NR 566 Final Exam With 100% Correct And Verified Answers, Exams of Advanced Education

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NR 566 Final Exam With 100% Correct

And Verified Answers

Primary Hypogonadism - Correct Answer-results of testicular failure and is characterized by low testosterone and elevated gonadotropins Secondary Hypogonadism - Correct Answer-result of hypothalamic-pituitary failure and is characterized by low testosterone and low normal gonadotropins Congenital hypogonadism - Correct Answer-- result of insufficient amounts of testosterone produce by the gonads during puberty. -Delayed, arrested, or absent testicular growth and delayed development of secondary sexual characteristics are hallmark signs

• Physical signs include a voice that does not deepen, no muscle mass increase, and male sex organs that do not develop and mature Symptoms of Hypogonadism in adults - Correct Answer-Depression Development of male breasts Erectile dysfunction Failure of facial and body hair to grow Increase in body fat, loss of energy Inhibited sexual desire Loss of muscle mass Onset of osteoporosis Shrinking and softening of the testicles Rational Drug Selection for ED - Correct Answer-treatment includes phosphodiesterase type 5 (PDE-5) inhibitors, or TRT phosphodiesterase type 5 (PDE-5) inhibitors - Correct Answer-sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) Contraindications of PDE-5 inhibitors - Correct Answer-- if taken concurrently with nitrates (nitroglycerine) there is potential for fatal hypotension
• acute myocardial infarction, stroke, or arrhythmia in past 6 months
• HIV protease inhibitors
• riociguat or other guanylate cyclase stimulator ADE of PDE 5 inhibitors - Correct Answer-- fatal hypotension if taken with nitrates
• vision and hearing problems in rare cases
• MI
• Sickle Cell Anemia with vasoocclusive crisis
• optic neuropathy -retinal hemorrhage

• priapism Testosterone therapy effects - Correct Answer-- Stimulates erythropoiesis
• Increased bone mass in eugonadal men
• Long-term benefit of TRT on bone mineral density is not known.
• May improve cognitive functioning
• Improves insulin sensitivity
• No association between TRT and cardiac events
• Has variable effects on mood, energy, and sense of well-being
• Muscle mass and strength
• May reverse age-dependent body composition changes and associated morbidity
• Associated with a greater improvement in grip strength than a placebo Sexual desire, function, and performance
• May benefit men with erectile dysfunction (ED) caused by hypogonadism
• Enhances libido Erythrocytosis from overuse or abuse of testosterone - Correct Answer-- Close monitoring is needed
• monitoring of hemoglobin and hematocrit is required
• Hgb > 17.5 or Hct > 54% suggests overtreatment
• Mechanisms involving iron bioavailability, erythropoietin production, and bone marrow stimulation have been postulated to explain the erythrogenic effect of TRT TRT Monitoring Timelines - Correct Answer-- Evaluate efficacy at 3 to 6 months of therapy.
• Evaluate testosterone level at 3 to 6 months from starting therapy. *Goal is mid-normal range.
• Evaluate Hct/Hgb at 3 and 6 months, then annually.
• Evaluate bone mineral density at 1 to 2 years.
• Evaluate PSA levels and digital rectal exam before beginning therapy and at 3 and 6 months. Contraindications for TRT - Correct Answer--Male breast cancer
• Pregnancy or use in Women
• Prostate Cancer Pharmacokinetic gender differences (men) - Correct Answer-- Men are less likely to receive annual exams and health screening
• leading causes of death in men are heart disease, cancer, and unintentional accidents Men who have sex with men - Correct Answer-- have higher rates of HIV infection and sexually transmitted infections
• African American and Latino American MSM are twice as likely to contract HIV
• Healthcare for gay men and other MSM is complicated due to physical, psychosocial, and cultural dynamics that require practitioner awareness

Non-pharm tx for menopause - Correct Answer--turn down thermostat, dressing in layers, avoid alcohol and spicy foods, reduce obesity, reduce stress

