PME Endocrine System

Question 1

sulfonylureas

Answer 1

• oral hypoglycemics
• first oral hypoglycemic class used to treat Type 2 DM
• prototype: glipizide
  
  • 2nd gen
  • stronger than 1st gen
• other: tolbutamide (1st gen)

Question 2

sulfonylurea drug mechanism of action

Answer 2

• stimulates release of insulin from pancreatic islet cells
• pt must have functioning pancreas
• insulin release related to blood glucose level, so hypoglycemia not usually a problem

Question 3

side effects of sulfonylureas

Answer 3

• mild hypoglycemia
  
  • in pts with impaired liver or kidney function
  • slower metabolism and excretion of drug → prolonged action
• nausea
• diarrhea

Question 4

s/sx of hypoglycemia

Answer 4

• diaphoresis
• tachycardia
• fatigue
• excessive hunger
• tremors
• BG level < 70

Question 5

Tx of mild hypoglycemia

Answer 5

• give 15-20 g carbohydrate
• if conscious, give oral, pill or food
  
  • 4 oz fruit juice
  • 6 saltines
  • 1 Tbsp honey
• if unconscious, give parenterally
  
  • IV glucose if access available
  • 1 mg glucagon SQ or IM
• check BG every 15 min until
  
  • level is in reference range
  • Sx resolved

Question 6

administration of glipizide

Answer 6

• give orally 30 min before selected meals
• swallow sustained-release form whole
• pregnancy: stop taking 48 hr before delivery

Question 7

pt education for hypoglycemia and sulfonylureas

Answer 7

• wear medical alert bracelet
• watch for a report sx of hypoglycemia and recurrent hypoglycemic episodes
  
  • test BG to confirm
  • eat 15-20 g carbs
  • retest in 15-20 min
  • repeat Tx if needed
• carry carb snack at all times
• nausea: lie down
• eat adequate carbs

Question 8

contraindications and precautions for sulfonylureas

Answer 8

• contra
  
  • pregnancy
  • lactation
  • DKA
• caution
  
  • thyroid dz
  • renal or hepatic dysfunction
  • adrenal or pituitary insufficiency

Question 9

interactions with sulfonylureas

Answer 9

• alcohol
  
  • N&V
  • palpitations
  • flushing
• increased effects
  
  • sulfonamide abx
  • NSAIDs
  • oral anticoagulants
  • salicylates
  • MOAIs
  • cimetidine
• thiazides counteract
• beta blockers mask hypoglycemia sx (tachycardia)

Question 10

meglitinides

Answer 10

• for Type 2 DM
• prototype: repaglinide
• other: nateglinide

Question 11

mechanism of action for meglitinides

Answer 11

• stimulate release of insuline from islet cells
  
  • must have functioning pancreas
  • insulin release related to BG level
• wont’ work for pts who don’t respond to sulfonylureas
• severe hypoglycemia not usually a problem

Question 12

side effects of meglitinides

Answer 12

• mild hypoglycemia: more common in pts with impaired liver function
• nausea
• diarrhea
• notify provider of persistent nausea, vomiting, or diarrhea

Question 13

administering repaglinide

Answer 13

• take orally 30 min or less before meal, usually 3x daily
• skip dose if skipping meal
• add dose if adding meal
• do not exceed 4 doses/day

Question 14

contraindications and precautions for meglitinides

Answer 14

• contra
  
  • DKA
• caution
  
  • older adults
  • renal or hepatic dysfunction
  • systemic infection

Question 15

interactions with meglitinides

Answer 15

• ↑ hypoglycemic effects
  
  • gemfibrozil
  • erythromycin
  • ketoconazole
  • grapefruit juice (> 1 L/day)
  • ginseng
  • garlic
• counteract
  
  • barbituates
  • carbamazepine
  • rifampin

Question 16

biguanides

Answer 16

• oral hypoglycemics
• Tx for Type 2 DM
• usually 1st drug Rx for newly diagnosed
• prototype (only drug in class): metformin
• can be combined with other oral hypoglycemics
  
  • glipizide
  • repaglinide

Question 17

mechanism of action for metformin (biguanide)

Answer 17

• lowers BG in 3 ways
  
  • ↓ absorption from intestines
  • ↓ synthesis of glucose in liver
  • ↑ sensitivity of insulin receptors
• different MOA from sulfonylureas and meglitinides
  
  • provides better control in combination therapy

Question 18

side effects of metformin

Answer 18

• can be severe
  
  • nausea
  • diarrhea
  • anorexia
• vitamin deficiencies: can affect absorption; monitor levels
  
  • B₁₂
  • folic acid
• lactic acidosis: rare, but potentially fatal
  
  • r/t effect on mitochondrial oxidation of lactic acid

Question 19

s/sx of lactic acidosis

Answer 19

• weakness
• fatigue
• lethargy
• hyperventilation

Question 20

Tx for lactic acidosis

Answer 20

• stop metformin immediately
• draw labs to test for acidosis
• hemodialysis may be needed

