Central Nervous System Drugs (Ch. 20-35+71)

Question 1

A psychiatric nurse is teaching a patient about an antidepressant medication. The nurse tells the patient that therapeutic effects may not occur for several weeks. The nurse understands that this is likely the result of:
a.
changes in the brain as a result of prolonged drug exposure.
b.
direct actions of the drug on specific synaptic functions in the brain.
c.
slowed drug absorption across the blood-brain barrier.
d.
tolerance to exposure to the drug over time.

Answer 1

A
It is thought that beneficial responses to central nervous system (CNS) drugs are delayed because they result from adaptive changes as the CNS modifies itself in response to prolonged drug exposure, and that the responses are not the result of the direct effects of the drugs on synaptic functions. The blood-brain barrier prevents protein-bound and highly ionized drugs from crossing into the CNS, but it does not slow the effects of drugs that can cross the barrier. Tolerance is a decreased response to a drug after prolonged use.

Question 2

A nurse is teaching a group of nursing students how the CNS adapts to psychotherapeutic medications. Which statement by a nursing student indicates a need for further teaching?
a.
“Adaptation can lead to tolerance of these drugs with prolonged use.”
b.
“Adaptation helps explain how physical dependence occurs.”
c.
“Adaptation often must occur before therapeutic effects develop.”
d.
“Adaptation results in an increased sensitivity to side effects over time.”

Answer 2

D
With adaptation of the central nervous system to prolonged exposure to CNS drugs, many adverse effects diminish and therapeutic effects remain. Adaptation helps explain how tolerance and physical dependence occur, as the brain adapts to the presence of the drug. Therapeutic effects can take several weeks to manifest, because they appear to work by initiating adaptive changes in the brain.

Question 3

A group of nursing students asks a nurse to explain the blood-brain barrier. The nurse would be correct to say that the blood-brain barrier:
a.
prevents some potentially toxic substances from crossing into the central nervous system.
b.
causes infants to be less sensitive to CNS drugs and thus require larger doses.
c.
allows only ionized or protein-bound drugs to cross into the central nervous system.
d.
prevents lipid-soluble drugs from entering the central nervous system.

Answer 3

A
The blood-brain barrier can prevent some drugs and some toxic substances from entering the CNS. The blood-brain barrier in infants is not fully developed, so infants are more sensitive to CNS drugs and often require lower doses. The blood-brain barrier prevents highly ionized and protein-bound drugs from crossing into the CNS and allows lipid-soluble drugs and those that can cross via specific transport systems to enter.

Question 4

A nurse is teaching a group of students about how CNS drugs are developed. Which statement by a student indicates a need for further teaching?
a.
“Central nervous system drug development relies on observations of their effects on human behavior.”
b.
“Studies of new central nervous system drugs in healthy subjects can produce paradoxical effects.”
c.
“Our knowledge of the neurochemical and physiologic changes that underlie mental illness is incomplete.”
d.
“These drugs are developed based on scientific knowledge of CNS transmitters and receptors.”

Answer 4

D
The deficiencies in knowledge about how CNS transmitters and receptors work make systematic development of CNS drugs difficult. Testing in healthy subjects often leads either to no effect or to paradoxical effects. Medical knowledge of the neurochemical and physiologic changes underlying mental illness is incomplete. The development of CNS drugs depends less on knowledge of how the CNS functions and how these drugs effect that process and more on how administering one of these agents leads to changes in behavior.

Question 5

A patient asks a nurse to explain what drug tolerance means. The nurse responds by telling the patient that when tolerance occurs, it means the patient:
a.
has developed a psychologic dependence on the drug.
b.
may need increased amounts of the drug over time.
c.
will cause an abstinence syndrome if the drug is discontinued abruptly.
d.
will have increased sensitivity to drug side effects.

Answer 5

B
When tolerance develops, a dose increase may be needed, because a decreased response may occur with prolonged use. Psychologic dependence involves cravings for drug effects and does not define tolerance. Physical dependence occurs when the drug becomes necessary for the brain to function “normally,” meaning the patient should be weaned from the drug slowly to prevent an abstinence syndrome. Patients may have a decreased sensitivity to drug side effects over time as the brain adapts to the medication.

Question 6

Which monoamines act as neurotransmitters in the central nervous system? (Select all that apply.)
a.
Acetylcholine
b.
Norepinephrine
c.
Serotonin
d.
Dopamine
e.
Epinephrine
f.
Histamine

Answer 6

B, C, D, E

Acetylcholine and histamines are not monoamines.

Question 7

A patient has taken levodopa (Dopar) for Parkinson’s disease for 2 weeks but reports no improvement in the symptoms. Which response by the nurse is correct?
a.
“Another agent will be needed to manage your symptoms.”
b.
“Double the dose to see whether an effect occurs.”
c.
“It may take several months for a response to occur.”
d.
“The prescriber may need to change your drug regimen.”

Answer 7

C
A full therapeutic response with levodopa may take several months to develop. Until the true effect of the dose is seen, it is not necessary to change to another drug, increase the dose, or change the drug regimen.

Question 8

A nurse provides teaching for a patient who is newly diagnosed with Parkinson’s disease. Which statement by the patient indicates understanding of the drug therapy for this disease?
a.
“A levodopa/carbidopa combination is used to improve motor function.”
b.
“There are several drugs available to treat dyskinesias.”
c.
“When ‘off’ times occur, I may need to increase my dose of levodopa.”
d.
“With adequate drug therapy, the disease progression may be slowed.”

Answer 8

A
Levodopa combined with carbidopa is the initial drug of choice to treat motor symptoms. Amantadine is the only drug recommended to treat dyskinesias. Entacapone and rasagiline are used to treat abrupt loss of effect, or “off” times. Drug therapy does not slow the progression of the disease.

Question 9

A patient has been diagnosed with Parkinson’s disease (PD) and begins treatment with levodopa/carbidopa (Sinemet). After several months of therapy, the patient reports no change in symptoms. The nurse will expect the provider to:
a.
add a dopamine agonist.
b.
discuss the “on-off” phenomenon.
c.
increase the dose of Sinemet.
d.
re-evaluate the diagnosis.

Answer 9

D
Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The “on-off” phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.

Question 10

A patient with Parkinson’s disease is taking levodopa/carbidopa (Sinemet) and reports occasional periods of loss of drug effect lasting from minutes to several hours. The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss:
a.
administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone.
b.
adding the DA-releasing agent amantadine to the regimen.
c.
giving a direct-acting dopamine agonist.
d.
shortening the dosing interval of levodopa/carbidopa.

Answer 10

A
This patient is describing abrupt loss of effect, or the “off” phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.

Question 11

A patient newly diagnosed with Parkinson’s disease has been taking levodopa/carbidopa (Sinemet) for several weeks and complains of nausea and vomiting. The nurse tells the patient to discuss what with the provider?
a.
Taking a lower dose on an empty stomach
b.
Taking an increased dose along with a high-protein snack
c.
Taking a lower dose with a low-protein snack
d.
Taking dopamine in addition to levodopa/carbidopa

Answer 11

C
Because levodopa activates the chemoreceptive trigger zone (CTZ) of the medulla, causing nausea and vomiting (N/V), the patient may need to take a lower dose temporarily until tolerance develops. A meal helps slow absorption to minimize this side effect. A high protein intake contributes to abrupt loss of effect, so meals should be low in protein. Taking a dose on an empty stomach increases absorption and also N/V. An increased dose with a high-protein snack increases N/V and also abrupt loss of effect. Dopamine increases N/V, because it activates the CTZ of the medulla.

Question 12

A nurse is discussing motor symptoms with a patient with Parkinson’s disease who has been taking levodopa/carbidopa (Sinemet) and who is now having regular tics. Which statement by the patient indicates understanding of this symptom?
a.
“I may need to try a lower dose of Sinemet to reduce my tics.”
b.
“My provider may order clozapine to treat these tics.”
c.
“These tics are an indication that my dose of Sinemet is too low.”
d.
“This means I will have to have surgery to stop the symptoms.”

Answer 12

A
Levodopa can cause movement disorders. If they occur, a lower dose of levodopa may be required to alleviate them. Clozapine is an antipsychotic used to treat levodopa-induced psychoses. Movement disorders generally occur as the dose of levodopa increases. Surgery is a last option for treating movement disorders, after amantadine fails.

Question 13

A patient who has begun taking levodopa/carbidopa (Sinemet) reports feeling lightheaded and dizzy, especially when standing up from a sitting position. What will the nurse recommend?
a.
An alpha-adrenergic antagonist medication
b.
Discussing amantadine with the prescriber
c.
Increasing the salt and water intake
d.
Taking a drug holiday

Answer 13

C
Postural hypotension is common early in treatment and can be reduced by increasing the intake of salt and water. An alpha-adrenergic agonist, not an antagonist, can help. Amantadine is used to treat levodopa-induced dyskinesias. Drug holidays are used when adverse effects increase with long-term use of levodopa; the drug holiday allows beneficial effects to be achieved with lower doses, which reduces the incidence of side effects.

Question 14

A nursing student wants to know why a patient who has been taking levodopa (Dopar) for years will now receive levodopa/carbidopa (Sinemet). The nurse explains the reasons that levodopa as a single agent is no longer available. Which statement by the student indicates a need for further education?
a.
“Carbidopa increases the availability of levodopa in the central nervous system.”
b.
“Carbidopa reduces the incidence of nausea and vomiting.”
c.
“Combination products reduce peripheral cardiovascular side effects.”
d.
“Combination products cause fewer dyskinesias and decreased psychosis.”

Answer 14

D
Adding carbidopa to levodopa does not reduce the incidence of dyskinesias or psychosis. In fact, carbidopa can increase the intensity and the speed of onset of these effects. Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Peripheral side effects are reduced, including nausea, vomiting, and cardiovascular effects.

Question 15

A nurse is teaching a group of nurses about Parkinson’s medications. The nurse is correct to state that one side effect associated with pramipexole (Mirapex) that is less likely to occur with other dopamine agonists is:
a.
sleep attacks.
b.
dizziness.
c.
hallucinations.
d.
dyskinesias.

Answer 15

A
A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias are listed as side effects of pramipexole and other dopamine agonists.

Question 16

A nursing student wants to know how carbidopa can be effective for treating Parkinson’s disease if it prevents the conversion of levodopa to dopamine. The nurse explains that carbidopa:
a.
can be taken with high-protein meals.
b.
does not cross the blood-brain barrier.
c.
has dopamine-like effects of its own.
d.
reduces abrupt loss of effect.

Answer 16

B
Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Carbidopa is not given with high-protein meals. Carbidopa does not have dopamine-like effects. Carbidopa does not affect abrupt loss of effect.

Question 17

A 25-year-old patient has been newly diagnosed with Parkinson’s disease, and the prescriber is considering using pramipexole (Mirapex). Before beginning therapy with this drug, the nurse will ask the patient about:
a.
any history of alcohol abuse or compulsive behaviors.
b.
any previous history of hypertension.
c.
difficulty falling asleep or staying asleep.
d.
whether any family members have experienced psychoses.

Answer 17

A
Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.

Question 18

A hospitalized patient with Parkinson’s disease who is receiving apomorphine to treat “off” episodes develops nausea and vomiting. The nurse will discuss the use of which medication with the patient’s provider?
a.
Levodopa (Dopar)
b.
Ondansetron (Zofran)
c.
Prochlorperazine (Compazine)
d.
Trimethobenzamide (Tigan)

Answer 18

D
Trimethobenzamide can be used as an antiemetic in patients treated with apomorphine. Serotonin receptor agonists (e.g., ondansetron) and dopamine receptor antagonists (e.g., prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.

Question 19

A patient with Parkinson’s disease is taking levodopa/carbidopa (Sinemet). The prescriber orders bromocriptine (Parlodel) to treat dyskinesias. The nurse notes that the patient is agitated, and the patient reports having frequent nightmares. The nurse will contact the provider to discuss: 
a.
adding an antipsychotic medication.
b.
changing from bromocriptine to cabergoline (Dostinex).
c.
reducing the dose of bromocriptine.
d.
reducing the dose of levodopa/carbidopa.

Answer 19

C
Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychologic side effects. The nurse should suggest reducing the dose of this drug to minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.

Question 20

A nurse is caring for an older adult man who has Alzheimer’s disease (AD). The patient’s daughter wants to know if testing can be done to determine her risk for developing the disease. What will the nurse tell her?
a.
Family history and female gender are both known to increase the risk.
b.
Genetic testing can provide a definitive measure of the risk.
c.
Patients with the apolipoprotein E2 gene (ApoE2) are more likely to develop the disease.
d.
Some biologic markers can be measured, but none is known to increase the risk.

Answer 20

D
Although several genes, proteins, and neurologic changes are associated with the presence of Alzheimer’s disease, none has been shown to have a direct causative link. Advancing age and a positive family history are the only two known risk factors. Female gender is not a known risk; the increased incidence among females may be the result of women living longer than men. No definitive genetic tests are available. The presence of ApoE2 seems to be protective.

