Chapter 25: Drug Therapy for Seizures

ANS: A Carbamazepine can cause a profound reduction in the white blood cell count (neutropenia), which then greatly increases the risk for infection.

Which precaution should you teach patients prescribed carbamazepine (Tegretol)? a. Avoid crowds and people who are ill. b. Take this drug with an antacid to prevent ulcers. c. Restrict your fluid intake to less than 1.5 L daily. d. Keep the bottle containing the drug in the refrigerator.

ANS: B, C, D The single most common cause of seizures is not known. However, for adults the most common causes of seizures include head injury, stroke, and tumors.

Which factors are among the most common causes of seizures in adults? (select all that apply) a. Emotional distress b. Head injury c. Stroke d. Tumors e. Lack of sleep f. Fever

ANS: C All of these first-line drugs can be given orally and intravenously except carbamazepine.

Which first-line antiseizure drug can only be given by the oral route? a. Gatifloxacin (Tequin) b. Phenytoin (Dilantin) c. Carbamazepine (Tegretol) d. Valproic acid (Depakote)

ANS: D Status epilepticus is a prolonged seizure (usually defined as lasting longer than 30 minutes) or a series of repeated seizures that may occur in almost any type of seizure. Rapid recognition and treatment of this disorder are essential to prevent brain damage.

Which health problem is the most serious possible side effect for status epilepticus? a. Ruptured spinal disks b. Brain tumor c. Broken bones d. Brain damage

ANS: C Serious adverse effects of valproic acid include damage to the liver (hepatotoxicity) and inflammation of the pancreas (pancreatitis).

Which organs can be badly damaged by valproic acid (Depakote)? a. Eyes and ears b. Skeletal muscles c. Liver and pancreas d. Brain and spinal cord

ANS: A First-line antiseizure drugs enter the brain and often cause drowsiness and dizziness. This effect is worsened by drinking alcohol, increasing the risk for injury and causing the patient to have reduced cognition. The drugs can be taken with food, but do not have to be. Having regular dental checkups is important, but the priority precaution relates to alcohol avoidance.

Which precaution is most important to teach a patient who is prescribed any of the first-line drugs for generalized seizures? a. "Avoid drinking alcoholic beverages." b. "Take the drug with food or a snack." c. "Engage in regular exercise daily." d. "See your dentist twice a year."

ANS: 2.5 1 kg = 2.2 lb. Child's weight in kilogram = 56 lb/2.2, or 25 kg. 25 kg 0.5 mg = 12.5 mg as the correct dose. Want 12.5 mg, Have 5 mg/tablet 12.5/5 = 2.5 tablets.

A child who weighs 56 lb is prescribed to receive lamotrigine (Lamictal) 0.5 mg/kg as the first dose of the drug. The drug available is lamotrigine 5 mg/scored tablet. How many tablets should you prepare to administer for a correct dose?

ANS: D It is important to try to keep to the dosing schedule to maintain blood levels of antiseizure drugs and prevent seizures. However, it has now been 10 hours since the missed dose. Taking it now and also taking the regularly scheduled second dose could cause blood levels to be too high leading to possible side or adverse effects. The missed dose should not be taken at all. The second dose can be taken now or at its regularly scheduled time and then the patient should return to his or her regular dosing schedule.

A patient who has been prescribed ethosuximide (Zarontin) twice daily (every 12 hours) for absence seizures reports that the morning dose was missed 10 hours ago. What is your best advice? a. "Skip today's second dose as well as the dose you already missed." b. "Take the missed dose now and the regularly scheduled dose in 2 hours." c. "Take the missed dose and the regularly scheduled second dose immediately." d. "Take the regularly scheduled second dose now and forget about the morning dose."

ANS: 20 11 lb/2.2 = 5 kg; 5 kg 4 mg = 20 mg.

An infant is prescribed phenobarbital 4 mg/kg in an oral suspension. The infant weighs 11 lb. How many milligrams will you give?

ANS: C Increased growth and hormone changes that occur with puberty can increase the need for higher drug dosages to control seizure disorders. Although some people who have a seizure disorder during childhood may not have the disorder to the same degree in adulthood, adolescents usually need not only to continue the drug therapy to control the seizures but need to have the dosages increased.

A 13-year-old boy who has a seizure disorder has grown 6 inches and gained 30 lb in the past 8 months. How do you expect these physical changes to affect his antiseizure drug therapy? a. No change will be needed. b. The dosage of the antiseizure drugs will probably need to be decreased. c. The dosage of the antiseizure drugs will probably need to be increased. d. The antiseizure drugs can be discontinued because it is likely he has outgrown the disorder.