Question 21

administering metformin

Answer 21

• monitor
  
  • fluid I/O
  • for persistent nausea, vomiting, or diarrhea
  • B12 or folic acid levels (recommend supplement)
• immediate-release: 2x/day with morning and evening meals
• extended-release: daily with evening meal; swallow whole

Question 22

pt education for metformin

Answer 22

• lactic acidosis
  
  • avoid alcohol
  • report weakness, fatigue, lethargy, hyperventilation
  • stop taking and seek medical care if sx develop
• GI problems
  
  • expect effects to ↓
  • lie down for nausea
  • ensure adequate carb, clear fluid intake
• vitamin deficiency
  
  • report weakness, fatigue, pallor, or red tongue

Question 23

contraindications and precautions for metformin

Answer 23

• contra: ↑ risk of lactic acidosis
  
  • DKA
  • cardiopulmonary, hepatic, or renal insufficiency
  • alcoholism
  • heart failure
  • severe infection
  • shock
  • acute MI
  • hypoxemia
  • lactic acidosis
• caution
  
  • older adults
  • diarrhea
  • dehydration
  • anemia
  • gastroparesis
  • pituitary insufficiency
  • hypothyroidism
  • GI obstruction
  • PCOS

Question 24

interactions with metformin

Answer 24

• ↑ risk of lactic acidosis
  
  • alcohol
  • cimetidine
• ↑ risk renal failure → lactic acidosis
  
  • contrast medium with iodine
• ↑ hypoglycemic effects
  
  • garlic
  • ginseng
  • captopril
  • nifedipine
  • furosemide
  • morphine
  • ranitidine
  • antifungals
  • many others

Question 25

thiazolidinediones (glitazones)

Answer 25

* Tx for Type 2 DM * with or without insuline or metformin * prototype: pioglitazone

Question 26

mechanism of action for glitazones

Answer 26

* reduce insulin resistance * insulin must be available * concurrent admin of metformin, a sulfonylurea, or insulin may be needed

Question 27

side effects of glitazones

Answer 27

* fluid retention * hepatotoxicity * increased serum lipid levels

Question 28

administration of glitazones

Answer 28

* monitor * edema * weight gain * indications of heart failure * serum ALT levels: baseline, every 3-6 mos after * ↑ serum triglyceride, HDL, LDL levels * **stop drug** for indications of liver injury * report to provider * swelling * SOB * wt gain \> 2-3 kg * indications of liver injury * ↑ LDLs, triglycerides * give orally once daily with or without food

Question 29

glitazone patient education

Answer 29

* report * immediately, significant change * SOB * wt gain * swelling * jaundice * dark urine * abd pain * vomiting * fatigue * chest pain or discomfort * diaphoresis * expect * period cholesterol testing * some swelling and wt gain

Question 30

contraindications and precautions for glitazones

Answer 30

* contra * CV dz, including HTN * heart failure * active hepatic dz * caution * mild heart failure * hx of heart failure * hepatic impairment

Question 31

interactions with pioglitazone

Answer 31

* ↑ risk of heart failure, edema * insulin * ↑ hypoglycemic effects * gemfibrozil * ketoconazole * green tea * ginseng * garlic

Question 32

short name for thiazolidinediones

Answer 32

glitazones

Question 33

alpha-glucosidase inhibitors (AGIs)

Answer 33

* Tx for Type 2 DM * with or without insulin, sulfonylurea, or metformin * prototype: acarbose * other: miglitol

Question 34

mechanism of action for AGIs

Answer 34

* block action of apha-glucosidase, an enzyme that breaks down carbs in intestine * slows absorption of carbs after meal * ↓ sudden postprandial BG ↑

Question 35

side effects of AGIs

Answer 35

* GI: 2/2 fermentation of bacteria from carbs left in colon * distention * flatus * hyperactive BS * diarrhea * hypoglycemia, in combo with sulfonylurea or insulin * Tx difficult because absorption blocked * give dextrose parenterally * liver dysfunction and iron-deficiency anemia * 2/2 long-term or high-dose use with carbose drug * liver dysfunction reversible upon D/C of drug

Question 36

administration of AGIs

Answer 36

* monitor * GI sx: hyperactive BS, distention, diarrhea * s/sx of hypoglycemia * liver enzymes: baseline, every 3 mos for 1 yr, periodically after * CBC (hgb), s/sx of anemia (pallor, fatigue) * report * persistent GI s/sx * s/sx of liver injury * Tx * hypoglycemia: 4g dextrose * liver injury: stop drug, report * anemia: iron-rich foods, supplements * give with first bite of food 3x/day * skip dose if skipping meal, only take 1 dose at next meal

Question 37

pt education for AGIs

Answer 37

* be aware of gastric SE; should ↓ over time * follow diet recommended by provider * wear medical alert bracelet * watch for and report s/sx of hypoglycemia * test BG to confirm * take 4g of dextrose * retest in 15 min * repeat Tx if necessary * carry dextrose tabs at all times * report signs of * liver dysfunction * dark urine * abd pain * vomiting * fatigue * anemia * pallor * fatigue * SOB

