NR565 Final Exam Study Guide
This study guide covers content for the question bank for this course. There are 100 questions on the exam
and more content in the exam study bank than will be seen on any given exam. Therefore, you may note more
than 100 topic items noted in this study guide. However, there may also be more than one question for a topic
listed so you should know each one well. Some items listed are more specific than others. If the item listed
seems vague, if it’s a more general question and to be more specific would be to risk the integrity of the
question itself.
Number of Questions on Exam: 100
Point Value of Each Question: 2
Styles of Questions of Exam: Multiple Choice Only
Knowledge Levels: Various (remember, understand, apply)
Time Limit: 150 minutes
Number of Attempts: 1
Use of Support Materials: Not Allowed
Platform Used for Exam: ExamSoft/Examplify
Exam Expectations: Review Exam Expectations in Course
Announcements
Tips on Using this Study Guide
1. Review the topics each week to take notes as you move through the course and focus your reading and
content review in the course.
2. You can make notes directly on each tab for the respective week or print out and hand write your notes.
3. If you choose to print, you will want to adjust the size of columns so the table width will fit on a printed
page.
4. Re-write your notes if you type them to connect the content to your memory more readily as the activity
of writing and saying it again as you write it creates repetition that helps commit the content to memory.
5. Create your own practice questions that are clinical scenario based to move the content from a
memorization (Remember) level of learning to an application type of learning. Much of your exam will be
at the application level so it's not enough to memorize your notes.
6. Review your study guide and notes as often as you can. Read them out loud so you hear the words
externally as well as internally. The more senses you can engage while studying, the more likely you are
to remember it.
,Chapter 48 Chapter 49
Glycemic Goals in Type 2 Diabetes: Primary goal
of 1&2 is prevention of long-term complications. Hypothyroidism
T2DM requires a comprehensive tx plan of lifestyle Treatment in Infants: Levothyroxine dosage is
(diet & physical activity), and drug therapy. adjusted for age and weight, decreasing as the child
Screening and tx of comorbidities HTN, grows. Initially higher doses may be required for
nephropathay, retinopathy, infants with congenital hypothyroidism with
neuropathy, and dyslipidemias. Glycemic control is adjustments made to maintain normal TSH and T4
started with both lifestyle and medication. Glycemic levels.
controls goals should be individualized and based off Levothyroxine Administration: indicated for all
of: duration of diabetes, Age/life expectancy, forms of hypothyroidism regardless of cause:
comorbid conditions, known CVD or advanced congenital hypothyroidism, myxedema coma, simple
microvascular complications, hypoglycemia goiter, and primary hypothyroidism, hypothyroidism
unawareness,, however the general targets are resulting from insufficient TSH secondary to pituitary
A1c <7.0%, Premeal plasma glucose 70-130, and malfunction and secondary to hypothalamic
peak postmeal plasma glucose <180. malfunction, maintain proper levels of THS after
Diabetic Nephropathy Prevention: Vitamin B12 thyroid surgery, irradiation, and tx w/antithyroid
1st generation vs 2nd generation Sulfonylurea: drugs. Administered by mouth, once daily on empty
Both reduce glucose levels to the same extent. 2nd stomach to enhance absorption, dosing is usually
Gen are much more potent, so doses are lower (as done in the morning at least 30-60 minutes before
much as 1K times lower), significant drug-drug eating. IV is used for myxedema coma and pts who
interactions are LESS common and the outcomes cannot take PO and doses are approx. 50% of the
tend to be milder. Due to this, 2nd Gen have nearly size of oral. Maintain consistency in timing of their
completely replaced 1st Gen. 1st Gen: Tolbutamide, dose to ensure stable thyroid hormone levels, Use
Tolazamide, and Chlorpropamide. 2nd Gen: Glipizide caution in those with CVD and start with lower doses
(immediate release- Glucotrol, sustained released- in older adult pts.
