CH 6 CHALLENGES TO EFFECTIVE DRUG THERAPY

Question 1

1. A nurse is preparing a drug for administration to a patient. The drug does not have an indicated use for the patient’s medical diagnosis. What should the nurse do?

A) Administer the drug as ordered.
B) Question the prescriber concerning the ordered drug.
C) Ask a coworker his or her thoughts about the ordered drug for the patient.
D) Ask the patient why the drug has been prescribed for him or her.

Answer 1

Ans: B
Feedback:
If the nurse is not sure about giving a drug, the order should be questioned. The nurse should never give a medication that is not clear. Mistakes do happen and the drug ordered, if not approved for the condition that the patient has, could be an error on someone’s part. The person who wrote the order should be questioned, not a co worker, who probably does not know why an off-label drug is being used. It would be unprofessional and inappropriate to ask the patient about the drug.

Question 2

2. According to Center for Disease Control and Prevention (CDC) recommendations, what is the role of the nurse in preparing for the possibility of bioterrorism?

A) Post updated information on signs and symptoms of infections caused by
biological agents
B) Provide guidelines for treating patients exposed to, or potentially exposed to,
biological agents
C) Remain current on recognition and treatment of infections caused by biological
weapons
D) Advocate for increased funding for research involving bioterrorism and patient
treatment

Answer 2

Ans: C
Feedback:
Nurses need to remain current about recognition of and treatment for those exposed to biological weapons because nurses are often called upon to answer questions, reassure the public, offer educational programs, and serve on emergency preparedness committees. The CDC posts updated information on signs and symptoms of infections caused by biological agents that nurses would read. The CDC also provides guidelines for how to treat patients exposed to biological agents and the nurse must remain current on this information. Although nurses could advocate for funding, this is not usually the role of the nurse.

Question 3

3. How can the nurse find the most up-to-date information about emergency preparedness related to bioterrorism agents?

A) Read textbooks devoted to the topic.
B) Ask coworkers to explain current events.
C) Read journal articles about bioterrorism agents.
D) Visit the Centers for Disease Control and Prevention (CDC) Web site.

Answer 3

Ans: D
Feedback:
The most current information will be found on the CDC Web site because new information can be posted immediately whereas textbooks and journal articles take time to print. Coworkers may or may not remain current on emergency preparedness and should not be the primary source of information.

Question 4

4. The nurse is assessing a diabetic patient who has presented at the clinic reporting several hypoglycemic episodes during the past 3 weeks. The nurse questions the patient about the use of herbal or alternative therapies, suspecting what herbal remedy could cause the hypoglycemic episodes?

A) St. John’s wort
B) Kava
C) Fish oil
D) Ginseng

Answer 4

Ans: D
Feedback:
Ginseng is known to decrease blood sugar levels. If the patient used this in combination with his or her oral antidiabetic agent, diet, and exercise, his or her blood sugar could drop below therapeutic levels. St. John’s wort interacts with many drugs, but not with antidiabetic agents. Kava is associated with liver toxicity. Fish oil has been associated with decreased coronary artery disease.

Question 5

5. A 22-year-old patient calls the clinic and tells the nurse that she has been depressed and is thinking about taking St. John’s wort but wants to know if it is safe first. The nurse begins by questioning what other medications the patient takes and would be concerned about a drug-alternative drug interaction if the patient is also taking what type of medication?

A) Antihistamines
B) Analgesics
C) Antibiotics
D) Oral contraceptives

Answer 5

Ans: D
Feedback:
St. John’s wort can interact with oral contraceptives that alter drug metabolism, which can decrease the effectiveness of the contraceptive. Analgesics, antibiotics, and antihistamines can be taken in combination with St. John’s wort without known adverse effects.

Question 6

6. A patient tells the clinic nurse that he or she has been taking over-the-counter (OTC) Pepcid to relieve acid indigestion for several years. This is the first time the patient has ever reported this issue to a health care provider. As part of the teaching plan for this patient, the nurse explains what risk associated with not sharing OTC drug use with the provider?

A) The OTC drug could be more expensive than seeking health care advice.
B) The drug could mask symptoms of a serious problem that is undiagnosed.
C) Use of the drug could cause a rebound effect of Pepcid.
D) The drug could interact with several cold medicines.

