Wikes University. Advanced Pharmacology Exam2

Question 1

Wikes University. Advanced Pharmacology Exam 2 . A 78-year-old female presents to the clinic with complaints of chronic knee pain due to osteoarthritis. She has a past medical history significant for hypertension, peptic ulcer disease, and chronic kidney disease with a creatinine clearance of 45 mL/min. The nurse practitioner plans to initiate pharmacological management for her knee pain. Which of the following medications should the nurse practitioner prescribe with caution due to the patient’s increased risk of adverse gastrointestinal (GI) and renal effects?

• Ibuprofen (motrin®)
• Tramadol (ultram®)
• Prednisone (Deltasone®)
• Acetaminophen (tylenol®)

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Question 2

Which of the following medications has been associated with a high risk of developing a clostridium difficile (C. diff) infection?

• Clindamycin (Cleocin)
• Loperamide (Immodium)
• Oral vancomycin (Firvanq)
• Amoxicillin (Amoxil)

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Question 3

Which of the following best describes the role of a Gram stain?

• Identifies morphologic characteristics of bacteria such as shape and cell wall make up
• Identifies the resistance of an organism
• Identifies the virulence of an organism
• Indentifies if an organism is sensitive to an antibiotic

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Question 4

CG is a 61 yo male with a new diagnosis of osteoporosis (T-score -2.7). His past medical history is significant for gastroesophageal reflux disease and diabetes. His medications include omeprazole (Prilosec) and metformin (Glucophage).

Among other therapies you intend to initiate, calcium supplementation will be included. Which calcium supplement could be taken without regards to meals, not interact with current medications and be a good choice for CG?

• Calcium citrate
• Calcium carbonate
• Calcium gluconate
• Calcium lactate

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Question 5

A 45-year-old female presents to the clinic with complaints of moderate lower back pain following a recent injury while lifting heavy objects. She describes the pain as dull and achy, radiating from her lower back to her right leg. Physical examination reveals tenderness over the lumbar region and limited range of motion. Based on the patient’s presentation, which of the following medications is the most appropriate initial choice for managing her pain?

• Oxycodone (OxyIR®)
• Ibuprofen (Motrin®)
• Hydromorphone (Dilaudid®)
• Morphine (MSIR®)

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Question 6

HP is a 73 yo female who brought to the ED with altered mental status, but is unable to reliably describe any other symptoms. Urinalysis would demonstrate cloudy colored urine, (+) for RBCs, WBCs, nitrites as well as leukocyte esterases. Her culture shows >100,000 bacteria in the urine.

TRUE or FALSE: You would treat this patient for a urinary tract infection (UTI).

• True Wikes University. Advanced Pharmacology Exam 2
• False

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Question 7

An absolute contraindication to the use of triptans would be :

• History of substance abuse
• Concurrent use of acetaminophen
• Previous failure on a similar agent in the same class
• Myocardial infarction or vascular disease

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Question 8

A 55-year-old male presents to the emergency department with a productive cough, fever, and chest pain. A chest X-ray confirms the diagnosis of community-acquired pneumonia (CAP). He is started on antibiotic therapy with levofloxacin. After 48 hours of treatment, the patient’s fever resolves, and his vital signs stabilize. He is afebrile with a heart rate of 90 beats/min, respiratory rate of 22 breaths/min, blood pressure of 120/80 mm Hg, and oxygen saturation of 95% on room air. He is tolerating oral intake well and has normal mental status. What is the appropriate course of action regarding antibiotic therapy for this patient?

• Continue levofloxacin therapy for 14-21 days.
• Continue levofloxacin therapy for a minimum of 5 days. If the patient has been afebrile for 48 to 72 hours and has no more than 1 CAP-associated sign of instability (heart rate ≤ 100 beats/min, respiratory rate ≤ 24 breaths/min, systolic blood pressure ≥ 90 mm Hg, oxygen saturation ≥ 90% on room air, tolerating oral intake or normal mental status), treatment can be discontinued.
• Discontinue levofloxacin therapy immediately
• Switch to a broad-spectrum antibiotic for extended therapy

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Question 9

A 68-year-old female presents with chronic right knee pain that worsens with walking and prolonged standing. She has a history of Osteoarthritis and reports taking Acetaminophen (Tylenol®) as needed with minimal relief. She denies gastrointestinal disease, chronic kidney disease, or cardiovascular disease. Physical examination reveals crepitus and mild joint line tenderness of the knee without erythema or warmth.

