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NR 565 Chamberlain Final Exam Questions and
Answers
Hypothyroidism - Correct answer underproduction of the hormone thyroxine (T4) (yellow) Too little thyroxine=slower metabolism fatigue, depressed mood, slow heart rate, constipation, weight gain, and irregular menstrual periods. MC in >60 women Hyperthyroidism - Correct answer overproduction of thyroid hormones: triiodothyronine (T3) (green), and thyroxine (T4) (yellow) What active hormones are produced by the thyroid? - Correct answer triiodothyronine (T3) and thyroxine (T4, tetraiodothyronine) 4 steps to synthesis of thyroid hormoness - Correct answer 1. Uptake
- Activation (Oxidation by peroxidase)
- Iodination of Tyrosine
- Coupling of Iodinated Tyrosine 3 Principle Actions of Thyroid Hormones - Correct answer (1) stimulation of energy use (2) stimulation of the heart (3) promotion of growth and development Most sensitive method for diagnosing hypothyroidism - Correct answer Serum TSH Levothyroxine Dosage in adults - Correct answer 100-125ug for 70kg adult ORAL Older adults- start at 25-50ug daily Levothyroxine dose in Myxedema Coma - Correct answer 200-500 ug once INJECTION Addition dose of 100-300 ug can be given a day later
Levothyroxine dose for Congenital Hypothyroidism - Correct answer <3mo: 10-15mg/kg 3-5mo: 8-10mg/kg 6-11mo: 6-8mg/kg 1-5yrs: 5-6mg/kg 6-12 yrs: 4-5mg/kg ORAL Dose DECREASES with age. Dose adjusted to normalize TSH and free T Levothyroxine dose for simple goiter - Correct answer 100-200ug ORAL Baseline data for levothyroxine - Correct answer Serum levels of TSH and free T What are thionamide drugs - Correct answer For hyperthyroidism ex. methimazole and propylthiouracil (PTU) Suppresses synthesis of thyroid hormones long term-hyperthyroidism short-term- subtotal thyroidectomy or tx with radioactive iodine Frequency of therapy for Methimazole and Propylthiouracil - Correct answer Methimazole: Initial therapy-3 times a day Maintenance therapy- Once a day Propyltiouracil: Initial therapy- 3 or 4 times a day Maintenance therapy- 2 or 3 times a day What is a first-line drug for hyperthyroidism - Correct answer Methimazole (Tapazole) Methimazole - Correct answer inhibits thyroid hormone synthesis--> DOES NOT DESTROY EXISTING STORES OF THYROID HORMONE SAFER and more convenient than PTU and preferred more EXCEPT in those who are pregnant or breastfeeding and those who are in thyrotoxic crisis May take 3-12 weeks to produce euthyroid state
Usually given with PTY last 10 days before surgery also in thyrotoxic crisus Dosage and administration of nonradioactive iodine - Correct answer 5- drops 3 times daily for 10 days immediately preceding surgery mix with juice or some other beverage thyrotoxic crisis- 10 drops Q8hours Insulin MOA - Correct answer Biguanides - Correct answer Sulfonylureas MOA - Correct answer Meglitinides MOA - Correct answer Thiazolidinediones - Correct answer a-Glucosidase Inhibitors - Correct answer Gliptins - Correct answer Sodium-Glucose Cotransporter 2 Inhibitos - Correct answer Glucagon-like Peptide-1 Receptor Antagonist - Correct answer Beta Agonists - Correct answer Therapeutic Goal: Short-acting inhaled β agonists are used as needed (PRN) for prophylaxis of exercise-induced bronchospasm and to relieve ongoing asthma attacks and chronic obstructive pulmonary disease exacerbations. Oral and inhaled long-acting β2 agonists are used for maintenance therapy. Baseline Data: Forced expiratory volume in 1 second (FEV1), frequency and severity of attacks. Attempt to identify trigger factors. Use systemic β
