NR566 -Week 5 Study Guide week 7 NR568 NR222 quiz 1 WGU D351 HRM Foundations NR 222 Exam #1 Chamberlain Chamberlain NR-222 Final Latest updated exam questions with complete verified solutions

Regarding osteoporosis, what are the two SERM drugs?

-Tamoxifen

-Raloxifene

Tamoxifen is a good drug because it protects against osteoporosis, but what is it's downside?

-Higher risk for cancer

-Higher risk for blood clots

What is the the awesome benefit of Tamoxifen other than bone health?

-Promotes good blood lipid levels

What is one thing that makes Raloxifene better than Tamoxifen?

-Lower risk for cancer

What is the only drug approved for prevention and treatment of osteoporosis?

-Duavee (conjugated estrogens/bazedoxifene)

What drug prevents osteoporosis and vasomotor symptoms in postmenopausal women with a uterus?

-Duavee (conjugated estrogens/bazedoxifene)

What are the 3 main benefits of hormone therapy?

-suppression of vasomotor symptoms

-prevention of urogenital atrophy

-prevention of osteoporosis and related fractures

Does urogenital atrophy and osteoporosis prevention sustain after withdrawal of HT?

--No, benefits will decline after HT withdrawal

Although HT therapy is great for bone loss prevention, what will happen when HT is stopped?

-bone mass rapidly decreases by approximately 12% ---Therapy must be life long--

Examples of progestins

-Medroxyprogesterone acetate

-Norethindrone

A patient has undiagnosed vaginal bleeding, should she be prescribed HT?

-No, don't give HT with undiagnosed vaginal bleeding

Julie has some blood clotting issues in his body. He has active thrombophlebitis & thromboembolic disorders Should she use HT?

-No, better not use HT with blood and clotting issues.

Amy has active liver disease, would HT be okay?

No, better not use HT with active liver problems

Yolanda has active breast cancer. Should she receive HT?

No, those with active breast cancer should not receive HT!

The nurse practitioner is considering adding progestin plus estrogen to his patient's med regimen. The patient has HX of blood clotting disorders. What considerations must be dicussed?

-Increased risk for

--DVT

--Stroke

--MI

--PE

Susie just had her 65th birthday. She also has dementia and cardiovascular disease. Regarding combination of estrogen/progestin, what is she at higher risk for ?

-With these things, she's at a higher risk for dementia

Tina has a mild risk of breast cancer. Is it a good idea for her to have estrogen/progestin combo?

-No, this combo of progestin/estrogen increases risk for breast cancer

The new doctor wants to prescribe progestins for a prepubertal child, his attendee says what?

-He screams "NO", those are not for prepubertal children.

A patient asks her doctor if progestin is okay while breast feeding. What does he say?

-Progestins while breastfeeding may cause neonatal jaundice.

What are the guidelines for tapering a patient off HT?

-There are no firm guidelines!

What kind of symptoms may occur while tapering off HT?

-Tapering of HT may cause vasomotor symptoms.

For women on EPT, the progestin dosage should remain...

-unchanged because lowering the progestin dosage might permit estrogen to stimulate endometrial growth, thereby posing a risk for endometrial hyperplasia.

What are some names of intravaginal inserts?

-Imvexxy

-Vagifem

-Yuvafem

What are some names of intravaginal creams?

-Estrace vaginal

-Premarin Vaginal

What is the name of a vaginal ring used for local effects?

-Estring

--treatment of vulval and vaginal atrophy associated with menopause

What is the name of a vaginal ring used for systemic effects?

-Femring

--(control of hot flashes and night sweats) as well as local effects (e.g., treatment of vulval and vaginal atrophy)

What is the best treatment for genitourinary symptoms of menopause?

-Estrogen is the best treatment for these symptoms.

What are some symptoms of genitourinary symptoms of menopause?

-dryness

-irritation

-uncomfortable intercourse

Because systemic estrogen carries significant risks, the FDA recommends...

-If HT is being used solely to manage vulvar and vaginal symptoms, a topical estrogen formulation should be considered.

All intravaginal estrogens are used to treat what?

-urogenital atrophy

Imvexxy has specific indications for what?

-Dyspareunia

With one product—Femring—estradiol is absorbed in amounts...

sufficient to cause systemic effects, both beneficial

Every woman undergoing systemic HT receives a...

Estrogen!

Every women with a uterus receives a what?

-Progestin, to counteract the stimulant effects of estrogen in the endometrium

What are some need to knows regarding the continuous administration of progestin & estrogen?

