NURS 615 PHARM EXAM 2 Q AND A 2017

1. Henry has recently started on carbamazepine to treat seizures. He comes to see you and you note that while his carbamazepine levels had been in the therapeutic range, they are now low. The possible cause for the low carbamazepine levels include: Carbamazepine auto-induces metabolism, leading to lower levels despite good compliance. 2. Carbamazepine has a Black Box Warning due to life-threatening: Dermatologic reaction, including Steven’s Johnson and toxic epidermal necrolysis 3. Long-term monitoring of patients who are taking carbamazepine includes: Complete blood count every 3 to 4 months (can be a decrease in WBC & platelets) 4. Six-year-old Felisha has recently been started on ethosuximide (Zarontin) for seizures. She should be monitored for: Blood dyscrasias, which are uncommon but possible 5. What should families be taught regarding seizure activity monitoring? Prevention of seizures, patient safety, quality of life issues, reach acceptable goals for treatment, & do not abruptly stop taking seizure meds 6. What electrolyte imbalance is associated with topiramate? Decreased sodium bicarb leading to hyperchloremic metabolic acidosis 7. Lisa, who is overweight, recently started taking topiramate for seizures and at her follow- up visit you note she has lost 4 kg. The appropriate action would be: Reassure her that this is a normal side effect of topiramate and continue to monitor her weight. 8. Travis’s seizures are well controlled on topiramate and he wants to start playing baseball. Education for Travis regarding his topiramate includes: He should monitor his temperature and ability to sweat in the heat while playing 9. Brandy is taking valproate (Depakote) for seizures and would like to get pregnant. What advice would you give her? Valproate is a known teratogen, but may be taken after the first trimester if necessary. Keppra is a better drug to be on until the second trimester, then she can go back to valproate. 10. What category is valproate? Category X 11. The tricyclic antidepressants should be prescribed cautiously in patients with: Heart disease 12. A 64-year-old male was prescribed phenelzine (Nardil) while in an acute psychiatric unit for recalcitrant depression. The NP managing his primary health care needs to understand the following regarding phenelzine and other monoamine oxidase inhibitors (MAOIs): He should not be prescribed any serotonergic drug such as sumatriptan (Imitrex), MAOIs interact with many common foods, including yogurt, sour cream, and soy sauce, and symptoms of hypertensive crisis (headache, tachycardia, sweating) require immediate treatment 13. What are the precautions and contraindications for tricyclic antidepressants? Side effects are similar to anticholinergic activity such as dry mouth, sedation, constipation, increased appetite, blurred vision, tinnitus, euphoria, and mania. Caution in patients with cardiac disease (terminate ventricular fibrillation, decrease cardiac contractility, increase collateral blood circulation to ischemic heart muscles). 14. Marla is started on paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI), for depression. Education regarding her antidepressant includes: SSRIs may take 2 to 6 weeks before she will have maximum drug effects. 15. What “onset of action” symptoms should be reviewed with patients who have been newly prescribed a selective serotonin reuptake inhibitor? They can feel a bit of nausea, but this resolves in a week. 16. Which of the following should not be taken with a selective serotonin reuptake inhibitor? Alcohol 17. Why is the consistency of taking paroxetine (Paxil) and never running out of medication more important than with most other selective serotonin reuptake inhibitors (SSRIs)? It has a shorter half-life and withdrawal syndrome has a faster onset without taper 18. Janet presents with depression associated with complaints of fatigue, sleeping all the time, and lack of motivation. An appropriate initial antidepressant for her would be: Duloxetine (Cymbalta) 19. A patient with anxiety and depression may respond to: Buspirone (Buspar) and an SSRI combined 20. When is buspirone (Buspar) and an SSRI combined? Buspar is helpful in augmenting the SSRI and in treating patients with agitated or anxious depression 21. An appropriate first-line drug to try for mild to moderate generalized anxiety disorder would be: Buspirone (Buspar) 22. Larry has been prescribed citalopram (Celexa) to treat his depression. Education regarding how quickly selective serotonin reuptake inhibitor (SSRI) antidepressants work would be: Appetite and concentration improve in the first 1 to 2 weeks 23. An appropriate drug for the treatment of depression with anxiety would be: Escitalopram (Lexapro) 24. One major drug used to treat bipolar disease is lithium. Because lithium has a narrow therapeutic range, it is important to recognize symptoms of toxicity, such as: Drowsiness and nausea 25. Simon is taking lithium for bipolar disorder. He should be taught to: Eat a diet with consistent levels of salt (sodium) 26. What are the side effects of tricyclic antidepressants? Dry mouth, constipation, urinary hesitancy or retention, blurred vision, sedation, orthostatic hypotension, weight gain, N/V, gynecomastia, and changes in libido. Remember it is similar to anticholinergic side effects-“can’t see, can’t pee, can’t spit, can’t shit.” 27. What are the side effects of SSRIs? N/V, H/A, light-headedness, dizziness, dry mouth, increased sweating, weight changes, exacerbation of anxiety, agitation, and sexual side effects. Side effects are generally minor. 