Question 38

contraindications and precautions for acarbose

Answer 38

* contra * GI disorders (inflammatory bowel disease) * GI obstruction * GI ulceration * caution * hepatic impairment * GI distress

Question 39

interactions with AGIs

Answer 39

* ↑ risk of hypoglycemia * insulin * sulfonylureas * ginseng * ↑ GI effects * metformin * conteract * estrogens * thiazides * corticosteroids * phenothiazines * isoniazid (INH) * phenytoin

Question 40

gliptins

Answer 40

* Tx for Type 2 DM * with or without metformin or glitazone * prototype (only drug, new class): sitagliptin * also comes in combo with metformin

Question 41

mechanism of action of sitagliptin

Answer 41

* augment endogenous incretin hormones by inhibiting enzyme that inactivates them * promotes release of insulin * ↓ secretion of glucagon * ↓ fasting and postprandial BG

Question 42

side effects of sitagliptin

Answer 42

* trials: small ↑ in * URI * inflammed nasal passages * headache * pancreatitis reported in post-release study, possible adverse effect

Question 43

administration of gliptins

Answer 43

* monitor for * respiratory sx * body temp * headaches (OTC analgesic if persistent) * GI effects, s/sx of pancreatitis * blood amylase level * admin * orally alone or as metformin combo * with or without food * ↓ dose for pts with severe renal impairment and low creatinine clearance

Question 44

pt education for sitagliptin

Answer 44

* report * persistent URI sx or fever * persistent or uncontrolled headache * severe upper abd pain * abd pain that radiates to back and nausea or vomiting

Question 45

contraindications and precautions for sitagliptin

Answer 45

* contra * Type 1 DM * lactic acidosis * caution * hemodialysis * mod-severe renal dysfunction * Hx of pancreatitis

Question 46

interactions with sitagliptin

Answer 46

↑ digoxin levels (only known interaction)

Question 47

injectable hypoglycemics

Answer 47

* insulin * amylin mimetics * incretin mimetics

Question 48

Type 1 DM

Answer 48

* beta cells of pancreas become damaged and don't produce insulin * thought to be autoimmune * oral hypoglycemics don't work * requires injectable hypoglycemics

Question 49

insulin

Answer 49

* for Tx of * DM (1 or 2) that can't be controlled with oral hypoglycemics and diet * gestational DM * categorized by duration of action * produced recombinant DNA tech * prototypes * rapid: lispro * short: regular insulin (Humulin R) * intermediate: NPH * long: insulin glargine * other * rapid: insulin aspart * short: regular insulin (Novolin R) * intermediate: insulin detemir * mixture: eliminates need to mix for pts who need multiple types * short and intermediate: NPH 70% and regular 30% (Humulin 70/30) * may be used to treat hyperkalemia

Question 50

onset, peak, and duration times for rapid-acting lispro insulin

Answer 50

* onset: 15-30 min * peak: 30 min to 2/5 hr * duration: 3-6 hr

Question 51

onset, peak, and duration times for short-acting regular insulin

Answer 51

* onset: 30 min to 1 hr * peak: 1-5 hr * duration: 6-10 hr

Question 52

onset, peak, and duration times for NPH insulin

Answer 52

* onset: 1-2 hr * peak: 6-14 hr * duration: 16-24 hr

Question 53

onset, peak, and duration times for insulin glargine

Answer 53

* onset: 70 min * peak: none, steady levels * duration: 24 hr

Question 54

insulin produced by recombinant DNA technology

Answer 54

* chemically identical to insulin produced in beta cells * promotes cellular uptake and use of glucose * converts macronutrients * glucose → glycogen * amino acids → proteins * fatty acids → triglycerides * promotes * storage of glucose * uptake of potassium to cells (hypokalemia can occur)

Question 55

side effects of insulin

Answer 55

* excess insulin intake * hypoglycemia * hypokalemia * lipohypertrophy * injecting in same place too often * stimulates synthesis of adipose tissue

Question 56

things to monitor when giving insulin

Answer 56

* signs of hypoglycemia * abrupt onset * tachycardia * diphoresis * shakiness * gradual onset * headache * tremors * weakness * BG levels * signs of lipohypertrophy * potassium levels * signs of hypokalemia

Question 57

treating insulin side effects

Answer 57

* hypoglycemia * check BG to confirm * give 15-20 g carbs * 4 oz fruit juice * 1 Tbsp honey * glucose tabs per instructions * for unconscious: parenteral dextrose * check BG after 15 min * repeat Tx if necessary * lipohypertrophy: rotate injection sites * hypokalemia: give potassium

Question 58

administration of insulin

Answer 58

* most often given SQ, but also for IV * SQ * use insulin syringe marked in units (0.01 mL) * for suspensions: rotate gently between palms * when mixing, draw up short-acting first, the long * do not mix glargine or detemir * do not give short-acting if cloudy, discolored * short-acting: make sure carbs available in body at onset and peak times

Question 59

reasons to adjust dosage of insulin

Answer 59

* caloric intake change * infection * exercise * stress * growth spurts * pregnancy * hospitalization, surgery: sliding scale, short-acting

