NR FINAL EXAM STUDY GUIDE Q & A DOWNLOAD TO SCORE A/2023.Qualified., Exams of Nursing

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When and when not to use progestin for hormone replacement therapy and why (pp. 430-433) Goals for noncontraceptive uses of progestins are to counteract endometrial hyperplasia caused by unopposed estrogen during hormone therapy; management of dysfunctional uterine bleeding, amenorrhea, & endometriosis; & support of pregnancy in women with corpus luteum deficiency. Progestins are also used in in vitro fertilization cycles & to prevent prematurity in women at high risk for preterm birth. Progestins are contraindicated in the presence of undiagnosed abnormal vaginal bleeding. Relative contraindications include active thrombophlebitis or a history of thromboembolic disorders (DVT, CVA), active liver disease, & carcinoma of the breast. Progestins should not be prescribed for women who have undergone hysterectomy. Local vs. systemic estrogen options and why one would be chosen over the other (p.

428. Local estrogen options: Transdermal: Transdermal estradiol is available is 4 formulations:

- Emulsion (Estrasorb) : Applied once daily to the top of both thighs & the back of both calves. - Spray (Evamist) : Applied once daily to the forearm. - Gels (EstroGel, Elestrin, Divigel) : Applied once daily to one arm, from the shoulder to the wrist or to the thigh (Divigel). - Patches (Alora, Climara, Estraderm, Menostar, Vivelle-Dot) : Applied to the skin of the trunk (but not the breast). Intravaginal: Estrogens for intravaginal administration are available as inserts, creams, & vaginal rings. All are used primarily for the treatment of vulval & vaginal atrophy associated with menopause. NOTE: Femring is also used for systemic effects to control hot flashes & night sweats. - Inserts (Imvexxy, Vagifem, Yuvafem)

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- Creams (Estrace Vaginal, Premarin Vaginal) - Vaginal rings (Estring, Femring) Systemic estrogen options: Oral: Owing to convenience, the oral route is used more than any other. The most active estrogenic compound— estradiol—is available alone & in combination with progestins. Parenteral: Although estrogens are formulated for IV & IM administration, use of these routes is rare. IV administration is generally limited to acute, emergency control of heavy uterine bleeding.

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should be used for the first 7 days. -What teaching needs to be done? (p. 442) Educate patient on proper protocol for missed doses (depending on medication type & cycle): For products that use a 28-day cycle , the following recommendations apply:

• If one or more pills are missed in the first week , take one pill as soon as possible & then continue with the pack. Use an additional form of contraception for 7 days.
• If one or two pills are missed during the second or third week , take one pill as soon as possible & then continue with the active pills in the pack but skip the placebo pills & go straight to a new pack once all the active pills have been taken.
• If three or more pills are missed during the second or third week , follow the same instructions given for missing one or two pills but use an additional form of contraception for 7 days. For combination OCs that use an extended or continuous cycle , up to 7 days can be missed with little or no increased risk for pregnancy provided that the pills have been taken continuously for the prior 3 weeks. For progestin-only OCs, if one or more doses is missed or taken greater than 3 hours after the scheduled dose, the following guidelines apply:
• If one pill is missed, it should be taken as soon as remembered & backup contraception should be used for at least 2 days. The pills should be resumed as scheduled on the next day.
• If two pills are missed, the regimen should be restarted & backup contraception should be used for at least 2 days.

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• In addition, if two or more pills are missed & no menstrual bleeding occurs, a pregnancy test should be done. Effectiveness of oral contraceptives can be reduced with some medications, including certain common antibiotics. -What baseline data is needed? (p. 446) Assess for history of hypertension, diabetes, thromboembolism, cerebrovascular or cardiovascular disease, breast cancer. Urine pregnancy test. -Contraindications for OCs (p. 446) Contraindications to use include current pregnancy, history of thromboembolus, breast cancer, & women over 35 years of age who continue to smoke tobacco. Use with caution in women with diabetes, hypertension, & cardiac disease. How to achieve an extended cycle with oral contraceptives (p. 442) Many health care providers recommend taking combination OCs for an extended time rather than following the traditional 28-day cycle because doing so decreases episodes of withdrawal bleeding, with the associated menstrual pain, premenstrual symptoms, headaches, & other problems. Prolonged use of OCs is possible because these drugs suppress endometrial thickening, hence monthly bleeding is not required to slough off hypertrophied tissue. At this time, 14 products are packaged & marketed for prolonged use. It is important to note that there is nothing special about the estrogen/progestin combinations used in these extended- cycle products. In other words, we could get the same results with other combination OCs, provided they are monophasic. To achieve an extended schedule, the user would simply purchase four packets of a 28- day product (each of which contains 21 active pills) & then take the active pills for 84 days straight. What behaviors would make one birth control method more effective over another? (pp. 437-438) -Be able to evaluate a patient scenario and suggest an appropriate birth control method (type of prescribed

