should be taken at approximately the same time each day beforebreakfast or on an empty stomach. Patients should be instructed to contactthe provider if signs of thyrotoxicosis are present. Thyroid replacementmedications are usually given for life

Question 20.20. A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should: (Points : 2) order a T4 level today. increase the dose to 100 mcg. check the TSH level in 1 week. reassure the patient that this will improve in several weeks. c.     Check the TSH level in 1 week

Question 21.21. A patient who has stable angina is taking nitroglycerin and a b-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: (Points : 2) isradipine (DynaCirc). nicardipine (Cardene). verapamil HCl (Calan). nifedipine (Procardia XL). d.     verapamil HCl (Calan). Nitrates and b-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose

Question 22.22. A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should: (Points : 2) order metformin (Glucophage). order a lipid profile, complete blood count, and liver function tests (LFTs). order an oral glucose tolerance test. set a weight loss goal of 10 to 15 lb. d. Set a weight loss goal of 10-15 lbs Response Feedback: To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose 5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated.

Question 23.23. The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: (Points : 2) 60 mg four times daily at 6-hour intervals. 40 mg twice daily 30 minutes before meals. 60 mg on awakening and 40 mg 7 hours later. 80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM. b.     40 mg twice daily 30 minutes before meals. Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point.

Question 24.24. A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which bile acid sequestrant should the primary care NP order? (Points : 2) Colesevelam (Welchol) Colestipol (Colestid) Cholestyramine (Questran) Cholestyramine (Questran Light) a.      Colesevelam (Welchol) Response Feedback: All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient

Question 25.25. A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient’s cardiologist to discuss adding: (Points : 2) amlodipine (Norvasc). diltiazem (Cardizem). verapamil HCl (Calan). nifedipine (Procardia XL). c.     nifedipine (Procardia XL). Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug. Answers: These are the automatically computed results of your exam. Grades for essay questions, and comments from your instructor, are in the “Details” section below. Date Taken: 2/28/2016 Time Spent: 40 min , 22 secs Points Received: 48 / 50  (96%) Question Type: # Of Questions: # Correct: Multiple Choice 25 24 Grade Details – All Questions Question 1. Question : A patient who has angina is taking nitroglycerin and long-acting nifedipine. The primary care NP notes a persistent blood pressure of 90/60 mm Hg at several follow-up visits. The patient reports lightheadedness associated with standing up. The NP should consult with the patient’s cardiologist about changing the medication to: Student Answer:  amlodipine (Norvasc).  isradipine (DynaCirc).  verapamil HCl (Calan).  short-acting nifedipine (Procardia). Instructor Explanation: Verapamil and diltiazem are less likely to cause hypotension than nifedipine and related drugs, such as isradipine and amlodipine. Points Received: 2 of 2 Comments: Question 2. Question : A patient who will begin using nitroglycerin for angina asks the primary care NP how the medication works to relieve pain. The NP should tell the patient that nitroglycerin acts to: Student Answer:  dissolve atheromatous lesions.  relax vascular smooth muscle.  prevent catecholamine release.  reduce C-reactive protein levels. Instructor Explanation: Nitrates relax vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production with the major effect being to reduce myocardial oxygen demand. Nitrates do not dissolve atheromatous lesions, prevent catecholamine release, or reduce C-reactive protein levels. Points Received: 2 of 2 Comments: Question 3. Question : A patient with Graves’ disease is taking methimazole. After 6 months of therapy, the primary care NP notes normal T3 and T4 and elevated TSH. The NP should: Student Answer:  order a complete blood count (CBC) with differential.  order aspartate aminotransferase, AGT, and LDH tests.  decrease the dose of the medication.  