Pharm Exam Final Part 2

A patient's medication regimen for treatment of anxiety has been changed from a benzodiazepine to buspirone (BuSpar). The patient asks the nurse what makes this medication safer than the benzodiazepine he has taken. What is the nurse's best response?

"It will not produce sedation like benzodiazepines." Rationale: Buspirone will not produce sedation. Compared with the benzodiazepines, buspirone (BuSpar) lacks muscle relaxant and anticonvulsant effects; does not cause sedation or physical or psychological dependence; does not increase the CNS depression of alcohol and other drugs; and is not a controlled substance.

An older adult living in a long-term care facility has been receiving lithium 600 mg twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. What is the most appropriate nursing intervention?

*Withholding the next dose of lithium and drawing blood to test it for toxicity * Obtaining a prescription for the antidote to lithium and administering it immediately Suggesting that the practitioner replace the lithium for an antiepileptic that will control the mania Assessing the client for coarse hand tremor and, if it is present, giving the daily dose of lithium with a bit of water

Amitriptyline (Elavil)

- Blocks NE and 5HT serotonin -Use: MS symptoms, treats depression, pain, insomnia, incontinence, 1st line fibromyalgia, bed wetting, OCD, panic attack -AE/SE: orthostatic hypotension, anticholinergic effects, sedation, enhance opioids, muscle stiffness, nausea, constipation, nervousness, dizziness, tremor, blurred vision, and changes in sexual function, hypomania, cardiac toxicity, seizures *takes 1-2 weeks to work *blocks reuptake of indirect sympathomimetic drugs *prolongs direct acting sympathomimetic drugs Effects: For depression → increases mood, appetite, decreases morbid ideas, increases alertness, normalizes sleep patterns, and increase activity. (second-line drug) For Bipolar → helps with the depressive episodes that occur with this disorder Fibromyalgia syndrome → reduces symptoms of pain, irregular sleeping, profound fatigue, insomnia, and cognitive dysfunction Can help with ADHD, OCD, neuropathic pain, and chronic insomnia

Chlorpromazine (Thorazine)

- Chlorpromazine is used to treat psychotic disorders such as schizophrenia or manic-depression, and severe behavioral problems in children ages 1 through 12. Chlorpromazine is also used to treat nausea and vomiting, anxiety before surgery, chronic hiccups, acute intermittent porphyria, and symptoms of tetanus. - This medication can cause photophobic skin reactions and damage to the retina of the eye if exposed to direct sunlight. PTs taking this should be reminded to wear protective clothing, apply sunscreen and wear sunglasses when they are outside.

estrogen and progesterone

- bone mineralization and lipid metabolism/ biosynthesis and elimination/cholesterol levels/blood coagulation/menopause/acne -AE: endometrial hyperplasia and carcinoma/promotes growth of existing breast cancer/ovarian cancer/nausea/ cardiovascular diseases

Finasteride (Proscar)

- treats BPH -increase cancer risk in healthy men, lower dose is used in male baldness -can protect against prostate cancer but only low grade -AE/SE: not for preggers (teratogenic to male fetus), decreased ejaculation, and libido, gynecomastia

Clozapine (Clozaril)

-2nd gen antipsychotic -Use: schizophrenia and levodopa-induced psychosis -AE/SE: sedation/weight gain, orthostatic hypotension, dry mouth, blurred vision, tachycardia, urinary retention, constipation, weight gain, DM, dyslipidemia. *agranulocytosis-keep count of WBC stop if <3000

Tegretol (carbamazepine)

-Anti-seizure, not for absence, myoclonic, or atonic seizure - best for partial seizures/anti-epileptic/mood stabilizer/ nerve pain *Don't give to pregnant, or HF *don't give to warfarin -phenytoin and phenobarbital decreases this drug -grapefruit causes toxicity -don't take with erythromycin -accelerates levothyroxine metabolism -Bone marrow suppression: leukopenia in beginning, thrombocytopenia and anemia always AE: SJS, water retention, nystagmus, ataxia, hepatotoxicity

Buspar (buspirone)

-Antianxiety -Advantages over BNZ: doesn't cause CNS depression, has no abuse potential, and does not intensify the effects of CNS depressants -levels can be increased by erythromycin, ketoconazole, and grapefruit juice -Disadvantage: anxiolytic effect develops slowly- takes a week -Common Rx: dizziness, nausea, headache, nervousness, lightheadedness, and excitement

Thorazine (chlorpromazine)

-Antipsychotic -anticholinergic and alpha blocking -blocks receptors for dopamine in the striatum -AE/SE: dizziness, drowsiness, anxiety, insomnia, dry mouth/ agranulocytosis *decreases therapeutic effects of levodopa

Lithium

-Bipolar mood -preferred for acute manic episodes -full benefits in 2-3 weeks; anti-manic effects in 5-7 days -rapid renal excretion -short 1/2 life -lithium excretion is decreased when serum sodium level is low -when Na is low, kidneys retain sodium and lithium --> increased serum lithium level -Therapeutic levels - 0.6 - 1.2 mEq/L -- toxicity >1.5 mEq/L AE: (<1.5) N/V/D/polyuria/polydipsia/muscle weakness/ lethargy/slurred speech (1.5-2) GI upset, hand tremor, muscle hyper irritability, ECG changes (2-2.5) Ataxia giddiness, high output of diluted urine, tinnitus, blurred vision, seizure, stupor, coma, death (>2.5) generalized convulsions, oliguria, death

