Exam V

Study questions Match the term in Column I with the letter of the description in Column II. Column IColumn II________1. Alpha1 blocker________2. Beta blocker________3. Selectivity________4. Sympathomimetic________5. Sympatholytica. Blocks action of sympathetic nervous systemb. Has a greater affinity for certain receptorsc. Causes vasodilationd. Causes decreased heart ratee. Similar in action to stimulation of the sympathetic nervous system Complete the following. 6. Adrenergic receptors are located on the ________________ cells of smooth muscles. 7. Bladder relaxation and urinary sphincter constriction resulting in urinary retention may occur with high doses of _____________________________ agonists. 8. Sympathomimetics (do/do not) pass into the breast milk. (Circle correct answer.) 9. Adrenergic blockers are also called _____________________________. 10. The antidote for infiltration intravenously (IV) of alpha- and beta-adrenergic drugs such as norepinephrine and dopamine is _______________________________. 11. A beta-adrenergic blocker that can be given for migraine or hypertension is ______________________________. 12. Mood changes such as depression and suicidal tendencies are possible when taking which type of adrenergic blocker? _____________________________ 13. Carvedilol, penbutolol, and pindolol are examples of selective/nonselective beta blockers. (Circle correct answer.) 14. Nonselective beta blockers, such as propranolol, are contraindicated in patients with _______________________ and _____________________________. 15. What is most likely to occur if a patient is taking an adrenergic agonist with an adrenergic blocker? _____________________________ Match the letter of the adrenergic response in Column I to the associated receptor in Column II (Receptors in Column II may be used more than once, and response may affect more than one receptor type.) Column IColumn II________16. Increases gastrointestinal relaxation________17. Increases force of heart contraction________18. Dilates pupils________19. Decreases salivary secretions________20. Inhibits release of norepinephrine________21. Dilates bronchioles________22. Increases heart rate________23. Promotes uterine relaxation________24. Dilates blood vesselsa. Alpha1b. Alpha2c. Beta1d. Beta2 Review questions Select the best response. 25. A patient with asthma asks the nurse how albuterol inhaler will work to help breathe better. Which response by the nurse best explains the action of the drug?a. "Albuterol will increase your heart rate so you will feel like you are able to breathe better."b. "Albuterol causes the airways to open up more in the lungs, improving function."c. "Albuterol will cause an increase in urinary output to remove extra fluid from the lungs."d. "Albuterol causes bronchial smooth muscle contraction that forces air into the lungs." 26. A patient presents to the clinic with a swollen face and tongue, difficulty breathing, and audible wheezes after eating a peanut butter sandwich for lunch. Which action would the nurse first take?a. Ensure a patent airway.b. Obtain an electrocardiogram (ECG).c. Administer 1 mg of 1:1000 epinephrine subcutaneously.d. Start an intravenous (IV) normal saline. 27. A patient calls the home health agency to tell the nurse about shaking and trembling after using the albuterol inhaler. Which question would the nurse first ask the patient?a. "Are you having any other symptoms?"b. "How long ago did this start?"c. "When was the last time you used your inhaler?"d. "How many puffs on the inhaler did you take?" 28. Which drug is classified as beta blockers? (Select all that apply.)a. Albuterolb. Atenololc. Propranolold. Amphetaminee. Acebutolol 29. The nurse discovers an intravenous (IV) site has infiltrated on a patient receiving IV dopamine. The nurse prepares to administer which drug as an antidote.a. Dobutamineb. Epinephrinec. Phentolamined. Reserpine 30. When completing the patient health history, the nurse finds a history of narrow-angle glaucoma. When performing the drug reconciliation, which drug would concern the nurse? (Select all that apply.)a. Pseudoephedrineb. Midodrinec. Albuterold. Carvedilol 31. Some over-the-counter (OTC) drugs for cold symptoms contain substances that have sympathetic properties. These drugs are contraindicated in patients with which disease process?a. Allergic rhinitisb. Hypertensionc. Orthostatic hypotensiond. Chronic bronchitis 32. Which adrenergic drug used in emergency settings does not decrease renal function?a. Norepinephrineb. Dopaminec. Phenylephrined. Dobutamine 33. Beta1 receptors are located in which area of the body? (Select all that apply.)a. Gastrointestinal tractb. Lungsc. Kidneysd. Braine. Heart 34. A patient tells the nurse during the admitting history that alternative and complementary therapies are used to help manage medical conditions. Which drug would raise a concern in a patient taking St. John's wort?a. Reserpineb. Albuterolc. Propranolold. Pseudoephedrine 35. A nurse received an order for timolol 100 mg b.i.d. Which action would be most appropriate by the nurse?a. Give the patient the drug after proper identification.b. Hold the drug, and contact the health care provider regarding the dosage.c. Give the drug now, and request a new order during patient rounds.d. Assess the patient's vital signs, and give the drug. 36. Catecholamine can be best defined by which statement?a. A substance that can produce a sympathomimetic responseb. Another name for a beta blockerc. A type of decongestantd. A receptor site in the lungs Clinical Judgment Unfolding Case Study Phase 1: Question 1: SLO: Apply knowledge of the mechanisms of action and adverse drug reactions for adrenergic agonists NGN Item Type: Highlight Text Cognitive Skills: Recognize Cues A 58-year-old male patient who presented to the emergency department (ED) unresponsive and in cardiac arrest received two ampules of epinephrine intravenously (IV) resulting in the patient becoming responsive. Patient continued with hypotension and bradycardia and received additional epinephrine in addition to starting dopamine 5 mcg/kg/min IV to be titrated by 2 mcg/kg/min every 15 minutes until patient's systolic blood pressure is 90 mm Hg or higher and the heart rate is at least 70 beats per minute. After being in the ED for 3 hours, the patient was transferred to the intensive care unit (ICU) with 0.9% sodium chloride infusing at 125 mL/hr and dopamine at 25 mcg/kg/min. Upon receiving the patient, the ICU nurse documents the following findings: • Blood pressure 88/48 mm Hg • Cardiac monitor showing sinus rhythm • Heart rate 80 beats per minute • Heart without murmurs, rubs, or gallops • IV site to left forearm with redness and pain • Lungs with faint wheezes to the bases on auscultation • Patient's complaint of "difficulty breathing" • Peripheral pulses palpable but weak • Respiratory rate 20 breaths per minute • Urine output in urine drainage bag with 20 mL of amber colored urine Highlight the above information the nurse recognizes requiring immediate attention. Question 2: SLO: Identify appropriate