05 Feb of adherence include:

Chapter 31. Contraception 1. Women who are taking an oral contraceptive containing the progesterone drospirenone may require monitoring of: 1. Hemoglobin 2. Serum calcium 3. White blood count 4. Serum potassium 2. The mechanism of action of oral combined contraceptives that prevents pregnancy is: 1. Estrogen prevents the luteinizing hormone surge necessary for ovulation. 2. Progestins thicken cervical mucus & slow tubal motility. 3. Estrogen thins the endometrium making implantation difficult. 4. Progestin suppresses follicle stimulating hormone release. 3. To improve actual effectiveness of oral contraceptives women should be educated regarding: 1. Use of a back-up method if they have vomiting or diarrhea during a pill packet 2. Doubling pills if they have diarrhea during the middle of a pill pack 3. The fact that they will have a normal menstrual cycle if they miss two pills 4. The fact that mid-cycle spotting is not normal & the provider should be contacted immediately 4. A contraindication to the use of combined contraceptives is: 1. Adolescence (not approved for this age) 2. A history of clotting disorder 3. Recent pregnancy 4. Being overweight 5. Obese women may have increased risk of failure with which contraceptive method? 1. Combined oral contraceptives 2. Progestin-only oral contraceptive pill 3. Injectable progestin 4. Combined topical patch 6. Ashley comes to the clinic with a request for oral contraceptives. She has successfully used oral contraceptives before & has recently started dating a new boyfriend so would like to restart contraception. She denies recent intercourse & has a negative urine pregnancy test in the clinic. An appropriate plan of care would be: 1. Recommend she return to the clinic at the start of her next menses to get a Depo Provera shot. 2. Prescribe oral combined contraceptives & recommend she start them at the beginning of her next period & use a back-up method for the first 7 days. 3. Prescribe oral contraceptives & have her start them the same day as the visit with a back-up method used for the first 7 days. 4. Discuss the advantages of using the topical birth control patch & recommend she consider using the patch. 7. When discussing with a patient the different start methods used for oral combined contraceptives, the advantage of a Sunday start over the other start methods is: 1. Immediate protection against pregnancy the first week of using the pill 2. No back-up method is needed when starting 3. Menses occur during the week 4. They can start the pill on the Sunday after the office visit 8. The topical patch combined contraceptive (Ortho Evra) is: 1. Started on the first day of the menstrual cycle 2. Recommended for women over 200 pounds 3. Not as effective as oral combined contraceptives 4. Known to have more adverse effects, such as nausea, than the oral combined contraceptives 9. Progesterone-only pills are recommended for women who: 1. Are breastfeeding 2. Have a history of migraine 3. Have a medical history that contradicts the use of estrogen 4. All of the above 10. Women who are prescribed progestin-only contraception need education regarding which common adverse drug effects? 1. Increased migraine headaches 2. Increased risk of developing blood clots 3. Irregular vaginal bleeding for the first few months 4. Increased risk for hypercalcemia 11. An advantage of using the NuvaRing vaginal ring for contraception is: 1. It does not require fitting & is easy to insert. 2. It is inserted once a week, eliminating the need to remember to take a daily pill. 3. Patients get a level of estrogen & progestin equal to combined oral contraceptives. 4. It also provides protection against vaginal infections. 12. Oral emergency contraception (Plan B) is contraindicated in women who: 1. Had intercourse within the past 72 hours 2. May be pregnant 3. Are taking combined oral contraceptives 4. Are using a diaphragm Chapter 32. Dermatologic Conditions 1. When choosing a topical corticosteroid cream to treat diaper dermatitis, the ideal medication would be: 1. Intermediate potency corticosteroid ointment (Kenalog) 2. A combination of a corticosteroid & an antifungal (Lotrisone) 3. A low-potency corticosteroid cream applied sparingly (hydrocortisone 1%) 4. A high-potency corticosteroid cream (Diprolene AF) 2. Topical immunomodulators such as pimecrolimus (Elidel) or tacrolimus (Protopic) are used for: 1. Short-term or intermittent treatment of atopic dermatitis 2. Topical treatment of fungal infections (C&ida) 3. Chronic, inflammatory seborrheic dermatitis 4. Recalcitrant nodular acne 3. Long-term treatment of moderate atopic dermatitis includes: 1. Topical corticosteroids & emollients 2. Topical corticosteroids alone 3. Topical antipruritics 4. Oral corticosteroids for exacerbations of atopic dermatitis 4. Severe contact dermatitis caused by poison ivy or poison oak exposure often requires treatment with: 1. Topical antipruritics 2. Oral corticosteroids for 2 to 3 weeks 3. Thickly applied topical intermediate-dose corticosteroids 4. Isolation of the patient to prevent spread of the dermatitis 5. When a patient has contact dermatitis, wet dressings with Domeboro solution are used for: 1. Cleaning the weeping area of dermatitis 2. Bathing the patient to prevent infection 3. Relief of inflammation 4. Providing a barrier layer to protect the surrounding skin 6. Appropriate initial treatment for psoriasis would be: 1. An immunomodulator (Protopic or Elidel) 2. Wet soaks with Burrow’s or Domeboro solution 3. Intermittent therapy with intermediate potency topical corticosteroids 4. Anthralin (Drithocreme) 7. Patient education when prescribing the vitamin D3 derivative calcipotriene for psoriasis includes: 1. Apply thickly to affected psoriatic areas two to three times a day. 2. A maximum of 100 grams per week may be applied. 3. Do not use calcipotriene in combination with their topical corticosteroids. 4. Calcipotriene may be augmented with the use of coal tar products. 8. Mild acne may be initially treated with: 1. Topical combined antibiotic 2. Minocycline 3. Topical retinoid 4. OTC benzoyl peroxide 9. Tobie presents to the clinic with moderate acne. He has been using OTC benzoyl peroxide at home with minimal improvement. A topical antibiotic (clindamycin) & a topical retinoid adapalene (Differin) are prescribed. Education of Tobie would include: 1. He should see an improvement in his acne within the first 2 weeks of treatment. 