FNP pharm GI, laxative, diarrhea, Peptic ulcer meds-PPI

A primary care nurse practitioner (NP) sees a patient who is concerned about constipation. The NP learns that the patient has three to four bowel movements per week with occasional hard stools but no straining with defecation. The NP should recommend:

a.

increased intake of fluids and fiber.

b.

docusate sodium (Colace) as needed.

c.

psyllium (Metamucil) on a daily basis.

d.

polyethylene glycol (MiraLAX) as needed.

ANS: A

The objective definition of constipation is two or fewer bowel movements per week or excessive straining. This patient does not meet these criteria, so the NP should recommend increasing fluids and fiber to help soften stools. Laxatives should not be used unless constipation is present or is chronic to avoid laxative dependence.

DIF: Cognitive Level: Applying (Application) REF: 341

A patient reports having occasional acute constipation with large, hard stools and pain and asks the primary care NP about medication to treat this condition. The NP learns that the patient drinks 1500 mL of water daily; eats fruits, vegetables, and bran; and exercises regularly. The NP should recommend:

a.

a daily bulk laxative.

b.

long-term docusate sodium.

c.

a saline laxative as needed.

d.

glycerin suppositories as needed.

ANS: C

Mild short-term constipation may be treated with a saline laxative or a bulk laxative as needed. Daily laxatives are not recommended. Glycerin suppositories can cause irritation of the rectum with long-term use.

DIF: Cognitive Level: Applying (Application) REF: 344

A 5-year-old child has chronic constipation. The primary care NP plans to prescribe a laxative for long-term management. In addition to pharmacologic therapy, the NP should also recommend _____ g of fiber per day.

a.10

b.15

c.20

d.25

ANS: A

Each day a child should receive 1 g of fiber per year of age plus 5 g after 2 years of age.

DIF: Cognitive Level: Applying (Application) REF: 343

A patient who has cerebral palsy is wheelchair dependent and receives enteral nutrition via a gastrostomy tube. The patient has infrequent, hard bowel movements despite using a high-fiber formula and receiving 1500 mL of fluid per day. The NP should order:

a.

bisacodyl (Dulcolax).

b.

docusate sodium (Colace).

c.

polyethylene glycol (MiraLAX).

d.

sodium phosphate (Fleets) enema.

ANS: C

Fluids, fiber, and exercise, which help most people, are not applicable to people who are wheelchair bound. Other individuals with congestive heart failure are unable to tolerate these mechanisms.

Osmotic laxatives, such as polyethylene glycol are used to manage long-term constipation. It is essential for clinicians to know their patients and assess what is reasonable for them to do.

DIF: Cognitive Level: Applying (Application) REF: 345

A primary care NP sees a patient who reports having decreased frequency of stools over the past few months. In the clinic today, the patient has severe abdominal cramping and an abdominal radiograph shows an increased stool load in the sigmoid colon and rectum. The NP should:

a.

give magnesium hydroxide (Milk of Magnesia).

b.

start daily methylcellulose (Citrucel) and increased fluids.

c.

order a sodium phosphate enema and psyllium (Metamucil).

d.

recommend polyethylene glycol (MiraLAX) and 2000 mL of fluid daily.

ANS: C

If a patient is severely constipated, an enema is indicated. When there is underlying chronic constipation, long-term management may be necessary. Bulk laxatives, such as psyllium, are first-line treatments for long-term constipation.

A female patient who is underweight tells the primary care NP that she has been using bisacodyl (Dulcolax) daily for several years. The NP should:

a.

prescribe docusate sodium (Colace) and decrease bisacodyl gradually.

b.

suggest she use polyethylene glycol (MiraLAX) on a daily basis instead.

c.

tell her that long-term use of suppositories is safer than long-term laxative use.

d.

counsel the patient to discontinue the laxative and increase fluid and fiber intake.

ANS: A

Patients who abuse laxatives are at risk for cathartic colon and for electrolyte imbalances. These patients should be weaned from their stimulant laxative and placed on safer long-term laxatives, such as a bulk laxative or stool softener.