ANS: D While prescribed and taking any antiseizure drug, patients should be taught to avoid grapefruit and grapefruit juice because they may increase the effects of these drugs.

A patient prescribed an antiseizure drug tells you that his favorite morning drink is grapefruit juice. What is your best action? a. Call the diet kitchen to order grapefruit juice with the patient's breakfast tray. b. Ask the patient if he would like to have grapefruit juice added to his dinner tray. c. Instruct the patient to drink at least 8 ounces of water with each glass of grapefruit juice. d. Teach the patient to avoid grapefruit juice because it can increase the effects of these drugs.

ANS: D Valproic acid taken during pregnancy has been associated with developmental defects, low IQ, birth defects, congenital anomalies, and damage to the infant's liver. This drug also passes into breast milk and should not be taken while a mother is breastfeeding.

A female patient with a seizure disorder who is prescribed valproic acid (Depakote) tells you she wants to have a child. What must be included when teaching this patient? a. "This drug is safe to use while breastfeeding." b. "Valproic acid should be used to prevent seizures during pregnancy." c. "This drug may interfere with the ability to become pregnant." d. "This drug should be avoided during pregnancy."

ANS: D Seizure disorders can be difficult to control and may require more than one type of antiseizure medications. In addition, responses are very individual. The drugs can be taken at the same time. Because phenobarbital can induce sleep, many people prefer to take this drug closer to bedtime.

A newly admitted patient with a seizure disorder is prescribed phenytoin (Dilantin) 100 mg orally every 8 hours and phenobarbital (Luminal) 300 mg orally daily. What is your best action? a. Remind the prescriber that these two drugs are both types of antiseizure medication. b. Ensure that the phenobarbital is given as early as possible in the morning. c. Separate the administration of the two drugs by at least 6 hours. d. Administer the drugs as prescribed.

ANS: A A prolonged seizure lasting longer than 30 minutes is status epilepticus. Actions for treating this life-threatening condition include protecting the airway, providing oxygen, establishing intravenous (IV) access to give 5 to 10 mg of diazepam (Valium) by slow IV injection, and determining and treating the cause.

A patient is having a prolonged seizure lasting more than 30 minutes. Which drug should you be prepared to administer? a. Diazepam (Valium) 5 to 10 mg slow IV push b. Carbamazepine (Tegretol) 1600 orally as a loading dose c. Phenytoin (Dilantin) 15 mg/kg orally as a loading dose d. Valproic acid (Depacon IV) 25 mg/kg slow IV push

ANS: A Clonazepam is a benzodiazepine CNS drug with the life-threatening adverse reaction of respiratory depression.

A patient is prescribed clonazepam (Klonopin). Which adverse effect will you monitor for after giving this drug? a. Respiratory depression b. Stevens-Johnson syndrome c. Angioedema d. Epidermal necrolysis

ANS: B Lamisil is not a brand of lamotrigine; it is an antifungal drug. This drug is easily confused with the Lamictal brand of lamotrigine. The drug should not be given. The pharmacy needs to be informed about the confusion and asked to send the correct drug.

A patient is prescribed lamotrigine for seizure control. The drug received from the pharmacy is Lamisil. What is your best action? a. Administer the drug as prescribed. b. Hold the dose and call the pharmacy immediately. c. Ask the patient whether he or she recognizes the tablet. d. Notify the prescriber that the usual brand of lamotrigine is not available.

ANS: B Depakote and other drugs for seizure control should not be stopped suddenly. This action could lead to severe and prolonged seizure episodes. If a patient is unable to keep the drug down or cannot take the drug orally for any reason, he or she should receive the drug parenterally to ensure seizure control.

A patient who has a seizure disorder and is prescribed valproic acid (Depakote) calls to report that she has been vomiting for 24 hours. What should you advise? a. Take the next dose of Depakote with an antacid. b. Go to the nearest emergency department to receive the Depakote parenterally. c. Take any missed doses and the regularly scheduled doses as soon as the vomiting subsides. d. Rather than swallowing the next drug dose, place the tablet under the tongue and let it dissolve.

ANS: C Among the most common side effects of first-line antiseizure drugs such as ethosuximide are GI symptoms such as nausea, vomiting, and indigestion. You should give this drug with food or a snack to minimize or prevent these symptoms. Also teach the patient who has these symptoms to take this drug with meals or a snack when he or she goes home.