Glucotrol XL), Glyburide (nonmicronized- DiaBeta, Levothyroxine: Drug interactions; reduced
micronized- GLynase PresTab, Glimepiride (Amaryl). absorption of levothyroxine: histamine 2 (H2)
DDP4I: Adverse Effects: Pancreatitis (s/s severe blockers: cimetidine (Tagamet), proton pump
and persistent abd pain with or without vomiting) inhibitors (lansoprazole:prevacid), sucralfate
including hemorrhagic or necrotizing pancreatitis. (caragate), colestipol (colestid), cholestyramine
Hypersensitivity reactions, Upper respiratory (questran), aluminum-containing antacids (Maalox,
infections, headache, inflammation of nasal Mylanta), calcium supplements (tums, os-cal), iron
passages and throat. Small risk of hypoglycemia supplements (e/g/ ferrous sulfate), magnesium salts,
DDP4I: MOA: Enhances action of incretin hormones orlistat (Xenical)- Should separate administration of
to stimulate glucose dependent insulin and any of these meds with levothyroxine by at least 4
suppresses postprandial release of glucagon hrs. Drugs that accelerate levothyroxine
GLP-1 receptor agonists: MOA: incretin mimetic metabolism: phenytoin (Dilantin), carbamazepine
that acts by activates receptors for GLP-1 slowing (Tegretol, carbatrol), rifampin (fifadin), sertraline
gastric emptying, inhibits glucagon, suppresses (zoloft), and phenobarbital- May need in INCREASE
appetite, and stimulates glucose-dependent release levothyroxine dosage while taking these meds.
of insulin, inhibits postprandial release of glucagon. Levothyroxine accelerates the degradation of
These actions collectively improve glucose control vitamin-K dependent clotting factors leading to
the enhancement of warfarin- the dosage of warfarin
and can induce weight loss.
may need to be reduced while concurrently taking
GLP-1 receptor agonists: Monitoring: BMP for
levothyroxine. Catecholamines: thyroid hormones
kidney function and blood glucose levels to adjust
increase cardiac responsiveness to catecholamines,
dosing accordingly; HgB A1c will provide information
thereby increasing the risk for catecholamine-
on the effectiveness of the treatment. random
induced dysrhythmias: caution must be exercised
plasma glucose, fasting plasma glucose, A1c, serum
when administering catecholamines and thyroid
electrolytes, urinary glucose, ketones. Pts should
meds together. Can increase requirements for
monitor glucose regularly. Evaluating therapeutic
insulin and digoxin- when converting pts from
effects: improvement in sx, including decrease in
hypothyroid to euthyroid dosages of insulin and
urination, fatigue, weight loss, and decrease in
digoxin may need to be increased.
plasma glucose levels and A1C.
, Glycemic Control Targets Levothyroxine: Adverse Effects: acute OD-
Incretin Mimetics: DDP-4: Stigliptin,GLP-1 receptor thyrotoxicosis (S/S: tachycardia, angina, tremor,
agonisits (Exenatide- byetta, bydureon; Liraglutide- nervousness, insomnia, hyperthermia, heat
Victoza; Dulaglutide-trulicity; intolerance, sweating). Chronic OD with long-term
Incretin Mimetics in Pregnancy: Use with caution; inappropriate doses: Osteoporosis bone loss and
benefits should outweigh the risks; avoid use in pts increased risk for fractures. A-fib: Chronic OD in
with renal dysfunction or have had renal transplant or older adult population. Precautions: used cautiously
those with history of pancreatitis. in clients with certain cardiovascular disorders due to
Meglitinides vs sulfonylureas: same mechanism potential to increase HR and BP. Contraindicated in
as sulfonylureas. Main difference is the individuals with uncorrected adrenal
pharmacokinetic profile- glinides are shorter acting insufficiency, as thyroid hormone replacement
and are taken WITH each meal. P. 410 can exacerbate this condition.
Metformin (1st line drug for T2DM): MOA: inhibits Levothyroxine Monitoring: Resolution of s/s of
glucose production in the liver, reduces glucose hypothyroidism and restoration of normal labs for
absorption in the gut, sensitizes insulin receptors in serum TSH and free T4 (obtain baseline for
target tissues (fat and skeletal muscle), thereby comparison). Check TSH q 6-8 wks after initiating
increases glucose uptake in response to whatever therapy and after any dosage change (TSH should
insulin may available. Does not involve the decrease to normal levels with a goal range of 0.5-2
stimulation of insulin release from the pancreas, microunits/mL). T4 may also be used to evaluate
thereby not directly lowering blood glucose levels but therapy in clients where TSH remains high with a
making the body more efficient at using its insulin. goal of normal to high T4 levels. Check TSH at least
Slowly absorbed by the small intestine and is not once a year after serum TSH is stabilized.
metabolized, however it is excreted unchanged by Hyperthyroidism
the kidneys. **can be toxic in those with renal Methimazole: MOA: 1st line for hyperthyroidism;
impairment. blocking synthesis of thyroid hormones by two
Metformin: Pregnancy: Is safe, however insulin is mechanisms: 1st prevents oxidation of iodine, thereby
preferred. inhibiting incorporation of iodine into tyrosine. 2nd
Metformin: Side Effects: GI sx: decreased appetite, prevents iodinated tyrosine’s from coupling; both
nausea, diarrhea, lactic acidosis. Decreases effects result from inhibiting peroxidase, the enzyme
absorption of B12 and folic acid. **Black box that catalyzes both reaction. It can take 3-12 weeks
warning: severe metabolic acidosis can occur and is to produce a euthyroid state.