Polyethylene glycol is a stimulant. Long-term use of suppositories causes rectal irritation. Discontinuing the laxative without a long-term laxative will lead to rebound constipation.

DIF:Cognitive Level: Applying (Application)

A patient who has a history of chronic constipation uses a bulk laxative to prevent episodes of acute constipation. The patient reports having an increased frequency of episodes. The primary care NP should recommend:

a.

adding docusate sodium (Colace).

b.

polyethylene glycol (MiraLAX) and bisacodyl (Dulcolax).

c.

lactulose (Chronulac) and polyethylene glycol (MiraLAX).

d.

adding nonpharmacologic measures such as biofeedback.

ANS: A

Patients treated for long-term constipation should begin with a bulk laxative. If that is not effective, the addition of a second laxative may be necessary. Using two laxatives from the same category is not recommended. A stool softener, such as docusate sodium, is appropriate. Bisacodyl is not a second-line treatment. Lactulose and polyethylene glycol are from the same category.

A patient who takes digoxin reports taking psyllium (Metamucil) three or four times each month for constipation. The primary care NP should counsel this patient to:

a.

decrease fluid intake to avoid cardiac overload.

b.

change the laxative to docusate sodium (Colace).

c.

take the digoxin 2 hours before taking the psyllium.

d.

ask the cardiologist about taking an increased dose of digoxin.

ANS: C

Laxatives can affect the absorption of drugs in the intestine by decreasing transit time. Digoxin is a drug that is affected by decreased transit time. Patients should be counseled to take the drugs 2 hours apart.

A patient in the clinic reports frequent episodes of bloating, abdominal pain, and loose stools to the primary care nurse practitioner (NP). An important question the NP should ask about the abdominal pain is:

a.

the relation of the pain to stools.

b.

what time of day the pain occurs.

c.

whether the pain is sharp or diffuse.

d.

the age of the patient when the pain began.

ANS: A

The new Rome II guidelines maintain that irritable bowel syndrome (IBS) of any subtype is characterized by a strong relationship between abdominal pain and defecation because of visceral hypersensitivity to gut-related events. The other characteristics of pain may be assessed to help guide management of IBS, but the first is necessary for a correct diagnosis.

DIF: Cognitive Level: Applying (Application) REF: 362 - 363

A patient has been diagnosed with IBS and tells the primary care NP that symptoms of diarrhea and cramping are worsening. The patient asks about possible drug therapy to treat the symptoms. The NP should prescribe:

a.

mesalamine (Asacol).

b.

dicyclomine (Bentyl).

c.

simethicone (Phazyme).

d.

metoclopramide (Reglan).

ANS: B

Dicyclomine has indirect and direct effects on the smooth muscle of the gastrointestinal (GI) tract. Both actions help to relieve smooth muscle spasm.

Mesalamine is used to treat ulcerative colitis.

Simethicone acts locally to treat symptoms of trapped air and gas.

Metoclopramide is used to increase motility.

A woman with IBS has been taking antispasmodic medications and reports some relief, but she tells the primary care NP that the disease is interfering with her ability to work because of increased pain. The NP should consider prescribing:

a.

alosetron (Lotronex).

b.

misoprostol (Cytotec).

c.

simethicone (Phazyme).

d.

tricyclic antidepressants (TCAs).

ANS: D

TCAs and selective serotonin reuptake inhibitors (SSRIs) have been shown to reduce symptoms and are useful for long-term treatment.

Alosetron is ordered by a GI specialist if symptoms are resistant to all other interventions and has been shown to be effective in women with diarrhea-predominant IBS. Misoprostol is used to treat NSAID-induced ulcers. Simethicone acts locally to treat symptoms of trapped air and gas.

A patient who has IBS experiences diarrhea, bloating, and pain but does not want to take medication. The primary care NP should recommend:

a.

25 g of fiber each day.

b.

avoiding gluten and lactose in the diet.

c.

increasing water intake to eight to ten glasses per day.

d.

beginning aerobic exercise, such as running, every day.