Question 21

The spouse of a patient who acts confused and forgetful wants to know if there is a test to determine whether the patient has Alzheimer’s disease. Which response by the nurse is correct?
a.
“A diagnosis is made by administering medications and observing for potential improvement in symptoms.”
b.
“The diagnosis is based on a patient’s age, family history, serum apolipoproteins, and genetic testing.”
c.
“Magnetic resonance imaging to demonstrate brain atrophy is the definitive test to determine Alzheimer’s disease.”
d.
“Proposed diagnostic criteria include measures of cognitive function and the presence of one known biomarker.”

Answer 21

D
In 2010 an international group of AD experts proposed revising diagnostic criteria to add the presence of at least one AD biomarker to current measures of cognitive function after a patient has been observed to have episodic memory impairment. The diagnosis currently is made by observing memory impairment and then measuring cognitive function. Most medications used for AD do not demonstrate sustained or unequivocal improvement, so they would not be useful for diagnostic purposes. The patient’s age and family history are risk factors. The serum ApoE level and genetic testing are not used to diagnose AD. Magnetic resonance imaging (MRI) can measure one brain marker of AD; however, brain atrophy has several different causes and is not definitive

Question 22

An older adult patient with Alzheimer’s disease is admitted to the hospital. The patient’s spouse reports that the patient is often confused and gets lost walking to the store, which is 3 blocks from their home. That evening, the nurse observes the patient pacing the hall and screaming. What will the nurse do?
a.
Notify the provider of this patient’s worsening symptoms.
b.
Prepare the patient’s spouse for impending death from Alzheimer’s disease.
c.
Request an increase in the medication dose to treat the exacerbation in symptoms.
d.
Tell the spouse that this is an expected progression of the disease.

Answer 22

D
This patient is showing signs of the natural progression of AD. Behavior problems such as these occur in 70% to 90% of patients with AD as the disease progresses. There is no need to notify the provider to report these symptoms, because they are expected. The time from onset of symptoms to death usually is 4 to 8 years, but it may be as long as 20 years; this progression does not represent the final stages. Medications are not effective for preventing disease progression, and their effects on memory and cognition are modest, so requesting an increase in the drug dose would not help in this situation.

Question 23

An older adult patient has confusion, memory loss, and disorientation in familiar surroundings. The patient has been taking donepezil (Aricept) 10 mg once daily for 6 months. The patient’s symptoms have begun to worsen, and the patient’s spouse asks if the medication dose can be increased. What will the nurse tell the spouse?
a.
The dose can be increased, because the patient has been taking the drug for longer than 3 months.
b.
The dose can be increased to twice daily dosing instead of once daily dosing.
c.
The increase in symptoms is the result of hepatotoxicity from the medication’s side effects.
d.
The patient must take the drug for longer than 1 year before the dose can be increased.

Answer 23

A
Donepezil is given for mild, moderate, and severe AD, and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.

Question 24

A patient will begin taking a cholinesterase inhibitor for early Alzheimer’s disease. The nurse is teaching the patient’s spouse about the medication. Which statement by the spouse indicates a need for further teaching?
a.
“Gastrointestinal symptoms are common with this medication.”
b.
“People taking this drug should not take antihistamines.”
c.
“This drug helps neurons that aren’t already damaged to function better.”
d.
“This drug significantly slows the progression of the disease.”

Answer 24

D
Cholinesterase inhibitors produce modest improvements in cognition, behavior, and function and may slightly delay disease progression; they do not have a major impact on delaying progression of the disease. Gastrointestinal symptoms are common side effects. Drugs that block cholinergic receptors, including antihistamines, can reduce therapeutic effects and should be avoided. Cholinesterase inhibitors do not affect neurons already damaged, but they do improve function in those not yet affected.

Question 25

The spouse of a patient with Alzheimer’s disease asks a nurse for more information about the rivastigmine (Exelon) transdermal patch that is being used. Which statement by the spouse indicates a need for further explanation? a. “Doses are lower but more steady with the transdermal patch.” b. “Reduced side effects occur with the transdermal patch.” c. “We only need to change the patch every 2 weeks.” d. “We should remove the old patch before applying the new one.”

Answer 25

C The rivastigmine transdermal patch needs to be changed daily. Sites used should not be reused for 14 days. Transdermal dosing provides lower, steady levels of the drug. Intensity of side effects is lower with the transdermal patch. The old patch must be removed prior to applying the new patch to prevent toxicity.

Question 26

A nurse is teaching a group of nursing students about the use of memantine (Namenda) for Alzheimer’s disease. Which statement by a student indicates understanding of the teaching? a. “Memantine is indicated for patients with mild to moderate Alzheimer’s disease.” b. “Memantine modulates the effects of glutamate to alter calcium influx into neurons.” c. “Memantine prevents calcium from leaving neurons, which improves their function.” d. “When used with donepezil, memantine increases the amount of calcium in neuronal cells.”

Answer 26

B Memantine modulates the effects of glutamate, which is involved in calcium influx into neuronal cells. Memantine is used for patients with moderate to severe AD. Memantine does not prevent calcium from leaving cells; it only affects the influx of calcium. Although the effects of memantine and donepezil appear to be synergistic, the result is not always an increase in the amount of calcium in the cells.

Question 27

``` A nurse is caring for an older adult patient who has Alzheimer’s disease. The patient is taking a cholinesterase inhibitor drug. Which side effects would concern the nurse? a. Confusion and memory impairment b. Dizziness and headache c. Nausea, vomiting, and diarrhea d. Slowed heart rate and lightheadedness ```

Answer 27

D Cardiovascular effects of cholinesterase inhibitor drugs are uncommon but cause the most concern. Bradycardia and fainting can occur when cholinergic receptors in the heart are activated. Confusion and memory impairment are signs of the disease and are not side effects of the drug. Dizziness, headache, nausea, vomiting, and diarrhea are all expected adverse effects, and although uncomfortable, they do not present an increased risk to the patient.

Question 28

``` A patient is worried about the risk of developing Alzheimer’s disease, because both parents had the disease. The nurse will tell this patient that known risk factors include what? (Select all that apply.) a. Advanced age b. Alcoholism c. Family history d. Gender e. Obesity ```

Answer 28

A, C The major known risk factor for AD is advancing age; the only other known risk factor is a family history of AD. Alcoholism, gender, and obesity are not known risk factors.

Question 29

``` A patient shows loss of consciousness, jaw clenching, contraction and relaxation of muscle groups, and periods of cyanosis. The nurse correctly identifies this as which type of seizure? a. Tonic-clonic b. Petit mal c. Myoclonic d. Atonic ```

Answer 29

A Tonic-clonic seizures (or grand mal seizures) are considered generalized seizures and are manifested by a loss of consciousness, jaw clenching, muscle relaxation alternating with muscle contractions, and periods of cyanosis. Absence seizures (or petit mal seizures) are characterized by loss of consciousness for a brief period and usually involve eye blinking and staring into space. Myoclonic seizures consist of sudden contractions that may be limited to one limb or may involve the entire body. Atonic seizures are characterized by sudden loss of muscle tone.

Question 30

A nurse is assessing a patient who becomes motionless and seems to stare at the wall and then experiences about 60 seconds of lip smacking and hand wringing. What should the nurse do? a. Ask the patient about a history of absence seizures. b. Contact the provider to report symptoms of a complex partial seizure. c. Notify the provider that the patient has had a grand mal seizure. d. Request an order for intravenous diazepam (Valium) to treat status epilepticus.

Answer 30

B This patient showed signs of a complex partial seizure, characterized by impaired consciousness beginning with a period of motionlessness with a fixed gaze, followed by a period of automatism. The entire episode generally lasts 45 to 90 seconds. Absence seizures are characterized by loss of consciousness for a brief period (about 10 to 30 seconds) and may involve mild, symmetric motor activity or no motor signs. A grand mal seizure is characterized by jaw clenching and rigidity followed by alternating muscle relaxation and contraction and then periods of cyanosis, all with a loss of consciousness. Status epilepticus is a seizure that persists for 30 minutes or longer.

Question 31

A nurse is discussing partial versus generalized seizures with a group of nursing students. Which statement by a student indicates understanding of the teaching? a. “Febrile seizures are a type of generalized tonic-clonic seizure.” b. “Generalized seizures are characterized by convulsive activity.” c. “Partial seizures do not last as long as generalized seizures.” d. “Patients having partial seizures do not lose consciousness.”

Answer 31

A Febrile seizures typically manifest as a tonic-clonic seizure of short duration and are a type of generalized seizure. Generalized seizures may be convulsive or nonconvulsive. Partial seizures may last longer than some types of generalized seizures. Patients with complex partial seizures and secondarily generalized seizures, which are types of partial seizures, may lose consciousness.

Question 32

A nurse provides teaching for a patient with a newly diagnosed partial complex seizure disorder who is about to begin therapy with antiepileptic drugs (AEDs). Which statement by the patient indicates understanding of the teaching? a. “Even with an accurate diagnosis of my seizures, it may be difficult to find an effective drug.” b. “I will soon know that the drugs are effective by being seizure free for several months.” c. “Serious side effects may occur, and if they do, I should stop taking the medication.” d. “When drug levels are maintained at therapeutic levels, I can expect to be seizure free.”

Answer 32

A Even with an accurate diagnosis of seizures, many patients have to try more than one AED to find a drug that is both effective and well tolerated. Unless patients are being treated for absence seizures, which occur frequently, monitoring of the clinical outcome is not sufficient for determining effectiveness, because patients with convulsive seizures often have long seizure-free periods. Serious side effects may occur, but withdrawing a drug precipitously can induce seizures. Not all patients have seizure control with therapeutic drug levels, because not all medications work for all patients.

Question 33

A nurse is caring for a patient who has been taking an antiepileptic drug for several weeks. The nurse asks the patient if the therapy is effective. The patient reports little change in seizure frequency. What will the nurse do? a. Ask the patient to complete a seizure frequency chart for the past few weeks. b. Contact the provider to request an order for serum drug levels. c. Reinforce the need to take the medications as prescribed. d. Request an order to increase the dose of the antiepileptic drug.

Answer 33

B If medication therapy is not effective, it is important to measure serum drug levels of the medication to determine whether therapeutic levels have been reached and to help monitor patient compliance. Patients should be asked at the beginning of therapy to keep a seizure frequency chart to help deepen their involvement in therapy; asking for historical information is not helpful. Until it is determined that the patient is not complying, the nurse should not reinforce the need to take the medication. Until the drug level is known, increasing the dose is not indicated.

Question 34

A patient with a form of epilepsy that may have spontaneous remission has been taking an AED for a year. The patient reports being seizure free for 6 months and asks the nurse when the drug can be discontinued. What will the nurse tell the patient? a. AEDs must be taken for life to maintain remission. b. Another AED will be substituted for the current AED. c. The provider will withdraw the drug over a 6- to 12-week period. d. The patient should stop taking the AED now and restart the drug if seizures recur.

Answer 34

C The most important rule about withdrawing AEDs is that they should be withdrawn slowly over 6 weeks to several months to reduce the risk of status epilepticus (SE). AEDs need not be taken for life if seizures no longer occur. Substituting one AED for another to withdraw AED therapy is not recommended. Stopping an AED abruptly increases the risk of SE.

Question 35

``` A patient with a seizure disorder is admitted to the hospital and has a partial convulsive episode shortly after arriving on the unit. The patient has been taking phenytoin (Dilantin) 100 mg three times daily and oxcarbazepine (Trileptal) 300 mg twice daily for several years. The patient’s phenytoin level is 8.6 mcg/mL, and the oxcarbazepine level is 22 mcg/mL. The nurse contacts the provider to report these levels and the seizure. What will the nurse expect the provider to order? a. A decreased dose of oxcarbazepine b. Extended-release phenytoin c. An increased dose of phenytoin d. Once-daily dosing of oxcarbazepine ```

Answer 35

C This patient’s phenytoin level is low; the therapeutic range is 10 to 20 mcg/mL. An increase in the phenytoin dose is necessary. The oxcarbazepine level is within the normal range of 3 to 40 mcg/mL, so changing the dose is not necessary. Extended-release phenytoin is absorbed more slowly and would not increase this patient’s serum phenytoin level. The dosing of oxcarbazepine does not need to be changed.

Question 36

A nurse counsels a patient who is to begin taking phenytoin (Dilantin) for epilepsy. Which statement by the patient indicates understanding of the teaching? a. “I should brush and floss my teeth regularly.” b. “Once therapeutic blood levels are reached, they are easy to maintain.” c. “I can consume alcohol in moderation while taking this drug.” d. “Rashes are a common side effect but are not serious.”

