Pharm Chapter 9-11: Questions

Prazosin (Minipress) 1. Reason For Concern 2. Alternative Treatments

(Prazosin can cause orthostatic hypotension and falls in older adults.) alpha blocker High risk of orthostatic hypotension and falls; less dangerous drugs are available Risk of bradycardia, orthostatic hypotension, adverse CNS effects, depression, sedation Thiazide diuretic, ACE inhibitor, beta-adrenergic blocker, calcium channel blocker

Lipid-soluble drugs cross the

Placenta Redily

All drugs cross the ______________to some extent

Placneta

Although most drugs can be detected in breast milk, concentrations are usually

Too low to harm the nursing infant.

T/F If possible, drugs should be avoided during breast-feeding.

True

T/F 10. ___Angiotensin-converting enzyme inhibitor drugs for hypertension are prohibited during the second and third trimesters of pregnancy.

True

T/F 2. ___For drug purposes, infancy is defined as from the end of 4 weeks to 1 year of age.

True

T/F 2. ___There is a wider individual variation in drug response in the older adult.

True

T/F 3. ___The health of the fetus depends on the health of the pregnant patient.

True

T/F 3. ___The majority of drugs used in pediatrics have never been tested on children.

True

T/F 5. ___Absorption of many drugs slows with aging.

True

T/F 5. ___The goal of the Medication Exposure in Pregnancy Risk Evaluation Program is to identify drugs that have adverse effects on birth outcomes.

True

T/F 5. ___Toddlers often need higher doses per body weight than preschool children.

True

T/F 6. ___Changes in body fat and lean body mass that occur with aging can cause lipid-soluble drugs to have a decrease in effect and water-soluble drugs to have a more intense effect.

True

T/F 7. ___Glomerular filtration increases during pregnancy.

True

T/F 8. ___All drugs can cross the placenta to some extent.

True

T/F 8. ___Drug accumulation secondary to decreased renal excretion is the most common cause of adverse reactions in older adults.

True

T/F 9. ___A reduction in the number of receptors and/or decreased affinity for receptors in the older adult may decrease the response to drugs that work by receptor interactions.

True

T/F 1. ___Drugs are not a common cause of birth defects.

True

13. The safe dose of a liquid drug for a 6-month-old is 0.75 mL. Which would be best used to accurately administer the drug? a. 1-mL syringe without the needle b. 3-mL syringe without the needle c. 5-mL syringe without the needle d. Calibrated plastic medicine cup

a. 1-mL syringe without the needle

11. Which drugs are recommended by the American Academy of Pediatrics (AAP) as safe and effective for relieving cold symptoms in a 4-year-old child? (Select all that apply.) a. Acetaminophen b. Dextromethorphan c. Ibuprofen d. Ibuprofen and pseudoephedrine e. Phenylephrine

a. Acetaminophen c. Ibuprofen

23. Which instruction should be included in patient teaching regarding breast-feeding and drug therapy? a. Avoid taking any drugs. b. Avoid drugs that have a long half-life. c. The best time to take a needed drug to minimize transfer to the infant is just after breast-feeding. d. Use sustained-release formulas of drugs.

c. The best time to take a needed drug to minimize transfer to the infant is just after breast-feeding.

Chapter 9 Key Points

■ Because hepatic metabolism and glomerular filtration increase during pregnancy, dosages of some drugs may need to be increased. ■ Lipid-soluble drugs cross the placenta readily, whereas drugs that are ionized, polar, or protein bound cross with difficulty. Nonetheless, all drugs cross to some extent. ■ When prescribing drugs during pregnancy, the clinician must try to balance the benefits of treatment versus the risks—often without knowing what the risks really are. ■ About 3% of all babies are born with gross structural malformations without teratogenic drug exposure. ■ Less than 1% of birth defects are caused by drugs. ■ Teratogen-induced gross malformations result from exposure early in pregnancy (weeks 3 through 8 of gestation), the time of organogenesis. ■ Functional impairments (e.g., intellectual disabilities) result from exposure to teratogens later in pregnancy. ■ For most drugs, we lack reliable data on the risks of use during pregnancy. ■ Lack of teratogenicity in animals is not proof of safety in humans. ■ Some drugs (e.g., thalidomide) cause birth defects with just one dose, whereas others (e.g., alcohol) require prolonged exposure. ■ FDA Pregnancy Risk Categories indicate relative risks of drug use. Drugs in Category X pose the highest risk of fetal harm and are contraindicated during pregnancy. ■ Any female patient of reproductive age who is taking a known teratogen must be counseled about the teratogenic risk and the necessity of using at least one reliable form of birth control. ■ Drugs that are lipid soluble readily enter breast milk, whereas drugs that are ionized, polar, or protein bound tend to be excluded. Nonetheless, all drugs enter to some extent. ■ Although most drugs can be detected in breast milk, concentrations are usually too low to harm the nursing infant. ■ If possible, drugs should be avoided during breast-feeding. ■ If drugs cannot be avoided during breast-feeding, common sense dictates choosing drugs known to be safe and avoiding drugs known to be dangerous.