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What effect does CYP450 inhibitors or inducers have on OCs? (p. 441) -Recall examples of CYP450 inhibitors and inducers from NR565 (Chapter 4 in textbook) -How does this impact prescribing of OCs? Products that induce hepatic cytochrome P3A4 can accelerate OC metabolism & thereby reduce OC effects. Common drugs that induce CYP450 are phenytoin, carbamazepine, rifampin, alcohol, & sulfonylureas. Women taking OCs in combination with any of these agents should be alert for indications of reduced OC blood levels, such as breakthrough bleeding or spotting. If these signs appear, it may be necessary to either:

1. Increase the estrogen dosage of the OC
2. Combine the OC with a second form of birth control (condom, etc.)
3. Switch to an alternative form of birth control OCs can decrease the benefits of warfarin & hypoglycemic agents. By increasing clotting factors, OCs can decrease the effectiveness of warfarin , an anticoagulant. By increasing levels of glucose, OCs can counteract the benefits of insulin & other hypoglycemic agents used in diabetes. Accordingly, when combined with OCs, warfarin & hypoglycemic agents may require increased dosage. OCs can impair the hepatic metabolism of several agents, including theophylline, tricyclic antidepressants, diazepam, & chlordiazepoxide. Because of reduced clearance, these drugs may accumulate to toxic levels. If signs of toxicity appear, the dosages of these drugs should be reduced. Benefits and drawbacks of progestin-only contraception (p. 442) Benefits: Because they lack estrogen, “minipills” do not cause thromboembolic disorders, headaches, nausea, or most of the other adverse effects associated with combination OCs. Drawbacks: Unfortunately, although slightly safer than combination OCs, the progestin-only preparations are less effective & are more likely to cause irregular bleeding (breakthrough bleeding, spotting, amenorrhea,

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inconsistent cycle length, variations in the volume & duration of monthly flow). Irregular bleeding is the major drawback of these products & the principal reason that women discontinue them. What are the most effective forms of contraception? (p. 437) The most effective methods are an etonogestrel implant (Nexplanon), an intrauterine device (IUD), & sterilization. OCs, medroxyprogesterone (Depo-Provera), the contraceptive ring, & the contraceptive patch are close behind. The least reliable methods include barrier methods, periodic abstinence, spermicides, & withdrawal. Testosterone replacement (pp. 450-453) -Administration

• Oral: Only 2 androgens are approved for oral therapy— fluoxymesterone & methyltestosterone. Despite the advantage of cost &. Ease of administration, they are not first-line agents. The androgenic effects of oral androgens are erratic & pose a risk for hepatotoxicity, therefore they should not be used long term.
• Transdermal patches: Androderm —applied once daily to the upper arm, thigh, back, or abdomen.
• Transdermal gel: AndroGel, Testim, Fortesta, Vogelxo —applied once daily (preferably in the morning) to clean, dry skin of the shoulders, upper arms, or abdomen. Can be transferred to others by skin-to-skin contact. Wash hands with soap & water after every application, cover the application site with clothing once the gel has dried, wash the application site before skin-to-skin contact with another person, women & children should avoid skin- to-skin contact with application sites on gel users & wash contaminated skin immediately if accidental contact with gel application site occurs.

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Androgens: Tell female patients about signs of virilization (deepening of the voice, acne, changes in body & facial hair, menstrual irregularities). Instruct them to report if these occur. Apprise patients of the signs of liver dysfunction (yellow tint to skin & eyes, fatigue, loss of appetite, nausea, dark- colored urine, light-colored stools). Advise them to report the occurrence of these changes. Inform patients that swelling of the extremities or unusual weight gain may be evidence of salt & water retention. Counsel them to report these events. Remind patients of child-bearing age that this drug can cause fetal malformations. If the patient is capable of becoming pregnant, emphasize the need for consistent use of reliable contraception. Treatment of delayed puberty -When is it appropriate to initiate androgen therapy (short course and long-term) (p. 448) In some boys, puberty fails to occur at the usual age (before 15 years old). Most often, this failure reflects a familial pattern of delayed puberty & does not indicate pathology. Puberty can be expected to occur spontaneously but later than usual. Hence treatment is not an absolute necessity. However, some providers will prescribe a limited course of androgen therapy off label if the psychologic pressure of delayed sexual maturation are causing a boy significant distress. In these cases, a limited course of androgen therapy is indicated. Both fluoxymesterone (Androxy, Halotestin) & methyltestosterone (Methitest) are approved for this purpose. If delayed puberty is the result of true hypogonadism, long-term replacement therapy is indicated.