A patient who has been prescribed ethosuximide (Zarontin) tells you about experiencing an upset stomach after each dose of the drug. What is your best action? a. Administer a dose of an antinausea drug. b. Instruct the patient to take the drug with a full glass of water. c. Give the drug with meals or a snack. d. Elevate the head of the bed to avoid aspiration.

ANS: C Phenytoin (Dilantin) can cause extra growth of gum tissues. Tell patients to visit their dentist regularly and to brush and floss teeth carefully.

A patient who has been prescribed phenytoin (Dilantin) reports gum swelling around the teeth. What is your best action? a. Tell the patient to document this unexpected change by taking a photograph. b. Instruct the patient to stop the drug and notify the prescriber immediately. c. Teach the patient to visit the dentist regularly and brush and flow carefully. d. Remind the patient to clean teeth gently with dental swabs and avoid flossing.

ANS: D Primidone decreases the effectiveness of anticoagulants, including warfarin. Warfarin effectiveness is measured by the INR. This value should be no less than 1.5 in a patient taking warfarin. With an INR level of only 0.5 the patient is at risk for forming clots and having a stroke, heart attack, pulmonary embolism, or deep vein thrombosis (DVT).

A patient who has been prescribed primidone (Mysoline) also takes warfarin (Coumadin). Which laboratory blood test results indicate a possible drug interaction? a. Hematocrit 32% b. Hemoglobin 11.2 g/dL c. Blood urea nitrogen (BUN) 21 mg/dL d. International normalized ratio (INR) 0.5

ANS: A Carbamazepine can suppress bone marrow activity and decrease the number of WBCs. This patient's WBC count is much lower than normal (normal range is 5000 to 10,000/mm3), greatly increasing his or her risk for infection. The drug must be discontinued as soon as possible (but not abruptly). The blood sodium level is slightly low as well, but it is not an immediate problem.

A patient who has been taking carbamazepine (Tegretol) for 2 months has all of the following blood laboratory results. Which result should you report to the prescriber immediately? a. White blood cell (WBC) count 2200/mm3 b. Platelet count 300,000/mm3 c. Potassium 3.6 mEq/L d. Sodium 132 mEq/L

ANS: B Antacids interfere with the absorption of gabapentin. At least 2 hours should be scheduled between doses of gabapentin and any antacid.

A patient who is prescribed gabapentin (Neurontin) for seizures is also taking aluminum hydroxide (Amphojel) for indigestion. What should you caution the patient about taking these two drugs? a. "Take the gabapentin 1 hour after the aluminum hydroxide." b. "Schedule at least 2 hours between taking the gabapentin and the aluminum hydroxide." c. "Take these two drugs together for the best action of both drugs to occur." d. "You may need to take a different antacid to avoid affecting the action of gabapentin."

ANS: A When a patient takes morphine at the same time as gabapentin, the blood level of gabapentin is increased. You should expect that the ordered dose of gabapentin will be decreased.

A patient who is prescribed gabapentin (Neurontin) is also taking morphine sulfate for severe pain. What dosage adjustment should you expect? a. Decreased dosage of gabapentin b. Increased dosage of gabapentin c. Decreased dosage of morphine d. Increased dosage of morphine

ANS: A Before a seizure, some people experience an aura, which is a strange sensation. It can be an odor, sound, taste, or visual sensation such as bright spots or flashes. It is a common occurrence and not an indicator of tumors or pressure in the brain. Confusion, lethargy, and an inability to respond are common for the postictal phase of a seizure, but asking about these symptoms does not address the patient's question.

A patient with a seizure disorder asks why bright spots are always seen before experiencing a seizure. What is your best response? a. "Some people experience a strange sensation called an aura before each seizure." b. "This is an unusual occurrence. I will notify your prescriber right away." c. "Bright spots before a seizure could indicate pressure in your brain from a tumor." d. "After the seizure do you feel confused, lethargic, and unable to respond to people?"

ANS: B An individual with a seizure disorder is more likely to have a seizure during times of increased emotional or physical stress (such as training for a marathon). While watching the diet and pacing the exercise program are important, they are not related to the patient's seizure disorder. Most antiseizure drugs do not require the patient to avoid exercise.

A patient with a seizure disorder tells you about training to participate in a marathon run. What is the most important factor to teach the patient at this time? a. "Your seizure medications prohibit training for this stressful event." b. "During times of increased physical stress you are more likely to have a seizure." c. "Be sure to watch your diet because during training you will need more calories." d. "Start your exercise program slowly and gradually build up your strength."

