Chapter 24: Antiinflammatories McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 11th Edition

Which antigout medication is considered first-line to treat chronic tophaceous gout? a. Allopurinol b. Colchicine c. Probenecid d. Celecoxib

ANS: A Allopurinol inhibits the biosynthesis of uric acid and is used long-term to manage chronic gout and is considered the drug of choice for chronic tophaceous gout. Colchicine does not inhibit uric acid synthesis or promote uric acid secretion and is not used for chronic gout. Probenecid can be used for chronic gout but is not the first choice. Celecoxib is a COX-2 selective anti inflammatory and does not have a role in treating chronic tophaceous gout.

The nurse is assessing a patient who has gout who will begin taking allopurinol. The nurse reviews the patient's medical record and will be concerned about which of the following findings? a. History of kidney stones b. Increased serum uric acid c. Slight increase in the white blood count d. Increased serum glucose

ANS: A Allopurinol use can increase the risk of kidney stones resulting from uric acid secretion. This can be prevented by increasing water intake and maintaining a urine pH above 6. A history of kidney stones would not be a contraindication to allopurinol use, but additional caution and patient teaching to prevent kidney stone formation is warranted.

A nursing student asks the nurse to explain the role of cyclooxygenase-2 (COX-2) and its role in inflammation. The nurse will explain that COX-2 a. converts arachidonic acid into a chemical mediator for inflammation. b. directly causes vasodilation and increased capillary permeability. c. directly irritates the gastric mucosa to cause gastrointestinal upset. d. releases prostaglandins, which cause inflammation and pain in tissues.

ANS: A COX-2 is an enzyme that converts arachidonic acid into prostaglandins and their products, and this synthesis causes pain and inflammation. The COX-2 enzyme does not directly cause inflammation. Prostaglandins produced by COX-1 serve to protect the stomach lining and regulates platelet function. COX-2 converts arachidonic acid to prostaglandins, but does not release prostaglandins per se.

A patient who takes high-dose aspirin to treat rheumatoid arthritis has a serum salicylate level of 35 mg/dL. The nurse will perform which action? a. Assess the patient for signs of toxicity, such as tinnitus. b. Monitor the patient for signs of Reye's syndrome. c. Notify the provider of severe aspirin toxicity. d. Request an order for an increased aspirin dose.

ANS: A Mild toxicity occurs at levels above 30 mg/dL, so the nurse should assess for signs of toxicity, such as tinnitus. This level will not increase the risk for Reye's syndrome. Severe toxicity occurs at levels greater than 50 mg/dL. The dose should not be increased.

A patient who has osteoarthritis with mild to moderate pain asks the nurse about taking over-the counter ibuprofen. What will the nurse tell this patient? a. "It may take several weeks to achieve maximum therapeutic effects." b. "Unlike aspirin, there is no increased risk of bleeding with ibuprofen." c. "Take ibuprofen twice daily for maximum analgesic benefit." d. "Combine ibuprofen with naproxen for best effect."

ANS: A OTC NSAIDs can be effective for mild to moderate arthritis pain, but the full effects may not appear for several weeks. NSAIDs carry a risk for bleeding. Ibuprofen is typically taken TID or QID for maintenance therapy. Ibuprofen and naproxen are both NSAIDs and ideally should not be combined.

A patient is taking ibuprofen 400 mg every 4 hours to treat moderate arthritis pain and reports that it is less effective than before. What action will the nurse take? a. Counsel the patient to discuss a change in dose or changing to a prescription NSAID with the provider. b. Recommend adding aspirin to increase the anti-inflammatory effect. c. Suggest asking the provider about a short course of corticosteroids. d. Tell the patient to increase the dose to 800 mg every 4 hours.

ANS: A The patient should discuss a possible change in dose or changing to a prescription NSAID with the provider if tolerance has developed to the over-the-counter NSAID. Taking aspirin in combination with NSAIDs can increase the risk of bleeding and gastrointestinal upset. Steroids are not the drugs of choice for arthritis because of their side effects and are not used unless inflammation is severe. A prescription NSAID would generally be used prior to starting corticosteroids. Increasing the dose will increase the potential for side effects but may not increase desired effects. It is important that the patient discuss any changes with their provider and not self-titrate the NSAID.

The nurse is performing a health history on a patient who has arthritis. The patient reports tinnitus. Suspecting a drug adverse effect, the nurse will ask the patient about which medication? a. Aspirin b. Acetaminophen c. Anakinra d. Prednisone

ANS: A Tinnitus is a sign of aspirin overdose or hypersensitivity to aspirin. The nurse should question the patient about this medication. The other medications are less likely to contribute to this side effect.

Which are characteristic signs of inflammation? (Select all that apply.) a. Edema b. Erythema c. Heat d. Numbness e. Pallor f. Paresthesia

ANS: A, B, C Edema, erythema, and heat are signs of inflammation. The other three are signs of neurocirculatory compromise.

Which of the following DMARD medications is an IL-1 receptor antagonist? a. Etanercept b. Anakinra c. Infliximab d. Rituximab

ANS: B Anakinra is a DMARD that works via antagonism of IL-1 receptors. Etanercept and infliximab are TNF inhibitors. Rituximab induces cell lysis of B cells. All of these agents are indicated to treat rheumatoid arthritis.