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Androgen therapy -Effects: Therapeutic (pp. 448-449)

• Male hypogonadism: A condition in which the testes fail to produce adequate amounts of testosterone. May be hereditary, or it may result from other causes, including pituitary failure, hypothalamic failure, & primary dysfunction of the testes.
• Replacement therapy: When testicular failure occurs in adult males. Treatment restores libido, increases ejaculate volume, & supports expression of secondary sex characteristics. Treatment will NOT restore fertility.
• Delayed puberty: If puberty fails to occur before age 15 years, some providers will prescribe a limited course of androgen therapy off label if the psychologic pressure of delayed sexual maturation are causing a boy significant distress.
• Testosterone therapy in menopausal women: Can alleviate some menopausal symptoms, especially fatigue, reduced libido, & reduced genital sensitivity.
• Cachexia: A wasting of the body associated with severe illnesses such as AIDS, severe trauma, & chronic systemic infections. Testosterone levels often decline in these patients, putting them at risk for wasting & loss of muscle mass. Testosterone therapy decreases this risk.
• Anemias: Sometimes used in men & women to treat anemias that have been refractory to other therapy. Adverse (p. 450)
• Virilization in women, girls, & boys: The most common complication of androgen therapy. When taken in high doses by women, androgens can cause acne, deepening of the voice, proliferation of facial & body hair, male-pattern baldness, increased libido, clitoral enlargement, & menstrual irregularities. Masculinization can also occur if taken by children (for sports

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Monitoring: Serum testosterone concentration, lipids, liver function, & PSA after 1 year (refer to urologist for evaluation if PSA is greater than 4.0 ng/mL or greater than 1.4 ng/mL above baseline).

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-Role of androgens in treating anemia (p. 449) Androgens are sometimes used in men & women to treat anemias that have been refractory to other therapy. Anemias most likely to respond include aplastic anemia, anemia associated with renal failure, Fanconi anemia, & anemia caused by cancer chemotherapy. Androgens help relieve anemia by promoting synthesis of erythropoietin, the renal hormone that stimulates production of red blood cells, & possibly white blood cells & platelets. With the emergence of other therapies such as erythropoietin-stimulating agents, androgens have fallen out of favor for off-label treatment of anemia. -Preferred administration route of alprostadil and why (pp. 459-460) Alprostadil is a nonoral drug for erectile dysfunction (ED) that can be given either by injection into the penis or by insertion into the urethra. Because of this inconvenient method of dosing, this drug is a second-line agent for ED. Penile fibrosis may develop with the continued use of injections; this complication has not been reported with the pellets inserted into the urethra. Treatment of hypogonadism -Benefits (p. 448) Androgen replacement therapy can restore libido, increase ejaculate volume, & support expression of secondary sex characteristics. Treatment will NOT restore fertility. -Administration methods for transdermal preparations (p. 450) Testosterone is available in 3 transdermal formulations: patch, gel, & liquid. With all 3 formulations, testosterone is absorbed through the skin & then slowly absorbed into the blood.

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▪ Phosphodiesterase-5 Inhibitor: Hypotension, priapism. ▪ α1a Blocker/5-α-Reductase Inhibitor: Decreased libido & abnormal ejaculation (ejaculation failure, reduced ejaculate volume, retrograde ejaculation).

- Therapeutic Effects Time to achieve : ▪ 5-α-Reductase Inhibitors: Anticipate symptom improvement after 6-12 months. (p. 464) ▪ α1 Blockers: Benefits develop rapidly. (p. 463) Patient education/Provider response ▪ 5-α-Reductase Inhibitors: Most appropriate for men with very large prostates (mechanical obstruction). Several months are required for a noticeable effect. In 5% to 10 % of patients, it decreases ejaculate volume & libido. Gynecomastia develops in some men. Advise men not to donate blood if taking & for up to 6 months after stopping the drug to avoid the risk of having a pregnant woman as the blood recipient due to teratogenic effects on the male fetus. Dutasteride capsule contents can be irritating to the oropharyngeal mucosa, so they must be swallowed whole with a full glass of water. ▪ α1 Blockers: Preferred for men with relatively small prostates (dynamic obstruction). Symptomatic improvement & increased urinary flow develop rapidly. To maintain benefits, they must be taken lifelong. For men undergoing cataract surgery, these medications increase the risk for intraoperative floppy-iris syndrome , a complication that can increase postoperative pain, delay recovery, & reduce the hoped-for improvement in vision acuity. In severe cases, the syndrome can cause defects to the iris that may lead to blindness. Men anticipating cataract surgery should postpone 𝛼-blocker therapy until after the procedure. Men already taking an 𝛼-blocker should be sure to tell their ophthalmologist.