2. If there is no response in a week, double the daily application of adapalene (Differin). 3. He may see an initial worsening of his acne that will improve in 6 to 8 weeks. 4. Adapalene may cause bleaching of clothing. 10. Josie has severe cystic acne & is requesting treatment with Accutane. The appropriate treatment for her would be: 1. Order a pregnancy test & if it is negative prescribe the isotretinoin (Accutane). 2. Order Accutane after educating her on the adverse effects. 3. Recommend she try oral antibiotics (minocycline). 4. Refer her to a dermatologist for treatment. 11. The most cost-effective treatment for two or three impetigo lesions on the face is: 1. Mupirocin ointment 2. Retapamulin (Altabax) ointment 3. Topical clindamycin solution 4. Oral amoxicillin/clavulanate (Augmentin) 12. Dwayne has classic tinea capitis. Treatment for tinea on the scalp is: 1. Miconazole cream rubbed in well for 4 weeks 2. Oral griseofulvin for 6 to 8 weeks 3. Ketoconazole shampoo daily for 6 weeks 4. Ciclopirox cream daily for 4 weeks 13. Nicolas is a football player who presents to the clinic with athlete’s foot. Patients with tinea pedis may be treated with: 1. OTC miconazole cream for 4 weeks 2. Oral ketoconazole for 6 weeks 3. Mupirocin ointment for 2 weeks 4. Nystatin cream for 2 weeks 14. Jim presents with fungal infection of two of his toenails (onychomycosis). Treatment for fungal infections of the nail includes: 1. Miconazole cream 2. Ketoconazole cream 3. Oral griseofulvin 4. Mupirocin cream 15. Scabies treatment for a 4-year-old child includes a prescription for: 1. Permethrin 5% cream applied from the neck down 2. Pyrethrin lotion 3. Lindane 1% shampoo 4. All of the above 16. Vanessa has been diagnosed with scabies. Her education would include: 1. She should apply the scabies treatment cream for an hour & wash it off. 2. Scabies may need to be retreated in a week after initial treatment. 3. All members of the household & close personal contacts should be treated. 4. Malathion is flammable & she should take care until the solution dries. 17. Catherine has head lice & her mother is asking about what products are available that are not neurotoxic. The only non-neurotoxin head lice treatment is: 1. Permethrin 1% (Nix) 2. Lindane shampoo 3. Malathion (Ovide) 4. Benzoyl alcohol (Ulesfia) 18. Rick has male pattern baldness on the vertex of his head & has been using Rogaine for 2 months. He asks how effective minoxidil (Rogaine) is. Minoxidil: 1. Provides a permanent solution to male pattern baldness if used for at least 4 months 2. Will show results after 4 months of twice-a-day use 3. May not work for Rick’s type of baldness 4. Works better if he also uses hydrocortisone cream daily on his scalp Chapter 33. Diabetes Mellitus 1. Type 1 diabetes results from autoimmune destruction of the beta cells. Eighty-five to 90% of type 1 diabetics have: 1. Autoantibodies to two tyrosine phosphatases 2. Mutation of the hepatic transcription factor on chromosome 12 3. A defective glucokinase molecule due to a defective gene on chromosome 7p 4. Mutation of the insulin promoter factor 2. Type 2 diabetes is a complex disorder involving: 1. Absence of insulin production by the beta cells 2. A suboptimal response of insulin-sensitive tissues in the liver 3. Increased levels of glucagon-like peptide in the postpr&ial period 4. Too much fat uptake in the intestine 3. Diagnostic criteria for diabetes include: 1. Fasting blood glucose greater than 140 mg/dl on two occasions 2. Postpr&ial blood glucose greater than 140 mg/dl 3. Fasting blood glucose 100 to 125 mg/dl on two occasions 4. Symptoms of diabetes plus a casual blood glucose greater than 200 mg/dl 4. Routine screening of asymptomatic adults for diabetes is appropriate for: 1. Individuals who are older than 45 & have a BMI of less than 25 kg/m2 2. Native Americans, African Americans, & Hispanics 3. Persons with HDL cholesterol greater than 100 mg/dl 4. Persons with prediabetes confirmed on at least two occasions 5. Screening for children who meet the following criteria should begin at age 10 & occur every 3 years thereafter: 1. BMI above the 85th percentile for age & sex 2. Family history of diabetes in first- or second-degree relative 3. Hypertension based on criteria for children 4. Any of the above 6. Insulin is used to treat both types of diabetes. It acts by: 1. Increasing beta cell response to low blood-glucose levels 2. Stimulating hepatic glucose production 3. Increasing peripheral glucose uptake by skeletal muscle & fat 4. Improving the circulation of free fatty acids 7. Adam has type 1 diabetes & plays tennis for his university. He exhibits a knowledge deficit about his insulin & his diagnosis. He should be taught that: 1. He should increase his carbohydrate intake during times of exercise. 2. Each brand of insulin is equal in bioavailability, so buy the least expensive. 3. Alcohol produces hypoglycemia & can help control his diabetes when taken in small amounts. 4. If he does not want to learn to give himself injections, he may substitute an oral hypoglycemic to control his diabetes. 8. Insulin preparations are divided into categories based on onset, duration, & intensity of action following subcutaneous injection. Which of the following insulin preparations has the shortest onset & duration of action? 1. Lispro 2. Glulisine 3. Glargine 4. Detemir 9. The drug of choice for type 2 diabetics is metformin. Metformin: 1. Decreases glycogenolysis by the liver 2. Increases the release of insulin from beta cells 3. Increases intestinal uptake of glucose 4. Prevents weight gain associated with hyperglycemia 10. Before prescribing metformin, the provider should: 1. Draw a serum creatinine level to assess renal function. 2. Try the patient on insulin. 3. Prescribe a thyroid preparation if the patient needs to lose weight. 4. All of the above 11. Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications & metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they: 1. Increase endogenous insulin secretion 2. Have a significant risk for hypoglycemia 3. Address the insulin resistance found in type 2 diabetics 4. Improve insulin binding to receptors 12. Dipeptidyl peptidase-4 inhibitors (gliptins) act on the incretin system to improve glycemic control. Advantages of these drugs include: 1. Better reduction in glucose levels than other classes 2. Less weight gain than sulfonylureas 3. Low risk for hypoglycemia 4. Can be given twice daily 13. Control targets for patients with diabetes include: 1. HbA1C between 7 & 8 2. Fasting blood glucose levels between 100 & 120 mg/dl 3. Blood pressure less than 130/80 mm Hg 4. LDL lipids less than 130 mg/dl 14. Establishing glycemic targets is the first step in treatment of both types of diabetes. For type 1 diabetes: 1. Tight control/intensive therapy can be given to adults who are willing to test their blood glucose at least twice daily. 