Answer 6

Ans: D
Feedback:
OTC drugs allow patients to self-diagnose and treat routine signs and symptoms without seeing a health care provider. This self-prescribed treatment, however, could mask a more serious underlying medical problem and result in a poor outcome for the patient. The issues of drug rebound and drug interaction need to be considered, but the safety issue related to self-diagnosis and self-prescription presents the greatest risk to the patient. Patients should always be encouraged to discuss the use of OTC products with their health care provider.

Question 7

7. What patient populations would the nurse expect is most likely to be prescribed a drug for an off-label use?

A) Adolescent and middle-aged adult patients
B) Patients with diabetes or heart disease
C) Obstetric and neonatal patients
D) Pediatric and geriatric patients

Answer 7

Ans: D
Feedback:
Drugs being used for an off-label purpose are commonly prescribed for pediatric and geriatric populations due to the lack of drug trial information and minimal premarket testing. Often a trial-and-error method is used in treating both the pediatric and geriatric populations when only adult information is known. The geriatric population responds to medication more like children because of their decreased ability to metabolize medications. Adolescents, especially later adolescents, use medications similarly to young adults as do middle-aged adults. Patients with different diagnoses are often involved in drug testing including those with diabetes and heart disease. Drugs are discouraged for use in obstetric patients.

Question 8

8. A patient calls the clinic and asks to speak to a nurse. The patient questions the nurse about the use of a drug that was advertised on TV. The patient tells the nurse he or she is sure that the drug will make him or her feel the same way as described in the commercial. What response is most appropriate for the nurse to make?

A) “I’m glad that you want to be involved in treatment decisions but you are not qualified to decide what medications are best for your condition.”
B) “It’s important to remember that drug advertisements emphasize the positive effects of drug therapy and not the adverse effects or contraindications.”
C) “You need to remember that the drugs being advertised are much more expensive than other drugs that have the same effect.”
D) “I’ve seen those advertisements and I would want to take that medication too if I had the condition it was designed to treat.”

Answer 8

Ans: B
Feedback:
It would be important for the nurse to remind the patient that advertisements always emphasize the positive effects of drug therapy. The patient should not be discouraged from contributing to the plan of care by being told she is not adequately qualified to make decisions because no one is more qualified to make decisions about her own body. Although the drug may be more expensive, this is not a reason to choose or avoid a medication that could be more effective. Agreeing with the patient is not meeting the nurse’s obligation to teach and inform.

Question 9

9. The clinic nurse is talking with a patient about information concerning a drug her or she bought online. What is the nurse’s responsibility to the patient concerning this information?

A) Encourage the patient to seek information about drugs from a pharmacist.
B) Explain that information obtained from the Internet is not always accurate.
C) Offer the patient a drug reference guide to read and learn more about the drug.
D) Interpret the information and explain it in terms that the patient will understand.

Answer 9

Ans: D
Feedback:
The Internet can be a good reference for drug information. However, the amount and reliability of the information can be overwhelming. The nurse should always try to interpret the information and explain it in terms that the patient will understand. A pharmacist is a good resource person but may not be able to teach from a holistic perspective. Drug reference guides may be hard for the patient to understand and he or she would still need someone to interpret the information.

Question 10

10. The triage nurse in the emergency department sees a patient suspected of abusing amphetamines brought in by friends. While assessing this patient, what would the nurse be likely to find if steroids are being abused?

A) Hypertension
B) Bradycardia
C) Drowsiness
D) Elated mood

Answer 10

Ans: A
Feedback:
Increases in blood pressure, tachycardia, and insomnia are symptoms of amphetamine abuse. Elation can indicate abuse of cannabis.

Question 11

11. The nursing instructor is discussing the off-label use of drugs. What group of drugs would the instructor tell the nursing students is often used for off-label indications?

A) Drugs used to treat psychiatric problems
B) Drugs used to treat gastrointestinal (GI) problems
C) Drugs used to treat cardiovascular problems
D) Drugs used to treat musculoskeletal problems

Answer 11

Ans: A
Feedback:
Drugs often used for off-label indications include the drugs used to treat various psychiatric problems. Drugs used to treat GI, cardiovascular, or musculoskeletal problems do not fall in the category of frequent off-label uses.

Question 12

12. The patient calls the clinic nurse and says, “I looked this medication up on the Internet after it was prescribed yesterday and there is nothing in the literature about this drug being used to treat my disorder. Should I still take it?” What is the nurse’s best response?