What is the most appropriate next pharmacologic step in management?

• Continue Acetaminophen (Tylenol®) as needed for intermittent pain relief and initiate a topical NSAID, such as Diclofenac gel (Voltaren Gel®)applied to the affected knee.
• Begin long-term opioid therapy with Tramadol (Ultram®) for chronic pain control.
• Increase acetaminophen dosing to 4,000 mg daily on a scheduled basis.
• Continue acetaminophen (Tylenol®) as needed because it remains first-line therapy for chronic osteoarthritis pain.

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Question 10

WN is a 66 year old female who complains of symptoms of a “cold” at your clinic today. She’s the local YMCA swim coach and she’s hoping to feel better for next weekend’s swim meet. She has allergic rhinitis chronically, though lately she’s had nasal congestion with purulent nasal/postnasal discharge (yellow in color) and a cough. She complains of pressure in her face and her ears feel like they need to “pop.” She’s had symptoms for 12 days now with little to no improvement and a fever (102.1° F) for the last 24 hours. WN has an allergy to sulfa drugs, cats, and environmental allergies. Her PMH is significant for asthma, hypertension and multiple dental infections / procedures. Her medications include Fluticasone / Salmeterol (Advair Diskus) 250mcg/50mcg one inhalation twice daily, albuterol (Ventolin) HFA 2 puffs as needed for shortness of breath and lisinopril (Zestril) 20 mg by mouth daily.

Which of the following best describes WN’s risk factors for developing acute bacterial rhinosinusitis (ABRS)?

• Swimmer, hypertension, allergic rhinitis
• Cat exposure, asthma, Sulfa allergyWikes University. Advanced Pharmacology Exam 2
• Asthma, female sex, age
• Swimmer, asthma, allergic rhinitis, dental infections / procedures

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Question 11

Which organism is the most common causative organism in community acquired pneumonia (CAP)?

• E Coli
• H. Pylori
• Streptococcus pneumoniae
• Pasturella Multicodia

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Question 12

Patient education should always be provided in conjunction therapeutic lifestyle changes and pharmacotherapeutic interventions. After prescribing which of the following medications for osteoporosis should the patient be instructed as follows: This medication must be taken on an empty stomach, first thing in the morning, with 8 ounces of plain water (no other liquid). After taking this medication, you must wait at least 60 minutes before eating, drinking or taking any other medication. You must remain upright for at least one hour after taking the medication

• Risedronate (Actonel)
• Calcitonin salmon (Miacalcin)

Question 13

BL is an otherwise healthy 6 yo boy who requires an antibiotic for an methicillin-sensitive staphylococcus aureus skin/soft tissue infection (i.e. mild MSSA cellulitis). He has no known medication allergies or significant medical history. Which of the following medications would be the best choice for this patient?

• Cephalexin (Keflex) ✓
• Doxycycline (Vibramycin)
• Levofloxacin (Levaquin)
• Tetracycline (Doryx)

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Question 14

All of the following patients are at risk of developing aspiration pneumonia EXCEPT?

• A patient on omeprazole therapy chronically for GERD
• A patient who does not visit a dentist regularly and has an infected tooth.
• A patient in the ER for seizure with loss of consciousness
• A mobile patient admitted to the hospital for skin/soft tissue infection on their left arm. ✓

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Question 15

LA is 30-year-old pregnant woman. She is 16 weeks pregnant (the start of the second trimester) and reports dysuria at her appointment today. Urinalysis and urine culture are conducted, and she is started on TMP-SMX (Bactrim / Septra) 1 (one) double strength (DS) tablet po bid. Three days later the clinic calls LA to tell her the culture results are back and she needs to change therapy. The culture was positive for E. coli, and it is resistant to TMP-SMX (Bactrim / Septra) only. What would be the new appropriate therapy (drug and duration) for LA?