higher in those with significant renal impairment. It Treatment During Pregnancy: should be avoided in
should be avoided in those with renal, liver disease, pregnancy and breastfeeding; can cause neonatal
severe infection or with a history of lactic acidosis, hypothyroidism, goiter, and congenital
those who consume ETOH to excess, and pt with hypothyroidism. Should be avoided during 1st
shock or other conditions that can result in trimester and only used in 2nd and 3rd. PTU poorly
hypoxemia. Also contraindicated in HF patients crosses the placenta and is considered lower risk to
pioglitazone (TZD): Adverse Effects: upper the fetus, hence is preferred in 1st trimester.
respiratory tract infection, headache, sinusitis, and Thyroid Storm: Thyrotoxic crisis can occur in pts
myalgia. BLACK BOX WARNING associated with with severe thyrotoxicosis when they undergo major
HF secondary to renal retention of fluid. If HF is dx, surgery or develop a severe intercurrent illness. PTU
pioglitazone should be discontinued or used in is preferred tx.
reduced dosage. M Symptoms: Profound hyperthermia (105F or
pioglitazone (TZD): MOA turn on insulin-responsive more), severe tachycardia, restlessness, agitation,
genes that help regulate carbohydrate and lipid tremor, unconsciousness, coma, hypotension, and
metabolism Peroxisome proliferator-activated HF. Can be life threatening and requires immediate
receptor Y- PPARy, this activates pioglitazone to turn treatment. High doses of potassium iodid or strong
on then turns on insulin-responsive genes that help iodine solution are given to suppress thyroid
regulate carbs and lipid metabolism. This results in hormone release. Methimazole is given to suppress
cellular responses to insulin are increased, thereby thyroid hormone synthesis. A beta blocker is given to
promoting increased glucose uptake by skeletal reduce heart rate. Additional measures include
muscle and adipose cells and partly decreased sedation, cooling, and giving glucocorticoids and IV
glucose production by the liver- insulin MUST be fluids.
present for the drug to work.
Repaglinide (Meglitinide): pt education: Eat NO
This study guide covers content for the question bank for this course. There are 100 questions on the exam
and more content in the exam study bank than will be seen on any given exam. Therefore, you may note more
than 100 topic items noted in this study guide. However, there may also be more than one question for a topic
listed so you should know each one well. Some items listed are more specific than others. If the item listed
seems vague, if it’s a more general question and to be more specific would be to risk the integrity of the
question itself.
Number of Questions on Exam: 100
Point Value of Each Question: 2
Styles of Questions of Exam: Multiple Choice Only
Knowledge Levels: Various (remember, understand, apply)
Time Limit: 150 minutes
Number of Attempts: 1
Use of Support Materials: Not Allowed
Platform Used for Exam: ExamSoft/Examplify
Exam Expectations: Review Exam Expectations in Course
Announcements
Tips on Using this Study Guide
1. Review the topics each week to take notes as you move through the course and focus your reading and
content review in the course.
2. You can make notes directly on each tab for the respective week or print out and hand write your notes.
3. If you choose to print, you will want to adjust the size of columns so the table width will fit on a printed
page.
4. Re-write your notes if you type them to connect the content to your memory more readily as the activity
of writing and saying it again as you write it creates repetition that helps commit the content to memory.
5. Create your own practice questions that are clinical scenario based to move the content from a
memorization (Remember) level of learning to an application type of learning. Much of your exam will be
at the application level so it's not enough to memorize your notes.
6. Review your study guide and notes as often as you can. Read them out loud so you hear the words
externally as well as internally. The more senses you can engage while studying, the more likely you are
to remember it.
,Chapter 48 Chapter 49
Glycemic Goals in Type 2 Diabetes: Primary goal
of 1&2 is prevention of long-term complications. Hypothyroidism
T2DM requires a comprehensive tx plan of lifestyle Treatment in Infants: Levothyroxine dosage is
(diet & physical activity), and drug therapy. adjusted for age and weight, decreasing as the child
Screening and tx of comorbidities HTN, grows. Initially higher doses may be required for
nephropathay, retinopathy, infants with congenital hypothyroidism with
neuropathy, and dyslipidemias. Glycemic control is adjustments made to maintain normal TSH and T4
started with both lifestyle and medication. Glycemic levels.
