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PMHNP Psychopharm Exam 2 2024
Once you graduate from an NP program, in order to prescribe you'll need: - - Advanced nurse prescriber license
- DEA # What is the purpose of a DEA #? - Needed to prescribed scheduled drugs Rules for prescribing Schedule II drugs: - - Written script needed
- 1 month supply only
- No refills What is the PDMP? - Prescription Drug Monitoring Program Used to effectively track patient's controlled substance uses across different health facilities (in the same state) What are clinical practice guidelines? - Recommendations that are intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits/harms of alternative care practices Ex: sepsis, CAP Common causes of medication errors: - - Illegible writing
- Drug names that sound alike
- Medications that look alike
- Administering a drug with the wrong route What is pharmacokinetics? What are its 4 categories? - What the body does to the drug
- Absorption
- Metabolism
- Distribution
- Excretion Quickest route of absorption? Slowest? - IV = quickest IM = slowest What is the most common way drugs pass through cell membranes? - Passive diffusion What characteristics of a drug allow it to pass most quickly through cell membranes (usually through passive diffusion)? - Small, uncharged (unionized), lipid soluble--pass through membrane without any energy What does it mean when a drug is ionized? - It means that the drug is stuck in the compartment it was ionized in and has to be moved to the next compartment (cannot be absorbed into the bloodstream) Where do weak acids absorb? - Stomach
Where do weak bases absorb? - Small intestine pH of stomach: - 2 - 4 pH of small intestine: - 6 - 7 pH of large intestine: - 6 - 7 pH of bloodstream: - 7.35-7. pH of bladder: - 5 - 8 pH of breastmilk: - 7. Where will a drug absorb if it is a weak base that ionizes at a pH of 4 and lower? - In the small intestine (since the stomach has a pH of 2-4, so the drug will become ionized and move to the small intestine where it will be able to absorb into the bloodstream) How can we manipulate the urine pH in cases of overdose? - Drugs that are weak acids (aspirin) can be trapped and excreted through the urine. We raise pH of the urine (with sodium bicarb) to force the drug to ionize and allow it to be excreted, not reabsorbed through the bloodstream. What is distribution? - How a drug will be transported to the tissues it needs to go to in order for it to exert its effects Drug factors related to distribution: - - Lipid solubility
- Molecular size
- Degree of ionization
- Duration of action
- Cellular binding
- Therapeutic effects
- Toxic effects (lipid soluble, small, and non-ionized drugs will distribute more quickly) Body factors related to distribution: - - Vascularity (poor perfusion, disruption of blood flow due to trauma--difficulty distributing)
- Blood barriers (blood-brain-barrier can be problematic if we need to get drugs to the brain-- will need very high dosing since only a small amount of the drug will get through)
- Transport mechanisms
- Plasma binding proteins
- Disease states
- Volume of distribution
- Drug interactions What is the key plasma protein involved with protein binding for medications? - Albumin
What is a drug's half-life? - The time it takes for the concentration of a drug in the body to be reduced by 50% How many half-lives does it take to remove most of the drug from the body? - Appx 4 Why is knowing half-life important? - When switching to another drug that cannot be given with the previous drug. How to determine when drug will be cleared from body: - Multiply half-life of drug by 4 Ex: Half-life of drug A = 8 hours 8 x 4 = 32 hours (how long you'd need to wait before starting the contraindicated new drug B) What is therapeutic index? - Statement of the relative safety of a drug Which is safer: a wide TI or a narrow TI? - A wide TI is safer (more dosing options before reaching toxic effects) What is the minimum effective concentration? - The minimum amount of drug required to produce a therapeutic effect What is receptor desensitization? - Decreased responsiveness of the receptor to the drug; decreased overall effects How does antibiotic resistance occur? - The bacteria find a way to become resistant to the antibiotic. They multiply leading to an ineffective antibiotic How to prevent antibiotic resistance: - - Don't prescribe for viral infections
- Only prescribe when needed
- Use the right dose and duration (use guidelines)
- Utilize cultures