• SSRI/SNRI
• Gabapentin/Pregabalin
• Clonidine if above meds aren't working or not tolerated
• OTC: Black Cohosh, Omega 3 , Red Clover, Vitamin E
• Mind and Body control: Anxiety control, Acupuncture, paced breathing, and Hypnosis Pharmacokinetic gender diff (women) - Correct Answer-- volume of distribution is greatly impacted by body composition
• higher body fat = fat soluble meds have > volume of distribution
• Meds with altered in women: Opioids, warfarin, aspirin, psychotropic drugs, and antiretroviral drugs RDS for PMDD - Correct Answer-*SSRI - 1st line therapy
• Spironolactone, oral contraceptives, and NSAIDs may be helpful Tx for dysmenorrhea - Correct Answer-*NSAIDs - 1st line therapy, start 2-3 days prior to menses
• Oral contraceptives may be effective
• Non-pharm: massage, yoga, exercise, and heating pad Patient education for NSAIDs for dysmenorrhea - Correct Answer-- start taking 2-3 days prior to menses or at first sign of bleeding
• OTC NSAIDs labeled recommended dose for general discomfort may be subtherapeutic for dysmenorrhea Recommendations of Vit D and Calcium for Adolescents and adults - Correct Answer-- Female adolescent athletes at risk for female athlete triad *Disordered eating and over exercise can lead to suppression of the hypothalamic- pituitary-ovarian axis. *Reduced estrogen levels can lead to amenorrhea and decreased bone mineralization. *Treatments may include calcium, vitamin D, and oral contraceptives. Depo should not be given for longer than 2 years to decrease bone mineral density loss sex-based differences - Correct Answer- absorption and bioavailability - gastric emptying slower in females, and gastric alcohol dehydrogenase are lower in females

• distribution - females have lower body weight and BMI, females have higher proportion of body fat, plasma volume lower in females, organ blood flow is lower in females, Exogenous estrogens increase levels of many serum-binding globulins such as corticosteroid-binding globulin and thyroxine-binding globulin resulting in less free drug.
• metabolism - Females have lower levels of p-glycoprotein and higher rates of drug clearance for drugs that are substrates of p-glycoprotein, high rates of metabolism for CYP450 3A4 substrates and lower rates for 1A2 and 2D6 substrates
• excretion - gender diff in rates of renal excretion is more related to weight differences.

LGBTQ population - Correct Answer-- Lesbian health is not the same as women's health

• Lesbians get STI and need cervical cancer screenings
• Providers need to treat with respect and dignity, be mindful of how sexuality is addressed, creating accepting environment Influence on med adherence pediatrics - Correct Answer-- unique dilemma due to must deal with child's compliance as well as parent or other caregiver. *Factors: Length of regimen, number of prescribed meds, medication interval, palatability, cost, and family issues. -Adherence is less than ideal in children and adolescents Teaching for parents for infants - Correct Answer-- No matter is infant dislikes taste, parent is in control of administering meds.
• teach properly how to administer the med (parent may be nervous)
• provide encouragement to parents -Dosing errors are common (EDUCATE, EDUCATE, EDUCATE) *Reason for med, dose, how to draw up med in ml, length of tx, tips on how to administer. Use of topical steroids in young children and infants - Correct Answer-- absorption is more rapid than adults leading to systemic toxicity
• systemic Cushingoid symptoms or HPA (hypothalamic-pituitary-adrenal-axis) suppression developing with topical use -many topical corticosteroids have been relabeled due to risks. Dosing of Ibuprofen in children - Correct Answer-- The correct dosage is 5- mg/kg/dose q6-8h. -should not be administered by parents to children under age 6 months because immature kidneys are unable to excrete it, leading to increased risk of toxicity and renal damage.
• Avoid if fluid intake is decreased to prevent renal damage Dosing of Acetaminophen in children - Correct Answer-- 10-15 mg/kg/dose q4-6h
• can be oral or rectal (suppository) -peaks in 30-60 minutes Pain relief in infants and children - Correct Answer-Acetaminophen or Ibuprofen may be used for mild to moderate pain and both can treat fever
• ibuprofen may be the drug of choice for night pain associated with otitis media because of its longer duration
• Combining acetaminophen and ibuprofen in an alternating schedule for fever or pain is not recommended in the outpatient setting