controls goals should be individualized and based off Levothyroxine Administration: indicated for all
of: duration of diabetes, Age/life expectancy, forms of hypothyroidism regardless of cause:
comorbid conditions, known CVD or advanced congenital hypothyroidism, myxedema coma, simple
microvascular complications, hypoglycemia goiter, and primary hypothyroidism, hypothyroidism
unawareness,, however the general targets are resulting from insufficient TSH secondary to pituitary
A1c <7.0%, Premeal plasma glucose 70-130, and malfunction and secondary to hypothalamic
peak postmeal plasma glucose <180. malfunction, maintain proper levels of THS after
Diabetic Nephropathy Prevention: Vitamin B12 thyroid surgery, irradiation, and tx w/antithyroid
1st generation vs 2nd generation Sulfonylurea: drugs. Administered by mouth, once daily on empty
Both reduce glucose levels to the same extent. 2nd stomach to enhance absorption, dosing is usually
Gen are much more potent, so doses are lower (as done in the morning at least 30-60 minutes before
much as 1K times lower), significant drug-drug eating. IV is used for myxedema coma and pts who
interactions are LESS common and the outcomes cannot take PO and doses are approx. 50% of the
tend to be milder. Due to this, 2nd Gen have nearly size of oral. Maintain consistency in timing of their
completely replaced 1st Gen. 1st Gen: Tolbutamide, dose to ensure stable thyroid hormone levels, Use
Tolazamide, and Chlorpropamide. 2nd Gen: Glipizide caution in those with CVD and start with lower doses
(immediate release- Glucotrol, sustained released- in older adult pts.
Glucotrol XL), Glyburide (nonmicronized- DiaBeta, Levothyroxine: Drug interactions; reduced
micronized- GLynase PresTab, Glimepiride (Amaryl). absorption of levothyroxine: histamine 2 (H2)
DDP4I: Adverse Effects: Pancreatitis (s/s severe blockers: cimetidine (Tagamet), proton pump
and persistent abd pain with or without vomiting) inhibitors (lansoprazole:prevacid), sucralfate
including hemorrhagic or necrotizing pancreatitis. (caragate), colestipol (colestid), cholestyramine
Hypersensitivity reactions, Upper respiratory (questran), aluminum-containing antacids (Maalox,
infections, headache, inflammation of nasal Mylanta), calcium supplements (tums, os-cal), iron
passages and throat. Small risk of hypoglycemia supplements (e/g/ ferrous sulfate), magnesium salts,
DDP4I: MOA: Enhances action of incretin hormones orlistat (Xenical)- Should separate administration of
to stimulate glucose dependent insulin and any of these meds with levothyroxine by at least 4
suppresses postprandial release of glucagon hrs. Drugs that accelerate levothyroxine
GLP-1 receptor agonists: MOA: incretin mimetic metabolism: phenytoin (Dilantin), carbamazepine
that acts by activates receptors for GLP-1 slowing (Tegretol, carbatrol), rifampin (fifadin), sertraline
gastric emptying, inhibits glucagon, suppresses (zoloft), and phenobarbital- May need in INCREASE
appetite, and stimulates glucose-dependent release levothyroxine dosage while taking these meds.
of insulin, inhibits postprandial release of glucagon. Levothyroxine accelerates the degradation of
These actions collectively improve glucose control vitamin-K dependent clotting factors leading to
the enhancement of warfarin- the dosage of warfarin
and can induce weight loss.
may need to be reduced while concurrently taking
GLP-1 receptor agonists: Monitoring: BMP for
levothyroxine. Catecholamines: thyroid hormones
kidney function and blood glucose levels to adjust
increase cardiac responsiveness to catecholamines,
dosing accordingly; HgB A1c will provide information
thereby increasing the risk for catecholamine-
on the effectiveness of the treatment. random
induced dysrhythmias: caution must be exercised
plasma glucose, fasting plasma glucose, A1c, serum
when administering catecholamines and thyroid
electrolytes, urinary glucose, ketones. Pts should
meds together. Can increase requirements for
monitor glucose regularly. Evaluating therapeutic
insulin and digoxin- when converting pts from
effects: improvement in sx, including decrease in
hypothyroid to euthyroid dosages of insulin and
urination, fatigue, weight loss, and decrease in
digoxin may need to be increased.
plasma glucose levels and A1C.