- Reassess treatment regime after cultures come back (don't just use broad spectrum drugs)
- Only use prophylactic antibiotics when completely necessary Skin infections are usually caused by gram positive or gram negative organisms? - Gram positive (staph, strep, candida) GI/GU infections are usually caused by gram positive or gram negative organisms? - Gram negative (E. coli, Klebsiella, Proteus) What kind of drug is vancomycin? - Glycopeptide antibiotic Why is it important to monitor vancomycin levels? - It has a narrow TI. Dose has to be adjusted according to amount of vanco in the blood serum (draw a vanco trough 1 hour before the next dose is due) What is antibiotic synergy? - When 2 antibiotics are combined in one combination drug to improve efficacy
Ex: Bactrim, Augmentin, Zosyn What are the components of bactrim? - Sulfamethoxazole: Disrupts production of dihydrofolic acid Trimethoprim: Disrupts production of tetrahydrafolic acid Together these drugs target different steps in the folic acid pathway that kills susceptible bacteria better than either drug would alone How does Augmentin work? - Irreversibly binds to bacterial beta lactamases which protects the penicillin drugs from destruction. The clavulanic acid protects the penicillin from being broken down by the bacteria (combats bacterial resistance). How do superinfections develop? - - Broad spectrum antibiotics
- Several antibiotics over a short period of time Major side effect of aminoglycosides (like Gentamicin): - Oto and nephrotoxicity Major side effect of Tetracyclines: - Photosensitivity and teeth stains in kids Major side effect of Vancomycin: - Red-man syndrome (if given too quickly) Major side effect of Bactrim: - Kidney stones if patients don't hydrate well Major side effect of Penicillins/Cephalosporins: - Allergies Which antibiotics are not safe for children (age less than 12)? - - Tetracycline (bones and teeth)
- Fluoroquinolones (tendon rupture) What is important to keep in mind when treating URIs in young infants? - Young infants are not fully vaccinated yet, so antibiotic treatment of URIs may be necessary How do antivirals work? - Interfere with the virus' replication within the host cell Which type of medication prescribed to a pregnant patient is more likely to have effects on the fetus? A. Drugs that are highly polar B. Ionized drugs C. Lipid-soluble drugs D. Protein-bound drugs - C
- Lipid-soluble drugs cross the placenta more easily
- Drugs that are highly polar, ionized, or are protein-bound will have more difficulty crossing A 5-year old child presents to your primary care clinic and has gray teeth. When taking a medication history, you will ask about previous use of which group of antibiotics?
You determine that a patient requires a prescription for a narrow-spectrum antibiotic to treat a gram positive cocci-related infection. What treatment options would you consider? (Select all that apply) A. Erythromycin B. Penicillin G C. Tetracycline D. Vancomycin E. Amoxicillin - A, B, D
- Erythromycin, penicillin G & vancomycin are all considered narrow-spectrum drugs and are great for treating gram positive cocci infections
- Tetracycline & amoxicillin are considered broad-spectrum drugs You have ordered intramuscular (IM) injections of morphine, a narcotic, every 4 hours PRN to treat pain in a patient who was in a motor vehicle accident. Under what category would morphine be classified? A. Schedule I B. Schedule II C. Schedule III D. Schedule IV - B Narcotics have a high potential for abuse and are classified as Schedule 2 drugs We never prescribe Schedule 1 drugs Schedules 3 and 4 have a lower abuse potential Drugs do not metabolize the same way in all people. For what patient would you expect to see an alteration in drug metabolism for drugs you prescribe? A. A 35 year-old woman with cervical cancer B.A 41 year-old man with kidney stones C. A 62 year-old woman in acute renal failure D. A 50 year-old man with cirrhosis of the liver - D
- The liver is the most important site for drug metabolism
- If it isn't functioning effectively, drugs won't metabolize normally & toxic drug levels will develop without dose reductions Which side effect of clindamycin causes the provider the most concern and may warrant discontinuation of the drug? A. Diarrhea B. Vomiting C. Nausea D. HA - A
- C. Difficile-associated diarrhea (CDAD) is a serious and sometimes life-threatening superinfection associated with clindamycin use