add levothyroxine to the patient’s regimen. Instructor Explanation: Once clinical levels of thyrotoxicosis have been resolved, elevated TSH indicates a need to reduce the dosage. A CBC with differential is performed at the beginning of treatment and when signs of infection are present. Liver function tests may be monitored periodically but are not indicated by the current laboratory results. Levothyroxine is not indicated. Points Received: 2 of 2 Comments: Question 4. Question : The primary care nurse practitioner (NP) sees a patient in the clinic who has a blood pressure of 130/85 mm Hg. The patient’s laboratory tests reveal high-density lipoprotein, 35 mg/dL; triglycerides, 120 mg/dL; and fasting plasma glucose, 100 mg/dL. The NP calculates a body mass index of 29. The patient has a positive family history for cardiovascular disease. The NP should: Student Answer:  prescribe a thiazide diuretic.  consider treatment with an angiotensin-converting enzyme inhibitor.  reassure the patient that these findings are normal.  counsel the patient about dietary and lifestyle changes. Instructor Explanation: The patient’s blood pressure indicates prehypertension, but the patient does not have cardiovascular risk factors such as hyperlipidemia or hyperinsulinemia. The body mass index indicates that the patient is overweight but not obese. Pharmacologic treatment is not recommended for prehypertension unless compelling reasons are present. The findings are not normal, so it is appropriate to counsel the patient about diet and exercise. Points Received: 2 of 2 Comments: Question 5. Question : A 45-year-old patient who has a positive family history but no personal history of coronary artery disease is seen by the primary care NP for a physical examination. The patient has a body mass index of 27 and a blood pressure of 130/78 mm Hg. Laboratory tests reveal low-density lipoprotein, 110 mg/dL; high-density lipoprotein, 70 mg/dL; and triglycerides, 120 mg/dL. The patient does not smoke but has a sedentary lifestyle. The NP should recommend: Student Answer:  30 minutes of aerobic exercise daily.  taking 81 to 325 mg of aspirin daily.  beginning therapy with a statin medication.  starting a thiazide diuretic to treat hypertension. Instructor Explanation: This patient is overweight but not obese, and blood lipids are within normal limits. Blood pressure is not elevated. Exercise is recommended as an initial risk reduction strategy because of its positive effects on blood pressure and blood lipids. Aspirin is generally given to patients older than 55 to 65 who are at risk. Statin medications and thiazide diuretics are not indicated. Points Received: 2 of 2 Comments: Question 6. Question : A patient has three consecutive blood pressure readings of 140/95 mm Hg. The patient’s body mass index is 24. A fasting plasma glucose is 100 mg/dL. Creatinine clearance and cholesterol tests are normal. The primary care NP should order: Student Answer:  a b-blocker.  an angiotensin-converting enzyme inhibitor.  a thiazide diuretic.  dietary and lifestyle changes. Instructor Explanation: The patient has stage I hypertension. Because there are no compelling indications for other treatment, a thiazide diuretic should be used initially to treat the hypertension. Dietary and lifestyle changes should also be recommended but are not sufficient for patients with stage I hypertension. Other drugs may be added later if thiazide diuretic therapy fails. Points Received: 2 of 2 Comments: Question 7. Question : An 80-year-old male patient will begin taking an a-antiadrenergic medication. The primary care NP should teach this patient to: Student Answer:  ask for assistance while bathing.  restrict fluids to aid with diuresis.  take the medication in the morning with food.  be aware that priapism is a common side effect. Instructor Explanation: All antihypertensives can cause orthostatic hypotension, so patients should be cautioned to avoid sudden changes in position and to use caution when bathing because a hot bath or shower may aggravate dizziness. Older patients are at increased risk for falls and should be cautioned to ask for assistance. Patients taking a-antiadrenergics should consume extra fluids because dehydration can increase the risk of orthostatic hypotension. Patients should take the medication at bedtime because drowsiness is a common side effect. Priapism is not a side effect of these drugs. Points Received: 2 of 2 Comments: Question 8. Question : A patient who is taking nifedipine develops mild edema of both feet. The primary care NP should contact the patient’s cardiologist to discuss: Student Answer:  changing to amlodipine.  ordering renal function tests.  increasing the dose of nifedipine.  