Chapter 48: Drug Therapy for Parkinson's Disease, Urinary Spasticity, and Disorders Requiring Anticholinergic Drug Therapy

The nurse is educating a client who has been prescribed atropine, an anticholinergic drug. Which instructions should the nurse provide to the client? a. "Do not drive or operate machinery." b. "If you experience eye pain, contact the health care provider about increasing the dosage." c. "Increase your fluid intake and activity level." d. "Take long, hot showers frequently to relieve uncomfortable side effects."

a. "Do not drive or operate machinery." Effects of anticholinergic drugs such as atropine include blurred vision and impaired ability to sweat. Clients should be cautioned to avoid activities that may be made dangerous by blurred vision; this may include driving and operating machinery. To avoid overheating, clients should avoid strenuous activity and take other measures to stay cool (e.g., frequent cool baths). Clients experiencing eye pain may have undiagnosed glaucoma; they should stop taking the medications and contact their health care providers.

Which would be important to perform for a client who has received an anticholinergic agent? (Select all that apply.) a. Auscultating bowel sounds b. Monitoring urine output c. Monitoring heart rate d. Administering an antidiarrheal agent e. Assessing deep tendon reflexes

a. Auscultating bowel sounds b. Monitoring urine output c. Monitoring heart rate Anticholinergic agents can slow GI activity leading to paralytic ileus. Urinary retention is possible, so it is important to monitor the patient's urine output. Tachycardia is possible, so monitoring the heart rate would be important. The client would most likely experience constipation, not diarrhea. Anticholinergics do not affect deep tendon reflexes, so assessment is not necessary.

Administration of which classes of medications can decrease secretions of the upper respiratory tract? a. Cholinergic blocking drug b. Opioids c. Antianxiolytic d. Antiemetics

a. Cholinergic blocking drug Cholinergic antagonists are the class of medications used to decrease secretions of the upper respiratory tract. Antianxiolytics decrease preoperative anxiety. Opioids decrease both anxiety and pain preoperatively. Antiemetics are used to decrease nausea after surgery.

Which would a nurse least likely expect to assess in a client experiencing mild atropine toxicity? a. Cough b. Dry mouth c. Profuse sweating d. Increasing of heart rate

a. Cough Cough is not associated with mild atropine toxicity. Dry mouth is associated with mild atropine toxicity. Inhibition of sweating is associated with mild atropine toxicity not profuse sweating. Slight cardiac slowing is associated with mild atropine toxicity not increased heart rate.

A nursing mother is being prepared for an eye condition which requires a prescription for atropine. What nursing intervention should the nurse implement to assure safe and effective atropine therapy? a. Discuss an alternative feeding method until the atropine is no longer prescribed b. Discuss pumping and then warming the breast milk before bottle feeding the baby c. Discuss feeding the baby prior to taking the prescribed atropine d. Discuss the mother's need to be well hydrated to minimize the amount to atropine in the breastmilk

a. Discuss an alternative feeding method until the atropine is no longer prescribed Because of the potential for serious adverse effects on the baby, nursing mothers should be assisted in finding another method of feeding the baby if an anticholinergic drug is needed. None of the other options effectively manage the safety risk to the infant.

What would be considered a peripheral anticholinergic effect of anticholinergic drug therapy? a. Delirium b. Blurred vision c. Agitation d. Memory loss

b. Blurred vision Blurred vision is considered a peripheral anticholinergic effect. Delirium, agitation, and memory loss are considered central effects affecting the CNS.

Which agent would a nurse expect to administer transdermally? a. Atropine b. Scopolamine c. Dicyclomine d. Propantheline

b. Scopolamine Only scopolamine is available as a transdermal system.

The nurse is caring for a client with glaucoma and is aware that which category of preanesthetic medication is contraindicated in this client? a. Opioid b. Antiemetic c. Cholinergic blocking d. Antianxiety

c. Cholinergic blocking Cholinergic blocking agents are contraindicated in clients with prostatic hypertrophy, glaucoma, and myocardial ischemia. Opioids, antiemetics, and antianxiety drugs are not contraindicated in clients with glaucoma.