nursing actions for patients receiving adrenergic agonists NGN Item Type: Drop-Down Cloze Cognitive Skills: Analyze Cues A 58-year-old male patient who presented to the emergency department (ED) unresponsive and in cardiac arrest received two ampules of epinephrine intravenously (IV) resulting in the patient becoming responsive. Patient continued with hypotension and bradycardia and received additional epinephrine in addition to starting dopamine 5 mcg/kg/min IV to be titrate by 2 mcg/kg/min every 15 minutes until patient's systolic blood pressure is 90 mm Hg or higher and the heart rate is at least 70 beats per minute. After being in the ED for 3 hours, the patient was transferred to the intensive care unit (ICU) with 0.9% sodium chloride infusing at 125 mL/hr and dopamine at 25 mcg/kg/min. Upon receiving the patient, the ICU nurse documents the following findings: • Blood pressure 88/48 mm Hg • Cardiac monitor showing sinus rhythm • Heart rate 80 beats per minute • Heart without murmurs, rubs, or gallops • IV site to left forearm with redness and pain • Lungs with faint wheezes to the bases on auscultation • Patient's complaint of "difficulty breathing" • Peripheral pulses palpable but weak • Respiratory rate 20 breaths per minute • Urine output in urine drainage bag with 20 mL of amber colored urine Choose the most likely options for the missing information from the statements below by selecting from the list of options provided. Based on the blood pressure, the nurse would most likely ___1___ the rate of dopamine to ___2___ after moving the IV site to another location. To prevent extravasation due to dopamine infiltration, the nurse would anticipate instilling ___3___ 5 mg that is diluted in 10 to 15 mL of normal saline. The nurse determines that the patient could be experiencing ___4___ because of wheezes to the lung's bases and complaint of "difficulty breathing.". Options for 1Options for 2Options for 3Options for 4Decrease23 mcg/kg/minProtamine sulfatefluid overloadIncrease25 mcg/kg/minPhytonadionepneumoniaNot change27 mcg/kg/minPhenterminecollapsed lungPhentolamine mesylate Phase 2: Question 3: SLO: Prioritize nursing care for patients receiving adrenergic agonists NGN Item Type: Multiple Response Select All That Apply Cognitive Skills: Prioritize Hypotheses A 58-year-old male patient has been in the ICU for 3 days post cardiac arrest receiving an infusion of dopamine at 27 mcg/kg/min and sodium chloride at 75 mL/hr. The patient continues to report "difficulty breathing" and "chest discomfort." Vital signs include blood pressure 102/64 mm Hg, heart rate 98 beats per minute, respiratory rate 22 breaths per minute. The nurse also auscultated crackles to the bases of the lungs. Cardiac monitor shows patient to be in sinus rhythm with occasional unifocal premature ventricular contractions. Urine output for the last 8 hours were 120 mL. Which priority assessment findings would the nurse further review for potential complications of adrenergic agonist? Select all that apply. ____ a. Complaints of "difficulty breathing" and "chest discomfort" ____ b. Decreased renal function ____ c. Blood pressure 102/64 mm Hg ____ d. Heart rate 98 beats per minute ____ e. Oliguria ____ f. Respiratory rate of 22 breaths per minute ____ g. Crackles to the bases of the lungs on auscultation Question 4: SLO: Plan nursing actions for a patient receiving adrenergic agonists NGN Item Type: Matrix Multiple Choice Cognitive Skills: Generate Solutions A 58-year-old male patient has been in the ICU for 3 days post cardiac arrest receiving an infusion of dopamine at 27 mcg/kg/min and sodium chloride at 75 mL/hr. The patient continues to report "difficulty breathing" and "chest discomfort." Vital signs include blood pressure 132/70 mm Hg, heart rate 100 beats per minute, respiratory rate 20 breaths per minute. The nurse also auscultated crackles to the bases of the lungs. Cardiac monitor shows patient to be in sinus rhythm with occasional unifocal premature ventricular contractions. Urine output for the last 8 hours were 120 mL. Further assessment revealed 1+ pedal and ankle edema and oxygen saturation of 92% on room air. The nurse notified the attending health care provider to report the assessment findings. Use an X for the potential order below that is Indicated (appropriate or necessary), or Contraindicated (could be harmful) for a patient receiving adrenergic agonist. Potential OrderAnticipatedContraindicated12-lead electrocardiogram (ECG)Chest x-rayDecrease sodium chloride infusion to 30 mL/hrFurosemide 10 mg IV onceIncrease intravenous fluidsMonitor blood pressure and heart rate every 5 minutesOxygen 2 L per nasal cannulaTitrate dopamine down Phase 3: Question 5: SLO: Select the appropriate teaching to patients who are taking adrenergic antagonist NGN Item Type: Drop-Down Table Cognitive Skills: Take Action A 58-year-old male patient, who is 7 days post cardiac arrest, is being transferred to a step-down unit. The nurse reviews the transfer orders that include metoprolol 50 mg twice daily. Indicate which nurse's response listed in the first column is appropriate for each patient's question. Note not all the nurse's response will be used. Nurse's ResponsePatient's QuestionsAppropriate Nurse's Response"When getting out of bed, change your position slowly to prevent a sudden drop in blood pressure.""Can I stop taking this medicine if my blood pressure is good?""Take the medicine twice daily, one in the morning and one just before you go to bed.""Will the medicine prevent me from enjoying sex?""Place ice pack to your genitalia to prevent long-term erection.""Can I take my nasal decongestant when I get home?""Stopping the medicine abruptly can cause severe high blood pressure or severe chest pain.""What do I need to do if I become dizzy when getting out of bed?""Metoprolol can cause erectile dysfunction.""My job requires me to work odd hours. Can I take both doses when I first wake up?""If your blood pressure is normal for five days, you can stop taking the medicine.""Nasal decongestants can decrease the effectiveness of metoprolol." Question 6: SLO: Evaluate the effectiveness of an adrenergic antagonist NGN Item Type: Multiple Response Select All That Apply Cognitive Skills: Evaluate Outcomes A 58-year-old male patient is being prepared for discharge from the hospital post cardiac arrest. Current vital signs are the following: blood pressure 138/84 mmHg, pulse 98 beats per minute, respiratory rate 16 breaths per minute, temperature 97.5o F. The patient is prescribed nitroglycerin sublingual spray as needed and metoprolol twice daily. For each statement, highlight the patient's correct understanding of the adrenergic antagonist. Select all that apply. a. "I can take my nose spray to decrease congestion." b. "I need to stand from a sitting a position slowly." c. "I am able to take ibuprofen for headaches." d. "The medicine increases oxygen to the heart." e. "I will call my doctor if I have trouble breathing." f. "I can take an extra dose if I have chest pain." g. "My blood pressure can decrease if I take a nitroglycerin."

