The Best Slime | Quizalize

What is the page mainly about? (Answer: C — Homes meet a basic need) A) House colors B) Old buildings C) Homes meet a basic need ✓ D) Travel What basic need do homes give? (Answer: B — Shelter) A) Food B) Shelter ✓ C) Clothes D) Money What does “basic need” mean here? (Answer: C — Something people must have to live) A) Something nice to have B) A school rule C) Something people must have to live ✓ D) A weekend plan Homes keep people ______ and ______. What are the two words from the page? (Answer: B — dry / safe) A) rich / tall B) dry / safe ✓ C) loud / fast D) clean / funny What else are homes for, according to the text? (Answer: B — Eating, sleeping, and being with family and friends) A) Shopping B) Eating, sleeping, and being with family and friends ✓ C) Driving D) Fighting What does the heading “Meeting our needs” tell you? (Answer: B — explains how homes fit the local climate) A) A joke is coming B) This part explains how homes fit the local climate ✓ C) It is a story D) It lists prices What does “climate” mean on this page? (Answer: C — the usual weather of a place) A) Yesterday’s forecast B) A big storm C) The usual weather of a place ✓ D) Room temperature Which roof is best for cold, snowy places? (Answer: D — Slanted) A) Flat B) Dome C) Glass D) Slanted ✓ Why is a slanted roof helpful in snowy places? (Answer: B — snow slides off more easily) A) It is cheaper B) Snow slides off more easily ✓ C) Birds like it D) It is quieter Why do many houses in hot places have many windows? (Answer: B — to let air move through and keep people cool) A) To block all light B) To let air move through and keep people cool ✓ C) To make walls heavy D) To reduce street noise Which detail best supports “climate changes home design”? (Answer: C — Hot → many windows; Snowy → slanted roofs) A) People like blue walls B) Kitchens are big C) Hot → many windows; Snowy → slanted roofs ✓ D) Cities are crowded What does the caption about a traditional Japanese house show? (Answer: C — People sit on mats on the floor to eat) A) People eat outdoors B) Families don’t eat together C) People sit on mats on the floor to eat ✓ D) People stand to eat Which sentence is LEAST connected to the main idea of the page? (Answer: D — Blue walls are relaxing) A) Homes protect people from weather B) Roofs can change with climate C) Windows help rooms stay cool D) Blue walls are relaxing ✓ Which text structure organizes the right paragraph? (Answer: C — Cause–effect) A) Timeline B) Problem–solution C) Cause–effect ✓ D) Description only What is the author’s purpose? (Answer: B — to explain how homes meet a human need) A) To sell houses B) To explain how homes meet a human need ✓ C) To tell a funny story D) To give building laws What can you guess about a flat roof in a snowy place? (Answer: B — snow can pile up and be unsafe) A) Best choice B) Snow can pile up and be unsafe ✓ C) Always cheaper D) Warmer in summer Which page feature helps you find ideas quickly? (Answer: C — Headings and photo captions) A) Rhyme B) Dialogue C) Headings and photo captions ✓ D) Footnotes Which sentence is the best summary of the page? (Answer: C — Homes give shelter; designs change with climate) A) Houses are beautiful in winter B) People prefer bright colors C) Homes give shelter; designs change with climate (slanted roofs, many windows) ✓ D) Windows are the most important part True/False or Short Answer (5) True/False: All homes have the same purpose, even if they look different. (Answer: True) True/False: In hot places, houses usually have fewer windows to keep heat in. (Answer: False — hot places → many windows for airflow/cooling) Short Answer (1–3 words): Homes provide shelter to keep people _____ and _____. (Answer: dry; safe) Short Answer (one example): Write one climate → design pair from the page. (Answer: cold/snowy → slanted roof OR hot → many windows) True/False: The photo shows people in Japan eating on mats on the floor. (Answer: True)

🧠 Game Objective: Agents analyze partial client profiles, then choose the best discovery questions to uncover the hidden insurance need. You’ll present: A brief, vague client case A list of potential fact-finding questions (mix of good/bad) The agent selects up to 5 questions Points are based on: How many “high-value” questions they choose Whether their questions align to the true need Bonus: If they uncover the hidden clue or issue (revealed after) 🎯 Quiz Format for Quizalize: Question Type: Multiple Select (choose up to 5) Scoring: 1 point per strong question, 0 or -1 for irrelevant/weak questions Bonus Reveal Slide: Show the full case need after each question 🔍 Sample Quizalize Scenario Set 🔹 Client Case #1: "James & April" James (38) is a freelance graphic designer. He and April (36) have one 3-year-old child. They just moved into their first