Answer 36

A Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly. Because small fluctuations in phenytoin levels can affect response, maintaining therapeutic levels is not easy. Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be serious and should be reported immediately.

Question 37

A patient is to begin taking phenytoin (Dilantin) for seizures. The patient tells the nurse that she is taking oral contraceptives. What will the nurse tell the patient? a. She may need to increase her dose of phenytoin while taking oral contraceptives. b. She should consider a different form of birth control while taking phenytoin. c. She should remain on oral contraceptives, because phenytoin causes birth defects. d. She should stop taking oral contraceptives, because they reduce the effectiveness of phenytoin.

Answer 37

B Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient’s dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.

Question 38

``` A patient is admitted to the hospital for a new onset seizure disorder, and the prescriber orders carbamazepine (Tegretol). The nurse reviewing the patient’s medical history notes that the patient is taking warfarin. The nurse will contact the provider to discuss _____ dose. a. reducing the carbamazepine b. reducing the warfarin c. increasing the carbamazepine d. increasing the warfarin ```

Answer 38

D Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which it and other drugs are metabolized, including oral contraceptives and warfarin; therefore, patients taking any of these drugs would need an increased dose. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.

Question 39

A patient who is taking oral contraceptives begins taking valproic acid (Depakote) for seizures. After a week of therapy with valproic acid, the patient tells the nurse that she is experiencing nausea. What will the nurse do? a. Ask the patient if she is taking the valproic acid with food, because taking the drug on an empty stomach can cause gastrointestinal side effects. b. Contact the provider to request an order for a blood ammonia level, because hyperammonemia can occur with valproic acid therapy. c. Suggest that the patient perform a home pregnancy test, because valproic acid can reduce the efficacy of oral contraceptives. d. Suspect that hepatotoxicity has occurred, because this is a common adverse effect of valproic acid.

Answer 39

A Gastrointestinal effects, including nausea, vomiting, and indigestion, are common with valproic acid and can be minimized by taking the drug with food or using an enteric-coated product. Hyperammonemia can occur when valproic acid is combined with topiramate. Signs of pregnancy usually do not occur within a week, so this is less likely. Hepatotoxicity is a rare adverse effect.

Question 40

A child is diagnosed with absence seizures, and the prescriber orders ethosuximide (Zarontin). When teaching the child’s parents about dosage adjustments for this drug, the nurse will stress the importance of: a. frequent serum drug level monitoring. b. learning as much as possible about the disorder and its treatment. c. recording the number of seizures the child has each day. d. reporting dizziness and drowsiness to the provider.

Answer 40

C Measurements of plasma drug levels are less important than observation of seizure activity for determining effective dosages for absence seizures, because this type of seizure is characterized by as many as several hundred occurrences a day. Keeping a chart of seizure activity is the best way to monitor drug effectiveness when treating absence seizures. Frequent drug level monitoring is important when side effects occur to ensure that drug toxicity is not occurring. Learning about the disorder is an important part of adherence. Dizziness and drowsiness are common side effects that diminish with continued use.

Question 41

A patient who has been taking phenobarbital for epilepsy begins taking valproic acid (Depakote) as adjunct therapy. The nurse notes that the patient is very drowsy. What will the nurse do? a. Explain to the patient that tolerance to sedation eventually will develop. b. Notify the prescriber, and request an order to reduce the dose of phenobarbital. c. Notify the prescriber of the need to increase the dose of valproic acid. d. Request an order for liver function tests to monitor for hepatotoxicity.

Answer 41

B Valproic acid competes with phenobarbital for drug-metabolizing enzymes and can increase plasma levels of phenobarbital by approximately 40%. When this combination is used, the dose of phenobarbital should be reduced. Increasing the dose of valproic acid would compound the problem. Patients taking phenobarbital alone experience sedation, which diminishes as tolerance develops. Liver toxicity is a rare adverse effect of valproic acid and is marked by symptoms of nausea, vomiting, and malaise, not drowsiness

Question 42

A nurse is providing teaching to a patient newly diagnosed with partial seizures who will begin taking oxcarbazepine (Trileptal). The patient also takes furosemide (Lasix) and digoxin (Lanoxin). Which statement by the patient indicates understanding of the teaching? a. “I may need to increase my dose of Trileptal while taking these medications.” b. “I may develop a rash and itching, but these are not considered serious.” c. “I should report any nausea, drowsiness, and headache to my provider.” d. “I should use salt substitutes instead of real salt while taking these drugs.”

Answer 42

C Oxcarbazepine can cause clinically significant hyponatremia in 2.5% of patients. If oxcarbazepine is combined with other drugs that reduce sodium, the patient should be monitored. Signs of hyponatremia include nausea, drowsiness, confusion, and headache, and patients should be taught to report these symptoms. Increasing the dose of oxcarbazepine is not indicated. Rashes can indicate a serious drug reaction, and providers should be notified so that the oxcarbazepine can be withdrawn. Salt substitutes would compound the problem of hyponatremia.

Question 43

``` A child who receives valproic acid (Depakote) begins taking lamotrigine (Lamictal) because of an increase in the number of seizures. The nurse will observe this child closely for which symptom? a. Angioedema b. Hypohidrosis c. Rash d. Psychosis ```

Answer 43

C Lamotrigine can cause life-threatening rashes, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, and this risk increases with concurrent use of valproic acid. Angioedema is an adverse effect associated with pregabalin. Hypohidrosis and psychosis are associated with topiramate.

Question 44

A nurse is completing a discharge plan for a 24-year-old patient who will begin taking phenytoin. Which information is important to teach this patient? a. She may stop taking the drug when she is seizure free for a year. b. Taking the medication will ensure that she no longer has seizures. c. She may need to discontinue the drug if serious side effects occur. d. She should be sure to use an effective contraceptive method.

Answer 44

D Because antiepileptic drugs can harm a fetus, female patients of childbearing age should be counseled about the use of contraceptives, which may also have drug-to-drug interactions with the antiepileptic drugs. Patients should be counseled that withdrawal of a seizure medication should be done only with the advice of their prescriber and not just when a certain period of time has passed without seizures. Taking a seizure medication is not a guarantee that seizures will not occur; managing seizures often requires experimenting with several different medications. Patients should report side effects and, if they are serious, should discontinue a drug but only under the guidance of their prescriber.

Question 45

``` A nurse is admitting a patient to the hospital. The patient reports taking oral baclofen (Lioresal) but stopped taking the drug the day before admission. The nurse would be correct to anticipate which adverse effects? a. Weakness and dizziness b. Fatigue and drowsiness c. Seizures and hallucinations d. Respiratory depression and coma ```

Answer 45

C Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Central nervous system effects of baclofen include weakness, dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of baclofen.

Question 46

``` A patient has localized muscle spasms after suffering a leg injury in sports. Treatment options for this patient will not include: a. analgesic anti-inflammatory drugs. b. chlorzoxazone (Paraflex). c. metaxalone (Skelaxin). d. whirlpool baths. ```

Answer 46

B Chlorzoxazone is a centrally acting muscle relaxant; however, its hepatic side effects can be severe and life threatening, and its effectiveness is minimal, so the risks of using this agent outweigh the benefits. Analgesic anti-inflammatory drugs are used as part of drug therapy in a patient with muscle spasms caused by localized muscle injury. Metaxalone is a centrally acting muscle relaxant that can be used with caution and with periodic liver function evaluation. Whirlpool baths are useful adjuncts to drug therapy.

Question 47

``` A nurse is caring for a patient receiving intrathecal baclofen (Lioresal). The patient is unresponsive. After asking a coworker to contact the provider, the nurse anticipates performing which intervention? a. Preparing to support respirations b. Administering an antidote to baclofen c. Administering diazepam to prevent seizures d. Obtaining an electrocardiogram ```

Answer 47

A An overdose of baclofen can produce coma and respiratory depression, so the nurse would be correct to suspect overdose in this patient. Respiratory support is essential to prevent a fatal outcome. There is no antidote for baclofen overdose. Diazepam would not be indicated, because seizures are not a result of baclofen overdose and may further depress respirations. An electrocardiogram is not indicated for this patient.

Question 48

``` A patient has localized muscle spasms after an injury. The prescriber has ordered tizanidine (Zanaflex) to alleviate the spasms. When obtaining the patient’s health history, the nurse should be concerned about which of the following as a possible reason for considering another drug? a. Concomitant use of aspirin b. A history of hepatitis c. A history of malignant hyperthermia d. Occasional use of alcohol ```

Answer 48

B Hepatotoxicity is a serious potential problem in a patient receiving tizanidine, because the drug can cause liver damage. Baseline liver enzymes should be obtained before dosing and periodically thereafter. Analgesic anti-inflammatory drugs commonly are used in conjunction with centrally acting muscle relaxants, so using aspirin is not a concern. This drug does not contribute to malignant hyperthermia. Patients should be advised to avoid alcohol when taking this drug, but a history of occasional alcohol use is not a contraindication.

Question 49

Which patient should receive dantrolene (Dantrium) with caution? a. A 20-year-old woman with a spinal cord injury b. A 45-year-old man with a history of malignant hyperthermia c. A 55-year-old woman with multiple sclerosis d. An 8-year-old child with cerebral palsy

Answer 49

C Dose-related liver damage is the most serious adverse effect of dantrolene and is most common in women older than 35 years. Dantrolene is used to treat spasticity associated with multiple sclerosis, cerebral palsy, and spinal cord injury, so all of these patients would be candidates for this agent. Dantrolene also is used to treat malignant hyperthermia.

Question 50

A nurse is teaching the parent of a child with spastic quadriplegia about intrathecal baclofen (Lioresal). Which statement by the parent indicates a need for further teaching? a. “I can expect my child to be more drowsy when receiving this medication.” b. “I should not notice any change in my child’s muscle strength.” c. “I will contact the provider if my child is constipated or cannot urinate.” d. “If my child has a seizure, I should stop giving the medication immediately.”

Answer 50

D Seizures may occur if oral baclofen is withdrawn abruptly; seizures are not an adverse effect of baclofen. If intrathecal baclofen is stopped abruptly, patients can experience life-threatening effects, so parents should be advised not to stop the drug abruptly. The central nervous system effects of baclofen include drowsiness and lethargy, so these effects are expected. Baclofen does not reduce muscle strength. It can cause constipation and urinary retention, and patients should be advised to contact their provider so that these conditions can be treated.

Question 51

``` A patient with cerebral palsy has severe muscle spasticity and muscle weakness. The patient is unable to take anything by mouth. The nurse is correct to anticipate that which medication will be ordered for home therapy? a. Baclofen (Lioresal) b. Dantrolene (Dantrium) c. Diazepam (Valium) d. Metaxalone (Skelaxin) ```

Answer 51

A Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this patient’s muscle weakness. It can be given intrathecally, via an implantable pump, and therefore is a good choice for patients who cannot take medications by mouth. Dantrolene must be given by mouth or intravenously and so would not be a good option for this patient. It also causes muscle weakness. Diazepam is not the first-line drug of choice. Alternative routes to PO administration are IM, IV, or by rectum. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.

Question 52

``` A patient with multiple sclerosis needs pharmacologic treatment for spasticity in order to begin strengthening exercises to improve walking ability. The nurse anticipates that which medication will be ordered for spasticity? a. Baclofen (Lioresal) b. Dantrolene (Dantrium) c. Diazepam (Valium) d. Metaxalone (Skelaxin) ```

Answer 52

A Baclofen is used to treat spasms associated with multiple sclerosis. It has no direct muscle relaxant effects, so it does not reduce muscle strength. Dantrolene works well to reduce spasms, but it also has significant effects on muscle strength. Diazepam is not the first-line drug of choice, but it could be used because it does not reduce muscle strength. Metaxalone is not indicated to treat spasms caused by multiple sclerosis.

Question 53

A nurse is teaching a patient who has a second-degree burn on one arm about the use of a topical anesthetic for pain. Which statement by the patient indicates understanding of the teaching? a. “I will apply a thin layer of the medication to a small area of skin.” b. “I will cover the burn with a dressing after applying the medication.” c. “I will make sure to apply the medication to the entire burn area.” d. “I will use the medication only on the most painful, blistered areas.”

Answer 53

A Topical anesthetics can be absorbed in sufficient amounts to cause serious and even life-threatening systemic toxicity, so they should be applied in the smallest amount needed to as small an area as possible. Covering the site increases the skin’s temperature, which increases absorption, so this should be avoided. Applying the medication to a large area increases systemic absorption. Applying the medication to broken skin increases systemic absorption.

Question 54

A nurse is discussing the use of cocaine as a local anesthetic with a nursing student. Which statement by the student indicates understanding of this agent? a. “Anesthetic effects develop slowly and persist for several hours.” b. “Cocaine is a local anesthetic administered by injection.” c. “Vasoconstrictors should not be used as adjunct agents with this drug.” d. “When abused, cocaine causes physical dependence.”