28. What are the side effects of SNRIs? (serotonin and norepinephrine reuptake inhibitor) H/A, somnolence, dizziness, insomnia, nervousness, nausea, dry mouth, constipation, abnormal ejaculations, anorexia/weight loss, and elevated BP at higher doses. 29. What are the side effects of MOIs? Insomnia, anxiety, agitation are initial adverse reactions. Common side effects include dizziness, H/A, restlessness, and hypotension. Also, dry mouth, blurred vision, urinary retention and constipation 30. In choosing a benzodiazepam to treat anxiety the prescriber needs to be aware of the possibility of dependence. The benzodiazepam with the greatest likelihood of rapidly developing dependence is: Alprazolam (Xanax) 31. What receptors do benzodiazepines act on? Enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA-A) receptors which results in a sedative hypnotic anxiolytics/anticonvulsant/muscle relaxer properties. 32. Long-acting benzos are prescribed for? Treatment of anxiety 33. Short and intermediate-acting benzos are prescribed for? Treatment of insomnia 34. An appropriate drug to initially treat panic disorder is: Diazepam (Valium) 35. Bernadette, a 42-year-old female, requests a prescription for an anorexiant to treat her obesity. A trial of phentermine is prescribed. Prescribing precautions include: Anorexiants may cause tolerance and should only be prescribed for 6 months 36. Before prescribing phentermine to Bernadette, a thorough drug history should be taken including assessing for the use of serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs) and St John’s wort due to: The risk of serotonin syndrome 37. Outside the brain phentermine releases norepi & epi causing what to break down? Fat cells to break down stored fat 38. When prescribing phentermine what should you assess for? You must inquire if the patient is taking St. John’s Wort and or an SSRI as these things can increase the risk of serotonin syndrome (H/A, agitation, hyomania, mental confusion, hallucinations, & coma). Wait, there’s more…you also get autonomic effects like shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea, and somatic effects such as myoclonis, hyperreflexia, and tremor! 39. Factors that place a patient at risk of developing an antimicrobial-resistant organism include: Inappropriate use of antimicrobials 40. Infants and young children are at higher risk of developing antibiotic-resistant infections due to: The fact that children this age are more likely to be in daycare and exposed to pathogens from other children 41. What must you instruct your patients do when taking an antibiotic? Counsel your patients that they need to take the entire antibiotic course for all of the days until the bottle is empty 42. There is often cross-sensitivity and cross-resistance between penicillins and cephalosporins because: Both drug classes contain a beta-lactam ring that is vulnerable to beta-lactamase- producing organisms 43. Andy has been diagnosed with strep throat and needs a prescription for an antibiotic. He says the last time he had penicillin he developed a red, blotchy rash. An appropriate antibiotic to prescribe would be: Azithromycin 44. Janis is a 25-year-old female who is 8 weeks pregnant and has a urinary tract infection. What would be the appropriate antibiotic to prescribe for her? Amoxicillin (Trimox) 45. Which antibiotics inhibit bacterial cell wall synthesis? These are the bactericidal antibiotics which inhibit the cell wall synthesis and include the beta-lactam ABX and vancomycin 46. Why is clavulanate added to amoxicillin? It is a combination of ABX consisting of amoxicillin trihydrate, a beta-lactam ABX and potassium clavulanate, it’s a beta-lactamse inhibitor. This combination results in an ABX with increased spectrum of action and restored efficacy against amoxicillin-resistant bacteria that produce beta-lactamase 47. What ABX are appropriate to prescribe to children? Penicillins and cephalosporins are generally regarded as safe 48. Which ABX class of drugs should be avoided in children? Fluoroquinolones and tetracyclines are to be avoided in childhood 49. Jaide is a 12-month-old child who is being treated with amoxicillin for acute otitis media. Her parents call the clinic