A client has been prescribed an anticholinergic medication. What instructions should the nurse provide related to safety when outside in hot weather? a. Wear a hat to protect the head b. Wear sunglasses to protect the eyes c. Keep well hydrated d. Keep arms and legs covered

c. Keep well hydrated Adults taking an anticholinergic medication should be encouraged to drink plenty of fluids and to avoid hot temperatures because heat intolerance can occur and it will be important to maintain hydration should this happen. While the other options are appropriate suggestions, none are directly related to the safety issue of heat intolerance caused by the medication.

The nurse is aware that cholinergic blocking agents will be used preoperatively for what type of anesthesia? a. Topical b. Local c. Regional d. General

d. General Cholinergic blocking agents are used to decrease respiratory secretions that pool in the lungs when the client's cough and swallowing reflexes are lost during general anesthesia. It would not be used prior to other forms of anesthesia unless there was the possibility of the loss of the swallowing reflexes.

Which of the following is an anticholinergic drug that may be used in the treatment of overactive bladder? a. Belladonna tincture b. Benztropine c. Trihexyphenidyl d. Oxybutynin

d. Oxybutynin Oxybutynin is prescribed in the treatment of overactive bladder.

A male client is diagnosed with Parkinson's disease. The nurse visits him 1 week after hospitalization to assess his progress and medication regimen compliance. He states that there is no significant improvement in his symptoms. What is the best response by the nurse? a. "Noticeable improvement may not occur for several weeks after the initial drug dose." b. "Noticeable improvement usually occurs 7 to 10 days after the initial drug dose." c. "You should have noticed improvement by now; I will notify your health care provider." d. "Are you sure that you are taking the medication as ordered?"

a. "Noticeable improvement may not occur for several weeks after the initial drug dose." The home care nurse can help clients and caregivers understand that the purpose of drug therapy for Parkinson's disease is to control symptoms and that noticeable improvement may not occur for several weeks.

A nurse is caring for 70-year-old patient who is undergoing anticholinergic drug therapy. The nurse should assess for which condition when caring for this elderly patient? a. Confusion and disorientation b. Choreiform movements c. Suicidal tendencies d. Psychotic episodes

a. Confusion and disorientation The nurse should assess for confusion and disorientation when caring for this elderly patient undergoing anticholinergic drug therapy. Individuals older than 60 years frequently develop increased sensitivity to anticholinergic drugs and require careful monitoring. Lower doses may also be required in such cases. Choreiform movements, suicidal tendencies, and psychotic episodes are serious adverse reactions associated with the use of levodopa, which is a dopaminergic drug.

Which of the following cholinergic-blocking drugs only affect the muscarinic receptors? Select all that apply: a. Darifenacin (Enablex) b. Oxybutynin (Ditropan) c. Benztropine (Cogentin) d. Biperiden (Akineton) e. Tolterodine (Detrol)

a. Darifenacin (Enablex) b. Oxybutynin (Ditropan) e. Tolterodine (Detrol) Antispasmodic cholinergic-blocking drugs, like darifenacin , oxybutynin (Ditropan), and tolterodine, only affect muscarinic receptors in the parasympathetic nervous system and have no affect on nicotinic receptors.

After administering an antiparkinson drug to a client, the nurse assesses for the drug's effectiveness. The nurse determines that the drug is effective based on assessment of which of the following? Select all that apply. a. Decrease in muscle rigidity b. Improved gait c. Reduction in tremors d. Greater slowing of movement e. Reduced dry mouth

a. Decrease in muscle rigidity b. Improved gait c. Reduction in tremors The drug is intended to address the signs and symptoms of Parkinson disease, such as muscle rigidity, shuffling gait, tremors, and slow movements. Therefore, a decrease in muscle rigidity, improved gait, and reduction in tremors would indicate drug effectiveness. Greater slowing of movement would indicate that the drug is not effective. Dry mouth is an adverse reaction and not considered an indicator of drug effectiveness.

