Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.  

The nurse practitioner is seeing a 24-year-old man for follow up visit. Three weeks ago, he was diagnosed with allergic rhinitis, reporting that, “For years, every spring, when the pollen count is high, I get a runny, stuffy nose and an itchy throat.” He was started on a regimen of daily use of an intranasal corticosteroid as a controller medication with PRN use of an oral second-generation antihistamine for more severe symptoms. Which statement indicates that the patient understands his medication instructions from his initial visit? 

A. “I take my antihistamine every day and I'm saving the nasal spray for really bad pollen days.”  

B. “I use my antihistamine every day and my prescribed nasal spray only when I have a really bad running or stuffy nose.”  

 C. “I use my prescribed nasal spray as advised every day, but I notice I haven't had to use the antihistamine for about a week.”  

 D. “I can use either the antihistamine pills or the nasal spray, since both work the same way.”

Where do you start?  

First, determine what kind of a question this is. Given that we've been informed the patient has a diagnosis of allergic rhinitis and has been treated, this is an evaluation question, here the NP is being asked to determine if he's responding as expected to treatment and if he understands how the medication should be used.  

 Let's take a look at what condition we're talking about here. Allergic rhinitis is a clinical diagnosis, meaning that no special testing is needed, but rather this diagnosis is arrived at via analysis and synthesis of the health history and physical exam. This patient's presentation is typical or classic with rhinorrhea, nasal congestion, pharyngeal itch, when local pollen counts are high. Watery itchy eyes indicating allergic conjunctivitis is also commonly reported.  

 Proper management of allergic rhinitis includes daily use of an intranasal corticosteroid spray to help suppress the development of the inflammation. Optimally, this action will keep symptoms from occurring; however, the use of an as needed oral antihistamine for breakthrough symptoms is required at the beginning of treatment and occasionally during exacerbations. While the intranasal corticosteroid does need to be used daily, even once symptom control occurs, the antihistamine should be looked at as a PRN medication. And what I will often say to patients, particularly who have allergic rhinitis and asthma is allergic rhinitis is really like asthma only up in your head, and you're dealing with recurrently chronically inflamed airways. These just happen to be airways within your head. Getting that intranasal steroid on board will help control that inflammation.  

Let's take a look at the options given.   

A. “I take my antihistamine every day and I'm saving the nasal spray for really bad pollen days.”  

This is incorrect. The backbone of AR therapy is that daily intranasal corticosteroid used to prevent the formation of a number of inflammatory mediators that contribute to the signs and symptoms of the condition. PRN use of steroid nasal sprays provides very little in the way of symptom relief.   

Looking at option B, “I use my antihistamine every day and my prescribed nasal spray only when I have a really bad, stuffy or runny nose.” 

This is also incorrect. Antihistamines work by blocking formed inflammatory mediators that contribute to AR symptoms. And this is the preferred way to treat is again, that prevention of the inflammatory mediators with the nasal steroid. The general rule is a number of days of use are needed prior to seeing clinical response. In addition, patients will often report that the steroid nasal spray “doesn't do anything for a stuffy nose” because what they're expecting it to be is like a decongestant nasal spray that will almost immediately relieve nasal stuffiness.  

Option C: “I use my prescribed nasal spray is advised every day, but I notice I haven't had to use the antihistamine for a week.” 

 This is the correct answer. The daily use of intranasal corticosteroids typically produces a marked reduction in allergic rhinitis signs and symptoms. As a result, patients will describe the need or less use of the oral anti histamine as a rescue medication.  

Generally, it's going to take a week, two weeks or so before the patient will notice that signs and symptoms have gotten a lot better with daily use of the nasal steroid spray. And he's telling you I haven't needed the antihistamine in about a week and he's been on therapy for about three weeks.  

 Last option there, option D, “I can use either the antihistamine pills or the nasal spray, since they both work the same way.” This is incorrect. As mentioned, the nasal steroid should be considered the controller therapy to prevent inflammatory mediator formation and the oral antihistamine as the rescue therapy.  

 Key takeaway: in order to evaluate response to therapy questions or evaluation questions, you must know what the evidence-based practice treatment options are, how these are used, and importantly, if the patient understands the treatment plan.

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