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Test everything - Family
Quiz by Jane Tulke
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Create multiple choice questions using the following information: In November, Mrs. Baker has Holling read The Tempest. Despite his preconceptions, Holling is captivated by all the "good stuff" in the play, especially the cussing, which he decides to learn by heart. He figures that Mrs. Baker could not have read the play herself; if she had, she certainly would not have let him have it. Holling is amazed when he discovers that his teacher not only has read the play, but she knows the bad parts as well. Mrs. Baker gives Holling a one-hundred-and-fifty question test on The Tempest, and assigns him to read the play again, telling him "there is a lot more to (it) than a list of colorful curses." The deadline set by Holling's classmates for him to bring them cream puffs arrives, but although Holling's father's company has won the Baker's Sporting Emporium contract, he refuses to extend an advance on his son's allowance. Desperate, Holling goes to Goldman's Best Bakery, offering to work for the money he lacks to buy the cream puffs. Coincidentally, Mr. Goldman, who is active in Long Island's Shakespeare Company, needs a boy to perform in their upcoming Extravaganza, and because of his work with Mrs. Baker, Holling fits the bill. Mr. Goldman gives Holling the required number of cream puffs in exchange, but sadly, while the students are at recess, Caliban and Sycorax, the escaped rats who inhabit the classroom walls and ceiling, come out and decimate the treats. Somehow, the disaster is blamed on Holling; he must clean up the mess, and his classmates decree that he still owes them cream puffs. The next Wednesday, Holling brings five cream puffs to school, which is all he can afford. In addition to facing his classmates' ire, he has to deal with the fact that, in the Shakespeare Company Holiday Extravaganza, he must play the part of Ariel, who is a fairy, and wear yellow tights with white feathers on an unmentionable part of his anatomy; "not a good thing for a boy from Camillo Junior High." To Holling's surprise, just when things are at their darkest, Mrs. Baker comes through for him, bringing cream puffs for the students on his behalf. That afternoon, Mrs. Baker and Holling discuss The Tempest, and whether or not Caliban, the "monster," deserves a happy ending. Holling argues that, as the antagonist, he does not, but Mrs. Baker muses whether Shakespeare might have shown, even in a monster, the capacity of humankind to use defeat to grow. Mrs. Bigio stumbles into the classroom at this point, emitting sounds of indescribable sadness; she has just learned that her husband has been killed in a futile reconnaissance mission in Vietnam. Two nights after his funeral, the Catholic Relief Agency, which houses Vietnamese refugees, including Holling's classmate Mai Thi, is the target of a hate crime. Holling reflects that Shakespeare, with his happy endings for nearly everyone in The Tempest, is wrong. He says, "sometimes, there isn't a Prospero to make everything fine...and...the quality of mercy is strained." In December, Camillo Junior High is awash in "signs of the season." Mrs. Baker, however, does not share the holiday spirit, but Holling is too absorbed with his problems with the Shakespeare Holiday Extravaganza to wonder why. As always, Holling seeks help from his family, but to no avail; his mother comments insipidly that his embarrassing costume is cute, his father tells him to wear it to please Mr. Goldman, who might one day need an architect, and his sister warns him that if news of his role gets to the high school, no one better find out they are related. The only thing that prevents December from being a total disaster is Mrs. Baker's announcement that Mickey Mantle will be signing autographs at the Baker Sporting Emporium. Unfortunately, Mrs. Baker also tells the class about Holling and the Shakespeare Extravaganza, and encourages the students to attend both events. Holling's classmates are intensely curious about his role as Ariel, whom he euphemistically describes as "a warrior." Mr. Goldman tells Mrs. Baker that Holling needs "some practice on interpretation", and she practices with him, playing the part of Prospero. Mrs. Baker is a terrific reader, and when she and Holling rehearse the part where Prospero releases Ariel from bondage, Holling is inspired, realizing what it means to be free "to create his own happy ending." On the night of the performance, Mrs. Baker, Mrs. Bigio, Danny Hupfer and his parents, Meryl Lee, and Mai Thi are in the audience to support Holling, unlike his own parents, who do not want to miss the Bing Crosby Christmas Special on television. Holling executes his part with such passion that his classmates are moved to tears, and do not even notice what he is wearing. When the show is over, Holling, finding the dressing room locked, rushes outside, still in costume, where his father is supposed to be waiting to take him to Baker's Sporting Emporium to see Mickey