When describing the various anticholinergic agents to a group of students, the instructor would identify which agent as being available in sublingual form? a. Hyoscyamine b. Scopolamine c. Propantheline d. Tiotropium

a. Hyoscyamine Hyoscyamine is available in oral or sublingual form and for subcutaneous, IM, or IV use. Scopolamine is available for subcutaneous or IM injection, in ophthalmic form, and as a transdermal system. Propantheline is available for oral use only. Tiotropium is available for inhalation.

A client is prescribed benztropine. The nurse would anticipate administering this drug by which route? a. Oral b. Subcutaneous c. Intramuscular d. Intravenous

a. Oral Benztropine is administered orally.

What are the classic symptoms associated with Parkinson's disease? Select all that apply. a. bradykinesia b. muscle rigidity c. urinary retention d. resting tremors e. worsening eyesight

a. bradykinesia b. muscle rigidity d. resting tremors Classic symptoms of Parkinson's disease include resting tremor, bradykinesia, rigidity, and postural instability.

A client has been prescribed benztropine as drug therapy for Parkinson disease. What assessment finding would suggest a therapeutic effect to the nurse? a. decreased rigidity and tremors b. increased level of consciousness c. increased motivation and muscle strength d. absence of seizure activity

a. decreased rigidity and tremors Benztropine should cause a decrease in rigidity and tremors. It does not affect LOC, motivation, strength, or seizure risk.

Common side effects of anticholinergics include: a. dry mouth, urinary retention, constipation, and increased pulse rate. b. blurred vision, decreased liver enzymes, increased B/P, and papillary constriction. c. decreased GI absorption, nausea, heartburn, and hypotension. d. skin rashes, decreased urinary output, constipation, and increased WBCs.

a. dry mouth, urinary retention, constipation, and increased pulse rate. Anticholinergic drugs may cause blurred vision, dry mouth, tachycardia, and urinary retention. They also decrease sweating and may cause fever or heatstroke. Fever may occur in any age group, but heatstroke is more likely to occur in older adults, especially with cardiovascular disease, strenuous activity, and high environmental temperatures. When centrally active anticholinergics are given for Parkinson's disease, agitation, mental confusion, hallucinations, and psychosis may occur.

Because of the systemic effects of anticholinergic drugs, patients using these drugs are more susceptible to: a. heat stroke related to decreased perspiration. b. diarrhea related to increased peristalsis. c. urinary frequency related to CNS effects. d. hypotension related to increased sympathetic response.

a. heat stroke related to decreased perspiration. By blocking cholinergic receptors, anticholinergic drugs reduce sweating, which decreases heat loss and increases the risk of hyperthermia and heat stroke.

While being intubated, a client with a head injury experienced bradycardia. Atropine was consequently administered. What assessment should be postponed until all atropine is excreted and no longer exerting an effect? a. pupil response b. electroencephalogram c. brainstem reflexes d. computed tomography of the brain

a. pupil response One test for neurological function is to shine a light in the client's eyes to test pupil reaction to light. Because this client has received atropine, pupils will be dilated and will not react normally to light. This could be mistaken as an indication of brain death if the nurse did not know atropine had been administered. This test will be postponed until the pupils are no longer dilated by the medication. The other tests would not have to be postponed because of atropine.

The nurse is speaking to a group at the senior citizen's center about Parkinson disease. What should the nurse explain is importance to avoiding when taking an anticholinergic medication? a. strenuous exercise in high environmental temperatures b. salt substitutes and foods high in potassium c. foods high in vitamin K such as dark green, leafy vegetables d. over-the-counter medications containing acetaminophen

a. strenuous exercise in high environmental temperatures Anticholinergic drugs decrease sweating. As a result, the body is not as effective at reducing internal temperature as this could result in fever and heatstroke. Elderly people taking anticholinergic drugs do not need to avoid potassium, foods high in vitamin K, or acetaminophen.

An older client is taking an anticholinergic agent. After teaching the client about the drug, which client statement indicates the need for additional teaching? a. "I should make sure that I drink plenty of fluids." b. "I need to exercise frequently outside in the warm weather." c. "I should avoid driving if I feel light-headed or dizzy." d. "I should eat plenty of fiber to prevent constipation."

b. "I need to exercise frequently outside in the warm weather." The client should avoid temperature extremes and exertion in warm temperatures because of possible heat intolerance, which could be more severe in older clients. Drinking fluids is important to maintain hydration and prevent heat intolerance. Avoiding driving is an appropriate safety measure. Constipation may occur with an anticholinergic; therefore, increased fiber intake would be appropriate.