home with a $400k mortgage. James doesn’t currently have employer benefits. April works part-time and doesn’t have group coverage. Question Prompt: Choose up to 5 questions to uncover James and April’s real protection need. Answer Options: ✅ What income would April need if you weren’t here to support your family? ✅ Do you have any existing life insurance or savings to cover the mortgage? ✅ How long would you want your family financially protected if something happened to you? ✅ Do either of you have any disability coverage? ✅ Would you want your child’s future education covered if something happened? ❌ How much do you currently pay for car insurance? ❌ Do you see yourself buying another house soon? ❌ What’s your favorite thing about your neighborhood? ✅ Hidden Need: Income replacement + mortgage protection for a non-benefits freelancer. 🔹 Client Case #2: "Rosa" Rosa is 29 and single. She recently got a promotion, moved into a new apartment, and is paying off $45k in student loans. She loves to travel and has no dependents. Answer Options: ✅ If something happened to you, who would take care of your student loans or final expenses? ✅ Do you have any emergency savings or a safety net? ✅ Would you be interested in locking in permanent coverage while you're young and healthy? ✅ Do your parents or anyone else rely on you financially, even occasionally? ❌ Are you planning to have children in the next 6 months? ❌ Do you want a pet in the next year? ❌ Do you have renter’s insurance? ✅ Hidden Need: Final expense coverage + early whole life for cash value & lock-in pricing. 🔹 Client Case #3: "The Smith Family" Mark (45) and Tasha (42) have two teenagers, ages 13 and 16. Mark makes $120k as a consultant; Tasha runs their household. They just finished paying off a second mortgage. They’re “starting to think about college and retirement.” Answer Options: ✅ Would you want the kids’ college plans funded if something happened to you? ✅ Do you have enough coverage to protect your spouse’s lifestyle if your income stopped? ✅ Have you considered combining life protection with cash value to support future goals? ✅ How are you currently saving for retirement? ❌ Have you started planning your estate yet? ❌ Do you plan on buying another property this year? ✅ Hidden Need: Blended whole/term strategy for income replacement and cash value for college/retirement. 🎮 Bonus Twist Slide (after each case): 💥 Hidden Need Revealed! Here’s what many missed: James has no group benefits — he needs full protection as a freelancer.

Rotations In a doubles game, the players have to take turns hitting the ball with their partner. After each shot, a player has to move out so that the partner can get into the best position for the next shot. It is very important that both players establish an effective rotation pattern and alternative rotation patterns. 1. Circular Rotations (Figure 16.1) Each player moves in a circular way behind the partner after each shot and should be ready to move up and hit. Both players move the same way and two left-handed or right-handed aggressive players can use this movement. 125 16.1 circular rotations 2. Up and Down Rotations (Figure 16.2) Each player moves toward table in a diagonal way to return a shot then back up the same way. One left-handed and one right-handed pair use this rotation. 16.2 up and down rotations 3. T-Rotations (Figure 16.3) The front person moves sideways and the back person moves back and forth. Mostly pairs of one fast style player (front) and one loop style player (back), or one close-table offensive player (front) and one slice style player (back) use this rotation. 16.3 “T” rotations 4. Triangle Rotations (Figure 16.4) Each player using this rotation pattern moves to sides to return shot, then step back to the middle for the next shot in a triangle way. It is used often to return angles shots to sides and it is similar to the circular rotation. 126 16.4 triangle rotations Teamwork and Strategies 1. Establish a good rotation and movement patterns. 2. Create chances for your partner when returning a shot or serve. 3. Cover your partner's weaknesses. 4. Attack the weaker opponent. 5. Hit to the opponent who just finished the shot and is moving away. 6. Use your best serves and shots in games to ensure your best play and reduce mistakes. 7. Change serves and shots to keep opponents guessing what the next motion will be. 8. Change speed, power, lines and placement of the shots and serves to avoid opponents adapting to them. 9. Combine spin and flat serves to force opponent make more mistakes. 10. Attack opponents’ weaknesses. 11. Avoid the strength of opponent. For example, hit to the backhand if opponent is strong at forehand, or use more short chop shots if opponent is very aggressive. 12. Hit to the openings, weak side, and an opponent's body.