Physiologic changes in geriatric patients - Correct Answer-*Mental - increased susceptibility to delirium and cognitive side effects of drugs

• Sensory - 1/3 have visual impairment, 1/3 have hearing impairment, diminished smell and taste may impair nutrition (compounded by meds), peripheral sensation contributes to increased fall risk (compounded by meds)
• Musculoskeletal - impaired manual dexterity Pharmacodynamic implications of the physiologic changes in geriatrics - Correct Answer-- reduced homeostatic mechanisms

• altered receptor sensitivity
• increased sensitivity to drugs pharmacokinetic implications of the physiologic changes in geriatrics - Correct Answer-* Absorption - not dramatically different that younger adult *Distribution - increased fat stores, decreased total body water and serum albumin *Metabolism - decreased hepatic blood flow, decreased CYP 450 system function

• Excretion - decreased renal mass and GFR and tubular secretion; serum creatinine is an unreliable marker or renal function Steps to avoid polypharmacy - Correct Answer-- Obtain complete drug history and review current drugs including OTC and inhaled at least every 6 months

• Avoid prescribing when the benefit is questionable (consider age and stage of disease)
• Evaluate for duplication of drug therapy (use drug combinations or prescribe single drugs that provide multiple therapeutic effects
• Review medication list for drugs prescribed for an ADR. (explore is drug causing ADR can be withdrawn or changed to avoid reaction)
• Prescribe lifestyle changes and other non-drug therapies whenever possible
• Clearly understand the difference between manifestations of the aging process and the disease state that must be treated. Common herbal medications used by elderly patients - Correct Answer-- Anti-aging DHEA and growth hormone
• Ginkgo biloba (prevent dementia)
• Saw Palmetto (relieve BPH symptoms)
• Chondroitin sulfate and glucosamine sulfate (OA)
• St. John's Wart and SAMe (depression) Hypoglycemia in geriatric patients - Correct Answer-- Diabetic drugs are more likely to cause hypoglycemia in geriatrics Warfarin pharmacokinetics - Correct Answer-- well absorbed when taken orally
• metabolized CYP 1A2 and 2C
• Half-life of 3-4 days Warfarin ADR - Correct Answer-- Bleeding (Antidote Vitamin K)

• Allergic reactions Warfarin drug interactions - Correct Answer-- Many drug-drug interactions
• Antiplatelet drugs
• Thrombolytic drugs
• Anticoagulant effect may be decreased by oral contraceptives, carbamazepine, etc. and Vitamin K containing foods. Warfarin clinical use - Correct Answer-- drug of choice for DVT and PE
• start at 5mg per day (7.5mg daily for weight > 80kg)
• consider loser dose in older adults (>75), multiple comorbidities, elevated liver enzymes, and changing thyroid status
• dose to maintain INR between 2- Warfarin monitoring - Correct Answer-- INR monitored daily until therapeutic range for 2 consecutive days
• Then INR 2 or 3 times weekly for 1-2 weeks
• Then less frequently but at least every 6 weeks Warfarin precautions - Correct Answer-- Pregnancy category X
• Use cautiously in patients with high fall risk, dementia, and uncontrolled HTN
• avoid in hypermetabolic state heparin pharmacokinetics - Correct Answer-- given IV or subq -extensively protein-bound
• metabolized by liver
• renally eliminated heparin precautions - Correct Answer--Pregnancy category C
• Avoid in advanced hepatic or renal disease
• avoid in bleeding disorders
• avoid in active bleeding heparin ADR - Correct Answer-- may cause thrombocytopenia
• life-threatening bleeding
• pain at injection site
• antidote is protamine sulfate heparin drug interactions - Correct Answer-- cephalosporins and PCN
• Warfarin, antiplatelet, and thrombolytics -valproic acid heparin clinical use and dosing - Correct Answer-*Heparin -given 2 hours pre-op -maintenance every 8-12 hrs for 7 days post surgery *Low molecular weight heparin (LMWH)