Answer 54

C Cocaine should not be combined with epinephrine or other vasoconstrictors, because it causes vasoconstriction itself, and the combination could precipitate severe hypertension. Cocaine has a rapid onset of effects, which last about 1 hour. It is used only topically for anesthesia. Although subject to widespread abuse with profound psychologic dependence, it does not cause substantial physical dependence.

Question 55

A nurse is assisting a physician who is preparing to suture a superficial laceration on a patient’s leg. The physician asks the nurse to draw up lidocaine with epinephrine. The nurse understands that epinephrine is used with the lidocaine to: a. allow more systemic absorption to speed up metabolism of the lidocaine. b. increase the rate of absorption of the lidocaine. c. improve perfusion by increasing blood flow to the area. d. prolong anesthetic effects and reduce the risk of systemic toxicity from lidocaine.

Answer 55

D Epinephrine causes vasoconstriction, which reduces local blood flow and delays systemic absorption of lidocaine, which prolongs local anesthetic effects and reduces the risk of systemic toxicity. Epinephrine slows the rate of absorption. Epinephrine delays systemic absorption of lidocaine, so metabolism is slowed and the effects are prolonged in the periphery. Epinephrine does not increase local blood flow.

Question 56

``` A nurse is assisting the physician during a procedure in which a local anesthetic is administered. Within a few minutes of administration of the anesthetic, the patient has a pulse of 54 beats per minute, respirations of 18 breaths per minute, and a blood pressure of 90/42 mm Hg. The nurse should monitor the patient for further signs of: a. heart block. b. anaphylaxis. c. central nervous system excitation. d. respiratory depression. ```

Answer 56

A When absorbed in a sufficient amount, local anesthetics can affect the heart and blood vessels. These drugs suppress excitability in the myocardium and conduction system and can cause hypotension, bradycardia, heart block, and potentially cardiac arrest. Anaphylaxis would be manifested by hypotension, bronchoconstriction, and edema of the glottis. Central nervous system excitation would be manifested by hyperactivity, restlessness, and anxiety and may be followed by convulsions. No evidence indicates respiratory depression; this patient’s respirations are within normal limits.

Question 57

A nurse is caring for a patient in the immediate postoperative period after surgery in which a spinal anesthetic was used. The patient has not voided and complains of headache. The patient has a pulse of 62 beats per minute, a respiratory rate of 16 breaths per minute, and a blood pressure of 92/48 mm Hg. Which action by the nurse is appropriate? a. Contact the anesthetist to request an order for ephedrine. b. Have the patient sit up to relieve the headache pain. c. Lower the head of the bed to a 10- to 15-degree head-down position. d. Obtain an order for a urinary catheter for urinary retention.

Answer 57

C Spinal anesthetics have several adverse effects, but the most significant is hypotension caused by the venous dilation that occurs from blockade of sympathetic nerves. The result is decreased blood return to the heart, which causes reduced cardiac output and a drop in blood pressure. The first step in treating this is to put the patient in a 10- to 15-degree head-down position to promote venous return to the heart. Ephedrine or phenylephrine is used if the first measure fails. Spinal headaches are common; the intervention for this is to have the patient assume a supine position. Urinary retention can occur secondary to autonomic blockade; it is a concern if the patient has not voided for 8 hours after the procedure, but not in the immediate postoperative period.

Question 58

``` A patient receives an epidural anesthetic during labor and delivery. The nurse caring for the newborn in the immediate postpartum period will observe the infant for: a. bradycardia. b. hypoglycemia. c. jitteriness. d. tachypnea. ```

Answer 58

A Local anesthetics can cross the placenta, causing bradycardia and central nervous system (CNS) depression in the infant. They do not affect blood glucose. Jitteriness is a sign of CNS excitation. Increased respirations are not an adverse effect in the newborn.

Question 59

A nurse is preparing a patient to go home from the emergency department after receiving sutures for a laceration on one hand. The provider used lidocaine with epinephrine as a local anesthetic. Which symptom in this patient causes the most concern? a. Difficulty moving the fingers of the affected hand b. Inability to feel pressure at the suture site c. Nervousness and tachycardia d. Sensation of pain returning to the wound

Answer 59

C Absorption of the vasoconstrictor can cause systemic effects, including nervousness and tachycardia. If severe, alpha- and beta-adrenergic antagonists can be given. Local anesthetics are nonselective modifiers of neuronal function and also can block motor neurons, so it is expected that patients may have difficulty with movement. The sensation of pressure also is affected and is an expected effect. As the local anesthetic wears off, the sensation of pain will return.

Question 60

A nurse is assisting a physician who is performing a circumcision on a newborn. The physician asks the nurse to prepare lidocaine and epinephrine for injection to provide anesthesia. What will the nurse do? a. Ask the provider why an injectable anesthetic is being used for this procedure. b. Draw up the medication as ordered and prepare the infant for the procedure. c. Make sure that seizure precautions are in place. d. Question the use of the epinephrine for this procedure.

Answer 60

D The physician is preparing to use infiltration anesthesia by injecting the local anesthetic directly into the immediate area of surgery. Epinephrine can be used in some cases but should never be used in areas supplied by end arteries, such as the penis, toes, fingers, nose, or ears, because restriction of blood flow in these areas can result in gangrene. Injectable agents are appropriate for this procedure. The nurse should not draw up the medication as requested, because the combination of agents can harm the patient. Seizure precautions are not necessary.

Question 61

A nurse is teaching a group of nursing students about local anesthetics. Which statement by a student reflects an understanding of the teaching? a. “Local anesthetics affect large myelinated neurons first.” b. “Local anesthetics affect motor and sensory nerves.” c. “Local anesthetics do not block temperature perception.” d. “Local anesthetics do not cause systemic effects.”

Answer 61

B Local anesthetics are nonselective modifiers of neuronal function. They block actions in both motor and sensory nerves. They affect small myelinated neurons first. They block temperature, pressure, and pain sensation. When absorbed into the systemic circulation, they can cause systemic effects.

Question 62

``` Vasoconstrictors are combined with local anesthetics for which reasons? (Select all that apply.) a. To enhance absorption b. To reduce the risk of toxicity c. To prevent bradycardia d. To shorten the duration of action e. To prolong anesthesia ```

Answer 62

B, E Vasoconstrictors, when combined with local anesthetics, reduce the risk of toxicity and prolong the anesthetic effects. Vasoconstrictors, when combined with local anesthetics, do not speed up the absorption process, prevent bradycardia, or shorten the duration of action.

Question 63

``` A postoperative patient is reporting pain as a 7 on a scale from 1 to 10, with 10 being the worst pain. The nurse caring for the patient assesses vital signs of HR, 76; RR, 16; and BP, 110/70. The patient has vomited twice. Which postoperative medications will the nurse expect to administer? a. Atropine and morphine b. Bethanechol and ibuprofen c. Morphine and ondansetron (Zofran) d. Promethazine and clonidine (Catapres) ```

Answer 63

C This patient is experiencing postoperative symptoms of moderate to severe pain and nausea and vomiting. Morphine is used postoperatively for this degree of pain, and ondansetron is one of the most effective antiemetics. Atropine is an anticholinergic drug and usually is given preoperatively or perioperatively to prevent bradycardia. Bethanechol is a muscarinic agonist that is used to counter postoperative abdominal distention and urinary retention. Ibuprofen can be used, but it is effective only for mild postoperative pain. Promethazine is less effective as an antiemetic and can be used, but clonidine, marketed as Catapres, is used for postoperative hypertension.

Question 64

A nurse is teaching nursing students about inhalation anesthesia and asks, “What is balanced anesthesia?” Which response by a student is correct? a. “An anesthesia that has a brief induction period with a rapid emergence from its effects.” b. “An inhalation anesthesia that produces both muscle relaxation and unconsciousness.” c. “An anesthesia that provides maximum analgesia with minimal respiratory side effects.” d. “An anesthesia that combines other drugs with inhalation anesthesia to produce the desired effects.”

Answer 64

D Balanced anesthesia is the use of a combination of drugs, along with an inhaled anesthetic, to produce effects that cannot safely be accomplished with inhalation anesthesia alone. These adjunct drugs are used to help induce anesthesia, provide muscle relaxation, and increase analgesia so that a lower and safer dose of the inhalation anesthetic can be used. The other three options describe characteristics of an ideal anesthetic, which does not exist; to get these effects, a combination of other drugs must be used.

Question 65

``` A surgical patient is receiving succinylcholine (Anectine) with an inhalation anesthetic. The patient is intubated, has an indwelling urinary catheter, and has ongoing monitoring of vital signs. Which symptom during the perioperative period is cause for concern? a. Elevated temperature b. Increased urine output c. Muscle paralysis d. No response to painful stimuli ```

Answer 65

``` A Combining succinylcholine (a skeletal muscle relaxant) with an inhalation anesthetic increases the risk of malignant hyperthermia. The mechanism is not understood. Temperature elevation can be profound, and cooling measures must be initiated or the condition can be fatal. A decrease in urine output would be a sign of hypotension. Muscle paralysis and lack of response to pain are desired effects of anesthesia. ```

Question 66

A nurse administers atropine to a patient before induction of anesthesia for a surgical procedure. When evaluating the effects of this medication, the nurse will: a. assess for excessive bronchial secretions. b. expect a reduction in the patient’s anxiety. c. monitor the patient’s heart rate. d. observe for muscle paralysis.

Answer 66

C Anticholinergic drugs, such as atropine (Sal-Tropine), may be given to reduce the risk of bradycardia during surgery. Atropine can alter bronchial secretions, but the effect would be to reduce them, not increase them. It is not used to reduce anxiety. It does not cause muscle paralysis.

Question 67

An anesthesiologist completes preoperative teaching for a patient the night before surgery. The patient asks the nurse to clarify the reason thiopental sodium will be given as an adjunct to the anesthetic. Which statement by the patient indicates understanding? a. “Pentothal allows a larger amount of inhaled anesthetic to be used without increased side effects.” b. “Pentothal is given to enhance the analgesic and muscle relaxation effects of the inhaled anesthetic.” c. “Pentothal is used to produce rapid unconsciousness before administration of the inhaled anesthetic.” d. “Pentothal is used to reduce cardiovascular and respiratory depression caused by the inhaled anesthetic.

Answer 67

C Thiopental sodium, a short-acting barbiturate, is given intravenously for induction of anesthesia. It has a rapid onset and short duration and must be followed immediately by an inhalation anesthetic. It does not alter the side effects of inhalation anesthetics. Most adjuncts to inhalation anesthetics are given so that lower doses of the anesthetic may be used. Thiopental sodium has very weak analgesic and muscle relaxation effects. Thiopental sodium causes cardiovascular and respiratory depression.

Question 68

``` A patient in the postanesthesia recovery unit received ketamine (Ketalar) for right open reduction internal fixation surgery. What drug would be beneficial as a premedication to help minimize adverse reactions? a. Thiopental sodium (Pentothal) b. Sevoflurane (Ultane) c. Atropine (Sal-Tropine) d. Diazepam (Valium) ```

Answer 68

D To minimize the effects of ketamine, the patient should be premedicated with diazepam or midazolam to reduce the risk of an adverse reaction. Thiopental sodium would further sedate the patient. Sevoflurane would further complicate sedation and would not be indicated. Atropine would not reduce the risk of an adverse reaction.

Question 69

``` A preoperative patient receives atropine before induction of anesthesia. The nurse caring for this patient understands that this agent is used to prevent: a. anxiety. b. bradycardia. c. dry mouth. d. hypertension. ```

Answer 69

B Atropine, an anticholinergic drug, is used as an adjunct to anesthesia to counter the effects of vagal stimulation, which is caused by surgical manipulations that trigger parasympathetic reflexes, resulting in bradycardia. Atropine is not an anxiolytic. Atropine causes dry mouth and sometimes is used to minimize bronchial secretions when irritating inhalation anesthetics are used. It is not used as an antihypertensive agent.

Question 70

A patient will receive intravenous midazolam (Versed) combined with fentanyl while undergoing an endoscopic procedure. The nurse is explaining the reasons for this to a nursing student before the procedure. Which statement by the student indicates understanding of the teaching? a. “The patient may appear anxious and restless during the procedure.” b. “The patient will be unconscious during the procedure.” c. “The patient will not need cardiorespiratory support during the procedure.” d. “The patient will not remember the procedure.”

Answer 70

D Midazolam, combined with an opioid analgesic, is used for conscious sedation for minor surgeries and endoscopic procedures. It does not cause anesthesia during this state, which is characterized by sedation, analgesia, amnesia, and lack of anxiety. The patient will not remember the events even though the person will be able to respond to commands during the procedure. The patient will appear unperturbed and passive and not anxious or restless. The patient is sedated, not unconscious. Midazolam can cause dangerous cardiorespiratory effects, including respiratory depression and respiratory and cardiac arrest.

