Pharmacology Unit 3: Chapters 12-22

Anticholinergics may be ordered for which of the following conditions? (Select all that apply) A) Peptic ulcer disease B) Bradycardia C) Decreased sexual function D) Irritable bowel syndrome E) Urine retention

Answer: A, B, D Rationale: Anticholinergics are used in the treatment of peptic ulcer disease, irritable bowel syndrome, and bradycardia because they suppress the effects of Ach and stimulate the sympathetic nervous system. Options C and E are incorrect. Anticholinergics may cause decreased sexual function because the parasympathetic impulses are blocked. Urine retention is a potential adverse effect of anticholinergics. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity

Cyclobenzaprine (Amrix, Flexeril) is prescribed for a patient with muscle spasms of the lower back. Appropriate nursing interventions would include which of the following? (Select all that apply) A) Assessing the heart rate for tachycardia B) Assessing the home environment for patient safety concerns C) Encouraging frequent ambulation D) Providing oral suction for excessive oral secretions E) Providing assistance with activities of daily living such as reading

Answer: A, B, E Rationale: Adverse reactions to cyclobenzaprine include drowsiness, dizziness, dry mouth, rash, blurred vision, and tachycardia. Because the medication can cause drowsiness and dizziness, ensuring patient safety must be a priority. The patient may need assistance with reading or other activities requiring visual acuity if blurred vision occurs. Options C and D are incorrect. Patients who are experiencing back pain often have orders for limited ambulation until muscle spasms have subsided. Suctioning should not be required related to this drug. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Safe and Effective Care Environment

The patient asks what can be expected from the levodopa/carbidopa (Sinemet) he is taking for treatment of Parkinson's Disease. What is the best response by the nurse? A) "A cure can be expected within 6 months." B) "Symptoms can be reduced and the ability to perform ADLs can be improved." C) "Disease progression will be stopped." D) "Extrapyramidal symptoms will be prevented."

Answer: B Rationale: Pharmacotherapy does not cure or stop the disease process but does improve the patient's ability to perform ADLs such as eating, bathing, and walking. Options A, C, and D are incorrect. Drug therapy for PD does not cure or halt progression of the disease. Depending on the drug therapy, EPS may be an adverse effect. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

A 77-year-old female patient is diagnosed with depression and anxiety and is started on imipramine. Because of this patient's age, which adverse effects would take priority when planning care? A) Dry mouth and photosensitivity B) Anxiety, headaches, insomnia C) Drowsiness and sedation D) Urinary frequency

Answer: C Rationale: TCAs such as imipramine (Tofranil) may cause drowsiness and sedation. Because of this patient's age, these effects may increase the risk of falls. Options A, B, and D are incorrect. Headache, insomnia, and anxiety are not common adverse effects associated with imipramine. The drug may cause photosensitivity, dry mouth, and urinary retention, but these would not be the top priority considering the fall risk. The drug does not cause urinary frequency. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Safe and Effective Care Environment

A 47-year-old patient with MS has had increasing motor difficulty and has been increasingly dependent on her walker to move about her house and work setting. Her provider gives her a new prescription for dalfampridine (Ampyra). What is the purpose of this drug and what will you, as the nurse first assess?

Dalfampridine (Ampyra) tablets are approved as a treatment to improve walking in patients with MS. It has been shown to increase nerve conduction and improve walking speed. Dalfampridine is the first FDA-approved oral drug addressing walking impairment in patients diagnosed with MS. The most bothersome adverse effect of dalfampridine is seizure activity. Because of this concern, you would first assess for a prior history of seizures. Ampyra is contraindicated in patients with a known seizure disorder.

What is the main goal of pharmacotherapy for neurodegenerative disorders such as PD, AD, and MS?

Drugs used to treat chronic neurodegenerative disorders such as PD, AD, and MS seek to slow the progression and to treat the symptoms of the underlying disorder. Currently there is no pharmacotherapy available that prevents, stops the progression of, or reverses these conditions. This may change in the years ahead as more is learned about the underlying pathogenesis of these disorders and newer treatments are investigated.

Isabel Turken is a 76-year-old retired school nurse. She has been married to Richard for 53 years, and they have three grown children who live within 25 miles of them. Isabel's physical health has been good. She has mild hypertension and had colon cancer successfully removed 20 years ago with no recurrence. Richard makes an appointment with Isabel's health care provider because he has noticed signs of decreasing mental acuity and increasing confusion over the past year. Isabel's physical exam is negative, but the health care provider suspects that she is experiencing the early stages of AD. Isabel is started on donepezil (Aricept), 5 mg at bedtime. 1) What information should be included in the initial assessment in order to determine a diagnosis for Isabel? 2) What recommendations will the health care provider most likely make to Isabel and her husband? 3) What should Richard be alert for with regard to the donepezil?

1) A complete physical exam and laboratory studies are necessary to determine any electrolyte imbalances, diabetes, or other conditions that may be present. A complete personal history, as well as a family history, is necessary to determine if any other close family members may have or had AD. The assessment should also include cognitive rating scale measurements and assessment of individual and family coping skills. A referral to social services agencies or respite care may be needed. 2) The health care provider will probably recommend that Isabel begin taking one of the medications used to treat early AD such as donepezil. Measures to ensure her safety and the safety of others should be taken. This includes making sure that she does not drive or leave home alone; leave pots cooking on the stove; or leave water running in the sink or tub. A bedside commode nearby may assist Mary with toileting if she has confusion or difficulty with walking. Furniture, clothing, and other belongings, and routines at home must be kept the same as much as possible, including where items are stored and people who come into the home. 3) Donepezil may cause some common adverse effects: headache, fatigue, insomnia, nausea, vomiting, diarrhea, anorexia, and abdominal pain. Other adverse effects include vertigo, depression, irritability, syncope, bradycardia, dehydration, incontinence, and blurred vision. Richard will have to be alert for anorexia and encourage Isabel to eat if she loses weight. If she is unable to sleep, she may begin to wander so he may have to install different locks on the doors.

George Orland is a 59-year-old salesman working at a local insurance company in the community. Due to the economy, his income has dropped significantly because it is partially based on commission and he is worried that he is not able to provide for his family. He begins to experience insomnia, difficulty concentrating, and other symptoms related to his anxiety. His health care provider prescribes a short-term course of lorazepam (Ativan) to help him through this difficult period. 1) What adverse effects are associated with this drug therapy? 2) What information should George receive about this medication? 3) What nonpharmacologic measures can the nurse recommend to George to assist him in feeling better about his current situation?

1) Adverse effects associated with lorazepam (Ativan) include dizziness, ataxia, drowsiness, blurred vision, vertigo, sedation, and confusion. These effects are dose related and tolerance to them may develop as therapy progresses. 2) The patient should be instructed to avoid performing potentially hazardous activities (e.g., driving) that require alert mental status until the effects of the drug are known. The drug should not be stopped abruptly and other CNS depressants such as alcohol and antihistamines must be avoided while the drug is used. D) The nurse can make several suggestions to George: Encourage complementary non-pharmacologic strategies for stress reduction such as daily walking or other moderate exercise; refer George to the appropriate the social service agency (e.g., local workforce development) for possible employment opportunities; encourage group or individual behavioral therapy if desired.

Lee Sutter, 45 years old, is on a PCA pump to manage postoperative pain related to recent cancer surgery. The PCA is set to deliver a basal rate of morphine of 6 mg/h. As his nurse, you discover Lee to be unresponsive with a respiratory rate of 8 breaths per minute and oxygen saturation of 84%. 1) What should be your first response? 2) What do you anticipate will be needed after that initial response? 3) What follow-up is needed after this time?

1) As the nurse, you would call for a rapid response team and initially manage the patient's airway, breathing, and circulation (ABCs) by opening the airway and providing oxygen support and then stop the PCA pump. Although the nurse's first reaction may be to go directly to the PCA to stop the medication, it is important to manage the patient's airway before stopping the PCA because it is unknown how long the patient has been hypoxic. 2) You would anticipate the need to administer IV naloxone (Evzio, Narcan), which is a narcotic antagonist. 3) After these initial steps have been completed and the patient is stabilized, you would inform the health care provider of this adverse effect of the morphine. A change in the basal rate of the PCA may be needed. Mr. Sutter should also be encouraged to continue deep breathing exercises every hour and to ambulate regularly.

Katisha Moore is a 68-year-old who enjoys working in her large rose garden. This morning, she noticed that insects had infested the plants. To avoid further damage, she powdered the plants with an insecticide. In her rush to finish, she accidentally contaminated herself with the insecticide and kept working for several hours before showering. Mrs. Moore is brought into the local emergency department (ED) by her husband that afternoon. She has nausea, dizziness, sweating, excessive salivation, weepy eyes, and a runny nose. She reports intermittent twitching of her upper extremities and uncoordinated movement. Her initial assessment reveals a 64-kg (142-lb) Caucasian female with a past medication history of hypertension diagnosed 5 years ago. She is married and has two adult children. Her vital signs are blood pressure, 158/94 mmHg; heart rate, 58; respiratory rate, 30; and temperature, 37.3°C (99.2°F). Her skin is pale and moist. She exhibits copious lacrimation and rhinorrhea. Both pupils are constricted. Crackles are heard bilaterally in all lung fields on inspiration. Since admission to the ED she has vomited twice and had one large diarrhea stool. She is diagnosed with acute organophosphate poisoning. Mrs. Moore is started on oxygen therapy, and the nurse will observe her closely for further respiratory distress. Atropine 2 mg is administered IV every 15 minutes over the next hour. 1) What is the mechanism of action associated with atropine. 2) Why is this drug being given to Mrs. Moore? 3) What adverse effects should you expect for the patient from the administration of atropine?

1) Atropine blocks acetylcholine effects on cholinergic receptors in smooth muscle, cardiac muscle, exocrine glands, urinary bladder, and the sinoatrial and atrioventricular nodes of the heart. Due to its diverse and widespread action, atropine has multiple uses that include certain types of bradycardia, spastic disorders of the GI system, and ophthalmic examinations. 2) In Mrs. Moore's case, the adverse effect of atropine (suppression of exocrine secretions) becomes a therapeutic effect. Atropine is useful in controlling the copious secretions associated with organophosphate poisoning. 3) As the nurse, you would anticipate that Mrs. Moore will probably experience dry mouth, constipation, urinary retention, increased heart rate, and blurred vision.