Chapter 17: Stimulants 1. brain; spinal cord 2. dysregulation 3. norepinephrine; dopamine 4. stimulant; suppress appetite 5. analeptics 6. a, c, d. CNS stimulants, such as amphetamines, analeptics, and anorexiants, are approved to treat ADHD, narcolepsy, and PTSD. 7. a, b, c, d. Methylphenidate is a stimulant to treat ADHD and narcolepsy. Patients taking methylphenidate should not operate hazardous equipment when they experience tremors, nervousness, or increased heart rate; avoid other stimulants, such as caffeine; and that nervousness or tremors can occur. The drug should be taken before meals. Weight loss can occur, not weight gain. 8. b. Analeptics stimulate the brainstem and medulla to stimulate respiration. Anorexiants stimulate the satiety center in the hypothalamic and limbic areas of the brain. Amphetamines stimulate the cerebral cortex. 9. a, b, c, d, f. Methylphenidate can cause euphoria, headache, hypertension, irritability, and vomiting. Hypotension is an adverse effect, not a common side effect. 10. b. An immediate-release drug can be taken in 2 or 3 divided doses. An extended-release drug should be taken once daily. 11. a. Phentermine hydrochloride should not be taken within 14 days of monoamine oxidase inhibitors (MAOIs) such as selegiline. Combinations of the two drugs intensify the stimulation and vasopressor effects of phentermine that can cause severe cardiovascular and cerebrovascular responses. Therefore, the nurse would contact the health care provider to verify the prescription. 12. d. Phentermine-topiramate is used for short-term weight management. 13. b. The nurse would include that counseling should be obtained while on methylphenidate. Diarrhea, not constipation, is a common side effect. Methylphenidate is usually prescribed long term and should not be stopped abruptly. Weight loss, not gain, can occur. 14. a, b, e. Methylphenidate and MAOIs taken together can increase hypertensive crisis. Methylphenidate can increase the effects of anticoagulants. The effects of methylphenidate can be increased by caffeine. 15. c. Hemorrhagic stroke is the most likely diagnosis of those listed. There is a high risk for hemorrhagic stroke attributable to hypertensive crisis in patients taking appetite suppressants or anorexiants. Pregnancy-induced hypertension is a possibility, but the patient has been trying to lose weight, not become pregnant. However, a pregnancy test should be obtained; anorexiants are contraindicated in pregnancy. 16. a, d, e. CNS stimulants are absolutely contraindicated in patients with angina, anxiety, and glaucoma. There is no contraindication for stimulants in those with diabetes or hypothyroidism. Hyperthyroidism, not hypothyroidism, is a contraindication. 17. a. Caffeine can stimulate the respiratory system to help the neonate breathe better. It will not cause the baby to gain weight and increase body's temperature. Case Study: Critical Thinking 1. Methylphenidate is absorbed from the GI tract and is taken before breakfast and lunch. It should be given at least 6 hours before sleep since it can cause insomnia. Methylphenidates decrease hyperactivity and improve attention span. 2. The drug is a CNS stimulant that is used in conjunction with appropriate counseling for treatment of ADHD. The best time to give the drug is 30-45 minutes before meals, so the nurse would need to review the lunch schedules of the students and plan accordingly on how best to administer the drugs. Baseline height, weight, and vital signs should be obtained and monitored throughout the course of treatment. A record of the students' complete blood count, including a white blood cell count with differential and platelet count, should be on file. Routine vital signs should be assessed since these drugs can cause an elevation in heart rate and blood pressure, especially if taken in conjunction with caffeine. Patients should also be monitored for an increase in hyperactivity. Health teaching is important not only for the student but also for the family and the teachers on staff. The goals of these drugs are to increase focus and attention and decrease impulsiveness and hyperactivity. The student and family should be encouraged to eat three nutritious meals per day along with healthy snacks because anorexia may be a side effect. Dry mouth may also occur, and if possible within school policy, the student should be allowed to chew gum or suck on hard candy. The importance of avoiding caffeinated beverages and foods, including chocolate, sodas, and energy drinks, must be stressed because high plasma levels of caffeine can be fatal. Drug administration at school must be handled with tact and ease. If possible, the school nurse's office should not be open and in the main hall where all other students can observe the comings and goings of the students requiring drug or care. Privacy is crucial. diazepam or lorazepam are used for status epilepticus. Diazepam is the drug of choice. Carbamazepine and topiramate are indicated for tonic-clonic and partial seizures. 17. b. Phenytoin prevents sodium from entering the cells. This reduces the activities of cells. Antiseizure drugs inhibit neurotransmitters; they do not destroy them. Antiseizure drugs suppress entry of calcium; they do not increase the influx. 18. a, b, d. Valproic acid is taken in divided doses. Doses start at 10-15 mg/kg/day and increase to a maximum of 60/mg/kg/day until seizures are controlled. Frequent labs are needed to monitor serum levels and liver functions. Antiseizure drugs control the frequency and severity of seizures, it does not cure. 19. b, c, d. An absolute contraindication is heart block and bradycardia. Cautious use is recommended for patients with hypoglycemia and hypotension. Dilantin is excreted in small amounts in the urine. Urine output should be monitored afterward, but not hourly. 20. d. Intravenous phenytoin is irritating to the tissue, and the nurse would discontinue the IV and restart the infusion at a different site. It is recommended that a central line or peripherally inserted central catheter (PICC) line be utilized when possible. The health care provider does not need to be notified immediately to change the medication to oral form. Continuing the infusion, even with a saline flush, may cause sloughing of the tissue. 21. a. Although a variety of antiseizures may be utilized over a patient's lifetime, at this time, there is no cure for seizure disorders. The patient will most likely need to take an antiseizure for one's lifetime. 22. b. 18 mcg/mL is within the therapeutic range of 10 to 20 mcg/mL for bound phenytoin and 1 to 2 mcg/mL for unbound/free drugs. 8 mcg/mL is below the therapeutic range and the patient may be at risk for seizure. 28 and 38 mcg/mL are too high, drug toxicity can occur. 23. a, b, d, e. Documenting the types of movements (tonic/clonic), the duration of seizure activity, and the locations where the movements started and progressed are important pieces of gathering the history of the seizure event. It is important to know, if possible, what the patient had been doing before the event and if the patient reported any warning before the seizure. The patient is unable to stop true seizure activity voluntarily. 24. c. Nosebleeds and sore throats may be a sign of blood dyscrasias and should be reported to the health care provider. A reddish pink discoloration of the urine may be expected. To prevent injury to the gums, a soft toothbrush should be utilized. Orthostatic hypotension is not associated with phenytoin use. 25. a. Gingival hyperplasia is a common side effect of phenytoin. Excessive thirst and weight gain are not common with phenytoin. 26. a. The first-line drug of choice for status epilepticus is diazepam. Midazolam, propofol, and high-dose phenobarbital are administered for continued seizures. 27. a, b, c. Up to 33% of women with history of seizures can have increased seizure activity during pregnancy. Many antiseizure drugs have teratogenic properties. Antiseizure drugs increase the excretion of folic acid; therefore, pregnant individuals should take daily folate supplement. Antiseizure drugs inhibit vitamin K, contributing to bleeding. 