NR 565 Final Exam Study Guide Questions With Correct Answers., Exams of Nursing

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NR 565 Final Exam Study Guide

Questions With Correct Answers

What labs are used to diagnose Thyroid? - ANSWER -TSH, total T4 and T3, free T4 and T Timeframe for re-check of labs after starting levothyroxine - ANSWER -6-8 wks after starting therapy Signs and symptoms of hypothyroidism - ANSWER -Face: Pale, puffy, expressionless Skin: Cold and dry Hair: Brittle and hair loss Heart rate and temp are lowered Complaints by patient: lethargy, fatigue, intolerance to cold Mentation may be impaired Thyroid enlargement if ↓'d levels of T3 and T4 promoting excessive release of TSH Treatment of thyroid storm - ANSWER -High dose potassium iodide or strong iodine solution to suppress thyroid hormone release, methimazole to suppress thyroid hormone synthesis, beta blocker to reduce heart rate, sedation cooling glucocorticoids and IV fluids Result of not treating hypothyroidism during pregnancy - ANSWER -permanent neurological defects, ↓'d IQ, large protruding tongue, potbelly dwarfish stature, impaired development of nervous system bone teeth and muscles. Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself) - ANSWER -Metoprolol could be used to treat tachycardia experienced with hyperthyroidism, but it does not treat hyperthyroidism itself.

Drug/Food/Supplement interactions with levothyroxine Absorption REDUCED by: - ANSWER - Histamine 2 receptor blockers (Cimetidine [Tagamet]) Proton pump inhibitors (Lansoprazole) Sucralfate (Carafate) Cholestyramine (Questran) Colestipol (Colestid) Aluminum containing antacids (maalox, mylanta) Calcium supplements (tums, os-cal) Iron supplements Magnesium salts Orlistat (Xenical)

• 4 hours between levothyroxine and the above meds is recommended and food reduces absorption as well How to confirm a diagnosis of DM prior to beginning treatment - ANSWER -Hemoglobin A1C > 6.5%, Fasting plasma glucose ≧ 126 mg/dL, Random plasma glucose ≧200 mg/dL plus symptoms of diabetes, Oral glucose tolerance test (OGTT): 2-h plasma glucose ≧200 mg/dL A1C General goals - ANSWER -less than 7%, less than 8% in patients with severe hypoglycemia, limited life expectancy, or advanced microvascular or macrovascular complications A1c - Older Adult goal - ANSWER - When should insulin be considered? - ANSWER -Type 1 Diabetics All are on insulin Type 2 Diabetics Step 3 - Three drug combination (inclusive of metformin)

Step 4 - Three drug therapy and basal insulin fails to reach goals after 3-6 months - injectable regimen inclusive of insulin and possibly GLP-1 receptor agonist. EXCEPTIONS: patient with A1C greater than 9% or greater start dual therapy (start at step 2) and patients with A1C greater than 10 % and fasting blood glucose of 300 or more or symptomatic may be started on combination injectable therapy immediately At what time interval should A1c be re-checked? - ANSWER -every 3 months until A1C drops below 7% and then every 6 months thereafter. Action of Insulin - ANSWER -Anabolic-promotes conservation of energy and buildup of energy stores (Glycogen) Stimulates cellular transport (Uptake) of glucose, amino acids, nucleotides & K Promotes synthesis of complex molecules Glucose ⇒ Glycogen, Amino Acids ⇒ Proteins, Fatty Acids ⇒ Triglycerides Promotes cellular growth and division Energy conservation Pioglitazone contraindications - ANSWER -Pioglitazone is contraindicated in patients with severe heart failure and should be used with caution in patients with mild heart failure. Should not be used in patients that have active bladder cancer or history of bladder cancer Be familiar with abbreviations of diabetic drug classifications (GLP-1, TZD, DPP4-I, SGLT2i) - ANSWER -GLP-1: Glucagon-like Peptide -1 Receptor Agonist TZD: Thiazolidinediones (Glitazones) DPP-4i: Dipeptidyl Peptidase- 4 Inhibitors (Gliptins) SGLT2i: Sodium-Glucose Cotransporter 2 Inhibitors Which drug class should be considered for diabetes prior to insulin? - ANSWER -Biguanides (Metformin)

Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin - ANSWER -•Basal insulin replacement encompasses approximately 50% of the total daily insulin dose which replaces insulin from fasting (overnight) and between meals. This dose is usually constant. Bolus insulin replacement encompasses approximately 50% of the total daily insulin dose Know the carbohydrate-to insulin ratio when calculating basal insulin - ANSWER -500 / TDD : 1 unit TDD = 0.6 units/kg/day Mechanism of Action o GLP-1 - ANSWER -GLP-1: Augment effects of incretin hormone GLP- can ↑ insulin production and inhibits postprandial glucagon release Which diabetic medication(s) come with a concern of hypoglycemia? - ANSWER -sulfonylureas, glinides, GLP-1, amylin mimetics, glitazones Methylxanthines o Who is at risk for toxicity and why? - ANSWER -Older patients are at much higher risk for toxicity when taking methylxanthines (Systemic anticholinergics are included in BEERS criteria for potentially inappropriate use for older adult Wk. 6 module.) Patients with liver dysfunction (increased risk for toxicity) Untreated seizure disorder or peptic ulcer disease Asthma & COPD o Step 1 therapy - ANSWER -•SABA → PRN Complete this sentence: Manage with a ______ as needed. - ANSWER -SABA Symptoms associated with Intermittent classification of asthma *Symptoms *Nighttime Awakening SABA USE - ANSWER -2 d/week or less *2 times/month or less

*2 d/week or less Know examples of drug classes (SABA) - ANSWER -oAlbuterol (Proventil), Levalbuterol (Xopenex) SABA Benefits of use - ANSWER -Activate the beta-adrenergic receptors in smooth muscle of the lung, thereby promoting bronchodilation and relieving bronchospasm. Beta 2 agonist limit role in suppressing histamine release in the lung and increasing ciliary motility Why is it important to know the frequency a patient is using their SABA? - ANSWER -To be able to assess the severity of asthma symptoms in each patient, and if they need adjunct treatment in more severe cases LABA Benefits of use Use in COPD by Category - ANSWER -A (few symptoms low risk) Symptom control SABA, 1st Choice LAMA or LABA B (Increased symptoms, low risk) Symptom control SABA, 1st Choice LAMA or LABA and management of persistent symptoms of further exacerbations combination LAMA/LABA C (few symptoms, high risk) Symptom control SABA, 1st Choice LAMA and management of persistent symptoms of further exacerbations combination LAMA/LABA or LABA/IGC D (Increased symptoms, high risk) Symptom control SABA, 1st Choice LAMA or LAMA/LABA or IGC/LABA and management of persistent symptoms of further exacerbations combination LAMA/LABA/IGC, if exacerbations continue, consider adding Roflumilast Azithromycin Inhaled Corticosteroid (ICS) Benefits of use - ANSWER -reduction and suppression of inflammation of airway At what point would an oral steroid be prescribed? - ANSWER -Only when symptoms cannot be controlled with safer medications. May be required for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD.

