1.A patient who has diabetes reports intense discomfort when needing to void. A urinalysis
is normal. To treat this, the primary care NP should consider prescribing: oxybutynin
chloride (Ditropan XL).
This patient is describing urge incontinence, or overactive bladder, which occurs when
the detrusor muscle is hyperactive, causing an intense urge to void before the bladder is
full. Urge incontinence is associated with many conditions, including diabetes.
Oxybutynin chloride, which is an anticholinergic, acts to decrease detrusor overactivity
and is indicated for treatment of urge incontinence. Flavoxate is used to treat dysuria
associated with UTI. Bethanechol is indicated for urinary retention. Phenazopyridine is
used to treat dysuria.
2.A patient reports difficulty returning to sleep after getting up to go to the bathroom every
night. A physical examination and a sleep hygiene history are noncontributory. The
primary care NP should prescribe: ZolpiMist.
ZolpiMist oral spray is useful for patients who have trouble returning to sleep in the
middle of the night. Zaleplon and ramelteon are used for insomnia caused by difficulty
with sleep onset. Chloral hydrate is not typically used as outpatient therapy.
3.A 5-year-old child who has no previous history of otitis media is seen in clinic with a
temperature of 100° F. The primary care NP visualizes bilateral erythematous,
nonbulging, intact tympanic membranes. The child is taking fluids well and is playing
with toys in the examination room. The NP should: initiate antibiotic therapy if the
child’s condition worsens.
Signs and symptoms of otitis media that indicate a need for antibiotic treatment include
otalgia, fever, otorrhea, or a bulging yellow or red tympanic membrane. This child has a
low-grade fever, no history of otitis media, a nonbulging tympanic membrane, and no
otorrhea, so watchful waiting is appropriate. When an antibiotic is started, amoxicillin is
the drug of choice.
4.An 80-year-old patient with congestive heart failure has a viral upper respiratory
infection. The patient asks the primary care NP about treating the fever, which is 38.5° C.
The NP should: recommend acetaminophen.
Patients with congestive heart failure may have tachycardia from fever that aggravates
their symptoms, so fever should be treated. High doses should be given with caution in
elderly patients because of possible decreased hepatic function. Antibiotics should not be
given without evidence of bacterial infection.
1
5.A patient who takes levodopa and carbidopa for Parkinson’s disease reports experiencing
freezing episodes between doses. The primary care NP should consider using:
apomorphine.
Apomorphine injection is used for acute treatment of immobility known as “freezing.”
6.A patient is being tapered from long-term therapy with prednisolone and reports weight
loss and fatigue. The primary care NP should counsel this patient to: increase the dose of
prednisolone to the most recent amount taken.
Sudden discontinuation or rapid tapering of glucocorticoids in patients who have
developed adrenal suppression can precipitate symptoms of adrenal insufficiency,
including nausea, weakness, depression, anorexia, myalgia, hypotension, and
hypoglycemia. When patients experience these symptoms during a drug taper, the dose
should be increased to the last dose. Vitamin D deficiency is common while taking
glucocorticoids, but these are not symptoms of vitamin D deficiency. Changing to another
glucocorticoid is not recommended. Patients should be taught to report the side effects so
that action can be taken and should not be told that they are to be expected.
7.The primary care nurse practitioner (NP) sees a 50-year-old woman who reports frequent
leakage of urine. The NP learns that this occurs when she laughs or sneezes. She also
reports having an increased urge to void even when her bladder is not full. She is not
taking any medications. The NP should: prescribe desmopressin (DDAVP).
A focused history with a careful physical examination is essential for determining the
cause of incontinence. Urinalysis can rule out urinary tract infection (UTI), which can
cause incontinence. Medications are prescribed after determining the cause, if any, and
treating underlying conditions. Exercises to strengthen the pelvic muscles are part of
treatment.
8.A 7-year-old patient who has severe asthma takes oral prednisone daily. At a well-child
examination, the primary care NP notes a decrease in the child’s linear growth rate. The
NP should consult the child’s asthma specialist about: giving a double dose of
prednisone every other day.
Administration of a double dose of a glucocorticoid every other morning has been found
to cause less suppression of the HPA axis and less growth suppression in children.
Because the child has severe asthma, an oral steroid is necessary. Growth hormone
therapy is not indicated. Twice-daily dosing would not change the HPA axis suppression.
Read More