NR 565 Final Exam Study Guide – Questions and Detailed Correct and Verified Answers

NR 565 Final Exam Study Guide – Questions and Detailed Correct and Verified Answers Thyroid o Diagnosis & Evaluation What labs are used to diagnose? - Correct Answer -TSH - used primarily for screening and diagnosing hypothyroid and for monitoring replacement therapy in hypothyroid patients -T4 - Used to monitor thyroid hormone replacement therapy and to screen for thyroid dysfunction -T3 - Useful in the diagnosis of hyperthyroidism; can also be used to monitor hormone replacement therapy -TSH low -T4 normal -T3 is high = hyperthyroidism Thyroid o Diagnosis & Evaluation Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself) - Correct Answer Methimazole - first line drug of choice (not given to women who are pregnant or breastfeeding) o Methimazole blocks synthesis of thyroid hormone. 1) Prevents the oxidation of iodine, therefore inhibiting incorporation of iodine into tyrosine. 2) prevents iodinated tyrosine from coupling Propylthiouracil - preferred treatment for thyroid storm Beta blockers - help with tachycardia experienced with hyperthyroidism Thyroid o Treatment Drug/Food/Supplement interactions with levothyroxine - Correct Answer Absorption of levothyroxine is reduced by food - it should be taken on an empty stomach in the morning, at least 30-60 minutes before breakfast Drugs that reduce absorption include: H2 receptor blockers, PPIs, Carafate, Questran, Colestid, Maalox/Mylanta, Tums, iron, Mag salts, Xenical Drugs that accelerate levothyroxine: Phenytoin, Carbamazepine, rifampin, Sertraline, and phenobarbital Timeframe for re-check of labs after starting levothyroxine? - Correct Answer Recheck TSH 6-8 weeks after initiating therapy and after any dosage change; Check TSH at least once a year after serum TSH is stabilized Thyroid o Diagnosis & Evaluation Signs and symptoms of hypothyroidism? - Correct Answer Hypothyroidism: Depend on severity. o Mild: subtle and may go unrecognized o Moderate to severe: -Face is pale, puffy, and expressionless. -Skin cold and dry. -Hair is brittle and hair loss occurs. -Slowed Heart rate. -Patient may complain of lethargy, fatigue, and -Temperature is lowered & intolerant to cold. -Thyroid Enlargement may occur if reduced levels of T3 and T4 Mentation may be impaired. Thyroid o Diagnosis & Evaluation Signs and symptoms of hyperthyroidism? - Correct Answer o Elevated Heart rate and strong, and dysrhythmias and angina may develop o The CNS is stimulated, resulting is nervousness, insomnia, rapid thought flow, and rapid speech, hyperreflexia, tremors o Skeletal muscles may weaken and atrophy o Metabolic rate is raised, resulting in health and skin that is warm and moist o Feeling Hot + Heat intolerance o Appetit is increased but fails to match metabolic rate resulting in weight loss o All of these signs are referred to as thyrotoxicosis o Also usually present with exophthalmos - bulging of the eyes Thyroid o Treatment Treatment of thyroid storm? - Correct Answer Characterized by profound hyperthermia (105 degrees F or higher), severe tachycardia, restlessness, agitation, and tremor. Unconsciousness, coma, hypotension, and heart failure may ensure. These symptoms are produced by excessive levels of thyroid hormone Thyroid crisis can be life threatening and requires immediate treatment. o High doses of potassium iodide or strong iodine solution are given to suppress thyroid hormone release. o Methimazole is given to suppress thyroid hormone synthesis o A beta blocker is given to reduce heart rate o Additional measures include sedation, cooling, and giving glucocorticoids and IVF Thyroid o Treatment Result of not treating hypothyroidism during pregnancy? - Correct Answer Can result in permanent neuropsychological deficits in the child - decrease child's IQ The effect of hypothyroidism is limited largely to the first trimester, a time during which the fetus is unable to produce thyroid hormone of its own Some authorities currently recommend routine screening for hypothyroidism as soon as pregnancy is confirmed Women already taking thyroid hormone replacement will need to increase dose by 50% max between weeks 4-8 of gestation and the levels will level out by week 16 Thyroid o Treatment Patients taking the following drugs may need to increase their dose of levothyroxine: Warfarin and catecholamines Levothyroxine can also increase requirements for insulin and digoxin Diabetes o How to confirm a diagnosis prior to beginning treatment - Correct Answer Fasting plasma glucose >/= 125mg/dl OR Random plasma glucose >/= 200mg/dl plus symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) OR Oral glucose tolerance test (OGTT): 2-hour plasma glucose >/= 200mg/dl OR HgbA1C pf 6.5% or greater - (a test that provides an estimate of glycemic control over the previous 2-3 months) is now considered a standard test as well Diabetes o A1C General goals - Correct Answer To keep A1C below 7% o <8% is less stringent for those with hx. Of severe hypoglycemia, limited life expectancy, pr advanced microvascular or macrovascular complications Diabetes o A1C Older Adult goal - Correct Answer Recommended goal for A1C in the geriatric population is 7.5-8% in older patients with moderate comorbidities and life expectancy less than 10 years