Question 60

storing insulin

Answer 60

* in use: room temp for one month * unopened, single type: refrigerate until expiration date * premixed in syringe * 1-2 wks in fridge * vertical, needles up * resuspend with gentle motion before admin

Question 61

pt education for insulin injections

Answer 61

* admin * draw up Rx amount * have pt demonstrate * rotate sites systematically (1 inch apart) * do not inject cold; keep vial in use at room temp * s/sx, Tx of hypoglycemia * medical alert bracelet

Question 62

contraindications and precautions for insulin

Answer 62

* # of insulins available → pts can usually tolerate one * contra * hypersensitivity * hypoglycemia * precautions * renal, hepatic dysfunction * fever * thyroid dz * older adults

Question 63

interactions with insulin

Answer 63

* ↑ hypoglycemic effects * sulfonylureas * meglitinides * beta blockers * alcohol * counteract: ↑ BG level * thiazide and loop diuretics * sympathomimetics * thyroid hormones * glucocorticoids * mask hypoglycemia (tachycardia, tremors): beta blockers

Question 64

amylin mimetics

Answer 64

* Tx of Types 1 and 2 DM * for pts who can't control with oral hypoglycemics and insulin * adjunct with insulin or oral hypoglycemic * prototype (new class): pramlintide

Question 65

mechanism of action for amylin mimetics

Answer 65

* mimics peptide hormone amylin from pancreas * ↓ postprandial BG levels 3 ways * slows gastric emptying * inhibits secretion of glucagon * ↑ feelings of satiety

Question 66

side effects of emylin mimetics

Answer 66

* hypoglycemia: severe when in combo with insulin * nausea: mostly in Type 1 DM; ↓ dose can help * injection site reactions: common

Question 67

administering amylin mimetics

Answer 67

expect ↓ insulin dose * monitor for s/sx of hypoglycemia, usually within 3 hr of dose * recommend gradual titration of doses * monitor for persistent N&V * do not mix with insulin * give SQ in thigh or abd * give AC: ≥ 30 g carbs * rotate sites * peak: 20 min * storage * in use: room temp for 28 days * unopened: fridge until expired

Question 68

pt education for amylin mimetics

Answer 68

* watch for and report hypoglycemia, especially 3 hr after dose * s/sx and Tx of hypoglycemia * carry carb snack at all times * return demonstrate proper injection * wear medical alert bracelet

Question 69

contraindications and precautions for amylin mimetics

Answer 69

* contra * renal failure * hemodialysis * poor insulin regimen adherence * HbA1c \> 9% * gastroparesis * caution * thyroid dz * osteoporosis * alcoholism

Question 70

interactions with pramlintide

Answer 70

* ↑ risk of hypoglycemia with insulin * take other meds 1-2 hr before or after because of ↓ absorption * ↓ gastric emptying, absorption * drugs that slow gastric emptying: opioids * drugs that delay absorption: acarbose, miglitol

Question 71

incretin mimetics

Answer 71

* for Tx of Type 2 DM * adjunct to sulfonylureas or metformin * prototype (new class): exenatide * synthetic peptide similar to glucagon

Question 72

mechanism of action for incretin mimetics

Answer 72

* activate GLP-1 receptors PC * slow gastric emptying * stimulate release of insulin in presence of glucose * ↓ secretion of glucagon * ↑ feelings of satiety

Question 73

side effects of incretin mimetics

Answer 73

* hypoglycemia * severe with sulfonylurea, but not with metformin * ↓ dose of oral hypoglycemic ↓ risk * nausea * vomiting * diarrhea * pancreatitis: usually requires D/C of drug

Question 74

administering incretin mimetics

Answer 74

* initial dose ↓ until effects determined * hypoglycemia * ↓ dose of oral hypoglycemic * most common SE * GI symptoms * nausea, vomiting, diarrhea * monitor fluid and carb intake * report if persistent or contribute to hypoglycemic episodes * pancreatitis * monitor for indications (severe, persistent abd pain) * stop drug and report if sx develop

Question 75

giving incretin mimetic injections

Answer 75

* injection * give SQ in thigh, abd, upper arm * up to 60 min AC morning and evening * NOT after meals * peak: 2 hr * prep * follow instructions * use appropriate needle size, Rx by provider * new needle for each injection * do not store with needle attached

Question 76

pt education for incretin mimetics

Answer 76

* s/sx and Tx for hypoglycemia * nausea, vomiting, diarrhea * nausea: lie down * ensure adequate caloric intake * pancreatitis * report severe, persistent abd pain * stop taking exenatide

Question 77

contraindications and precautions for exenatide

Answer 77

* contra * renal failure * Type 1 DM * DKA * ulcerative colitis * Crohn's * gastroparesis * caution * older adults * thyroid dz * renal dysfunction

Question 78

interactions with exenatide

Answer 78

* ↑ risk of hypoglycemia: sulfonylureas * give other oral drugs (especially oral contraceptives, abx) 1-2 hr before or after exenatide (slowed absorption)

