Brief cessation counselling is one of the highest-yield things done in primary care, and the exam expects you to know the structure. These questions cover the 5 As framework, matching nicotine replacement to dependence level, varenicline and bupropion including their cautions, and how to respond to relapse without losing the patient.
Question 1
A 25-year-old using nicotine lozenges for acute cravings reports they are ineffective. The patient mentions drinking coffee while the lozenge dissolves. What is the most appropriate guidance to improve the medication's efficacy?
- A) Switch to nicotine gum because it is unaffected by dietary acidic beverages.
- B) Increase the lozenge dose to overcome the rapid metabolism caused by caffeine.
- C) Avoid eating or drinking for fifteen minutes before using the nicotine lozenge.✓
- D) Chew the lozenge quickly to ensure absorption before the coffee alters pH.
💡 Key Takeaway
Acidic beverages lower oral pH, which significantly impairs the buccal absorption of nicotine from lozenges and gum.
Show rationale
Nicotine lozenges, like nicotine gum, rely heavily on buccal absorption to deliver rapid relief for breakthrough cravings. This absorption is highly dependent on an alkaline oral environment. Consuming acidic beverages like coffee, soda, or juice lowers oral pH, which ionizes the nicotine and severely impairs its absorption across the mucosa. Therefore, option C is correct; patients must avoid eating or drinking for 15 minutes before and during use. Option A is incorrect because nicotine gum is equally susceptible to pH changes from acidic beverages. Option B is incorrect; increasing the dose does not fix the absorption block and may cause toxicity later. Option D is incorrect because lozenges are designed to dissolve slowly over 20 to 30 minutes; chewing them defeats the delivery mechanism and causes gastrointestinal distress.
Question 2
A 32-year-old female with mild persistent asthma tells the FNP she wants to quit eventually because of her breathing, but she enjoys the stress relief that a cigarette provides after a long day. Which approach should the FNP utilize to advance her readiness?
- A) Recommend immediate initiation of varenicline to manage her daily cravings.
- B) Explore how smoking for stress relief affects her daily asthma.✓
- C) Advise her to set a firm quit date within fourteen days.
- D) Reassure her that many patients struggle with quitting tobacco products.
💡 Key Takeaway
Developing discrepancy helps ambivalent patients weigh their current behaviors against their stated health goals.
Show rationale
This patient is in the contemplation stage, demonstrating clear ambivalence. Exploring how smoking affects her asthma helps develop discrepancy between her current behavior and her health goals. Recommending varenicline (A) or setting a firm quit date (C) jumps to the preparation or action stage prematurely, which can cause resistance. Reassurance (D) is empathetic but fails to elicit change talk or actively address her ambivalence.
Question 3
50-year-old male requests bupropion for smoking cessation. He reports drinking six beers daily for ten years but plans to stop drinking abruptly today.
- A) Initiate bupropion and provide education on managing mild alcohol withdrawal.
- B) Initiate bupropion and prescribe a short course of oral benzodiazepines.
- C) Recommend varenicline instead due to the significantly elevated risk for seizures.✓
- D) Recommend varenicline instead due to the significantly elevated risk for hepatotoxicity.
💡 Key Takeaway
Bupropion is contraindicated during abrupt alcohol withdrawal due to a compounded risk of seizures.
Show rationale
Bupropion lowers the seizure threshold and is strictly contraindicated in patients undergoing abrupt alcohol withdrawal, which independently increases seizure risk. Varenicline is the safer first-line alternative in this scenario. Option A is incorrect because bupropion remains contraindicated regardless of withdrawal education. Option B is incorrect; while benzodiazepines treat alcohol withdrawal, they do not make bupropion safe to use during this acute high-risk period. Option D is incorrect because the primary contraindication for bupropion in this context is seizures, not hepatotoxicity.
Question 4
A 45-year-old male presents for a routine physical. He smokes one pack daily and explicitly states he has no desire to quit because it helps him manage his demanding work schedule. Which response by the Family Nurse Practitioner best aligns with motivational interviewing principles?