2. Tight control is acceptable for older adults if they are without complications. 3. Plasma glucose levels are the same for children as adults. 4. Conventional therapy has a fasting plasma glucose target between 120 & 150 mg/dl. 15. Treatment with insulin for type 1 diabetics: 1. Starts with a total daily dose of 0.2 to 0.4 units per kg of body weight 2. Divides the total doses into three injections based on meal size 3. Uses a total daily dose of insulin glargine given once daily with no other insulin required 4. Is based on the level of blood glucose 16. When the total daily insulin dose is split & given twice daily, which of the following rules may be followed? 1. Give two-thirds of the total dose in the morning & one-third in the evening. 2. Give 0.3 units per kg of premixed 70/30 insulin with one-third in the morning & two-thirds in the evening. 3. Give 50% of an insulin glargine dose in the morning & 50% in the evening. 4. Give long-acting insulin in the morning & short-acting insulin at bedtime. 17. Studies have shown that control targets that reduce the HbA1C to less than 7% are associated with fewer long-term complications of diabetes. Patients who should have such a target include: 1. Those with long-st&ing diabetes 2. Older adults 3. Those with no significant cardiovascular disease 4. Young children who are early in their disease 18. Prevention of conversion from prediabetes to diabetes in young children must take highest priority & should focus on: 1. Aggressive dietary manipulation to prevent obesity 2. Fostering LDL levels less than 100 mg/dl & total cholesterol less than 170 mg/dl to prevent cardiovascular disease 3. Maintaining a blood pressure that is less than 80% based on weight & height to prevent hypertension 4. All of the above 19. The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are: 1. Metformin & insulin 2. Sulfonylureas & insulin glargine 3. Split-mixed dose insulin & GPL-1 agonists 4. Biguanides & insulin lispro 20. Unlike most type 2 diabetics where obesity is a major issue, older adults with low body weight have higher risks for morbidity & mortality. The most reliable indicator of poor nutritional status in older adults is: 1. Weight loss in previously overweight persons 2. Involuntary loss of 10% of body weight in less than 6 months 3. Decline in lean body mass over a 12-month period 4. Increase in central versus peripheral body adiposity 21. The drugs recommended for older adults with type 2 diabetes include: 1. Second-generation sulfonylureas 2. Metformin 3. Pioglitazone 4. Third-generation sulfonylureas 22. Ethnic groups differ in their risk for & presentation of diabetes. Hispanics: 1. Have a high incidence of obesity, elevated triglycerides, & hypertension 2. Do best with drugs that foster weight loss, such as metformin 3. Both 1 & 2 4. Neither 1 nor 2 23. The American Heart Association states that people with diabetes have a 2- to 4-fold increase in the risk of dying from cardiovascular disease. Treatments & targets that do not appear to decrease risk for micro- & macro-vascular complications include: 1. Glycemic targets between 7% & 7.5% 2. Use of insulin in type 2 diabetics 3. Control of hypertension & hyperlipidemia 4. Stopping smoking 24. All diabetic patients with known cardiovascular disease should be treated with: 1. Beta blockers to prevent MIs 2. Angiotensin-converting enzymeinhibitors & aspirin to reduce risk of cardiovascular events 3. Sulfonylureas to decrease cardiovascular mortality 4. Pioglitazone to decrease atherosclerotic plaque buildup 25. All diabetic patients with hyperlipidemia should be treated with: 1. HMG-CoA reductase inhibitors 2. Fibric acid derivatives 3. Nicotinic acid 4. Colestipol 26. Both angiotensin converting enzymeinhibitors & some angiotensin II receptor blockers have been approved in treating: 1. Hypertension in diabetic patients 2. Diabetic nephropathy 3. Both 1 & 2 4. Neither 1 nor 2 27. Protein restriction helps slow the progression of albuminuria, glomerular filtration rate, decline, & end stage renal disease in some patients with diabetes. It is useful for patients who: 1. Cannot tolerate angiotensin converting enzymeinhibitors or angiotensin receptorblockers 2. Have uncontrolled hypertension 3. Have HbA1C levels above 7% 4. Show progression of diabetic nephropathy despite optimal glucose & blood pressure control 28. Diabetic autonomic neuropathy (DAN) is the earliest & most common complication of diabetes. Symptoms associated with DAN include: 1. Resting tachycardia, exercise intolerance, & orthostatic hypotension 2. Gastroparesis, cold intolerance, & moist skin 3. Hyperglycemia, erectile dysfunction, & deficiency of free fatty acids 4. Pain, loss of sensation, & muscle weakness 29. Drugs used to treat diabetic peripheral neuropathy include: 1. Metoclopramide 2. Cholinergic agonists 3. Cardioselective beta blockers 4. Gabapentin 30. The American Diabetic Association has recommended which of the following tests for ongoing management of diabetes? 1. Fasting blood glucose 2. HbA1C 3. Thyroid function tests 4. Electrocardiograms 31. Allison is an 18-year-old college student with type 1 diabetes. She is on NPH twice daily & Novolog before meals. She usually walks for 40 minutes each evening as part of her exercise regimen. She is beginning a 30-minute swimming class three times a week at 1 p.m. What is important for her to do with this change in routine? 1. Delay eating the midday meal until after the swimming class. 2. Increase the morning dose of NPH insulin on days of the swimming class. 3. Adjust the morning insulin injection so that the peak occurs while swimming. 4. Check glucose level before, during, & after swimming. 32. Allison is an 18-year-old college student with type 1 diabetes. Allison’s pre-meal BG at 11:30 a.m. is 130. She eats an apple & has a sugar-free soft drink. At 1 p.m. before swimming her BG is 80. What should she do? 1. Proceed with the swimming class. 