Mantle. Typically, his father is not there, and Holling, frantic, flags down a bus and begs the driver to take him to the Emporium. The driver takes pity on him and complies, getting him to the Emporium just in time, but when Holling approaches Mickey Mantle for an autograph, the famous player looks derisively at his costume and snaps rudely, "I don't sign baseballs for kids in yellow tights." Danny Hupfer witnesses this snub, and loyally returns his own autographed baseball to Mickey Mantle, saying, "I guess I don't need this after all." Holling and Danny leave together in silence, smarting because "when gods die, they die hard." During the days remaining until holiday break, Mrs. Bigio is especially cantankerous; her cafeteria cooking is unappetizing at best, and her comments to the students are impatient and unkind. Holling, remembering Mrs. Bigio's sadness when she received the news of her husband's death, does not complain, but he is bewildered at the sheer desolation he witnesses when Mrs. Bigio bitterly tells Mai Thi that she "shouldn't even be here...a queen in a refugee home while American boys are sitting in swamps on Christmas Day." After school on the last day before break, Mrs. Baker gives Holling, Danny Hupfer, and Doug Swieteck each a new baseball and mitt, and sends them to the gym, where, to their delight, they meet Joe Pepitone and Horace Clark in their Yankee uniforms, and receive tickets to Opening Day at the Stadium. Mrs. Baker's family knows what happened with Mickey Mantle, and wants to make it up to the boys. The next day, President Johnson declares a Christmas ceasefire in Vietnam, and the holiday season begins in earnest.Test everything - SchoolTest everything - About meKindly create a 30 items multiple choice test from this laboratory activity entitled laboratory do's and donts: LABORATORY SAFETY Dos: Wear Appropriate Attire: Wear lab coats, safety goggles, gloves, and any other required personal protective equipment (PPE) at all times in the lab. Follow Protocols: Adhere strictly to established protocols and procedures for all experiments and tasks. Label Everything: Clearly label all containers, tubes, vials, and equipment with relevant information, including date, contents, and your initials. Calibrate Instruments: Regularly calibrate and maintain all lab equipment according to manufacturer guidelines to ensure accurate measurements. Keep Workspace Organized: Maintain a clean and organized workspace to prevent contamination and ensure efficient work. Dispose of Waste Properly: Follow the correct disposal procedures for hazardous waste, sharps, and non-hazardous materials in accordance with local regulations. Use Pipette Aids: Always use pipette aids or bulb fillers to avoid mouth pipetting and potential exposure to hazardous substances. Record Observations: Keep detailed and accurate records of your experiments, observations, procedures, and results. Label Samples Clearly: Label all samples with accurate and descriptive information to avoid mix-ups and confusion. Communicate: Maintain clear communication with colleagues and supervisors about your work, findings, and any potential issues. Follow Safety Guidelines: Adhere to all safety guidelines, emergency procedures, and evacuation plans in case of accidents or incidents. Report Accidents and Incidents: Report any accidents, spills, or incidents to your supervisor immediately, no matter how minor they may seem. Don'ts: Don't Eat, Drink, or Smoke: Never consume food, drinks, or smoke inside the laboratory to prevent contamination and chemical exposure. Don't Pipette by Mouth: Avoid mouth pipetting to prevent the risk of inhaling or ingesting hazardous substances. Don't Use Chipped Glassware: Do not use chipped, cracked, or compromised glassware, as they can lead to leaks and contamination. Don't Work Alone: Avoid working in the lab alone, especially with hazardous materials or equipment. Don't Ignore Safety Procedures: Never disregard safety procedures or skip steps, even if you're experienced with a particular task. Don't Contaminate Reagents: Avoid contaminating reagents by using clean tools, pipettes, and containers. Don't Rush: Take your time and follow protocols accurately. Rushing can lead to mistakes and unsafe conditions. Don't Block Emergency Equipment: Keep emergency equipment, such as eyewash stations, fire extinguishers, and safety showers, unobstructed and easily accessible. Don't Pour Chemicals into Sinks: Do not pour chemicals down sinks unless you are certain they are safe to do so, as this can lead to environmental contamination. Don't Use Unlabeled Chemicals: Never use unlabeled or improperly labeled chemicals. Always know what you're working with. Don't Wear Loose Clothing or Jewelry: Avoid wearing loose clothing, open-toed shoes, and excessive jewelry that could get caught in equipment or chemicals. Don't Assume, Ask: If you're unsure about something, never assume. Always ask for guidance from your supervisor or colleagueChapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)test110.31.b.17.C Topic: Reading/Vocabulary Development