Some anticholinergic drugs have the same clinical indications in the pediatric population as in the adult population. Which statement accurately describes a difference between the populations related to the use of anticholinergics? a. Anticholinergic drugs create different adverse effects in children. b. Adverse effects tend to be more severe in children. c. Anticholinergic drugs are more effective in the pediatric population. d. Adverse effects tend to be less severe in children.

b. Adverse effects tend to be more severe in children. Anticholinergic drugs have essentially the same intended effects and adverse effects in the pediatric population as in the adult population. However, children are especially sensitive to these drugs, so the adverse effects may be more severe in that population.

The nurse understands that older clients taking anticholinergic drugs are more likely to have all of the following symptoms EXCEPT: a. Blurred vision. b. Hypertension. c. Constipation. d. Confusion.

b. Hypertension. Older adults are especially likely to have significant adverse reactions because of slowed drug metabolism and the frequent presence of several disease processes. Some common adverse effects are blurred vision, confusion, constipation, and confusion or other psychotic symptoms. These are most likely to occur with the centrally active anticholinergics given for Parkinson's disease or drug-induced extrapyramidal effects, such as trihexyphenidyl or benztropine. They are not typically the causative agent for hypertension in routine medication treatment.

The nurse is preparing a client for pacemaker surgery. The health care provider orders atropine to be given 30 minutes before the client is taken to the operating room. The nurse knows this medication is ordered for what reason? a. To increase the heart rate to prevent complication prior to the pacemaker being inserted b. To dry up respiratory secretions to prevent aspiration during surgery c. To cause bladder relaxation during surgery so that the client will not have the urge to void during surgery d. To relax the bowel to prevent the client from having a bowel movement during surgery

b. To dry up respiratory secretions to prevent aspiration during surgery Atropine is an anticholinergic agent. The principal actions of atropine are a reduction in salivary, bronchial, and sweat gland secretions; mydriasis; cycloplegia; changes in heart rate; contraction of the bladder detrusor muscle and of the gastrointestinal smooth muscle; decreased gastric secretion; and decreased gastrointestinal motility. The reason this client is given the medication preoperatively is to dry up secretions to prevent aspiration during surgery.

A client who is going on a cruise is concerned about motion sickness and sees the health care provider, who prescribes scopolamine. The nurse informs the client that using scopolamine may cause the client to experience: a. pupil constriction. b. drowsiness. c. diarrhea. d. urinary incontinence.

b. drowsiness. Scopolamine at therapeutic doses produces CNS depression characterized by drowsiness, euphoria, amnesia, fatigue, and dreamless sleep resulting from decreased periods of rapid eye movement.

How does bethanechol affect bladder emptying? a. relaxing the urinary sphincter b. increasing the muscle tone of the detrusor muscle c. relaxing the smooth muscle that forms the urethra d. stimulating the urinary reflex in the micturition center

b. increasing the muscle tone of the detrusor muscle Bethanechol is a sympathomimetic agent that acts at the cholinergic receptors in the urinary tracts to increase muscle tone. The increased tone of the detrusor muscle in the urinary bladder allows for bladder emptying. Bethanechol does not act in the way described by any of the other options.

One of the neurotransmitters can become decreased in the area of the corpus striatum. This results in the manifestations of Parkinson's disease. Which neurotransmitter will cause this? a. Gamma-aminobutyric acid (GABA) b. Acetylcholine c. Dopamine d. Serotonin

c. Dopamine When dopamine is decreased in the area of the corpus striatum there is a chemical imbalance that allows the cholinergic or excitatory cells to dominate. This affects the functioning of the basal ganglia and cortical and cerebella components of the extrapyramidal motor system. This system provides coordination for unconscious muscle movements, including those that control position, posture, and movement. The result of the imbalance produces the signs and symptoms of Parkinson's disease. The corpus striatum in the brain is connected to the substantia nigra by a series of neurons that utilize the inhibitory neurotransmitter GABA. Higher neurons from the cerebral cortex secrete acetylcholine in the area of the corpus stratum as an excitatory neurotransmitter to coordinate movements of the body. Serotonin is not involved in these functions.