John Delarcy, a 68-year-old patient has been started on olanzapine (Zyprexa) for treatment of acute psychoses. He has both positive symptoms (e.g., hallucinations and disorganized thought patterns) and negative symptoms (e.g., lack of responsiveness). 1) What is a priority of care for this patient? 2) What teaching is important for this patient?

1) Because of the patient's age (68), safety is a priority concern when administering antipsychotic drugs such as olanzapine (Zyprexa). Orthostatic hypotension and dizziness are common adverse effects, and the patient should move or change position slowly. Constipation may also be a concern for this patient, and increasing the amount of fluids and fiber in the diet may prevent this from occurring. 2) Mr. Delarcy and his family or caregiver need to be taught that the olanzapine (Zyprexa) will not cure his underlying illness, but will help to prevent or manage the symptoms he is currently having. He should not stop taking the medication and should take it on a regular schedule. He should also use the same manufacturer's brand each time a refill is needed. If he stops or refuses to take his medication, the provider should be notified. Because antipsychotic drugs have a cardiometabolic effect, Mr. Delarcy will require occasional laboratory work to assess his lipid and glucose levels. He should maintain a healthy lifestyle with sound nutritional habits and adequate exercise. Weight gain, increased abdominal circumference, excessive thirst, hunger, or urination should be reported to the provider.

Patient-Focused Case Study Joelle Birdwell, 16 years old, presents to the clinic with fatigue and pallor. She has a history of a generalized tonic-clonic seizure disorder that has been managed well on carbamazepine (Tegretol). In addition to her pallor and fatigue, Joelle has multiple small petechiae and bruises on her arms and legs. Her hematocrit is 26%. 1) In which drug classification does carbamazepine (Tegretol) belong? 2) What are adverse effects associated with carbamazepine? 3) Can Joelle's symptoms be related to her use of carbamazepine?

1) Carbamazepine (Tegretol) belongs to the classification of phenytoin-like drugs that have a similar mechanism of action to phenytoin (Dilantin). 2) Carbamazepine (Tegretol) adverse effects are drowsiness, dizziness, nausea, ataxia, and blurred vision. Serious and sometimes fatal blood dyscrasias secondary to bone marrow suppression have occurred with carbamazepine. 3) The patient's hematocrit suggests anemia, and the petechiae and bruising suggest thrombocytopenia. The nurse should evaluate for complaints of fever and sore throat that would suggest leukopenia and report the findings to the patient's primary health care provider.

Nathan Ebbens, a 32-year-old farmer, injured his lower back while unloading a truck at a farm cooperative. His health care provider started him on cyclobenzaprine (Amrix, Flexeril) 10 mg tid for 7 days and referred him to outpatient physical therapy. After 4 days, the patient reports back to the office nurse that he is constipated and having trouble emptying his bladder. 1) What might be the cause of these effects? 2) As the nurse, what orders do you anticipate from the provider? 3) Nathan is switched to baclofen (Lioresal) orally. What additional teaching will he need?

1) Cyclobenzaprine (Amrix, Flexeril) has been demonstrated to produce significant anticholinergic activity. Anticholinergics block the action of the neurotransmitter acetylcholine at the muscarinic receptors in the parasympathetic nervous system. This allows the activities of the sympathetic nervous system to dominate. In this case, the result has been a relaxation of the smooth muscles of the GI tract, decreasing peristalsis and motility, and resulting in constipation. The anticholinergic effect is also responsible for urine retention because of increased constriction of the internal sphincter. 2) Because Nathan is experiencing urinary retention, secondary to the cyclobenzaprine, you would anticipate that the drug will be discontinued, and a different drug substituted. 3) Baclofen (Lioresal) has a good safety profile but may cause drowsiness, dizziness, weakness, and fatigue. Because of the type of work he does, Nathan should be reminded that drowsiness and dizziness are possible adverse effects. He should be careful working around farm machinery until the effects of the drug are known. Nonpharmacologic measures such as localized heat may also help.

An older adult patient, age 77, is scheduled for an open reduction with internal fixation of the right hip for a fracture. When preparing the postoperative care plan, what should be included for this patient in the immediate postoperative recovery period?

1) In the postoperative period, the nurse will ensure that vital signs are taken frequently and that any abnormal findings are reported to the health care provider. If the patient received succinylcholine (Anectine, Quelicin) with the general anesthetic, the nurse will also frequently monitor temperature for signs of malignant hyperthermia. The patient should be reoriented to his surroundings until full consciousness returns, and safety measures such as a convenient call light and frequent visual checks should be initiated. Any signs of confusion, disorientation, or other cognitive impairment should be reported to the provider. The nurse should ensure return of the patient's gag reflex and ability to swallow before allowing the patient to eat or drink.

Rob Valetti is a 28-year-old steelworker for a heating and cooling company. While on the job he cut his right hand with a piece of steel for an air-conditioning vent. He is admitted to the emergency department for sutures to the right middle and ring fingers, and palm. The laceration will be anesthetized with lidocaine prior to suturing. 1) What is the action of lidocaine? 2) Why do some solutions of lidocaine contain epinephrine? 3) As the nurse, what post-procedure instructions will you give Rob?

1) Lidocaine blocks the conduction of electrical impulses by reducing the sodium permeability at the cellular level. This prevents pain transmission to the CNS. 2) Epinephrine added to lidocaine (Xylocaine) increases the local anesthetic action from about 20 minutes to as long as 60 minutes. The vasoconstriction caused by the epinephrine will also decrease bleeding and allow for better visualization of the area. 3) Post-procedure, Rob should be taught that the area may remain numb for some time and he should take precautions to avoid injury to the area. The area around the suture line may appear blanched which is normal and related to the epinephrine that was used. He should continue to observe the area for any redness, swelling, warmth, or other signs of infection, and return to the provider as directed for suture removal.

Tyrone Mathey is a 48-year-old African American man who is an attorney at a large law firm. He has made an appointment with his provider today for increased feelings of anxiety, headaches, and "just not feeling well." His medical and family histories indicate that both of his parents died within the last 10 years. His father died of a stroke and his mother died of a heart attack. Mr. Mathey states that he has been prescribed prazosin (Minipress) in the past but he stopped taking it. When questioned about why he chose not to take the medication, he reluctantly confides in you that he suspected the medication was causing adverse sexual effects. His body temperature is 37°C (98.6°F), heart rate is 88 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 160/90 mmHg. During the examination an ECG and laboratory test results were all within normal limits. 1) Identify the mechanism of action associated with prazosin (Minipress). 2) Could the prazosin (Minipress) be the cause of his sexual adverse effects? 3) As this patient's nurse, how would you approach the topic of medication-induced sexual dysfunction?

1) Prazosin works by decreasing peripheral resistance (vasodilation) so that blood may flow through the vessels more easily. This effect helps to lower blood pressure. 2) Many drugs including antihypertensive medications can induce impotence. The physiological mechanism that creates this situation in male patients is related to the muscle contraction in the vas deferens, which is the main duct through which semen is carried from the epididymis to the ejaculatory duct. When these smooth muscles are inhibited, ejaculation becomes difficult. 3) Many men are reluctant to talk about medication-induced impotence. The nurse must determine exactly what the patient means by "sexual" adverse effects by using a direct, but nonjudgmental approach. The nurse could say "Do you mean problems with erection or problems with ejaculation?" Not all antihypertensive drugs cause sexual dysfunction and health care providers want him to report such adverse effects. When a medication creates adverse effects that prompt the patient to discontinue a necessary medication without consulting the health care provider, other alternatives should be explored.

Margot Cinotti is a 26-year-old mother of three young children who has been followed since her last pregnancy when she experienced post-partum depression. She was placed on sertraline (Zoloft) and experienced improvement, but not complete resolution of her depression. Lately, her husband reports that she seems increasingly depressed and disinterested in the usual activities around the house or with the children that she used to enjoy. He is concerned that the drug is not working. 1) Which drug classification does sertraline (Zoloft) belong to? What are some of the adverse effects associated with this class? 2) What assessment data should be gathered at this time to help determine the cause of Mrs. Cinotti's increased depression? 3) What changes might be made to her treatment plan?

1) Sertraline (Zoloft) is an SSRI. Adverse effects include nausea, dry mouth, insomnia, somnolence, headache, nervousness, anxiety, GI disturbances, dizziness, anorexia, fatigue, sexual dysfunction, suicidal ideation, and SES. 2) Important assessment data to gather include whether Mrs. Cinotti has been consistently taking her medication and a complete medication history, including herbal products, for possible drug interactions. Other changes to her physical or psycho-social routines should also be noted. Are there any new or concurrent conditions? Has she recently experienced any losses or significant changes in lifestyle? 3) Depending on the dose that Mrs. Cinotti is currently taking, the provider may increase the dose. If a change in dose is not possible, a different drug in the same class or one from a different drug classification, such as the TCAs may be tried. Cognitive and behavioral therapy may also be used as adjuncts to medication therapy.

What is a major drawback to all of the centrally-acting muscle relaxant drugs used to treat muscle spasms or spasticity?

All of the centrally-acting drugs used to treat muscle spasms or spasticity may cause significant drowsiness, dizziness, or weakness. This creates safety concerns for the patient taking these drugs.

A 12-year-old girl has been diagnosed with ADHD. Her parents have been reluctant to agree with the pediatrician's recommendation for pharmacologic management; however, the child's performance in school has deteriorated. A school nurse notes that the child has been placed on amphetamine and dextroamphetamine (Adderall). What information do her parents need about this medication?

Amphetamine and dextroamphetamine (Adderall) is a CNS stimulant used to control the symptoms of ADHD. The drug should be taken in the morning to avoid night-time insomnia. Because the drug causes anorexia, the child should eat an adequate breakfast before the drug is taken. If anorexia at lunch is a problem, high-calorie, nutrient-dense foods can be packed in a lunch sack and an afternoon snack provided when she arrives home. Weekly weights should be taken and a record kept to show the provider to ensure that adequate growth is continuing. Insomnia, heart palpitations, excessive anxiety, or nervousness should be reported to the health care provider. The drug should be kept secured in the home. If the drug is to be taken at school, the school's protocols should be followed for dosages and labeling.