evaluation of left ventricular function. Instructor Explanation: Mild to moderate peripheral edema occurs in the lower extremities in about 10% of patients; this is caused by arterial dilation, not by left ventricular dysfunction. Amlodipine is less likely to have this effect. Renal function tests are not indicated. Increasing the nifedipine dose would worsen the symptoms. Points Received: 2 of 2 Comments: Question 9. Question : A primary care NP sees a 46-year-old male patient and orders a fasting lipoprotein profile that reveals LDL of 190 mg/dL, HDL of 40 mg/dL, and triglycerides of 200 mg/dL. The patient has no previous history of coronary heart disease, but the patient’s father developed coronary heart disease at age 55 years. The NP should prescribe: Student Answer:  atorvastatin (Lipitor).  gemfibrozil (Lopid).  cholestyramine (Questran).  lovastatin/niacin (Advicor). Instructor Explanation: HMG-CoA reductase inhibitors are used to treat hyperlipidemia when the LDL is the primary lipid elevation. This patient has risk factors of being a man older than 45 years, with a positive family history of coronary heart disease before age 55 in a male first-degree relative. Gemfibrozil is used for patients with elevated triglycerides and low HDL. Bile acid sequestrants are used as adjunctive and not first-line therapy for reducing LDL. A combination product is not indicated for first-line therapy. Points Received: 2 of 2 Comments: Question 10. Question : A patient with type 2 diabetes mellitus takes metformin (Glucophage) 1000 mg twice daily and glyburide (Micronase) 12 mg daily. At an annual physical examination, the BMI is 29 and hemoglobin A1c is 7.3%. The NP should: Student Answer:  begin insulin therapy.  change to therapy with colesevelam (Welchol).  add a third oral antidiabetic agent to this patient’s drug regimen.  enroll the patient in a weight loss program to achieve better glycemic control. Instructor Explanation: The target hemoglobin A1c goal for adults is less than 7%. Insulin therapy is indicated if maximum doses of two oral antidiabetic drugs are not effective. This patient is taking the maximum recommended doses of metformin and glyburide. Colesevelam does not decrease hemoglobin A1c. Adding a third oral antidiabetic agent is not recommended. A weight loss program may be a part of this patient’s treatment, but insulin is necessary to maintain glycemic control. Points Received: 2 of 2 Comments: Question 11. Question : A patient who is newly diagnosed with type 2 diabetes mellitus has not responded to changes in diet or exercise. The patient is mildly obese and has a fasting blood glucose of 130 mg/dL. The patient has normal renal function tests. The primary care NP plans to prescribe a combination product. Which of the following is indicated for this patient? Student Answer:  Metformin/glyburide (Glucovance)  Insulin and metformin (Glucophage)  Saxagliptin/metformin (Kombiglyze)  Metformin/pioglitazone (ACTOplus met) Instructor Explanation: Obese patients with normal renal function and elevated fasting plasma glucose may be started on a combination of metformin and a second-generation sulfonylurea. Points Received: 2 of 2 Comments: Question 12. Question : A patient who has type 2 diabetes mellitus takes metformin (Glucophage). The patient tells the primary care NP that he will have surgery in a few weeks. The NP should recommend: Student Answer:  taking the metformin dose as usual the morning of surgery.  using insulin during the perioperative and postoperative periods.  that the patient stop taking metformin several days before surgery.  adding a sulfonylurea medication until recovery from surgery is complete. Instructor Explanation: Insulin should be considered for patients with diabetes during times of physical stress, such as illness or surgery. Points Received: 0 of 2 Comments: Question 13. Question : The primary care NP sees a new African-American patient who has blood pressure readings of 140/90 mm Hg, 130/85 mm Hg, and 142/80 mm Hg on three separate occasions. The NP learns that the patient has a family history of hypertension. The NP should: Student Answer:  initiate monotherapy with a thiazide diuretic.  prescribe a thiazide diuretic and an angiotensin-converting enzyme inhibitor.  discuss dietary and lifestyle modifications with the patient.  