Donepezil

-Cholinesterase Inhibitor (Alzheimer's) -increases acetylcholine availability at cholinergic synapses -modest improvements in cognition, behavior, and function in 1/12 AD Pt's -Side Effects: Cholinergic side effects, GI effects (N/V/dyspepsia/diarrhea); can cause bradycardia, fainting, falls, and pacemaker placement; can also cause bronchoconstriction (elevation of ACH at synapses in the lungs) -Drugs that block cholinergic receptors (1st gen. antihistamines, TCA, conventional antipsychotics) can reduce cholinesterase inhibitors

Ergotamine

-Ergot alkaloid: vascular effect prototype, causes prolonged vasoconstriction, uterine contraction. Used in migraine, obstetrics -alters transmission at different junctions -Treats migraines and headaches- 2nd line meds -AE: N/V/weakness in the legs and tingling; angina-like pain, ischemia, gangrene *Do not combine with triptans or CYP4A3 *Can cause physical dependence -Not for pregnancy, CAD, uncontrolled HTN, Ren/Hep problems

Memantine (Namenda)

-NMDA receptor antagonist (Alzheimer's disease) -approved for moderate to severe AD -only modest beneficial effects -better tolerated than cholinesterase inhibitors -common side effects: dizziness, headache, confusion, and constipation

Gabapentin (Neurontin)

-anti-seizure, mood stabilizer, and nerve pain -enhances GABA release -Use: neuropathic pain, MS symptoms, anticonvulsant, adjunctive for seizures -AE/SE: fatigue, nausea, sedation, drowsiness, dizziness, and weight gain

Cervidil (Dinoprostone)

-cervical ripening agent, oxytocics, prostaglandins -Naturally occurring form of prostaglandin -Ripens the cervix & can stimulate the smooth muscle of the uterus to enhance uterine contractions -12 hours- removed & oxytocin can be started 30 minutes later -induction of labor or abortion

Ethosuximide

-suppresses neurons in thalamus that are responsible for absence seizures -Use: absense seizures -AE/SE: drowsiness, dizziness, lethargy, N/V,SJS rare, SLE, fatigue -take with food -doesn't cause hepatotoxicity *don't stop abruptly, monitor seizure activity

A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son:

1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." **** 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together." The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

A practitioner prescribes routine checks of the client's lithium level to be performed. How many hours after the last dose of lithium should the nurse plan to obtain the blood specimen?

A 2 to 4 B 4 to 6 C 6 to 8 D 8 to 12 *** Lithium absorption and excretion occur 8 to 12 hours after the last dose. Concentrations may be falsely higher at 2 to 4, 4 to 6, or 6 to 8 hours after administration, affecting the reliability of the readings.

A nurse discusses the implications of diet and fluid intake with a client who is receiving lithium therapy. What should the nurse teach the client and family about nutrition?

A A regular diet should be maintained. *** B Daily fluid intake should be limited to 1 L. C Daily salt intake should be limited to 2,000 g. D A weight-reducing diet should be implemented. A regular diet maintains sodium balance; lithium decreases sodium resorption by the renal tubules. Initially, weight-reducing diets deplete body fluids; this can result in lithium retention and toxicity. Lithium is excreted in urine; decreased fluid intake and a consequent decreased urine output can result in lithium retention and toxicity. Limitation of daily salt intake to 2,000 g is unsafe because lithium decreases sodium resorption, resulting in sodium excretion; sodium intake should not be decreased.

The nurse reads in the patient's medication history that the patient is taking buspirone (BuSpar). The nurse interprets that the patient may have which disorder?

A Anxiety disorder *** B Depression C Schizophrenia D Bipolar disorder

Lithium carbonate 600 mg by mouth three times a day is prescribed for a client. The nurse concludes that the teaching about its side effects is understood when the client says that she will call her primary health care provider immediately if she notices any:

A Difficulty urinating B Sensitivity to bright light or sun C Fine hand tremor or slurred speech *** D Sexual dysfunction or breast enlargement Fine hand tremor or slurred speech in a person taking lithium may signal the development of toxicity; signs of toxicity include marked tremors, lack of coordination, sluggishness, and confusion. Lithium carbonate can cause polyuria and incontinence, not urine retention. Sensitivity to bright light or sun is a side effect of the phenothiazine group of medications. Neither sexual dysfunction nor breast enlargement is associated with lithium carbonate intake.

What medication should the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

A Lithium B Flumazenil ** C Methadone D Chlorpromazine Flumazenil (Romazicon) is the drug of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. Flumazenil medication competitively inhibits activity at benzodiazepine recognition sites on γ-aminobutyric acid-benzodiazepine receptor complexes. Lithium is used in the treatment of mood disorders. Methadone is used for narcotic addiction withdrawal. Chlorpromazine is contraindicated in the presence of central nervous system depressants.

A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline:

A Renal studies *** B Liver enzyme studies C Adrenal function studies D Pulmonary function studies Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be used for comparison in the future. Liver enzyme studies are not necessary; lithium does not alter liver function. Adrenal function studies are not necessary; lithium does not alter adrenal gland functions. Pulmonary function studies are not necessary; lithium does not cause alterations in pulmonary function.

A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine?

A Risk for falls B Inability to sit still C Increase in temperature *** D Dizziness upon standing Clozapine (Clozaril) may cause agranulocytosis, which can result in the development of infection. Risk for falls is more common with typical antipsychotic medications because they may cause orthostatic hypotension and extrapyramidal side effects. Inability to sit still (akathisia) and dizziness upon standing (orthostatic hypotension) are more common with typical antipsychotics because they may cause extrapyramidal side effects.

A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do?