• Levofloxacin (Levaquin) x 7 days
• TMP-SMX (Bactrim / Septra) x 4 additional days (7 days total)
• Nitrofurantoin (Macrobid) x 7 days ✓
• Amoxicillin +/- clavulanate (Amoxil / Augmentin) x 1 dose

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Question 16

A 55-year-old female presents to the clinic with complaints of knee pain and stiffness, particularly worse in the mornings and with activity. She reports a history of osteoarthritis (OA) in her family and is interested in using dietary supplements to manage her symptoms. Based on the information provided, which of the following statements regarding the use of glucosamine and chondroitin in osteoarthritis is most accurate?

• Glucosamine and chondroitin are contraindicated in patients with hand osteoarthritis.
• Glucosamine and chondroitin are recommended as first-line therapy for knee and hip osteoarthritis.
• Glucosamine and chondroitin have consistent evidence supporting their efficacy in treating all forms of osteoarthritis.
• When used, glucosamine and chondroitin should only adjuncts to evidence-based nonpharmacologic and pharmacologic therapies. ✓

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Question 17

A 45-year-old female presents to the clinic with a history of recurrent migraines. She reports experiencing throbbing headaches associated with nausea, photophobia, and phonophobia, occurring approximately twice a month and lasting for 24-48 hours. Despite trying over-the-counter medications, she finds little relief from her symptoms. Given her history, the nurse practitioner decides to initiate prophylactic therapy for migraine prevention. Which of the following medications might not be the best choice (i.e., relative contraindication) in this patient due to comorbid reactive airway disease (i.e., severe asthma)?

• Verapamil (Calan)
• Topiramate (topamax®)
• Amitriptyline (Elavil®)
• Propranolol (Inderal®) ✓

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Question 18

A 55-year-old female presents to the clinic with complaints of chronic hand pain secondary to osteoarthritis (OA). Despite taking oral NSAIDs, she reports suboptimal pain relief. Although benefits typically are observed only after several weeks of therapy, which of the following medications, used as adjunctive therapy, is a centrally acting option (i.e. modulating pain perception and response through modulation of norepinephrine and serotonin) that may provide moderate benefits on pain, function, and quality of life in patients with OA?

• Glucosamine / Chondroitin (MoveFree®)
• Celecoxib (Celebrex®)
• Duloxetine (Cymbalta®) ✓Wikes University. Advanced Pharmacology Exam 2
• Naproxen (Naprosyn®)

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Question 19

A 45-year-old female presents to the clinic with complaints of persistent headaches for the past two weeks. She describes the pain as sudden and severe, unlike any headache she has experienced before and denies any visual disturbances but reports feeling nauseous during the headaches. The patient has no significant past medical history. Which of the following red flags suggests a potentially serious underlying cause of her headaches?

• Nausea during headaches
• No visual disturbances
• Past medical history of hypertension
• New-onset sudden and severe pain ✓

Question 20

WN is a 54 year old female who complains of symptoms of a “cold” at your clinic today. She’s the local YMCA swim coach and she’s hoping to feel better for next weekend’s swim meet. She has allergic rhinitis chronically, though lately she’s had nasal congestion with purulent nasal/postnasal discharge (yellow in color) and a cough. She complains of pressure in her face and her ears feel like they need to “pop.” She’s had symptoms for 12 days now with little to no improvement and a fever (102.1° F) for the last 24 hours. WN has an allergy to sulfa drugs, cats, and environmental allergies. Her PMH is significant for asthma, hypertension and multiple dental infections / procedures. Her medications include Fluticasone / Salmeterol (Advair Diskus) 250mcg/50mcg one inhalation twice daily, albuterol (Ventolin) HFA 2 puffs as needed for shortness of breath and lisinopril (Zestril) 20 mg by mouth daily. She reports an allergy to sulfa medications.

Which of following regimens would be the best choice to treat her ABRS?

• Amoxicillin/clavulanate (Augmentin)
• Trimethoprim/sulfamethoxazole (Bactrim)
• Clindamycin (Cleocin) ✓
• Gentamicin

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Question 21

TL is a 24 yo male with a mild methicillin-sensitive staphylococcus aureus (MSSA) cellulitis. He has an allergy to penicillins / cephalosporins (anaphylaxis). Which of the following would be the best treatment choice for this patient?