o 8-8.5% for older patients with complex medical issues Diabetes o A1C When should insulin be considered? - Correct Answer Recommendation: A GLP-1 should be considered before starting insulin Insulin is introduced in Step 3 which includes a 3-drug combination which includes insulin. A1C of 9% of greater would start at Step 2 with dual med therapy A1C of 10% or greater or fasting glucose of 300 or greater and is symptomatic would start on combination injectable therapy immediately (Step 4) Diabetes o A1C At what time interval should it be re-checked? - Correct Answer Should be monitored every 3 months until value drops to 7% and at least every 6 months thereafter Diabetes o Action of Insulin - Correct Answer Metabolic actions of insulin are primarily anabolic - Insulin promotes conservation of energy and buildup of energy stores, such as glycogen and the hormone also promotes cell growth and division Stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and potassium Insulin promotes synthesis of complex organic molecules In all: Under the influence of insulin - glucose is converted into glycogen, amino acids are assembled into proteins, and fatty acids are incorporated into triglycerides Diabetes o Pioglitazone contraindications - Correct Answer Associated with heart failure secondary to renal retention of fluid. If heart failure is diagnosed, pioglitazone should be discontinued or used in reduced dosage Diabetes o Be familiar with abbreviations of diabetic drug classifications (GLP-1, TZD, DPP4-I, SGLT2i) - Correct Answer .... GLP-1: Glucagon-like Peptide-1 Receptor Agonists - Correct Answer Dulaglutide (Trulicity) Semaglutide (Ozempic) Liraglutide (Victoza) TZD: Thiazolidinediones - Correct Answer Rosiglitazone (Avandia) Pioglitazone (Actos) DPP4-I: Dipeptidylpeptidase-4 Inhibitors - Correct Answer Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina) SGLT2-I: Sodium-glucose co-transporter 2 Inhibitors - Correct Answer Canagliflozin (Invokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance) Diabetes o Which drug class should be considered for diabetes prior to insulin? - Correct Answer Patients should always be started at step 1 with lifestyle change and metformin, unless their A1C is greater than 9%, then should be placed on 2 PO medications like in step 2 Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin? - Correct Answer o Total daily insulin dose (TDD) calculation includes basal insulin replacement and bolus insulin replacement. In all: 50% is basal dose and 50% is rapid acting Daily dose - Total weight of patient in kilograms, multiplied by 0.6. Ex: 80kg (184) x 0.6 units = 24; this means 24 units of the TDD is the basal insulin dose (long acting) (50%) and the other 24 units of rapid acting bolus/mealtime insulin (50%). Know the carbohydrate-to insulin ratio when calculating basal insulin o Simple calculation (No calculators are allowed and will not be needed) - Correct Answer Calculated using the 450 rule for regular insulin and the 500 rule for rapid acting insulin Ex for rapid acting: 500 divided by 48 = 10.4 (rounded to 10). Therefore, the carb-to-insulin ratio is 1:10 o If the meal is 60 grams of carbs, 60 divided by 10 = 6 units for carb coverage Mechanism of Action o GLP-1 (Exenatide) (AKA mimetics) - Correct Answer Lowers blood glucose by slowing gastric acid emptying, stimulating glucose- dependent insulin release, suppressing postprandial glucagon release, and reducing appetite Mechanism of Action -Biguanide (Metformin) - Correct Answer -Decreases Glucose production by the liver Mechanism of Action o TZD (Pioglitazone) - Correct Answer Decrease insulin resistance and increase glucose uptake by muscle and adipose tissue -and decrease glucose production by the liver Mechanism of Action o DPP-4i (Alogliptin) - Correct Answer Enhance the activity of incretins (by inhibiting their breakdown of DPP-4) and thereby increase insulin release, reduce glucagon release -and decrease hepatic glucose production Mechanism of Action o Sulfonylureas -Glipizide (Glucotrol) - Correct Answer Promote insulin secretion by the pancreases; may also increase tissue response to insulin -Educate on risk of Hypoglycemia side effect Mechanism of Action o SGLT2i (Canagliflozin) - Correct Answer Increase glucose excretion via the urine by inhibiting SGLT-2 in the kidney tubules -decreasing glucose levels, and inducing weight loss by caloric loss through the urine Which diabetic medication(s) come with a concern of hypoglycemia? - Correct Answer o Sulfonylureas o Meglitinides (Glinides) o Thiazolidinediones (Glitazones) - only in the presence of excessive insulin o Glucagon-like Peptide-1 Receptor Agonists (GLP-1) (Incretin Mimetics) o Amylin Mimetics ADA's DM Treatment Algorithm - Correct Answer Step 1: At diagnosis, initiate lifestyle changes plus metformin. Step 2: Continue step 1 & add a 2nd drug (TZD, DPP-4, SGLT-2, or GLP-1). A sulfonylurea or basal insulin should be considered if patient doesn't achieve goal with these drugs. Step 3: 3-drug combo, including metformin. Step 4: 3 drug therapy that includes basal insulin fails to reach goals after 3-6 months, proceed to combination injectable insulin. WEEK 6 - Correct Answer ... Methylxanthines o Who is at risk for toxicity and why? - Correct Answer At risk: Those with liver