A Stay in bed, drink fluids, take a dose of aspirin, and ask the health care provider to reduce the dosage of clozapine. B Discontinue the medication immediately and see the health care provider as soon as an appointment becomes available. C Continue the medication, drink fluids, take aspirin, and see the health care provider in a few days if the symptoms do not improve. D Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation. ****

An older adult living in a long-term care facility has been receiving lithium 600 mg twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. What is the most appropriate nursing intervention?

A Withholding the next dose of lithium and drawing blood to test it for toxicity *** B Obtaining a prescription for the antidote to lithium and administering it immediately C Suggesting that the practitioner replace the lithium for an antiepileptic that will control the mania D Assessing the client for coarse hand tremor and, if it is present, giving the daily dose of lithium with a bit of water

Methadone (Dolophine)

Abstinence maintenance med. Binds with opiate receptors in CNS to produce analgesic and euphoric effects. Prevents withdrawal symptoms in clients who were addicted to opiate drugs. Precautions/interactions: do not use in clients who have severe asthma, chronic respiratory disease, or history of head injury. Side/adverse effects: sedation, respiratory depression, paradoxical CNS excitation.

A client has been taking the prescribed dose of clozapine. The nurse will assess the client for which life-threatening side effect of this drug?

Agranulocytosis

Clozapine, an atypical antipsychotic, is prescribed for a client with psychosis. It is important for client to have frequent blood tests for which possible complication?

Agranulocytosis

Haloperidol (Haldol)

An antipsychotic drug thought to block receptor sites for dopamine, making it effective in treating the delusional thinking, hallucinations and agitation commonly associated with schizophrenia.

Phenytoin (Dilantin)

Anticonvulsant

Sumatriptan (Imitrex)

Antimigraine

Phenobarbital (Luminal)

Antiseizure med. Precautions/interactions: contraindicated in history of substance use disorder. Side effects: drowsiness, hypotension, respiratory depression.

A client who is on haloperidol therapy has developed akathisia and acute dystonia. Which drugs would be used to manage extrapyramidal effects?

Benztropine Trihexyphenidyl

A patient with a history of abusing prescription painkillers is being treated for anxiety. Which medication should the nurse expect to be prescribed?

Buspirone

Which anxiolytic drug promotes agonistic activity at both the serotonin and dopamine receptors?

Buspirone Buspirone is an anxiolytic drug, which has agonist activity at both the serotonin and dopamine receptors to exert its antianxiety effect. Alprazolam is a benzodiazepine that is commonly used as an anxiolytic. The drug elicits its effects by increasing the activity of gamma-aminobutyric acid (GABA) receptors that block nerve transmission in the central nervous system. Lorazepam is an intermediate-acting benzodiazepine that increases the activity of the GABA receptors. Amitriptyline is the most commonly used tricyclic antidepressant.

The nurse is describing an anxiolytic that has no sedative, anticonvulsant, or muscle relaxant properties, but is effective in reducing the signs and symptoms of anxiety. Which agent would the nurse most likely be describing?

Buspirone Rationale: Buspirone has no sedative, anticonvulsant, or muscle relaxant properties, but it does reduce the signs and symptoms of anxiety. Zaleplon causes sedation and is used for short-term treatment of insomnia. Meprobamate has some anticonvulsant properties and central nervous system relaxing effects. Diphenhydramine is an antihistamine that can be sedating.

Which drug used to treat anxiety would be appropriate for a patient who is a school teacher and is concerned about feeling sedated at work?

Buspirone (BuSpar) Rationale: Buspirone does not cause as much sedation and functional impairment as lorazepam, alprazolam, and diazepam. However, it can cause dizziness, nausea, headache, nervousness, lightheadedness, or excitement.

Neostigmine (Prostigmin)

Cholinesterase inhibitor. Prevent cholinesterase from inactivating acetylcholine, resulting in improved transmission of nerve impulses. Used for myasthenia gravis. Precautions/interactions: do not administer if systolic BP is less than 90 mm Hg. Side effects: slow HR, chest pain, weak pulse, increased sweating and dizziness, feeling like need to pass out, weak or shallow breathing, urinating more than usual, seizures, and trouble swallowing. Wear medic alert bracelet. Monitor for cholinergic crisis.

Thiothixene (Navane)

Conventional Antipsychotic for schizophrenia and bipolar disorder. Action: alters effect of dopamine in CNS Contra: hypersensitivity, circulatory collapse, blood dycrasias and CNS depression Caution: geriatric or debillitated clients, diabetes, rest. diseases, prostatic hypertrophy, CNS tumors, epilepsy,

A client who takes insulin for type 1 diabetes has a psychosis and is to receive haloperidol. Which response does a nurse anticipate with this drug combination?

Decreased control of the diabetes

The primary healthcare provider is concerned that one of the clients receiving haloperidol may be developing neuroleptic malignant syndrome. When assessing the client for this syndrome, for which clinical manifestations does the nurse monitor the client?

Diaphoresis and hyperpyrexia

Benzodiazepine antidote?

Flumazenil (Romazicon), short half life, effects fade in an hour -may precipitate seizures & should be given slowly -treats drowsiness post surgery or OD -wakes you up after Benzos

A patient is prescribed buspirone. The nurse teaches this patient not to consume what juice?

Grapefruit juice

The nurse is caring for a 60-year-old client who is diagnosed with dementia. Which antipsychotic drugs would be contraindicated for the client?

Haloperidol Chlorpromazine

The nurse recognizes that buspirone has what advantages over benzodiazepines in the treatment of anxiety? (Select all that apply.)

It does not cause sedation. It has no abuse potential. It does not intensify the effects of a CNS depressant

Which antipsychotic drugs have the higher risk of causing tardive dyskinesia?