Question 71

``` A patient receives a neuromuscular blocking agent as an adjunct to inhalation anesthesia. When caring for this patient, it is important for the nurse to remember that neuromuscular blocking agents: a. cause vagal slowing of the heart. b. increase the required dose of inhalation anesthetics. c. increase the depth of unconsciousness. d. prevent contraction of the diaphragm. ```

Answer 71

D Neuromuscular blocking agents enhance skeletal muscle relaxation so that the dose of inhalation anesthetics can be reduced to a safer amount. Because these drugs prevent contraction of all skeletal muscles, including the diaphragm, mechanical ventilation is required to support respiration. These agents do not cause vagal slowing of the heart. They reduce the required dose of inhalation agents. They do not affect the level of consciousness.

Question 72

``` A postoperative patient complains of abdominal bloating and discomfort. The nurse caring for this patient will contact the provider to request which medication? a. Bethanechol b. Droperidol c. Promethazine d. Ondansetron ```

Answer 72

A Bethanechol is a muscarinic agonist that is used to treat abdominal distention and urinary retention. The other three agents are antiemetics and would not be useful in this situation.

Question 73

``` A patient will receive isoflurane (Forane) as an anesthetic for a surgical procedure. The nurse caring for this patient during the perioperative period knows that, unlike halothane, this agent will not cause: a. myocardial depression. b. muscle relaxation. c. rapid induction. d. respiratory depression. ```

Answer 73

A Isoflurane does not cause myocardial depression and does not reduce cardiac output. Isoflurane actually produces more muscle relaxation than halothane. Induction with isoflurane is rapid. Isoflurane causes respiratory depression, as do all inhalation anesthetics.

Question 74

A patient is given nitrous oxide, along with another inhalation anesthetic. The nurse knows that the benefits of nitrous oxide include what? (Select all that apply.) a. It is a potent analgesic. b. It has high anesthetic potency. c. It is less likely to cause nausea and vomiting. d. It is less likely to precipitate malignant hyperthermia. e. It can significantly reduce the dose of inhalation anesthetic.

Answer 74

A, D, E Nitrous oxide is an inhalation agent with high analgesic potency. It is not likely to precipitate malignant hyperthermia. It can significantly reduce the dose of the primary anesthetic by as much as 50% or more. It does not have high anesthetic potency, so it cannot be used alone to induce anesthesia. It is more likely to cause postoperative nausea and vomiting.

Question 75

``` A patient asks the nurse what can be given to alleviate severe, chronic pain of several months’ duration. The patient has been taking oxycodone (OxyContin) and states that it is no longer effective. The nurse will suggest discussing which medication with the provider? a. Fentanyl (Duragesic) transdermal patch b. Hydrocodone (Vicodin) PO c. Meperidine (Demerol) PO d. Pentazocine (Talwin) PO ```

Answer 75

A Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

Question 76

A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient’s pupils are dilated and that the patient is drowsy and lethargic. The patient’s heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do? a. Discuss possible opiate dependence with the patient’s provider. b. Encourage the patient to turn over and cough and take deep breaths. c. Note the effectiveness of the analgesia in the patient’s chart. d. Prepare to administer naloxone and possibly ventilatory support.

Answer 76

D Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

Question 77

A patient with moderate to severe chronic pain has been taking oxycodone (OxyContin) 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss: a. administering a combination opioid analgesic/acetaminophen preparation. b. changing the medication to a continued-release preparation. c. confronting the patient about drug-seeking behaviors. d. withdrawing the medication, because physical dependence has occurred.

Answer 77

B Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

Question 78

A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient? a. PRN dosing of the drug may be more effective. b. The risk of respiratory depression increases over time. c. The patient should discuss increasing the dose with the provider. d. The patient should request the addition of a benzodiazepine to augment pain relief.

Answer 78

C This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, as they increase the risk of oversedation.

Question 79

``` A woman in labor receives meperidine (Demerol) for pain. The nurse caring for the infant will observe the infant closely for: a. congenital anomalies. b. excessive crying and sneezing. c. respiratory depression. d. tremors and hyperreflexia. ```

Answer 79

C Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are all signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

Question 80

``` A postoperative patient has received an epidural infusion of morphine sulfate. The patient’s respiratory rate decreases to 8 breaths per minute, and he has a decreased level of consciousness and miosis. Which medication would the nurse anticipate administering? a. Naloxone (Narcan) b. Acetylcysteine (Mucomyst) c. Methylprednisolone (Medrol) d. Physostigmine (Antilirium) ```

Answer 80

A Narcan is an opioid antagonist and would counteract the apparent toxicity. Acetylcysteine is the antidote for acetaminophen poisoning. Methylprednisolone is an anti-inflammatory agent and would not have an effect on toxicity related to opiate overdose. Physostigmine is indicated for organophosphate poisoning.

Question 81

``` A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient’s arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient’s pupils are dilated. The nurse recognizes these symptoms as signs of: a. a mild opioid overdose. b. decreased opioid drug levels. c. improved ventilation. d. worsening hypoxia. ```

Answer 81

D The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

Question 82

``` A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine (Talwin). The nurse will monitor the patient for: a. euphoria. b. hypotension. c. respiratory depression. d. yawning and sweating. ```

Answer 82

D Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.

Question 83

``` A patient will receive buprenorphine (Butrans) as a transdermal patch for pain. What is important to teach this patient about the use of this drug? a. Avoid prolonged exposure to the sun. b. Cleanse the site with soap or alcohol. c. Remove the patch daily at bedtime. d. Remove hair by shaving before applying the patch. ```

Answer 83

A Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

Question 84

A nurse is preparing a patient for surgery and is teaching the patient about the use of the patient-controlled analgesia pump. The patient voices concern about becoming addicted to morphine. What will the nurse do? a. Ask the patient about any previous drug or alcohol abuse. b. Discuss possible nonopioid options for postoperative pain control. c. Suggest that the patient use the PCA sparingly. d. Tell the patient that the pump can be programmed for PRN dosing only.

Answer 84

A The nurse should remember that addiction to opioids usually occurs in patients who already have tendencies for addiction, so an assessment of previous experiences with addictive substances would be indicated. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

Question 85

``` A patient has been taking methadone (Dolophine) for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes? a. Prolonged QT interval b. Prolonged P-R interval c. AV block d. An elevated QRS complex ```

Answer 85

A Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

Question 86

A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.) a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids c. Monitoring the patient’s blood pressure closely for hypertension d. Palpating the patient’s lower abdomen every 4 to 6 hours e. Requesting an order for methylnaltrexone (Relistor) to prevent constipation

Answer 86

A, B, D Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient’s abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

Question 87

``` Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.) a. Biliary colic b. Cough suppression c. Suppression of bowel motility d. Urinary retention e. Vasodilation ```

Answer 87

B, C, E Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

Question 88

``` A patient who has cancer reports pain as “burning” and “shooting” alternating with feelings of numbness and coldness. The nurse will contact the provider to discuss the use of which medication? a. Acetaminophen b. Ibuprofen c. Imipramine (Tofranil) d. Oxycodone (OxyContin) ```

Answer 88

C This patient is describing neuropathic pain, which results from injury to peripheral nerves. This type of pain responds poorly to opioid analgesics but does respond to adjuvant analgesics, which include antidepressants such as imipramine. Acetaminophen and ibuprofen are used for mild nociceptive pain, and oxycodone is used for more severe nociceptive pain.

Question 89

A patient with bone cancer has recently undergone chemotherapy and radiation therapy to reduce the size of the tumor. The patient is taking a large dose of an opioid analgesic, along with acetaminophen and an antidepressant. The nursing student caring for this patient is concerned that the patient is showing drug-seeking behaviors, because the individual requested an increased dose of the opioid. The student discusses this concern with the nurse. Which statement by the student indicates a need for further teaching? a. “It would probably help this patient more to give a larger antidepressant dose.” b. “Patients often need more drug to achieve the same effect.” c. “Radiation and chemotherapy can damage bone tissue and cause increased pain.” d. “The patient’s description of pain is the most important part of the assessment of pain.”

Answer 89

A Pain in cancer patients can arise both from the cancer itself and from the treatments. This patient has bone cancer, which causes somatic pain, and the treatments can increase this pain. Although neuropathic pain can occur as well, this patient is more likely to need analgesia for the nociceptive pain, so increasing the antidepressant dose is not indicated. Patients very often require more drug to achieve the same effect as tolerance develops. Radiation and chemotherapy can damage tissue and increase pain. When assessing pain in patients, the patient’s own description of pain intensity is the most important.

Question 90

``` A patient with cancer who has been receiving an opioid analgesic reports having pain at a new location even though the previous pain is well controlled. The nurse will contact the provider to discuss: a. breakthrough pain. b. drug-seeking behavior. c. infection or metastasis. d. tolerance to drug therapy. ```

Answer 90

C Caregivers should be alert for new pain; this usually results from a new cause, such as metastasis, infection, or fracture, and should be investigated. Breakthrough pain is pain that occurs even when adequate levels of analgesics are given. Drug-seeking behavior refers to patients who use drugs for euphoric effects instead of for intended effects. Tolerance occurs when more drug is required to receive the same effect.

Question 91

An 8-year-old child with advanced cancer has an order for oxycodone (OxyContin) PO, PRN for moderate to severe pain. The nurse notes that the child is constantly playing computer games and repeatedly denies having pain. What will the nurse do? a. Administer the oxycodone at regular intervals around the clock. b. Contact the provider to discuss using patient-controlled analgesia (PCA). c. Reassure the child’s parent that the child will ask for pain medication as needed. d. Tell the child to notify the nurse when pain is present.

Answer 91

B For a number of reasons, even children who can verbalize pain correctly often underreport it. The child may fear that reporting pain may lead to painful procedures or may worry caregivers, or the child may be unaware that pain can be alleviated. Children involved in activities such as computer games may actually be using the activity to distract themselves from the pain, so such an activity is not an indication that the child is comfortable. This child has advanced cancer and is likely to have severe pain. A PCA device would give the child control and provide adequate pain relief. The oxycodone order is for PRN dosing, so the nurse cannot administer it around the clock without a prescriber’s order to do so. Also, because this child is more likely to have severe pain, a PCA would be more effective. Reassuring the parent that the child will report pain and asking the child to report pain do not take into account the fact that children often hide pain for the reasons previously mentioned.

Question 92

An older adult patient who has cancer and Alzheimer’s disease is crying but shakes her head “no” when asked about pain. The prescriber has ordered morphine sulfate 2 to 4 mg IV every 2 hours PRN pain. It has been 4 hours since a dose has been given. What will the nurse do? a. Administer 4 mg of morphine and monitor this patient’s verbal and nonverbal responses. b. Give 2 mg of morphine for pain to avoid increasing this patient’s level of confusion. c. Request an order for a nonopioid analgesic or an antidepressant adjuvant analgesic. d. Withhold any analgesic at this time and reassess the patient in 30 to 60 minutes.

Answer 92

A Older adult patients often are undertreated for pain, because assessing pain is difficult in patients with cognitive impairment and because practitioners often believe that reduced dosages are necessary to alleviate side effects. This patient does not verbalize pain, but her nonverbal cue (crying) indicates that pain is present. The nurse should give the higher dose, especially because the dosing interval has already been exceeded, and then monitor the patient’s response to the medication. Giving 2 mg to avoid side effects is not indicated; patients with Alzheimer’s disease will continue to have confusion unrelated to the opioid. Nonopioid analgesics and antidepressants are not indicated. Withholding pain medication is not appropriate, because this patient shows nonverbal signs of pain.

Question 93

A nursing student caring for a patient with cancer tells the nurse that the patient seems to be exaggerating when reporting the degree of pain. Which statement by the nurse is an appropriate response to this concern? a. “Evaluation of the patient’s vital signs can help you tell if this patient is exaggerating.” b. “It is important to give pain medication as ordered for the degree of pain the patient reports.” c. “We may need to evaluate the patient for the development of metastasis or infection.” d. “You should monitor this patient’s behavior and facial expressions for a more accurate assessment.”

Answer 93

B The patient’s description of his or her pain is the cornerstone of assessment. Pain is a personal experience, and caregivers must act on what the patient says, even if they suspect the patient is exaggerating or not telling the truth. Evaluation of vital signs can be used to monitor responses to pain medication, as can assessments of behaviors and facial expressions, but they are not determinants of the level of pain in initial assessments. Patients with pain in new locations should be evaluated for metastases or infection or other causes.

Question 94

``` A patient with cancer has been receiving codeine and a nonsteroidal anti-inflammatory medication for pain. The patient reports worsening of pain in both intensity and frequency. The nurse will tell the patient to contact the provider to discuss: a. using a fentanyl transdermal patch. b. adding an adjuvant analgesic drug. c. increasing the dose of the codeine. d. using hydrocodone or oxycodone. ```

Answer 94

D As patients have increased pain, it is important to increase the level of analgesia. Hydrocodone or oxycodone is useful as pain increases, after nonopioid analgesics have been tried. Fentanyl transdermal patches are used for chronic, severe pain in patients who are already tolerant to opioids. Adjuvant analgesics can be used at any stage of pain progression but are used for neuropathic pain. Codeine is not recommended for cancer pain, because it has dose-limiting side effects; increasing the dose of codeine is never recommended.