- Typically the drug is discontinued immediately, cultures are drawn, and the C. Diff is treated if confirmed A patient presents to the ER with a serum drug level of 50 g/mL. The half-life of this drug is 1 hour. With this drug, concentrations above 25 g/mL are considered toxic. How long will it take for the blood level to reach the non-toxic range? A. 30 minutes B. 1 hour C. 2 hours D. 3 hours - B
- Half-life is the time required for the serum concentration of a drug to reduce by 50%
- After 1 hour, the serum concentration would be 25 g/mL (which is no longer toxic) You are treating a patient who has been receiving an IM drug, but will transition to the PO route upon discharge. What is responsible for the increased dosage prescribed for the PO dose of this drug? A. Passive diffusion B. Glomerular filtration C. Active transport D. 1st pass effect - D
- The 1st pass effect involves drugs that are absorbed from the GI tract directly into the portal venous system, which delivers the drug to the liver for biotransformation
- A large percentage of the PO dose is usually destroyed & never reaches the systemic circulation or the tissues
- This is why higher doses are needed for PO forms of a drug vs. IV or IM You are caring for a patient who is being treated with gentamicin and fluconazole. If these 2 drugs are competing with each other for protein-binding sites, what would be the result? A. Altered efficacy of both drugs B. Counteract any positive benefit the drugs would have C. There will be no problems giving these drugs together D. Puts the patient at risk for an allergic reaction - A When 2 drugs compete with each other for protein-binding sites on albumin, this alters the effectiveness of both drugs (and can also cause toxicity of both drugs) due to inconsistent binding and free drug concentrations in the plasma A cancer patient is receiving morphine to treat their cancer-related pain. Approximately every 7 days, the medication is no longer effective in controlling her pain and a larger dose is needed to achieve the same effect. What is happening? A. Cumulation effect B. Drug interactions C. Drug tolerance D. Addiction - C
- Usually we follow BUN/creatinine labs and urine output as clinical indicators of worsening kidney function You have recently graduated from an NP program and are exploring licensure in a variety of states. Prescribing authority is ... A. determined by state law B. the same for PAs and APRNs C. the same in all states D. regulated by the federal government - A
- Individual states determine prescribing authority regulations, so you'll need to check these in the state you want to practice in
- The federal government isn't involved in this and there are definitely differences between PA and APRN prescriptive authority laws A patient is taking 2 PO drugs, A and B. Drug A absorbs well in the small intestine, but is poorly absorbed in the stomach. Drug B absorbs well in the stomach, but is poorly absorbed in the intestines. What is likely true? A. Drug A is probably a weak acid and drug B is probably a weak base B. Drug A is probably a weak base and drug B is probably a weak acid C. Drug A is a weak base, but becomes an acid when in the stomach D. Drug B is a weak acid, but becomes a base when in the intestines - B Always remember that weak acids absorb well in the stomach & weak bases absorb well in the intestines (because they are not ionized in those body compartments) Mr. G, PA is recent graduate of a master's degree PA program. His program has prepared him in prescribing using rational drug selection. He feels confident that he can promote positive outcomes when prescribing. He is exploring licensure in a variety of states. (Ch. 1) Several factors influence PA or APRN prescribing authority. Prescribing authority is: A. determined by state law B. the same for PAs and APRNs C. is the same in all states D. regulated by the federal government - A. Determined by state law While rational drug selection is based on the individual patient the aspect of rational drug selection addressing disease-specific information by a national medical or nursing organization is A. a guideline B. cost C. availability D. patient hepatic and renal function - A. A guideline One aspect of promotion of positive outcomes is medication education. Identify the incorrect statement. (Ch. 3)