Loxapine Haloperidol

Levodopa/Carbidopa

MOA: increase level of DA in the brain; L-dopa can cross the BBB (unlike regular DA) and is converted by dopa darboxylase in the CNS → DA -Carbidopa = blocks peripheral conversion of L-dopa to dopamine by inhibiting DOPA decarboxylase, given w/ L-dopa to ↑ bioavailability of L-dopa in brain/limit peripheral side effects Clinical use: Parkinson's disease Toxicity: arrhythmias from increased peripheral formation of catecholamines; long term use may → dyskinesia following administration w/ akinesia between doses ("on-off" phenomenon)

Pramipexole

Mirapex/ Antiparkinson agent, dopamine agonist

A client has been taking lithium carbonate (Eskalith) for 3 days. The nurse has the client's lithium level checked before administering the medication and finds it to be 0.3 mEq/L. The nurse should:

Notify the practitioner. Administer the medication. Watch for adverse side effects. Withhold the next dose of the medication.

A primary healthcare provider prescribes 10 mg of haloperidol by mouth twice a day for a client who is also receiving phenytoin for control of epilepsy. When planning the client's care, the nurse considers that, when anticonvulsants interact with haloperidol, what effect may occur?

Potentiation of haloperidol's central nervous system depressant effect

The nurse administered donepezil (Aricept) to a client. Which finding indicates that the medication is therapeutic?

The client has increased cognition. Donepezil (Aricept) is used to treat Alzheimer's disease, a disorder of decreased acetylcholine levels in the brain. It can increase cognition.

Amyltripltyline

Tricyclic antidepressant, reduces uptake of 5-HT and NA. Also used as analgaesic

The laboratory report of a client undergoing long-term treatment with lithium carbonate indicates a level of 1.5 mEq/L (1.5 mmol/L). What will the nurse do?

Watch for signs of lithium toxicity.

After reviewing the data of a client who has been taking clozapine for two months, the primary healthcare provider instructs the client to discontinue the drug for a few weeks. Which laboratory parameter assessed by the primary healthcare provider would support the intervention?

White blood cell count of 2,500/mm 3, Because clozapine may cause agranulocytosis

The patient has been taking phenobarbital to control seizures. The patient complains to the nurse of experiencing occasional stomach upset when taking the medication. What is the nurse's best response?

a "You can take the medication with food or milk." *** b "You should take the medication on an empty stomach." c "You should call your health care provider because the dose may need to be adjusted." d "You should call your health care provider because the drug may need to be stopped." The medication can be taken with food or milk to minimize gastric distress, which is an expected side effect of the medication.

What information will the nurse teach the patient who is considering stopping the antiepileptic drug phenytoin?

a "You may go into status epilepticus." *** b "You may have an acute withdrawal." c "You will have severe hypotension." d "You may become confused and delirious." Abrupt withdrawal of antiepileptic drugs can cause the development of status epilepticus. However, stopping phenytoin should not result in acute withdrawal, severe hypotension, or confusion.

A patient asks the nurse why she is receiving a different drug than her usual phenytoin. The patient is to have nothing by mouth and is receiving intravenous fosphenytoin. What is the nurse's best response?

a "Your serum phenytoin levels were not therapeutic, so your health care provider has changed your medication to a more effective drug." b "Phenytoin is not effective while you are to have nothing by mouth, so your health care provider has changed your medication to a more effective drug." c "Fosphenytoin is converted to phenytoin once it is in your bloodstream. Since you are not taking anything by mouth, IV fosphenytoin is easier on your veins than phenytoin." *** d "Since you are not taking medication by mouth, you cannot take phenytoin orally. Phenytoin does not come in an intravenous form. You will resume phenytoin after you recover from this illness." Fosphenytoin is a prodrug of phenytoin developed to minimize the irritating effects of phenytoin on blood vessels. Compared to phenytoin, the pH of fosphenytoin is less alkaline and easier on the veins. Once administered, it is converted in the body to phenytoin.

The nurse is caring for a patient who is starting clozapine (Clozaril). Which nursing intervention is a priority for this patient?

a Assess baseline white blood cell count and absolute neutrophil count. *** b Evaluate suicidal tendencies. c Take a baseline EEG. d Evaluate creatinine clearance. Patients taking clozapine (Clozaril) must be monitored for the life-threatening side effect of agranulocytosis. A baseline white blood cell count and absolute neutrophil count must be taken. Patients started on this medication are chronically and severely ill. Evaluation of suicidal tendencies would not need to happen before the patient started the medication. Patients on this medication may have an increased risk of seizures; however, a baseline EEG will not assist in predicting or preventing this side effect. This medication is metabolized before excretion. Evaluation of creatinine clearance is not a priority for the patient starting on the medication.

While obtaining a patient history, the nurse notes that the patient has been prescribed ethosuximide (Zarontin). What is the nurse's primary assessment?

a Assess patient for absence seizures. *** b Assess patient for panic attacks. c Assess patient for migraines. d Assess patient for tonic-clonic seizures. Ethosuximide (Zarontin) is the first-line drug of choice to treat absence seizures. It does not treat panic attacks, migraines, or tonic-clonic seizures.

A client is diagnosed with Parkinson disease and receives a prescription for levodopa (l-dopa) therapy. The nurse concludes that the medication is appropriate for this client because it:

a Blocks the effects of acetylcholine. b Increases the production of dopamine. c Restores the dopamine levels in the brain. *** d Promotes the production of acetylcholine. Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic drugs. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.