Question 95

A patient who is taking a fixed-dose combination drug with an opioid and acetaminophen for cancer pain reports increased muscular pain. The patient asks the nurse if the pain medication dose can be increased. What will the nurse tell this patient? a. An adjuvant analgesic medication will probably be used to help with this pain. b. An additional dose of acetaminophen can be used to enhance pain relief. c. Increasing the dose is possible, because there is no ceiling to opioid pain relief. d. The provider will prescribe separate dosing of the opioid and acetaminophen.

Answer 95

D Fixed-dose combination products are not useful as pain increases, because the side effects of the nonopioid drug become intolerable as the dosage increases. As pain becomes more severe, the components of the combined regimen should be given separately. Adjuvant analgesics are used for neuropathic pain and not nociceptive pain (which this patient has described). Acetaminophen doses should not be increased. Increasing the dose of a fixed-dose combination drug is not recommended.

Question 96

A patient with cancer is admitted to the hospital. The nurse obtains an admission history and learns that the patient has been taking oxycodone and a nonsteroidal anti-inflammatory drug (NSAID) for a year. The patient reports a recent increase in the intensity of pain, along with a new pain described as “burning” and “shooting.” The nurse anticipates that the prescriber will order: a. a combination opioid/NSAID and an adjunctive analgesic. b. a fentanyl transdermal patch, acetaminophen, and an adjunctive analgesic. c. an increase in the oxycodone and NSAID doses. d. intramuscular morphine sulfate and acetaminophen.

Answer 96

B As pain increases in severity, more powerful opioids should be used. This patient has been taking oxycodone, which is a moderate-strength opioid; fentanyl is stronger. Because the pain is chronic and is now severe and because the patient has opioid tolerance, a transdermal patch may be used. Long-term use of NSAIDs is not recommended because of the risk of thrombotic events. The patient also is describing neuropathic pain, which can be treated with an adjuvant analgesic. Fixed-dose combination drugs are not recommended for increasing pain. NSAIDs are not recommended long term. Intramuscular medications are not recommended because of the pain associated with administration.

Question 97

``` 10. A patient is taking hydrocodone and ibuprofen for cancer pain and is admitted to the hospital for chemotherapy. The nurse anticipates that the prescriber will _____ ibuprofen. a. reduce the dose of b. discontinue the c. increase the dose of d. order aspirin (ASA) instead of ```

Answer 97

B NSAIDs are contraindicated in patients undergoing chemotherapy because of decreased platelet production caused by bone marrow suppression. Any NSAID further increases the risk of bruising and bleeding. ASA is especially dangerous, because it causes irreversible inhibition of platelet aggregation. Ibuprofen should be discontinued, not reduced or increased.

Question 98

A nurse is teaching a group of nursing students about the differences between pure opioid agonists and agonist-antagonist opioids. Which statement by a student indicates understanding of the teaching? a. “Agonist-antagonists opioids act as agonists at mu receptors only.” b. “Agonist-antagonists opioids are effective for treating cancer pain.” c. “Agonist-antagonists opioids enhance the effects of pure agonists.” d. “Pure agonists act as agonists at both mu receptors and kappa receptors.”

Answer 98

D Pure agonists are agonists at mu and kappa receptors. Agonist-antagonist opioids are agonists at kappa, not mu, receptors. At mu receptors, agonist-antagonists act as antagonists. Agonist-antagonists are not recommended for treating cancer pain; because of their antagonist effect, they block access of the pure agonists to mu receptors and thus block their actions.

Question 99

``` A patient newly diagnosed with cancer is admitted to the hospital, and the provider orders oxycodone (OxyContin) every 4 to 6 hours PRN pain. The patient requests pain medication whenever he reports pain as a 7 or 8 on a scale of 1 to 10 (10 being the worst pain), but he tells the nurse the medication is not working well. The nurse will contact the provider to discuss: a. a fixed dosing schedule for the oxycodone. b. intramuscular meperidine (Demerol). c. intravenous morphine sulfate. d. transdermal fentanyl. ```

Answer 99

A Dosing should be done on a fixed schedule to prevent opioid levels from becoming subtherapeutic once patients begin to have more severe pain. IM and IV dosing are more invasive and should not be used unless other methods have failed. Transdermal fentanyl is used for chronic, severe pain in patients tolerant to opioids

Question 100

A patient who has had cancer for 1 year uses a fentanyl transdermal patch for pain relief. The patient reports having three or four episodes of pain (which she rates as 8 or 9 on a scale of 1 to 10) each day, and each episode lasts 15 to 30 minutes. The nurse will contact the provider to: a. discuss the use of an adjuvant analgesic. b. request an order for an NSAID. c. request a strong, short-acting opioid PRN. d. suggest increasing the dose of fentanyl.

Answer 100

C Breakthrough pain can occur in patients who otherwise have well-controlled pain, and it should be managed with extra doses of short-acting, strong opioids. This pain is moderate to severe and is not neuropathic, so adjuvant analgesics or NSAIDs are not useful. Increasing the dose of the long-acting opioid would not alleviate breakthrough pain.

Question 101

``` Over time, patients taking opioid analgesics develop tolerance to which side effects? (Select all that apply.) a. Constipation b. Euphoria c. Physical dependence d. Respiratory depression e. Sedation ```

Answer 101

B, D, E | With continuous use, tolerance develops to most side effects of opioids, except to constipation and physical dependence.

Question 102

``` Which nonpharmacologic therapies are effective in reducing cancer pain? (Select all that apply.) a. Acupuncture b. Cold c. Exercise d. Heat e. Transcutaneous electrical nerve stimulation (TENS) ```

Answer 102

B, C, D Cold, heat, and exercise have been shown to reduce pain. Acupuncture and TENS have not been demonstrated to be effective, although in theory they should work.

Question 103

A patient who has occasional migraine headaches tells a nurse that the abortive medication works well, but she would like to do more to prevent the occurrence of these headaches. The nurse will suggest that the patient: a. ask the provider about an adjunct medication, such as prochlorperazine. b. discuss the use of prophylactic medications with the provider. c. keep a headache diary to help determine possible triggers. d. take the abortive medication regularly instead of PRN.

Answer 103

C Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications are used when headaches are more frequent. To prevent medication overuse headache, abortive medications should not be used more than 1 to 2 days at a time.

Question 104

``` A woman with moderate migraine headaches asks a nurse why the provider has ordered metoclopramide (Reglan) as an adjunct to aspirin therapy, because she does not usually experience nausea and vomiting with her migraines. The nurse will tell her that the metoclopramide is used to: a. help induce sleep. b. improve absorption of the aspirin. c. prevent gastric irritation caused by the aspirin. d. prolong the effects of the aspirin. ```

Answer 104

B Besides reducing nausea and vomiting, metoclopramide also reverses gastric stasis and improves absorption of oral antimigraine drugs. It is not used to induce sleep. It does not prevent gastric irritation or prolong the effects of the aspirin.

Question 105

A patient who uses ergotamine (Ergomar) to abort migraine headaches reports nausea and vomiting with the headaches. What will the nurse tell the patient? a. “Ask your provider about using another antimigraine medication.” b. “Nausea and vomiting are signs of ergotamine toxicity.” c. “These symptoms occur with migraine headaches and will diminish over time.” d. “You should talk to your provider about an adjunct antiemetic medication.”

Answer 105

D Nausea and vomiting, which occur with migraines, can increase with ergotamine use, because the drug can stimulate the chemoreceptor trigger zone. Patients should be treated with metoclopramide or a phenothiazine antiemetic. It is not necessary to change antimigraine medications at this time. Nausea and vomiting do not indicate ergotamine toxicity. These symptoms will not diminish over time.

Question 106

A prescriber orders sumatriptan (Imitrex) for a patient for a migraine headache. Before administration of this drug, it would be important for the nurse to assess whether the patient: a. has a family history of migraines. b. has taken acetaminophen in the past 3 hours. c. has taken ergotamine in the past 24 hours. d. is allergic to sulfa compounds.

Answer 106

C Sumatriptan, other triptans, and ergot alkaloids all cause vasoconstriction and should not be combined, or excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative and another triptan. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-to-drug interaction with sumatriptan. Sulfa is not a component of sumatriptan and therefore is not relevant.

Question 107

``` A patient arrives in the emergency department complaining of numbness in the extremities. The nurse notes that the patient’s hands and feet are cool and pale. When conducting a health history, the nurse learns that the patient has a history of migraine headaches. The nurse recognizes this patient’s symptoms as: a. ergotamine withdrawal. b. ergotism. c. severe migraine symptoms. d. sumatriptan side effects. ```

Answer 107

B Ergotism is a serious toxicity caused by acute or chronic overdose of ergotamine. The toxicity results in ischemia, causing the extremities to become cold, pale, and numb. Symptoms associated with ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.

Question 108

``` A patient is being treated for an infection with erythromycin. The nurse obtains a health history and learns that the patient has migraine headaches. The nurse will tell the patient to avoid which medication while taking the erythromycin? a. Acetaminophen b. Ergotamine (Ergomar) c. Sumatriptan (Imitrex) d. Topiramate ```

Answer 108

B Macrolide antibiotics, such as erythromycin, are potent inhibitors of CYP3A4; these drugs can raise ergotamine to dangerous levels, so this combination should be avoided. It is safe to take acetaminophen, sumatriptan, and topiramate with erythromycin.

Question 109

A young woman with migraine headaches who has recently begun taking sumatriptan (Imitrex) calls the nurse to report a sensation of chest and arm heaviness. The nurse questions the patient and determines that she feels pressure and not pain. What will the nurse do? a. Ask the patient about any history of hypertension or coronary artery disease. b. Determine whether the patient might be pregnant. c. Reassure the patient that this is a transient, reversible side effect of sumatriptan. d. Tell the patient to stop taking the medication immediately.

Answer 109

C Some patients taking sumatriptan experience unpleasant chest symptoms, usually described as “heavy arms” or “chest pressure.” These symptoms are transient and are not related to heart disease. Patients experiencing angina-like pain when taking sumatriptan, as a result of coronary vasospasm, should be asked about hypertension or coronary artery disease (CAD); they should not take sumatriptan if they have a history of either of these. The symptoms this patient describes are not characteristic of pregnancy. There is no need to stop taking the medication.

Question 110

``` A patient who has a history of asthma experiences three or four migraine headaches each month. The patient uses sumatriptan (Imitrex) as an abortive medication and has developed medication overuse headaches. The patient asks the nurse what can be done to prevent migraines. The nurse will suggest that the patient discuss which preventive medication with the provider? a. Botulinum toxin b. Meperidine (Demerol) c. Timolol d. Topiramate (Topamax) ```

Answer 110

D Topiramate can be used for migraine prophylaxis, and its benefits appear equal to those of the first line beta blockers. Botulinum toxin can be used for migraine prophylaxis in patients who have 15 or more headaches a month. Meperidine may be used as abortive therapy but has addictive potential. Timolol is a beta blocker; this patient has asthma, and because beta blockers cause bronchoconstriction, these agents are not recommended

Question 111

``` Supplemental oxygen has been shown to help reduce symptoms for which type of headache? a. Cluster b. Menstrual migraine c. Migraine d. Tension-type ```

Answer 111

A Cluster headaches can be treated with 100% oxygen inhalation. Oxygen therapy is not used to treat other types of headaches.

Question 112

``` A patient on the unit complains of cluster headaches. A new graduate nurse is asked to differentiate between a migraine headache and cluster headaches. The graduate nurse is correct to state that manifestations and/or risk factors for a patient with cluster headaches include what? (Select all that apply.) a. Female gender b. Male gender c. Complaints of nausea and vomiting d. Short duration (15 minutes to 2 hours) e. Auras before the onset of headache pain f. Throbbing, sometimes piercing pain ```

Answer 112

B, D, F Cluster headaches are more common in males, are short in duration, and present as throbbing and piercing pain. Migraine headaches are more common in females and are manifested by nausea and vomiting and the presence of an aura before the onset of headache pain.

Question 113

A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement? a. “Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia.” b. “Benzodiazepines depress neuronal functions by acting at a single site in the brain.” c. “Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous system.” d. “Benzodiazepines promote sleep through effects on the limbic system.”

Answer 113

A All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness “clock.”

Question 114

A patient who has been using secobarbital for several months to treat insomnia tells the nurse that the prescriber has said the prescription will be changed to temazepam (Restoril) because it is safer. The patient asks why this agent is safer. The nurse is correct in telling the patient that temazepam: a. does not depress the central nervous system. b. shows no respiratory depression, even in toxic doses. c. mimics the actions of a central nervous system inhibitory neurotransmitter. d. only potentiates the action of endogenous gamma-aminobutyric acid (GABA).