+Enoxaparin -DVT or PE -Given 2 hours before surgery +Fondaparinux -DVT -Hip fx surgery or knee replacement Dalteparin -Prevent DVT after abdominal surgery or hip replacement heparin monitoring - Correct Answer--activated partial thromboplastin time (PTT) -Platelet and Hct every 2-3 days initially Antiplatelet drugs - Correct Answer-ASA - inhibits cycloxygenase - interferes with platelet aggregation Clopidogrel and Ticlodipine - reduces platelet aggregation by inhibiting adenosine diphosphate pathway Antiplatelet Pharmacokinetics - Correct Answer-ASA - well absorbed orally - metabolized in liver - renally excreted (pH effects excretion) *Ticlopidine - rapidly absorbed after oral admin - metabolized in liver - half-life lengthens with repeated dosing - decreased renal clearance with age Clopidogrel - metabolized into active metabolite - excreted in urine and feces Antiplatelet Contraindications - Correct Answer- ASA - hypersensitivity, cross sensitivity with NSAIDs - Pregnancy category C (D in 3rd trimester) - Reyes syndrome in kids Clopidogrel and Ticlopidine - avoid in liver dysfunction Antiplatelet ADR - Correct Answer-ASA -bleeding

• may cause GI bleed
• Salicylism (tinnitus) *Ticlopidine -Neutropenia *Clopidogrel
• Bleeding Antiplatelet drug interaction - Correct Answer-*Concurrent use of other antiplatelet, anticoagulant, or fibrinolytic drugs *ASA -Herbals (ginko, garlic, ginseng)
• NSAIDs *Clopidogrel -PPIs
• CYP 2C19 inhibitors *Ticlopidine
• Antacids
• Digoxin
• Cimetadine

Antiplatelet clinical use - Correct Answer-*ASA

• MI prevention 75-162mg daily
• Persistent Afib 75-325mg daily
• Stroke or TIA 50-100mg daily *Clopidogrel
• MI prevention 75mg daily
• STEMI 300mg daily if <75yo and 75mg daily if >75yo *Ticlopidine -Prevent stones in patients intolerant of Acetylsalicylic acid 250mg BID Patient education for anticoagulant - Correct Answer--dosage may vary from day to day -Subq administration instructions for LMWH at home
• risk of bleeding -Avoid vitamin K-containing foods Patient education for antiplatelet - Correct Answer-- take ASA with full glass of water
• ASA must be stopped 7 days before surgery
• Clopidogrel not taken with PPIs
• be aware of ASA toxicity
• bleeding precautions INR target goals - Correct Answer-- Dose to maintain international normalized ratio (INR) between 2 and 3 Population needed warfarin starting dose adjustment - Correct Answer--patients weighing more than 80kg (176 lbs) should be started on 7.5mg daily -normal starting dose is 5mg daily Use of anticoagulants in pregnancy - Correct Answer--women with a mechanical heart valve be treated with one of three regimens: (1) LMWH twice daily during pregnancy; (2) SC heparin every 12 hours; or (3) SX heparin or LMWH until the 13th week of pregnancy, then warfarin until close to delivery when LMWH or heparin is resumed -Warfarin is a known teratogen and may cause fetal hemorrhage, whereas heparin and LMWH do not cross the placenta and therefore do not cause teratogenicity or fetal bleeding, though bleeding at the uteroplacental junction is possible -Women on warfarin who are planning a pregnancy should have frequent pregnancy tests and substitution of heparin or LMWH when pregnancy is achieved
• should be managed by an anticoagulation specialist and perinatologist Thromboprophylaxis - Correct Answer--The ACCP recommends the use of LMWH, low- dose heparin, or fondaparinux as thromboprophylaxis in the following surgical procedures: moderate-risk major general surgery, higher-risk patients who are having a major procedure for cancer, major vascular surgery, major gynecological surgery, major urological procedures, bariatric surgery, thoracic surgery, and many orthopedic surgeries