GRADE 4 Module 6 Lesson 3. Interpret Remainders This PowerPoint file contains instructional aids for teachers who have purchased Into Math. It is intended to be projected to students and used in conjunction with the Student Edition and manipulatives as needed. These slides can be used to move the conversation forward in the classroom, but they should not serve as a replacement for student-centered, collaborative conversations in which students have the space they need to find an entry point, construct meaning, and build understanding. About the Slide Presentation Presenter View: Use the Presenter view to see notes while presenting. Customization: Add or delete content or notes to get the best learning experience for your classroom. 1 Problem of the Day. Which equations can be used to solve the following problem? Rita makes 40 bracelets and gives an equal number to 8 friends, including Veronica. Veronica gives 2 of the bracelets that she received to her sister. How many bracelets does Veronica have left? A. 40 – 8 = 32 32 ÷ 2 = 16 B. 40 ÷ 8 = 5 5 + 2 = 7 C. 8 + 2 = 10 40 ÷ 10 = 4 D. 40 ÷ 8 = 5 5 – 2 = 3 2 I Can. I Can solve a division problem and interpret the remainder in the context of the problem. 3 Spark Your Learning. Aiden is building solar toy cars in his science club. The cars collect and use energy from the sun for power. Aiden buys 18 wheels. Each car needs 4 wheels. How many cars can Aiden build? Show your thinking. 4 Turn and Talk. What is the remainder in this problem? What does the remainder mean? Professional Development note: Use the Professional Learning Cards to provide language routines that may help students access the meaning of the problem. 5 Build Understanding • Task 1 ACTIVITY. There are 57 students going to the science museum. Each van can take 5 students. How many vans are needed to take all the students? Use a visual model to show how the students are divided into groups of 5. 6 Turn and Talk. How can you use the whole-number quotient and remainder to answer these questions? How many vans will be full? How many students will ride in the van that is not full? Professional Development note: Use the Professional Learning Cards to provide language routines that may help students access the meaning of the problem. 7 Step It Out • Task 2 ACTIVITY.. Amanda has 73 inches of wire for a science experiment. She needs to cut all the wire into 8 identical pieces. How many inches long will each piece be? 8 Turn and Talk. Why is this problem a good situation to write the remainder as a fraction? Professional Development note: Use the Professional Learning Cards to provide language routines that may help students access the meaning of the problem. 9 Check Understanding. 1. Maya needs 44 batteries for smoke alarms. The batteries come in packs of 6. How many packs does Maya need to buy? For 44 ÷ 6, the whole-number quotient is ____ and the remainder is ____. Maya needs to buy ____ packs. Circle how you interpreted the remainder to solve the problem. 10 I Can Scale. 4 I can explain how to solve a division problem and interpret the remainder in the context of the problem. 3 I can solve a division problem and interpret the remainder in the context of the problem. 2 I can solve a division problem and identify the whole-number quotient and the remainder. 1 I can solve a division problem with a remainder. 11 Exit Ticket. Mr. Jenkins’ class is giving speeches during a 46-minute class. Each student will be able to talk for 4 minutes. How many students can give speeches? Justify your answer.