A) “No, stop taking it immediately until I can consult with the doctor because it is obvious a mistake was made.”
B) “Oh, that’s okay. Go ahead and take it because the doctor wouldn’t order it if he or she didn’t think it would be effective.”
C) “It is quite common for drugs to be found to have positive effects for a condition not originally intended so it is safe to take.”
D) “Let me talk with the physician about why this medication was ordered for you and I will call you back.”

Answer 12

Ans: D
Feedback:
Off-label use is relatively common because new information is gathered when the drug is used by large numbers of people that may indicate another condition for which the drug is effective. However, if the nurse does not know for a fact that the drug prescribed is the right drug for the patient’s condition, it is always best to consult with the prescriber to make sure the patient is taking the right drug and to avoid a medication error. The medication may be perfectly safe so the patient should not be told the doctor made a mistake.

Question 13

13. When a drug is ordered off-label, what must the nurse be clear about before administering the drug? (Select all that apply.)

A) Why the drug is being given
B) Its potential for problems
C) The research that has been done
D) The age group it was pretested on
E) The intended use

Answer 13

Ans: A, B, E
Feedback:
Liability issues surrounding many of these uses are very unclear, and the nurse should be clear about the intended use, why the drug is being given, and its potential for problems. Knowing the age group it was pretested on and knowing the research that has been done are not factors the nurse needs to know before administering the drug.

Question 14

14. It is important for the nurse to be aware of what related to the way drugs are marketed?

A) The adverse effects the advertisements do not mention
B) What magazines and Web sites contain the advertisement
C) What patients are seeing in the advertisements about these drugs
D) The name of the cheerful, happy models who are advertising these drugs

Answer 14

Ans: C
Feedback:
As the marketing power for prescription drugs continues to grow, the nurse must be constantly aware of what patients are seeing, what the ads are claiming, and the real data behind the indications and contraindications for these “hot” drugs. The Food and Drug Administration regulates the information that needs to be contained within medication ads. Where the patient saw the ad and the actors in the ads are unimportant.

Question 15

15. When evaluating information accessed over the Internet, an important question the nurse should teach the patient to ask is what?

A) Is the information anecdotal?
B) Where has this information been obtained?
C) Is this information paid for by the drug company?
D) How many patients have had input into the information?

Answer 15

Ans: A
Feedback:
Many people do not know how to evaluate the drug-related information that they can access over the Internet. Is it accurate or anecdotal is an important concept for the nurse to teach the patient to assess to verify the accuracy of the information. Where the information came from is unimportant. It would be expected that all drug advertising is paid for by the drug company and this is not an important concern. Number of patients with input into the information is most likely none because information is gathered from health care professionals.

Question 16

16. How has the patient’s access to drug information changed the way the patient interacts with the nurse and other health care providers?

A) Patients share information from research reports with health care providers.
B) Patients are contacting drug companies to see what their latest reports say.
C) Patients are more likely to challenge the health care provider with their own research.
D) Patients are more likely to self-prescribe and not obtain prescriptions from their health care provider.

Answer 16

Ans: C
Feedback:
Access to consumer advertising, mass media health reports, and the Internet influence some patients to request specific treatments, to question therapy, and to challenge the health care provider. Consumers do not generally read research reports from medical facilities and contact drug companies to see what their reports say, and they cannot self-medicate because many of these drugs require a prescription to obtain them.

Question 17

17. What can make a nurse or any health care provider lose credibility with the patient?

A) Being unprepared to deal with “the disease of the week”
B) Refusing to write prescriptions for the drug the patient requests
C) Not being knowledgeable about diseases described on House
D) Being prepared to discuss the role of “concierge” doctor

Answer 17

Ans: A
Feedback:
Some health care providers have learned to deal with the “disease of the week” as seen on talk shows; others can be unprepared to deal with what was presented and may lose credibility with the patient.

Question 18

18. Today, an abundance of information is available in the health care arena for consumers, resulting in the nurse encountering patients who have a much greater use of what?

A) Over-the-counter (OTC) therapies
B) Alternative therapies
C) Prescription drugs
D) Off-label drugs

Answer 18

Ans: B
Feedback:
The patient now comes into the health care system burdened with the influence of advertising, the Internet, and a growing alternative therapy industry. Many patients no longer calmly accept whatever medication is selected for them. Indeed, an increasing number of patients are turning to alternative therapies with the belief that they will treat their disorder and reduce risk of adverse effects. Although more prescription drugs are used today, that is not related to abundant information. No indication exists of an increase in use of OTC or off-label drugs.