28. c. Valproic acid and topiramate are indicated for migraine. Diazepam can be used additionally to those with spasms, anxiety, and alcohol withdrawal. Clorazepate can be used for anxiety and alcohol withdrawal. Clinical Judgment Unfolding Case Study Phase 1 Question 1 • 12-lead electrocardiogram (ECG) showed atrial fibrillation with ventricular rate of 135 beats per minute • Serum sodium 130 mEq/L • Chest x-ray with ground-glass opacities bilaterally • Abdomen distended • Arterial blood gas revealed pH 7.28, pCO2 52 mmHg, HCO3 18 mEq/L, O2 saturation 86% Rationale: Patients who drown require careful assessment of possible complications, such as hypoxemia and acidosis (McCall & Sternard, 2020); elevated pCO2 (35-45 mmHg), decreased HCO3 (22-28 mEq/L), and decreased oxygen saturation (96-100%) indicate acidemia and hypoxemia. Cardiac dysrhythmias may ensue (McCall & Sternard, 2020); therefore a 12-lead ECG is warranted. Any dysrhythmia, such as atrial fibrillation, needs further investigation. Electrolyte abnormalities can also occur (McCall & Sternard, 2020). Serum sodium of 130 mEq/L is below the normal range of 135-145 mEq/L and may indicate water ingestion. Distended abdomen can also be indicative of water ingestion. Any abnormal chest x-ray would need a follow-up. Ground-glass opacities within the lung field could indicate inhaled water (McCall & Sternard, 2020). Acidosis, hypoxemia, and electrolyte imbalance could all be risk factors for seizure activity. All other test results are normal. Reference: McCall, J.D., & Sternard, B.T. (2020, Aug 12). Drowning. StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430833/ McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 219-226 Question 2 Options for 1Options for 2Options for 3Options for 4drowningtonic-clonicDiazepam2373 Rationale: Even though emphysema and diabetes can cause acidosis, the most likely cause of this patient's current acid-base imbalance is related to her drowning with continued acid-base imbalance causing the patient to experience seizure activities. Seizure activities are classified by their characteristics. Muscle contractions that are dysrhythmic bilaterally and sustained indicate the patient is experiencing tonic-clonic (grand mal seizure) seizure activities. Tonic seizure is when there is sustained muscle contraction without being dysrhythmic. Clonic seizure is when there is nonsustained dysrhythmic muscle contractions. Myoclonic seizure is an isolated clonic contractions or jerks that last 3-10 seconds that is focal or massive myoclonia. Partial seizure involves one hemisphere of the brain with unilateral muscle involvement. Diazepam is an example of a benzodiazepine and phenytoin is a hydantoin. The total amount of phenytoin the patient would receive is 2373 mg [(174/2.2) x 30] = 2373 mg. References: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 219-226 Phase 2: Question 3 c. Aspiration e. Falls f. Hyperglycemia g. Myocardial infarction h. Respiratory depression i. Sepsis j. Tissue hypoxia Rationale: Priority complications the nurse would monitor the patient for include aspiration, tissue hypoxia, myocardial infarction, hyperglycemia, respiratory depression, sepsis, and falls. Persons who sustained drowning are at risk for tissue hypoxia and aspiration pneumonia (McCall & Sternard, 2020). Patients with aspiration can develop pulmonary infection and if not treated, can progress into sepsis. Sepsis can exacerbate tissue hypoxia. Tissue hypoxia to the brain can cause cerebral damage and hypoxia to the cardiac muscles can result in myocardial infarction. Persons with continued seizure activity are at risk for further injury, such as falls. Phenytoin and diazepam can suppress respiratory center in the brain further exacerbating tissue hypoxia. Hyperglycemia can be an adverse drug reaction from phenytoin, which is exacerbated by the patient being a diabetic. Reference: McCall, J.D., & Sternard, B.T. (2020, Aug 12), Drowning. StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430833/ McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 220-224 Question 4 Nurse's ResponsePatient's QuestionAppropriate Nurse's Response"The antiseizure medications help prevent abnormal electrical impulses in your brain.""Usually, persons with seizures are on antiseizure medicines for the rest of their life. But, if the person has been seizure free for 3 to 5 years, the doctor may stop the medicine.""Be sure to discuss this with your doctor. Phenytoin can harm the fetus so a different antiseizure medication may be needed""Phenytoin can cause blood sugars to increase, not decrease. You may need to increase your insulin dose.""Phenytoin can cause your urine to turn pinkish-red or reddish-brown in color. This is normal and does not indicate you are bleeding." Rationale: Seizure disorder is due to abnormal electric discharges from the brain causing involuntary, uncontrolled movements. The antiseizure medications help prevent abnormal electrical impulses in the brain. Antiseizure drugs are usually taken for the duration of one's life, but there are occasions when the person has been seizure free for 3 to 5 years, the doctor may stop the medicine. Some of the side effects of phenytoin include hyperglycemia, cephalgia, dizziness, drowsiness, and insomnia, among others. The patient may need to increase their insulin dose. Also, urine may turn pinkish-red or reddish-brown in color. Patients who are contemplating pregnancy or becomes pregnant should discuss with their health care provider on alternative antiseizure drug. Phenytoin is teratogenic. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 220-224 Phase 3: Question 5 Discharge TeachingIndicatedContraindicated"Decrease your insulin dosage by 4 units since phenytoin can cause hypoglycemia."X"Have dental check-ups on a regular basis. Phenytoin can cause overgrowth of your gums."X"You will need routine labs to monitor the drug level."X"It is normal if you develop nose bleeds."X"You will need to eat a high-fat diet while you are on phenytoin for better drug action."X"Check your blood sugars more frequently."X Rationale: Teaching patients to lower their insulin dosage is contraindicated. Phenytoin can cause hyperglycemia, not hypoglycemia. Therefore, patients may need to increase, not decrease, their insulin dosage. Teaching patients to have regular dental check-up while on phenytoin is indicated. Phenytoin can cause gingival hyperplasia or reddened gums and can bleed easily. Also, teaching them about the need for frequent lab work is indicated. For effective seizure control, therapeutic range for phenytoin is 10-20 mcg/mL. If it is outside this range, the dosage may need to be adjusted. Decreased therapeutic range can increase the risk of seizures, whereas adverse drug reactions, such as pancytopenia and liver failure. Patients should notify their health care provider if they develop nose bleeds. Nose bleeds or unusual bruises could indicate hematologic toxicity or blood dyscrasia. There is not enough information regarding patient's work environment. Teaching them to eat a high-fat foods is contraindicated. Phenytoin is highly protein bound and must have adequate protein to prevent toxic level. Drug toxicity can cause adverse drug reaction, such as pancytopenia and liver failure. Patients on phenytoin should be taught to check their blood sugars more frequently since phenytoin can prevent insulin being released from the pancreas. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 220-222 Question 6 Assessment FindingEffectiveIneffectiveFingerstick blood sugar 98 mg/dLXPatient states "I do not need to worry about getting pregnant since I am on the pill."XBlood pressure 94/50 mm HgXPhenytoin drug level 17 mcg/mLXAbdomen nondistended, active bowel sounds and nontender.XGait even, smooth, and controlledX Rationale: Glucose of 98 mg/dL indicates effective control of blood glucose. Phenytoin can cause hyperglycemia. Persons prescribed phenytoin, especially those who have diabetes, should monitor their blood sugar more often. Patients may need to increase their insulin dose while on phenytoin. Ineffective teaching occurred when a female patient states they do not need to worry about pregnancy since they are on oral contraceptives. Phenytoin is teratogenic to the fetus. Female patients who are of childbearing age should use additional contraceptive method. Phenytoin drug level of 17 mcg/mL is within the therapeutic range of 10-20 mcg/mL indicating patient is receiving proper dose. Levels greater than 20 mcg/mL indicate toxicity. A blood pressure of 94/50 is hypotensive. Hypotension could be a later sign of phenytoin toxicity. Side effects of phenytoin include constipation, nausea, and vomiting. Abdomen that is nondistended with active bowel sounds and nontender are normal expected findings for patients not experiencing gastrointestinal side effects. Noticing patient's gait as even, smooth, and controlled is effective finding. Ataxia and nystagmus are initial symptoms of phenytoin toxicity.