2. Recheck her BG immediately. 3. Eat a granola bar or other snack with CHO. 4. Take an additional dose of insulin. 33. Bart is a patient is a 67-year-old male with T2 DM. He is on glipizide & metformin. He presents to the clinic with confusion, sluggishness, & extreme thirst. His wife tells you Bart does not follow his meal plan or exercise regularly, & hasn’t checked his BG for 1 week. A r&om glucose is drawn & it is 500. What is a likely diagnosis based on preliminary assessment? 1. Diabetic keto acidosis (DKA) 2. Hyperglycemic hyperosmolar syndrome (HHS) 3. Infection 4. Hypoglycemia 34. What would one expected assessment finding be for hyperglycemic hyperosmolar syndrome? 1. Low hemoglobin 2. Ketones in the urine 3. Deep, labored breathing 4. pH of 7.35 35. A patient on metformin & glipizide arrives at her 11:30 a.m. clinic appointment diaphoretic & dizzy. She reports taking her medication this morning & ate a bagel & coffee for breakfast. BP is 110/70 & r&om finger-stick glucose is 64. How should this patient be treated? 1. 12 oz apple juice with 1 tsp sugar 2. 10 oz diet soda 3. 8 oz milk or 4 oz orange juice 4. 4 cookies & 8 oz chocolate milk Chapter 34. Gastroesophageal Reflux & Peptic Ulcer Disease 1. Gastroesophageal reflux disease may be aggravated by the following medication that affects lower esophageal sphincter (LES) tone: 1. Calcium carbonate 2. Estrogen 3. Furosemide 4. Metoclopramide 2. Lifestyle changes are the first step in treatment of gastroesophageal reflux disease (GERD). Food or drink that may aggravate GERD include: 1. Eggs 2. Caffeine 3. Chocolate 4. Soda pop 3. Metoclopramide improves gastroesophageal reflux disease symptoms by: 1. Reducing acid secretion 2. Increasing gastric pH 3. Increasing lower esophageal tone 4. Decreasing lower esophageal tone 4. Antacids treat gastroesophageal reflux disease by: 1. Increasing lower esophageal tone 2. Increasing gastric pH 3. Inhibiting gastric acid secretion 4. Increasing serum calcium level 5. When treating patients using the “Step-Down” approach the patient with gastroesophageal reflux disease is started on ___ first. 1. Antacids 2. Histamine2 receptor antagonists 3. Prokinetics 4. Proton pump inhibitors 6. If a patient with symptoms of gastroesophageal reflux disease states that he has been self-treating at home with OTC ranitidine daily, the appropriate treatment would be: 1. Prokinetic (metoclopramide) for 4 to 8 weeks 2. Proton pump inhibitor (omeprazole) for 12 weeks 3. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks 4. Cytoprotective drug (misoprostol) for 2 weeks 7. If a patient with gastroesophageal reflux disease who is taking a proton pump inhibitor daily is not improving, the plan of care would be: 1. Prokinetic (metoclopramide) for 8 to 12 weeks 2. Proton pump inhibitor (omeprazole) twice a day for 4 to 8 weeks 3. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks 4. Cytoprotective drug (misoprostol) for 4 to 8 weeks 8. The next step in treatment when a patient has been on proton pump inhibitors twice daily for 12 weeks & not improving is: 1. Add a prokinetic (metoclopramide) 2. Referral for endoscopy 3. Switch to another proton pump inhibitor 4. Add a cytoprotective drug 9. Infants with reflux are initially treated with: 1. Histamine2 receptor antagonist (ranitidine) 2. Proton pump inhibitor (omeprazole) 3. Anti-reflux maneuvers (elevate head of bed) 4. Prokinetic (metoclopramide) 10. Long-term use of proton pump inhibitors may lead to: 1. Hip fractures in at-risk persons 2. Vitamin B6 deficiency 3. Liver cancer 4. All of the above 11. An acceptable first-line treatment for peptic ulcer disease with positive H. pylori test is: 1. Histamine2 receptor antagonists for 4 to 8 weeks 2. Proton pump inhibitor bid for 12 weeks until healing is complete 3. Proton pump inhibitor bid plus clarithromycin plus amoxicillin for 14 days 4. Proton pump inhibitor bid & levofloxacin for 14 days 12. Treatment failure in patients with peptic ulcer disease associated with H. pylori may be because of: 1. Antimicrobial resistance 2. An ineffective antacid 3. Overuse of proton pump inhibitors 4. All of the above 13. If a patient with H. pylori-positive peptic ulcer disease fails first-line therapy, the second-line treatment is: 1. Proton pump inhibitor bid plus metronidazole plus tetracycline plus bismuth subsalicylate for 14 days 2. Test H. pylori for resistance to common treatment regimens 3. Proton pump inhibitor plus clarithromycin plus amoxicillin for 14 days 4. Proton pump inhibitor & levofloxacin for 14 days 14. After H. pylori treatment is completed, the next step in peptic ulcer disease therapy is: 1. Testing for H. pylori eradication with a serum ELISA test 2. Endoscopy by a specialist 3. A proton pump inhibitor for 8 to 12 weeks until healing is complete 4. All of the above Chapter 35. Headaches 1. Paige has a history of chronic migraines & would benefit from preventative medication. Education regarding migraine preventive medication includes: 1. Medication is taken at the beginning of the headache to prevent it from getting worse. 2. Medication alone is the best preventative against migraines occurring. 3. Medication should not be used more than four times a month. 4. The goal of treatment is to reduce migraine occurrence by 50%. 2. A first-line drug for abortive therapy in simple migraine is: 1. Sumatriptan (Imitrex) 2. Naproxen (Aleve) 3. Butorphanol nasal spray (Stadol NS) 4. Butalbital & acetaminophen (Fioricet) 3. Vicky, age 56 years, comes to the clinic requesting a refill of her Fiorinal (aspirin & butalbital) that she takes for migraines. She has been taking this medication for over 2 years for migraines & states one dose usually works to abort her migraine. What is the best care for her? 1. Switch her to sumatriptan (Imitrex) to treat her migraines. 2. Assess how often she is using Fiorinal & refill her medication. 3. Switch her to a beta blocker such as propranolol to prevent her migraine. 4. Request she return to the original prescriber of Fiorinal as you do not prescribe butalbital for migraines. 4. When prescribing ergotamine suppositories (Wigraine) to treat acute migraine, patient education would include: 1. Ergotamine will briefly make the migraine worse before the migraine resolves. 2. The patient may experience bradycardia & dizziness. 3. They may need premedication with an antinausea medication. 