ANS: A

A diet with adequate fiber is the cornerstone of treatment, and 25 g per day is recommended. Unless the patient has a documented gluten or lactose malabsorption, avoiding these substances is not recommended. Water intake should be six to eight glasses per day. Regular walking is usually the best exercise.

A patient who has IBS has been taking dicyclomine and reports decreased pain and diarrhea but is now having occasional constipation. The primary care NP should recommend:

a.

beginning treatment with an SSRI.

b.

beginning therapy with a TCA.

c.

over-the-counter (OTC) laxatives as needed when constipated.

d.

increasing the amounts of raw fruits and vegetables in the diet.

ANS: C

Patients who experience constipation may use OTC laxatives as needed. Antidepressants, such as SSRIs or TCAs, are used long-term to help with pain. Raw fruits and vegetables can increase the likelihood of bloating.

A patient takes an antispasmodic and an occasional antidiarrheal medication to treat IBS. The patient comes to the clinic and reports having dry mouth, difficulty urinating, and more frequent constipation. The primary care NP notes a heart rate of 92 beats per minute. The NP should:

a.

prescribe a TCA.

b.

discontinue the antidiarrheal medication.

c.

encourage the patient to increase water intake.

d.

lower the dose of the antispasmodic medication.

ANS: D

Patients taking antispasmodic medications should be monitored for anticholinergic side effects, such as increased heart rate, dry mouth, difficulty urinating, and constipation. The NP should lower the dose if needed. TCAs are used to treat pain long-term. Because the antidiarrheal medication is used as needed, there is no reason to discontinue it. Increasing water intake may improve symptoms associated with side effects but would not treat the underlying cause of these symptoms.

A woman has severe IBS and takes hyoscyamine sulfate (Levsin), simethicone (Phazyme), and a TCA. She reports having continued severe diarrhea. The primary care NP should:

a.

order diphenoxylate (Lomotil).

b.

prescribe alosetron after ruling out pregnancy.

c.

refer her to a gastroenterologist for endoscopy.

d.

increase the fiber in her diet to 30 g per day.

ANS: C

Alosetron is given only to women with severe chronic diarrhea-predominant IBS and only after anatomic or biochemical abnormalities of the GI tract have been excluded. Because this woman's symptoms are persistent and severe, diphenoxylate and increased dietary fiber are not indicated.

A patient who has diabetic gastroparesis sees a gastroenterology specialist who orders metoclopramide (Reglan). Within 24 hours, the patient describes having extrapyramidal symptoms (EPS) to the primary care NP. The NP will contact the gastroenterologist and should expect to prescribe:

a.

benztropine (Cogentin).

b.

cimetidine.

c.

an SSRI antidepressant.

d.

a TCA.

ANS: A

Cogentin is indicated to treat EPS side effects of medications such as metoclopramide. The patient should be monitored during the first 24 to 48 hours for any adverse reactions. Should EPS occur, treat with intramuscular diphenhydramine (Benadryl) 50 mg or benztropine (Cogentin) 1 to 2 mg

A woman is in her first trimester of pregnancy. She tells the primary care nurse practitioner (NP) that she continues to have severe morning sickness on a daily basis. The NP notes a weight loss of 1 pound from her previous visit 2 weeks prior. The NP should consult an obstetrician and prescribe:

a.

aprepitant (Emend).

b.

ondansetron (Zofran).

c.

scopolamine transdermal.

d.

prochlorperazine (Compazine).

ANS: B

No antiemetic drugs should be used for nausea and vomiting during pregnancy unless approved by an obstetrician. Ondansetron has been shown to be safe and effective (off-label) for hyperemesis gravidum.

A primary care NP sees a patient who is about to take a cruise and reports having had motion sickness with nausea on a previous cruise. The NP prescribes the scopolamine transdermal patch and should instruct the patient to apply the patch:

a.

daily.

b.

every 3 days.

c.

as needed for nausea.

d.

1 hour before embarking.