agonists with caution in patients with diabetes, hyperthyroidism, organic heart disease, hypertension, or angina pectoris. Contraindications: Systemic (oral, parenteral) β2 agonists are contraindicated for patients with tachydysrhythmias or tachycardia associated with digitalis toxicity. Use systemic β2 agonists with caution in patients with diabetes, hyperthyroidism, organic heart disease, hypertension, or angina pectoris. Monitoring Requirements: FEV1, peak flow. Monitor home assessments of peak expiratory flow (PEF) at each clinic encounter. Evaluation of Therapeutic Effect: Asthma control should be assessed at each clinic encounter. Monitor PEF, symptom frequency and symptom intensity, nighttime awakenings, effect on normal activity, and short-acting β2 agonist use. It is also important to discuss medication adherence or deviation from the management plan. Because patients may forget some of the finer points of inhaled medication administration, this is a good time to have the patient demonstrate their technique for using inhalers. Minimizing Adverse Effects: Inhaled short-acting β2 agonists: When used at recommended doses, SABAs are generally devoid of significant adverse effects. Inhaled long-acting β2 agonists: When used correctly, LABAs are safe; however, when used alone for prophylaxis, they may increase the risk for severe asthma attacks and asthma-related death. (Th Inhaled Corticosteroids - Correct answer Therapeutic Goal: To achieve symptom control through suppression of airway inflammation. Baseline Data: Strong history and physical data with a focus on respiratory system. Pulmonary function tests. Baseline height for children is needed. Bone density for older adults or anyone at risk. Contraindications: Contraindicated in patients with persistent positive sputum cultures for Candida albicans. Note: Okay to use in patients with candidiasis. Monitoring Requirements: Monitor FEV1 and peak flow, oral candidiasis, glaucoma, adrenal insufficiency. In children, monitor growth patterns and adrenal function if a combination drug that includes glucocorticoid is used
6 months. Evaluation of Therapeutic Effect: Monitor peak expiratory flow, symptom frequency, and symptom intensity, nighttime awakenings, effect on normal activity, and short-acting β2 agonist use. Minimizing Adverse Effects: If candidiasis develops, antifungal medications can be administered. Spacers can help prevent the development of candidiasis.
Also considered muscarinic receptor agonist BlackBox Warning for Montelukast - Correct answer drug is known to cause serious neuropsychiatric effects such as agitation, aggression, insomnia, depression, anxiety, and suicidal ideation. Mast Cell Stabilizers - Correct answer alternative therapy (cromolyn and nedocromil). rarely used, and when indicated they are prescribed for exercise-induced asthma. Act by stabilizing the cell membranes of mast cells to prevent the release of histamine, an inflammatory mediator. Mast cells are cells responsible for releasing histamine and other substances during inflammatory and allergic reactions. Phosphodiesterase-4 Inhibitor (PDE) - Correct answer Roflumilast COPD not asthma selective action that inactivates cyclic adenosine monophosphate (cAMP) which results in decreased cytokine release and subsequent lower levels of pulmonary infiltration by neutrophils and other white blood cells. cough and excess mucus production are also diminished. not a first-line drug treatment and is reserved for severe cases of COPD with a primary component of chronic bronchitis Antihistamines - Correct answer tx allergies, rhinitis, hay fever, hives, itching, running nose, anaphylaxis, angioedema, drug fevers, and sneezing ex. diphenhydramine, fexofenadine, and loratadine antihistamine medications compete with histamine for the receptor site. The antihistamine binds to the cell instead and stops the inflammatory process. Can also be used for motion sickness, parkinson's, and vertigo Adverse effects of antihistamines - Correct answer Drowsiness is most common side effect Others: dry mouth vision changes difficulty urinating constipation