Clients with what disorder should not be given anticholinergic drugs? a. Epilepsy b. Attention deficit disorder c. Glaucoma d. Severe anxiety or hyperactivity

c. Glaucoma Anticholinergic drugs are contraindicated for patients with benign prostatic hypertrophy, myasthenia gravis, hyperthyroidism, glaucoma, tachyarrhythmia, myocardial infarction, heart failure, or conditions associated with esophageal reflux.

A 70-year-old client is taking a cholinergic blocking drug. The family has noticed the client is a confused, excited, and not voiding normally. What would be the appropriate action by the nurse in this situation? a. Instruct the client's family to continue the medication and ignore the symptoms. b. Instruct the client's family to increase the dose of the medication to combat these symptoms. c. Instruct the client's family to withhold the next dose and the nurse will contact the prescribing provider. d. Instruct the client's family to take the client to the emergency department immediately.

c. Instruct the client's family to withhold the next dose and the nurse will contact the prescribing provider. Older clients taking cholinergic blocking medications may exhibit symptoms such as excitement, mental confusion, and urinary retention. If a client is exhibiting these symptoms, the medication should be withheld for the next dose and the nurse should contact the prescribing provider. Ignoring symptoms is not advised because they could become worse. Increasing the dose would probably increase the symptoms and it is not appropriate for the nurse to change medication dosage without a provider order. It is not a medical emergency, so going to the emergency department is not necessary. The family is given the instruction due to the fact the client is confused.

An elderly woman is given scopolamine while on a cruise. She becomes very agitated and confused and is taken to the sick-bay of the ship. The nurse knows that which is a likely reason for these symptoms? a. Most elderly clients have dementia, which would prevent them from having normal, visual adverse reactions to cholinergic blocking drugs. b. Urinary retention often causes agitation. c. Older clients have a greater chance of adverse reactions to cholinergic blocking drugs. d. Elderly clients have more difficulty sleeping than regular clients, so the drowsiness that is a common side effect does not occur.

c. Older clients have a greater chance of adverse reactions to cholinergic blocking drugs. Older clients receiving cholinergic blocking drugs may have a greater chance of adverse reactions, including excitement, agitation, mental confusion, drowsiness, and urinary retention. Dementia does not prevent visual adverse effects. Urinary retention does not cause agitation. Drowsiness from cholinergic blocking drugs is unrelated to the sleep pattern of a client.

A student asks the pharmacology instructor to explain the action of anticholinergic agents. What would be the instructor's best response? a. They block nicotinic receptors. b. They compete with serotonin for muscarinic acetylcholine receptor sites. c. They act to block the effects of the parasympathetic nervous system. d. They increase norepinephrine at the neuromuscular junction.

c. They act to block the effects of the parasympathetic nervous system. Anticholinergic drugs block the effects of the parasympathetic nervous system. Atropine is the only widely used anticholinergic drug. The drug works by blocking only the muscarinic effectors in the parasympathetic nervous system. They compete with acetylcholine for the muscarinic acetylcholine receptor sites. They do not block the nicotinic receptors and have little or no effect at the neuromuscular junction.

A client, newly diagnosed with Parkinson's disease, has been prescribed an anticholinergic drug. What assessment should the nurse perform when monitoring for adverse effects of anticholinergic agents used for the treatment of Parkinson disease? a. monitoring of laboratory results for blood dyscrasias b. focused respiratory assessment c. assessment of the client's bowel pattern d. monitoring of prothrombin time and international normalized ratio (INR)

c. assessment of the client's bowel pattern Anticholinergics often cause decreased bowel motility, resulting in constipation. This is especially true in older adults. Anticholinergics are not associated with coagulation disorders, blood dyscrasias, or respiratory problems.