Chapter 10 Key Points

■ The majority of drugs used in pediatrics have never been tested in children. As a result, we often lack reliable information on which to base drug selection or dosage. ■ Because of organ system immaturity, very young patients are highly sensitive to drugs. ■ In neonates and young infants, drug responses may be unusually intense and prolonged. ■ The absorption of IM drugs in neonates is slower than in adults. In contrast, the absorption of IM drugs in infants is more rapid than in adults. ■ Protein-binding capacity is limited early in life, so free concentrations of some drugs may be especially high. ■ The blood-brain barrier is not fully developed at birth. Therefore, neonates are especially sensitive to drugs that affect the CNS. ■ The drug-metabolizing capacity of neonates is low, so neonates are especially sensitive to drugs that are eliminated primarily by hepatic metabolism. ■ Renal excretion of drugs is low in neonates. Thus, drugs that are eliminated primarily by the kidney must be given in reduced dosage and/or at longer dosing intervals. ■ In children 1 year of age and older, most pharmacokinetic parameters are similar to those in adults. Hence, drug sensitivity is more like that of adults than the very young. ■ Children (1 to 12 years) differ pharmacokinetically from adults in that children metabolize drugs faster. ■ Initial pediatric doses are at best an approximation. To ensure optimal dosing, subsequent doses must be adjusted on the basis of clinical outcome and plasma drug levels.

Chapter 11 Key Points

▪ Older patients are generally more sensitive to drugs than are younger adults, and they show wider individual variation. ▪ Individualization of therapy for older adults is essential. Each patient must be monitored for desired and adverse responses, and the regimen must be adjusted accordingly. ▪ Aging-related organ decline can change drug --- - absorption - distribution - metabolism, and (especially) - excretion. ▪ The rate of drug absorption may be slowed in older adults, although the extent of absorption is usually unchanged. ▪ Plasma concentrations of lipid-soluble drugs may be low in older adults, and concentrations of water-soluble drugs may be high. ▪ Reduced liver function may prolong drug effects. ▪ Reduced renal function, with resultant drug accumulation, is the most important cause of adverse drug reactions in older adults. ▪ Because the degree of renal impairment among older adults varies, creatinine clearance (a measure of renal function) should be determined for all patients taking drugs that are eliminated primarily by the kidneys. ▪ Adverse drug reactions are much more common in older adults than in younger adults. ▪ Factors underlying the increase in adverse reactions include - polypharmacy - severe illness - comorbidities - treatment with dangerous drugs. ▪ Tools such as the Beers list or START and STOPP criteria can be used to identify potentially inappropriate drug choices for elderly patients. ▪ Nonadherence is common among older adults. ▪ Reasons for unintentional nonadherence include - - complex regimens - awkward drug packaging - forgetfulness, - side effects - low income - failure to comprehend instructions. ▪ Most cases (75%) of nonadherence among older adults are intentional. Reasons include - expense - side effects - the patient's conviction that the drug is unnecessary or the dosage too high. ▪ Priority treatment varies as goals shift from disease prevention and management to provision of comfort measures.

T/F 6. ___Hepatic metabolism decreases during pregnancy.

False

T/F 7. ___Liver enzyme activity often is increased in the older adult.

False

T/F 9. ___Drugs are most likely to pass into fetal circulation if they are water-soluble.

False

T/F drugs that are ionized, polar, or protein bound cross placenta easily

False They cross with difficulty

About 3% of all babies are born with____________ ______________ _____________ without teratogenic drug exposure.

Gross structural malformations

FDA Pregnancy Risk Categories indicate relative risks of drug use. Drugs in Category X pose the

Highest risk of fetal harm and are contraindicated during pregnancy.

Tolterodine (Detrol) can cause

Incontinence A Drugs for Urge Incontinence: CYP3A4

Because hepatic metabolism and glomerular filtration increase during pregnancy, dosages of some drugs may need to be

Increased

Drugs cause less than ___% of birth defects

1%

A patient with a history of heroin addiction has delivered a full-term infant. 1. What should be included in the nursing care to address possible drug withdrawal in the neonate? 2. Exposure to teratogens during the embryonic period can produce gross malformation in the fetus. What nursing actions can help decrease teratogenesis during this period?

