ADULT-GERONTOLOGY ACUTE CARE NURSE PRACTITIONER CERTIFICATION QUESTIONS AND ANSWERS

ADULT-GERONTOLOGY ACUTE CARE NURSE PRACTITIONER CERTIFICATION QUESTIONS AND ANSWERS 

Exam 1
1. The patient is a 27-year-old woman who presents to your health care facility
with a history of depressed mood that has worsened during the past few weeks.
She gained 8 kg in the past 2 months; she reports that she is eating when she is
not sleeping. She is very stressed and worried about her job. She has passive
thoughts of harming herself but no definite plan. Her medical history includes
anxiety, and she takes 0.5 mg of alprazolam three times daily. Which medication
is the best to treat this patient?
1. Paroxetine.
2. Fluoxetine.
3. Imipramine.
4. Mirtazapine.
2. Fluoxetine.
Rationale: The patient presents with signs and symptoms of major depressive disorder.
Selective serotonin receptor inhibitors are considered a first-line agent in treatment for
this patient. The patient gained 8 kg in the past 2 months; therefore paroxetine (answer
1) is not recommended for her case because it leads to increased appetite and causes
somnolence. Fluoxetine (answer 2) is the best medication for this patient because it
does not affect weight or appetite. In addition, fluoxetine could concomitantly relieve her
symptoms of anxiety. Imipramine is a tricyclic antidepressant agent (TCA) that has a
warning that patients with passive suicidal ideas should not receive TCAs (answer 3).
Mirtazapine (answer 4), like paroxetine, could increase appetite and lead to weight gain.
2. The patient is a 43-year-old Hispanic man who is getting ready to be
discharged from your health care facility after a myocardial infarction. He has a
23-year history of cigarette smoking and smokes 1 pack/day. He has tried to quit
several times, but he was unsuccessful. He tried 2-mg nicotine gum, and to save
money, he chewed only 6 pieces daily. He has a history of depression along with
his cardiac problems. Which medication is the best for this patient?
1. Nicotine 4-mg gum.
2. Varenicline 0.5 mg once daily.
3. Bupropion SR 150 mg twice daily.
4. Nicotine patch 21 mg/day.
3. Bupropion SR 150 mg twice daily.
Rationale: The patient's previous attempt to quit smoking with nicotine gum was
probably unsuccessful because the gum strength (2 mg) and the frequency of use
(fewer than 9 pieces a day) were too low to manage his nicotine craving; therefore his
previous use of nicotine gum is not a true treatment failure. Varenicline (answer 2) is not
contraindicated because of the cardiac problems, but it is contraindicated because the
patient has a depression history. Bupropion (answer 3) is a better fit because of its
appropriateness for depressive disorders. Nicotine gum (answer 1) or patch (answer 4)
are appropriate and can be added when bupropion fails as monotherapy to treat his
nicotine craving.
3. The patient is a 53-year-old African American woman (weight 95 kg, height 73
inches) who comes to your clinic for management of her type 2 diabetes, mild
congestive heart disease, neuropathy, and recurrent major depression. Her
medications are metformin 1000 mg twice daily, carvedilol 12.5 mg twice daily,
citalopram 40 mg daily, and ramipril 10 mg daily. She still has depressive
symptoms and wants to change her medication. What is the best action for her?
1. Duloxetine.
2. Desipramine.
3. Sertraline.
4. Bupropion.
1. Duloxetine.
Rationale: This patient still has depressive symptoms and diabetic neuropathy;
therefore duloxetine (answer 1) is the best choice for this patient. Although desipramine
(answer 2) could be used for treating her neuropathy, it is not a good choice because of
her heart disease. Sertraline (answer 3) would be a better choice for her depression, but
it does not help diabetic neuropathy. However, bupropion can lead to weight loss, but
data are not strong for treatment of neuropathy (answer 4).
4. The patient is a 58-year-old Asian man with a 25-year history of alcoholic
dependence. He drinks 1 cup of vodka every day. He has tried to quit several
times without success. His laboratory tests reveal aspartate aminotransferase
135 international units/L, alanine aminotransferase 75 international units/L,
albumin 4 g/dL, total bilirubin 0.3 mg/dL, prothrombin time 0.8 seconds, platelet
count 350,000/mm3, and creatinine clearance 35 mL/min. After detoxification,
which maintenance treatment is most appropriate?
1. Chlordiazepoxide.
2. Disulfiram.
3. Naltrexone.
4. Acamprosate.
4. Acamprosate.
Rationale: This patient has alcoholic hepatitis, as indicated by his elevated liver
enzymes; thus it could improve with abstinence. His liver function is normal, as
evidenced by his albumin, prothrombin time. and platelet count. Chlordiazepoxide
(answer 1) has an important role in acute alcohol detoxification, but there are limited
data about its role for the maintenance treatment. Disulfiram (answer 2) requires a
strong recommendation from the patient to abstain. Moreover, it should be used with
caution for patients with active liver disease. Naltrexone (answer 3) should be used with
caution for patients with acute liver disease. Acamprosate (answer 4) is the most
appropriate medication for this patient. In addition, the dose of Acamprosate should be
reduced for patients with a creatinine clearance between 50 and 30 mL/min.

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