begin combination therapy with an ARB and a calcium-channel blocker. Instructor Explanation: African Americans tend to respond better than whites to diuretic monotherapy, so this is an appropriate starting therapy. Calcium-channel blockers and ARBs are preferred as adjunct medications in African Americans. Points Received: 2 of 2 Comments: Question 14. Question : A child who has congenital hypothyroidism takes levothyroxine 75 mcg/day. The child weighs 15 kg. The primary care NP sees the child for a 3-year-old check-up. The NP should consult with a pediatric endocrinologist to discuss: Student Answer:  increasing the dose to 90 mcg/day.  decreasing the dose to 30 mcg/day.  stopping the medication and checking TSH and T4 in 4 weeks.  discussing the need for lifetime replacement therapy with the child’s parents. Instructor Explanation: In congenital hypothyroidism, therapy may be stopped for 2 to 8 weeks after the patient reaches 3 years of age. If TSH levels remain normal, thyroid supplementation may be discontinued permanently. Points Received: 2 of 2 Comments: Question 15. Question : A patient who has insulin-dependent type 2 diabetes reports having difficulty keeping blood glucose within normal limits and has had multiple episodes of both hypoglycemia and hyperglycemia. As adjunct therapy to manage this problem, the primary care NP should prescribe: Student Answer:  pramlintide (Symlin).  repaglinide (Prandin).  glyburide (Micronase).  metformin (Glucophage). Instructor Explanation: Pramlintide is indicated in patients with type 1 diabetes and insulin-dependent type 2 diabetes and is helpful for patients with wide glycemic swings. Repaglinide requires a functioning pancreas to be effective. Glyburide and metformin are first-line oral agents and are not indicated. Points Received: 2 of 2 Comments: Question 16. Question : A primary care NP prescribes a nitroglycerin transdermal patch, 0.4 mg/hour release, for a patient with chronic stable angina. The NP should teach the patient to: Student Answer:  change the patch four times daily.  use the patch as needed for angina pain.  use two patches daily and change them every 12 hours.  apply one patch daily in the morning and remove in 12 hours. Instructor Explanation: To avoid tolerance, the patient should remove the patch after 12 hours. The transdermal patch is not changed four times daily or used on a prn basis. The patch is applied once daily. Points Received: 2 of 2 Comments: Question 17. Question : A patient who has stable angina and uses sublingual nitroglycerin tablets is in the clinic and begins having chest pain. The primary care NP administers a nitroglycerin tablet and instructs the patient to lie down. The NP’s next action should be to: Student Answer:  obtain an electrocardiogram.  administer oxygen at 2 L/minute.  give 325 mg of chewable aspirin.  call EMS. Instructor Explanation: When a patient experiences an acute attack of angina in the clinic, the primary care NP should be prepared to treat the condition. After giving nitroglycerin, oxygen should be administered. An electrocardiogram is not immediately indicated. Chewable aspirin is given if the angina is unrelieved and when the patient is being transported to the hospital. EMS should be activated if there is no pain relief 5 minutes after the first dose of nitroglycerin. Points Received: 2 of 2 Comments: Question 18. Question : A 12-year-old patient who is obese develops type 2 diabetes mellitus. The primary care NP should order: Student Answer:  nateglinide (Starlix).  glyburide (Micronase).  colesevelam (Welchol).  metformin (Glucophage). Instructor Explanation: Metformin is the only drug listed that is recommended for children. Points Received: 2 of 2 Comments: Question 19. Question : A primary care NP prescribes levothyroxine for a patient to treat thyroid deficiency. When teaching this patient about the medication, the NP should: Student Answer:  counsel the patient to take the medication with food.  tell the patient that changing brands of the medication should be avoided.  instruct the patient to stop taking the medication if signs of thyrotoxicosis occur.  tell the patient that the drug may be stopped when thyroid function tests stabilize. Instructor Explanation: Patients should be told not to change brands of the medication; there is potential variability in the bioequivalence between manufacturers. The medication should be taken at approximately the same time each day before breakfast or on an empty stomach. Patients should be instructed to contact the provider if signs of thyrotoxicosis are present. Thyroid replacement medications are usually given for life. Points Received: 2 of 2 Comments: Question 20. Question : A patient who has hypothyroidism has been taking levothyroxine 50 mcg daily for 2 weeks. The patient reports continued fatigue. The primary care NP should: Student Answer:  order a T4 level today.  