Question 19

19. Because of the amount of care now being done in the home care setting, it is imperative that the nurse teach the patients what? (Select all that apply.)

A) Care givers’ educational level.
B) Generic names of medication
C) Over-the-counter (OTC) drugs that need to be avoided 
D) Alleviation of adverse effects
E) How to calculate safe dosages

Answer 19

Ans: B, C, D
Feedback:
The responsibility of meeting the tremendous increase in teaching needs of patients frequently resides with the nurse. Patients need to know exactly what medications they are taking (generic and brand names), the dose of each medication, and what each is supposed to do. Patients also need to know what they can do to alleviate some of the adverse effects that are expected with each drug (e.g., small meals if gastrointestinal upset is common, use of a humidifier if secretions will be dried and make breathing difficult), which OTC drugs or alternative therapies they need to avoid while taking their prescribed drugs, and what to watch for that would indicate a need to call the health care provider.

Question 20

20. What concerns might the nurse legitimately have related to the use of alternative therapies? (Select all that apply.)

A) The Food and Drug Administration (FDA) does not test or regulate active
ingredients.
B) The incidental ingredients are clearly marked on the label.
C) The dosage contained in each tablet may vary greatly.
D) No alternative therapies have been found to be effective.
E) Advertising of alternative products is not as restrictive or accurate

Answer 20

Ans: A, C, E
Feedback:
Alternative products are not controlled or tested by the FDA and advertising is not as restrictive or accurate as with classic drugs. Incidental ingredients are often unknown and strength of tablets may vary within the bottle depending on the conditions under which they were grown. While some alternative therapies have been found to be effective, there are others who have not been studied.

Question 21

21. The nurse provides teaching to the patient using herbal therapies and includes what important information related to the effects of the herbal therapy?

A) They can interact with prescription drugs.
B) They always contain known ingredients.
C) They are natural so they are effective and safe.
D) The ingredients are natural, meaning toxicity is not a concern.

Answer 21

Ans: A
Feedback:
Herbal therapies can produce unexpected adverse effects and toxic reactions, can interact with prescription drugs, and can contain various unknown ingredients that alter the therapies’ effectiveness and toxicity.

Question 22

22. When patients do not understand the information provided with their medication, whose responsibility is it to help them sort through and comprehend the meaning?

A) Care giver
B) Nurse
C) Patient
D) Physician

Answer 22

Ans: B
Feedback:
Many pharmacies provide written information with each drug that is dispensed, but trying to organize these sheets of information into a usable and understandable form is difficult for many patients. The nurse is often the one who needs to sort through the provided information to organize, simplify, and make sense of it for the patient.

Question 23

23. The nurse is providing an inservice on alternative therapies for peers and explains that the term “alternative therapies” includes what?

A) Holistic drug therapy
B) Hospice care
C) Nondrug measures
D) Home care

Answer 23

Ans: C
Feedback:
Herbal medicines and alternative therapies are found in ancient records and have often been the basis for discovery of an active ingredient that is later developed into a regulated medication. Today, alternative therapies can also include non-drug measures, such as imaging and relaxation. Options A, B, and D are not included in alternative therapies.

Question 24

24. The patient calls the clinic and talks to the nurse saying, “I found the same drug the provider prescribed on the Internet and it is much cheaper. Is it safe for me to order my drug from this site?” What is the nurse’s best response?

A) “It is usually safe to order drugs from Internet Web sites if it is a reliable site.”
B) “Most drugs ordered online come from another country and are safely used there.”
C) “The drug you get will be the same chemical prescribed but the dosage may
differ.”
D) “The Food and Drug Administration (FDA) has issued warnings to consumers
about the risk of taking unregulated drugs.”

Answer 24

Ans: D
Feedback:
The FDA has begun checking these drugs when they arrive in this country and have found many discrepancies between what was ordered and what is in the product, as well as problems in the storage of these products. Some foreign brand names are the same as brand names in this country but are associated with different generic drugs. The FDA has issued many warnings to consumers about the risk of taking some of these drugs without medical supervision, reminding consumers that they are not protected by U.S. laws or regulations when they purchase drugs from other countries.