Propranolol (Inderal) has been ordered for a patient with hypertension. Because of adverse effects related to this drug, the nurse would carefully monitor for which adverse effect? A) Bronchodilation B) Tachycardia C) Edema D) Bradycardia

Answer: 4 Rationale: Because beta-adrenergic blockers such as propranolol (Inderal) slow electrical conduction through the cardiac conduction system, they may cause bradycardia. Options A, B, and C are incorrect. Bronchodilation, tachycardia, and edema are not adverse effects associated with beta-adrenergic blockers. Cognitive Level: Applying Nursing Process: Evaluation Client Need: Physiological Integrity

Following administration of phenylephrine (Neo-Synephrine), the nurse would assess for which of the following adverse drug effects? A) Insomnia, nervousness, and hypertension B) Nausea, vomiting, and hypotension C) Dry mouth, drowsiness, and dyspnea D) Increased bronchial secretions, hypotension, and bradycardia

Answer: A Rationale: Adrenergic agonists such as phenylephrine (Neo-Synephrine) stimulate the sympathetic nervous system and produce symptoms including insomnia, nervousness, and hypertension. Options B, C, and D are incorrect. Nausea, vomiting, and drowsiness are not adverse effects known to occur with adrenergic agonists. Hypotension and bradycardia are potential adverse reactions related to the use of adrenergic antagonists. Dry mouth may occur from anticholinergics, and increased bronchial secretions are an effect of cholinergic agents. Dyspnea is not an adverse reaction related to adrenergic agonists, and adrenergics may be ordered for bronchodilation properties. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity

A 16-year-old patient has taken an overdosage of citalopram (Celexa) and is brought to the emergency department. What symptoms would the nurse expect to be present? A) Seizures, hypertension, tachycardia, extreme anxiety B) Hypotension, bradycardia, hypothermia, sedation C) Miosis, respiratory depression, absent bowel sounds, hypoactive reflexes D) Manic behavior, paranoia, delusions, tremors

Answer: A Rationale: An overdose of citalopram (Celexa) causes symptoms similar to serotonin syndrome including seizures, hypertension, tachycardia, and extreme anxiety. Options B, C, and D are incorrect. These are not symptoms of an SSRI overdose. Cognitive Level: Analyzing Nursing Process: Assessment Client Need: Physiological Integrity

A patient is treated for psychosis with fluphenazine. What drug will the nurse anticipate may be given to prevent the development of acute dystonia? A) Benztropine (Cogentin) B) Diazepam (Valium) C) Haloperidol (Haldol) D) Lorazepam (Ativan)

Answer: A Rationale: Benztropine (Cogentin), an anticholinergic, may be given to suppress the tremor and rigidity that may be caused by fluphenazine or other phenothiazine antipsychotic drugs. Options B, C, and D are incorrect. Diazepam (Valium) and lorazepam (Ativan) are benzodiazepines and will not prevent acute dystonia. Haloperidol (Haldol) is an antipsychotic drug and may increase the risk for acute dystonia. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

A patient has purchased capsaicin over-the-counter cream to use for muscle aches and pains. What education is most important to give this patient? A) Apply with a gloved hand only to the site of pain. B) Apply the medication liberally above and below the site of pain. C) Apply to areas of redness and irritation only. D) Apply liberally with a bare hand to the affected limb.

Answer: A Rationale: Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options B, C, and D are incorrect. Capsaicin should be applied only to the site of pain and never with the bare hand. It should not be applied to irritated or open skin areas and should be discontinued if irritation occurs. Cognitive Level: Applying Nursing Process: Implementation Client Need: Health Promotion and Maintenance

To avoid the first-dose phenomenon, the nurse knows that the initial dose of prazosin (Minipress) should be: A) Very low and given at bedtime. B) Doubled and given before breakfast. C) The usual dose and given before breakfast. D) The usual dose and given immediately after breakfast.

Answer: A Rationale: Drugs that cause a "first-dose phenomenon" should have very low initial doses administered at bedtime. The decline in blood pressure due to prazosin is often marked when beginning pharmacotherapy and when increasing the dose. This "first-dose phenomenon" can lead to syncope due to reduced blood flow to the brain. Options B, C, and D are incorrect. Doses of antihypertensive medications should never be doubled, but should be gradually increased to avoid hypotension, and the best time to give prazosin in the initial phases of therapy is at bedtime. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

The nurse should immediately report the development of which of the following symptoms in a patient taking antipsychotic medication? A) Fever, tachycardia, confusion, incontinence B) Pacing, squirming, or difficulty with gait such as bradykinesia C) Severe spasms of the muscles of the tongue, face, neck, or back D) Sexual dysfunction or gynecomastia

Answer: A Rationale: Fever, tachycardia, confusion, and incontinence are symptoms of the development of NMS and should be immediately reported. Options B, C, and D are incorrect. Pacing and squirming are signs of akathisia, and bradykinesia and tremors are symptoms of secondary parkinsonism. These adverse effects, along with sexual dysfunction and gynecomastia, are adverse effects that may occur with therapy and may not be preventable. NMS is a medical emergency requiring immediate treatment. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity

A patient who has been prescribed baclofen (Lioresal) returns to the health care provider after a week of drug therapy, complaining of continued muscle spasms of the lower back. What further assessment data will the nurse gather? A) Whether the patient has been taking the medication consistently or only when the pain is severe B) Whether the patient has been consuming alcohol during this time C) Whether the patient has increased the dosage without consulting the health care provider D) Whether the patient's log of symptoms indicates that the patient is telling the truth

Answer: A Rationale: Muscle relaxers such as baclofen (Lioresal) work best when taken consistently and not prn. Noting consistency of dosing helps to determine the appropriateness of dose, frequency, and drug effects. Options B, C, and D are incorrect. Consumption of alcohol or increasing the dose of muscle relaxers will increase the risk of sedation and drowsiness. The patient's log of symptoms and drug dose and frequency may assist the provider in determining the therapeutic outcome of the medication. The patient's report of pain or continued spasms should be considered an accurate account. Cognitive Level: Analyzing Nursing Process: Evaluation Client Need: Physiological Integrity

The patient or family of a patient taking neostigmine (Prostigmin) should be taught to be observant for which of the following adverse effects that may signal that a possible overdose has occurred? A) Excessive sweating, salivation, and drooling B) Extreme constipation C) Hypertension and tachycardia D) Excessively dry eyes and reddened sclera

Answer: A Rationale: Overdosage of parasympathomimetics (cholinesterase-inhibitors) such as neostigmine (Prostigmin) may produce excessive sweating, drooling, dyspnea, or excessive fatigue. These symptoms should be promptly reported. Options B, C, and D are incorrect. Diarrhea is an adverse effect associated with cholinergics and cholinesterase-inhibitors, not constipation. Hypertension, tachycardia, dry eyes, or reddened sclera are not associated with these drugs. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

A patient has received succinylcholine (Anectine, Quelicin) along with the general anesthetic in surgery. Which of the following abnormal findings in the recovery period should be reported immediately to the provider? A) Temperature 38.9°C (102°F) B) Heart rate 56 C) Blood pressure 92/58 D) Respiratory rate 15

Answer: A Rationale: The combination of succinylcholine (Anectine, Quelicin) and general anesthetics is known to trigger malignant hyperthermia in some patients. A temperature of 38.9°C (102°F) may signal the development of malignant hyperthermia and should be immediately reported. Options B, C, and D are incorrect. General anesthetics depress CNS function, and bradycardia, bradypnea, and lowered blood pressure or hypotension are not uncommon findings in the immediate postoperative period. The nurse should compare these patient findings with the baseline assessment to determine if they are abnormal or a normal expected effect of the general anesthesia. Cognitive Level: Analyzing Nursing Process: Assessment Client Need: Physiological Integrity

A patient who is taking an adrenergic-blocker for hypertension reports being dizzy when first getting out of bed in the morning. The nurse should advise the patient to: A) Move slowly from the recumbent to the upright position. B) Drink a full glass of water before rising to increase vascular circulatory volume. C) Avoid sleeping in a prone position. D) Stop taking the medication.

Answer: A Rationale: The nurse should suspect that the patient is describing orthostatic hypotension induced by the medication. Most patients find it helpful to move slowly from a recumbent position to avoid dizziness and syncope. Options B, C, and D are incorrect. Although drinking a full glass of water with the medication is a health promotion activity that the nurse might suggest, this action does not eliminate orthostatic hypotension. Sleeping positions do not influence the presence of orthostatic hypotension. The patient should never abruptly stop taking antihypertensive medication. Such action could result in hypertensive crisis, stroke, or heart attack. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

The patient received lidocaine viscous before a gastroscopy was performed. Which of the following would be a priority for the nurse to assess during the postprocedural period? A) Return of gag reflex B) Ability to urinate C) Leg pain D) Ability to stand

Answer: A Rationale: The patient's throat was anesthetized during gastroscopy with lidocaine viscous. The patient should be assessed for the return of the gag reflex before being allowed to drink or eat to prevent aspiration. Options B, C, and D are incorrect. Leg pain, ability to stand, and ability to urinate are not assessments related to the procedure or the lidocaine viscous use. If these are noted as abnormal, other causes should be investigated. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity

The nurse is providing education for a 12-year-old patient with partial seizures currently prescribed valproic acid (Depakene). The nurse will teach the patient and the parents to immediately report which symptom? A) Increasing or severe abdominal pain B) Decreased or foul taste in the mouth C) Pruritus and dry skin D) Bone and joint pain

Answer: A Rationale: Valproic acid may cause life- threatening pancreatitis, and any severe or increasing abdominal pain should be reported immediately. Options B, C, and D are incorrect. The drug is not known to cause dysgeusia (altered sense of taste) or effects on bones or joints. Although pruritus is an adverse effect associated with valproic acid, it may be managed with simple therapies, and unless it progresses to a more serious rash, it does not need to be reported immediately. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity

A patient is started on atenolol (Tenormin). Which is the most important action to be included in the plan of care for this patient related to this medication? A) Monitor apical pulse and blood pressure B) Elevate the head of the bed during meals C) Take the medication after meals D) Consume foods high in potassium

Answer: A Rationale: With beta-adrenergic blockers such as propranolol, the most important action is to monitor the patient for adverse effects associated with the cardiovascular system such as changes in pulse and blood pressure. Options B, C, and D are incorrect. Elevation of the head of the bed is not specifically required for this drug regimen. Atenolol (Tenormin) can be taken anytime regardless of meals, and the therapeutic action of atenolol is not contingent on serum K+ levels. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

The nurse is monitoring the patient for early signs of lithium (Eskalith) toxicity. Which symptoms, if present, may indicate that toxicity is developing? (Select all that apply.) A) Persistent gastrointestinal upset (e.g., nausea, vomiting) B) Confusion C) Increased urination D) Convulsions E) Ataxia

Answer: A, B, C Rationale: Persistent GI upset such as nausea, vomiting, and abdominal pain; increased urination; and confusion are signs of elevated lithium levels and may signal the early stages of toxicity. Options D and E are incorrect. Convulsions and ataxia may occur later in lithium toxicity. Cognitive Level: Applying Nursing Process: Evaluation Client Need: Physiological Integrity

Nursing implications of the administration of haloperidol (Haldol) to a patient exhibiting psychotic behavior include which of the following? (Select all that apply) A) Take 1 hour before or 2 hours after antacids. B) The incidence of extrapyramidal symptoms is high. C) It is therapeutic if ordered on an as-needed (prn) basis. D) Haldol is contraindicated in Parkinson's disease, seizure disorders, alcoholism, and severe mental depression. E) Crush the sustained-release form for easier swallowing.

Answer: A, B, D Rationale: Aluminum- and magnesium-based antacids decrease absorption of haloperidol (Haldol). Haldol also has a high incidence of EPS. It is contraindicated in Parkinson's disease, seizure disorders, alcoholism, and severe mental depression. Options C and E are incorrect. Haldol must be taken as ordered for therapeutic results to occur and should not be given prn for psychosis. The sustained-release forms must not be opened or crushed. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

Which of the following medications may be used to treat partial seizures? (Select all that apply) A) Phenytoin (Dilantin) B) Valproic acid (Depakene) C) Diazepam (Valium) D) Carbamazepine (Tegretol) E) Ethosuximide (Zarontin)

Answer: A, B, D Rationale: The phenytoin-like drugs including phenytoin (Dilantin), valproic acid (Depakene), and carbamazepine (Tegretol) are used to treat partial seizures. Options C and E are incorrect. Diazepam (Valium) is a benzodiazepine that is used to treat tonic-clonic seizures and status epilepticus. Ethosuximide (Zarontin) is used in the control of generalized seizures such as absence seizures. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

The patient returns to the postanesthesia recovery unit (PACU) for observation and recovery following surgery with a general anesthetic. Which of the following assessment findings may the nurse expect to find during this recovery period? (Select all that apply) A) Bradycardia B) Severe headache C) Hypertension D) Respiratory depression E) Urinary frequency

Answer: A, D Rationale: Bradycardia and respiratory depression are common findings with general anesthetics in the immediate postoperative period due to the CNS depressant effects of the drugs. Options B, C, and E are incorrect. General anesthetics may cause hypotension or urinary retention and generally do not cause a severe headache. If it occurs, other causes should be investigated. Cognitive Level: Analyzing Nursing Process: Assessment Client Need: Physiological Integrity

Prior to discharge, the nurse plans for patient teaching related to side effects of phenothiazines to the patient, family, or caregiver. Which of the following should be included? A) The patient may experience withdrawal and slowed activity. B) Severe muscle spasms may occur early in therapy. C) Tardive dyskinesia is likely early in therapy. D) Medications should be taken as prescribed to prevent adverse effects.

Answer: B Rationale: Acute dystonias, or severe muscle spasms, particularly of the back, neck, face, or tongue, may occur within hours or days of the first dose of a phenothiazine drug and should be reported immediately. Options A, C, and D are incorrect. Social withdrawal may be a symptom of the disease but is not related to the medication. Tardive dyskinesias occur late in therapy. Adverse effects are common with all antipsychotics, even when taken as prescribed. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

The patient taking benztropine (Cogentin) should be provided education on methods to manage which common adverse effect? A) Heartburn B) Constipation C) Hypothermia D) Increased gastric motility

Answer: B Rationale: Anticholinergic medications such as benztropine (Cogentin) slow intestinal motility; therefore, constipation is a potential side effect. Patients should be taught methods to manage constipation such as increasing fluids and fiber in the diet. Options A, C, and D are incorrect. Heartburn and hypothermia are not associated with the use of benztropine. Cognitive Level: Applying Nursing Process: Implementation Client Need: Health Promotion and Maintenance

A 20-year-old man is admitted to the psychiatric unit for treatment of acute schizophrenia and is started on risperidone (Risperdal). Which patient effects should the nurse assess for to determine whether the drug is having therapeutic effects? A) Restful sleep, elevated mood, and coping abilities B) Decreased delusional thinking and lessened auditory/visual hallucinations C) Orthostatic hypotension, reflex tachycardia, and sedation D) Relief of anxiety and improved sleep and dietary habits

Answer: B Rationale: Antipsychotic drugs such as risperidone (Risperdal) treat the positive and negative effects of the underlying mental disorder. A decrease in delusional thinking, lessened hallucinations, and overall improvement in mental thought processes should be noted. Options A, C, and D are incorrect. Improvement in sleep patterns, anxiety, and nutrition may be noted as secondary effects of treatment of the underlying thought disorder. Orthostatic hypotension, reflex tachycardia, and sedation are potential adverse effects. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity

Which factor in the patient's history would cause the nurse to question a medication order for atropine? A) A 32-year-old man with a history of drug abuse B) A 65-year-old man with benign prostatic hyperplasia C) An 8-year-old boy with chronic tonsillitis D) A 22-year-old woman on the second day of her menstrual cycle

Answer: B Rationale: Atropine causes urinary retention to worsen in patients with BPH. Options A, C, and D are incorrect because they are not contraindications for using atropine. Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

An 8-year-old boy is evaluated and diagnosed with absence seizures. He is started on ethosuximide (Zarontin). Which information should the nurse provide the parents? A) After-school sports activities will need to be stopped because they will increase the risk of seizures. B) Monitor height and weight to assess that growth is progressing normally. C) Fractures may occur, so increase the amount of vitamin D and calcium-rich foods in the diet. D) Avoid dehydration with activities and increase fluid intake.

Answer: B Rationale: Because adverse drug effects such as nausea, anorexia, or abdominal pain may occur with ethosuximide (Zarontin), the parents should monitor the child's height and weight to assess whether nutritional intake is sufficient for normal growth and development. Options A, C, and D are incorrect. Physical activity does not increase the risk of seizure activity or need to be curtailed, and the drug does not affect bone growth or require extra vitamin D or calcium in the diet. Dehydration is a condition to be avoided in all clients, although increasing fluid intake is not necessarily related to the use of ethosuximide. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

The patient is scheduled to receive rimabotulinumtoxinB (Myobloc) for treatment of muscle spasticity. Which of the following will the nurse teach the patient to report immediately? A) Fever, aches, or chills B) Difficulty swallowing, ptosis, blurred vision C) Continuous spasms and pain on the affected side D) Moderate levels of muscle weakness on the affected side

Answer: B Rationale: Dysphagia, ptosis, and blurred vision are all symptoms of possible botulinum toxin B toxicity and must be reported immediately. Options A, C, and D are incorrect. Fever, aches, and chills are not anticipated side effects. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur because the drug blocks muscle contraction. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

A 17-year-old patient has been prescribed escitalopram (Lexapro) for increasing anxiety uncontrolled by other treatment measures. Because of this patient's age, the nurse will ensure that the patient and parents are taught what important information? A) Cigarette smoking will counteract the effects of the drug. B) Signs of increasing depression or thoughts of suicide should be reported immediately. C) The drug causes dizziness and alternative schooling arrangements may be needed for the first two months of use. D) Anxiety and excitability may increase during the first two weeks of use but then will have significant improvement.

Answer: B Rationale: Escitalopram (Lexapro) is an antidepressant in the SSRI class. The drug carries a black box warning of increased risk of suicidal thinking and behavior in children, adolescents, and young adults. Signs of increasing depression or suicidal thoughts should be reported immediately. Options A, C, and D are incorrect. Smoking has no direct effects on escitalopram. Although dizziness may occur, it should not be significant enough to warrant a change in schooling needs. Escitalopram should not cause increased anxiety or excitability in the first few weeks of use, and other causes should be investigated should these occur. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

The nurse discusses the disease process of multiple sclerosis with the patient and caregiver. The patient will begin taking glatiramer (Copaxone), and the nurse is teaching the patient about the drug. Which of the following points should be included? A) Drink extra fluids while this drug is given. B) Local injection site irritation is a common effect. C) Take the drug with plenty of water and remain in an upright position for at least 30 minutes. D) The drug causes a loss of vitamin C so include extra citrus and foods containing vitamin C in the diet.

Answer: B Rationale: Glatiramer (Copaxone) is given by injection and often causes injection site irritation. Options A, C, and D are incorrect. Extra fluids do not need to be included and the drug is not given orally. It does not deplete vitamin C from the body. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity

A patient has been taking phenytoin (Dilantin) for control of generalized seizures, tonic-clonic type. The patient is admitted to the medical unit with symptoms of nystagmus, confusion, and ataxia. What change in the phenytoin dosage does the nurse anticipate will be made based on these symptoms? A) The dosage will be increased. B) The dosage will be decreased. C) The dosage will remain unchanged; these are symptoms unrelated to the phenytoin. D) The dosage will remain unchanged but an additional antiseizure medication may be added.