Question 79

hyperglycemics

Answer 79

* Tx for hypoglycemia 2/2 insulin overdose * other: IV 50% glucose * immediate onset * preferred * prototype: glucagon * IV, SQ, IM * slower onset

Question 80

mechanism of action for glucagon

Answer 80

* converts glycogen from liver to glucose * onset: about 20 min

Question 81

side effects of glucagon

Answer 81

* high incidence of GI effects: nausea, vomiting * may persist after admin * monitor for persistence * monitor fluid and carb intake * turn unconscious pts on side to prevent aspiration

Question 82

administering glucagon

Answer 82

* give IM, SQ, or IV * unconscious pts * expect consciousness about 20 min after IV admin * give food after consciousness, swallowing regained * IV glucose still Tx of choice

Question 83

pt education for glucagon

Answer 83

* emergency admin * teach pt and fam how/when to inject * carry at all times * N&V * warn about probable vomiting * keep pt on their side * encourage oral intake when tolerated

Question 84

contraindications and precautions for glucagon

Answer 84

* contra * hypoglycemia from starvation (depleted glycogen) * pheochromocytoma (adrenal tumor) * caution * CV disorders * adrenal insufficiency

Question 85

interactions with glucagon

Answer 85

↑ effects of oral anticoagulants

Question 86

2 types of thyroid drugs

Answer 86

* thyroid replacements (for hypothyroid) * antithyroid (for hyperthyroid)

Question 87

thyroid replacement

Answer 87

* oral: for Tx of hypothyroidism * IV: for myxedema coma * prototype: levothyroxine (synth; T₄) * other * liothyronine (synth; T₃) * liotrix (synth; T₄ and T₃) * thyroid (natural; animal-sourced)

Question 88

levothyroxine mechanism of action

Answer 88

synthetic form of T₄ which is converted to T₃ in the body

Question 89

side effect of thyroid replacements

Answer 89

hyperthyroidism

Question 90

s/sx of hyperthyroidism

Answer 90

* anxiety * tachycardia * palpitations * tremors * altered appetite * abd cramping * diarrhea * heat intolerance * fever * diaphoresis * wt loss * menstrual irregularities

Question 91

myxedema coma

Answer 91

* severe or prolonged hypothyroidism * body basically shuts down

Question 92

administering thyroid replacements

Answer 92

* oral * daily on empty stomach * get baseline and monitor VS, wt, height * monitor for cardiac excitability * angina * chest pain * palpitations * dysrhythmias * monitor thyroxine and TSH levels * thyroxine formulations not interchangeable * therapy is life-long

Question 93

pt education for thyroid replacements

Answer 93

* formulations not interchangeable: notify pharmacy if different product dispensed * expect lifelong therapy * take daily * watch for and report s/sx of hyperthyroidism

Question 94

contraindications and precautions for thyroid replacements

Answer 94

* contra * thyrotoxicosis * recent MI * caution * older adults * renal impairment * DM * CV disorders * HTN * angina pectoris * ischemic heart dz

Question 95

interactions with thyroid replacements

Answer 95

* ↓ absorption of levothyroxine: don't take within 4 hr * food * cholestyramine * antacids * iron * calcium * sucralfate * ↓ levo levels: antiseizure and antidepressant drugs * phenytoin * phenobarbitol * sertraline * carbamazepine * ↑ anticoagulant effects of warfarin * ↑ cardiac reponse to catecholamines

Question 96

antithyroid drugs

Answer 96

* Tx hyperthyroidism (Graves' dz) * alone or with radiation * supression of thyroid hormone * in prep for thyroidectomy * in thyrotoxic crisis * prototype: propylthiouracil (PTU) * other: methimazole

Question 97

thyrotoxic crisis

Answer 97

* 2/2 to * uncontrolled hyperthyroidism * exposure to stressor: surgery, pregnancy * sx * tachycardia * HTN * fever

Question 98

mechanism of action of antithyroid drugs

Answer 98

* blocks synthesis of thyroid hormone * blocks iodine integration into tyrosine * blocks conversion of T₄ to T₃

Question 99

side effects of antithyroid drugs

Answer 99

* hypothyroidism * agranulocytosis * uncommon * during initial therapy * reversible * rash * arthralgia * myalgia * headache

Question 100

administering propylthiouracil

Answer 100

* hypothyroidism * monitor thyroid function * get baseline and monitor T₃ and T₄ * ↓ dose if hypo * agranulocytosis * get baseline and monitor CBC * monitor for s/sx * stop and notify if ↓ leukocytes and neutrophils * rash, joint or muscle pain, headache * mild analgesic for pain * orally at regular intervals (usually 8 hr) * get baseline and monitor VS, wt * 3-12 wks for euthyroid state * 6-12 mos to stabilize * do not D/C abruptly

Question 101

s/sx of hypothyroidism

Answer 101

* drowsiness * depression * wt gain * edema * bradycardia * anorexia * cold intolerance * dry skin * menorrhagia