The nurse is teaching a patient about using high-dose aspirin to treat arthritis. What information will the nurse include when teaching this patient? a. "A normal serum aspirin level is between 30 and 40 mg/dL." b. "You may need to stop taking this drug a week prior to surgery." c. "You will need to monitor aspirin levels if you are also taking warfarin." d. "Your stools may become dark, but this is a harmless side effect."

ANS: B Aspirin should be discontinued prior to surgery to avoid prolonged bleeding time. A normal serum level is 15 to 30 mg/dL. Patients taking warfarin and aspirin will require INR monitoring. Tarry stools are a symptom of gastrointestinal bleeding and should be reported.

The nurse provides teaching for a patient who will begin taking indomethacin to treat symptoms of rheumatoid arthritis. Which statement by the patient indicates a need for further teaching? a. "I should avoid this medication if I am allergic to aspirin." b. "I should take indomethacin on an empty stomach." c. "I should not take this in combination with other over-the-counter NSAIDs." d. "I will take the medication twice daily."

ANS: B Indomethacin is very irritating to the stomach and should be taken with food. The medication is taken twice daily. Indomethacin is not recommended for use in patients who are allergic to aspirin, and should not be used in combination with OTC NSAID products to avoid duplication.

The nurse is caring for a patient who has rheumatoid arthritis and who is receiving infliximab IV every 8 weeks. Which laboratory test will the nurse anticipate that this patient will need? a. Calcium level b. Complete blood count c. Electrolytes d. Potassium

ANS: B Infliximab is an immunomodulator and can cause agranulocytosis, so patients should have regular CBC monitoring.

A nursing student asks how nonsteroidal anti-inflammatory drugs (NSAIDs) work to suppress inflammation and reduce pain. The nurse will explain that NSAIDs a. exert direct actions to cause relaxation of smooth muscle. b. inhibit the enzyme cyclooxygenase that is necessary for prostaglandin synthesis. c. interfere with neuronal pathways associated with prostaglandin action. d. suppress prostaglandin activity by blocking tissue receptor sites.

ANS: B NSAIDs act by inhibiting COX-1 and COX-2 to help block prostaglandin synthesis. They do not have direct action on tissues, nor do they interfere with chemical receptor sites or neuronal pathways.

The nurse provides teaching for a patient who will begin taking allopurinol. Which statement by the patient indicates understanding of the teaching? a. "I should increase my vitamin C intake." b. "I will get yearly eye exams." c. "I will increase my protein intake." d. "I will limit fluids to prevent edema."

ANS: B Patients taking allopurinol can have visual changes with prolonged use and should have yearly eye exams. It is not necessary to increase vitamin C. Protein can increase purine intake, which is not recommended. Patients should consume extra fluids.

The nurse is caring for a patient who has been taking an NSAID for 4 weeks for osteoarthritis. The patient reports decreased pain, but the nurse notes continued swelling of the affected joints. The nurse will perform which action? a. Assess the patient for drug-seeking behaviors. b. Notify the provider that the drug is not effective. c. Reassure the patient that swelling will decrease eventually. d. Remind the patient that this drug is given for pain only.

ANS: B This medication is effective for both pain and swelling. After 4 weeks, there should be some decrease in swelling, so the nurse should report that this medication is ineffective. There is no indication that this patient is seeking an opioid analgesic. The drug should be effective within several weeks.

The nurse is caring for a postpartum woman who is refusing opioid analgesics but is rating her pain as a 7 or 8 on a 10-point pain scale. The nurse will contact the provider to request an order for which analgesic medication? a. Diclofenac b. Ketoprofen c. Ketorolac d. Naproxen

ANS: C Ketorolac is an injectable NSAID and has shown analgesic efficacy equal or superior to that of opioid analgesics. The other NSAIDs listed are not used for postoperative pain.

A patient who is taking aspirin for arthritis pain asks the nurse why it also causes gastrointestinal upset. The nurse understands that this is because aspirin a. increases gastrointestinal secretions. b. increases hypersensitivity reactions. c. inhibits both COX-1 and COX-2. d. selectively inhibits COX-2.

ANS: C Aspirin is a non-specific COX-1 and COX-2 inhibitor. COX-1 protects the stomach lining, so when it is inhibited, gastric upset can occur. Aspirin does not increase gastrointestinal secretions or hypersensitivity reactions.

A patient is taking aspirin for secondary prevention of myocardial infarction and is experiencing moderate gastrointestinal upset. The nurse will contact the patient's provider to discuss changing from aspirin to which of the following? a. A COX-2 inhibitor b. Celecoxib c. Enteric-coated aspirin d. Ibuprofen

ANS: C Aspirin is often used to inhibit platelet aggregation for cardiovascular prevention. Patients taking aspirin for this purpose would not benefit from COX-2 inhibitors, since the COX-1 enzyme is responsible for inhibiting platelet aggregation. The patient may benefit from taking an enteric-coated aspirin product to lessen the gastrointestinal distress. Celecoxib and is a COX-2 selective inhibitor. Ibuprofen is not indicated for cardiovascular event prevention.

The nurse is teaching a patient about taking colchicine to treat gout. What information will the nurse include when teaching this patient about this drug? a. Avoid all alcohol except beer. b. Include salmon in the diet. c. Increase fluid intake. d. Take on an empty stomach.

ANS: C The patient who is taking colchicine (and other antigout agents) should increase fluid intake to promote uric acid excretion and prevent renal calculi. Foods rich in purine should be avoided, including beer, and some sea foods, such as salmon. Gastric irritation is a common problem, so colchicine should be taken with food.