ANS: B

The transdermal system allows steady-state plasma levels of scopolamine to be reached rapidly and maintained for 3 days. The onset of action is approximately 4 hours. The patch should be changed every 3 days and left on at all times, not as needed.

A primary care NP sees a patient 2 days after an outpatient surgical procedure. The patient reports using ondansetron for nausea. The NP notes a blood pressure of 88/56 mm Hg, and the patient reports feeling faint. The NP should suspect:

a.

hemorrhage.

b.

dehydration.

c.

drug toxicity.

d.

drug interaction.

ANS: C

Hypotension and faintness are signs of overdose of ondansetron, and drug toxicity is the more likely cause of this patient's decrease in blood pressure.

A patient reports having episodes of dizziness, nausea, and lightheadedness and describes a sensation of the room spinning when these occur. The primary care NP will refer the patient to a specialist who, after diagnostic testing, is likely to prescribe:

a.

meclizine.

b.

ondansetron.

c.

scopolamine.

d.

dimenhydrinate.

ANS: A

Patients with vertigo may experience whirling or a feeling of the room spinning around. In true vertigo, the patient can identify the direction in which the room is spinning. Anticholinergics are the most effective agents in cases of motion sickness or vertigo. Meclizine has a specific indication to treat vertigo.

A patient is in the clinic complaining of nausea and vomiting that has lasted 2 to 3 days. The patient has dry oral mucous membranes, a blood pressure of 90/56 mm Hg, a pulse of 96 beats per minute, and a temperature of 38.8° C. The primary care NP notes a capillary refill of greater than 3 seconds. The NP should:

a.

obtain a complete blood count and serum electrolytes.

b.

prescribe a rectal antiemetic medication.

c.

admit to the hospital for intravenous (IV) rehydration.

d.

encourage the patient to take small, frequent sips of Gatorade.

ANS: C

If vomiting is not controlled, dehydration may occur. Patients who are dehydrated, as this patient is, must be treated with IV fluids in a hospital or emergency department setting.

A patient who is about to begin chemotherapy expresses concern to the primary care NP about gastrointestinal side effects of the treatments. The NP should reassure the patient that:

a.

most newer chemotherapeutic agents do not cause nausea and vomiting.

b.

antiemetics will be administered as needed if nausea and vomiting occur.

c.

taking ondansetron before chemotherapy decreases nausea and vomiting.

d.

a scopolamine patch is an effective way to prevent nausea and vomiting.

ANS: C

In many situations, nausea and vomiting may be anticipated. These situations may involve motion sickness or chemotherapy. Premedicating the patient with an antiemetic may be necessary in order for the patient to receive full therapy; this is the current standard of care. Although most chemotherapeutic agents have emetogenic potential, the use of premedication with 5-HT3 receptor antagonists significantly decreases the nausea and vomiting experienced during and after administration The most common agent in this class, ondansetron, is now available as a generic.

A primary care NP sees a 3-year-old patient who has been vomiting for several days. The child has had fewer episodes of vomiting the past day and is now able to take sips of fluids without vomiting. The child has dry oral mucous membranes, 2-second capillary refill, and pale but warm skin. The child's blood pressure is 88/46 mm Hg, the heart rate is 110 beats per minute, and the temperature is 37.2° C. The NP should:

a.

prescribe promethazine.

b.

prescribe a scopolamine patch.

c.

begin oral rehydration therapy.

d.

send the child to the hospital for IV fluids.

ANS: C

The use of antiemetics in children is discouraged for cases of uncomplicated vomiting. The child has compensated, mild dehydration and is now able to tolerate fluids, so oral rehydration is indicated.

A woman who is 4 months pregnant comes to the clinic with acute diarrhea and nausea. Her husband is experiencing similar symptoms. The primary care nurse practitioner (NP) notes a temperature of 38.5° C, a heart rate of 92 beats per minute, and a blood pressure of 100/60 mm Hg. The NP should:

a.

prescribe attapulgite to treat her diarrhea.

b.

obtain a stool culture and start antibiotic therapy.

c.

instruct her to replace lost fluids by drinking Pedialyte.

d.

refer her to an emergency department for intravenous (IV) fluids.