Antitussives - Correct answer suppress the cough reflex, decrease mucous in the respiratory track and reduce pain. Expectorants - Correct answer encourage the expectoration (coughing up, spitting out) of excessive mucus in the respiratory tract Work in break down and thin secretions for easier expectoration Proton Pump Inhibitors - Correct answer most effective for inhibiting acid secretion Bind to gastric proton pumps, blocking acid production take 2-3 daays to reach max effect and are acid-activated act by irreversibly blocking hydrogen and ultimately the amount of HCL produced by the stomach PPI side effects - Correct answer MC: headaches, nausea, diarrhea long term use associated with renal complications, bone fractures, and dementia in older adults cause decreased absorption of calcium, magnesium, and vitamin B contraindicated in hypocalcemia short term tx= risk for CAP Histamine 2-Receptor Antagonist - Correct answer Cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axis), ranitidine (Zantac) reduce acid secretion by blocking histamine 2-receptors in gastric parietal cells More efficacious than antacids at controlling chronic GERD symptoms but less effective than PPIs side effects of H2RA - Correct answer mild and most commonly include headache and nausea
antibacterial and antisecretory properties (tx travelers diarrhea 2 tabs or 2 fl oz b4 each meal and at bedtime (4xd for up to 3 weeks during periods of high risk no kids/teens c recent chickenpox or flu-like illness (Reyes syndrome) or aspirin sensitivity SE: gray/black stools and black tongue Herd Immunity - Correct answer The resistance to an infectious organism because a large group of people is immune to the infectious organism through immunization/vaccine. Herd or Community immunity is contingent on the likelihood individuals are prone to the infection will encounter the infected person. For example, most of the people in the community are immune to an infectious disease, which means everyone does not need immunity to prevent the spread of the infection. Active Immunity - Correct answer When the immune system produces antibodies in response to an antigen by the vaccine, or by the infection itself. For example, if a person who has never had hepatitis B contracts hepatitis B and recovers from it, that person becomes immune to hepatitis B because of the immune system's antibody response to the hepatitis B virus. Passive Immunity - Correct answer The immunity that occurs naturally. This type of immunity is passed on when an antibody is produced in another host. For example, immunity is passed on from a mother to her infant or by artificial administration of antibody-containing formulations. Non-routine vaccines include - Correct answer rabies travel vaccines Other non-routine vaccinations include: Adenovirus Anthrax Cholera Japanese encephalitis Smallpox Typhoid Yellow fever
insulin lispro - Correct answer short duration, rapid acting MOA: stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism (rapid-acting insulin) Contraindications: hypersens. to drug/class/compon. IV administration (200 units/mL INJ form) continuous SC infusion pump (200 units/mL INJ form) hypoglycemia caution in pts 65 yo and older w/o concurrent basal or long-acting insulin caution if infection, illness, or stress caution if hypokalemia caution if renal impairment caution if hepatic impairment caution if visual impairment (pen form) caution if localized cutaneous amyloidosis Regular Insulin - Correct answer short duration, rapid acting MOA: stimulates peripheral glucose uptake, inhibits hepatic glucose production, inhibits lipolysis and proteolysis, regulating glucose metabolism (short- acting insulin) Contraindications: hypersens. to drug/class/compon. continuous SC infusion pump hypoglycemia caution in pts 65 yo and older w/o concurrent basal or long-acting insulin caution if infection, illness, or stress caution if hypokalemia caution if renal impairment caution if hepatic impairment caution if visual impairment (pen form) caution if localized cutaneous amyloidosis