The nurse is developing a teaching plan for a patient prescribed carbidopa-levodopa (Sinemet). What information does the nurse use as a basis for the teaching plan?

a Carbidopa decreases levodopa's conversion in the periphery, increasing the amount of levodopa available to cross the blood-brain barrier. *** b Carbidopa increases levodopa's conversion in the periphery, enhancing the amount of dopamine available to the brain. c Giving both drugs together minimizes side effects. d Carbidopa crosses the blood-brain barrier to increase the metabolism of levodopa to dopamine in the brain. Adding carbidopa to levodopa decreases the breakdown of levodopa in the periphery, increasing the amount available to cross the blood-brain barrier and decreasing the extrapyramidal side effects caused by dopamine in the periphery.

When teaching a patient about the use of tricyclic antidepressants, what will the nurse emphasize?

a Common side effects can be relieved by increasing fluid and fiber intake and sucking hard candy. *** b The patient should notify the health care provider if therapeutic effects are not noted within 10 days. c The drugs are often given with monoamine oxidase inhibitors (MAOIs) for synergistic effect. d Dietary restrictions of beer and chocolate are needed to prevent a hypertensive crisis Tricyclic antidepressants (TCAs) cause anticholinergic side effects, including constipation and dry mouth. The time period required to produce therapeutic effects ranges from 2 to 4 weeks. Concurrent use of MAOIs with amitriptyline may lead to cardiovascular instability and toxic psychosis. The patient does not need to avoid beer and chocolate to prevent a hypertensive crisis as the patient would need to with MAOIs, but beer would potentiate central nervous system depression when taken with TCAs.

The patient is scheduled to begin treatment with carbidopa-levodopa (Sinemet). A family member tells the nurse that the patient has a history of undergoing treatment for narrow-angle glaucoma. What is the highest priority action on the part of the nurse?

a Contact the health care provider with this information. *** b Reassure the family that this will not affect the patient's treatment. c Contact the pharmacist since the dosage will need to be decreased. d Contact the pharmacist since the dosage will need to be increased. Glaucoma is known to be a contraindication to use of carbidopa-levodopa (Sinemet). Adjusting the dosage will not change this fact.

The nurse is monitoring phenytoin (Dilantin) being infused intravenously at 55 mg/min. What action will the nurse take next?

a Continue to monitor the infusion. b Have the drug changed to PO. c Decrease the infusion and assess blood pressure. *** d Increase the infusion. Infusing phenytoin (Dilantin) at rates >50 mg/min can cause severe hypotension or cardiac dysrhythmias. The infusion should not be increased nor discontinued

The nurse assesses a patient taking phenytoin (Dilantin) and finds gingival hyperplasia. What is the nurse's priority action?

a Instruct the patient on oral hygiene. *** b Call for a consult with a dentist. c Call the health care provider. d Hold the next dose of the drug. A side effect of phenytoin (Dilantin) is overgrowth of gum tissue. This can be minimized by frequent oral hygiene. If oral hygiene efforts do not improve gum condition, a consult with a dentist is recommended. Since this is an expected side effect, there is no indication to notify the health care provider or to hold the next dose.

The health care provider prescribes neostigmine (Prostigmin) for a client with myasthenia gravis. The nurse evaluates that the client understands the teaching about this drug when the client says, "I should:

a Keep the drug in a container in the refrigerator." b Take the drug at the exact time that is listed on the prescription." **** c Plan to take the drug between meals to promote absorption." d Expect that the onset of the action of the drug will occur several hours after I take it." Neostigmine should be taken as prescribed, usually before meals, to limit dysphagia and possible aspiration. Keeping neostigmine refrigerated is not necessary; it may be kept at room temperature. Neostigmine should be taken with milk to prevent gastrointestinal irritation; usually it is taken about 30 minutes before meals. The onset of the action of neostigmine occurs 45 to 75 minutes after administration; the duration of its action is 2½ to 4 hours.

The nurse is reviewing a patient's medication history and notes that the patient recently began taking lithium (Lithibid). What intervention is a priority for this patient?

a Monitoring for the recurrence of seizure activity b Assessing lithium levels every other week *** c Asking the patient if they have ringing in the ears d Monitoring the patient's intake and output Lithium is the drug of choice to treat manic episodes associated with bipolar disorders. It has a narrow therapeutic range, and levels should be monitored biweekly until the therapeutic level has been obtained and then monitored monthly on the maintenance dose.

What should the nurse include when teaching a client with severe Parkinson disease about carbidopa-levodopa (Sinemet)?

a Multivitamins should be taken daily b Alcohol consumption should be in moderation c The medication should be taken with meals **** d A high-protein diet should be followed Carbidopa-levodopa should be taken with meals to reduce the nausea and vomiting that commonly are caused by this drug. Multivitamins are contraindicated; vitamins may contain pyridoxine (vitamin B6), which diminishes the effects of levodopa. Moderate amounts of alcohol will antagonize the drug's effects; a rare, occasional drink is not harmful. A high-protein diet is contraindicated. Sinemet contains levodopa, an amino acid that may increase blood urea nitrogen (BUN) levels. Also, some proteins contain pyridoxine, which increases peripheral metabolism of levodopa, decreasing the amount of levodopa crossing the blood-brain barrier.

A client is to receive donepezil (Aricept) for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed?

a Nausea b Dizziness c Headache d Constipation *** Donepezil (Aricept), a cholinesterase inhibitor, may cause nausea, vomiting, increased salivation, diarrhea, and involuntary defecation related to the increase in gastrointestinal secretions and activity caused by parasympathetic nervous stimulation; it does not cause constipation. Common side effects of donepezil include anorexia, nausea, and vomiting that result from stimulation of the parasympathetic nervous system. Dizziness and headache are common side effects of donepezil that result from central nervous system cholinergic effects.