Broken windows are covered. Floorboards are patched and doors screwed back on. The road that was ruined by German tanks is shovelled and raked smooth. Boot-shaped bruises turn yellow then fade and disappear. Flowers grow and spread across the ugly German footprints stomped into garden beds. The village looks pretty once more. School stops for the summer and everyone is put to work on the kolkhoz, the village farm. Women and big boys begin harvesting the barley crops in the outer fields. The biggest girls milk the cows, morning and night, and keep the barns clean. Old Nikolay mends ploughs, horse harnesses, pitchforks and scythes in his workshop. Anna Pushinka teaches Yelena and her friends how to get the honey from the beehives that are scattered through the orchards. I am in charge of collecting eggs. My friends Olga and Nina help. Olga and Nina are five, a year younger than me. They are twins and look exactly alike, except Nina’s nose is a little bit crooked from when she fell out of bed and squashed it sideways on the floor. The hens, ducks and geese wander free in the summer, so collecting eggs is like a treasure hunt and takes hours. Catching the hens for their daily hugs takes even longer, but I think it’s important because hugs make everyone happy and happy hens lay bigger eggs. Olga says I’m the best hen-hugger in all of Russia. Nina says I’ll be the best cow-hugger, too, when my arms grow longer. But good hugs have nothing to do with the size of your arms. It’s all to do with the size of your heart. When we are done with the hens, Olga, Nina and I can spend the rest of the day doing whatever we like. We climb the apricot trees, chase squirrels, lie in the meadow marvelling at how hot Ushanka’s black fur becomes in the sunshine, make daisy chains and race little boats of bark in the stream. I teach Olga and Nina the alphabet and we use charcoal to write our letters and our names all over the village – on doors and walls and the freshly cut ends of firewood. In between, I practise my knots. In case the German princemonsters return. I slip into Old Nikolay’s workshop and tie knots in the harnesses hanging on the walls. I wander into gardens where the washing is hung out to dry and tie knots in the laces on pants and smocks. I creep up behind Anna Pushinka and tie knots in her apron strings. I find baling twine in the hay shed and tie my own ankles together. I do such a good job of these last knots that I can’t get them undone. I have to jump all the way to Olga and Nina’s house and ask them to cut me free with their mama’s knife. At the end of each day, Ushanka and I run out into the distant barley fields to meet Mama. This is my favourite part of the day, because Mama always shouts, ‘Little Rabbit!’ and smothers my head with kisses. And as we walk home, we sing. Everyone – women, big boys and me. I love to sing. Almost as much as I love to be kissed by Mama. Sometimes one of the boys, Mikhail, has his balalaika with him. He takes the instrument out from beneath the sheaves of barley piled high on the wagon and plays music. We sing about forests and orchards and people who find their true love. As we walk home, arm in arm, my heart fills with happiness and my belly swells with pride that I am allowed to sing along with the big boys. And I can almost forget about the German prince-monsters and their lies about Russia and their big ugly boots. Almost. But today, when Mikhail reaches for his balalaika, I see other things hiding beneath the barley sheaves. Three of the mamas rush forward and cover them up, but it’s too late. I know they are there. I’ve already seen them. Rifles. Lots of rifles. Mikhail hugs his balalaika to his chest and blushes. ‘So play!’ cries Mama, her voice oddly loud and high. ‘Let’s play Sasha’s favourite song, “The Little Birch Tree”.’ So Mikhail plays and everyone sings about the lovely birch tree with its curly leaves and the branches that will be turned into silver flutes. They sing too quickly, too loudly, and as they sing and walk, they cast nervous sideways glances at me. ‘It’s alright,’ I say, when the song comes to an end. ‘I didn’t see the rifles.’ Mama nods and smiles, and I know it was the right thing to say. But I did see the rifles. And I think about Yelena wanting to get lots of guns and dynamite for the Partisans so they can shoot the Germans and blow them into thousands of tiny pieces, and Mama looking as though she agreed, and I know this is what the mamas and the big boys are doing. As well as harvesting, they are helping the Partisans. Three days later, I wake before dawn and I am all alone. Yelena is always here beside me when I wake. But not this morning. I climb down from our bed above the stove. Mama is filling a cloth sack with bread. She ties it closed with a piece of string and hands it to Yelena. ‘Stay out of sight,’ says Mama. ‘And don’t return until after dark.’ ‘Where’s she going?’ I ask. ‘Nowhere,’ snaps Mama. ‘Then why does she need all that bread?’ I ask. ‘There’s nothing left for us.’ Mama baked four loaves last night and she has stuffed them all into the sack. Yelena opens her mouth, but before she can speak, Mama shoves her out the door and sends her on the way to nowhere. Mama turns and stares at me, her blue, blue cornflower eyes wide with worry. ‘I know,’ I say, flopping down on the bench. ‘I didn’t see any bread.’ Mama sits beside me and takes my hand. ‘And . . .?’ she prods, obviously waiting for more. I puzzle for a while, then say, ‘And I don’t have a sister called Yelena.’ Mama laughs, softly and with a little bit of sadness around the edges. ‘Sweet Little Rabbit! You do have a sister called Yelena.’ ‘I do?’ I ask, now confused. ‘I haven’t seen the rifles or the bread, but I have seen Yelena?’ ‘Yes.’ Mama smiles and the magic makes me smile, too. And I am glad that Yelena is real because I love her very much. ‘Yelena is real,’ Mama explains, ‘but she does not carry sacks of bread into the forest for the Partisans.’ ‘Of course not!’ I shout, slapping my forehead. ‘Because there is no bread!’ Mama laughs loudly now, with not a hint of sadness. She hugs me, pressing me against her warm, loving heart, covering my head with kisses. ‘Clever Little Rabbit,’ she murmurs, and then, in barely a whisper, ‘Your papa would be so proud.’ When I wake the next morning, Yelena is sleeping beside me, her mouth open, her braided hair unravelling. Mama is serving kasha to a strange woman seated at our table. I crawl down from above the stove and slide along the bench beside her. I stare at her pants, her tunic, the rope she is using as a belt and her big boots. She’s dressed like a man! And there’s a rifle leaning against the wall near the door. ‘Hello,’ I say. ‘I’m Sasha.’ The woman doesn’t reply. She just shovels down her kasha. I line my four wooden bears along the table in front of her bowl and say, ‘These are my bears: Big Bear, Medium Bear, Little Bear and Even Littler Bear.’ ‘Hello, Sasha. Hello, bears.’ She smiles but she doesn’t tell me her name. ‘Why are you dressed like a man?’ I ask, tugging at the sleeve of her tunic. ‘Because men’s clothes make it easier to run and climb and crawl and shoot,’ she says. ‘You’re a Partisan!’ I gasp. ‘But she’s not real,’ says Mama, placing a bowl of kasha before me. ‘Is the kasha real?’ I ask. Mama laughs. ‘Yes, Little Rabbit.’ I’m glad the food is real, because I’m hungry. But I’m disappointed that the woman is not real. I was going to ask if I could use her rope-belt to tie her ankles together. For practice. But if she’s not real, then the rope and her ankles aren’t either. The woman finishes her kasha, hangs her rifle over her shoulder, kisses Mama on the cheek then slips out the door. I run to the window to watch her leave, but by the time I get there, she’s gone. Vanished. ‘Because she’s not real,’ I whisper. A week later, Mama and I are working in the garden. We sing as we weed between the flowers and pluck caterpillars from the vegetables. Anna Pushinka is picking strawberries in her garden and wanders over. ‘Taste these,’ she says, holding out the basket. Mama reaches in and takes out a fat strawberry and a tiny piece of folded paper. The strawberry goes into her mouth, the paper into her pocket. ‘What’s on the paper?’ I ask. ‘Paper?’ Anna Pushinka replies with a wave of her hand. ‘Goodness, Sasha! Who has money for paper? These are lean times. We must choose between paper for writing and noodles for our soup. And I always choose noodles.’ She chuckles and I know the paper is yet another thing that is not real. That night, Mama slips the paper to Yelena, but she drops it on the floor. I pick it up for her, and I see that there are tiny words and numbers written all over it. I wish I could read better. I’m desperate to know what it says. Or rather, what it doesn’t say, because it’s not real. Later, when Mama has tucked us into our bed above the stove and Ushanka has wrapped herself around the top of my head, I ask Yelena, ‘What’s on the paper?’ ‘What paper?’ says Yelena. ‘The paper that isn’t real,’ I reply. Yelena stares at me, nibbling her lip, then whispers, ‘A message for the Partisans. Stuff about where the Germans have their headquarters and when their trains are travelling and where they store their ammunition.’ ‘Why?’ ‘So the Partisans can blow them up.’ Yelena grabs my arm. ‘But don’t tell anyone. It’s a secret.’ ‘What’s a secret?’ I ask. ‘The message.’ ‘What message?’ I say, my eyes wide. Yelena laughs. ‘Good boy, Sasha.’ My belly swells with pride. I know how to play this game. ‘How are your knots coming along?’ asks Yelena. ‘Good! Yesterday, I crept into the dairy and tied knots in the apron strings of all the girls who were milking and only one of them noticed. Today, I tied Olga’s ankles together with Mama’s embroidery thread and just now, while you were taking a bath, I tied the sleeves of your blouse together in an enormous knot.’ Yelena rolls her eyes, then says, ‘I’ll see if I can find you some rope for practising.’ ‘Practising what?’ I ask. ‘Your knots,’ she says. ‘What knots?’ Yelena, my big sister who is twelve and always serious t

Chapter 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 DrugAlpha1 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 DrugsAlpha 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 Inhibitorsaka 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 HTNTreatment 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)

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