disease, smokers, caffeine drinkers, those taking certain medications Why: Liver disease - theophylline is metabolized in the liver, and this can cause decreased metabolism which increases drug levels = toxicity Smokers - smoking can induce theophylline metabolism which increases drug clearance. Therefore, if the patient stops smoking and does not have the dose of theophylline is not decreased, the patient is at risk for developing toxicity Caffeine drinkers - Caffeine can intensify the adverse effects of theophylline on the CNS and the heart. Caffeine can also complete with theophylline for drug-metabolizing enzymes causing theophylline levels to rise. Those taking theophylline should avoid caffeine products and those containing caffeine Drugs that increase theophylline levels - cimetidine and the fluoroquinolone antibiotics (ciprofloxacin). These can elevate plasma levels of theophylline by inhibiting hepatic metabolism. The dosage of theophylline should be reduced when the drug is combined with these agents Asthma & COPD o Step 1 therapy Complete this sentence: Manage with a ______ as needed. - Correct Answer Complete this sentence: Manage with a _SABA_ as needed. Asthma Step 1: Intermittent - Correct Answer Symptoms= 2 days/week or less. Nighttime awakenings= none (2 times/month or less for 5 y.o. & up). SABA use= 2 days/week or less. Effect on activity= none. Risk for exacerbations requiring systemic glucocorticoids= 0-1 time/year. Asthma Step 2: Mild Persistent - Correct Answer Symptoms= more than 2 days/week but less than daily. Nighttime awakenings= 1-2 times/month (3-4 times/month for 5 y.o. & up). SABA use= more than 2 days/week but less than daily AND no more than 1 time on any day. Effect on activity= minimal activity limitation. Risk for exacerbations requiring systemic glucocorticoids= 2 or more times/6 months OR wheezing lasting more than 1 day 4 or more times/year (2 or more times/year for 5 y.o. & up). Asthma Step 3: Moderate Persistent - Correct Answer Symptoms= daily Nighttime awakenings= 3-4 times/month (more than once/week but less than nightly for 5 y.o. & up). SABA use= daily. Effect on activity= some activity limitation. Risk for exacerbations requiring systemic glucocorticoids= increased frequency & intensity of exacerbations or wheezing. Asthma Step 4: Severe Persistent - Correct Answer Symptoms= several times daily Nighttime awakenings= more than once/week (often nightly for 5 y.o. & up). SABA use= several times a day Effect on activity= severe activity limitation. Risk for exacerbations requiring systemic glucocorticoids= even greater increased frequency & intensity of exacerbations or wheezing. 0-4 y.o (STEP 3), 5-11 y.o. (STEP 3 OR 4), 12 y.o. & up (STEP 4 OR 5) Asthma & COPD o Symptoms associated with each classification of asthma (mild-persistent, moderate-persistent, etc.). - Correct Answer - Nighttime wakening from ages 0-4 years old is normal and cannot be used in the data due to asthma nighttime wakening Steps 3-5 are more aggressive as our patients get older Pg. 575 in the book for classifications of asthma severity and recommendation for initial treatment Intermittent: symptoms 2 days a week or less No nighttime wakening SABA use is 2 days a week or less Mild-persistent: symptoms more than 2 days a week but less than daily Nighttime wakening 1-2 times a month SABA use is more than 2 days a week but less than daily Moderate-persistent: Symptoms daily Nighttime wakening 3-4 times a month SABA use is daily Severe-persistent: Symptoms several times a day Nighttime wakening more than once a week SABA use is several times a day 7 Recommended step is step 3-4 for ages 5-11 and step 4-5 for those above 12 years old (Steps on pg. 576-577 in book) Asthma & COPD o Know examples of drug classes (SABA, LABA, ICS, etc.) - Correct Answer SABA, LABA, Anticholinergics (ipratropium & aclindinium), inhaled corticosteroids, leukotriene receptor agonists (montelukast & zafirlukast), and oral corticosteroids (prednisone) Asthma & COPD o SABA Know examples - Correct Answer Examples: Albuterol, isoproterenol, levalbuterol, terbutaline sulphate Asthma & COPD o SABA Benefits of use Patient instructions - Correct Answer Benefits of use: Rescue inhaler, all asthma patients should have a SABA, they are for prophylaxis of exercise-induced bronchospasms and to relieve ongoing asthma attacks and COPD exacerbations Patient instructions: How to use the inhaler (have patients demonstrate), use a spacer for those with difficulty with hand-breath coordination, patients with asthma should assess peak expiratory flow daily and compare with personal best and keep record, patients using meter dose inhalers or dry powder inhalers should have at least 1-minute intervals between inhalers if using more than one, report chest pain associated with changes in HR or rhythm, do not exceed recommended dosages (Provider should be notified if symptoms require more frequent use of SABA) Asthma & COPD o SABA Why is it important to know the frequency a patient is using their SABA? - Correct Answer If patients are using it more frequently due to symptoms, the provider should be notified so medication changes can take place and the NP can provide adequate asthma relief Asthma & COPD o LABA Know examples - Correct Answer Examples: Salmeterol, formoterol, oldaterol