increase the dose to 100 mcg.  check the TSH level in 1 week.  reassure the patient that this will improve in several weeks. Instructor Explanation: Full therapeutic effectiveness may not be achieved for 3 to 6 weeks. Measuring the TSH level is indicated to evaluate drug effectiveness. The dose should not be increased without first evaluating the patient’s TSH level. Points Received: 2 of 2 Comments: Question 21. Question : A patient who has stable angina is taking nitroglycerin and a b-blocker. The patient tells the primary care NP that the cardiologist is considering adding a calcium channel blocker. The NP should anticipate that the cardiologist will prescribe: Student Answer:  isradipine (DynaCirc).  nicardipine (Cardene).  verapamil HCl (Calan).  nifedipine (Procardia XL). Instructor Explanation: Nitrates and b-blockers are first-line therapy for stable angina. Calcium channel blockers should be reserved for patients who cannot take these agents or patients whose symptoms are not controlled with these agents. Verapamil is one of the calcium channel blockers that should be used. The other calcium channel blockers are not recommended for this purpose. Points Received: 2 of 2 Comments: Question 22. Question : A 30-year-old white woman has a BMI of 26 and weighs 150 lb. At an annual physical examination, the patient’s fasting plasma glucose is 130 mg/dL. The patient walks 1 mile three or four times weekly. She has had two children who weighed 7 lb and 8 lb at birth. Her personal and family histories are noncontributory. The primary care NP should: Student Answer:  order metformin (Glucophage).  order a lipid profile, complete blood count, and liver function tests (LFTs).  order an oral glucose tolerance test.  set a weight loss goal of 10 to 15 lb. Instructor Explanation: To prevent or delay onset of diabetes, patients with impaired glucose should be advised to lose 5% to 10% of body weight. Metformin should be considered in patients with high risk of developing diabetes. This woman does not have risk factors. Other tests are not indicated. Points Received: 2 of 2 Comments: Question 23. Question : The primary care NP is preparing to prescribe isosorbide dinitrate sustained release (Dilatrate SR) for a patient who has chronic, stable angina. The NP should recommend initial dosing of: Student Answer:  60 mg four times daily at 6-hour intervals.  40 mg twice daily 30 minutes before meals.  60 mg on awakening and 40 mg 7 hours later.  80 mg three times daily at 8:00 AM, 1:00 PM, and 6:00 PM. Instructor Explanation: Long-acting nitrates should be considered to treat chronic, stable angina. The main limitation is tolerance, which can be limited by providing a nitrate-free period of 6 to 10 hours each day. The medication should be taken on an empty stomach, 30 to 60 minutes before a meal. An appropriate initial dose of isosorbide dinitrate is 40 mg every 12 hours. This dose can be increased as needed. Isosorbide mononitrate is given on awakening and again 7 hours later. The medication is not given four times daily. Dosing may be increased to 80 mg tid, and the dosing schedule of 8:00 AM, 1:00 PM, and 6:00 PM. would be appropriate at that point. Points Received: 2 of 2 Comments: Question 24. Question : A patient who has type 2 diabetes mellitus will begin taking a bile acid sequestrant. Which bile acid sequestrant should the primary care NP order? Student Answer:  Colesevelam (Welchol)  Colestipol (Colestid)  Cholestyramine (Questran)  Cholestyramine (Questran Light) Instructor Explanation: All bile acid sequestrants are equally effective. Colesevelam has an additional indication to improve glycemic control in adults with type 2 diabetes and so should be selected when prescribing a bile acid sequestrant for this patient. Points Received: 2 of 2 Comments: Question 25. Question : A patient who takes nitroglycerin for stable angina pectoris develops hypertension. The primary care NP should contact the patient’s cardiologist to discuss adding: Student Answer:  amlodipine (Norvasc).  diltiazem (Cardizem).  verapamil HCl (Calan).  nifedipine (Procardia XL). Instructor Explanation: Nifedipine and related drugs are potent vasodilators, which makes them more effective for hypertension than verapamil and diltiazem. Amlodipine is not a first-line drug. Points Received: 2 of 2 Comments:  * Times are displayed in (GMT-07:00) Mountain Time (US & Canada)

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