A. Teach the patient purpose of the drug. B. Teach the patient where to purchase the drug. C. Teach the patient the dosing schedule. D. Teach the patient about adverse reactions. - B. Teach the pt where to purchase the drug A medication is a weak base that ionizes at a pH of 4 and lower. The medication is administered orally. Which of the following statements is accurate? A. It will be absorbed primarily in the stomach and become ionized once it reaches the small intestine. B. it will be absorbed primarily in the small intestine and become ionized once it reaches the blood stream. C. Whenever it becomes ionized, the drug will attach to an active transport receptor and be carried into the blood stream. D. It will be absorbed in the small intestine and be non-ionized in the blood stream and will be able to enter into a lactating woman's breast milk and also return to the bloodstream from the breast milk. - D It is a weak base so, in this case it is a non-ionized in any pH greater than 4 - so it will be absorbed in small intestines, stay ionized in blood (7.45-7.45) and also be able to enter breast milk; since breast milk is 7.1, it will not ionize there either; there are not transport receptors for just any drug and they would not be active transport bc it is not an up gradient situation. Referring to the same drug above (weak base that ionizes at <4). What will happen to its absorbability if the person takes omeprazole which raises the gastric pH to 5? A. The drug will only be absorbed in the small intestine because it is a weak base. B. The drug will be absorbed in the stomach and the small intestines. C. The drug will ionize in both stomach and small intestine thus increasing its total absorption. D. The drug will become a weak acid. - B The only that changes is that it is not ionized in the stomach so it can also be absorbed there as well as any other area with a pH of 4. A blood pressure drug is small, lipid soluble with no charge at all times and is 99% protein bound. The patient's dose has been titrated and is at the appropriate dose maintain good control of his HTN. Recently, the patient begins to take daily high doses of an additional OTC drug that is also small, lipid soluble, carries no charge and is highly protein bound. Which of the following is likely to happen with the introduction of the second drug? A. The absorption of the blood pressure drug will increase because it is small, lipid soluble and has no charge B. The blood pressure drug will have decreased effectiveness. C. The patient will need to be monitored as he may become hypotensive. D. Since both drugs are small, lipid soluble and have no charge, the will compete with eachother at the same receptor sites on body tissues. - C
A. 60 min B. 8 hrs C. 24 hrs D. 48 hrs - C Steady state is always 4 half-lives (4x6=24) - it cannot be changed by a loading dose, it is the time it takes for excretion to match the amount administered An otherwise healthy 13 yr old presents with a minor bacterial skin infection. Think about what is the most likely bacterial cause an infection of the skin and what is known about the resistance of these organisms. You note that the appearance of the infection suggests it may be MRSA. You have done a culture that will be back in 3 days but feel that the infection should be treated with an antibiotic now. Which of the drugs below has the greatest chance of treating the organism without adverse side effects? A. a fluoroquinolone B. amoxicillin/ clavanulate C. dicloxacillin D. tetracycline E. vancomycin - D The most likely organism is staph aureus & 80% of staph makes beta-lactamase - so don't use anything w/ a beta-lactam ring that is easily detached or w/o a beta-lactamase inhibitor. If not for the MRSA, you could use Augmentin or the dicloxacillin but bc it appears to be MRSA, you cannot. The PBP receptor has changed & a beta-lactam ring will not fit. The fluoroquinolone should not be used in kids (a new FDA report in May 2016 recommends against use in anyone unless there is no other choice). You certainly do not want an IV med - that is inappropriate so do a med that does not work by breaking down the cell well. A tetracycline like doxycycline works well. The patient needs an antibiotic for his mycoplasma pneumonia. He is 84 yrs old and is frail and has had a past MI with a resultant right bundle branch block and atrial fbrillation. He is on warfarin to prevent stroke. Which medication below is your best choice for treatment of his pneumonia. A. clarithromycin B. trimethoprim /sulfamethoxazole C. third generation cephalosporin D. Amoxicillin - B You can't use any drug that will prolong the QT interval in a pt who already has a prolongation. Biaxin is not a good choice bc it will further prolong QT interval w/ warfarin. Since there is no cell wall in a mycoplasma, you cannot use any abx that's action is to destroy a cell wall. Other mechanism will work.