Answer: B Rationale: Nystagmus, confusion, and ataxia may occur with phenytoin, particularly with higher dosages. The dosage is likely to be decreased. Options A, C, and D are incorrect. The dosage would not remain the same or be increased because these are adverse effects of phenytoin that are related to overdosage. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

Planning teaching needs for a patient who is to be discharged postoperatively with a prescription for oxycodone with acetaminophen (Percocet) should include which of the following? A) Refer the patient to a drug treatment center if addiction occurs. B) Encourage increased fluids and fiber in the diet. C) Monitor for GI bleeding. D) Teach the patient to self-assess blood pressure.

Answer: B Rationale: Opioids such as hydrocodone with acetaminophen (Percocet) slow peristalsis which can lead to constipation. Increasing fluids and fiber in the diet may help prevent this adverse effect. Options A, C, and D are incorrect. Drug treatment programs are not needed if the drug is taken as ordered for the time prescribed. The drugs should not cause GI bleeding and for most patients will not cause a significant drop in blood pressure. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity

The nurse teaches the patient relaxation techniques and guided imagery as an adjunct to medication for treatment of pain. What is the main rationale for the use of these techniques as adjuncts to analgesic medication? A) They are less costly techniques. B) They may allow lower doses of drugs with fewer adverse effects. C) They can be used at home. D) They do not require self-injection.

Answer: B Rationale: When used concurrently with medication, nonpharmacologic techniques may allow for lower doses and possibly fewer drug-related adverse effects. Relaxation techniques and guided imagery may also be used in the acute care setting. Options A, C, and D are incorrect. Although nonpharmacologic measures of pain control are less costly, may be used at home, and do not require injections, those are not the main rationale for using such techniques. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

A female patient is prescribed dantrolene (Dantrium) for painful muscle spasms associated with multiple sclerosis. The nurse is writing the discharge plan for the patient and will include which of the following teaching points? (Select all that apply) A) If muscle spasms are severe, supplement the medication with hot baths or showers three times per day. B) Inform the health care provider if she is taking estrogen products. C) Sip water, ice, or hard candy to relieve dry mouth. D) Return periodically for required laboratory work. E) Obtain at least 20 minutes of sun exposure per day to boost vitamin D levels.

Answer: B, C, D Rationale: Dantrolene (Dantrium) may cause hepatotoxicity with the greatest risk occurring for women over age 35, and periodic laboratory tests will be required for monitoring. Estrogen taken concurrently with dantrolene may increase this risk. The drug may cause dry mouth and sucking on hard candy, sucking ice chips, or sipping water may help relieve the dryness. Options A and E are incorrect. Dantrolene may cause erratic blood pressure, including hypotension, and hot baths or showers cause vasodilation, increasing the risk for syncope and falls. The drug may cause photosensitivity and direct exposure to the sun should be avoided. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity

The nurse knows that which of the following are major disadvantages for the use of donepezil (Aricept) to treat the symptoms of early Alzheimer's disease? (Select all that apply) A) It must be administered four times per day. B) It may causes significant weight loss. C) It may cause potentially fatal cardiac dysrhythmias. D) It may cause serious hepatic damage. E) It results in only modest cognitive improvement and results do not last.

Answer: B, C, D, E Rationale: Donepezil (Aricept) may cause serious liver damage and potentially fatal dysrhythmias including severe bradycardia and heart block. It may also cause significant weight loss, and the patient's weight should be monitored. While cognitive improvement may be observed in as few as 1 to 4 weeks, patients should receive pharmacotherapy for at least 6 months prior to assessing maximum benefits of drug therapy. Unfortunately, cognitive improvement is only modest and short-term. Option A is incorrect. Donepezil is taken once per day usually at bedtime. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

The nurse should assess a patient who is taking lorazepam (Ativan) for the development of which of these adverse effects? A) Tachypnea B) Astigmatism C) Ataxia D) Euphoria

Answer: C Rationale: Adverse CNS effects for lorazepam (Ativan) include ataxia, amnesia, weakness, disorientation, blurred vision, diplopia, nausea, and vomiting. Options A, B, and D are incorrect. Lorazepam is not known to cause tachycardia, astigmatism, or euphoria. If these symptoms occur, the patient should be assessed for other causative factors. Cognitive Level: Applying Nursing Process: Assessment Client Need: Physiological Integrity

Which of the following patient statements indicates that the levodopa/carbidopa (Sinemet) is effective? A) "I'm sleeping a lot more, especially during the day." B) "My appetite has improved." C) "I'm able to shower by myself." D) "My skin doesn't itch anymore."

Answer: C Rationale: Becoming more independent in ADLs shows an improvement in physical abilities. Options A, B, and D are incorrect. Drowsiness is a common adverse effect of medications for PD. Anorexia or loss of appetite is also a common adverse effect and skin itching is not related to medication use. Cognitive Level: Applying Nursing Process: Evaluation Client Need: Health Promotion and Maintenance

An early sign(s) of levodopa toxicity is (are) which of the following? A) Orthostatic hypotension B) Drooling C) Spasmodic eye winking and muscle twitching D) Nausea, vomiting, and diarrhea

Answer: C Rationale: Blepharospasm (spasmodic eye winking) and muscle twitching are early signs of potential overdose or toxicity. Options A, B, and D are incorrect. Orthostatic hypotension is a common adverse effect of both PD and many drugs used to treat the condition but is not a symptom of overdosage or toxicity. Drooling, nausea, vomiting, and diarrhea are also not symptoms of overdose or toxicity. Cognitive Level: Analyzing Nursing Process: Evaluation Client Need: Physiological Integrity

A patient has been prescribed clonazepam (Klonopin) for muscle spasms and stiffness secondary to an automobile accident. While the patient is taking this drug, what is the nurse's primary concern? A) Monitoring hepatic laboratory work B) Encouraging fluid intake to prevent dehydration C) Assessing for drowsiness and implementing safety measures D) Providing social services referral for patient concerns about the cost of the drug

Answer: C Rationale: Clonazepam (Klonopin) is a benzodiazepine; because it works on the CNS, it may cause significant drowsiness and dizziness. Safety measures should be implemented to prevent falls and injury. Options A, B, and D are incorrect. Benzodiazepines may cause hepatotoxicity in patients with existing hepatic insufficiency and may be needed for long-term monitoring. This drug was prescribed after a health care provider's assessment and is currently given to treat a potential short-term condition. The drug should not cause dehydration and is available in generic form. If cost is a concern, social service aid may be needed, but the primary concern for the nurse is safety. Cognitive Level: Applying Nursing Process: Implementation Client Need: Safe and Effective Care Environment

A patient admitted with hepatitis B is prescribed hydrocodone with acetaminophen (Vicodin) 2 tablets for pain. What is the most appropriate action for the nurse to take? A) Administer the drug as ordered. B) Administer 1 tablet only. C) Recheck the order with the health care provider. D) Hold the drug until the health care provider arrives.

Answer: C Rationale: Hydrocodone with acetaminophen (Vicodin) contains acetaminophen which can be hepatotoxic. This patient has hepatitis B, a chronic liver infection with inflammation, which may affect the metabolism of the drug. Options A, B, and D are incorrect. The drug should not be given as ordered and the patient may require pain relief before the health care provider arrives. It is not within the scope of practice for a nurse to determine the dosage of medication unless the nurse has received advanced specialty practice certification with prescriptive authority. Cognitive Level: Applying Nursing Process: Implementation Client Need: Safe and Effective Care Environment

The parents of a young patient receiving methylphenidate (Ritalin) express concern that the health care provider has suggested the child have a "holiday" from the drug. What is the purpose of a drug-free period? A) To reduce or eliminate the risk of drug toxicity B) To allow the child's "normal" behavior to return C) To decrease drug dependence and assess the patient's status D) To prevent the occurrence of a hypertensive crisis

Answer: C Rationale: Methylphenidate (Ritalin) is a Schedule II drug with potential to cause drug dependence when used over an extended period. The drug holiday helps to decrease the risk of dependence. It is also useful to evaluate current behavior; if improvement is noted, the drug dosage may be lowered or the drug stopped. Options A, B, and D are incorrect. Brief holidays off the medication will not eliminate the risk of toxicity. Toxicity may still occur while the patient takes the medication. The child's "normal" behavior may have been the reason for medication therapy. Hypertension may occur from methylphenidate but, except in the case of an overdose, should not reach a crisis level. Cognitive Level: Applying Nursing Process: Implementation Client Need: Safe and Effective Care Environment

The patient who is scheduled to have a minor in-office surgical procedure will receive nitrous oxide and expresses concern to the nurse that the procedure will hurt. Which of the following would be the nurse's best response? A) "You may feel pain during the procedure but you won't remember any of it." B) "You will be unconscious the entire time and won't feel any pain." C) "You will not feel any pain during the procedure because the drug blocks the pain signals." D) "You will feel pain but you won't perceive it the same way; that's why it's called 'laughing gas.'"

Answer: C Rationale: Nitrous oxide suppresses the pain mechanisms within the CNS thereby causing analgesia. Options A, B, and D are incorrect. Nitrous oxide does not produce complete loss of consciousness or the profound relaxation of skeletal muscles as general anesthetics do and the patient does not perceive pain differently; it is suppressed. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

What is the most appropriate method to ensure adequate pain relief in the immediate postoperative period from an opioid drug? A) Give the drug only when the family members report that the patient is complaining of pain. B) Give the drug every time the patient complains of acute pain. C) Give the drug as consistently as possible for the first 24 to 48 hours. D) Give the drug only when the nurse observes signs and symptoms of pain.

Answer: C Rationale: Opioid pain relievers should be given as consistently as possible and before the onset of acute pain in the immediate postoperative period unless the patient's condition does not allow the consistent dosing (e.g., vital signs do not support regular doses). Options A, B, and D are incorrect. These methods of drug administration would potentially allow pain to become severe before being adequately treated. Patients or family members may not always report pain or may downplay the severity. Cultural norms may also influence the patient's way of exhibiting pain. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Safe and Effective Care Environment

Which of the following would be a priority component of the teaching plan for a patient prescribed phenelzine (Nardil) for treatment of depression? A) Headaches may occur. Over-the-counter medications will usually be effective. B) Hyperglycemia may occur and any unusual thirst, hunger, or urination should be reported. C) Read labels of food and over-the-counter drugs to avoid those with substances that should be avoided as directed. D) Monitor blood pressure for hypotension and report any blood pressure below 90/60.