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▪ Assessment for therapeutic effect (p. 463) ▪ 5-α-Reductase Inhibitors: Reduction of dihydrotestosterone (DHT) production causes the prostate to shrink, which reduces mechanical obstruction of the urethra. May also delay BPH progression. Benefits take months to develop. ▪ α1 Blockers: Blockade of 𝛼-receptors relaxes smooth muscle in the bladder neck, prostate capsule, & prostatic urethra, thereby decreasing dynamic obstruction of the urethra. Benefits develop rapidly. ▪ Phosphodiesterase-5 Inhibitor: Smooth muscle relaxation in the bladder, prostate, & urethra. Produces a modest decrease in symptoms (urinary frequency, urinary urgency, straining) but does not improve urinary flow rate. Initial improvement is seen in 2 weeks. (p. 465) National STI/STD Curriculum -Treatment of STIs/STDs (pp. 764-765) ▪ Chlamydia: Azithromycin, 1 gram PO once OR Doxycycline, 100 mg PO BID x 7 days ▪ Uncomplicated gonococcal urethritis: Ceftriaxone, 250 mg IM once PLUS Azithromycin, 1 gram PO once

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For patients with more severe symptoms, treatment should begin with either levodopa (combined with carbidopa ) or a dopamine agonist ( apomorphine, pramipexole, ropinirole, rotigotine, bromocriptine, cabergoline ). Levodopa is more effective than the dopamine agonists, but long-term use carries a higher risk for disabling dyskinesias. Hence the choice must be tailored to the patient: if improving motor function is the primary objective, then levodopa is preferred. However, if drug-induced dyskinesias are a primary concern, then a dopamine agonist would be preferred. -Combination therapy (p. 131) Because of peripheral metabolism, less than 2% of each dose enters the brain if levodopa is given alone. For this reason, levodopa is now available only in combination preparations with either carbidopa OR carbidopa & entacapone. These additional agents decrease the amount of decarboxylation in the periphery so that more of the drug can enter the CNS. -Medications used to treat “off” times including “wearing off” experiences (pp. 128-

129. Acute loss of effect occurs in 2 patterns: gradual loss & abrupt loss. Gradual loss—“wearing off”—develops near the end of the dosing interval & simply indicates that drug levels have declined to a subtherapeutic value. Wearing off can be minimized in 3 ways:

1. Shortening the dosing interval
2. Giving a drug that prolongs levodopa’s plasma half-life ( entacapone —a COMT inhibitor)
3. Giving a direct-active dopamine agonist Abrupt loss of effect, often referred to as the “on-off” phenomenon, can occur at any time during the dosing interval— even while drug levels are high. Off times may last from minutes to hours. Over the course of treatment, off periods are

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likely to increase in both intensity & frequency. Off times can be reduced with 3 types of drugs: dopamine agonist, COMT inhibitors, & MAO-B inhibitors. Evidence of efficacy is strongest for entacapone (a COMT inhibitor) & rasagiline (an MAO- B inhibitor). The only drug recommended for dyskinesias is amantadine (a dopamine releaser). -Adverse Effects (p. 137) ▪ Pramipexole (Mirapex) : A nonergot dopamine receptor agonist; used alone is early-stage Parkinson’s disease (PD) & is combined with levodopa in advanced-stage PD. Can produce a variety of adverse effects, primarily by activating dopamine receptors. The most common effects seen when pramipexole is used alone are nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, & hallucinations. When the drug is combined with levodopa , about 50% of patients experience orthostatic hypotension & dyskinesias, which are not seen when the drug is used by itself. In addition, the incidence of hallucinations nearly doubles. A few patients have reported sleep attacks (overwhelming & irresistible sleepiness that comes on without warning). Sleep attacks should not be equated with the normal sleepiness that occurs with dopaminergic agents. Pramipexole has been associated with impulse control disorders , including compulsive gambling, shopping, binge eating, & hypersexuality. These behaviors are dose related, begin about 9 months after starting the medication, & reverse when the drug is discontinued. Risk factors include younger adulthood, a family or personal history of alcohol abuse, & a personality trait called novelty seeking, characterized by impulsivity, a quick temper, & a low threshold for boredom. Before prescribing pramipexole, providers should screen patients for compulsive behaviors. Management of seizures -Which medication would be the safest choice for someone on an oral contraceptive? (p. 155)