Question 102

s/sx of agranulocytosis

Answer 102

* ↓ leukocytes and neutrophiles * fever * sore throat

Question 103

pt education for propylthiouracil

Answer 103

* regimens * sometimes lifelong * adjunct with radiation * in prep for thyroidectomy * report * s/sx of hypothyroidism * s/sx of agranulocytosis * joint/muscle pain, headache * take OTC analgesic

Question 104

contraindications and precautions for propylthiouracil

Answer 104

* contra * pregnancy category D: neonatal hypothyroidism and goiter * caution * immunosuppression * bone marrow depression * infection * liver dysfunction

Question 105

interactions with propylthiouracil

Answer 105

* ↑ effects of anticoagulants * food alters absorption rates * counteracted by * potassium iodide * sodium iodide * amiodarone

Question 106

radioactive iodine

Answer 106

* Tx for hyperthyroidism (Graves' dz) * thyroid cancer * prototype: iodine-131 * other * sodium iodide * potassium iodide

Question 107

mechanism of action of radioactive iodine

Answer 107

* absorbed by thyroid gland * gradually destroys thyroid tissue * gradually decreases thyroid function

Question 108

side effects of radioactive iodine

Answer 108

* hypothyroidism * expected for most * requires hormone therapy * bone marrow depression (rare) * radiation sickness (rare)

Question 109

administering radioactive iodine

Answer 109

* labs * TSH * T₄ * T₃ * CBC: baseline and after * s/sx of * hypothyroidism * anemia * leukopenia * thrombocytopenia * radiation sickness * give once, subsequently for some pt * get negative hCG before * VS and wt: baseline and after * onset: effects in few days or wks; full effect in 2-3 mos * radiation precautions for large doses * limit contact * increase fluids * body waste disposal per protocol

Question 110

s/sx of radiation sickness

Answer 110

* hematemesis * epistaxis * intense nausea, vomiting

Question 111

pt education for radioactive iodine

Answer 111

* info about goal of therapy * watch for and report s/sx of * hypothyroidism * bone marrow depression * radiation sickness

Question 112

contraindications and precautions for radioactive iodine

Answer 112

* contra * pregnancy category X: damage to fetus and fetal thyroid * lactation: damage to baby's thyroid * caution: prepubescent children

Question 113

interactions with radioactive iodine

Answer 113

antithyroid drugs ↓ uptake

Question 114

drugs for hypothalamic disorders

Answer 114

* growth hormone * antidiuretic hormone (ADH)

Question 115

growth hormone

Answer 115

* Tx for * deficiency in children: Turner's syndrome * deficiency in adults: to increase lean muscle mass * AIDS wasting syndrome * prototype: somatropin

Question 116

mechanism of action for growth hormone

Answer 116

stimulates release of insulin-like growth factor-1 (IGF-1) from liver and other tissues

Question 117

mechanism of action of somatostatin

Answer 117

inhibits release of growth hormone from pituitary

Question 118

imbalance in growth hormone

Answer 118

* children * inadequate: short stature * adolescents * excessive: gigantism * adults * excessive: acromegaly

Question 119

acromegaly

Answer 119

* caused by excessive growth hormone in adults, especially middle-aged * big bones * notable in hands, face, feet

Question 120

side effects of somatropin

Answer 120

* hyperglycemia * myalgia * hypercalciuria

Question 121

administering somatropin

Answer 121

* monitor * BG levels * muscle pain (mild analgesic) * urine calcium * renal stones * IM or SQ (preferred) * dosage wt-based * daily or multiple/wk * very costly * baseline and monitor * VS * wt * thyroid function * growth hormone levels * annual X-rays of long bones * reconstituting: rotate gently, do not shake * inject into abd and thighs * rotate sites

Question 122

pt education for somatropin

Answer 122

* watch for and report * hyperglycemia * polyphagia (hunger) * polydipsia (thirst) * polyuria * myalgia * hypercalcemia * flank pain * urinary frequency * hematuria * proper injection technique

Question 123

contraindications and precautions for somatropin

Answer 123

* contra * severe obesity * severe respiratory impairment * closed epiphyses in children * critical illness * caution * DM * chronic renal failure * hypothyroidism * Prader-Willi syndrome (PWS)

Question 124

interactions with somatropin

Answer 124

* counteracted by * glucocorticoids * adrenocorticotropic hormone * promote epiphyseal closure * thyroid hormones * estrogens * androgens

Question 125

antidiuretic hormone (ADH)

Answer 125

* Tx for * diabetes insipidus * hemophilia * prototype: desmopressin (DDAVP) * preferred because of short DOA, parenteral route * other: vasopressin * ADH produced by hypothalamus, stored in posterior pituitary

Question 126

mechanism of action for ADH

Answer 126

* produces effects on kidneys * ↑ reabsorption of water * ↓ urine volume

Question 127

side effects of ADH

Answer 127

* fluid retention → water intoxication * hyponatremia * vasoconstriction (vasopressin only)