An alternative is to give estrogen continuously but give the progestin cyclically (e.g., on calendar days 15 through 28). However, cyclic progestin has the disadvantage of promoting monthly bleeding, which may explain why most women prefer continuous dosing.

Estring remains in the vagina for how many months?

-For 3 months. It is then removed and replaced with a new ring.

Cindy wants to know whether topical or oral estrogen is safer. How does her doctor answer this?

-Although long-term data are lacking, it seems likely that topical estrogen is safer than oral estrogen because, with nearly all topical formulations, blood levels of estrogen remain low.

-The notable exception is the Femring, which releases enough estrogen to cause significant systemic effects.

Which form of estrogen therapy has fewer adverse effects?

-Transdermal estrogen therapy has fewer adverse effects.

Example of combo OC?

-Ethinyl estradiol/norethindrone

When changing one combination oral contraceptive for another, the change is best made at

the beginning of a new cycle. This doesn't mean it's the only time that can be done. It is just noted as the best time

Lilly wants to know the best time to initiate her OC treatment. What counsel does the doctor tell her?

-Right at the beginning of the cycle

-The patient begins taking the pills on the first day of menstrual bleeding.

-The patient begins taking the pills on the first Sunday after menstrual bleeding begins.

-The patient begins taking the pills immediately if she is definitely not pregnant and has not had unprotected sex since her last menstrual period.

What individuals need to be caution when on OCs?

-Those with HTN

-Those with heart disease

-Those with DM

When prescribing OCs, the doctor should assess what kind of patient history?

HTN, DM, CLOTS, BRAIN STROKE STUFF, HEART DZ, BREAST CX, PREGO TEST

A doctor tells the patient she can't have OC's. What are the contraindications for OCs?

-Pregnancy

-Blood clots

-Strokes

-Acute coronary syndrome

-Liver problems

-Breast cancer

-Unknown vaginal bleeding

-Smoking (35yrs >)

What are some relative contraindications for OCs"

-HTN, HEART, DM, CHOLESTATIC DZ OF PREG, GALLBL, UTERINE LEIOMYOMA, EPILEPSY, MIGRAINE

How to achieve an extended cycle with oral contraceptives

-To achieve an extended schedule, the user would simply purchase four packets of a 28-day product (each of which contains 21 active pills) and then take the active pills for 84 days straight.

What behaviors would make one birth control method more effective over another?

-able to evaluate a patient scenario and suggest an appropriate birth control

method (type of prescribed contraception: OC, long-term methods, IUD, etc.

If one takes oral contraceptives, they are INHIBITING CYP1A2--> Thus INCREASING drug levels of

-Amiptriptline, clomipramine, clozapine, despramine, duloxetine, fluvoxamine, haldol, imipramine, methadone, ramelteon, resagiline, roprinirole, tacrine, theophyline, tizanidine, warfarin

These drugs Inhibit metabolism of Ocs..thus increasing their effectiveness

-Amiodarone, Amprenavir, Aprepitant, Atazanavir, Azole antifungals

Chloramphenicol, Cimetidine, Clarithromycin, Cobicistat, Conivaptan, Cyclosporine

Darunavir/ritonavir, Delavirdine, Diltiazem, Dronedarone, erythromycin, Fluvoxamine, Fosamprenavir

Grapefruit juice, Indinavir, Isoniazid, Methylprednisolone, Nefazodone, Nelfinavir, Nicardipine, Nifedipine, Norfloxacin, Pazopanib, Prednisone, Protease inhibitors, Quinine, Quinupristin/dalfopristin, Ritonavir, Saquinavir. Telithromycin, Tipranavir/ritonavir, Verapamil

These drugs induce metabolism of Ocs..thus decreasing their effectiveness

-Amprenavir, aprepitant, bosentan, carbamezapine, dexamethazone, efavirenz, ethosuxmide, etravirine, garlic supplements, garlic supplements, nevirapine, oxcarbazepne, phenobarbitol, phenyroin, primidone, rifabutin, rifampin, rifapentine, ritonavir, St. Johns Wort.

A doctor tells his patient that there are two scary progestin-only drugs that have HIGH risk for blood clots. What are these?

-Drospirenone & Desogestrel

Too much progestin does what?

Increased appetite

Weight gain

Depression

Tiredness

Fatigue

Hypomenorrhea

Breast regression

Monilial vaginitis

Acne, oily scalpa

Hair lossa

Hirsutisma

Too little progestin does what?

Late breakthrough bleeding

Amenorrhea

Hypermenorrhea

Why should a diabetic be afraid of progestins?

Progestins can increase blood sugar

Progestin only "mini pills" do not cause blood clots, HAs, or NZA. Why?