Answer 114

D Benzodiazepines potentiate the actions of GABA, and because the amount of GABA in the CNS is finite, these drugs’ depressive effect on the CNS is limited. Benzodiazepines depress the CNS but not to the extent that barbiturates do. Benzodiazepines are weak respiratory depressants at therapeutic doses and moderate respiratory depressants at toxic doses. Barbiturates mimic GABA; therefore, because they produce CNS depression, this effect is limited only by the amount of barbiturate administered.

Question 115

A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug’s half-life is only 2 to 3 hours. Which response by the nurse is correct? a. “Benzodiazepines commonly cause residual effects lasting into the day after the dose is given.” b. “The patient is having a paradoxical reaction to this medication.” c. “This patient must have developed a previous tolerance to benzodiazepines.” d. “When this drug is metabolized, the resulting compound has longer lasting effects.”

Answer 115

D Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication.

Question 116

A nursing student asks a nurse what criteria are used to determine which benzodiazepine is prescribed in different situations. The nurse correctly states that selection is based on differences in the onset and duration of effects, as well as on: a. differences in sites of action in the central nervous system. b. marketing decisions of pharmaceutical companies. c. relative differences in abuse potential. d. variations in adverse effects and drug interactions.

Answer 116

B The principal factors determining the applications of a particular benzodiazepine are the pharmacokinetic properties having to do with absorption, metabolism, and excretion and the research and marketing decisions of the drug makers. All of the benzodiazepines produce a similar spectrum of responses, and all act at various sites in the CNS. All benzodiazepines have a lower abuse potential than barbiturates. Drug effects and drug interactions are similar for all benzodiazepines.

Question 117

A patient takes temazepam (Restoril) for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do? a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine. b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration. c. Reassure the patient that this is most likely caused by a paradoxical reaction to the benzodiazepine. d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect of benzodiazepine.

Answer 117

A This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.

Question 118

A patient has been taking high doses of clorazepate (Tranxene) for several months for an anxiety disorder. The nurse assessing the patient observes that the patient is agitated, euphoric, and anxious. What will the nurse do? a. Double-check the chart to make sure the last dose was given. b. Request an order for a longer acting benzodiazepine. c. Suspect a possible paradoxical reaction to the clorazepate. d. Withhold the next dose until a drug level can be drawn.

Answer 118

C Patients taking benzodiazepines for anxiety sometimes develop paradoxical responses to the drug, which include insomnia, excitation, euphoria, heightened anxiety, and rage. A missed dose would trigger withdrawal symptoms, which would include anxiety, insomnia, sweating, tremors, and dizziness. Because this is a paradoxical reaction to the drug, a longer acting drug would make the symptoms worse. This is not caused by overdose, which would manifest as drowsiness, lethargy, and confusion, so a drug level is not warranted.

Question 119

``` A patient in the emergency department is given intravenous diazepam (Valium) for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following? a. Flumazenil (Romazicon) b. Gastric lavage c. Respiratory support d. Toxicology testing ```

Answer 119

C When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil (Romazicon) is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.

Question 120

A patient is brought to the emergency department by friends, who say that they were at a party where alcohol and a mix of barbiturates and benzodiazepines were all available. They tell the nurse that the patient was among the first to arrive at the party, which started several hours ago. The patient is nonresponsive and has pinpoint pupils and respirations of 6 breaths per minute. After oxygen has been administered, the nurse should prepare the patient for which intervention? a. A central nervous system stimulant and IV fluids b. Activated charcoal and flumazenil (Romazicon) c. Gastric lavage and possible hemodialysis d. Naloxone (Narcan) and a cathartic

Answer 120

C Because time has elapsed, enough medication is present in the system to warrant elimination by hemodialysis, and any remainder in the stomach may be eliminated by gastric lavage. A central nervous system stimulant is contraindicated, and intravenous fluids do not address the overdose. Although activated charcoal may assist in absorption of medication in the gut, flumazenil will be effective only for the benzodiazepines. Naloxone, a narcotic antagonist, is not effective for barbiturates and benzodiazepines.

Question 121

``` A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient? a. Flurazepam b. Trazodone (Desyrel) c. Zaleplon (Sonata) d. Zolpidem (Ambien) ```

Answer 121

``` C Zaleplon (Sonata) works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem (Ambien) has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess. ```

Question 122

A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects of this drug. Which response by the nurse is correct? a. “Phenobarbital doses for seizures are nonsedating.” b. “This is a short-acting barbiturate, so sedation wears off quickly.” c. “Tolerance to the sedative effects will develop in a few weeks.” d. “You may actually experience paradoxical effects of euphoria.”

Answer 122

A Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are nonsedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur. Paradoxical drug effects are associated with benzodiazepines and in older adults and debilitated patients with barbiturates.

Question 123

A patient with a history of depression and suicidal ideation is taking fluoxetine (Prozac). The patient reports difficulty maintaining sleep and is prescribed secobarbital (Seconal) as a sedative-hypnotic. The nurse preparing this patient for discharge from the hospital will: a. contact the provider to suggest an order for ramelteon (Rozerem). b. instruct the patient to use alcohol in moderation. c. request an order to change to trazodone (Desyrel) for sleep. d. suggest that the patient try alternative remedies for sleep.

Answer 123

C Trazodone is an atypical antidepressant with sedative actions and can be used to prolong sleep duration. It is useful for treating insomnia related to antidepressants such as Prozac. Ramelteon is not a drug of choice to treat patients who have difficulty maintaining sleep. Patients who are depressed or at increased risk for suicide should not take barbiturates, because overdose can readily cause death. Alcohol is contraindicated when taking barbiturates. Alternative remedies have not shown effectiveness in treating insomnia.

Question 124

``` A nurse is obtaining a health history from an older adult patient in an outpatient clinic. The patient reports chronic difficulty falling asleep and staying asleep. The nurse knows that the best treatment for this patient will be: a. alternative medications. b. improved sleep hygiene. c. short-term barbiturates. d. triazolam (Halcion). ```

Answer 124

B Research has shown that cognitive behavioral therapy is superior to drug therapy for both short-term and long-term management of chronic insomnia in older adults. Alternative remedies have not been proven effective. Barbiturates may elicit paradoxical effects in elderly patients. Triazolam does not help to maintain sleep.

Question 125

A patient complains of chronic insomnia and reports being tired of being tired all the time. The patient is reluctant to try pharmacologic remedies and asks the nurse what to do. What will the nurse suggest? a. “Eat a large meal in the evening to induce drowsiness.” b. “Get out of bed for a while if you can’t fall asleep.” c. “Have a glass of wine at bedtime to relax.” d. “Take a short nap early in the afternoon every day.”

Answer 125

B Rules for sleep fitness recommend getting out of bed if unable to fall asleep in 20 minutes and doing something relaxing and then returning to bed when drowsy. Eating a large meal will increase insomnia. Drinking alcohol helps some people to fall asleep but causes fragmented sleep. Taking a nap reduces feelings of drowsiness at bedtime.

Question 126

``` A nurse recognizes that the actions of benzodiazepines include which findings? (Select all that apply.) a. Sleep deprivation b. Relief of general anxiety c. Suppression of seizures and/or seizure activity d. Development of tardive dyskinesia e. Increase in muscle spasms ```

Answer 126

B, C Benzodiazepines are indicated to relieve the symptoms of general anxiety and to suppress the central nervous system, thereby suppressing seizures and/or seizure activity. Benzodiazepines cause sleepiness, not sleep deprivation. Benzodiazepines do not cause tardive dyskinesia. Benzodiazepines relax muscles; they do not increase muscle spasms.

Question 127

``` Which sedative-hypnotics are useful for both difficulty falling asleep and difficulty maintaining sleep? (Select all that apply.) a. Eszopiclone (Lunesta) b. Flurazepam c. Temazepam (Restoril) d. Triazolam (Halcion) e. Extended-release zolpidem (Ambien CR) ```

Answer 127

A, B, E Eszopiclone (Lunesta), flurazepam, and extended-release zolpidem (Ambien CR) all help with difficulty falling asleep and difficulty maintaining sleep. Temazepam is useful for maintaining sleep only. Triazolam helps with difficulty falling asleep but does not maintain sleep.

Question 128

An agitated, extremely anxious patient is brought to the emergency department. The prescriber orders a benzodiazepine. The nurse understands that benzodiazepines are used in this clinical situation based on which principle? a. Benzodiazepines have a very short half-life. b. Physical dependence is not a risk when taking benzodiazepines. c. Benzodiazepines are known to cure generalized anxiety. d. Benzodiazepines have a rapid onset of action.

Answer 128

D The patient is clearly in a state of extreme, uncontrolled anxiety. Benzodiazepines are the drug of choice for acute episodes of anxiety because of their rapid onset of action. Benzodiazepines do not have a very short half-life. Benzodiazepines are associated with physical dependence. Benzodiazepines do not cure generalized anxiety, nor do any other drugs.

Question 129

``` A nurse is admitting a patient to a hospital unit and is taking a history. The patient reports taking alprazolam (Xanax) for “nerves.” The nurse knows that this patient is most likely being treated for which condition? a. Generalized anxiety disorder b. Obsessive-compulsive disorder (OCD) c. Panic disorder d. Post-traumatic stress disorder (PTSD) ```

Answer 129

A Benzodiazepines are first-choice drugs for anxiety, and alprazolam and lorazepam are prescribed most often. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs for the treatment of OCD. Panic disorder is treated with any of the three classes of antidepressants: SSRIs, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Research has not shown any drug to be effective in the treatment of PTSD, although two SSRIs have been approved for use for this disorder.

Question 130

A nurse is preparing a patient to change from taking lorazepam (Ativan) for anxiety to buspirone (Buspar). Which statement by the patient indicates a need for further teaching? a. “I can drink alcohol when taking Buspar, but not grapefruit juice.” b. “I may need to use a sedative medication if I experience insomnia.” c. “I may not feel the effects of Buspar for a few weeks.” d. “I should stop taking the Ativan when I start taking the Buspar.”

Answer 130

D Ativan should not be withdrawn quickly; it needs to be tapered to prevent withdrawal symptoms. Moreover, Buspar does not have immediate effects. Because no cross-dependence occurs with these two medications, they may be taken together while the benzodiazepine is tapered. Because Buspar does not have sedative effects, patients can consume alcohol without increasing sedation. Levels of Buspar can be increased by grapefruit juice, leading to drowsiness and a feeling of dysphoria. Buspar can cause nervousness and excitement and does not have sedative effects, so patients with insomnia must use a sedative. Buspar does not have immediate effects.

Question 131

``` A patient reports having occasional periods of tremors, palpitations, nausea, and a sense of fear. To treat this condition, the nurse anticipates the provider will prescribe a drug in which drug class? a. Benzodiazepines b. Monoamine oxidase inhibitors c. Selective serotonin reuptake inhibitors d. Tricyclic antidepressants ```

Answer 131

C This patient is showing characteristics of panic disorder. All three major classes of antidepressants are effective, but selective serotonin reuptake inhibitors are first-line drugs. Benzodiazepines are second-line drugs and are rarely used because of their abuse potential. MAOIs are effective but are difficult to use because of side effects and drug and food interactions. Tricyclic antidepressants are second-line drugs, and their use is recommended only after a trial of at least one SSRI has failed.

Question 132

``` A patient describes feelings of anxiety and fear when speaking in front of an audience and is having difficulty at work because of an inability to present information at meetings three or four times each year. The patient is reluctant to take long-term medications. The nurse will expect the provider to order which treatment? a. Alprazolam (Xanax) as needed b. Cognitive behavioral therapy c. Paroxetine (Paxil) d. Psychotherapy ```

Answer 132

A This patient is describing social anxiety disorder; the symptoms are related to performance only and are not generalized to all social situations. Because this patient must speak in front of an audience only three or four times per year, a PRN medication can be used. Cognitive behavioral therapy is used for OCD. Paroxetine must be used continuously for at least 1 year. Psychotherapy can be used but is more effective when used in combination with drugs.

Question 133

During an admission history, a patient reports a frequent need to return to a room multiple times to make sure an iron or other appliance is unplugged. What does the nurse understand about this patient’s behavior? a. It helps the patient reduce anxiety about causing a fire. b. It usually is treated with clomipramine (Anafranil). c. It seems perfectly normal to the patient. d. It will best respond to deep brain stimulation.

Answer 133

A Patients with OCD have compulsive behaviors, such as repeatedly checking to make sure appliances have been unplugged. The compulsion is a ritualized behavior resulting from obsessive anxiety or fear that something bad will happen, such as starting a fire with an overheated appliance. Clomipramine is not a first-line drug for treating OCD. Patients usually understand that compulsive behaviors are excessive and senseless but are unable to stop. Deep brain stimulation is indicated for patients in whom other treatments have failed; its effectiveness at reducing symptoms has been shown to be about 40%.

Question 134

``` Selective serotonin reuptake inhibitors are known to be effective for which disorders? (Select all that apply.) a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder c. Panic disorder d. Post-traumatic stress disorder e. Social anxiety disorder ```

Answer 134

A, B, C, E SSRIs have been shown to be effective in treating GAD, OCD, panic disorder, and social anxiety disorder. They are used to treat PTSD but have not demonstrated effectiveness in clinical research.