Question 128

nursing actions when giving ADH

Answer 128

* fluid retention * headache, confusion, other signs of water intoxication * monitor I/O * monitor serum Na levels * restrict fluid intake if needed * recommend diuretic therapy if mod-severe * monitor for s/sx of * MI * angina * cardiac insufficiency

Question 129

administering desmopressin

Answer 129

* oral, intranasal, SQ, or IV * intranasally * high into nasal cavity * not into throat * monitor * BP * I/O * urine and plasma osmolality * creatinine clearance

Question 130

administering IV vasopressin

Answer 130

* monitor IV site * extravasation → gangrene

Question 131

pt education for ADH

Answer 131

* report water intoxication Sx * pounding headache * sleepiness * fluid retention * weight gain * edema * record fluid I/O daily * limit fluid intake during therapy * report chest pain or pressure * expect lifelong therapy

Question 132

contraindications for vasopressin

Answer 132

* coronary artery disease * poor peripheral circulation * chronic nephritis

Question 133

contraindications and precautions for desmopressin

Answer 133

* contra * renal failure * nephrogenic diabetes insipidus * electrolyte imbalances (oral form) * precautions * older adults * CV disease * HTN * Hx of hyponatremia * Hx of thromboembolic events * severe heart failure

Question 134

interactions with vasopressin and desmopressin

Answer 134

* ↑ antidiuretic action * carbamazepine * chlorpropamide * ↓ antidiuretic action * other vasopressors * lithium

Question 135

drug classes to treat adrenal disorders

Answer 135

* glucocorticoids * mineralocorticoids * androgens

Question 136

glucocorticoids for adrenal disorders

Answer 136

* replacement therapy for acute and chronic adrenocortical insufficiency (Addison’s disease) * prototype: hydrocortisone * other: prednisone, dexamethasone

Question 137

mechanism of action for glucocorticoids in Tx of adrenal disorders

Answer 137

* synth of cortisol in adrenal gland stimulated by adrenocorticotropic hormone (ACTH) * pituitary gland stimulated to release ACTH in response to the release of corticotropin releasing hormone by the hypothalamus. * cortisol: primary glucocorticoid the body needs * makes glucose available * promotes breakdown of proteins and lipids → glucose * production increased during stress to support BP and BG

Question 138

side/adverse effects of glucocorticoid replacement therapy

Answer 138

* few effects at low, therapeutic levels * multiple effects at high levels to suppress inflammation and immune system * * hypercortisolism * hyperglycemia * fat redistribution * osteoporosis * hypocortisolism * fatigue * wt loss * hypoglycemia

Question 139

administering glucocorticoids for adrenal disorders

Answer 139

* labs (baseline and monitor) * CBC * electrolyte * glucose * glucocorticoid * oral for chronic insufficiency * total daily dose HS or * divided: 2/3 morning, 1/3 early afternoon * IV for acute situations * taper slowly and establish minimum therapeutic dose * supplemental doses PRN during stress

Question 140

pt education for glucocorticoids for Tx of adrenal disorders

Answer 140

* wear medical alert bracelet * carry emergency dose * report increased physical/emotional stress * ↑ dose needed to prevent hypocortisolism * expect lifelong therapy

Question 141

contraindications and precautions for glucocorticoids

Answer 141

* low doses: none * high doses: SE can complicate current or previous disorders (e.g. DM)

Question 142

interactions with glucocorticoids

Answer 142

* small doses: none * high doses: multiple

Question 143

mineralocorticoids

Answer 143

* replacement therapy for acute and chronic adrenocortical insufficiency * Addison’s disease * primary hypoaldosteronism * congenital adrenal hyperplasia * usually along with hydrocortisone * prototype (only): fludrocortisone

Question 144

mechanism of action of fludrocortisone

Answer 144

* replaces insufficient aldosterone * synthesis stimulated by the renin-angiotensin-aldosterone system (RAAS) * regulates sodium, potassium, and water levels in the body * promotes sodium and water reabsorption by the kidneys * promotes excretion of potassium by the kidneys * deficiency → dangerous fluid-electrolyte imbalances

Question 145

side effects of fludrocortisone

Answer 145

* low, therapeutic dose: few * inadequate dose * wt loss * poor appetite * fatigue * muscle weakness * hypotension * excess dose * wt gain * fluid retention * ↑ BP * hypokalemia * high dose: fluid and electrolyte imbalances → HTN, edema, heart failure, hypokalemia

Question 146

administering fludrocortisone

Answer 146

* orally daily or 3x/wk * get baseline and monitor CBC and electrolyte levels

Question 147

pt education for fludrocortisone

Answer 147

* medical alert bracelet * report Sx of ↑ Na * wt gain * swelling * report Sx of low potassium (life-threatening) * weakness * heart palpitations * have BP checked regularly

Question 148

contraindications and precautions for fludrocortisone

Answer 148

* contra * potassium-depleting diuretics * acute glomerulohephritis * hypercortisolism * viral or bacterial skin dz uncontrolled by abx * caution * heart failure * systemic fungal infection * thromboembolic disorder * DM * HTN * renal dysfunction

Question 149

interactions with fludrocortisone

Answer 149

* ↓ fludrocortisone levels: rifampin * ↓ anti-diabetes effects of insulin and sulfonylureas * ↑ risk of hypokalemia: potassium-depleting diuretics such as furosemide

Question 150

You are caring for a pt taking exenatide to treat Type 2 DM. Pt reports severe abd pain. You suspect what adverse reaction to this drug?