Study Questions Identify the induction time for the following anesthetics—slow or rapid: 1. Halothane _______________ 2. Enflurane _______________ 3. Midazolam _______________ 4. Propofol _______________ 5. Nitrous oxide _______________ Complete the following. 6. The broad classification of CNS depressants includes the following seven groups: _______________, _________________, _________________, _________________, _________________, _________________, and _______________. 7. The two phases of sleep are _______________ and _______________. 8. The mildest form of CNS depression is _______________. 9. Anesthesia (may/may not) be achieved with high doses of sedative-hypnotics. (Circle correct answer.) 10. Procaine hydrochloride is used in local anesthesia as a short/moderate/long-acting anesthetic (Circle correct answer.) 11. General anesthesia depresses the _______________ system, alleviates _______________, and causes a loss of _______________. 12. Surgery is performed during the _______________ stage of anesthesia. The other three stages are _______________, _______________, and _______________. 13. Bupivacaine and tetracaine are drugs commonly used for _______________ anesthesia. 14. A major potential adverse effect of spinal anesthesia is _______________. 15. A type of spinal anesthesia used for patients in labor is a(n) _______________. 16. Muscle relaxants (are/are not) part of balanced anesthesia. (Circle correct answer.) 17. Drugs used to induce sleep in those who have difficulty getting to sleep are _______________-acting barbiturates. 18. One example of a nonbenzodiazepine drug for the treatment of insomnia is _______________. (Answers may vary.). 19. The drug of choice for the management of benzodiazepine overdose is _______________. 20. Local anesthetics are divided into two groups: _______________ and _______________. Match the common side effect of sedative-hypnotics in Column I with the the description in Column II. Column IColumn II________21. Hangover________22. REM rebound________23. Dependence________24. Tolerance________25. Respiratory depression________26. Hypersensitivitya. Need to increase dosage to get desired effectb. Suppression of respiratory center in the medullac. Skin rashesd. Residual drowsinesse. Results in withdrawal symptomsf. Vivid dreams and nightmares Review Questions Select the best response. 27. Which class of drug is the most commonly prescribed drug to assist patients with sleep disorders?a. Analepticb. Anestheticc. Sedative-hypnoticd. Triptan 28. Which drugs may be prescribed to control seizures?a. Intermediate-acting barbituratesb. Long-acting barbituratesc. Short-acting barbituratesd. Ultra-short-acting barbiturates 29. A patient returns to the unit after having surgery with spinal anesthesia. Which action would the nurse take to decrease the possibility of spinal headache? (Select all that apply.)a. Administer morphine 1 to 2 mg intravenously (IV).b. Ambulate the patient as soon as she regains sensation.c. Encourage the patient to stay flat in bed.d. Increase fluid intake.e. Position the patient in high-Fowler's position. 30. The patient who will be receiving spinal anesthesia for surgery is positioned with the back arched. The patient asks "Why do I have to sit a certain way? Why can't I just be comfortable?" Which statement would be best for the nurse to provide to the patient?a. "It is easier for the anesthesiologist if you sit this way."b. "Because of your age, you have to sit straight up."c. "The anesthesia is injected in a specific area so it distributes evenly."d. "You can sit however you like." 31. The patient is postoperative day 3 from major orthopedic surgery and is unable to sleep. If nonpharmacologic measures have not been effective, which drug would the nurse anticipate may be prescribed?a. Flumazenilb. Phenobarbitalc. Triazolamd. Zolpidem 32. Which type(s) of anesthesia is/are administered using lidocaine? (Select all that apply.)a. Generalb. Inhaledc. Intravenousd. Locale. Spinal 33. The patient works 12-hour night shifts 1 week and 12-hour day shifts the following week. The patient tells the nurse that "some kind of sleeping pill from the drugstore" is used to help with sleep. Which main ingredient would the nurse suspect is contained in the over-the-counter medication to facilitate sleep?a. Antihistaminesb. Barbituratesc. Benzodiazepinesd. Opioid agonists 34. The 71-year-old patient presents to the health care provider with complaints of inability to go to sleep and inability to stay asleep. Which question would the nurse ask to further evaluate the complaint? (Select all that apply.)a. "What are your bedtime routine?"b. "How many caffeinated beverages do you drink per day?"c. "Do you take naps?"d. "Do you sleep with the windows open?"e. "Are you taking diuretics?" Case Study: Critical Thinking Read the scenario and answer the following questions on a separate sheet of paper. A 42-years-old patient is scheduled for a laparoscopic cholecystectomy. The patient has had bad experiences with anesthesia before and is very anxious. 1. Identify the drugs the patient might be prescribed before the patient's surgery for anxiety? 2. Explain the principles of balanced anesthesia.