Answer: C Rationale: Phenelzine (Nardil) is an MAOI. This class of drugs has many drug and food interactions that may cause a hypertensive crisis. A list of foods, beverages, and medications to avoid should also be given to the patient. Options A, B, and D are incorrect. Headaches, especially if severe, may signal the beginning of a hypertensive crisis and any severe or increasing headache should be reported immediately. MAOIs are not known to cause hyperglycemia and other causes should be investigated if it occurs. The use of CNS depressants, including narcotics, along with an MAOI may cause profound hypotension, but the risk of hypertensive crisis is much greater and would have priority for teaching. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

The nurse is preparing a plan of care for a patient with myasthenia gravis. Which of the following outcome statements would be appropriate for a patient receiving a cholinergic agonist such as pyridostigmine (Mestinon) for this condition? The patient will exhibit: A) An increase in pulse rate, blood pressure, and respiratory rate. B) Enhanced urinary elimination. C) A decrease in muscle weakness, ptosis, and diplopia. D) Prolonged muscle contractions and proprioception.

Answer: C Rationale: Pyridostigmine is used primarily for myasthenia gravis, a neurologic disorder characterized by muscle weakness and ptosis. A decrease in these symptoms is an expected therapeutic outcome for this drug. Options A, B, and D are incorrect because the symptoms listed are not usual problems faced by the patient with myasthenia gravis and would therefore be inappropriate outcome statements. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

The nurse determines that the teaching plan for a patient prescribed sertraline (Zoloft) has been effective when the patient makes which statement? A) "I should not decrease my sodium or water intake." B) "The drug can be taken concurrently with the phenelzine (Nardil) that I'm taking." C) "It may take up to a month for the drug to reach full therapeutic effects and I'm feeling better." D) "There are no other drugs I need to worry about; Zoloft doesn't react with them."

Answer: C Rationale: SSRI antidepressant drugs such as sertraline (Zoloft) may not have full effects for a month or longer, but some improvement in mood and depression should be noticeable after beginning therapy. Options A, B, and D are incorrect. Sodium and fluid intake is a concern with lithium but does not adversely affect the SSRIs. The SSRIs should not be used concurrently with MAOIs because of an increased risk of hypertensive crisis. They also have many interactions with other drugs Cognitive Level: Applying Nursing Process: Evaluation Client Need: Health Promotion and Maintenance

Levodopa is prescribed for a patient with Parkinson's disease. At discharge, which of the following teaching points should the nurse include? A) Monitor blood pressure every 2 hours for the first 2 weeks. B) Report the development of diarrhea. C) Take the pill on an empty stomach or 2 hours after a meal containing protein. D) If tremors seem to worsen, take a double dose for two doses and call the provider.

Answer: C Rationale: Taking dopamine replacement drugs such as levodopa with meals containing protein significantly impairs absorption. The drug should be taken on an empty stomach or 2 or more hours after a meal containing protein. Options A, B, and D are incorrect. Although the patient should be taught to rise gradually from lying or sitting to standing, the patient does not need to monitor blood pressure every 2 hours. Diarrhea should be reported but is unrelated to the effects of levodopa, and other causes should be explored. An increase in tremors should be evaluated, and the dose of the drug should not be independently increased. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

A 32-year-old female patient has been taking lorazepam (Ativan) for her anxiety and is brought into the emergency department after taking 30 days' worth at one time. What antagonist for benzodiazepines may be used in this case? A) Epinephrine B) Atropine C) Flumazenil D) Naloxone

Answer: C Rationale: The competitive antagonist drug used in cases of benzodiazepine overdosage is flumazenil (Romazicon). Options A, B, and D are incorrect. Epinephrine, an adrenergic agonist, is not an antagonist to the benzodiazepines. Atropine is an anticholinergic, and naloxone is a competitive antagonist to opioid (narcotic) drugs. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity

Older adult patients taking bethanechol (Urecholine) need to be assessed more frequently because of which of the following adverse effects? A) Tachycardia B) Hypertension C) Dizziness D) Urinary retention

Answer: C Rationale: The nurse should monitor older adult patients for episodes of dizziness caused by CNS stimulation from the parasympathomimetic system. Options A, B, and D are incorrect. Bethanechol does not cause tachycardia or hypertension and is used to treat nonobstructive urinary retention. Cognitive Level: Applying Nursing Process: Evaluation Client Need: Physiological Integrity

The nurse administers morphine 4 mg IV to a patient for treatment of severe pain. Which of the following assessments require immediate nursing interventions? (Select all that apply) A) The patient's blood pressure is 110/70 mmHg. B) The patient is drowsy. C) The patient's pain is unrelieved in 15 minutes. D) The patient's respiratory rate is 10 breaths per minute. E) The patient becomes unresponsive.

Answer: C, D, E Rationale: Opioids may cause respiratory depression, particularly with the first dose given. The patient's respiratory rate should remain above 12 breaths per minute. Although the patient may also become drowsy, he or she should not become unresponsive after administration of morphine sulfate. Because of the rapid onset of drugs when given IV, the provider should be notified if the patient's pain is unrelieved in 15 minutes. Options A and B are incorrect. Drowsiness is a common adverse effect of opioids, and 110/70 mmHg is within normal range for blood pressure. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

Zolpidem (Ambien, Edluar, Intermezzo) has been ordered for a patient for the treatment of insomnia. What information will the nurse provide for this patient? (Select all that apply) A) Be cautious when performing morning activities because it may cause a significant "hangover" effect with drowsiness and dizziness. B) Take the drug with food; this enhances the absorption for quicker effects. C) Take the drug immediately before going to bed; it has a quick onset of action. D) If the insomnia is long-lasting, this drug may safely be used for up to one year. E) Alcohol and other drugs that cause CNS depression (e.g., antihistamines) should be avoided while taking this drug.

Answer: C, E Rationale: Zolpidem (Ambien, Intermezzo) has a rapid onset, approximately 7 to 27 minutes, and should be taken immediately before going to bed. It should not be taken with alcohol or other drugs that cause CNS depression because of increased sedation and CNS depression. Options A, B, and D are incorrect. Taking the drug with food will significantly impair its absorption and the onset of action may be delayed. Zolpidem has a duration of action of approximately 6 to 8 hours. Depending on when the drug is taken the night before, significant "hangover" effects such as sedation are not as likely to occur as with other drugs in the category. The drug is approved for short-term treatment of insomnia only. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

The patient states that he has not taken his antipsychotic drug for the past 2 weeks because it was causing sexual dysfunction. What is the nurse's primary concern at this time? A) A hypertensive crisis may occur with such abrupt withdrawal of the drug. B) Significant muscle twitching may occur, increasing fall risk. C) Extrapyramidal symptoms such as secondary parkinsonism are likely to occur. D) Symptoms of psychosis are likely to return.

Answer: D Rationale: Antipsychotic medications treat the symptoms associated with mental illness but do not cure the underlying disorder. Without the medication, symptoms of the disorder are likely to return. Options A, B, and C are incorrect. Hypertensive crisis does not occur upon withdrawal of antipsychotic medication. EPS including muscle twitching and rigidity, and secondary parkinsonism may occur related to the dosage of the medication and length of therapy, not withdrawal from the drug. Cognitive Level: Analyzing| Nursing Process: Implementation Client Need: Physiological Integrity

The nurse is caring for a 72-year-old patient taking gabapentin (Gralise, Horizant, Neurontin) for a seizure disorder. Because of this patient's age, the nurse would establish which nursing diagnosis related to the drug's common adverse effects? A) Risk for Deficient Fluid Volume B) Risk for Impaired Verbal Communication C) Risk for Constipation D) Risk for Falls

Answer: D Rationale: CNS depression including dizziness and drowsiness is a common adverse effect of gabapentin (Gralise, Horizant, Neurontin). Because of this patient's age, these effects may increase the risk of falls. Options A, B, and C are incorrect. The drug is not known to cause dehydration (fluid volume deficit) or constipation or impair the ability to communicate. Cognitive Level: Applying Nursing Process: Planning Client Need: Physiological Integrity

Teaching for a patient receiving carbamazepine (Tegretol) should include instructions that the patient should immediately report which symptom? A) Leg cramping B) Blurred vision C) Lethargy D) Blister-like rash

Answer: D Rationale: Carbamazepine (Tegretol) is associated with Stevens-Johnson syndrome and exfoliative dermatitis. A blister-like skin rash may indicate that these conditions are developing. Options A, B, and C are incorrect. Blurred vision, leg cramping, and drowsiness or lethargy are adverse effects of carbamazepine but do not require immediate reporting and may diminish over time. Cognitive Level: Applying Nursing Process: Implementation Client Need: Physiological Integrity

The health care provider prescribes epinephrine (adrenalin) for a patient who was stung by several wasps 30 minutes ago and is experiencing an allergic reaction. The nurse knows that the primary purpose of this medication for this patient is to: A) Stop the systemic release of histamine produced by the mast cells. B) Counteract the formation of antibodies in response to an invading antigen. C) Increase the number of white blood cells produced to fight the primary invader. D) Increase a declining blood pressure and dilate constricting bronchi associated with anaphylaxis.

Answer: D Rationale: Epinephrine is used during anaphylaxis to prevent hypotension and bronchoconstriction. Options A, B, and C are incorrect because the administration of epinephrine for anaphylaxis does not prevent the formation of histamine or the formation of antibodies in response to an invading antigen, nor does it affect white blood cell function. Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Evaluation

Education given to patients about the use of all drugs to treat insomnia should include an emphasis on what important issue? A) They will be required long-term to achieve lasting effects. B) They require frequent blood counts to avoid adverse effects. C) They are among the safest drugs available and have few adverse effects. D) Long-term use may increase the risk of adverse effects, create a "sleep debt," and cause rebound insomnia when stopped.