Answer 150

pancreatitis

Question 151

You are caring for a pt on acarbose and a sulfonylurea to treat Type 2 DM. Which of the following is an indication of an adverse reaction to this drug combination? * polyuria * tremors * bradycardia * thirst

Answer 151

tremors

Question 152

Name the therapeutic uses of each. 1. desmopressin 2. glucagon 3. glipizide 4. radioactive iodine-131

Answer 152

1. diabetes insipidus 2. hypoglycemia 3. Type 2 DM 4. thyroid cancer

Question 153

A pt is about to start taking sustained-release glipizide (Glucotrol) to treat Type 2 DM. Which of the following instructions should you include when talking with the patient about taking this drug? * chew tab completely before swallowing * take once a day, 30 min before selected meals * take in the evening before bed * drink 16 oz of water after taking

Answer 153

take once a day, 30 min before selected meals

Question 154

You are caring for a pt taking levothyroxine for hypothyroidism. The patient reports palpitations, wt loss, diarrhea. You suspect which adverse effect? * hyperthyroidism * Addison's dz * myxedema * hyperglycemia

Answer 154

hyperthyroidism

Question 155

A pt is about to start taking somatropin. You evaluate the effectiveness with which of the following assessments? * LOC * ECG * ht and wt * breath sounds and RR

Answer 155

ht and wt

Question 156

A patient is about to start taking hydrocortisone to treat adrenocortical insufficiency. You instruct the patient to do which of the following to help reduce her risk for adverse effects? (Select all that apply.) * expect lifelong therapy * carry extra doses * expect periodic blood tests * urinate every 4 hr * report increased stress

Answer 156

* expect lifelong therapy * carry extra doses * expect periodic blood tests * report increased stress

Question 157

Name therapeutic uses for each. 1. hydrocortisone 2. somatropin 3. propylthiouracil (PTU) 4. levothyroxine

Answer 157

1. Addison's dz 2. Turner's syndrome 3. thyrotoxic crisis 4. hypothyroidism

Question 158

When talking with a patient about self-administering regular insulin (Humulin R), you should include which of the following instructions? * shake vial vigorously * expect cloudy appearance * store unopened vials at room temp * inject insulin SQ

Answer 158

inject insulin SQ

Question 159

When talking with a 30-year-old woman who will receive radioactive iodine-131 (Iodotope) to treat Graves’ disease, you should include which of the following instructions? (Select all that apply.) * report wt gain, edema * use effective contraception * allow 2-3 mos for full effect * expect periodic labs * get regular eye exams

Answer 159

* report wt gain, edema * use effective contraception * allow 2-3 mos for full effect * expect periodic labs

Question 160

What Dx do you expect with the following Sx and lab results for a 19-year-old woman who hasn't eaten in \> 12 hr? * N&V * polyuria * nocturia * persistent thirst * BG: 185 mg/dL * glucose and ketones in urine

Answer 160

Type 1 DM

Question 161

The patient will self-inject 8 units of NPH insulin and 4 units of regular insulin each day before breakfast. As you show the patient how to self-administer insulin, you should include which of the following instructions? (Select all that apply.) * draw regular insulin first, then NPH * inject in large muscle * discard unused premix within 5 days * use 5-mL syrine when mixing * use one syringe to ↓ injections

Answer 161

* draw regular insulin first, then NPH * use one syringe to ↓ injections

Question 162

You instruct the patient to watch for and report which of the following indications of an adverse reaction to insulin? * palpitations * wt gain * low UOP * constipation

Answer 162

palpitations

Question 163

As you continue to talk with the patient about managing her diabetes with regular insulin (Humulin R), you should include which of the following instructions? (Select all that apply.) * Self-inject chilled insulin. * Carry a carbohydrate snack. * Rotate injection sites. * Wear a medical alert bracelet. * Expect to adjust the dosage during illness.

Answer 163

* Carry a carbohydrate snack. * Rotate injection sites. * Wear a medical alert bracelet. * Expect to adjust the dosage during illness.

Question 164

You give the patient 5 units of lispro insulin (Humalog) and 10 units of insulin glargine SQ at 1400. Based on your instructions, the patient should expect her blood glucose level to be the lowest at which of the following times? * 1430 * 1530 * 1630 * 1730

Answer 164

1430

Question 165

The next day, two hours after self-administering regular insulin SQ, the patient contacts you at the provider's office to report that she is sweating, shaky, and has a rapid pulse. Which of the following actions should you advise her to take? * Drink 4 oz of orange juice. * Check her blood glucose level. * Take an oral hypoglycemic. * Measure her urine output. * Self-administer a long-acting insulin.

Answer 165

* Drink 4 oz of orange juice. * Check her blood glucose level.