The patient receiving phenytoin (Dilantin) has a serum drug level of 12 mcg/mL. What is the nurse's best action

a Perform a neurological assessment. b Assess the patient's gums and mouth. c Call the health care provider. d Continue to monitor the patient.*** Therapeutic serum drug level for phenytoin (Dilantin) is 10 to 20 mcg/mL. The nurse should continue to monitor. Since the drug is at the therapeutic level, there is no need to intervene further by calling the health care provider or performing a more in-depth assessment.

The patient has been started on donepezil (Aricept). The patient's family member notifies the nurse that the patient fainted at home. What is the highest priority action on the part of the nurse?

a Reassure the family member that this is an expected side effect of the medication. b Instruct the family member not to administer any further doses of the drug. c Notify the health care provider; the patient may need to be taken off the drug. *** d Instruct the family member to call if the patient continues to exhibit fainting episodes. Donezepil (Aricept) is known to cause slow heartbeat and fainting. The health care provider should be notified because the patient may need to be taken off the medication. It is beyond the nurse's scope to take the patient off a drug.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider?

a Shuffling gait b Tremor at rest c Cogwheel rigidity of limbs d Uncontrolled head movement ***

A client with myasthenia gravis has been receiving neostigmine (Prostigmin) and asks about its action. What information about its action should the nurse consider when formulating a response?

a Stimulates the cerebral cortex b Blocks the action of cholinesterase *** c Replaces deficient neurotransmitters d Accelerates transmission along neural sheaths Neostigmine, an anticholinesterase, inhibits the breakdown of acetylcholine (ACh), thus prolonging neurotransmission. Neostigmine's action is at the myoneural junction, not the cerebral cortex. Neostigmine prevents neurotransmitter breakdown but is not a neurotransmitter. Neostigmine's action is at the myoneural junction, not the sheath.

The health care provider is considering placing the patient on memantine (Namenda). The patient's family member tells the nurse that the patient has a history of kidney disease. Based on this information, the nurse anticipates which adjustment in drug therapy?

a The dosage of the drug will be reduced. *** b A different drug will be ordered instead. c The dosage of the drug will be increased. d All drug therapy will be stopped. The reduction in kidney function may lead the health care provider to choose to reduce the dosage of the medication to prevent toxicity from developing.

The patient has been diagnosed with Alzheimer's disease and has been forgetting the location of objects in addition to having difficulty finding the word to use in conversation. The patient has been started on donepezil (Aricept). The patient is most likely in which stage of the disease process?

a Very mild *** b Mild c Moderate d Moderately severe Donepezil (Aricept) can be used in all stages of Alzheimer's disease. The symptoms noted will occur in the very mild stage of Alzheimer's disease.

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply.

a Vomiting *** b Anorexia *** c Slow heart rate d Changes in mood *** e Peripheral edema Nausea and vomiting may occur; it reflects a central emetic reaction to levodopa. Anorexia may occur; decreased appetite results because of nausea and vomiting. Changes in affect, mood, and behavior are related to toxic effects of the drug. Tachycardia and palpitations, not bradycardia, occur. Peripheral edema is not a side effect of carbidopa-levodopa.

A patient who has parkinsonism will begin taking carbidopa-levodopa. What information will the nurse include when teaching this patient about this medication?

a. "Call your health care provider immediately if your urine or perspiration turn a dark color." b. "Rise slowly from your bed or your chair to avoid dizziness and falls." *** c. "Take the drug with foods high in protein to improve drug delivery." d. "Discontinue the drug if you experience insomnia."

A 25 year-old female patient will begin taking phenytoin for epilepsy. The patient tells the nurse she is taking oral contraceptives (OCPs). Which response will the nurse give?

a. "Continue taking OCPs because phenytoin is not safe during pregnancy." b. "You should use a backup method of contraception along with OCPs."*** c. "You should stop taking OCPs because of drug-drug interactions with phenytoin." d. "You should take low-dose aspirin while taking these medications to reduce your risk of stroke."

The nurse provides teaching for a patient who will begin taking lithium (Lithibid). Which statement by the patient indicates understanding of the teaching?

a. "I may drink tea or cola but not coffee." b. "I may stop taking the drug when mania symptoms subside." c. "I should consume a sodium-restricted diet." d. "I should drink 2 to 3 liters of fluid each day." *** ANS: D Patients taking lithium should be encouraged to maintain adequate fluid intake of 2 to 3 L/day initially and then 1 to 2 L/day as maintenance. Patients should not drink any caffeine-containing drinks, including tea and cola. Patients must continue taking lithium even when symptoms subside, or else symptoms will recur. It is not necessary to consume a sodium-restricted diet.

The nurse is teaching a patient who has Parkinson's disease about the side effects of carbidopa-levodopa. Which statement by the patient indicates a need for further teaching?

a. "I may experience urinary retention, dry mouth, and constipation." b. "I may feel dizzy at first, but this side effect will go away with time." c. "I should report nightmares and mental disturbances to my provider." d. "I should take the drug with food to increase absorption." ***

When administering phenytoin, the nurse realizes more teaching is needed if the patient makes which statement?

a. "I must shake the oral suspension very well before pouring it in the dose cup." b. "I cannot drink alcoholic beverages when taking phenytoin." c. "I should take phenytoin 1 hour before meals." *** d. "I will need to get periodic dental checkups."