caution if CHF caution if alcohol abuse caution if hypoglycemia risk Sulfonylureas - Correct answer Glyburide stimulates pancreatic islet beta cell insulin release Meglitinides (Glinides) - Correct answer Repaglinide stimulates pancreatic islet beta cell insulin release, lowering serum glucose levels hypersens. to drug/class/compon. diabetes mellitus, type 1 diabetic ketoacidosis caution if CrCl < caution if hepatic impairment caution in elderly pts caution in debilitated pts caution if malnutrition caution if adrenal insufficiency caution if hypopituitarism thiazolinides (Glitazones) - Correct answer Pioglitazone increases insulin sensitivity hypersens. to drug/class/compon. pediatric pts diabetes mellitus, type 1 diabetic ketoacidosis active bladder CA CHF, NYHA Class III-IV CHF, symptomatic caution if CHF, NYHA Class I-II caution if CHF risk caution if edema caution if hepatic impairment caution if bladder CA hx caution in premenopausal anovulatory pts a-Glucosidase Inhibitors - Correct answer Acarbose
inhibits pancreatic alpha-amylase and intestinal alpha-glucoside hydrolase, delaying glucose absorption hypersens. to drug/class/compon. diabetic ketoacidosis, cirrhosis, inflammatory bowel dz, colonic ulcer, partial GI obstruction, GI obstruction risk, malabsorption syndromes, Cr > Gliptins (Dipeptidyl Peptidase-4 Inhibitors)- - Correct answer Sitagliptin inhibits dipeptidyl peptidase-4, slowing incretin metabolism, increasing insulin synthesis/release, decreasing glucagon levels hypersens. to drug/class/compon., diabetes mellitus, type 1, caution if eGFR <45, ,caution if heart failure risk, , caution if pancreatitis hx Sodium-Glucose Cotransporter 2 Inhibitor- - Correct answer canaglifozin (Invokana) inhibits s odium-glucose cotransporter 2 (SGLT2), reducing glucose/sodium reabsorption, incr. urinary glucose excretion and sodium delivery to distal tubule hypersens. to drug/class/compon., pregnancy 2nd or 3rd trimester, ,diabetes mellitus, type 1, diabetic ketoacidosis, volume depletion, ,eGFR <30, caution if eGFR 30-59, caution if concurrent nephrotoxic agent use, caution if hypotension,, caution if CHF, caution in elderly pts, ,caution if ketoacidosis risk, caution if pancreatic insulin deficiency, caution if prolonged fasting, caution if alcohol abuse, ,caution if genital mycotic infection hx, caution in uncircumcised male pts, caution if fracture risk, caution if prior amputation hx, caution if PVD, caution if neuropathy, caution if diabetic foot ulcer, caution if osteomyelitis, caution if gangrene Glucagon-like Peptide-1 Receptor Antagonist- - Correct answer Exenatide activates glucagon-like-peptide-1 (GLP-1) receptor, increasing insulin secretion, decreasing glucagon secretion, and delaying gastric emptying (incretin mimetic)
(canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance))
- Correct answer block glucose reabsorption by the kidneys in the proximal nephron and increase the release of glucose in urine effective in all stages of T2DM with no concerns for hypoglycemia risk for volume depletion and hypotension and can lead to DKA may cause weightloss monitor creatinine and urinalysis (higher risk for UTI and pyelonephritis) fyi: increased risk for need for leg and foot amputations in these pt's Dipeptidyl Peptidase-4 Inhibitors (DPP-4i) (sitagliptin (Januvia), Saxagliptin (onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)) - Correct answer inhibit DPP-4 activity and increase active incretin concentrations which result in increased insulin secretion and decreased glucagon may cause severe/disabling joint pain @ any time during tx--> may cause angioedema and acute pancreatitis Thiazolidinedione's (TZD) (Rosiglitazone (Avandia), Pioglitazone (Actos)) - Correct answer enhance insulin sensitivity in muscle tissue and reduce glucagon production in the liver take daily with breakfast and can be combined with other diabetic agents avoid in CHF, hx bladder cancer, active liver disease, ,T1DM, or pregnancy may cause weight gain (monitor weight and BMI), regular LFT monitoring (due to action on liver) Sulfonylureas (Glyburide, Glipizide, Glimepiride) - Correct answer Stimulate beta cells of the pancreas to secrete more insulin