4. Ergotamine works best if the patient starts off with a full suppository to get the full effect. 5. Migraines in pregnancy may be safely treated with: 1. Acetaminophen with codeine (Tylenol #3) 2. Sumatriptan (Imitrex) 3. Ergotamine tablets (Ergostat) 4. Dihydroergotamine (DHE) 6. Xi, a 54-year-old female, has a history of migraines that do not respond well to OTC migraine medication. She is asking to try Maxalt (rizatriptan) because it works well for her friend. Appropriate decision making would be: 1. Prescribe the Maxalt, but only give her four tablets with no refills to monitor the use. 2. Prescribe Maxalt & arrange to have her observed in the clinic or urgent care with the first dose. 3. Explain that rizatriptan is not used for postmenopausal migraines & recommend Fiorinal (aspirin & butalbital). 4. Prescribe sumatriptan (Imitrex) with the explanation that it is the most effective triptan. 7. Kelly is a 14-year-old patient who presents to the clinic with a classic migraine. She says she is having a headache two to three times a month. The initial plan would be: 1. Prescribe NSAIDs as abortive therapy & have her keep a headache diary to identify her triggers. 2. Prescribe zolmitriptan (Zomig) as abortive therapy & recommend relaxation therapy to reduce her stress. 3. Prescribe acetaminophen with codeine (Tylenol #3) for her to take at the first onset of her migraine. 4. Prescribe sumatriptan (Imitrex) nasal spray & arrange for her to receive the first dose in the clinic. 8. Jayla is a 9-year-old patient who has been diagnosed with migraines for almost 2 years. She is missing up to a week of school each month. Her headache diary confirms she averages four or five migraines per month. Which of the following would be appropriate? 1. Prescribe amitriptyline (Elavil) daily, start at a low dose & increase dosage slowly every 2 weeks until it’s effective in eliminating migraines. 2. Encourage her mother to give her Excedrin Migraine (aspirin, acetaminophen, & caffeine) at the first sign of a headache to abort the headache. 3. Prescribe propranolol (Inderal) to be taken daily for at least 3 months. 4. Explain that it is rare for a 9-year-old child to get migraines & she needs an MRI to rule out a brain tumor. 9. Amber is a 24-year-old patient who has had migraines for 10 years. She reports a migraine on average of once a month. The migraines are effectively aborted with naratriptan (Amerge). When refilling Amber’s naratriptan, education would include: 1. Naratriptan will interact with antidepressants, including selective serotonin reuptake inhibitors (SSRIs) & St John’s wort, & she should inform any providers she sees that she has migraines. 2. Continue to monitor her headaches, if the migraine is consistently happening around her menses there is preventive therapy available. 3. Pregnancy is contraindicated when taking a triptan. 4. All of the above 10. When prescribing for migraines, patient education includes: 1. Triptans are safe to be used as often as needed as long as the patient is healthy. 2. Use triptan before trying OTC meds such as acetaminophen or naproxen. 3. Stress reduction & regular sleep are integral to migraine treatment. 4. If migraines worsen they are to increase their medication. 11. Juanita presents to the clinic with a complaint of headaches off & on for months. She reports they feel like someone is “squeezing” her head. She occasionally takes Tylenol for the pain, but usually just “toughs it out.” Initial treatment for tension headache includes asking her to keep a headache diary & a prescription for: 1. Sumatriptan (Imitrex) 2. Naproxen (Aleve) 3. Ergotamine (Ergostat) 4. Tylenol with codeine (Tylenol #3) 12. Nonpharmacologic therapy for tension headaches includes: 1. Biofeedback 2. Stress management 3. Massage therapy 4. All of the above 13. James has been diagnosed with cluster headaches. Appropriate acute therapy would be: 1. Butalbital & aspirin (Fiorinal) 2. Meperidine IM (Demerol) 3. Oxygen 100% for 15 to 30 minutes 4. Indomethacin (Indocin) 14. Preventative therapy for cluster headaches includes: 1. Massage or relaxation therapy 2. Ergotamine nightly before bed 3. Intranasal lidocaine four times a day during “clusters” of headaches 4. Propranolol (Inderal) daily 15. When prescribing any headache therapy, appropriate use of medications needs to be discussed to prevent medication-overuse headaches. A clinical characteristic of medication-overuse headaches is that they: 1. Are increasing in frequency 2. Are increasing in intensity 3. Recur when medication wears off 4. Begin to “cluster” into a pattern Chapter 36. Heart Failure 1. Angiotensin-converting-enzyme(ACE) inhibitors are a central part of the treatment of heart failure because they have more than one action to address the pathological changes in this disorder. Which of the following pathological changes in heart failure is NOT addressed by ACE inhibitors? 1. Changes in the structure of the left ventricle so that it dilates, hypertrophies, & uses energy less efficiently. 2. Reduced formation of cross-bridges so that contractile force decreases. 3. Activation of the sympathetic nervous system that increases heart rate & preload. 4. Decreased renal blood flow that decreases oxygen supply to the kidneys. 2. One of the three types of heart failure involves systolic dysfunction. Potential causes of this most common form of heart failure include: 1. Myocardial ischemia & injury secondary to myocardial infarction 2. Inadequate relaxation & loss of muscle fiber secondary to valvular dysfunction 3. Increased dem&s of the heart beyond its ability to adapt secondary to anemia 4. Slower filling rate & elevated systolic pressures secondary to uncontrolled hypertension 3. The American Heart Association & the American College of Cardiology have devised a classification system for heart failure that can be used to direct treatment. Patients with symptoms & underlying disease are classified as stage: 1. A 2. B 3. C 4. D 4. Diagnosis of heart failure cannot be made by symptoms alone because many disorders share the same symptoms. The most specific & sensitive diagnostic test for heart failure is: 1. Chest x-rays that show cephalization & measure heart size 2. Two-dimensional echocardiograms that identify structural anomalies & cardiac dysfunction 3. Complete blood count, blood urea nitrogen, & serum electrolytes that facilitate staging for end-organ damage 4. Measurement of brain natriuretic peptide to distinguish between