A patient who is about to begin taking the atypical antipsychotic medication clozapine (Clozaril) is concerned about side effects. What information will the nurse include when teaching the patient about this medication?

a. "You are more likely to experience dry mouth, constipation, and urinary retention." (this is with lithium) b. "You may experience weight gain, drowsiness, and headaches." *** c. "You will not experience extrapyramidal side effects with this medication." d. "You will not need frequent lab work while taking this medication."

A patient who takes phenytoin reports regular alcohol consumption. The nurse might expect a serum phenytoin level in this patient to be in which range?

a. 5 to 10 mcg/mL *** b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 50 mcg/mL

A female patient who takes phenytoin for epilepsy becomes pregnant. The nurse will notify the patient's provider and will anticipate that the provider will take which action?

a. Add valproic acid (Depakote) for improved seizure control. b. Change the medication to phenobarbital (Luminal). **** c. Closely monitor this patient's serum phenytoin levels. d. Discontinue all anticonvulsant medications.

The nurse is preparing to administer a dose of lithium (Lithibid) to a patient who has been taking the drug as maintenance therapy to treat bipolar disorder. The nurse assesses the patient and notes tremors and confusion. The patient's latest serum lithium level was 2 mEq/L. Which action will the nurse take?

a. Administer the dose. b. Hold the dose and notify the provider. (**** c. Request an order for a higher dose. d. Request an order for a lower dose. The patient has symptoms of lithium toxicity, and the serum drug level is in toxic range. The nurse should hold the dose and notify the provider.

The nurse is preparing to administer phenytoin to an 80-year-old patient and notes the following order: IVP phenytoin 50 mg. The nurse will perform which action?

a. Administer the undiluted drug through a Y-tube over two minutes.

A patient has recently begun taking carbamazepine (Tegretol) as an adjunct medication to treat refractory seizures. The patient has a serum carbamazepine level of 18 mcg/mL. What action will the nurse take?

a. Ask the patient about usual dietary preferences. *** b. Reassure the patient that this is a therapeutic drug level. c. Report a subtherapeutic drug dose to the provider. d. Suspect a drug-drug interaction.

A patient has recently begun taking phenytoin (Dilantin) for a seizure disorder. The nurse notes a reddish-brown color to the patient's urine. Which action will the nurse take?

a. Ask the provider to order a serum drug level. b. Reassure the patient that this is a harmless side effect. *** c. Report possible thrombocytopenia to the provider. d. Request an order for a urinalysis and creatinine clearance.

A nurse performs a medication history on a newly admitted patient. The patient reports taking amitriptyline (Elavil) 75 mg at bedtime for 6 weeks to treat depression. The patient reports having continued fatigue, lack of energy, and depressed mood. The nurse will contact the provider to discuss which intervention?

a. Beginning to taper the amitriptyline *** b. Changing to a morning dose schedule c. Giving the amitriptyline twice daily d. Increasing the dose of amitriptyline The response to tricyclic antidepressants (TCAs) should occur after 2 to 4 weeks of therapy. If there is no improvement at this time, the TCA should be gradually withdrawn and an SSRI prescribed. TCAs should never be stopped abruptly. TCAs cause fatigue and drowsiness, so they should be given at bedtime. Changing the dose or the dosing schedule are not indicated.

The nurse is preparing to assist with blood collection on a newly admitted patient who has been taking phenytoin for several years. The provider has ordered a complete blood count and liver function tests. Which other blood test will the nurse discuss with the provider?

a. Blood glucose **** b. Coagulation studies c. Renal function tests d. Serum electrolytes

The nurse is caring for a patient who has been diagnosed with petit mal seizures. The nurse will anticipate teaching this patient about which antiepileptic medication?

a. Carbamazepine (Tegretol) b. Ethosuximide (Zarontin) *** c. Phenobarbital (Luminal) d. Phenytoin (Dilantin)

An older patient exhibits a shuffling gait, lack of facial expression, and tremors at rest. The nurse will expect the provider to order which medication for this patient?

a. Carbidopa-levodopa (Sinemet) *** b. Donepezil (Aricept) c. Rivastigmine (Exelon) d. Tacrine (Cognex)

A patient is receiving carbidopa-levodopa for parkinson- ism. What should the nurse know about this drug?

a. Carbidopa-levodopa may lead to hypertension. b. Carbidopa-levodopa may lead to excessive salivation. c. Dopaminergic and anticholinergic therapy may lead to drowsiness and sedation. d. Dopaminergics and anticholinergics are contraindi- cated in patients with glaucoma. ***

The nurse assesses a patient who is taking lithium (Lithibid) and notes a large output of clear, dilute urine. The nurse suspects which cause for this finding?

a. Cardiovascular complications b. Expected lithium side effects c. Increased mania d. Lithium toxicity *** An increased output of dilute urine is a sign of lithium toxicity.

A patient who has recently begun taking lithium (Lithibid) calls the clinic to report nausea, vomiting, anorexia, and drowsiness. What will the nurse do next?

a. Contact the provider to obtain an order for a serum lithium level. b. Reassure the patient that these symptoms are common and transient. c. Tell the patient that the lithium dose is probably too low. d. Tell the patient to stop taking the medication immediately. ANS: A Early symptoms of lithium toxicity include nausea and vomiting, anorexia, and drowsiness. The nurse should obtain an order for a lithium level to evaluate this. Patients should be encouraged to report these symptoms if they occur. Patients should never be counseled to stop the medication abruptly.

Which is a nursing intervention for a patient taking carbidopa-levodopa for Parkinsonism?

a. Encourage the patient to adhere to a high-protein diet. b. Inform the patient that perspiration may be dark and stain clothing. *** c. Advise the patient that glucose levels should be checked with urine testing. d. Warn the patient that it may take 4 to 5 days before symptoms are controlled.