Chapter 18: Depressants 1. rapid 2. rapid 3. slow 4. rapid 5. rapid 6. sedative-hypnotics; general anesthetics; analgesics; opioid and nonopioid analgesics; anticonvulsants; antipsychotics; antidepressants 7. rapid eye movement; nonrapid eye movement 8. sedation 9. may 10. short 11. central nervous; pain; consciousness 12. surgical; analgesia; excitement or delirium; medullary paralysis 13. spinal 14. respiratory distress or failure 15. saddle block 16. are 17. short 18. zolpidem tartrate (also eszopiclone, zaleplon, and ramelteon) 19. flumazenil 20. esters; amides 21. d 22. f 23. e 24. a 25. b 26. c 27. c. Sedative-hypnotics are commonly prescribed to treat sleep disorders. Analeptics are CNS stimulants. Anesthetics are CNS depressants and are not prescribed for sleep. Triptans help with migraines. 28. b. Long-acting barbiturates, such as phenobarbital, are used to control seizures. Intermediate-acting barbiturates, such as butabarbital, use useful to sustain sleep. Short-acting, such as secobarbital, may be used for sedation. Ultra-short-acting barbiturates, such as methohexital sodium, are used for anesthesia induction. 29. c, d. Postdural-puncture headache can occur because of a decrease in pressure due to fluid leakage from the cerebrospinal space. Maintaining the patient flat in bed for 24 to 48 hours and encouraging adequate oral fluid intake as tolerated may help prevent a spinal headache. The patient may also require IV fluids to supplement oral intake. 30. c. By explaining the reason for positioning (either seated with an arched back or fetal position), the patient will feel more control. The nurse can reassure the patient that assistance in maintaining the proper position will be provided. 31. d. Zolpidem may be ordered. It is a nonbenzodiazepine for short-term treatment of insomnia. Flumazenil is an antidote for benzodiazepine overdose. Phenobarbital, a long-acting barbiturate, is used to treat seizures. Triazolam is a benzodiazepine. While this class of drug can help with insomnia, a nonbenzodiazepine is a better choice. 32. d, e. Lidocaine is used for local and spinal anesthesia that has a rapid onset with its effects long-lasting. 33. a. Antihistamines, such as diphenhydramine, are the primary ingredient in over-the-counter sleep aids. 34. a, b, c, e. Older patients may have more problems with Stage 3 and Stage 4 nonrapid eye movement (NREM) sleep and awaken frequently. Establishing a bedtime routine, maintaining a schedule of going to bed and arising in the morning, and avoiding caffeine and alcohol at bedtime may help. Although it sounds intuitive to take naps, they may hinder a patient from obtaining a good night's sleep if the naps last longer than 20-30 minutes. Diuretics should be taken in the morning and fluids should be limited at bedtime to prevent frequent trips to the bathroom, which may interrupt sleep. Case Study: Critical Thinking 1. Benzodiazepines are frequently prescribed before surgery. They increase the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to the GABA receptors and reduce the excitability of the neurons. Drugs such as alprazolam or lorazepam might be prescribed for anxiety. 2. Balanced anesthesia includes many parts leading up to surgery. By using a variety of agents, less general anesthetic is needed, fewer cardiovascular side effects occur, less nausea and vomiting occur, pain is decreased, and a quicker recovery is promoted. This is also true if utilizing a laparoscopic approach instead of an "open" approach to this surgery. The night before the surgery, a medication such as zolpidem might be prescribed to ensure a good night's sleep. After the patient has arrived in the preoperative area and approximately 1 hour before surgery, a combination of an opioid or anxiolytic and an anticholinergic such as atropine might be given. The purpose of the anticholinergic is to decrease secretions, and therefore the risk of aspiration. Once the patient is transferred to the operating room, a short-acting sedative such as pentothal, propofol, or etomidate may be given and the patient will be given inhaled anesthetics. This procedure will require general anesthesia, so the patient will also receive a muscle relaxant to facilitate endotracheal intubation and maintain neuromuscular blockade.