Asthma & COPD o LABA Benefits of use Use in COPD - Correct Answer Benefits of use: LABAs are for patients who experience frequent attacks and dosing is done on a fixed, NOT PRN, schedule. For asthma, they must be combined with a glucocorticoid because they are not a first line therapy in asthma (FDA recommends a LABA and glucocorticoid are both contained in the same inhaler to prevent a LABA asthma-associated death - LABA monotherapy in asthma is contraindicated) Use in COPD: LABAs are preferred over SABAs for patients with stable COPD. LABA can increase the risk for severe asthma attacks and asthma related death; however, this is not a concern for those with COPD Asthma & COPD o Inhaled Corticosteroid (ICS) Know examples - Correct Answer Examples: Budesonide, ciclesonide, beclomethasone Asthma & COPD o Inhaled Corticosteroid (ICS) Benefits of use - Correct Answer Benefits of use: Most effective drugs available for long-term control of airway inflammation. By reducing inflammation, they reduce bronchial hyper-reactivity and decrease airway mucus production in both asthma and COPD. They do not alter the course of the conditions, but they provide significant long-term control and management of symptoms Cromolyn - Correct Answer Used as prophylaxis for mild to moderate asthma Monoclonal Antibodies - Correct Answer Used for allergy-related asthma and Eosinophilic asthma Leukotriene Receptor antagonists - Correct Answer Second-line therapy to reduce inflammation and bronchoconstriction B2RA (Beta 2 Receptor Agonists) - Correct Answer Can be used PRN, for EIB, COPD exacerbations, and maintenance therapy Methylxanthines - Correct Answer Maintenance therapy for chronic stable asthma Anticholinergics - Correct Answer Approved for bronchospasm related COPD Asthma & COPD o At what point would an oral steroid be prescribed? - Correct Answer May be required for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma of COPD. Because of their 8 potential for toxicity, they are prescribed only when symptoms cannot be controlled with safer medications (inhaled glucocorticoids or inhaled B2 agonists). Treatment should also be as brief as possible because of the risk for toxicity with duration of use. Asthma & COPD o When would roflumilast be indicated for a COPD patient? - Correct Answer For patients with severe, chronic COPD with a primary chronic bronchitis component, the risk for exacerbations may be reduced with this drug. Smoking Cessation o Nicotine replacement How it works - Correct Answer How it works: NRT allows smokers to substitute a pharmaceutical source of nicotine for the nicotine in cigarettes - and then gradually withdraw the replacement nicotine. This is analogous to using methadone to wean addicts of heroin. With gum, lozenges, patches, and inhaler, blood levels of nicotine rise slowly which produce less pleasure than cigarettes but do relieve symptoms of withdrawal. Long-term quit rates are greater with NRT than with placebo (although success rates still remain low). Smoking Cessation o Nicotine replacement Patient education needed for various types - Correct Answer Patch: Patches are applied once a day to clean, dry, nonhairy skin of the upper body or upper arm. The site should be changed daily and not reused for at least 1 week. Starting patch is determined based on the number of cigarettes smoked daily. o Adverse effects: short lived erythema, itching, and burning can occur under the patch. Discontinue patch is there is severe erythema, itching, and edema. Gum: Patients should be advised to chew the gum slowly and intermittently for approximately 30 minutes. Rapid chewing can release too much nicotine at one time which results in effects similar to those of excessive smoking (nausea, throat irritation, and hiccups). Foods and beverages can reduce nicotine absorption, so patients should not eat or drink 15 minutes before chewing the gum. Nasal spray: The nasal spray increases blood levels of nicotine rapidly like it does with smoking. Some patients are unable to give the spray up because of the similar effects to smoking that it gives. o Adverse effects my most users include rhinitis, sneezing, coughing, watering eyes, and nasal/throat irritation which usually only last a few days. Nicotine nasal spray should be avoided by patients with sinus problems, allergies, and asthma. Smoking Cessation o Nicotine replacement Gum - Correct Answer Gum: Patients should be advised to chew the gum slowly and intermittently for approximately 30 minutes. Rapid chewing can release too much nicotine at one time which results in effects similar to those of excessive smoking (nausea, throat irritation, and hiccups). Foods and beverages can reduce nicotine absorption, so patients should not eat or drink 15 minutes before chewing the gum. Smoking Cessation o Nicotine replacement Patch - Correct Answer Patch: Patches are applied once a day to clean, dry, nonhairy skin of the upper body or upper arm. The site should be changed daily and not reused for at least 1 week. Starting patch is determined based on the number of cigarettes smoked daily. o Adverse effects: short lived erythema, itching, and burning can occur under the patch. Discontinue patch is there is severe erythema, itching, and edema. Smoking Cessation o Nicotine replacement Nasal spray - Correct Answer Nasal spray: The nasal spray increases blood levels of nicotine rapidly like it does with smoking. Some patients are unable to give the spray up because of the similar effects to smoking that it gives. o Adverse effects my most users include rhinitis, sneezing, coughing, watering eyes, and nasal/throat irritation which usually only last a few days. Nicotine nasal spray should be avoided by patients with sinus problems, allergies, and asthma. Wellbutrin Contraindications - Correct Answer Seizure disorders, anorexia/bulimia, stroke, alcohol use, CNS depressants, and barbiturates. Bupropion Recommended length of treatment - Correct Answer 150mg PO daily for 3 days, then 150mg PO twice daily for 7-12 weeks. Treatment with Bupropion should start 1-2 weeks before smoking cessation and should decrease use after 7-12 weeks. Bupropion was the first non-nicotine drug approved as an aid to smoking cessation. It reduced the urge to smoke and reduces some symptoms of nicotine withdrawal (irritability and anxiety). Tuberculosis (TB) o What constitutes drug-resistant TB - Correct Answer Occurs when TB bacteria become resistant to the drugs used to treat the disease and includes multidrug-resistant (MDR TB) and extensively drug-resistant (XDR TB). MDR TB is caused by bacteria that are resistant to both isoniazid and rifampin, two potent TB drugs XDR TB infection is less common and is caused by resistance to isoniazid and rifampin as well as any fluoroquinolone and at least one of three second-line medications. These patients have a greatly decreased number of treatment options and a higher risk of death Tuberculosis (TB) o Treatment of TB in a pregnant person, what all should be included? - Correct Answer Rifabutin is deemed the safest during pregnancy. The CDC reports that the benefit justifies the risk for isoniazid, rifampin, and pyrazinamide. The CDC does not recommend rifapentine due to insufficient data on pregnant women. Ethambutol has caused teratogenesis in animal studies and there have been reports of eye abnormalities in children; therefore, should only be given if the benefits are deemed greater than the risks Tuberculosis (TB) o Isoniazid (INH) is a drug that can be used to prevent TB in people that have been exposed. - Correct Answer Primary agent for treatment and prophylaxis of TB. This drug has early bactericidal activity and is superior to alternative drugs with regard to efficacy, toxicity, ease of use, patient acceptance, and affordability. It is highly selective for M. TB. It suppressed the bacterial growth by inhibiting the synthesis of mycolic acid, a component of the mycobacterial cell wall. Because mycolic acid is not produced by other bacteria or by cells of the host, this mechanism would explain why isoniazid is so selective for tubercle bacilli. Cold & Cough o Which drug class has no significant drug interactions - Correct Answer Expectorants have no known significant interactions with other medications Cold & Cough o Examples of decongestant - Correct Answer Beclomethasone dipropionate, budesonide, fluticasone, riamcinolone WEEK 7 - Correct Answer ... H2 receptor antagonists o Examples - Correct Answer Cimetidine (Tagamet), Famotidine, Nizatidine, and Ranitidine H2 receptor antagonists o Which is most likely to interact due to CYP450 enzyme system? - Correct Answer Cimetidine: it inhibits the inducers of CYP450 Proton Pump Inhibitors o Associated vitamin and/or mineral deficiencies - Correct Answer Can decrease absorption of calcium and can lower magnesium level Proton Pump Inhibitors o Short-term use increases the risk of what? Symptoms this may be occurring - Correct Answer Risk of community-acquired pneumonia Long-term can cause C.Diff -Symptoms this may be occurring: -Pneumonia by altering the upper GI flora and impairing WBC function, this risk is only limited to the first few days of use, and then it is the same risk as nonusers GERD o How to treat moderate to severe GERD - Correct Answer PPIs are the best treatment for long term maintenance therapy is recommended GERD o What medication for GERD to avoid in older adults and why? - Correct Answer PPIs due to increased risk for fractures and dementia GERD o Treating GERD during pregnancy Which cytoprotective agents would be used - Correct Answer Do not use Cytotec (Misoprostol): Because prostaglandins stimulation uterine contractions and the use of this medication during pregnancy has caused partial or complete expulsion of the developing fetus GERD o When to test for h. Pylori How to treat h. Pylori - Correct Answer Test after the failure of lifestyle modifications and OTC antacids of H2 blockers have not worked Pg. 593 table 64.2: 2 antibiotics and an antisecretory agent PUD o Lifestyle modifications to support ulcer healing - Correct Answer Eat 5-6 small meals per day, stop smoking, avoid NSAIDS in PUD, decrease stress and anxiety, alcohol can exacerbate PUD symptoms Anti-diarrheal o Which one contradicted in children during or after chickenpox - Correct Answer Bismuth (Pepto bismol): increased risk for Reye's syndrome Anti-diarrheal o Patient teaching for ciprofloxacin for traveler's diarrhea - Correct Answer Use drug if symptoms develop and are severe or do not improve within a few days Don't give cipro for someone who is pregnant, febrile, or has