long half-life and not commonly utilized due to high risk of severe hypoglycemia cause photosensitivity (use sunscreen), also causes blood dyscrasias, weight gain avoid in pts with impaired hepatic or renal function Total Daily Insulin Dose - Correct answer includes basal insulin replacement and bolus insulin replacement basal insulin= approx. 50% of total daily insulin dose which replaces insulin from fasting (overnight) and between meals (usually constant) and provides carbohydrate coverage (carbohydrate ratio) carbohydrate ratio - Correct answer how many grams of carbohydrate are covered or disposed of by 1 unit of insulin Total daily insulin dose - Correct answer TDD= total wght in kgx 0.6u ex. 80kgx0.6=48 (half is 24 u of long acting and 1/2=24 rapid acting/mealtime) mealtime carb to insulin dose - Correct answer 450 rule for regular insulin and 500 rule for rapid acting 500 divided by the TDD (ex. 48= 10.4 and round down to 10) so car ration is 1: so if meal is 60g of carbs then 60?10 is 6 units of rapid acting insulin for carb coverage elevated blood sugar correction dose - Correct answer subtracting the target blood sugar (90) from actual blood sugar (ex. 166) and dividing the difference (ex. 76) by the correction factor correction factor= taking insulin sensitivity factor constant which is 1500 for regular insulin and 1800 for rapid-acting insulin and dividing by the TDD ex. correction factor is 1800/48=37.5 (rounded up to 38) which means 1u insulin will drop blood sugar by 38mg/dl
Monitoring for levothyroxine - Correct answer serum levels of TSH and free T labs for Radioactive Iodine - Correct answer serum levels of thyroid- stimulating hormone (TSH), free triiodothyronine (T3), and free thyroxine (T4) monitoring for levothyroxine - Correct answer check TSH 6-8 weeks after initiating therapy and after any dosage change check TSH at least once a year after serum TSH is stabilized monitoring for methimazole - Correct answer check CBC with diff if s/s of infection. check LFTs if signs or symptoms of liver dysfunction monitoring for Radioactive Iodine - Correct answer NONE Levothyroxine - Correct answer with caution in those with cardiovascular disease and start with lower doses in older adults lifetime considerations with methimazole - Correct answer avoid in first trimester of pregnancy. If thionamide is needed during first trimester of pregnancy, PTU is preferred lifetime considerations for Radioactive Iodine - Correct answer contraindicated in pregnancy and lactation. avoid is very young children Therapeutic effects of levothyroxine - Correct answer reversal of signs of thyroid deficiency and an absence of s/s of thyroid excess, normalization of intellectual function, growth, and development should occur. IN children, monthly height measurements demonstrate thyroid sufficiency, laboratory tests indicate normal plasma levels of TSH and T therapeutic effect of Methimazole - Correct answer weight gain, decreased heart rate, and other indications that thyroid levels have declined, laboratory test indicate a decrease in serum free T3 and free T education for levothyroxine - Correct answer symptoms of thyrotoxicosis include tachycardia, angina, tremor, nervousness, insomnia, sweating, and heat intolerance
pt education for methimazole - Correct answer early signs of agranulocytosis include fever or sore throat. If follow-up blood tests reveal leukopenia, methimazole should be stopped. May cause excessive reductions in thyroid hormone synthesis. If signs of hypothyroidism develop or if plasma levels of T3 and T4 become subnormal, dosage should be reduced pt education for radioactive iodine - Correct answer symptoms of drug toxicity, include brassy taste, burning sensation in the mouth, and soreness of gums and teeth. Drug can also cause corrosive injury to GI tract. Notify the prescriber if severe abdominal distress develops Emphysema - Correct answer affects alveoli alveolar walls are broken down causing alveolar air spaces to becocme permanently and abnormally enlarged less alveolar space leads to less surface area for gas exchange to occur, limiting airflow Chronic Bronchitis - Correct answer affects bronchi and bronchioles airways become narrowed and blocked with mucus, limiting airflow