Question 135

A nurse is teaching a group of nursing students about cyclooxygenase inhibitors. Which statement by a student indicates understanding of the teaching? a. “Cyclooxygenase-2 inhibition causes gastrointestinal side effects.” b. “Cyclooxygenase-2 is considered the ‘bad COX.’” c. “Inhibition of cyclooxygenase-1 promotes myocardial infarction and stroke.” d. “Inhibition of cyclooxygenase-1 results in suppression of inflammation.”

Answer 135

B Because cyclooxygenase-2 (COX-2) primarily mediates harmful processes in the body, it is called the “bad COX”; suppression of COX-2 results in largely beneficial effects. The gastrointestinal (GI) side effects of COX inhibitors are the result of COX-1 inhibition. One of two harmful side effects of COX-2 inhibition is suppression of vasodilation, which leads to an increased risk of myocardial infarction (MI) and stroke. Inhibition of COX-2 causes suppression of inflammation.

Question 136

A patient who takes daily doses of aspirin is scheduled for surgery next week. The nurse should advise the patient to: a. continue to use aspirin as scheduled. b. reduce the aspirin dosage by half until after surgery. c. stop using aspirin immediately. d. stop using aspirin 3 days before surgery.

Answer 136

C Aspirin must be withdrawn at least 1 week before surgery. Aspirin cannot be continued as scheduled, because the risk for bleeding is too great. An interval of 3 days is not long enough for the bleeding effects of aspirin to be reversed. Cutting the dose in half would not reduce the effects of bleeding associated with aspirin use.

Question 137

A patient who is taking acetaminophen for pain wants to know why it does not cause gastrointestinal upset, as do other over-the-counter pain medications. The nurse will explain that this is most likely because of which property of acetaminophen? a. It does not inhibit cyclooxygenase. b. It has minimal effects at peripheral sites. c. It is more similar to opioids than to nonsteroidal anti-inflammatory drugs (NSAIDs). d. It is selective for cyclooxygenase-2.

Answer 137

B The differences between the effects of acetaminophen and aspirin are thought to result from selective inhibition of cyclooxygenase; acetaminophen has only minimal effects on cyclooxygenase at peripheral sites, which may explain why acetaminophen does not have adverse GI, renal, and antiplatelet effects. Acetaminophen is a selective COX inhibitor. It is not more similar to opioids than NSAIDs. It is not selective for COX-2.

Question 138

A patient tells the nurse that she takes aspirin for menstrual cramps, but she does not feel that it works well. What will the nurse suggest? a. The patient should avoid any type of COX inhibitor because of the risk of Reye’s syndrome. b. The patient should increase the dose to a level that suppresses inflammation. c. The patient should use a first-generation nonsteroidal anti-inflammatory medication instead. d. The patient should use acetaminophen because of its selective effects on uterine smooth muscle.

Answer 138

``` C Aspirin (ASA) has analgesic effects for joint pain, muscle pain, and headache, but it is relatively ineffective against visceral pain, including uterine smooth muscle pain, for which NSAIDs are indicated. The risk of Reye’s syndrome is associated with the use of ASA in children to treat fever. Increasing the ASA dose to anti-inflammatory levels is useful for rheumatic fever, tendonitis, and bursitis. Acetaminophen is not effective for dysmenorrhea. ```

Question 139

A patient who takes aspirin for rheumatoid arthritis is admitted to the hospital complaining of headache and ringing in the ears. The plasma salicylate level is 300 mcg/mL, and the urine pH is 6.0. What will the nurse do? a. Increase the aspirin dose to treat the patient’s headache. b. Notify the provider of possible renal toxicity. c. Prepare to provide respiratory support, because the patient shows signs of overdose. d. Withhold the aspirin until the patient’s symptoms have subsided.

Answer 139

D This patient shows signs of salicylism, which occurs when ASA levels climb just slightly above therapeutic level. Salicylism is characterized by tinnitus, sweating, headache, and dizziness. Tinnitus is an indication that the maximum acceptable dose has been achieved. Toxicity occurs at a salicylate level of 400 mcg/mL or higher. ASA should be withheld until the symptoms subside and then should be resumed at a lower dose. Increasing the dose would only increase the risk of toxicity. Signs of renal impairment include oliguria and weight gain, which are not present in this patient. This patient has salicylism, not salicylate toxicity, so respiratory support measures are not indicated.

Question 140

``` An adolescent is brought to the emergency department by a parent who reports that the patient took a whole bottle of extended-release acetaminophen tablets somewhere between 8 and 10 hours ago. The nurse will anticipate administering which of the following? a. Acetylcysteine (Mucomyst) b. Activated charcoal c. Hemodialysis d. Respiratory support ```

Answer 140

A The nurse should anticipate giving acetylcysteine, because it is the specific antidote for acetaminophen overdose. It is 100% effective when given within 8 to 10 hours after ingestion and may still have some benefit after this interval. Activated charcoal is effective only if given before the medication is absorbed, so it must be given much sooner. Hemodialysis is not indicated. Respiratory support is used for ASA overdose.

Question 141

``` An older male patient with an increased risk of MI is taking furosemide (Lasix) and low-dose aspirin. The patient is admitted to the hospital, and the nurse notes an initial blood pressure of 140/80 mm Hg. The patient has had a 10-pound weight gain since a previous admission 3 months earlier. The patient has voided only a small amount of concentrated urine. The serum creatinine and blood urea nitrogen (BUN) levels are elevated. The nurse will contact the provider to discuss: a. adding an antihypertensive medication. b. obtaining serum electrolytes. c. ordering a potassium-sparing diuretic. d. withdrawing the aspirin. ```

Answer 141

D This patient shows signs of renal impairment, as evidenced by weight gain despite the use of diuretics, decreased urine output, hypertension, and elevated serum creatinine and BUN. ASA can cause acute, reversible renal impairment and should be withdrawn. Hypertensive medications do not treat the underlying cause. Serum electrolytes are not indicated. Addition of a potassium-sparing diuretic is not indicated.

Question 142

A pregnant patient in her third trimester asks the nurse whether she can take aspirin for headaches. Which response by the nurse is correct? a. “Aspirin is safe during the second and third trimesters of pregnancy.” b. “Aspirin may cause premature closure of the ductus arteriosus in your baby.” c. “Aspirin may induce premature labor and should be avoided in the third trimester.” d. “You should use a first-generation nonsteroidal anti-inflammatory medication.”

Answer 142

B Aspirin poses risks to the pregnant patient and her fetus, including premature closure of the ductus arteriosus. ASA is not safe, especially in the third trimester, because it can cause anemia and can contribute to postpartum hemorrhage. ASA does not induce labor but can prolong labor by inhibiting prostaglandin synthesis. NSAIDs have similar effects and also should be avoided.

Question 143

``` A nurse is caring for a patient who has been taking low-dose aspirin for several days. The nurse notes that the patient has copious amounts of watery nasal secretions and an urticarial rash. The nurse will contact the provider to discuss: a. administering epinephrine. b. changing to a first-generation NSAID. c. reducing the dose of aspirin. d. giving an antihistamine. ```

Answer 143

A Aspirin can cause a hypersensitivity reaction in some patients. This may start with profuse, water rhinorrhea and progress to generalized urticaria, bronchospasm, laryngeal edema, and shock. It is not a true anaphylactic reaction, because it is not mediated by the immune system. Epinephrine is the treatment of choice. Patients with sensitivity to ASA often also have sensitivity to NSAIDs; the first indication with this patient is to treat the potential life-threatening effect, not to change the medication. Reduction of the dose of ASA is not indicated, because this reaction is not dose dependant. Antihistamines are not effective, because this is not an allergic reaction.

Question 144

A nurse is teaching a nursing student who wants to know how aspirin and nonaspirin first-generation NSAIDs differ. Which statement by the student indicates a need for further teaching? a. “Unlike aspirin, first-generation NSAIDs cause reversible inhibition of cyclooxygenase.” b. “NSAIDs do not increase the risk of MI and stroke; however, unlike ASA, they do not provide protective benefits against those conditions.” c. “Unlike aspirin, first-generation NSAIDs do not carry a risk of hypersensitivity reactions.” d. “Unlike aspirin, first-generation NSAIDs cause little or no suppression of platelet aggregation.”

Answer 144

C Nonaspirin first-generation NSAIDs carry a risk of hypersensitivity reactions similar to the risk posed by ASA. These agents cause reversible COX inhibition, whereas ASA causes irreversible COX inhibition. NSAIDs do not provide protective benefits for MI or stroke, as does ASA. Nonaspirin first-generation NSAIDs do cause suppression of platelet aggregation, but the suppression is reversible.

Question 145

A nurse is providing teaching for an adult patient with arthritis who has been instructed to take ibuprofen (Motrin) for discomfort. Which statement by the patient indicates a need for further teaching? a. “I may experience tinnitus with higher doses of this medication.” b. “I may take up to 800 mg 4 times daily for pain.” c. “I should limit alcohol intake to fewer than three drinks a day.” d. “I will take this medication with meals to help prevent stomach upset.”

Answer 145

A NSAIDs do not cause salicylism and therefore do not cause tinnitus with higher doses. The maximum dose for adults is 3200 mg/day, or 800 mg 4 times/day. Patients taking NSAIDs should be cautioned to limit alcohol intake. Taking NSAIDs with meals helps prevent GI upset.

Question 146

``` A patient with arthritis asks a nurse which nonsteroidal anti-inflammatory medication is best to take. The nurse learns that this patient has a family history of cardiovascular disease. The nurse will recommend which NSAID? a. Celecoxib (Celebrex) b. Diclofenac (Voltaren) c. Ketorolac intranasal (Sprix) d. Naproxen (Aleve) ```

Answer 146

B Naproxen is COX-1 selective, and the risk of MI and stroke appear lower with this drug than with other NSAIDs. Celecoxib is a COX-2 inhibitor and has increased risks of cardiovascular effects. Cardiovascular risks appear to be increased with diclofenac. Ketorolac carries the same risk as other NSAIDs, even with intranasal dosing

Question 147

A nurse is providing medication teaching for a patient who will begin taking diclofenac (Voltaren) gel for osteoarthritis in both knees and elbows. Which statement by the patient indicates understanding of the teaching? a. “Because this is a topical drug, liver toxicity will not occur.” b. “I should cover areas where the gel is applied to protect them from sunlight.” c. “I will apply equal amounts of gel to all affected areas.” d. “The topical formulation has the same toxicity as the oral formulation.”

Answer 147

B Diclofenac is available in topical and oral preparations. Patients should be warned to protect treated areas from sunlight. Side effects occur, such as liver toxicity, even with topical dosing. Patients should apply smaller amounts to the upper extremities. Systemic toxicity is lower with topical formulations.

Question 148

A patient has been receiving intravenous ketorolac 30 mg every 6 hours for postoperative pain for 4 days. The patient will begin taking oral ketorolac 10 mg every 4 to 6 hours to prepare for discharge in 1 or 2 days. The patient asks the nurse whether this drug will be prescribed for management of pain after discharge. The nurse will respond by telling the patient that the provider will prescribe a(n): a. different nonsteroidal anti-inflammatory drug for home management of pain. b. fixed-dose opioid analgesic/nonsteroidal anti-inflammatory medication. c. lower dose of the oral ketorolac for long-term pain management. d. intranasal preparation of ketorolac for pain management at home.

Answer 148

A Ketorolac is not indicated for chronic or minor pain and should not be used longer than 5 days. Patients discharged home will be instructed to use other NSAIDs for pain. A fixed-dose opioid/NSAID is not indicated. Low-dose ketorolac would not be used, because 5 days would have passed. The intranasal therapy would not be indicated after 5 days.

Question 149

A patient who reports regular consumption of two or three alcoholic beverages per day asks about taking acetaminophen when needed for occasional, recurrent pain. What will the nurse tell the patient? a. “Do not take more than 2 gm of acetaminophen a day.” b. “Do not take more than 3 gm of acetaminophen a day.” c. “Do not take more than 4 gm of acetaminophen a day.” d. “Do not take a fixed-dose preparation with opioid analgesics.”

Answer 149

A Acetaminophen poses a risk of liver toxicity when taken chronically or in larger doses, especially when combined with alcohol. Patients who drink regularly should be advised to take acetaminophen in low doses and not to exceed 2 gm per day.