- A) Ask permission to discuss tobacco use at future clinic visits.✓
- B) Explain the long-term cardiovascular risks of continued tobacco use.
- C) Provide a list of local smoking cessation support group meetings.
- D) Prescribe nicotine replacement therapy for when he decides to quit.
💡 Key Takeaway
Rolling with resistance in precontemplation requires respecting autonomy to maintain the therapeutic relationship.
Show rationale
In the precontemplation stage, the patient has no intent to quit. Asking permission respects autonomy and rolls with resistance, keeping the communication door open for future visits. Explaining risks (B) often creates defensiveness and damages rapport. Providing support groups (C) or prescribing nicotine replacement therapy (D) are action-oriented interventions that are clinically inappropriate for a patient in precontemplation.
Question 5
An asymptomatic 68-year-old smoker is screened for peripheral arterial disease during an annual wellness visit. The nurse practitioner obtains an ABI result of 0.95. Which action represents the best management plan for this patient?
- A) Schedule immediate invasive peripheral angiography testing.
- B) Diagnose moderate peripheral arterial disease conditions.
- C) Order a resting toe-brachial index test.
- D) Implement aggressive cardiovascular risk reduction measures.✓
💡 Key Takeaway
A borderline ABI (0.91–0.99) in an asymptomatic patient warrants aggressive cardiovascular risk factor modification.
Show rationale
An ABI of 0.91 to 0.99 is considered borderline peripheral arterial disease. In an asymptomatic patient, the primary focus should be cardiovascular risk reduction, including smoking cessation, blood pressure control, and lipid management (D) to prevent disease progression. Angiography (A) is an invasive procedure reserved for severe, limb-threatening ischemia. The patient does not have moderate PAD (B), which correlates with an ABI of 0.41 to 0.90. A toe-brachial index (C) is indicated for abnormally high ABIs (greater than 1.40), not for borderline results.
Question 6
A 42-year-old patient reports minimal improvement in depressive symptoms after four weeks of paroxetine therapy. The patient is highly distressed by severe medication-induced sexual dysfunction and refuses to take it anymore. Which approach is best?
- A) Add sildenafil to manage the severe adverse effects.
- B) Decrease the paroxetine dose to 10 mg daily.
- C) Switch the paroxetine to bupropion 150 mg daily.✓
- D) Continue paroxetine and reassess in four more weeks.
💡 Key Takeaway
Switch antidepressants when severe intolerable adverse effects occur before achieving clinical remission.
Show rationale
When a patient experiences intolerable adverse effects early in treatment without significant clinical benefit, the best strategy is to switch the medication class. Bupropion is an excellent choice here because it lacks serotonergic activity and has a very low risk of sexual dysfunction. Adding sildenafil increases polypharmacy and doesn't address the lack of mood improvement. Decreasing the paroxetine dose might reduce side effects but will likely result in subtherapeutic treatment. Continuing the medication is inappropriate when the patient is highly distressed and refusing the drug.
Question 7
A 29-year-old patient with well-controlled major depressive disorder is requesting varenicline for smoking cessation. Based on current prescribing guidelines, what is the most appropriate action for the nurse practitioner?
- A) Prescribe the medication but monitor closely for mood changes or suicidal ideation.✓
- B) Refuse the prescription because varenicline is strictly contraindicated in psychiatric patients.
- C) Recommend nicotine replacement therapy as the only safe option for this patient.
- D) Require a psychiatric clearance letter before initiating any smoking cessation pharmacotherapy.
💡 Key Takeaway
Varenicline can be prescribed to patients with stable psychiatric conditions provided there is close monitoring for mood changes.