A patient who is taking amitriptyline (Elavil) reports constipation and dry mouth. The nurse will give the patient which instruction?

a. Increase fluid intake. *** b. Notify the provider. c. Request another antidepressant. d. Stop taking the medication immediately. Constipation and dry mouth are common side effects of tricyclic antidepressants (TCAs), and patients should be taught to manage these symptoms. There is no need to notify the provider or to switch medications unless the side effects become too uncomfortable. Patients should not stop taking TCAs abruptly.

The nurse is preparing to administer intramuscular haloperidol (Haldol) to a patient who has schizophrenia. What action will the nurse perform?

a. Massage the site after injecting the medication to ensure complete absorption. b. Teach the patient to return every week to receive medication doses. c. Use a small bore needle when injecting the medication. d. Use the Z-track method and inject the medication into deep muscle tissue. ****

A patient who is taking chlorpromazine calls the clinic to report having reddish-brown urine. What action will the nurse take?

a. Notify the provider and request orders for creatinine clearance and BUN levels. b. Reassure the patient that this is a harmless side effect of this medication. **** c. Tell the patient to come to the clinic for a urinalysis. d. Tell the patient to discard any drug on hand and request a new prescription. ANS: B Aliphatic phenothiazines, such as chlorpromazine, can cause a harmless pink or red-brown urine discoloration. There is no need to evaluate renal function with creatinine clearance, BUN, or urinalysis. The discoloration does not indicate that the medication has expired.

A patient is taking lithium. The nurse should be aware of the importance of which nursing intervention(s)? (Select that apply.)

a. Observe the patient for motor tremors. *** b. Monitor the patient for orthostatic hypotension. *** c. Draw lithium blood levels immediately after a dose. d. Advise the patient to drink 750 mL/d of fluid in hot weather. e. Advise the patient to avoid caffeinated foods and beverages. *** f. Teach the patient to take lithium with meals to decrease gastric irritation.***

The nurse should monitor the patient receiving phenytoin for which adverse effect?

a. Psychosis b. Nosebleeds *** c. Hypertension d. Gum erosion

Phenytoin has been prescribed for a patient with seizures. The nurse should include which appropriate nursing intervention in the plan of care?

a. Report an abnormal phenytoin level of 18 mcg/mL. b. Monitor CBC levels for early detection of blood dyscrasias. *** c. Encourage the patient to brush teeth vigorously to prevent plaque buildup. d. Teach the patient to stop the drug immediately when passing pinkish-red or reddish-brown urine.

A home-health patient with Alzheimer's disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?

a. Setting the medications up weekly in a medication box b. Calling the patient daily with a reminder to take the medication c. Having the patient's spouse administer the medication d. Posting reminders to take the medications in the patient's house Correct Answer: C Rationale: Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

Which statement is true concerning lithium?

a. The maximum dose is 3.4 g/d. b. The therapeutic drug range is 2.5 to 3.5 mEq/L. c. Lithium increases receptor sensitivity to GABA. d. Concurrent NSAIDs may increase lithium levels.***

The nurse is caring for a patient who has begun taking chlorpromazine HCl (Thorazine) 75 mg BID to treat schizophrenia. A family member tells the nurse that the patient's agitation, hallucinations, and delusional symptoms have improved, but the patient continues to withdraw from social interaction and won't bathe unless reminded to do so. The nurse will tell the family member that

a. all symptoms will eventually resolve over time with this medication. b. the patient may need an increased dose of the antipsychotic medication. c. these results may indicate that the patient does not have schizophrenia. d. they should consider discussing adding another medication. ANS: D Chlorpromazine is a typical antipsychotic medication; drugs in this class manage positive symptoms rather than the negative symptoms of withdrawal and poor self-care. It is not likely that the negative symptoms will improve over time with this medication. Increasing the dose will not improve control of negative symptoms. This patient exhibits signs of schizophrenia.

A nursing student asks the nurse why patients who have parkinsonism receive a combination of carbidopa and levodopa. The nurse will explain that the combination product

a. allows larger doses of levodopa to be given without causing increased adverse reactions. b. causes more levodopa to be converted to dopamine before crossing the blood-brain barrier. c. eliminates almost all drug side effects of both levodopa and carbidopa. d. reduces peripheral side effects by inhibiting decarboxylase in the peripheral nervous system. ***

A patient will begin taking the antiepileptic drug ethosuximide (Zarontin) and asks the nurse whether to take the drug with or without food. The nurse will counsel the patient to take this medication

a. at bedtime. b. 1 hour before meals. c. 2 hours after meals. d. with meals. ***

An atypical antipsychotic is prescribed for a patient with psychosis. The nurse understands that this category of medications includes which drugs? (Select all that apply.)

a. clozapine (Clozaril)*** b. fluphenazine (Prolixin) c. haloperidol (Haldol) d. olanzapine (Zyprexa) *** e. aripiprazole (Abilify) ***

A patient is having absence (petit mal) seizures. Which of the following does the nurse expect to be prescribed for this type of seizures? (Select all that apply.)

a. phenytoin (Dilantin) b. phenobarbital (Luminal) c. valproic acid (Depakote) *** d. clonazepam (Klonopin)*** e. ethosuximide (Zarontin)***

Flumazenil

antidote for benzodiazepines

The nurse administering donepezil (Aricept) to a patient understands that the expected therapeutic action of this drug is to

increase levels of acetylcholine in the brain by blocking its breakdown

Testosterone

the most important of the male sex hormones. Both males and females have it, but the additional testosterone in males stimulates the growth of the male sex organs in the fetus and the development of the male sex characteristics during puberty