ANS: C Ratio and proportion—340 mg/X mL is equal to 500 mg/5 mL, 1700X/500 = 3.4 mL.

A pediatric patient is prescribed valproic acid (Depacon) 340 mg intravenously. The available drug solution is 500 mg in 5 mL. How many milliliters should you give? a. 1.4 b. 2.4 c. 3.4 d. 4.4

ANS: C Carbamazepine blocks sodium channels in the brain, which slows the transmission of electrical impulses. It does not work by changing the amount of GABA and it does not interfere with calcium channels.

How does carbamazepine (Tegretol) work to decrease seizure activity? a. Increasing the amount of the neurotransmitter gamma-aminobutyric acid (GABA) present in the brain b. Decreasing the amount of the neurotransmitter gamma-aminobutyric acid (GABA) present in the brain c. Slowing electrical impulse conduction in the brain by altering sodium channels d. Slowing electrical impulse conduction in the brain by altering calcium channels

ANS: D Older adults are also more sensitive to second-line antiseizure drugs and are more likely to develop side effects. They may develop unusual restlessness or excitement with primidone. Ankle swelling is associated with gabapentin (Neurontin) and pregabalin (Lyrica), not with primidone

What is an important teaching point for an older patient prescribed primidone (Mysoline)? a. This drug may cause very high fevers. b. You may develop a severe rash with this drug. c. Your ankles are likely to swell while you are taking this drug. d. Primidone can cause development of unusual restlessness and excitement.

ANS: A An individual with repeated seizures has a seizure disorder, sometimes called epilepsy.

What is another term for seizure disorder? a. Epilepsy b. Enkephalin c. Narcolepsy d. Neuropathy

ANS: C All drugs for seizure disorders affect the central nervous system and have the potential to alter the level of consciousness shortly after taking them. The development of gingival hyperplasia or bleeding occurs with repeated doses over time. Checking the level of consciousness is more important than assessing deep tendon reflexes.

What is the most important action or assessment to perform after giving a patient the first dose of any antiseizure drug? a. Check for gingival hyperplasia. b. Assess any IV sites and skin areas for bleeding. c. Check the patient's level of consciousness. d. Assess the patient's deep tendon reflexes.

ANS: D The priorities for care of a patient experiencing a seizure include maintaining an airway and providing for safety during the seizure. Forcing a padded tongue blade into a patient's mouth can damage teeth and lead to aspiration of tooth fragments. Padded side rails are controversial because it is not known if they help maintain safety; they may cause embarrassment to the patient. During a seizure is not the time to place a saline lock.

What is the priority intervention for a patient experiencing a tonic-clonic (grand mal) seizure? a. Place a padded tongue blade in the patient's mouth to prevent biting the tongue. b. Start a saline lock to administer IV antiseizure medication. c. Attach pads to the bedside rails to protect the patient from injury. d. Monitor for and keep the patient's airway open.

ANS: C Carbamazepine is a first-line drug for partial and generalized seizures. These drugs can cause dizziness and drowsiness. You must teach the patient to ask for assistance when getting out of bed and ensure that the call light is within easy reach.

What is the priority safety measure to implement when a patient has been started on carbamazepine (Tegretol)? a. Ask the patient about symptoms of nausea/vomiting. b. Monitor for and manage seizure activity. c. Assist the patient when getting out of bed. d. Always give this drug with food.

ANS: B Ethosuximide can make the eyes more sensitive to light. Instruct patients to protect their eyes by wearing dark glasses when going out into bright light. Ethosuximide does not cause skin photosensitivity.

What should you teach a patient who is prescribed ethosuximide (Zarontin) about spending time outdoors? a. Move slowly to avoid dizziness. b. Wear dark glasses when the sun is bright. c. Be sure to wear long sleeves and a broad-brimmed hat. d. Apply a strong sunscreen whenever you will be exposed to sunlight.

ANS: B A simple, partial seizure does not result in loss of consciousness or respiratory problems. The patient is observed and the duration of the seizure is documented. Administering drugs at this time would not stop the seizure and the attempt could stimulate further seizure activity.

Which action is most important to perform for a patient during a simple partial seizure? a. Administering the prescribed antiseizure drug b. Record timing the duration of the seizure c. Inserting a padded tongue blade d. Applying oxygen by mask

ANS: C The action of valproic acid may be related to increased availability of the neurotransmitter gamma-aminobutyric acid (GABA).