When would roflumilast be indicated for a COPD patient? - ANSWER -*Not 1st Line. *Used for exacerbation prophylaxis in patients with severe COPD with a primary chronic bronchitis and Hx of frequent exacerbations. *Not prescribed alone, needs to have a LAMA or SABA with it *can cause suicidal hallucinations, no black box warning Nicotine replacement How it works - ANSWER -Allows smokers to substitute a pharmaceutical source of nicotine in replacement of the nicotine found in cigarettes. Levels will rise slowly, but help relieve the sx of withdrawal. Success rates highest when combined with counseling. Patient education needed for various types • Patch - ANSWER -Apply new patch daily in a clean, dry, non-hairy skin on upper part or arm/body. Patch left in place for 24 hrs. Rotate sites everyday & don't use same site for at least a week. Start with larger patches & progressively wean down over weeks. Those <100 lbs, with CAD, or smoke < ½ pack per day, should start with a smaller patch. Wellbutrin Contraindications - ANSWER -Taken off the market in the US Bupropion Recommended length of treatment - ANSWER -Daily for 12 weeks, if abstinence is achieved, an additional 12 weeks of treatment is warranted. Treatment should begin 8-35 days before smoking cessation. What constitutes drug resistant TB - ANSWER -MDR- TB is TB that is resistant to both isoniazid and rifampin XDR-TB is a sev. Form of MDR-TB & is resistant to not only isoniazid and rifampin, but also ALL fluoroquinolones AND at least one of the injectable second line anti-TB drugs (amikacin or capreomycin) Treatment of TB in a pregnant person, what all should be included? - ANSWER -oINH & Rifabutin(safest), along with pyridoxine supplements.

Isoniazid (INH) is a drug that can be used to prevent TB in people that have been exposed. - ANSWER -o Examples of decongestant - ANSWER -Phenylephrine (Neo-synephrine) Pseudoephedrine (Sudafed) Naphazoline (Privine) Oxymetazoline (Afrin, Dristan) Tetrahydrozoline (Tyzine) Xylometazoline (Otrivin) Which cold and cough drug class has no significant drug interactions - ANSWER -Intranasal CROMOLYM. Expectorants H2 receptor antagonists o Examples - ANSWER -Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) Ranitidine (Zantac) Which H2 receptor is most likely to interact due to CYP450 enzyme system? - ANSWER - Cimetidine (Tagamet) Proton Pump Inhibitors o Associated vitamin and/or mineral deficiencies - ANSWER -Decreased absorption of calcium, magnesium, and vitamin B12 have also been associated with long-term PPI use; PPI Short term use increases risk of what? - ANSWER -Fractures, pneumonia, acid rebound, and, possibly, intestinal infection with C-Diff

How to treat moderate to severe GERD - ANSWER -oPPI Therapy What medication for GERD to avoid in older adults and why? - ANSWER -Ranitidine (Zantac) and Cimetidine (tagamet) = causes mental status changes. Older adults are often taking several prescription and over-the-counter drugs that increase number of drug interactions o PPIs are associated with increased risk for fractures from osteoporosis and cause medication interactions and vitamin or mineral deficiencies *Treating GERD during pregnancy Which cytoprotective agents would be used - ANSWER -Esomeprazole, and Ranitidine are safe *Sucralfate (Carafate) When to test for h. Pylori - ANSWER -o How to treat h. Pylori - ANSWER -Treatment is not recommended for asymptomatic individuals who test positive for H. pylori. Otherwise treat with clarithromycin, amoxicillin, bismuth, metronidazole, and tetracycline. Drug resistance may occur, so the recommendations is to use at least two antibiotics preferably three, and an antisecretory agent or H2RA. PUD o Lifestyle modifications to support ulcer healing - ANSWER -change in eating pattern consumption of five or six small meals a day, rather than 3 large ones, can reduce fluctuations in intragastric pH and may facilitate recovery. Avoid smoking, aspirin and NSAIDS should be avoided. Stop ETOH if causal relationship of symptoms exist Anti-diarrheal o Which one contradicted in children during or after chickenpox - ANSWER - Bismuth subsalicylate (Pepto Bismol) increase risk of Reye's syndrome

Patient teaching for ciprofloxacin for traveler's diarrhea - ANSWER -generally caused by Escherichia coli; treatment is usually unnecessary because the disease runs its course in a few days. If symptoms are severe or prolonged, an antibiotic, such as ciprofloxacin, may be helpful only in nonpregnant women