ANS: D

Diarrhea in pregnant women can have serious consequences, and the patient may need to be referred. This woman is showing signs of dehydration and needs IV rehydration. Attapulgite is a category B drug for pregnancy and should be avoided if possible. Acute diarrhea is usually viral, and antibiotics are not given unless a stool culture is performed and is positive. Because the patient is pregnant and has nausea, oral rehydration would not be effective.

A patient has been taking antibiotics to treat recurrent pneumonia. The patient is in the clinic after having diarrhea for 5 days with six to seven liquid stools each day. The primary care NP should:

a.

obtain a stool specimen and order vancomycin.

b.

order testing for Clostridium difficile and consider metronidazole therapy.

c.

prescribe diphenoxylate (Lomotil) to provide symptomatic relief.

d.

reassure the patient that diarrhea is a common side effect of antibiotic therapy.

ANS: B

The guidelines for treatment of diarrhea emphasize comprehensive evaluation before treatment begins. Antibiotic use points to C. difficile as a possible cause, and metronidazole is often used to treat mild to moderate infection. Vancomycin is used when C. difficile is severe. Diphenoxylate can worsen the infection because it slows transit time of the bacteria in the gut. Prolonged diarrhea during antibiotic therapy should be investigated.

A patient who has had four to five liquid stools per day for 4 days is seen by the primary care NP. The patient asks about medications to stop the diarrhea. The NP tells the patient that antidiarrheal medications are:

a.

not curative and may prolong the illness.

b.

useful in cases of acute infection with elevated temperature.

c.

most beneficial when symptoms persist longer than 2 weeks.

d.

useful when other symptoms, such as hematochezia, develop.

ANS: A

Treatment of patients with acute diarrhea with antidiarrheals can prolong infection and should be avoided if possible. Antidiarrheals are best used in patients with mild to moderate diarrhea and are used for comfort and not cure. They should not be used for patients with bloody diarrhea or high fever because they can worsen the disease. Prolonged diarrhea can indicate a more serious cause, and antidiarrheals should not be used in those cases.

A patient who has experienced five to seven liquid stools for 3 days is seen in the clinic by the primary care NP. The patient reports having had fever, mucoid stools, and nausea without vomiting. The patient has been drinking Gatorade to stay hydrated. The NP obtains a stool specimen for culture and should prescribe:

a.

diphenoxylate (Lomotil).

b.

attapulgite (Kaopectate).

c.

bismuth subsalicylate (Pepto-Bismol).

d.

loperamide hydrochloride (Imodium).

ANS: C

Bismuth reduces symptoms through antidiarrheal and antibacterial properties and can decrease nausea and vomiting. Opioid antidiarrheals should be given after the cause of infectious diarrhea is treated; these can actually prolong symptoms because they slow transit of the causative organisms through the gut. Attapulgite can be used because it binds bacteria and toxins in the gastrointestinal tract, but bismuth is a better choice in this case because it helps to treat nausea. The patient is drinking Gatorade and is getting electrolyte replacement.

A 2-year-old child has chronic "toddler's" diarrhea, which has an unknown but benign etiology. The child's parent asks the primary care NP if a medication can be used to treat the child's symptoms. The NP should recommend giving:

a.

diphenoxylate (Lomotil).

b.

attapulgite (Kaopectate).

c.

an electrolyte solution (Pedialyte).

d.

bismuth subsalicylate (Pepto-Bismol).

ANS: C

Antidiarrheals are not recommended in children. Opioids are contraindicated in children younger than 2 years. Bismuth and attapulgite are not recommended in children younger than 3 years of age. Oral rehydration with electrolyte solution is safe for young children.