Which antiseizure drug increases the availability of the neurotransmitter gamma-aminobutyric acid (GABA)? a. Phenobarbital (Luminal) b. Carbamazepine (Tegretol) c. Valproic acid (Depakote) d. Phenytoin (Dilantin)

ANS: A Cigarette smoking decreases the effectiveness of clonazepam. Smoking is not a contraindication; however, higher dosages of the drug may be needed for smokers.

Which assessment question is most important to ask a patient who is prescribed clonazepam (Klonopin) before administering the first dose? a. "Do you smoke cigarettes?" b. "How many seizures do you have daily?" c. "Have you ever had high blood pressure?" d. "Do you currently have an open sore or signs of an infection?"

ANS: D Phenytoin interacts with many other drugs and changes their activity. When patients who are prescribed phenytoin are also taking other drugs, the dosages of the other drugs may need to be altered, and additional monitoring may be needed.

Which question is most important to ask a patient who is prescribed phenytoin (Dilantin) before? a. "Do you drink coffee or other caffeinated beverages?" b. "Have you ever had high blood pressure?" c. "How many seizures do you have daily?" d. "What other drugs do you take daily?"

ANS: D Second-line drugs for seizures are alternative drugs for the treatment of seizures. Included in this group are phenobarbital (Luminal) and primidone (Mysoline), which increase the body's threshold against seizure activity by blocking or slowing the spread of abnormal impulses. The disadvantage of phenobarbital is that it can lead to physical dependence.

Which second-line drug for seizure control has a potential for physical dependence? a. Terbinafine (Lamisil) b. Primidone (Mysoline) c. Lamotrigine (Lamictal) d. Phenobarbital (Luminal)

ANS: A Common side effects of first-line drugs for seizures include the GI symptoms of nausea, vomiting, and indigestion. They may also cause loss of appetite (anorexia) and weight loss.

Which side effect is most common among people taking first-line drugs for absence seizures? a. Weight loss b. Weight gain c. Low blood pressure d. High blood pressure

ANS: D Phenytoin must be used carefully for children because of extra growth of gums while taking the drug.

Which side effect of phenytoin (Dilantin) commonly occurs among children taking the drug? a. Delayed bone growth b. Darkening of the eyes c. Thickening of the eyelashes d. Thickening of the gum tissues

ANS: C Absence (petit mal) seizures are more common in children. They involve a brief (few seconds) loss of consciousness and blank staring. A child may appear to be daydreaming. After the seizure the child returns to normal immediately.

Which sign should you expect to see when a patient has an absence seizure? a. Rigidity of arm and leg muscles b. Automatisms such as lip smacking c. Blank staring as if daydreaming d. One-sided movement of an extremity

ANS: B Lamotrigine limits the body's production of folic acid. Folic acid deficiency during pregnancy is associated with a variety of birth defects. To prevent deficiency during pregnancy, a woman taking lamotrigine should take folic acid supplements throughout the pregnancy.

Which supplement is needed when a pregnant woman with a seizure disorder is prescribed to take lamotrigine (Lamictal)? a. Ascorbic acid b. Folic acid c. Citric acid d. Nicotinic acid

ANS: D During seizure activity, especially a generalized seizure, the brain is not well-oxygenated and the individual is not aware of his or her surroundings and events. This result in a brief period of confusion after the seizure is over.

Which temporary condition is considered a brief but expected response immediately after an individual has a seizure? a. Residual muscle twitches b. Low blood pressure c. Unconsciousness d. Confusion

ANS: C Without rapid recognition and treatment, status epilepticus can result in brain damage, coma, and death.

Which two conditions are possible complications of status epilepticus? a. Blurred vision and ringing in the ears b. Muscle paralysis and weakness c. Brain damage and death d. Asthma and wheezing

ANS: B With an atonic seizure typically there is sudden loss of muscle tone for a few seconds, followed by postictal (after the seizure) confusion.

Which type of seizure has a sudden loss of muscle tone for a few seconds followed by confusion? a. Partial seizures b. Atonic seizures c. Myoclonic seizures d. Tonic-clonic seizures

ANS: B Carbamazepine can also cause thrombocytopenia (low platelet count), increasing a patient's risk for severe bleeding.

You are removing an IV catheter from a patient prescribed carbamazepine (Tegretol). What safety technique will you apply while completing this procedure? a. Place a 2 by 2 dressing over the site with extra tape. b. Hold pressure on the IV site for at least a minute or until the bleeding stops. c. Ask the patient to hold pressure over the IV site for at least 30 seconds. d. Put a Band-Aid over the site after to catheter is removed to prevent infection.