• clindamycin (Cleocin)
• cephalexin (Keflex) ✓
• amoxicillin+clavulanate (Augmentin)
• Fosfomycin (Monurol)

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Question 22

JP, a 17-year-old male, presents with a three-day history of redness, tenderness, and warmth in his left lower leg, where he also reports a spider bite that has not healed properly. Given that the infection is non-purulent and localized, with no systemic signs or symptoms, you suspect an uncomplicated case of cellulitis. Considering JP’s medical background of hypothyroidism, for which he takes levothyroxine, and his obesity, which pathogens are most likely responsible for his cellulitis?

• Staphylococcus aureus and Streptococcus pneumoniae
• Streptococcus pyogenes and Staphylococcus epidermidis
• Staphylococcus aureus and Streptococcus pyogenes ✓
• Escherichia coli and Pseudomonas aeruginosa

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Question 23

JP is a 17-year-old male who complains of redness, tenderness and warmth of his left lower leg which has been spreading for the past 3 days. From your questioning, you discover JP has a recent spider bite in the same area but it never seemed to heal. You suspect that JP has an uncomplicated cellulitis since the infection appears to be localized and JP does not have signs/symptoms of systemic infection. JP has a history of hypothyroidism and obesity. He currently takes levothyroxine (Synthroid) 50 mcg po daily. He has no medication allergies.

What were JP’s risk factors for developing cellulitis?

• age, insect bite (trauma to skin)
• obesity, insect bite (trauma to skin) ✓
• levothyroxine use, insect bite (trauma to skin)
• hypothyroidism, insect bite (trauma to skin)

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Question 24

Which medication is considered to be the drug of choice for children with acute otitis media? Assume no drug allergies or recent antibiotic therapy.

• Azithromycin (Zithromax)
• Metronidazole (Flagyl)
• Amoxicillin (Amoxil) ✓
• Clindamycin (Cleocin)

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Question 25

Which of the following medications would be the safest to use in a patient who has a history of GI ulceration?

• Celecoxib (Celebrex) ✓
• Aspirin (Bayer) [At analgesic and anti-inflammatory doses]
• Naproxen (Aleve)
• Ibuprofen (Motrin, Advil)

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Question 26

The ID physician on your floor comments that your patient has a virulent pathogen that is not resistant to antibiotics. What does this mean?

• The organism will not cause severe disease, and is not easily treated with antibiotics.
• The organism has the ability to cause severe disease, but is easily treated with antibiotics. ✓
• The organism has ability to cause severe disease, and is not easily treated with antibiotics.
• The organism will not cause severe disease, and is easily treated with antibiotics.

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Question 27

A 45-year-old female presents to the clinic with complaints of chronic lower back pain that has been ongoing for the past two years following a motor vehicle accident. She has tried various nonpharmacologic therapies such as physical therapy and acupuncture with limited relief. She expresses interest in exploring opioid therapy for her pain management. Which of the following statements regarding opioid therapy for chronic pain aligns with current CDC recommendations?

• The initial opioid dosage should be the highest possible to provide adequate pain relief.
• Opioid therapy should be considered only if expected benefits for both pain and function are anticipated to outweigh risks to the patient, and it should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. ✓
• Opioid therapy should be initiated as the first-line treatment for chronic pain without considering nonpharmacologic or nonopioid pharmacologic therapies.Wikes University. Advanced Pharmacology Exam 2
• Clinicians should prescribe extended-release/long-acting (ER/LA) opioids when starting opioid therapy for chronic pain.

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Question 28

A 70-year-old postmenopausal woman presents to the clinic with a history of multiple vertebral fractures secondary to osteoporosis. She has not responded adequately to previous oral bisphosphonate therapy. Based on her fracture history and risk profile, the nurse practitioner placed her on anabolic therapy with teriparatide (Forteo®) to improve her bone mineral density (BMD) and reduce fracture risk. She has now completed 2 years of therapy with teriparatide (Forteo®).

What is the most appropriate next step in her management to maintain bone mineral density (BMD) and reduce fracture risk?

• Discontinue all osteoporosis medications and monitor BMD annually.
• Discontinue teriparatide (Forteo®) and begin bisphosphonate therapy to maintain or prevent bone losses and provide further reduction in fracture risk ✓
• Begin calcium and vitamin D supplementation only.
• Continue teriparatide (Forteo®) for another year and re-evaluate at that time

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Question 29

A 60-year-old patient with recurrent gout presents for follow-up. He has no cardiovascular risk factors, normal renal & hepatic function. HLA-B*5801 testing, performed due to his Southeast Asian ancestry, returns positive. The provider wants to initiate urate-lowering therapy.