1. Monitor vital signs; assess for seizure activity; protect from injury; decrease stimulation, light, and noise. 2. All drugs have the potential to reach the developing fetus. Teratogenic drugs do not always produce the same effect. Teratogenic effects may be delayed. Behavioral effects are difficult to document. Nurses are crucial in promoting preconception health. Nurses can help women in childbearing years to understand teratogens and strategies to avoid them. Nurses also need to improve history-taking to improve their ability to discern teratogen exposure in women who are pregnant or intend to become pregnant.

14. The prescriber has prescribed 225 mg of a drug twice a day for a 7-year-old child who is 43 inches tall and weighs 45 lb. The recommended adult dose of this drug is 500 mg twice a day. Based on body surface area, is this dose safe?

14. 227 mg is calculated safe dose. Yes, 225 mg is safe.

15. The drug is available in an elixir of 250 mg/5 mL. How much medication will the nurse administer?

15. 4.5 mL

Teratogen-induced gross malformations result from

Early exposure in pregnancy during the organogenesis Stage (weeks 3 through 8 of gestation), .

T/F 1. ___All drugs that are considered safe to administer to adults are safe for administration to pediatric patients if the dose is adjusted appropriately for size.

False

T/F 1. ___The goal of therapy for older adult is to cure the disease.

False

T/F 2. ___The health of the fetus supersedes the health of the mother when drugs are prescribed to pregnant patients.

False

Match the drug with its potential teratogenic effect(s). 11. ___Alcohol 12. ___Ibuprofen 13. ___Isotretinoin 14. ___Lisinopril 15. ___Methotrexate 16. ___Phenytoin 17. ___Tetracycline 18. ___Valproic acid a. CNS, craniofacial, and cardiovascular defects b. CNS and limb malformations c. Growth delay and CNS defects d. Low birth weight and intellectual disabilities e. Neural tube defects and hypospadias f. Premature closure of the ductus arteriosus g. Renal failure and skull hypoplasia h. Tooth and bone anomalies

Alcohol Low birth weight and intellectual disabilities Ibuprofen Premature closure of the ductus arteriosus Isotretinoin CNS, craniofacial, and cardiovascular defects Lisinopril Renal failure and skull hypoplasia Methotrexate CNS and limb malformations Phenytoin Growth delay and CNS defects Tetracycline Tooth and bone anomalies Valproic acid Neural tube defects and hypospadias - Valproic acid is highly teratogenic, especially when taken during the first trimester. The risk of a major congenital malformation is 4 times higher than with other AEDs. Neural tube defects (e.g., spina bifida) are the greatest concern. The risk is 1 in 20 among women taking valproic acid versus 1 in 1000 among women in the general population

When prescribing drugs during pregnancy, the clinician must try to balance the

Benefits of treatment versus the risks Often without knowing what the risks really are

Any female patient of reproductive age who is taking a known teratogen must be counseled about the teratogenic risk and the necessity of using at least one reliable form of

Birth Control

Drugs that are lipid soluble readily enter ________ __________, whereas drugs that are ionized, polar, or protein bound tend to be excluded. Nonetheless, all drugs enter to some extent.

Breast Milk

T/F 3. ___Older adults are less sensitive to drugs.

False

T/F 4. ___Intramuscular absorption of drugs is slower in the infant than in the adult.

False

T/F 4. ___Older adults absorb less of the dose of medication than young adults.

False

T/F 4. ___Pregnant women should not take any drugs.

False

T/F 6. ___Approximating safe doses of drugs for children is most accurate when calculated based on weight.

False

8. An infant is diagnosed with scurvy caused by vitamin C deficiency. Based on the principles of pH-dependent ionization and ion trapping and the differences in gastrointestinal physiology in the infant, the nurse would expect that the prescribed dose of vitamin C (ascorbic acid) adjusted for weight would be what? a. Less than an adult dose b. Equal to an adult dose c. More than an adult dose d. None; vitamin C should not be given to infants.

a. Less than an adult dose

20. A patient with a history of heroin addiction has delivered a full-term infant. Which signs and symptoms suggest the infant is experiencing withdrawal symptoms? a. Shrill cry and irritability b. Respiratory depression and lethargy c. Peripheral cyanosis and hypotension d. Apgar score of 3 at 1 minute and 4 at 5 minutes

a. Shrill cry and irritability

10. The nurse is preparing to administer 4.5 mL of medication to a shy 6-year-old child. Which nursing intervention is most likely to gain cooperation from the child with taking the drug? a. Use a syringe to accurately measure the medication and ask the parents if they have any special technique for administering medication that has been effective with this child. b. Mix the medication in a 6-ounce glass of juice to mask the taste. c. Place the medication in a large empty glass so that the child can see that there is only a small amount of medication. d. Use a syringe to accurately measure the medication and squirt the medication into the child's mouth.

a. Use a syringe to accurately measure the medication and ask the parents if they have any special technique for administering medication that has been effective with this child.