1. When a 12-year-old child is prescribed methylphenidate, which is most important for the nurse to monitor? a. Temperature b. Respirations c. Intake and output d. Height and weight

Chapter 17 Answers: 1. d; 2. d; 3. c; 4. a; 5. c.

Study questions Match the classifications of multiple sclerosis (MS) in Column I with the definition in Column II. Column IColumn II________1. Relapsing remitting MS________2. Primary progressive MS________3. Secondary progressive MS________4. Progressive relapsing MSa. May have relapses, remissions, and plateausb. Relapse with full recovery and residual deficitc. Clear acute relapses with or without full recoveryd. Will have slowly worsening symptoms with no relapses or remissions Complete the following. 5. Muscle spasms can result from ________________ injuries and spasticity from chronic ___________ ___________. 6. Muscle relaxants suppress the ________________ reflex and are prescribed for muscle spasms that do not respond to ________________ drugs or other forms of therapy. 7. Baclofen, dantrolene, and tizanidine are some drugs to ________________ pain and ________________ mobility for hyperexcitable, spastic muscles. Short answer questions Identify the affected neuromuscular site(s) for each of the autoimmune neuromuscular disorders and the drugs to treat the disorders. 8. Myasthenia gravis 9. Multiple sclerosis Review questions Select the best response. 10. The nurse is assessing a patient who is receiving treatment for myasthenia gravis with pyridostigmine. Which clinical manifestations would be noted if the drug's action is therapeutic?a. Increased salivationb. Maintenance of muscle strengthc. Miosisd. Tachycardia 11. The patient is receiving treatment for myasthenia gravis with an acetylcholinesterase (AChE) inhibitor. The nurse observes that the patient is diaphoretic, drooling, and eyes are tearing. The nurse would be most concerned about the patient exhibiting these clinical manifestations in which medical condition?a. Anaphylactic reactionb. Cholinergic crisisc. Early stages of myasthenic crisisd. Vascular spasm 12. Which emergency drug would be administered to a patient exhibiting signs of cholinergic crisis?a. Atropineb. Diazepamc. Neostigmined. Pyridostigmine 13. The patient presents to the health care provider with complaints of double vision, headache, and muscle weakness. The patient states that these symptoms come and go every few weeks, but these "spells" seem to be getting closer together. Which diagnostic test is likely to be obtained if multiple sclerosis is considered?a. Angiographyb. Computerized tomography (CT) scanc. Magnetic resonance imaging (MRI)d. Myelogram 14. The patient has been receiving pyridostigmine. Which drug when prescribed by the health care provider would the nurse question before administering to the patient?a. Histamine2 blockerb. Propranololc. Cephalosporind. Tetracycline 15. The patient has been prescribed azathioprine and interferon-β for remissions and exacerbations of multiple sclerosis. The patient inquires, "How will this help me feel better?" Which response would be appropriate by the nurse?a. "These drugs will help form new neurons and axons."b. "They will improve muscle strength."c. "They will reduce spasticity and improve muscular movement."d. "They will stop the progression of the disease." 16. The patient has multiple sclerosis and is experiencing muscle spasms. Centrally acting muscle relaxants improve spasms by which mechanism?a. Affect mu receptors to decrease pain.b. Decrease pain and increase range of motion.c. Decrease inflammation of the peripheral nerves.d. Speed conduction to improve flexibility. 17. The patient has been involved in a motor vehicle collision and has been prescribed methocarbamol for muscle spasms of the neck and back. Which side effect would the nurse discuss with the patient before discharge? (Select all that apply.)a. Urine discolorationb. Diarrheac. Drowsinessd. Increased appetite 18. A nurse is preparing several medications for a patient. Which drug would the nurse seek clarification?a. Dantrolene sodium for muscle spasmsb. Diazepam for narrow-angle glaucomac. Acetylcholine receptor (AChR) antibody for diagnostic testing for myasthenia gravisd. Chlorzoxazone for muscle trauma Case Study: Critical Thinking Read the scenario and answer the following questions on a separate sheet of paper. A 24-years-old patient was involved in a high-speed rollover motor vehicle accident and has a spinal cord injury. The patient has muscle spasms and some spasticity to the lower extremities bilaterally. The patient also has been prescribed carisoprodol and will be started on baclofen. 1. Describe the pathophysiology of muscle spasms occur in patients with spinal cord injuries? 2. Discuss the mechanism of carisoprodol? How does baclofen work? 3. Discuss the side effects of each drug?

Chapter 21: Drugs for Neuromuscular Disorders and Muscle Spasms 1. b 2. d 3. a 4. c 5. traumatic; debilitating disorders 6. hyperactive; antiinflammatory 7. decrease; increase 8. Myasthenia gravis is an autoimmune disorder that involves an antibody response against acetylcholine receptor (AChR) sites, eventually destroying the receptor sites for acetylcholine (Ach). Drugs used to treat myasthenia gravis (MG) are the acetylcholinesterase (AChE) inhibitors (cholinesterase inhibitors and anticholinesterase), such as neostigmine or pyridostigmine. They inhibit the action of AChE, which allows more activation of the cholinergic receptors. 9. Multiple sclerosis (MS) is an autoimmune disorder that attacks the myelin sheath of the nerve fibers of the central nervous system, resulting in plaques. Drugs used to treat MS include corticosteroids and immunomodulators, such as teriflunomide, alemtuzumab, and glatiramer acetate. 10. b. Pyridostigmine increases muscle strength in patients with myasthenia gravis. Increased salivation and miosis are signs and symptoms of overdose. Bradycardia, not tachycardia can be an adverse drug effect. 11. b. Drooling, excessive tearing, sweating, and miosis are signs of a cholinergic crisis, an overdose of AChE inhibitors. 12. a. Atropine is the antidote for AChE inhibitor. 13. c. Multiple sclerosis is difficult to diagnose. MRI, assessing brain's electrical activity, or analysis of cerebrospinal fluid can aide in confirming the diagnosis. 14. d. There is an increased toxicity when taken with tetracycline. AChE inhibitor can cause gastrointestinal distress. Histamine2 blocker can decrease these side effects. Another side effect of AChE inhibitor is bradycardia. Risk of bradycardia increases when taking propranolol; the nurse would need to monitor more closely the patient's heart rate. There is no concern with cephalosporin and AChE inhibitors. 15. c. Azathioprine is an immunosuppressant and interferon-β is an immunomodulators. Both decrease the inflammatory process of the nerve fibers. Interferon-β delays neurological deterioration. Decreased inflammation and delaying of deterioration will decrease spasticity and hopefully muscular movement will improve. They do not form new neurons and axons nor will they stop the progression of the disease, but they can delay the deterioration. 16. b. Centrally acting muscle relaxant, such as baclofen, has actions to the neuronal activities in the brain and spinal cord. They suppress hyperreflexia and muscle spasms that do not respond to other forms of therapy. By suppressing the spasms, pain is decreased, which allows increased movement. 17. a, c. Centrally acting muscle relaxants, such as methocarbamol, can cause drowsiness and change the color of the urine. Other side effects include dizziness, lightheadedness, headaches, altered taste, and anorexia, not increased appetite. 18. b. Diazepam can increase intraocular pressure and is contraindicated in narrow-angle glaucoma. Case Study: Critical Thinking 1. Patients with spinal cord injuries may have spasticity attributable to hyperexcitability of neurons caused by increased stimulation from the cerebral neurons or lack of inhibition in the spinal cord or at the skeletal muscles. 2. Carisoprodol is a centrally acting muscle relaxant and is utilized for muscle spasms. Baclofen is used specifically for muscle spasticity, either caused by trauma or resulting from multiple sclerosis. 3. Side effects of these drugs include drowsiness, dizziness, nausea, and hypotension. They should not be taken with other central nervous system depressants or alcohol. Baclofen can be used for an extended period without developing tolerance. It does not have abuse potential. Carisoprodol is now a Schedule IV drug and has the potential for abuse.