bloody diarrhea Should only be used when symptoms are severe; mild symptoms are treated with loperamide. The med can cause serious side effects, so prophylaxis is not recommended Anti-diarrheal o Which one is associated with gray/black stools and a black tongue - Correct Answer Bismuth (Pepto bismol) Constipation o Lifestyle modifications to suggest prior to treatment - Correct Answer Increase fluids, exercise after meals, improve diet, and increase fiber Constipation o Risks of laxatives during pregnancy - Correct Answer GI stimulation can cause labor Constipation o Preferred treatment during breastfeeding - Correct Answer Senna is safe during breastfeeding. Caution with use of polyethylene glycol and bisacodyl Constipation o Psyllium How it works and what to assess for if it doesn't produce a bowel movement - Correct Answer This is a bulk forming laxative. Stool swells in water to produce a viscous solution or gel which softens the fecal mass and increases its bulk. It can cause upper and lower GI obstructions Irritable Bowel Syndrome (IBS) o A diary can be helpful to aid in diagnosis and treatment - Correct Answer Yes, it can help manage which foods are triggers for IBS symptoms and which ones are safe to eat due to trial and error Vomiting o How to treat gastroparesis - Correct Answer Reglan (Metronidazole) because it increases GI motility Vomiting Black box warning associated with treatment with Reglan (Metronidazole) - Correct Answer Tardive dyskinesia and parkinsonism Metronidazole o Patient teaching needed - Correct Answer Do not drink alcohol (can cause nausea and vomiting, dizziness, flushing, headache [hangover-like feeling]), and do not take during pregnancy WEEK 8 - Correct Answer ... DTaP or Tdap o Who should receive the Tdap vaccine? - Correct Answer Teens and adults after receiving full DTaP course during childhood Vaccine Contraindications o True contraindication for DTaP or Tdap vaccine. - Correct Answer Moderate to severe febrile illness Hx of post-vaccination anaphylactic reaction (immediate) or encephalopathy within 7 days Caution: if prior vaccination produced a shock-like state, fever over 105 within 48 hours, persistent inconsolable crying within 48 hours lasting for 3 hours, or seizures within 3 days. Vaccine Contraindications o Varicella - Correct Answer Pregnancy, certain cancers, hypersensitivity to neomycin or gelatin, immunocompromised. Children should avoid salicylates for 6 weeks after Vaccine Contraindications o Hepatitis B virus (HBV) vaccine - Correct Answer Prior anaphylactic reaction to vaccine or baker's yeast Examples of vaccine types o Attenuated - Correct Answer MMR, varicella, rotavirus, influenza (intranasal) Examples of vaccine types o Live virus - Correct Answer MMR, varicella, rotavirus, influenza Examples of vaccine types o Toxoid - Correct Answer Dtap Examples of vaccine types o Inactive viral antigen - Correct Answer Polio, Hep A and B, influenzas (inactivated) Types of immunity o What are they and how is each one achieved? - Correct Answer Herd/community - when a large group of people is immune Active - when responding to either real infection or vaccination Passive - transmitted from mother to baby or via antibodies Natural immunity - nonspecific, such as physical barriers, NK cells, etc. Acquired immunity - specific after exposure to a foreign substance, produce antigens Cell-mediated immunity - immune response where targets are attacked directly by cells Humoral immunity - immunity response medicated by antibodies Definition of vaccine - Correct Answer o a preparation containing whole or fractionated microorganisms. Administration causes the recipient's immune system to manufacture antibodies directed against the microbe from which the vaccine was made Post exposure prophylaxis for suspected rabies bite - Correct Answer o 4 doses of vaccine - 1ml IM on days 0,3,7,14, with RIG (rabies immune globulin) given on day 0. Those who have previously been vaccinated, 2 doses are given on days 0 and 3, no RIG Patient teaching and assessments for post vaccine side effects - Correct Answer o Vaccine Information Statement (VIS) on administered vaccines, Administer Tylenol to the patient before discharge, discuss reactions for administered vaccines, provide a schedule for upcoming vaccine doses, have patient wait 15 minutes before discharge Who can receive attenuated influenza vaccine (FluMist)? - Correct Answer o Healthy non-pregnant patients ages 2 49, with no hx of previous reactions to this vaccine, not immunocompromised or caring for someone who is. Contraindicated in kids with asthma or kids receiving meds with salicylates. Pantoprazole -common doses (calculations to figure quantity) -directions for use -indication - Correct Answer o Common Doses: 20 and 40mg delayed-release tablets and 40mg enteric-coated granules o Directions for use: Monitor for pain relief and eradication of H. pylori infection. When used long term, there is an increase for osteoporosis and fractures = maintain an adequate intake of calcium and vitamin D, and inform patients about symptoms of hypomagnesemia, including muscle cramps, palpitations, and tremors o Indication: Gastric and duodenal ulcers, as well as GERD Metronidazole -common doses (calculations to figure quantity) -directions for use -indication - Correct Answer