Which of the following is the most appropriate initial urate-lowering therapy?

• Febuxostat (Uloric®)
• Allopurinol (Zyloprim®) ✓
• Colchicine (Colcrys®)
• Probenecid (Benemid®)

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Question 30

An orthopedic surgeon writes an order for a 85 y/o elderly male patient who is post-op hip replacement. He has acute pain from his procedure (7 on scale 0-10) and no history of chronic pain. The surgeon asks for your opinion on his order. He writes:

Hydrocodone 5mg/Acetaminophen 500mg (Vicodin, Norco) per tablet. Dosage: I-II (One or Two) tablets Q3H (Every Three Hours) as needed for pain.

What is the best response to this order?

• Everything looks fine with this order.
• Hydrocodone is contraindicated for use in elderly patients. I would suggest acetaminophen (Tylenol) alone.
• This order exceeds the maximum recommended dosage of acetaminophen (Tylenol), especially for a patient who is elderly. I would suggest lowering the dose and / or decreasing the frequency of administration. ✓
• Acetaminophen (Tylenol) is contraindicated for use in elderly patients. I would suggest using an NSAID instead.

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Question 31

A 45-year-old male presents to the clinic with complaints of dysuria, urinary frequency, and suprapubic discomfort. Urinalysis reveals pyuria and bacteriuria. Based on the patient’s symptoms and urinalysis findings, the nurse practitioner suspects a urinary tract infection (UTI). Which of the following is the most appropriate treatment approach for this patient?

• Recommend increasing fluid intake and observation without antibiotic therapy
• Prescribe a single dose of trimethoprim/sulfamethoxazole
• Initiate a 3-day course of ciprofloxacin
• Prescribe a 7 to 14-day course of ciprofloxacin ✓

Question 33

A 58-year-old male with a history of gout presents to the clinic complaining of sudden-onset severe pain, redness, and swelling in his left big toe. He reports similar episodes in the past and suspects another gout flare. Based on the ACR guideline recommendation for early management of acute gout flares, which of the following medications would NOT be included in the “medication-in-pocket” strategy for this patient?

• Febuxostat (Uloric®) ✓
• Colchicine (Colcrys®)
• Prednisone (Deltasone®)
• Indomethacin (Indocin®)

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Question 34

Accounting for more than half of the cases, what two bacterial pathogens are most likely to be involved in acute bacterial rhinosinusitis (ABRS)?

• Streptococcus pneumoniae and Haemophilus influenzae ✓
• Staphylococcus aureus and Streptococcus pneumoniae
• Streptococcus pyogenes and Peptostreptococcus
• Staphylococcus aureus and Haemophilus influenzaeWikes University. Advanced Pharmacology Exam 2

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Question 35

Which of the following antibiotics has a drug-drug interaction with antacids, iron and calcium and therefore requires the medications to be separated by at least 2 hours?

• Levofloxacin (Levaquin) ✓
• Trimethoprim/sulfamethoxazole (Bactrim)
• Penicillin V (PenVK)
• Amoxicillin (Amoxil)

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Question 36

Which of the following is the recommended daily calcium and vitamin D intake for a 76 yo woman?

• Calcium 1000 mg, Vitamin D 1000 IU
• Calcium 600 mg, Vitamin D 800 IU
• Calcium 1200 mg, Vitamin D 800 IU ✓
• Calcium 800 mg, Vitamin D 600 IU

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Question 37

A 56-year-old male is hospitalized with community-acquired pneumonia and started on empiric intravenous antimicrobial therapy. After 48 hours of treatment, the provider wants to determine whether the patient is demonstrating an early therapeutic response to the prescribed antimicrobial regimen. Which of the following clinical or laboratory parameters is most appropriate for assessing response to antimicrobial therapy?

• Serial monitoring of serum electrolyte concentrations
• Monitoring of the white blood cell (WBC) count for normalization trends ✓
• Tracking total daily caloric intake to evaluate metabolic recovery
• Routine repeat microbiologic cultures obtained twice daily until negative

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Question 38

A 7-year-old child is evaluated for fever, headache, and a recent history of tick exposure after hiking in a wooded area. The clinician considers several antimicrobial options. One potential medication is generally avoided in pediatric patients younger than 8 years because it chelates calcium and can incorporate into developing teeth, resulting in permanent discoloration and enamel hypoplasia.