, Glycemic Control Targets Levothyroxine: Adverse Effects: acute OD-
Incretin Mimetics: DDP-4: Stigliptin,GLP-1 receptor thyrotoxicosis (S/S: tachycardia, angina, tremor,
agonisits (Exenatide- byetta, bydureon; Liraglutide- nervousness, insomnia, hyperthermia, heat
Victoza; Dulaglutide-trulicity; intolerance, sweating). Chronic OD with long-term
Incretin Mimetics in Pregnancy: Use with caution; inappropriate doses: Osteoporosis bone loss and
benefits should outweigh the risks; avoid use in pts increased risk for fractures. A-fib: Chronic OD in
with renal dysfunction or have had renal transplant or older adult population. Precautions: used cautiously
those with history of pancreatitis. in clients with certain cardiovascular disorders due to
Meglitinides vs sulfonylureas: same mechanism potential to increase HR and BP. Contraindicated in
as sulfonylureas. Main difference is the individuals with uncorrected adrenal
pharmacokinetic profile- glinides are shorter acting insufficiency, as thyroid hormone replacement
and are taken WITH each meal. P. 410 can exacerbate this condition.
Metformin (1st line drug for T2DM): MOA: inhibits Levothyroxine Monitoring: Resolution of s/s of
glucose production in the liver, reduces glucose hypothyroidism and restoration of normal labs for
absorption in the gut, sensitizes insulin receptors in serum TSH and free T4 (obtain baseline for
target tissues (fat and skeletal muscle), thereby comparison). Check TSH q 6-8 wks after initiating
increases glucose uptake in response to whatever therapy and after any dosage change (TSH should
insulin may available. Does not involve the decrease to normal levels with a goal range of 0.5-2
stimulation of insulin release from the pancreas, microunits/mL). T4 may also be used to evaluate
thereby not directly lowering blood glucose levels but therapy in clients where TSH remains high with a
making the body more efficient at using its insulin. goal of normal to high T4 levels. Check TSH at least
Slowly absorbed by the small intestine and is not once a year after serum TSH is stabilized.
metabolized, however it is excreted unchanged by Hyperthyroidism
the kidneys. **can be toxic in those with renal Methimazole: MOA: 1st line for hyperthyroidism;
impairment. blocking synthesis of thyroid hormones by two
Metformin: Pregnancy: Is safe, however insulin is mechanisms: 1st prevents oxidation of iodine, thereby
preferred. inhibiting incorporation of iodine into tyrosine. 2nd
Metformin: Side Effects: GI sx: decreased appetite, prevents iodinated tyrosine’s from coupling; both
nausea, diarrhea, lactic acidosis. Decreases effects result from inhibiting peroxidase, the enzyme
absorption of B12 and folic acid. **Black box that catalyzes both reaction. It can take 3-12 weeks
warning: severe metabolic acidosis can occur and is to produce a euthyroid state.
higher in those with significant renal impairment. It Treatment During Pregnancy: should be avoided in
should be avoided in those with renal, liver disease, pregnancy and breastfeeding; can cause neonatal
severe infection or with a history of lactic acidosis, hypothyroidism, goiter, and congenital
those who consume ETOH to excess, and pt with hypothyroidism. Should be avoided during 1st
shock or other conditions that can result in trimester and only used in 2nd and 3rd. PTU poorly
hypoxemia. Also contraindicated in HF patients crosses the placenta and is considered lower risk to
pioglitazone (TZD): Adverse Effects: upper the fetus, hence is preferred in 1st trimester.
respiratory tract infection, headache, sinusitis, and Thyroid Storm: Thyrotoxic crisis can occur in pts
myalgia. BLACK BOX WARNING associated with with severe thyrotoxicosis when they undergo major
HF secondary to renal retention of fluid. If HF is dx, surgery or develop a severe intercurrent illness. PTU
pioglitazone should be discontinued or used in is preferred tx.
reduced dosage. M Symptoms: Profound hyperthermia (105F or
pioglitazone (TZD): MOA turn on insulin-responsive more), severe tachycardia, restlessness, agitation,
genes that help regulate carbohydrate and lipid tremor, unconsciousness, coma, hypotension, and
metabolism Peroxisome proliferator-activated HF. Can be life threatening and requires immediate
receptor Y- PPARy, this activates pioglitazone to turn treatment. High doses of potassium iodid or strong
on then turns on insulin-responsive genes that help iodine solution are given to suppress thyroid
regulate carbs and lipid metabolism. This results in hormone release. Methimazole is given to suppress
cellular responses to insulin are increased, thereby thyroid hormone synthesis. A beta blocker is given to
promoting increased glucose uptake by skeletal reduce heart rate. Additional measures include
muscle and adipose cells and partly decreased sedation, cooling, and giving glucocorticoids and IV
glucose production by the liver- insulin MUST be fluids.
present for the drug to work.
Repaglinide (Meglitinide): pt education: Eat NO