o Common Doses: 500mg three times a day for 10-14 days o Directions for use: The most common side effect is nausea and headache. A disulfiram-like reaction can occur if used with alcohol and it should also not be taken during pregnancy. o Indication: H. pylori treatment (very effective against sensitive strains of H. pylori Ondansetron -common doses (calculations to figure quantity) -directions for use -indication - Correct Answer o Common Doses: 0.15mg/kg IV starting 30 minutes before chemo; 8mg PO TID for radiation therapy o Directions for use: Use caution with patients with electrolyte imbalances, heart failure, or brady dysrhythmias. Can also cause prolonged QT o Indication: Chemo-induced nausea and vomiting. Is also used for the prevention of nausea and vomiting with radiation therapy and anesthesia. Can also be used for nausea and vomiting from other causes as well like gastritis and morning sickness from pregnancy. Albuterol MDI -common doses (calculations to figure quantity) -directions for use -indication - Correct Answer o Common Doses: MDI: 2 inhalations every 4-6 hours PRN o Directions for use: Used PRN for prophylaxis of exercise induced bronchospasms and are to relieve ongoing asthma attacks and COPD exacerbations. Side effects include tachycardia, angina and tremors. Use a spacer for those with hand-mouth coordination issues and if using as school (for a child), do not exceed dosage prescribed and provider should be notified if needing to use more than prescribed of SABA o Indication: SABAs are taken PRN to abort an ongoing attack. Can also be taken before exercising to prevent EIB A patient has just been prescribed levothyroxine, the NP puts in a lab order to check TSH levels in? - Correct Answer 6-8 weeks A patient comes into the clinic complaining of sore throat and fever. She has recently started Methimazole in the last 4 weeks. What does this suggest? - Correct Answer -Agranulocytosis -PPI class A patient who takes NSAIDS almost daily for arthritic pain and refuses to try another med is at risk for an NSAID-induced ulcer. The provider states... - Correct Answer I will start a PPI to prevent an Ulcer A pregnant patient is taking NSAIDS for pain and a Misoprostol for an ulcer. What action does the provider take? - Correct Answer Stop the medication and switch her to a PPI Misoprostol can cause a miscarriage A patient comes into the clinic with c/o bloating and abdominal pain for a few weeks. What are appropriate options for treatment? - Correct Answer Lifestyle mods and H2RA A patient has tested positive for H.Pylori. What are appropriate treatment options? - Correct Answer Start antibiotics for 10-14 days A pregnant woman comes in asking for GERD meds, what can you recommend? - Correct Answer Sucralafate What is the MOA of Metaclopramide? - Correct Answer Blocks dopamine receptors in the chemo receptor zone Metaclopramide (Reglan) can be used for? - Correct Answer -N/V -Diabetic Gastroparesis -Gastroesophageal reflux What TB med is not safe for pregnancy? - Correct Answer Ethambutol If a mother is taking isoniazid and rifampin, can she breastfeed? - Correct Answer -Yes What to assess if Psyllium does not work? - Correct Answer -Obstruction or impaction MOA of bulk forming laxatives - Correct Answer Absorb water into intestines, increase bulk and peristalsis -Work much like a dietary fiber-producing stool in 1-3 days MOA of surfactants - Correct Answer Lowers surface oil:water tension allowing more water to penetrate the stool (softens) MOA of stimulant laxatives - Correct Answer Increases peristalsis via intestinal nerve stimulation MOA of osmotic laxatives - Correct Answer -Causes water retention in stool (osmotic effect pulls water into gut) -Often used as bowel prep What is the risk of laxatives in pregnancy? - Correct Answer Can induce labor What laxative can you give a woman who is breastfeeding? - Correct Answer Senna When should a person get the DTaP vaccine? - Correct Answer -Immunocompromised (HIV, Cancer) -Pregnancy -High dose glucocorticoid use Varicella contraindications - Correct Answer Pregnancy and immunocompromised (HIV and cancer), hypersensitivity to neomycin or gelatin Hep B vaccine contraindications - Correct Answer Allergy, Baker's yeast What is an example of a toxoid vaccine type? - Correct Answer Tetanus DTaP Who can receive attenuated influenza vaccines? - Correct Answer -Anyone 2< and >50 who are not pregnant or immunocompromised -Labs to check: CBC LFTs A newly pregnant patient shows understanding of Hypothyroidism in pregnant women by stating? - Correct Answer 2. I know that if I do not take my medicine it can cause permanent damage to my baby. 3. I will need to increase my dose of medicine for a short time. (Increased by 50% from weeks 4-8, back to normal by wk 16) What are some food/supp interactions that can occur with levothyroxine? - Correct Answer -Calcium -Iron -Magnesium -Vit C -Antacids -Take 30-60 mins before meals in the morning What labs would you order to help diagnose thyroid conditions? - Correct Answer -TSH -T3 -T4 -Anti TPO What is the role of Radioactive iodine and what is a possible adverse effect? - Correct Answer -Destruction of thyroid tissue -May need levothyroxine for life What adjunctive med can be used for hyperthyroidism? - Correct Answer -Beta-blockers (Mask