DIF: Cognitive Level: Applying (Application) REF: 353

A patient comes to the clinic with a 4-day history of 10 to 12 liquid stools each day. The patient reports seeing blood and mucus in the stools. The patient has had nausea but no vomiting. The primary care NP notes a temperature of 37.9° C, a heart rate of 96 beats per minute, and a blood pressure of 90/60 mm Hg. A physical examination reveals dry oral mucous membranes and capillary refill of 4 seconds. The NP's priority should be to:

a.

obtain stool cultures.

b.

begin rehydration therapy.

c.

consider prescribing metronidazole.

d.

administer opioid antidiarrheal medications.

ANS: B

Acute diarrhea is usually mild and self-limited. Nonpharmacologic measures, especially bowel rest and adequate hydration, are helpful and should be a priority. Stool cultures may be ordered after hydration therapy is begun. Metronidazole is indicated if C. difficile is present. Opioid antidiarrheals may prolong symptoms.

A 12-year-old patient has acute diarrhea and an upper respiratory infection. Other family members have had similar symptoms, which have resolved. The primary care NP should recommend:

a.

diphenoxylate (Lomotil).

b.

attapulgite (Kaopectate).

c.

an electrolyte solution (Pedialyte).

d.

bismuth subsalicylate (Pepto-Bismol).

ANS: C

Antidiarrheals are not generally recommended in children. Bismuth is not recommended in children younger than 16 years of age with viral illnesses because it can mask symptoms of Reye's syndrome. Oral rehydration with electrolyte solution is safe.

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.

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.

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

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.

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.

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.

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.

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

A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that:

a.

a fundoplication will be necessary to correct the cause of GERD.

b.

over-the-counter (OTC) antacids can be effective and should be tried first.

c.

elevation of the head of the bed at night can relieve most symptoms.

d.

a combination of lifestyle changes, medications, and surgery may be necessary.

ANS: D

People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids are sometimes used but are rarely used as first-line treatment.

DIF: Cognitive Level: Applying (Application) REF: 329

A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums:

a.

can help to heal erosions in esophageal tissue.

b.

do not help reduce symptoms of erosive esophagitis.

c.

neutralize stomach acid as well as proton pump inhibitors (PPIs).

d.

help reduce symptoms in conjunction with PPIs.

ANS: D

Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI.

A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and reports a decrease in symptoms. The patient asks the primary care NP if the medication may be discontinued. The NP should tell the patient that:

a.

the dose may be decreased for long-term therapy.

b.

antireflux surgery must be done before the PPI can be discontinued.

c.

the condition may eventually be cured, but therapy must continue for years.

d.

once the symptoms have cleared completely, the medication may be discontinued.

ANS: A

Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy should be continued long-term and titrated down to the lowest effective dose based on symptom control. PPI therapy is considered safer than surgery and should be tried first before surgery is performed. GERD is a lifelong syndrome and is not curable.

A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend:

a.

antacid therapy as needed.

b.

changes in diet to avoid acidic foods.

c.

daily treatment with a PPI.

d.

consultation with a gastroenterologist for endoscopy.

ANS: C

This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications.

Changes in diet are not recommended as treatment but may help with symptoms.

Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy.

A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in symptoms. The next response of the primary care NP is to:

a.

add a histamine-2-receptor agonist.

b.

increase the dose of the PPI.

c.

change to long-term, low-dose PPI therapy.

d.

refer the patient to an endocrinologist for endoscopy and further management.

ANS: A

If treatment with a PPI is inadequate by 2 months, antihistmine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated.

Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis.

When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist.

A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to:

a.

change to aluminum hydroxide (Amphojel).

b.

use magnesium hydroxide (Milk of Magnesia) instead.

c.

continue using sodium bicarbonate (Alka-Seltzer) as needed.

d.

take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer).

ANS: D

Sodium bicarbonate is NOT suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances.

An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:

a.

calcium carbonate (Tums).

b.

aluminum hydroxide (Amphojel).

c.

sodium bicarbonate (Alka-Seltzer).

d.

magnesium hydroxide (Milk of Magnesia).

ANS: A

Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients.

Aluminum hydroxide is not as effective as calcium carbonate.

DIF: Cognitive Level: Applying (Application) REF: 330