A person with diabetes has a candida infection beneath her breasts and in her abdominal skin folds. Which of the antimicrobials is most appropriate treatment? A. oral metronidazole B. oral griseofulvin C. topical Nystatin- Mycostatin D. oral acyclovir - C This is a fungal infection so you can't use abx or antivirals. Topical antifungals are fine but oral griseofulvin does not treat yeast & it is wise to avoid systemic drugs if they can be avoided. A patient presents with fever and malaise and a one day history of an itchy erythematous rash unilaterally along dermatome T12. The APRN strongly suspects that it is herpes zoster though no pathognomonic vesicular lesions are present. Which of the following is the most appropriate approach to this situation? A. Treat immediately with oral valacyclovir TID for 7 days. B. Treat BID with famiciclovir once the vesicles appear to be sure it is herpes zoster. C. apply zovirax ointment to the rash six times a day until the rash is resolved. D. Slowly Infuse IV cyclovir over an hour twice a day for 5 days. - A Tx of zoster should be systematic not topical & needs to begin ASAP but IV tx is not indicated. Which scheduled drugs can be called into a pharmacy? A. Schedule 5 B. Schedule 1 C. Schedule 3 D. Schedule 2 - A. Schedule 5 C. Schedule 3
- schedule I is not prescribed for use in Wisconsin
- schedule II needs to be written prescription T/F: Schedule 1 drugs need a prescription to be called into a pharmacy. - False: schedule 1 can't be prescribed Consideration w/ drug prescribing include A. Route of admin B. Interactions C. Age changes D. Cost - All of the above What is prescriptive authority? A. The right to prescribe drugs B. A right that physicians have to administer medications C. Can be restricted for non-physician providers
What is the study of what the body does to the drugs? A. Pharmacology B. Pharmacokinetics C. Pharmacokinetics D. Pharmacosciences - C. Pharmacokinetics What are routes of administration that can affect absorption? A. PO B. IT (intrathecal) C. IV D. IM - All of the above Which drug would you choose for the most rapid absorption? A. PO B. IM C. IV D. SQ - C. IV Which are factors that affect absorption? A. Rate of dissolution B. Surface area C. Blood flow D. Lipid solubility - All of the above What is the movement of drugs from the systemic circulation to the site of the drug action? A. Absorption B. Elimination C. Distribution D. Metabolism - C. Distribution What are the major components in distribution? A. Blood flow to the tissues B. Ability of the drugs to exist the vascular system C. How much drug is present D. Ability of the drug to enter the cells - All of the above T/F: Protein bound drugs can enter the tissues - False bc protein size is too big T/F: Free drug can enter the tissues - True T/F: Two protein bound drugs will compete for albumin receptor sites - True.
When 2 protein bound drugs enter the body, the drug w/ a higher affinity will bind to the protein molecule. This will increase the effect of the expected free drug of the lesser affinity drug, decreasing the effect of the greater affinity drug. What is the enzymatic alteration of drug structure w/in the body? A. Absorption B. Distribution C. Metabolism D. Elimination/excretion - C. Metabolism What are a few possible consequences of drug metabolism? A. Drug inactivation B. Increased toxicity C. Activation of prodrugs D. Decreased effect - All of the above What are the steps in the first-pass effect?
- Decreased or no therapeutic effect of the drug.
- Drug absorbed from the GI tract
- Drug carried to the liver via the portal vein prior to the systemic circulation
- Liver breaks down the drug - 2, 3, 4, 1 T/F: Two drugs are CYP2 enzyme inducers - the effect could be toxicity - False bc inducers activate enzyme to work more, breaking down the drug —> decreased effect T/F: Two drugs are CYP1 enzyme inhibitors - the effect could be decreased drug effect - False bc inhibitors work to break down the drugs less —> toxicity Factors in metabolism could include A. Pregnancy B. Age C. Nutrition D. Prodrug activation - All of the above What is the removal of drugs from the body? A. Absorption B. Distribution C. Metabolism D. Elimination/excretion - D. Elimination/excretion What are components that can affect elimination? A. Renal failure B. Ion trapping C. Age
A. They decrease the effect of beta-lactamases B. They work on different parts of the bacterial production style C. They can increase the risk of an allergy & suprainfection D. Decreasing the doses needed, decreasing potential toxicities - A, B, D Which of the following hx factors would concern you for a C-diff infection? A. Large amounts of watery diarrhea B. Recent surgical drainage of abdominal abscess C. Holding off of treating a fever of unknown origin D. Abx use in the past months/weeks - A, D T/F: IV Vanco would be your preferred method of C-diff treatment - False, you wanna give it PO bc that is how bacteria get into the gut. How does suprainfection occur?
- An infection occurs that is appropriate to treat
- The bodies natural system is unbalanced allowing the other microbes to thrive
- The infection is treated
- The usual microbes to the body get killed off d/t the tx. - 1, 3, 4, 2 Which of the following could be sx of suprainfection? A. Thrush B. Yeast infection C. Anal itching D. Candida induction under the breast - All of the above T/F: All medications that can be used for adults can be used for children. - False What can be done before a pt w/ renal disease in consideration w/ nephrotoxic drugs? A. Choose a different abx B. Decrease the dose if possible C. Consult a pharmacist & ID to assess risk, benefits, & options. D. Hydrate if possible - All of the above