Answer: D Rationale: Long-term use of drugs to treat insomnia is not recommended. They have significant adverse effects, may cause a "sleep debt" due to effects on the sleep cycle, and may cause rebound insomnia when discontinued. Options A, B, and C are incorrect. Many of the drugs used for insomnia have significant adverse effects and are not used long term. Whereas some drugs in the category may require concurrent blood counts, this is not required for all drugs in the category. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Health Promotion and Maintenance

A patient is admitted to the postanesthesia recovery unit (PACU) after receiving ketamine (Ketalar) after his minor orthopedic surgery. What is the most appropriate nursing action in the recovery period for this patient? A) Frequently orient the patient to time, place, and person. B) Keep the patient in a bright environment so there is less drowsiness. C) Frequently assess the patient for sensory deprivation. D) Place the patient in a quiet area of the unit with low lights and away from excessive noise.

Answer: D Rationale: Neuroleptanalgesia drugs such as ketamine do not result in full loss of consciousness but cause disconnection from events that are occurring. Confusion, anxiety, fear, or panic may occur in the immediate postprocedure period if sensory stimulation is misinterpreted. Sensory stimulation should be kept to a minimum during this period for this reason. Options A, B, and C are incorrect. Frequent assessments, above those required for patient safety or monitoring, increase sensory stimulation and may result in extreme reactions by the patient. Cognitive Level: Applying Nursing Process: Implementation Client Need: Safe and Effective Care Environment

A young patient requires suturing of a laceration to the right forearm and the provider will use lidocaine (Xylocaine) with epinephrine as the local anesthetic prior to the procedure. Why is epinephrine included in the lidocaine for this patient? A) It will increase vasodilation at the site of the laceration. B) It will prevent hypotension. C) It will ensure that infection risk is minimized postsuturing. D) It will prolong anesthetic action at the site.

Answer: D Rationale: Solutions of lidocaine containing epinephrine are used for local anesthesia because the epinephrine will prolong the anesthetic action at the site. Because this is a young patient, that may be particularly advantageous. Options A, B, and C are incorrect. Epinephrine causes vasoconstriction and HTN when given systemically; this drug is being used locally. Epinephrine will not prevent postsuturing infection and the site should continue to be monitored. Cognitive Level: Analyzing Nursing Process: Implementation Client Need: Physiological Integrity

A patient is receiving temazepam (Restoril). Which of these responses should a nurse expect the patient to have if the medication is achieving the desired effect? A) The patient sleeps in 3-hour intervals, awakens for a short time, and then falls back to sleep. B) The patient reports feeling less anxiety during activities of daily living. C) The patient reports having fewer episodes of panic attacks when stressed. D) The patient reports sleeping 7 hours without awakening.

Answer: D Rationale: Temazepam (Restoril) is a benzodiazepine ordered for insomnia. Therefore, the patient should be experiencing relief from insomnia and reporting feeling rested when awakening. Options A, B, and C are incorrect. Sleeping 3 hours or less would indicate less than therapeutic effects. Whereas some benzodiazepines are used in the treatment of anxiety or panic disorders, temazepam's primary use is in the treatment of insomnia. Cognitive Level: Analyzing Nursing Process: Evaluation Client Need: Physiological Integrity

The emergency department nurse is caring for a patient with a migraine. Which drug would the nurse anticipate administering to abort the patient's migraine attack? A) Morphine B) Propranolol (Inderal) C) Ibuprofen (Motrin) D) Sumatriptan (Imitrex)

Answer: D Rationale: Triptans such as sumatriptan (Imitrex) are used to abort a migraine attack. Options A, B, and C are incorrect. Morphine and other narcotics are not effective in aborting a migraine. Propranolol (Inderal) and ibuprofen (Motrin) may be used as adjunctive therapy in migraine therapy but will not stop a headache from occurring. Cognitive Level: Analyzing Nursing Process: Planning Client Need: Physiological Integrity

A patient is experiencing significant adverse effects from his antipsychotic drug, and because there are few symptoms of his original disease (schizophrenia) decides that he is cured and stops taking his medication. As the nurse, how would you respond?

Antipsychotic drugs do not cure mental illness, and symptoms remain in remission only as long as the patient chooses to take the drug. The relapse rate for patients who discontinue their medication is 60% to 80%. As the nurse, you would report the patient's discontinuation of his medication to the provider. If possible, depending on current mental condition, you would explain to the patient the necessity of his medication. If the adverse effects are severe enough that the patient stops taking the medication, the provider may be able to consider alternative drugs that may have fewer adverse effects.

A patient who has a history of cardiac dysrhythmias returns from surgery during which the patient received isoflurane (Forane) as a general anesthetic. What adverse effect of isoflurane might occur related to this patient's past medical history? What priority assessment data will the nurse gather in the recovery period related to this?

Because of the patient's prior history of dysrhythmias, this may result in life-threatening cardiac dysrhythmias. The nurse should frequently monitor the patient's ECG, blood pressure, and pulse rate and volume during the recovery period. Adrenergic drugs, phenothiazines, and other specific medications will have to be avoided after surgery unless necessary, or drugs will have to be monitored due to the possibility of dysrhythmias

Is there a "drug of choice" for depression? With so many drug groups available, why would one be preferred over another?

Because seizures are likely to occur when antiseizure drugs are abruptly withdrawn, the medication is usually discontinued over a period of 6 to 12 weeks.

Benzodiazepines are among the first-line drugs for treating insomnia and anxiety disorders. Why would these drugs pose a safety risk in the older adult? What are the nursing considerations for these drugs when used in the older adult population?

Benzodiazepines have possible adverse effects of oversedation, confusion, or impaired mobility, which may occur even at normal doses. This is especially true for the older patient who may be at greater risk for falls. The nurse should evaluate the safety of the home environment, evaluate other risk factors contributing to insomnia (e.g., diuretic use), and explore nondrug options that may be useful in treating the patient's underlying insomnia or anxiety. Whenever possible, the lowest dose of a benzodiazepine for the shortest amount of time should be used.

A 42-year-old male was diagnosed with Parkinson's disease 4 years ago. He is being treated with a regimen that includes benztropine (Cogentin). The nurse recognizes Cogentin as an anticholinergic drug. What assessment data should the nurse gather from this patient? Discuss the potential side effects of benztropine for which the nurse should assess in this patient.

Benztropine (Cogentin) is an anticholinergic. Blocking the parasympathetic nerves allows the sympathetic nervous system to dominate. The drug is given as an adjunct in Parkinson's disease to reduce muscular tremor and rigidity. Anticholinergics affect many body systems and produce a wide variety of side effects. The nurse should monitor for decreased heart rate, dilated pupils, decreased peristalsis, and decreased salivation in addition to decreased muscular tremor and rigidity. Many of the adverse effects of anticholinergics are dose dependent. Adverse effects include typical signs of sympathetic nervous system stimulation.

A 74-year-old female patient required an indwelling bladder (Foley) catheter for 4 days postoperatively and, after removal, she was still unable to void. She was recatheterized, and a bladder rehabilitation program was begun that included bethanechol (Urecholine). What nursing diagnosis should be considered as a part of this patient's plan of care given this new drug regimen?

Bethanechol is a direct-acting cholinergic agent that works by stimulating the parasympathetic nervous system. The desired effect, in this case, is an increase in smooth-muscle tone in the bladder with increased ease in emptying the bladder. Any adverse effects would be related to an overstimulation of the parasympathetic nervous system. Following are possible nursing diagnoses: Risk for Injury, related to adverse effects of cholinergic agents (hypotension, bradycardia, and syncope) Impaired Comfort, related to adverse effects of cholinergic agents (abdominal cramping, nausea, and vomiting) Urge Urinary Incontinence, related to therapeutic effects from cholinergic therapy (Herdman & Kamitsuru, 2014)

A 52-year-old executive has started treatment with onabotulinumtoxinA (Botox) and is preparing to return home after her first injections. What should the nurse teach her?

Botulinum toxin type A (Botox) is widely used for cosmetic procedures to reduce the appearance of wrinkles and creases. Although the drug is usually effective, it may take up to 6 weeks for full effects to be realized. These effects last 3 to 6 months, requiring further injections to maintain results. There is a risk of systemic effects from the drug that may occur immediately, within weeks, or even months after the injection. Dysphagia, dysphonia, diplopia, blurred vision, ptosis, urinary incontinence, generalized muscle weakness, and respiratory distress are all signs of systemic effects of botulinum toxins. If any of the symptoms occur, the patient should immediately report them to the health care provider.

A 66-year-old man has had increasing trouble with urination, including difficulty starting to urinate and feeling that his bladder has not completely emptied. His provider prescribes doxazocin (Cardura) for treatment of BPH. The patient is alarmed and asks the nurse, "Why was I prescribed this? My brother takes it for high blood pressure and my blood pressure is normal!" As the nurse, how would you respond?

Doxazosin (Cardura) is an adrenergic-blocking drug that is prescribed for the treatment of hypertension. It is also given in the treatment of BPH, due to its ability to increase urine flow by relaxing smooth muscle in the bladder neck, prostate, and urethra. He should notify his provider if, after taking the medication, his symptoms related to BPH do not improve or worsen. Because the drug may have effects on this patient's blood pressure, you would want to also include appropriate teaching related to managing symptoms such as dizziness, and teach him how to take his pulse.

The nurse is admitting a 17-year-old female patient with a history of seizure disorder. The patient has broken her leg in a car accident in which she was the driver. The patient states that she hates having to take her phenytoin (Dilantin) and that she stopped the drug because she was not allowed to drive and it was making her angry. Explain the possible long-term effects of phenytoin therapy and their impact on patient compliance with the treatment plan. What additional information could the nurse provide for this patient?

Long-term phenytoin therapy can produce an androgenic stimulus. Reported skin manifestations include acne, hirsutism, and an increase in subcutaneous facial tissue, changes that have been characterized as "Dilantin facies." These changes, coupled with the risk for gingival hypertrophy, may be difficult for the adolescent to cope with. In addition, the adolescent with a seizure disorder may be prohibited from operating a motor vehicle at the very age when driving becomes key to achieving young-adult status. The nurse will consider the range of possible support groups for this patient once she is discharged and will encourage the patient to discuss her concerns about the drug regimen with her health care provider.

A 42-year-old female patient with ovarian cancer suffered profound nausea and vomiting after her first round of chemotherapy. The oncologist has added lorazepam (Ativan) 2 mg per IV in addition to a previously ordered antinausea medication as part of the prechemotherapy regimen. What is the purpose for adding this benzodiazepine?