Which class of antibiotics is associated with this adverse developmental effect?

• Clindamycin (Cleocin)
• Trimethoprim/sulfamethoxazole (Bactrim)
• Cefdinir (Omnicef)
• Tetracycline ✓

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Question 39

NJ is receiving 40 mg po morphine/day. You wish to convert him to po oxycodone (Oxy IR). Which of the following regimens is the best recommendation for this patient?

Assume a 25% reduction for incomplete cross tolerance. The following conversions are provided for you:

Table

Drug	IV (mg)	Oral (mg)
Morphine	10	30
Oxycodone	N/A	20

(Note: Based on standard conversion calculations — 40 mg oral morphine ≈ 26.7 mg oral oxycodone; with 25% reduction ≈ 20 mg oxycodone/day, typically divided as 5 mg q6h or 10 mg q12h. The most common correct answer choice for this type of question is typically the regimen closest to Oxy IR 5 mg q6h or 10 mg q12h.)

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Question 40

A 65-year-old female presents to the clinic with complaints of chronic joint pain in her knees and hands, which worsens with activity and improves with rest. She reports stiffness in the morning lasting less than 30 minutes. Physical examination reveals bony enlargement of the distal interphalangeal joints and crepitus on movement. Based on the goals of osteoarthritis therapy, which of the following interventions should the nurse practitioner prioritize for this patient?

• Prescribing an opioid analgesic combination such as oxycodone / acetaminophen (Percocet®)
• Implementing a multimodal approach including patient education, exercise, and weight management ✓
• Referral for joint replacement surgery
• Initiation of corticosteroid injections

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Question 41

A 45-year-old female presents to the clinic with complaints of persistent joint pain and swelling in her hands consistent with rheumatoid arthritis. She has a history of intermittent use of over-the-counter ibuprofen for pain relief but reports inadequate symptom control. Based on the information provided, what is the minimal duration that should be considered an adequate trial of oral NSAID therapy for this patient?

• 2-3 weeks ✓
• 2 days
• 3 months
• 1 week

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Question 42

Which of the following medication(s) is a xanthine oxidase inhibitor and can therefore be beneficial in hyperuricemia?

• Aspirin (Bayer)
• Allopurinol (Zyloprim) ✓
• Atorvastatin (Lipitor)Wikes University. Advanced Pharmacology Exam 2
• Niacin (Niaspan)

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Question 43

A 55-year-old male presents to the clinic with complaints of sudden onset severe pain, erythema, and swelling in his right big toe joint. Based on the presenting symptoms, the nurse practitioner suspects an acute gout attack. Which of the following statements regarding the diagnosis of gout is true?

• Gout can only be diagnosed definitively through the presence of hyperuricemia.
• Gout can be presumptively diagnosed based on presenting symptoms, and confirmed later with laboratory and other diagnostic tests. ✓
• Hyperuricemia is present in all patients with signs and symptoms of an acute gout attack.
• Presence of tophi is necessary for the diagnosis of acute gout.

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Question 44

A 45-year-old male presents to the clinic with acute onset of severe pain and swelling in his right great toe. He reports a history of similar episodes in the past, which resolved spontaneously after a few days. On examination, the affected toe is erythematous, warm to touch, and extremely tender to palpation. Laboratory investigations reveal an elevated serum uric acid level. Based on the patient’s presentation and history, the nurse practitioner diagnoses him with acute gouty arthritis. Which of the following treatment options is considered first-line monotherapy for this patient’s acute gout flare?

• Hydroxychloroquine (Plaquenil®)
• Methotrexate (Trexall®)
• Colchicine (Colcrys®) ✓
• Allopurinol (Zyloprim®)

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Question 45

A 62-year-old patient presents with acute gout flare in the right first metatarsophalangeal joint. In addition to pharmacologic management, which of the following is considered an evidence-based nonpharmacologic intervention to help alleviate symptoms?

• Increasing intake of foods high in purines (e.g., red meat, organ meats, shellfish)
• Engaging in high-impact weight-bearing exercise during the flare
• Substituting beer or wine with spirits (hard alcohol)
• Applying cold therapy (ice packs) to affected joints as tolerated ✓

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Question 46

A patient is prescribed his first prescription for allopurinol (Zyloprim®). Which statement below is NOT correct regarding this medication?