. This agent should be taken only if needed as antidiarrheal medications may slow the export of the organism and prolong the course of the disease. Prophylactic treatment with antibiotics is not recommended. Ciprofloxacin is taken twice daily, avoiding meals. Which Anti-diarrheal is associated with gray/black stools and black tongue - ANSWER -Bismuth Constipation o Lifestyle modifications to suggest prior to treatment - ANSWER -•Increasing fiber and fluid in diet *Mild exercise, especially after meals Risks of laxatives during pregnancy - ANSWER -oGI stimulation might induce labor Preferred Constipation treatment during breastfeeding - ANSWER -oSenna is safe for use during breastfeeding. Psyllium How it works and what to assess for if it doesn't produce a bowel movement - ANSWER -oAbsorb water in the small intestine and colon, thereby softening and enlarging the fecal mass; fecal swelling promotes peristalsis. If bowel movement does not occur assess for intestinal obstruction or impaction. Irritable Bowel Syndrome (IBS) o A diary can be helpful to aid in diagnosis and treatment - ANSWER -• Vomiting o How to treat gastroparesis - ANSWER -•Metoclopramide (Reglan) = increases upper GI motility

Black box warning associated with gastroparesis treatment - ANSWER -long-term high-dose therapy can cause irreversible tardive dyskinesia, characterized by repetitive, involuntary movements of the arms, legs, and facial muscles. Contraindicated in patients with GI obstruction, perforation, or hemorrhage. Metronidazole (Flagyl) o Patient teaching needed - ANSWER -Side effects - Nausea and vomiting Alcohol must be avoided Should not be taken during pregnancy DTaP or Tdap Who should receive the Tdap vaccine? - ANSWER -Tdap vaccine is given to adolescents > years old and adults. Vaccine Contraindications. Varicella - ANSWER -Pregnant patients, individuals with certain cancers (leukemia, lymphomas), and individuals with hypersensitivity to neomycin or gelatin, both of which are in the vaccine. The vaccine should be avoided by immunocompromised individuals including HIV infection or congenital immunodeficiency, and those taking immunosuppressant True contraindication for DTaP or Tdap vaccine. - ANSWER -if a prior vaccination with DTap produced an immediate anaphylactic reaction or encephalopathy within 7 days of vaccination Vaccine Contraindications - Hepatitis B virus (HBV) vaccine - ANSWER -prior anaphylactic reaction to Hep B itself or baker's yeast. Examples of vaccine types - Attenuated - ANSWER -Influenza (Live Attenuated) Examples of vaccine types - Live virus - ANSWER -MMR MMRV

Varicella Rotavirus Influenza Examples of vaccine types - Toxoid - ANSWER -DTaP Diphtheria and tetanus and acellular pertussis adsorbed, hepatitis B (recombinant), and inactivated poliovirus vaccine Examples of vaccine types - Inactive viral antigen - ANSWER -Hep A Hep B Influenza (inactivated) Poliovirus o Herd Immunity What are they and how is each one achieved? - 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. Definition of vaccine - ANSWER -a preparation containing whole or fractionated microorganisms. Administration causes the recipient's immune system to manufacture antibodies directed against the microbe. Post exposure prophylaxis for suspected rabies bite - ANSWER -dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3, 7, and 14. For people who have never been vaccinated against rabies previously, post exposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The

combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment Patient teaching and assessments for post vaccine side effects - ANSWER -Many children experience local reactions (discomfort, swelling, and erythema at the injection site.) Fever is also common. Very rare but severe effects include anaphylaxis; acute encephalopathy, and vaccine-associated paralytic poliomyelitis Who can receive attenuated influenza vaccine (FluMist)? - ANSWER -approved after age 2 years Signs and symptoms of hyperthyroidism - ANSWER -Heartbeat is rapid and strong - dysrhythmias and angina possible Nervousness, insomnia, rapid thought flow, and speech Skeletal muscles may weaken and atrophy Metabolic rate is raised - increased heat production increased body temp Intolerance to heat, skin warm and moist Appetite ↑'d but patient experiences weight loss All the symptoms are called thyrotoxicosis If the patient has Graves Disease - exophthalmos Drug/Food/Supplement interactions with levothyroxine Metabolism ACCELERATED by: - ANSWER -Phenytoin (Dilantin) Carbamazepine (Tegratol, Caratrol) Rifampin (Rifadin) Sertraline (Zoloft) Phenobarbital Patients taking these medications will need to have dose of levothyroxine increased

Warfarin and Levothyroxine Interaction - ANSWER -Levothyroxine accelerates degradation of vitamin k dependant clotting factors May need to reduce the dose of warfarin Catecholamines and Levothyroxine Interaction - ANSWER -↑'d cardiac responsiveness - at an increased risk of catecholamine - induced dysrhythmias Digoxin and insulin May need to have ↑'d dosages of these if patient is taking levothyroxine Mechanism of Action o TZD - ANSWER -Decrease insulin resistance Mechanism of Action o DPP-4 - ANSWER -inhibit DPP-4 activity and ↑ active incretin concentration which results in ↑'d insulin secretion and ↓'d glucagon Mechanism of Action o SGLT2 - ANSWER -Blocks glucose reabsorption by the kidneys and the proximal nephron and increases the release of glucose in the urine. SGLT2i" Limits reabsorption of glucose in the renal tubules Mechanism of Action o Sulfonylureas - ANSWER -Act primarily by stimulating the release of insulin from pancreatic islets. They promote insulin release by binding with and thereby blocking adenosine triphosphate (ATP)-sensitive potassium channels in the cell membrane. As a result, the membrane depolarizes, thereby permitting influx of calcium, which in turn causes insulin release. The extent of release is glucose dependent and diminishes when plasma glucose declines. Symptoms associated with Mild-Persistent classification of asthma *Symptoms *Nighttime Awakening SABA USE - ANSWER -More than 2 d/wk but <daily *3-4 times/month

*More than 2 d/week but <daily and no more than 1 time on any day Symptoms associated with Moderate-Persistent classification of asthma *Symptoms *Nighttime Awakening SABA USE - ANSWER -Daily *More than once/week but <nightly *Daily Symptoms associated with Severe-Persistent classification of asthma *Symptoms *Nighttime Awakening SABA USE - ANSWER -Several times daily *Often nightly *Several times a day Know examples of drug classes (LABA) - ANSWER -Formoterol (Foradil), Salmeterol (Serevent) Know examples of drug classes (ICS) - ANSWER -Beclomethasone dipropionate (QVAR), Budesonide (Pulmicort Flexhaler) SABA Patient instructions - ANSWER -SABA is for acute asthma attacks -NOT LONG TERM use. Proper use of inhaler and spacer. Advise pt's w/asthma to assess peak expiratory flow daily, and record data, along with symptom frequency and symptom intensity, nighttime awakenings, effect on normal activity, and SABA use.

Patient education needed for various types • Gum • - ANSWER -*chew the gum slowly and intermittently for approximately 30 minutes. (Rapid chewing can release too much nicotine at one time), resulting in effects similar to those of excessive smoking (e.g., nausea, throat irritation, hiccups). *Do not eat or drink while chewing or for 15 minutes before chewing (Decrease absorption). *D/C after 3 mos. nicotine use. *Withdrawal should be done gradually.

• not recommended > 6 mom. Patient education needed for various types • Nasal spray - ANSWER -*Not for L/T use Nicotine nasal spray (Nicotrol NS) *nicotine levels rise rapidly, the spray provides some of the subjective pleasure associated with cigarettes. *Avoid with sinus problems, allergies, asthma o Active Immunity What are they and how is each one achieved? - 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 o Passive Immunity What are they and how is each one achieved? - 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.