Lorazepam (Ativan) is an antianxiety agent. As a benzodiazepine, it will also cause some sedation and relaxation. It is given in this situation because it has an unlabeled use as a treatment for chemotherapy-induced nausea and vomiting.

A 58-year-old male patient underwent an emergency coronary artery bypass graft. He is still experiencing a high degree of pain and also states that he cannot fall asleep. The patient has been ordered estazolam (Prosom) at night for sleep and an opioid (narcotic) analgesic for pain. As the nurse, explain to the student nurse why both medications should be administered.

Pain often interferes with adequate sleep. Drugs used in the treatment of insomnia such as estazolam (Prosom) do not provide pain relief. Giving an opioid (narcotic) analgesic along with the estazolam will treat the patient's pain and help ensure adequate sleep. Because both drug groups cause CNS depression, the patient's respiratory and heart rates and blood pressure will be closely monitored.

A 24-year-old patient is evaluated for seasonal allergies by his provider. Phenylephrine (Neo-Synephrine) nasal spray is recommended by the provider to treat symptoms related to allergic rhinitis. When teaching this patient about his medication, what therapeutic effects will the phenylephrine (Neo-Synephrine) provide? What adverse effects should the patient be observant for?

Phenylephrine (Neo-Synephrine) is an adrenergic agonist. Given intranasally, it will cause vasoconstriction in the nasal passages, relieving the nasal congestion associated with allergic rhinitis. The patient should be taught to not use nasal spray longer than 3-5 days without consulting the provider because rebound congestion may occur. OTC saline nasal sprays may provide comfort if mucosa is dry and irritated. Increasing oral fluid intake may also help with hydration. The patient should inspect his nasal mucosa for irritation, increased rhinorrhea, or bleeding after nasal use and should discontinue the drug if they occur.

What are the symptoms of a cholinergic crisis and what are the drugs of choice for reversing this condition?

Signs and symptoms of a cholinergic crisis include miosis, nausea, vomiting, urinary incontinence, increased exocrine secretions, abdominal cramping, tachycardia, hyperglycemia, and progressive muscle weakness. These are all signs of parasympathetic stimulation, which can be reversed with an anticholinergic drug.

A 64-year-old patient has had a long-standing history of migraines as well as coronary artery disease, type 2 diabetes, and hypertension. On review of the medical history, the nurse notes that this patient has recently started on sumatriptan (Imitrex), prescribed by the patient's new neurologist. What intervention and teaching is appropriate for this patient?

Sumatriptan (Imitrex) is not recommended for patients with CAD, diabetes, or HTN because of the drug's vasoconstrictive properties. The nurse should refer the patient to the health care provider for review of medications and possible adverse reactions related to sumatriptan.

Is there a "drug of choice" for depression? With so many drug groups available, why would one be preferred over another?

The SSRIs have become the preferred drugs of choice for treatment of depression. They have approximately the same efficacy at relieving depression as the MAOIs and the TCAs, with a better safety profile. Depression is associated with an imbalance of neurotransmitters in regions of the brain associated with focused cognition and emotion. Because a patient's unique biochemistry may affect the way a drug works, SSRIs may not be the most effective in all patients and other antidepressants may need to be used. As with many drugs, the drug with the fewest adverse effects is often prescribed first with changes in drug therapy made based on the patient's response.

A 20-year-old newly diagnosed patient with schizophrenia has been on chlorpromazine and is doing well. Today the nurse notices that the patient appears more anxious and is demonstrating increased paranoia. What is the nurse's initial action? What is the potential problem? What patient teaching is important?

The nurse should initially assess whether the patient has been taking the medication as ordered or has altered the dose in any way. It is not uncommon for a patient to "cheek" the medication or attempt to cut back on the dose because of the lack of desire to take the medication on a continual basis or the belief that the disease is now cured. It is important that the patient understand the necessity of being on this medication in order to maintain therapeutic effects, and that the dose is not to be adjusted without consulting a health care provider.

A 56-year-old female patient has been diagnosed with clinical depression following the death of her husband. She says that she has not been able to sleep for weeks and that she is drinking a lot of coffee. She is also smoking more than she usually has. The health care provider prescribes fluoxetine (Prozac). The patient seeks reassurance from the nurse regarding when she should begin feeling "more like myself." How should the nurse respond?

The nurse should teach the patient that it might take 2 to 4 weeks before she begins to notice therapeutic benefit. The nurse should help the patient identify a support person or network to help as she works through her grief; if unavailable, a support group may be available through the local health care agency or community services. The nurse also needs to instruct the patient that both caffeine and nicotine are CNS stimulants and decrease the effectiveness of the medication

A 46-year-old male quadriplegic patient has been experiencing severe spasticity in the lower extremities, making it difficult for him to maintain his position in his electric wheelchair. Prior to the episodes of spasticity, the patient was able to maintain a sitting posture. The risks and benefits of therapy with dantrolene (Dantrium) have been explained to him, and he has decided that the benefits outweigh the risks. What assessments should the nurse make to determine whether the treatment is beneficial?

The nurse would anticipate a decrease in the patient's spasticity after 1 week of therapy. If there has been no improvement in 45 days, the medication regimen is usually discontinued. To evaluate for a decrease in spasticity, the nurse should assess the patient's muscle firmness, pain experience, range of motion, and ability to maintain posture and alignment when in a wheelchair. When spasticity is necessary to maintain posture, dantrolene should not be used. In this case, the patient's spasticity was of recent origin and was the causative factor in his inability to maintain posture, something he was able to do before it began.

A 22-year-old male patient has been on haloperidol (Haldol LA) for 2 weeks for the treatment of schizophrenia. During a follow-up assessment, the nurse notices that the patient keeps rubbing his neck and is complaining of neck spasms. What is the nurse's initial action? What is the potential cause of the sore neck and what would be the potential treatment? What teaching is appropriate for this patient?

The patient is exhibiting signs of developing acute dystonia, an EPS. Initially, the nurse would assess the patient to ensure that he had sustained no recent neck injury or trauma, but if the neck spasms started spontaneously, acute dystonia may be suspected. The patient may need treatment with an anticholinergic medication such as benztropine (Cogentin) to decrease the EPS. The patient, family, or caregiver should be taught to recognize EPS and to seek medical evaluation if the symptoms occur or worsen.

A 58-year-old woman with a history of a recent MI is on beta-blocker and anticoagulant therapy. The patient also has a history of arthritis and during a recent flare-up began taking aspirin because it helped control pain in the past. What teaching or recommendation would the nurse have for this patient?

The patient should be taught not to take any medication, including OTC medications, without the approval of the health care provider. This patient is taking an anticoagulant and aspirin increases bleeding time. The patient needs to be taught how to recognize the signs and symptoms of bleeding related to the anticoagulant therapy. The patient should review all her medications with the health care provider. It is possible that her anti-inflammatory medication can be changed from aspirin to another drug for treatment of arthritis.

A 58-year-old patient with PD is placed on levodopa. In obtaining her health history, the nurse notes that the patient takes Mylanta on a regular basis for mild indigestion and also takes multivitamins daily (vitamins A, B6, D, and E). What should the nurse include in teaching for this patient?

The patient should consult the health care provider about the need for regular Mylanta doses. This antacid drug contains magnesium which may cause increased absorption and toxicity of the levodopa. The patient also needs teaching about decreasing foods that contain vitamin B6 (for example, bananas, wheat germ, and green vegetables) because vitamin B6 may adversely interact with the medication.

A 24-year-old woman is brought to the emergency department by her husband. He tells the triage nurse that his wife has been treated for seizure disorder secondary to a head injury she received in an automobile accident. She takes phenytoin (Dilantin) 100 mg every 8 hours. He relates a history of increasing drowsiness and lethargy in his wife over the past 24 hours. A phenytoin level is performed, and the nurse notes that the results are 24 mcg/dL. What does this result signify, and what changes does the nurse anticipate will be made to this patient's treatment? (A laboratory guide may need to be consulted.)

The therapeutic drug level of phenytoin (Dilantin) is 5 to 20 mg/dL and this increased level may indicate drug toxicity. Patients may develop signs of CNS depression such as drowsiness and lethargy as the level increases. Exaggerated effects of Dilantin may also be seen if the drug has been combined with alcohol or other drugs that cause CNS depression. Depending on the existence of these other factors, the nurse would anticipate that the drug dosage will be reduced.

To improve oxygenation and to prevent secretions from being retained, patients are encouraged to deep breathe following surgery with general anesthetics. Following surgery where inhaled volatile anesthetics were used, why is deep breathing especially essential?

The volatile liquids used for general anesthesia, such as isoflurane, are excreted almost entirely by the lungs through exhalation. Deep breathing exercises are essential to help the patient clear the anesthetic from the body more quickly.

A 64-year-old man is taking atenolol (Tenormin) for treatment of hypertension. His seasonal allergies have been worse this year, and he is considering an OTC decongestant, pseudoephedrine (Sudafed), which a friend recommended. Is this medication safe for him to take?

There are two reasons why he should not take pseudoephedrine for his allergic symptoms. First, adrenergic agonists such as pseudoephedrine (Sudafed) antagonize the antihypertensive action of atenolol, thereby causing the medication to be ineffective. Secondly, adrenergic agonists create vasoconstriction, which will elevate his blood pressure.

Combination products containing an opioid analgesic with an adjuvant drug such as acetaminophen, may be used so that the dose of the opioid can be lower as it works synergistically with the adjuvant drug to control pain. Refer to Table 18.3, Opioids for Pain Management, and using Vicodin (hydrocodone and acetaminophen) as an example, explain why a combination product may not always be the best practice for pain control.

With growing concern over the risk of hepatic toxicity related to large doses of nonopioid products such as acetaminophen, additional doses of combination products may raise the dose of adjuvant drugs to unacceptable levels. Additional doses of a combination product should not be used unless the dose of the nonnarcotic analgesic does not exceed the recommended dose. Giving Vicodin (hydrocodone and acetaminophen) on an every four hours dosing schedule may exceed the recommended maximum acetaminophen daily dose.