Chapter 27 - Pharmacology for the Primary Care Provider - Test Bank

Chapter 27: Histamine-2 Blockers and Proton Pump Inhibitors Test Bank MULTIPLE CHOICE 1. A patient who has severe arthritis and who takes nonsteroidal antiinflammatory drugs (NSAIDs) daily develops a duodenal ulcer. The patient has tried a cyclooxygenase-2 selective NSAID in the past and states that it is not as effective as the current NSAID. The primary care nurse practitioner (NP) should: a. prescribe cimetidine (Tagamet). b. prescribe omeprazole (Prilosec). c. teach the patient about a bland diet. d. change the NSAID to a corticosteroid. ANS: B Patients with NSAID-induced ulcer should discontinue the NSAID if possible and use an acid suppressant. This patient has severe arthritis and so cannot discontinue the NSAID. In a situation such as this, a PPI is indicated. Cimetidine is a histamine-2 blocker, which would be a second-line choice, but cimetidine has many serious side effects. Bland diets are not effective in treating ulcers. Corticosteroids are not indicated. DIF: Cognitive Level: Applying (Application) REF: 336 - 337 2. A patient is given a diagnosis of peptic ulcer disease. A laboratory test confirms the presence of Helicobacter pylori. The primary care NP orders a proton pump inhibitor (PPI) before meals twice daily, clarithromycin, and amoxicillin. After 14 days of treatment, H. pylori is still present. The NP should order: a. continuation of the PPI for 4 to 8 weeks. b. a PPI, amoxicillin, and metronidazole for 14 days. c. a PPI, clarithromycin, and amoxicillin for 14 more days. d. a PPI, bismuth subsalicylate, tetracycline, and metronidazole. ANS: B A PPI, along with amoxicillin and metronidazole, is used as first-line treatment in macrolide-allergic patients and for re-treatment for 14 days if first-line treatment of choice failed because of occasional resistance to clarithromycin. DIF: Cognitive Level: Applying (Application) REF: 336 3. A patient with a diagnosis of peptic ulcer disease asks the primary care NP about nonpharmacologic treatment. Which statement by the NP is correct? a. ?You should consume a diet that is high in fiber.? b. ?One or two cups of coffee each day won?t hurt you.? c. ?Alcoholic beverages are strictly prohibited when you have an ulcer.? d. ?Lifestyle changes and proper diet may eliminate the need for medication.? ANS: A Balanced meals consumed at regular times that are high in fiber are encouraged. Caffeine increases acid secretion and should be avoided. Patients may consume alcohol in moderation. Although lifestyle changes and proper diet are an integral part of treatment for peptic ulcer disease, they do not eliminate the need for medications. DIF: Cognitive Level: Understanding (Comprehension) REF: 336 4. A patient has NSAID-induced ulcer and has started taking ranitidine (Zantac). At a follow-up appointment 3 days later, the patient reports no alleviation of symptoms. The primary care NP should: a. order cimetidine (Tagamet). b. add metronidazole to the drug regimen. c. change from ranitidine to omeprazole (Prilosec). d. reassure the patient that drug effects take several weeks. ANS: C If the patient does not start to see improvement within a few days after initiation of treatment with a histamine-2 blocker, the provider either should increase the dose of the medication or should change to a PPI. Cimetidine is a histamine-2 blocker and has many serious side effects. Metronidazole is used only when H. pylori is known to be present. Patients should start to get relief within a few days. DIF: Cognitive Level: Applying (Application) REF: 337 5. An 80-year-old patient has a history of renal disease and develops a duodenal ulcer. The primary care NP should order a: a. normal dose of a histamine-2 blocker. b. decreased dose of a histamine-2 blocker. c. normal dose of a PPI. d. decreased dose of a PPI. ANS: C No adjustment of dosage is necessary for older patients taking PPIs. Patients with a history of renal disease may have decreased elimination of histamine-2 blockers, so the NP should avoid these if possible. DIF: Cognitive Level: Applying (Application) REF: 337 6. A patient with peptic ulcer disease is taking a histamine-2 blocker and tells the primary care NP that over-the-counter antacid tablets help with the discomfort. The NP should tell this patient to: a. discontinue the antacid. b. discontinue the histamine-2 blocker. c. take the antacid and the histamine-2 blocker at the same time. d. take the histamine-2 blocker 2 hours before taking the antacid. ANS: D Histamine-2 blockers should not be taken within 2 hours of antacid ingestion because antacids decrease the action of histamine-2 blockers. DIF: Cognitive Level: Applying (Application) REF: 339 7. A patient with erosive esophagitis is taking lansoprazole (Prevacid). The primary care NP performs a medication history and learns that the patient also takes digoxin. The NP should recommend: a. decreasing the dose of digoxin. b. obtaining a serum digoxin level. c. changing the PPI to omeprazole. d. increasing the dose of lansoprazole. ANS: B Because PPIs decrease gastric acid, they may interfere with the absorption of drugs that require absorption in an acid stomach, including digoxin. It may be necessary to increase the dose of digoxin but not before obtaining a serum digoxin level. All PPIs have this effect, so changing to another PPI would not solve the problem. Increasing the dose of lansoprazole would decrease the absorption of digoxin. DIF: Cognitive Level: Applying (Application) REF: 339 8. A postmenopausal woman develops NSAID-induced ulcer. The primary care NP should prescribe: a. ranitidine (Zantac). b. omeprazole (Prilosec). c. esomeprazole (Nexium). d. pantoprazole (Protonix). ANS: A PPIs carry a possible increased risk of fractures in postmenopausal women. The NP should begin therapy with a histamine-2 blocker, such as ranitidine. DIF: Cognitive Level: Applying (Application) REF: 339