• Allopurinol (Zyloprim®) may be started during an acute gout attack only if anti-inflammatory treatment is also initiated, because sudden shifts in sUA levels from mobilization of tissue urate stores may precipitate or exacerbate gouty arthritis
• The American College of Rheumatology (ACR) endorses a proactive “treat-to-target” approach to urate lowering therapy. Therefore, serum uric acid (sUA) levels need to be monitored every 2 to 5 weeks during initiation then every 6 months after the target sUA is achieved
• Patients should be educated to “Report any rash or skin changes to your healthcare provider immediately.” A generalized, maculopapular rash occurs in about 2% of patients, but can progress to severe skin reactions such as Stevens-Johnson syndrome
• Patients can be told “You can stop the medication once your gout symptoms improve.” ✓

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Question 47

A 35-year-old female presents to the clinic with complaints of recurrent severe headaches associated with nausea, photophobia, and phonophobia. She reports that these headaches often interfere with her ability to work and perform daily activities. Based on the patient’s history and symptomatology, the nurse practitioner suspects migraines. Which of the following treatment strategies would be most appropriate for aborting this patient’s severe acute migraines?

• Prescribing a triptan for use at the onset of severe migraine attacks ✓
• Recommending lifestyle modifications to prevent migraine triggers
• Using corticosteroids as prophylactic therapy for migraine prevention
• Administering OTC NSAIDs (e.g., Ibuprofen (Motrin / Advil®) 200mg) at the onset of headache

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Question 48

SM is a 35 yo female with a history of migraine headaches with aura for about 10 years. She is a nonsmoker and limits her alcohol intake to about 2 drinks/month. Her diet includes regular soda (caffeine free) and regular coffee (caffeinated). She eats chocolate frequently, in part due to recent stress. SM exercises frequently and is an avid, well-trained endurance runner. She usually uses Excedrin Migraine (acetaminophen/caffeine/aspirin) for her symptoms, though her migraines are more frequent (2-3 per week) in the past few months.

You decide to discuss headache triggers with SM. Which of the following is likely a headache trigger for SM?

• Chocolate ✓
• Smoking
• Alcohol
• Soda

Question 49

A 68-year-old man presents to your clinic complaining of excruciating pain in his left big toe. After being diagnosed with an acute gout flare, his provider wants to start him on therapy. A prescription for indomethacin (Indocin®), a typical NSAID used in gouty flares, is ordered.

Not long after the patient leaves the clinic (~90 minutes), as the provider on duty, you receive a call from the pharmacist questioning the order. After reviewing the medical record, you see that the patient is also being treated for a recent gastrointestinal (GI) bleed with a proton pump inhibitor (PPI) prescribed by a GI specialist. His past medical history also includes acute blood loss anemia, hypertension (well controlled), hyperlipidemia, and chronic kidney disease.

Considering his age, comorbidities, safety and efficacy, which of the following is the most appropriate response to the pharmacists inquiry?

• Tell the pharmacist that he/she has no authority to question any providers orders, you will be reporting them to the state licensing board and to fill the original prescription as is.
• After reviewing the patient’s medical record, please dispense the nonsteroidal anti-inflammatory drug (NSAID) therapy as previously ordered
• After reviewing the patient’s medical record, please disregard the order for indomethacin (Indocin®). Prednisone (Deltasone) 40mg daily until flare resolution begins, followed by taper, will be ordered in its place
• After reviewing the patient’s medical record, please disregard the order for indomethacin (Indocin®). Allopurinol (Zyloprim) 300mg daily will be ordered in its place

Question 50

A 45-year-old female presents to the clinic with complaints of severe pain in her lower back, radiating down her left leg. She describes the pain as burning and shooting, with occasional numbness and tingling. Physical examination reveals decreased sensation in the left L5 dermatome and diminished reflexes in the left lower extremity. Based on these findings, the nurse practitioner suspects lumbar radiculopathy. Which of the following medications would be the most effective for managing the patient’s neuropathic pain?

• Naproxen (Naprosyn® / Aleve®)
• Ibuprofen (Motrin®)
• Celecoxib (Celebrex®)
• Amitriptyline (Elavil®)

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