Show rationale
Varenicline is a highly effective smoking cessation aid, but it requires careful consideration in patients with underlying psychiatric conditions. The FDA previously mandated a boxed warning regarding neuropsychiatric adverse events, but this was removed after large trials showed the risk was lower than initially thought. Therefore, option A is correct; you can prescribe it to a patient with well-controlled depression, provided you monitor them closely for mood changes. Option B is incorrect because a psychiatric history is a precaution, not an absolute contraindication. Option C is incorrect; while NRT is safe, varenicline is not strictly unsafe and often provides superior cessation rates. Option D is unnecessary gatekeeping; APRNs can safely initiate this therapy in stable patients without requiring formal psychiatric clearance, provided appropriate follow-up is maintained.
Question 8
35-year-old female insists on quitting smoking tomorrow morning. She requests a prescription for bupropion sustained release to help manage her anticipated nicotine withdrawal cravings.
- A) Prescribe bupropion and support her decision to quit smoking tomorrow.
- B) Prescribe bupropion and add a nicotine patch for the first week.
- C) Recommend delaying bupropion until she has been smoke-free for one week.
- D) Recommend delaying the quit date for one week while starting bupropion.✓
💡 Key Takeaway
Bupropion must be initiated one to two weeks prior to the patient's target quit date.
Show rationale
Bupropion requires approximately one to two weeks to reach steady-state therapeutic levels in the bloodstream. Patients should begin taking the medication while they are still smoking and set a target quit date for the second week of treatment. Option A is incorrect because quitting tomorrow will cause withdrawal symptoms before the medication becomes effective. Option B is incorrect because adding a patch does not resolve the delayed onset of bupropion. Option C is incorrect because bupropion must be initiated before the quit date, not after.
Question 9
24-year-old female requests an oral medication to help quit smoking. Her medical history includes bulimia nervosa in remission and major depressive disorder.
- A) Prescribe bupropion and monitor for unexpected weight loss.
- B) Prescribe varenicline and monitor for unexpected mood shifts.✓
- C) Prescribe nortriptyline and monitor for severe dry mouth.
- D) Prescribe clonidine and monitor for orthostatic hypotension.
💡 Key Takeaway
Bupropion is contraindicated in patients with eating disorders due to an increased risk of seizures.
Show rationale
Bupropion is contraindicated in patients with a history of eating disorders like bulimia nervosa due to a significantly lowered seizure threshold. Varenicline is a safe, effective oral alternative that does not carry this specific risk. Option A is incorrect because bupropion could provoke seizures in this patient, regardless of monitoring. Options C and D are incorrect; while nortriptyline and clonidine are second-line off-label options for smoking cessation, varenicline is an FDA-approved first-line agent with superior efficacy and should be prioritized over second-line therapies.
Question 10
A 68-year-old male with a history of shipyard construction presents with a gradually worsening dry cough and dyspnea on exertion over the past year. He quit smoking 15 years ago. Chest radiography reveals calcified pleural plaques along the lower lung fields. Which of the following is the most appropriate ongoing assessment priority?
- A) Assess for underlying alpha-1 antitrypsin deficiency.
- B) Assess for concurrent active tuberculosis infection.
- C) Assess for developing malignant pleural mesothelioma.✓
- D) Assess for acute hypersensitivity pneumonitis exposure.
💡 Key Takeaway
Asbestos exposure causes calcified pleural plaques and significantly increases the risk of malignant pleural mesothelioma and bronchogenic carcinoma.
Show rationale
The patient's extensive history of shipyard construction combined with the incidental finding of calcified pleural plaques on chest imaging is highly specific for prior occupational asbestos exposure. Asbestosis significantly increases the patient's long-term risk of developing bronchogenic carcinoma and malignant pleural mesothelioma, making targeted assessment for these malignancies a critical ongoing priority for the nurse practitioner. Assessing for an underlying alpha-1 antitrypsin deficiency is incorrect because it causes early-onset panacinar emphysema, not pleural plaques. Assessing for a concurrent active tuberculosis infection is vital for patients with silicosis, not asbestosis, and typically presents with upper lobe cavitations. Assessing for acute hypersensitivity pneumonitis exposure is incorrect because it is an immunologic reaction to inhaled organic antigens, not inorganic asbestos fibers.