Question 25

25. With the need to protect our environment, what is it now important for the nurse to teach patients to do?

A) Dispose of drugs no longer used on an annual basis.
B) Flush drugs down the toilet.
C) Bury unused in the yard.
D) Throw unused pill bottles in the trash in original containers.

Answer 25

Ans: A
Feedback:
Patients should go through their medicine cabinet annually and dispose of drugs no longer used. Unused drugs should not be flushed down the toilet or buried in the yard because they seep into the community water supply. Pills should be removed from their bottle and mixed with an undesirable substance to prevent someone from using the medication if found.

Question 26

26. The nurse receives a call from a frantic mother saying, “My child swallowed some of my birth control pills. Should I give Ipecac?” What is the nurse’s best response?

A) “Yes, give Ipecac and follow the dosage directions on the bottle.”
B) “Ipecac is not effective for this use so you should not give it to your child.”
C) “Give the Ipecac only if you are absolutely sure your child swallowed the pills.”
D) “No, don’t give Ipecac because it will cause your child to vomit and make a
mess.”

Answer 26

Ans: B
Feedback:
Ipecac is a drug that the Food and Drug Administration tested in 2003 and found, despite its use for many years, that it was not effective in inducing vomiting in children suspected of poisoning. As a result, it is no longer used. The mother should be instructed not to give it and to call poison control to get up-to-date instructions on how to deal with this emergency. Whether the pills were swallowed, this child requires appropriate intervention because it is better to err on the side of caution. Making a mess is not a concern.

Question 27

27. The patient tells the nurse that he or she has begun ordering his or her medications over the Internet because it is cheaper. What statement made by the nurse in response to this information is accurate?

A) All drugs are manufactured with the same quality controls.
B) Any drug that is shipped into this country is safe to use.
C) Foreign drugs may have the same name as domestic drugs, but they are not the
same drug.
D) If you order from Canada or Mexico, the drugs are safe because they undergo
testing.

Answer 27

Ans: C
Feedback:
The Food and Drug Administration has begun checking these drugs when they arrive in this country and have found many discrepancies between what was ordered and what is in the product, as well as problems in the storage of these products. Some foreign brand names are the same as brand names in this country but are associated with different generic drugs. Options A, B, and D are incorrect because not all drugs are manufactured the same and they are not always safe coming from another country.

Question 28

28. The increasing number of patients who go to their health care provider and request a drug they have seen advertised on television or in a magazine has created what continuing challenge to health care providers?

A) Treating infections appropriately
B) Treating sicker patients
C) Prescribing cost-effectively
D) Staying knowledgeable about drug therapy

Answer 28

Ans: D
Feedback:
As the marketing power for prescription drugs continues to grow, the health care provider must be constantly aware of what patients are seeing (or reading), what the commercials and ads are promising, and the real data behind the indications and contraindications for these “hot” drugs. It is a continuing challenge to stay up-to-date and knowledgeable about drug therapy.

Question 29

29. Ipecac, formerly used as the drug of choice by parents for treatment of suspected poisoning in children, was tested by the Food and Drug Administration (FDA) in 2003. What was the finding of this testing?

A) Ipecac is ineffective for its intended use.
B) Ipecac is the safest treatment for poisoning in children.
C) Ipecac was “grandfathered” in as an ineffective drug.
D) Ipecac induces vomiting.

Answer 29

Ans: A
Feedback:
Ipecac, a formerly standard over-the-counter drug, was used for many years by parents to induce vomiting in children in cases of suspected poisoning or suspected drug overdose. The drug was finally tested and in 2003, the FDA announced that it was not found to be effective for its intended use. Although it was grandfathered in as an effective drug, this was not what the study researched. Ipecac is not effective and does not consistently induce vomiting.

Question 30

30. Federal guidelines state that when advertising a drug, if the company states what the drug is used for, what other information must also be included in the advertisement? (Select all that apply.)

A) Symptoms
B) Contraindications 
C) Adverse effects 
D) Precautions
E) Cost

Answer 30

Ans: B, C, D
Feedback:
If a drug advertisement states what the drug is used for, it must also state contraindications, adverse effects, and precautions. The advertisement does not have to state symptoms or cost.