systolic & diastolic dysfunction 5. Treatments for heart failure, including drug therapy, are based on the stages developed by the ACC/AHA. Stage A patients are treated with: 1. Drugs for hypertension & hyperlipidemia, if they exist 2. Lifestyle management including diet, exercise, & smoking cessation only 3. Angiotensin-converting enzyme(ACE) inhibitors to directly affect the heart failure only 4. No drugs are used in this early stage 6. Class I recommendations for stage A heart failure include: 1. Aerobic exercise within tolerance levels to prevent the development of heart failure 2. Reduction of sodium intake to less than 2,000 mg/day to prevent fluid retention 3. Beta blockers for all patients regardless of cardiac history 4. Treatment of thyroid disorders, especially if they are associated with tachyarrhythmias 7. Stage B patients should have beta blockers added to their heart failure treatment regimen when: 1. They have an ejection fraction less than 40% 2. They have had a recent MI 3. Both 1 & 2 4. Neither 1 nor 2 8. Increased life expectancy for patients with heart failure has been associated with the use of: 1. ACE inhibitors, especially when started early in the disease process 2. All beta blockers regardless of selectivity 3. Thiazide & loop diuretics 4. Cardiac glycosides 9. Stage C patients usually require a combination of three to four drugs to manage their heart failure. In addition to ACE inhibitors & beta blockers, diuretics may be added. Which of the following statements about diuretics is NOT true? 1. Diuretics reduce preload associated with fluid retention. 2. Diuretics can be used earlier than stage C when the goal is control of hypertension. 3. Diuretics may produce problems with electrolyte imbalances & abnormal glucose & lipid metabolism. 4. Diuretics from the potassium-sparing class should be used when using an angiotensin receptor blocker(ARB). 10. Digoxin has a very limited role in treatment of heart failure. It is used mainly for patients with: 1. Ejection fractions above 40% 2. An audible S3 3. Mitral stenosis as a primary cause for heart failure 4. Renal insufficiency 11. Which of the following classes of drugs is contraindicated in heart failure? 1. Nitrates 2. Long-acting dihydropyridines 3. Calcium channel blockers 4. Alpha-beta blockers 12. Heart failure is a leading cause of death & hospitalization in older adults (greater than 65 years old). The drug of choice for this population is: 1. Aldosterone antagonists 2. Eplerenone 3. ACE inhibitors 4. ARBs 13. ACE inhibitors are contraindicated in pregnancy. While treatment of heart failure during pregnancy is best done by a specialist, which of the following drug classes is considered to be safe, at least in the later parts of pregnancy? 1. Diuretics 2. ARBs 3. Beta blockers 4. Nitrates 14. Heart failure is a chronic condition that can be adequately managed in primary care. However, consultation with or referral to a cardiologist is appropriate when: 1. Symptoms markedly worsen or the patient becomes hypotensive & has syncope 2. There is evidence of progressive renal insufficiency or failure 3. The patient remains symptomatic on optimal doses of an ACE inhibitor, a beta blocker, & a diuretic 4. Any of the above 15. ACE inhibitors are a foundational medication in HF. Which group of patients cannot take them safely? 1. Elderly patients with reduced renal clearance 2. Pregnant women 3. Women under age 30 4. 1 & 2 16. What assessment that can be done at home is the most reliable for making decisions to change HF medications? 1. Weight 2. BP 3. Heart rate 4. Serum Glucose 17. Evidence is strong that the timing of HF interventions are best initiated when: 1. The person enters stage C 2. The person has functional disabilities 3. At the earliest indication 4. When stage IV is determined 18. HF patients frequently take more than one drug. When are anticoagulants typically used? 1. When the patient enters stage III 2. Only in cases of diastolic failure 3. When there is concurrent A Fib 4. In all cases 19. What can chest x-rays contribute to the diagnosis & management of HF? 1. They have no role. 2. They can give very precise pictures of pulmonary fluid status. 3. They provide an idea of general cardiac size & pulmonary great vessel distribution. 4. They can confirm the diagnosis. Chapter 38. Hormone Replacement Therapy & Osteoporosis 1. The goals of therapy when prescribing hormone replacement therapy (HRT) include reducing: 1. Cardiovascular risk 2. Risk of stroke or other thromboembolic event 3. Breast cancer 4. Vasomotor symptoms 2. The optimal maximum time frame for HRT or estrogen replacement therapy (ERT) is: 1. 2 years 2. 5 years 3. 10 years 4. 15 years 3. Dosage changes of conjugated equine estrogen (Premarin) are made at _ intervals. 1. 1 to 2 week 2. 2 to 4 week 3. 6 to 8 week 4. 12 week 4. The advantage of vaginal estrogen preparations in the treatment of vulvovaginal atrophy & dryness is: 1. Ability to deliver higher doses of estrogen in a non-oral form 2. The vaginal cream formula provides moisture to the vaginal area 3. Relief of symptoms without increasing cardiovascular risk 4. All of the above 5. Women with an intact uterus should be treated with both estrogen & progestin due to: 1. Increased risk for endometrial cancer if estrogen alone is used 2. Combination therapy provides the best relief of menopausal vasomotor symptoms 3. Reduced risk for colon cancer with combined therapy 4. Lower risk of developing blood clots with combined therapy 6. Ongoing monitoring for women on ERT includes: 1. Lipid levels, repeated annually if abnormal 2. Annual health history & review of risk profile 3. Annual mammogram 4. All of the above 7. Kristine would like to start HRT to treat the significant vasomotor symptoms she is experiencing during menopause. Education for a woman considering hormone replacement would include: 1. Explaining that HRT is totally safe if used short term 2. Telling her to ignore media hype regarding HRT 3. Discussing the advantages & risks of HRT 4. Encouraging the patient to use phytoestrogens with the HRT 8. Angela is a black woman who has heard that women of African descent do not need to worry about osteoporosis. What education would you provide Angela about her risk? 1. She is correct, black women do not have much risk of developing osteoporosis due to their dark skin. 2. Black women are at risk of developing osteoporosis due to their lower calcium intake as a group. 