-Because they lack estrogen

A patient wants to know if progestin-only "mini pills" are effective too? How should the doctor reply?

-They are not as productive, but they are considered more safe.

Progestin-only pills are more likely to cause what?

Irregular bleeding

Extremely effective contraceptive

-Estonogestral subdermal implant (Nexplanon)

-Surgical sterilization

-Tubal ligation

-Vasectomy

-Intrauterine devices

-Copper T 380A

-Levonogestrel T(Mirena)

Very effective contraceptive

-Oral contraceptive

-Combination pills

-Progestin-only pills

-Intramuscular medroxyprogesterone acetate

-Vaginal contraceptive

-Contraceptive patch

Effective

-Condoms

-Diaphram with spermicide

Least effective

-contraceptive sponge

-Parous

-Nulliparous

-Spermicide alone

-Periodic abstinence

-Withdrawal

Regarding testosterone replacement, oral androgens are indicated for what?

Hypogonadism

Regarding tesosterone replacement, transdermal patches are indicated for hypogonadism. How does administration work?

-One would give 2 or 4mgs over 24hrs. Applied to arm, thigh, or back.

Regarding testosterone replacement, gels have the following BLACKBOX warning of?

-Secondary exposure has caused virilization in kiddoz.

What are some names to testosterone replacement gels?

-Androgel

-Testim

-Fortesta

-Vogelxo

In regards to testosterone replacement, gels may be better compared to patches because?

Less local irritation, can't fall off, more consistent teste levels

In kiddos, those who accidentally get secondary exposure to testosterone gel may experience?

Large genitals, preme pubic hair, adv bone age, increased libido, agressiveness

testosterone gel users should do the following...

Wash hands, cover apl site, wash site prior to skin to skin, avoid women and kidz, if accidental contact victim should wash.

Testosterone topical application goes under the forearm. What should users do after application?

-They should avoid swimming or bathing for 2 hours post application

Billy bob took some nasal testosterone, he wants to know possible side effects. What should you tell him?

Sir, you may experience:

-runny nose

-nose bleeds

-or nasopharyngitis

John asks his NP for instructions on his testosterone nasal pump. How should his NP reply?

Prime pump, remove excess gel, blow nose prior, tip toward lateral nose, avoid blowing/sniffing 1hr post

Jack implants his testosterone pellets into his hip (because he's cool like that), what are the doses?

Dose is 150-450 every 3-6 months

What should a NP know before prescribing testosterone buccal tablets?

These are not effected by eating or drinking. Apply in the gum area above incisor tooth, and

Kissing could cause transfer..maybe

Does IM testosterone have varying blood levels?

Yep, sure does.

Patient teaching for topical testosterone:

To minimize the risk for accidental skin-to-skin transfer, advise users of testosterone gel or testosterone topical solution to (1) wash their hands after every application, (2) cover the application site with clothing after the gel has dried, and (3) wash the application site before anticipated contact with another person. Also, warn women and children to avoid contact with the user's skin where testosterone was applied and advise them to wash contaminated skin if accidental contact with an application site should occur.

Patient teachings for androgens

Tell female patients about signs of virilization (deepening of the voice, acne, changes in body and facial hair, menstrual irregularities). Instruct them to report these if they occur.

Apprise patients of the signs of liver dysfunction (yellow tint to skin and eyes, fatigue, loss of appetite, nausea, dark-colored urine, light-colored stools). Advise them to report the occurrence of these changes.

Inform patients that swelling of the extremities or unusual weight gain may be evidence of salt and water retention. Counsel them to report these events.

Remind patients of child-bearing age that this drug can cause fetal malformations. If the patient is capable of becoming pregnant, emphasize the need for consistent use of reliable contraception.

When is it appropriate to prescribe and initiate androgen therapy for delayed puberty?

In some, puberty fails at the usual age (i.e., before age 15 years). Often, failure reflects familial pattern of delayed puberty and does not indicate pathology. Puberty can be expected to occur spontaneously but later than usual. Hence treatment aint absolute necessity.

Why might a NP prescribe androgen therapy off label?

the psychologic pressures of delayed sexual maturation are causing a boy significant distress. In these cases, a limited course of androgen therapy is indicated. Both fluoxymesterone (Androxy, Halotestin) and methyltestosterone (Methitest) are approved for this purpose.

If delayed puberty is the result of true hypogonadism...

long-term replacement therapy is indicated (see later section titled Androgen Preparations for Male Hypogonadism).

Androgen replacement therapy is indicated for when testicle failure occurs. What are the benefits?