Which medication is the antidote for poisoning by insecticides containing organophosphates? a. darifenacin b. solifenacin c. atropine d. benztropine

c. atropine Atropine is the antidote for poisoning by cholinergic agonists such as certain species of mushrooms, cholinergic agonist drugs, cholinesterase inhibitor drugs, and insecticides containing organophosphates.

A 72-year-old man should be aware that the adverse effects of centrally acting anticholinergic drugs include: a. gout. b. diabetes mellitus. c. confusion. d. sedation.

c. confusion. Anticholinergic drugs may cause agitation, mental confusion, hallucinations, and psychosis in the older adult.

Indications for use of anticholinergic drugs in the treatment for Parkinsonism include to: a. decrease headaches. b. improve blurred vision. c. decrease salivation, spasticity, and tremors. d. decrease motor movement.

c. decrease salivation, spasticity, and tremors. Anticholinergic drugs are used in idiopathic parkinsonism to decrease salivation, spasticity, and tremors. They are used primarily in people who have minimal symptoms or who cannot tolerate levodopa, or in combination with other antiparkinson drugs.

Which would lead the nurse to suspect that a client is experiencing an adverse effect to an anticholinergic agent? a. Diarrhea b. Diaphoresis c. Excess salivation d. Agitation

d. Agitation Agitation would be noted due to the blocking of central acetylcholine receptors. Constipation, reduced sweating, and dry mouth may be noted as well.

A male client, age 75, is started on flavoxate. What adverse effect should the client be made aware of? a. Skin rash b. Urinary incontinence c. Weight gain d. Blurred vision

d. Blurred vision Some adverse effects of flavoxate include blurred vision, urinary retention, pupil dilation, photophobia, cycloplegia, increased intraocular pressure, dry mouth, constipation, and decreased sweating. Skin rash and weight gain are not noted as adverse effects of flavoxate.

Which agent would the nurse identify as acting specifically on the receptors in the GI tract? a. Ipratropium b. Tiotropium c. Trospium d. Hyoscyamine

d. Hyoscyamine Hyoscyamine acts more specifically on the receptors of the gastrointestinal tract. Ipratropium and tiotropium act more specifically to decreased respiratory secretions and cause bronchodilation. Trospium acts more specifically on the smooth muscle of the urinary tract.

The pharmacology instructor is discussing the adverse effects of anticholinergic drugs. What drug would the instructor indicate is administered to counteract the effects of atropine poisoning? a. Bethanechol b. Neostigmine c. Edrophonium d. Physostigmine

d. Physostigmine Physostigmine is a specific antidote for overdose of anticholinergics such as atropine.

A male client is prescribed an anticholinergic drug by his health care provider. He likes to hike with his grandchildren. The home care nurse instructs the client that anticholinergic medications have which effect? a. Increased sweating and the risk for heat stroke and dehydration b. Postural hypotension and increased risk for falls and from exposure to the elements c. Bradycardia in older adults, which increases the risk for falls and from exposure to the elements d. Prevents sweating and heat loss and increasing the risk of heat stroke

d. Prevents sweating and heat loss and increasing the risk of heat stroke Anticholinergic drugs are commonly used in home care with children and adults. The home care nurse may need to teach older clients or caregivers that the drugs prevent sweating and heat loss and increase risks of heat stroke if precautions to avoid overheating are not taken.

Unwanted anticholinergic effects include: a. wakefulness, mental alertness, and decreased fatigue. b. drowsiness or sleep; decreased muscle tone; and decreased ability to move. c. increasing hyperactivity, excessive talking, nervousness, and insomnia. d. constipation and dry mouth.

d. constipation and dry mouth. Unwanted anticholinergic effects include dry mouth, constipation, and mydriasis.

A client with hypertension is to receive an anticholinergic agent. The nurse would be especially alert for: a. bladder obstruction. b. paralytic ileus. c. increased intraocular pressure. d. increased blood pressure.

d. increased blood pressure. A client with hypertension who receives an anticholinergic is at risk for additive hypertensive effects due to the dominance of the sympathetic system with parasympathetic blockage. Bladder obstruction, paralytic ileus, and increased intraocular pressure are contraindications for the use of an anticholinergic agent.