and say she has developed diarrhea. The appropriate action would be to: Advise the parents that some diarrhea is normal with amoxicillin and recommend probiotics daily 50. Allison is a 13-year old child who comes to clinic with a 4-day history of cough, low-grade fever, and rhinorrhea. When she blows her nose or coughs the mucous is greenish- yellow. The appropriate antibiotic to prescribe would be: No ABX should be prescribed because this is a virus (mucous is greenish-yellow) 51. Cindy was recently treated with clindamycin for an infection. She calls the advice nurse because she is having frequent diarrhea that she thinks may have blood in it. What would be the appropriate care for her? Assess her for pseudomembranous colitis 52. MEMORIZE: the American College of Cardiology and the American Heart Association’s guide to ABX prophylactic use for dental appointments. See below… 53. According to the American College of Cardiology and the American Heart Association, what are the guidelines related to prophylactic antibiotics prior to a dental appointment? a. This is a very important question. This will be on your exam. If you go to the American Heart Association and look up the guideline, I would memorize this because these questions can be very tricky. b. Antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis including: i. Prosthetic cardiac valve or prosthetic material used in valve repair ii. Previous endocarditis iii. Congenital heart disease only in the following categories: 1. Unrepaired cyanotic congenital heart disease including those with palliative shunts and conduits 2. Completely repaired congenital heart disease with prosthetic material device, whether place by surgery or catheter intervention during the six months after the procedure 3. Repaired congenital heart disease with residual effects at the site or adjacent to the site of a prosthetic patch or prosthetic device, which inhibit endothelialization 4. Cardiac transplantation recipients with cardiac valvular disease c. Pay very close attention to those subtypes d. The treatment used for a dental appointment is amoxicillin orally two grams. In children it would be 50 milligrams per kilogram e. Dental Procedures and Infective EndocarditisIn the past, patients with nearly every type of congenital heart defect needed to receive antibiotics one hour before dental procedures or operations on the mouth, throat, gastrointestinal genital, or urinary tract. However, in 2007 the American Heart Association simplified its recommendations. Today, antibiotics before dental procedures are only recommended for patients with the highest risk of IE, those who have: i. A prosthetic heart valve or who have had a heart valve repaired with prosthetic material. ii. A history of endocarditis. iii. A heart transplant with abnormal heart valve function iv. Certain congenital heart defects including: 1. Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had a surgical shunts and conduits. 2. A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure. 3. Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic devices f. Key changes for patients with congenital heart defectsPreventive antibiotics are no longer recommended for any other congenital heart disease than these: i. Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had a surgical shunts and conduits. ii. A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure. iii. Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device. g. Additionally, taking antibiotics just to prevent endocarditis is not recommended for patients who have procedures involving the reproductive, urinary or gastrointestinal tracts. 54. Kristine had a small ventricle septal defect (VSD) repaired when she was 3 years old and has no residual cardiac problems. She is now 28 and is requesting prophylactic antibiotics for an upcoming dental visit. The appropriate antibiotic to prescribe according to current American College of Cardiology and American Heart Association guidelines is: None, no antibiotic is required for dental procedures 55. What patient teaching will you provide to a patient who is experiencing non-infectious diarrhea related to ABX administration? Patient will need to be assessed for C. diff colitis. Advise patient to increase their probiotic intake with yogurt to repopulate the gut flora 56. To prevent further development of antibacterial resistance it is recommended that fluoroquinolones be reserved for treatment of: Community-acquired pneumonia in patients with comorbidities 57. Fluoroquinolones have a Black Box Warning regarding even months after treatment. Tendon rupture 58. Fluoroquinolones have been reported to enhance the effective of and appropriate laboratory tests should be routinely monitored. It’s postulated to affect gut flora, which displaces warfarin from albumin and interfere with hepatic metabolism by inhibiting the cytochrome P450 enzyme system. Warfarin