Question 31

31. The parent of a 2-year-old child is visiting his or her pediatric health care provider and shows the nurse the advertisement for allergy medication found in a magazine in the waiting room saying, “This drug sounds like it would be far more effective to treat my son’s asthma and I’d only have to give it once a day.” What is the nurse’s best response?

A) “Talk with your health care provider about this drug, but be aware that
advertisements do not always provide all the important information you need to
know.”
B) “Oh, I need to throw that magazine away because so many people show me that
ad and it is all complete nonsense with no truth to it at all.”
C) “I’ve been seeing amazingly positive results from that medication so you are
absolutely right to want to give it to your child.”
D) “That drug is dangerous and should not be given to children under the age of 5
unless there are no other good options.”

Answer 31

Ans: A
Feedback:
The health care provider should make the decision about what medications are to be prescribed, not the nurse. However, the nurse can make the mother aware of the fact that there is often more that goes into choosing the correct drug than the bit of information disclosed in the advertisement. Becoming upset with the mother, agreeing with the mother, or frightening the mother about the medication is the wrong approach for the nurse to use.

Question 32

32. The local news has been discussing a specific rare disorder that killed a child in the community this week, describing the symptoms of the disease as including nasal congestion, ear pain, and a cough. The pediatrician’s office is receiving numerous calls asking to make appointments to rule out this rare disease. What is the nurse’s best action?

A) Prepare a handout that describes the disorder discussed in the news in greater detail.
B) Tell parents their child is experiencing the common cold and do not need to be seen.
C) Direct all calls to the local news agency to answer questions and provide details.
D) Become familiar with the disorder and screen each call for more specific
symptoms.

Answer 32

Ans: A
Feedback:
The nurse needs to not only become more familiar with the disorder in the news, but also needs to be prepared to teach parents about the “disease of the week” to allay fears so a handout with detailed information would allow the parents to have something to consult after leaving the provider’s office. Turning parents away without seeing their child will increase fears and the office will lose credibility for lack of interest in their child’s well-being. Directing calls to the news agencies will not provide parents with essential information. Screening calls without seeing the child could be potentially very dangerous.

Question 33

33. The nurse is teaching the patient how to safely use the Internet for health information and includes what information in the teaching plan?

A) The Web site where information is obtained needs to be evaluated for credibility.
B) Most information found on the Internet is accurate.
C) Information on the Internet is most reliable when people give their reviews of the drug.
D) Only a health care professional can tell whether a Web site is reliable.

Answer 33

Ans: A
Feedback:
There are excellent sites for reliable drug information, but each site must be evaluated for credibility and the nurse can teach the patient things to look for to increase confidence in the site. However, a lot of information on the Internet is not accurate; the patient needs to learn how to recognize unreliable information when he or she comes across these sites. Just because a person reviews a drug and gives it multiple stars or a thumbs up does not mean the drug is any more effective or useful in the patient’s care.

Question 34

34. The nursing instructor is teaching the class about how prescription drugs become over-the-counter (OTC) drugs and lists what factor as preventing a drug from becoming classified as OTC?

A) If the patient cannot reliably self-diagnose the condition the drug is intended to
treat
B) If it would mask signs and symptoms of an underlying problem, the drug remains
available by prescription only.
C) If the drug would cause toxic effects if not taken as directed, it remains a
prescription drug.
D) OTC drugs must not have any adverse effects that could harm the patient.

Answer 34

Ans: A
Feedback:
If a diagnosis requires medical intervention, such as hyperlipidemia, which can only be diagnosed through laboratory studies, there is no point in making the drug an OTC medication. Most, if not all, OTC drugs have the capacity to mask signs and symptoms of an underlying disease so this is not a factor in deciding if a drug can be sold OTC. All drugs have the potential for toxic effects if not taken as directed and virtually all drugs have the potential for adverse effects.

Question 35

35. The nurse needs to ask what specific questions when collecting a drug history? (Select all that apply.)

A) “Do you take any over-the-counter medications?”
B) “Do you take any herbal supplements?”
C) “Do you use any alternative therapies?”
D) “Do you take any natural supplements or vitamins?”
E) “What unusual therapies do you take?”

Answer 35

Ans: A, B, D
Feedback:
The nurse needs to specifically question the patient’s use of over-the-counter drugs, herbal supplements, natural supplements, and vitamins. Use of terms like “alternative therapies” or “unusual therapies” is too vague and may not elicit the kind of information needed.