symptoms of Hypoglycemia) -Non-radioactive iodine Once a patient reaches a euthyroid state, how often should the be tested? - Correct Answer -Once a year A patient has a TSH of .28 (Low), a free T4 of 3 (High), and a free T3 over 650 (Very High). What med should she be started on? - Correct Answer -Patient has Hyperthyroidism -Treatment for a thyroid storm is (to suppress hormone release): Potassium iodide Strong iodine solution Methimazole A patient receives his first lab results showing an A1C of 7.2%. What is the diagnosis? - Correct Answer -Cannot confirm because you need a second A1C after 3 months (value is borderline) An A1C of _______ is considered prediabetes. - Correct Answer 5.7%-6.4% A random glucose of _______ is considered diabetic. - Correct Answer 200 with signs and symptoms A person with diabetes has recurrent severe hypoglycemia events. What should his A1C goal be? - Correct Answer 8% When is it okay for a patient to have an A1C goal of 6.5%? - Correct Answer When they can tolerate it and have no comorbidities. How often should an A1C be monitored when stable or when unstable? - Correct Answer -Stable: every 6 months -Unstable: every 3 months (A1C of 7 or >) A person comes in with an A1C of 10% and a fasting blood glucose of >300. What are the next steps for the provider? - Correct Answer -Start insulin (when A1C is above >9% start at step 2= insulin combo therapy) Who should not take Metformin? - Correct Answer -Due to increased risk of Lactic acidosis: patients with CHF, older than 80 years of age, kidney disease (Renal insufficiency) Sulfonylureas should not be used during __________ or with _____________ or _________ impairments. - Correct Answer -Pregnancy -Liver -Renal A patient who has a history of bladder cancer and HF should avoid what class of DM meds? - Correct Answer Pioglitazones -Can cause renal fluid retention associated with HF When is it appropriate to increase insulin needs? - Correct Answer -Pregnancy -Infection -Stress -Growth spurts What is the TDD of a person that weighs 70kg? - Correct Answer TDD= (Kgx0.6) 50% will be long acting 50% Rapid acting IF a person is eating a 50 carb meal, how much insulin will be needed based on the TDD from the above question? - Correct Answer 500 / TDD = Carb to insulin ratio 500/42 = 11.9 50/ 11 = 4.5 Units Metformin - Correct Answer -Best antidiabetic for patients that skip meals -Can be used to treat PCOS A patient states that she will take her insulin lispro 30-60 minutes before a meal? - Correct Answer Nope- must be within 15-30 mins of meal "As long as the short-acting insulin is drawn up first I can mix my insulin glargine with it". - Correct Answer Nope- Only NPH can be mixed with short acting -Always draw regular (Clear) before NPH (Cloudy) A patient states, "My sugars have been around 65-68 at times but I feel like the med is working". - Correct Answer Nope- Values are too low -Hypoglycemia unawareness, need to educate A woman taking Pioglitazone states, "I'm glad that this med promotes weight loss." - Correct Answer Nope- Promotes an increase in LDL levels Increases cardiovascular risk -Educate about exercise and weight loss A female patient taking Canagliflozin comes in with a UTI and 6 months ago had a fungal infection. What are your next steps? - Correct Answer -Stop the med and start a new one A patient taking Sitagliptin (Pioglitazone) reports abdominal pain with vomiting. What are your next steps? - Correct Answer -Patient experiencing pancreatitis -> stop this med Insulin onset times - Correct Answer -Aspart= 15 - 30 mins -Regular= 30 - 60 mins -NPH= 60 - 120 mins -Glargine= 60 - 120 mins Mechanism of Action (MOA) B2RA (Beta 2 Receptor Agonists) - Correct Answer Promotes bronchodilation, relieving bronchospasms, has limited role in suppressing histamine release in the lungs. What is the first step (med) in asthma and COPD control? - Correct Answer SABA inhaler At what point is a patient prescribed an oral glucocorticoid? - Correct Answer -Moderate to severe persistent asthma or for management for acute exacerbations of asthma or COPD Roflumilast - Correct Answer -Reduces inflammation -Not intended during pregnancy -Only used for COPD -Second line drug for COPD -Used for exacerbation prophylaxis For Asthma, a LABA has been prescribed what other medication must a LABA be used with? - Correct Answer -ICS What are some benefits of using ICS? - Correct Answer -Reduced inflammation -Safer than systemic drugs -Less side effects What patient education can you provide for ICS use? - Correct Answer -Rinse mouth after use to prevent candidiasis What are some prevention strategies to prevent COPD exacerbations? - Correct Answer -Pulm rehab -Physical activity -Flu vaccine -Nutritional counseling GINA Guideline steps Chart - Correct Answer What patient teaching can a provider give when prescribing a PPI? - Correct Answer -S&S of hypomagnesemia (Muscle cramps, tremors, palpitations) -Supplement vitamin D and Calcium -Watch for S&S of C. Diff What patient teaching can a provider give when prescribing a H2RA? - Correct Answer -Report lethargy, hallucinations, restlessness, AMS, reduced libido, impotence, and gynecomastia Zollinger-Ellison syndrome is due to a ________ producing tumor. Treatment is long-term therapy of what medication class? - Correct Answer -Gastrin