3. If she doesn’t drink alcohol, her risk of developing osteoporosis is low. 4. If she has not lost more than 10% of her weight lately, her risk is low. 9. Drugs that increase the risk of osteoporosis developing include: 1. Oral combined contraceptives 2. Carbamazepine 3. Calcium channel blockers 4. High doses of vitamin D 10. Selective estrogen receptor modifiers (SERMs) treat osteoporosis by selectively: 1. Inhibiting magnesium resorption in the kidneys 2. Increasing calcium absorption from the GI tract 3. Acting on the bone to inhibit osteoblast activity 4. Selectively acting on the estrogen receptors in the bone 11. Sallie has been diagnosed with osteoporosis & is asking about the “once a month” pill to treat her condition. How do bisphosphonates treat osteoporosis? 1. By selectively activating estrogen pathways in the bone 2. By reducing bone resorption by inhibiting parathyroid hormone (PTH) 3. By reducing bone resorption & inhibiting osteoclastic activity 4. By increasing PTH production 12. Inadequate vitamin D intake can contribute to the development of osteoporosis by: 1. Increasing calcitonin production 2. Increasing calcium absorption from the intestine 3. Altering calcium metabolism 4. Stimulating bone formation 13. The drug recommended as primary prevention of osteoporosis in women over age 70 years is: 1. Alendronate (Fosamax) 2. Ib&ronate (Boniva) 3. Calcium carbonate 4. Raloxifene (Evista) 14. The drug recommended as primary prevention of osteoporosis in men over age 70 years is: 1. Alendronate (Fosamax) 2. Ib&ronate (Boniva) 3. Calcium carbonate 4. Raloxifene (Evista) 15. The ongoing monitoring for patients over age 65 years taking alendronate (Fosamax) or any other bisphosphonate is: 1. Annual dual-energy x-ray absorptiometry (DEXA) scans 2. Annual vitamin D level 3. Annual renal function evaluation 4. Electrolytes every 3 months 16. Bisphosphonate administration education includes: 1. Taking it on a full stomach 2. Requiring sitting erect for at least 30 minutes afterward 3. Drinking it with orange juice 4. Taking it with H2 blockers or proton pump inhibitors (PPI) to protect the stomach 17. IV forms of bisphosphonates are used for all the following except: 1. Severe gastric irritation with oral forms 2. Known cancer mets into the bone 3. Persons with advancing renal dysfunction 4. Progression of bone loss on oral formulations 18. What is the established frequency of repeating DEXA imaging after stating bisphosphonates? 1. Every 2 years 2. Every 5 years 3. There is no evidence-based time line for monitoring after the first 2 years 4. There need to be annual exams 19. What is the duration of SERM use for menopausal issues? 1. It matches the 5 years for estrogen products 2. The bone health impact allows long-term use 3. The increased risk of breast cancer encourages tapering as soon as possible 4. The abnormal lipid profile contributes to an early termination as soon as hot flashes no longer occur 20. Why are SERMS generally not ordered for women early into menopause? 1. The rapid onset of severe hot flashes can be unbearable. 2. The bone remodeling effect results in osteoporosis. 3. They tend to induce intermittent spotting. 4. They create more risk with breast cancer than they are worth. Chapter 39. Hyperlipidemia 1. The overall goal of treating hyperlipidemia is: 1. Maintain an LDL level of less than 160 mg/dL 2. To reduce atherogenesis 3. Lowering apo B, one of the apoliproteins 4. All of the above 2. When considering which cholesterol-lowering drug to prescribe, which factor determines the type & intensity of treatment? 1. Total LDL 2. Fasting HDL 3. Coronary artery disease risk level 4. Fasting total cholesterol 3. First-line therapy for hyperlipidemia is: 1. Statins 2. Niacin 3. Lifestyle changes 4. Bile acid-binding resins 4. James is a 45-year-old patient with an LDL level of 120 & normal triglycerides. Appropriate first-line therapy for James may include diet counseling, increased physical activity, &: 1. A statin 2. Niacin 3. Sterols 4. A fibric acid derivative 5. Joanne is a 60-year-old patient with an LDL of 132 & a family history of coronary artery disease. She has already tried diet changes (increased fiber & plant sterols) to lower her LDL & after 6 months her LDL is slightly higher. The next step in her treatment would be: 1. A statin 2. Niacin 3. Sterols 4. A fibric acid derivative 6. Sharlene is a 65-year-old patient who has been on a lipid-lowering diet & using plant sterol margarine daily for the past 3 months. Her LDL is 135 mg/dL. An appropriate treatment for her would be: 1. A statin 2. Niacin 3. A fibric acid derivative 4. Determined by her risk factors 7. Phil is a 54-year-old male with multiple risk factors who has been on a high-dose statin for 3 months to treat his high LDL level. His LDL is 135 mg/dL & his triglycerides are elevated. A reasonable change in therapy would be to: 1. Discontinue the statin & change to a fibric acid derivative. 2. Discontinue the statin & change to ezetimibe. 3. Continue the statin & add in ezetimibe. 4. Refer him to a specialist in managing patients with recalcitrant hyperlipidemia. 8. Jamie is a 34-year-old pregnant woman with familial hyperlipidemia & elevated LDL levels. What is the appropriate treatment for a pregnant woman? 1. A statin 2. Niacin 3. Fibric acid derivative 4. Bile acid-binding resins 9. Han is a 48-year-old diabetic with hyperlipidemia & high triglycerides. His LDL is 112 mg/dL & he has not tolerated statins. He warrants a trial of a: 1. Sterol 2. Niacin 3. Fibric acid derivative 4. Bile acid-binding resin 10. Jose is a 12-year-old overweight child with a total cholesterol of 180 mg/dL & LDL of 125 mg/dL. Along with diet education & recommending increased physical activity, a treatment plan for Jose would include with a reevaluation in 6 months. 1. Statins 2. Niacin 3. Sterols 4. Bile acid-binding resins 11. Monitoring of a patient who is on a lipid-lowering drug includes: 1. Fasting total cholesterol every 6 months 2. Lipid profile with attention to serum LDL 6 to 8 weeks after starting therapy, then again in 6 weeks 3. Complete blood count, C-reactive protein, & erythrocyte sedimentation rate after 6 weeks of therapy 4. All of the above 12. Before starting therapy with a statin, the following baseline laboratory values should be evaluated: 1. Complete blood count 2. Liver function (ALT/AST) & creatine kinase 3. C-reactive protein 4. All of the above 13. When starting a patient on a statin, education would include: 1. If they stop the medication their lipid levels will return to pretreatment levels. 