Restores libido

Increases ejaculatory volume

Secondary sex characteristics

WILL NOT RESTORE FERTILITY

Two main drugs for androgen replacement therapy are...

testosterone enanthate and

testosterone cypionate

Regarding androgen therapy, two drugs are approved for delayed puberty. What are they?

fluoxymesterone (Androxy, Halotestin) and

methyltestosterone (Methitest)

Testosterone therapy in menopausal women (NOT IN THE U.S/BUT IS APPROVEDIN U.K) Helps to alleviate...

Fatigue

Reduce libido

Reduced genital sensitivity

In women, testosterone therapy should mimic premenopause testosterone at what strength?

300ug/day

Regarding andreogen therapy &

Cachexia (wasting of the body/failure to thrive)

Oxandrolone (Oxandrin) is...

FDA-approved for this purpose. Oxandrolone is an anabolic steroid that is a synthetic derivative of testosterone.

OXANDROLONE has BLACKBOX WARNING OF...

Oxandrolone can cause peliosis hepatitis, a condition in which blood-filled cysts form in the liver, leading to liver failure or intra-abdominal hemorrhage. It can also contribute to the development of highly vascular liver tumors.

An increased risk for atherosclerosis can occur secondary to marked elevations in low-density lipoprotein (LDL) and decreases in high-density lipoprotein (HDL).

Regarding androgen therapy, this therapy can help with anemia. What types of anemia does this therapy help?

Aplastic anemia, renal failure, fanconi anemia, cancer assocaited

Androgen therapy helps with anemia by doing what?

Promote synth of erythropoetin

With the emergence of other therapies such as erythropoietin-stimulating agents, however, androgens have fallen out of favor for off-label treatment of anemia.

Drug therapy for transgender men

although not approved by the FDA for this purpose, testosterone is prescribed off label as part of gender-affirmation drug therapy.

In Women, Girls, and Boys, Virilization is the most common complication of androgen therapy. When taken in high doses by women, androgens can cause....

acne, deepening of the voice, proliferation of facial and body hair, male-pattern baldness, increased libido, clitoral enlargement, and menstrual irregularities. Clitoral growth, hair loss, and lowering of the voice may be irreversible. Masculinization can also occur if taken by children (e.g., for sports performance enhancement). Boys may experience growth of pubic hair, penile enlargement, increased frequency of erections, and even priapism (persistent erection). In girls, growth of pubic hair and clitoral enlargement may occur

To prevent irreversible masculinization, androgens must be discontinued when...

virilizing effects first appear.

When given to children, androgens can accelerate

epiphyseal closure, thereby decreasing adult height. To evaluate androgen effects on the epiphyses, radiographic examination of the hand and wrist should be performed every 6 months.

Androgens can cause cholestatic hepatitis and other disorders of the liver. Clinical jaundice may occur but is rare. Patients receiving androgens should undergo

periodic tests of liver function. If jaundice develops, it will reverse after discontinuation of androgen use.

Androgens may also be carcinogenic. Expound further.

hepatocellular carcinoma has developed in some patients after prolonged use of these drugs.

It must be emphasized that not all androgens are hepatotoxic: liver damage is associated primarily with the

17-α-alkylated androgens. These androgens all share a structural feature in common: an alkyl group substituted on carbon 17 of the steroid nucleus. Because of their capacity to cause liver damage, the 17-α-alkylated compounds should not be used long term. In contrast to the 17-α-alkylated androgens, testosterone and the testosterone esters (testosterone cypionate, testosterone enanthate) are not associated with liver disease.

Androgens can lower plasma levels of

HDL cholesterol and elevate plasma levels of LDL cholesterol. These actions may increase the risk for atherosclerosis and related cardiovascular events.

Androgens do not cause prostate cancer, but.......

they can promote the growth of this cancer after it occurs. Accordingly, androgens are contraindicated for men with diagnosed prostate cancer. Men without diagnosed prostate cancer should be monitored for the emergence of covert cancer.

Edema can result from androgen-induced retention of salt and water. This complication is a concern for patients with

heart failure and those with a predisposition to developing edema from other causes. Treatment consists of discontinuing the androgen and giving a diuretic if needed.

androgens are frequently misused to enhance athletic performance. Because of their abuse potential, nearly all androgens are regulated as

schedule III controlled substances.

Testosterone has postmarking reports of...

thromboembolic events including stroke, myocardial infarction, deep venous thrombosis, and pulmonary embolism. These events are believed to have been the result of testosterone's erythropoietic effects. To address this potentially life-threatening concern, the FDA has issued a Testosterone Product Safety Alert requiring labeling changes in 2018.