11. An older adult with liver disease is receiving several drugs that are normally highly protein bound. The patient's serum albumin is 2.8 mg/dL (normal 3.5 to 5 mg/dL). Drug effects in this patient may be a. increased. b. decreased. c. unchanged. d. unknown.

a. increased.

∗13. Which assessment is a priority before administering prazosin to a geriatric patient? a. Alertness and orientation b. Blood pressure (BP) and pulse c. Bowel and bladder elimination d. Intake and output

b. Blood pressure (BP) and pulse

15. The nurse is aware that an older adult patient is at risk for which problem when prescribed tolterodine? a. Diarrhea b. Disturbed cognition c. Fluid volume deficit d. Impaired skin integrity

b. Disturbed cognition

12. Which is the recommendation by the Centers for Disease Control and Prevention (CDC) for over-the-counter (OTC) cough and cold drug use in children younger than 2 years? a. Do not give any OTC drugs to a child younger than 2 years. b. Do not give any OTC cough and cold preparations to a child younger than 2 years. c. OTC cough and cold drugs are safe and effective if the preparation is specifically made for children and is properly measured. d. Use accurate measuring devices specifically designed for pediatric use when administering OTC cough and cold drugs to children younger than 2 years.

b. Do not give any OTC cough and cold preparations to a child younger than 2 years.

7. Premature infants are at risk for what kind of response to drugs? a. Inadequate and short-lived response b. Intense and prolonged response c. Inadequate but prolonged response d. Intense but short-lived response

b. Intense and prolonged response

∗9. A pregnant patient received morphine sulfate late in labor. The neonate was born 22 minutes later. Because the drug crosses the placenta, and the characteristics of the blood-brain barrier of the neonate, which neonatal assessment finding would be of most concern to the nurse? a. Abdominal breathing b. Pulse 160 beats/min c. Respirations 22/min d. Temperature 98.1°F (36.7°C)

c. Respirations 22/min (Normal respiratory rate for a newborn is 30-60 respirations per minute; a respiratory rate of 22/min is depressed.)

21. A pregnant patient with a history of controlled hypertension asks the nurse why the prescriber changed her high blood pressure medication from quinapril to methyldopa. The nurse's response should be based on what knowledge? a. Methyldopa is more effective for treating hypertension during pregnancy. b. There is no known risk of fetal harm with use of methyldopa during pregnancy. c. The dose of quinapril is more potent than the dose of methyldopa. d. Quinapril crosses the placenta, but methyldopa does not.

b. There is no known risk of fetal harm with use of methyldopa during pregnancy.

∗10. When evaluating kidney function in the older debilitated adult, it is a priority for the nurse to review the results if which test? a. Serum blood urea nitrogen (BUN) b. Serum creatinine c. Creatinine clearance d. Renal ultrasound

c. Creatinine clearance (Creatinine clearance is a more precise test used to help detect and diagnose kidney dysfunction.) In older adults, the proper index of renal function is creatinine clearance, not serum creatinine levels. Creatinine levels do not adequately reflect kidney function in older adults because the source of serum creatinine—lean muscle mass—declines in parallel with the decline in kidney function. As a result, creatinine levels may be normal even though renal function is greatly reduced.

∗14. The nurse is aware that anticholinergic adverse effects of drugs commonly cause more problems in older adults than in younger adults. Which anticholinergic effect would be a priority to report to the prescriber? a. Blurred vision b. Dry mouth c. Has not voided in 16 hours d. No bowel movement for 48 hours

c. Has not voided in 16 hours (Is an indicator of severe urinary retention requiring catheterization.)

22. What is an important role of the nurse when a pregnant patient has a known exposure to a known teratogen during week 4 of the pregnancy? a. Ordering an ultrasound b. Providing the diagnosis from the ultrasound to the parents c. Providing information and emotional support d. Recommending termination of pregnancy if a severe malformation is detected

c. Providing information and emotional support

►12. The nurse is preparing to administer ketorolac to a debilitated 83-year-old woman who has joint pain. Which symptom would warrant withholding the drug and contacting the prescriber? a. Constipation b. Difficulty waking up in the morning c. Dizziness when changing from a prone to upright position d. Tarry stools

d. Tarry stools (Increased risk of GI bleeding with long-term use in the geriatric patient)