2. Medication is a supplement to diet therapy & exercise. 3. If they have any muscle aches or pain, they should contact their provider. 4. All of the above 14. Omega 3 fatty acids are best used to help treat: 1. High HDL 2. Low LDL 3. High triglycerides 4. Any high lipid value 15. When are statins traditionally ordered to be taken? 1. At bedtime 2. At noon 3. At breakfast 4. With the evening meal 16. Which the following persons should not have a statin medication ordered? 1. Someone with 3 first- or second-degree family members with history of muscle issues when started on statins 2. Someone with high lipids, but low BMI 3. Premenopausal woman with recent history of hysterectomy 4. Prediabetic male with known metabolic syndrome 17. Fiber supplements are great options for elderly patients who have the concurrent problem of: 1. End-stage renal failure on fluid restriction 2. Recurrent episodes of diarrhea several times a day 3. Long-term issues of constipation 4. Needing to take multiple medications around the clock every 2 hours 18. What is considered the order of statin strength from lowest effect to highest? 1. Lovastatin, Simvastatin, Rosuvastatin 2. Rosuvastatin, Lovastatin, Atorvastatin 3. Atorvastatin, Rosuvastatin, Simvastatin 4. Simvastatin, Atorvastatin, Lovastatin Chapter 40. Hypertension 1. Because primary hypertension has no identifiable cause, treatment is based on interfering with the physiological mechanisms that regulate blood pressure. Thiazide diuretics treat hypertension because they: 1. Increase renin secretion 2. Decrease the production of aldosterone 3. Deplete body sodium & reduce fluid volume 4. Decrease blood viscosity 2. Because of its action on various body systems, the patient taking a thiazide or loop diuretic may also need to receive the following supplement: 1. Potassium 2. Calcium 3. Magnesium 4. Phosphates 3. All patients with hypertension benefit from diuretic therapy, but those who benefit the most are: 1. Those with orthostatic hypertension 2. African Americans 3. Those with stable angina 4. Diabetics 4. Beta blockers treat hypertension because they: 1. Reduce peripheral resistance 2. Vasoconstrict coronary arteries 3. Reduce norepinephrine 4. Reduce angiotensin II production 5. Which of the following disease processes could be made worse by taking a nonselective beta blocker? 1. Asthma 2. Diabetes 3. Both might worsen 4. Beta blockade does not affect these disorders 6. Disease states in addition to hypertension in which beta blockade is a compelling indication for the use of beta blockers include: 1. Heart failure 2. Angina 3. Myocardial infarction 4. Dyslipidemia 7. Angiotensin-converting enzyme(ACE) inhibitors treat hypertension because they: 1. Reduce sodium & water retention 2. Decrease vasoconstriction 3. Increase vasodilation 4. All of the above 8. Compelling indications for an ACE inhibitor as treatment for hypertension based on clinical trials includes: 1. Pregnancy 2. Renal parenchymal disease 3. Stable angina 4. Dyslipidemia 9. An ACE inhibitor & what other class of drug may reduce proteinuria in patients with diabetes better than either drug alone? 1. Beta blockers 2. Diuretics 3. Nondihydropyridine calcium channel blockers 4. Angiotensin II receptor blockers 10. If not chosen as the first drug in hypertension treatment, which drug class should be added as a second step because it will enhance the effects of most other agents? 1. ACE inhibitors 2. Beta blockers 3. Calcium channel blockers 4. Diuretics 11. Treatment costs are important for patients with hypertension. Which of the following statements about cost is NOT true? 1. Hypertension is a chronic disease where patients may be taking drugs for a long time. 2. Most patients will require more than one drug to treat the hypertension. 3. The cost includes the price of any routine or special laboratory tests that a specific drug may require. 4. Few antihypertensive drugs come in generic formulations. 12. Caffeine, exercise, & smoking should be avoided for at least how many minutes before blood pressure measurement? 1. 15 2. 30 3. 60 4. 90 13. Blood pressure checks in children: 1. Should occur with their annual physical examinations after 6 years of age 2. Require a blood pressure cuff that is one-third the diameter of the child’s arm 3. Should be done during every health-care visit after 3 years of age 4. Require additional laboratory tests such as serum creatinine 14. Lack of adherence to blood pressure management is very common. Reasons for this lack of adherence include: 1. Lifestyle changes are difficult to achieve & maintain. 2. Adverse drug reactions are common & often fall into the categories more associated with nonadherence. 3. Costs of drugs & monitoring with laboratory tests can be expensive. 4. All of the above 15. Lifestyle modifications for patients with prehypertension or hypertension include: 1. Diet & increase exercise to achieve a BMI greater than 25. 2. Drink 4 ounces of red wine at least once per week. 3. Adopt the dietary approaches to stop hypertension (DASH) diet. 4. Increase potassium intake. 16. Which diuretic agents typically do not need potassium supplementation? 1. The loop diuretics 2. The thiazide diuretics 3. The aldosterone inhibitors 4. They all need supplementation 17. Aldactone family medications are frequently used when the hypertensive patient also has: 1. Hyperkalemia 2. Advancing liver dysfunction 3. The need for birth control 4. Rheumatoid arthritis 18. Hypertensive African Americans are typically listed as not being as responsive to which drug groups? 1. ACE inhibitors 2. Calcium channel blockers 3. Diuretics 4. Bidil (hydralazine family of medications) 19. What educational points concerning fluid intake must be covered with diuretic prescriptions? 1. Fluid should be restricted when on them. 2. Fluids should contain at least one salty item daily. 3. Fluid intake should remain near normal for optimal performance. 4. Avoidance of potassium-rich fluids is encouraged. 20. What is a common side effect concern with hypertensive medications & all individuals, but especially the elderly? 1. Risk of falls 2. Triggering of a hypertensive crisis 3. Erectile priapism 4. Risk for bladder cancer development

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