-The length of treatment is determined by the type of surgery, ranging from a single dose with minor procedures to 10 days for most orthopedic procedures, to 28 days in high-risk patients, patients undergoing major gynecological surgery, and patients having major surgery for cancer -Apixaban dose following hip or knee replacement surgery is 2.5 mg twice daily Anticoagulant preferred for high risk of CVA with Afib - Correct Answer--The 2012 ACCP guidelines recommend 150 mg of dabigatran twice daily as the anticoagulant therapy of choice rather than warfarin

• For patients with persistent or paroxysmal AF at high risk for stroke, the recommendation is warfarin with a target INR between 2 and 3. Drugs which decrease anticoagulant effectiveness - Correct Answer-- Oral contraceptives, carbamazepine, etc.
• Vitamin K-containing foods Iron deficiency anemia prevention: - Correct Answer--adequate iron intake -monitor in periods of rapid growth (infancy, adolescence, pregnancy) -replacement in infants (1mg/kg/day starting at 4 months) (2mg/kg/day in preterm infants) -folic acid supplementation in pregnancy Iron deficiency anemia Tx - Correct Answer--iron replacement (based on age)
• divide dose in 3 doses per day Iron deficiency anemia monitoring: - Correct Answer-- reticulocyte count 5 to 10 days after starting therapy,
• Hgb, Hct, Ferritin at 4 weeks, then at 3 months and annually iron deficiency anemia outcome evaluation: - Correct Answer-- return to normal Hgb, Hct, and ferritin levels -If Hgb, Hct, and ferritin do not return to normal patient should be evaluated for source of blood loss iron deficiency anemia Pt education: - Correct Answer-- importance of prevention with adequate iron intake
• administration (empty stomach if tolerated, 3 times daily)
• constipation (may need stool softener)
• Take with vitamin C to enhance absorption.
• Avoid taking with dairy products, calcium, antacids. iron deficiency anemia risk groups: - Correct Answer--infants fed goat's milk or powdered formula
• vegetarians and vegans -pregnancy -patients with sprue, crohn's disease, giardia infections, and short bowel syndrome

-patients taking drugs that affect folic acid absorption Folic acid deficiency prevention - Correct Answer-- Adequate dietary intake

• Folic acid supplementation in pregnancy
• 0.4 mg/day prior to conception and during pregnancy
• Women of childbearing age and pregnant women should consume 0.4 to 0.8 mg/day. Folic acid deficiency drug therapy - Correct Answer-- Oral folic acid 1 to 2 mg/day for 4 to 5 weeks
• Hgb levels start to rise in a week -Initial dose: 1 mg/day in adults in children
• Maintenance dose Infants 0.1 mg/day Pregnant or lactating women: 0.8 mg/day Folic acid deficiency monitoring - Correct Answer--Hgb/Hct in 4 weeks and then regularly Folic acid deficiency education - Correct Answer-- need for folic acid
• administration Folic acid deficiency causes - Correct Answer-- Poor intake
• Impaired absorption
• Increased demand
• Impaired utilization Folic acid deficiency pharmacokinetics - Correct Answer-- Oral, IM or SC well absorbed
• Metabolized by liver
• Excreted in urine and stool Iron preparations pharmacokinetics - Correct Answer-- Enhanced absorption if iron stores low
• Ferrous form is absorbed more readily.
• Food affects absorption.
• Eliminated via shedding of GI mucosal cells or via bleeding Iron preparations contraindications - Correct Answer-- hemochromatosis
• hemolytic anemia Iron preparations ADR - Correct Answer-- GI symptoms (constipation, GI upset)
• Acute toxicity possible especially in children Iron preparations drug interactions - Correct Answer-- Chelation
• Decreased absorption Iron preparations clinical dosing - Correct Answer-- Treatment for 3 to 4 months after Hgb/Hct return to normal

• Adults: 150 to 300 mg elemental iron daily
• Premature infants: 2 to 4 mg/kg/day
• Infants and young children: 4 to 6 mg/kg/day