Critical Thinking Case Study A 7-year-old child has been diagnosed with attention-deficit/hyperactivity disorder. The physician is considering putting the child on medication. 1. What symptoms does a child with attention-deficit/hyperactivity disorder display? 2. What medication might be prescribed? What class of drugs does the medication fall under? 3. What behavioral improvements might be seen after medication administration? 4. What physical assessment should be completed before medication administration? 5. What teaching should the nurse include related to the use of methylphenidate?

1. Children with attention-deficit/hyperactivity disorder (ADHD) may display behaviors of restlessness, hyperactivity, inattentiveness, impulsivity, and inability to complete tasks. 2. Methylphenidate, an amphetamine-like drug is commonly prescribed for ADHD. It is classified as a controlled substance. 3. The child may have a longer attention span, increased cognitive performance, decreased impulsiveness, decreased hyperactivity, and restlessness. This may improve memory and learning ability. 4. The child's assessment before medication administration should include family history, physical problems, height, weight, mental status, complete blood work, behavior problems, learning disabilities, and functional behavior. 5. A teaching plan for methylphenidate should include the following: teach family and child when to take medication, explain possible side effects, monitor behavior, notify school nurse if the child must take medication during school, do not stop the drug abruptly, avoid foods that contain caffeine, explain long-term drug use, and evaluate knowledge of methylphenidate therapy.

A 26-year-old woman takes phenytoin 100 mg three times daily to control tonic-clonic seizures. She and her husband are contemplating starting a family. 1. What action should the nurse take in regard to the patient's family planning? The patient complains of frequent upset stomach and bleeding gums when brushing her teeth. 2. To decrease gastrointestinal (GI) distress, what can be suggested? 3. To alleviate bleeding gums, what patient teaching for the patient may be included? 4. The nurse checks the patient's serum phenytoin level. What are the indications of an abnormal serum level? What appropriate actions should be taken?

1. Encourage the patient to speak with her health care provider, who will discuss the pros and cons of taking the drug during pregnancy. Phenytoin may have a teratogenic effect. 2. Suggest giving phenytoin with a snack or at mealtime. 3. Suggest good oral hygiene and use of a soft toothbrush to prevent gum irritation and bleeding. 4. Therapeutic target range is 10 to 20 mcg/mL. Toxic levels are greater than 30 mcg/mL. The serum phenytoin level should be closely monitored until the phenytoin dose is determined and stabilized; then the serum phenytoin level should be monitored periodically.

A 29-year-old woman was diagnosed with myasthenia gravis (MG) 2 years ago. She is receiving pyridostigmine 120 mg three times a day. Last evening, the patient was involved in an automobile accident. She was taken to the emergency department unconscious and missed two evening doses of pyridostigmine. 1. How does pyridostigmine alleviate the symptoms of MG? 2. What are the potential side effects and adverse effects of pyridostigmine? 3. What problems are likely to develop after delayed pyridostigmine dosing? 4. What medication is the antidote for pyridostigmine overdose? 5. What problems may develop from pyridostigmine overdosing? 6. What are the similarities between myasthenic crisis and cholinergic crisis?

1. Pyridostigmine facilitates the transmission of neuromuscular impulses across myoneural junctions by preventing the destruction of acetylcholine. Pyridostigmine alleviates symptoms of myasthenia gravis by increasing muscle tone. 2. The side effects of pyridostigmine include abdomen pain, blurred vision, confusion, depression, hyperesthesia, fecal and urinary incontinence, and seizures. The adverse effects of pyridostigmine are hypertension, cardiac dysrhythmias, and chronic obstructive pulmonary disease. 3. Because it has a short half-life, muscle weakness or myasthenic crisis may develop if a dose of pyridostigmine is delayed. 4. Atropine and nondepolarizing muscle relaxants interact with pyridostigmine by antagonizing its effects. 5. Pyridostigmine overdosing may lead to cholinergic crisis (extreme muscle weakness; respiratory failure; increased salivation, tears, sweating, and bronchial secretions; and miosis, bradycardia, and abdominal pain). 6. Both myasthenic crisis and cholinergic crisis are evidenced by muscle weakness, which can include the muscles of respiration, the diaphragm, and the intercostal muscles, resulting in dyspnea, as well as dysphagia.

A 35-year-old patient has allergic rhinitis. Her prescriptions include loratadine 5 mg/day and fluticasone, two nasal inhalations per day. Previously, she had taken OTC drugs and asked if she should continue to take the OTC drug with her prescriptions. She has never used a nasal inhaler before. 1. What additional information is needed from the patient concerning her health problem? 2. What is your response to the patient concerning the use of OTC drugs with her prescription drugs? 3. How would you instruct the patient to use a nasal inhaler? Explain your answer. 4. What are the similarities and differences between loratadine and diphenhydramine? Could one of these antihistamines be more effective than the other? Explain your answer. 5. What could you suggest to decrease allergens such as dust mites in the home?

1. When is the occurrence of rhinitis more prevalent? Has the patient's allergic rhinitis affected her breathing, such as causing asthma? Is her nasal discharge clear or yellow? 2. Over-the-counter drugs taken with prescribed medications should be approved by the health care provider. Adverse reactions and drug-drug interactions might result. 3. See Chapter 10 on the use of the nasal inhaler. 4. Both loratadine and diphenhydramine are antihistamines. Diphenhydramine, a first-generation antihistamine, has been available for years and is frequently found as an ingredient in common cold remedies. Loratadine, a second-generation drug, is used as a single agent for rhinitis. It has fewer anticholinergic effects than diphenhydramine. 5. Instruct the patient to use protective mattress and pillow covers designed to prevent dust mites and an allergen filtration vacuum cleaner. Instruct the patient, her partner, or a family member in proper dusting techniques.

1. It is important for the nurse teaching the patient regarding secobarbital to include which information about the drug? a. It is a short-acting drug that may cause one to awaken early in the morning. b. It is an intermediate-acting drug that frequently causes rapid eye movement rebound. c. It is an intermediate-acting drug that frequently causes a hangover effect. d. It is a long-acting drug that is frequently associated with dependence. e. It is an ultra-short-acting central nervous system depressant that induces hypnosis. f. It may cause seizures after prolonged use.

Chapter 18 Answers: 1. a; 2. c; 3. d; 4. c; 5. b; 6. d; 7. a, b, c.

1. The nurse witnesses a patient's seizure involving generalized contraction of the body followed by jerkiness of the arms and legs. The nurse reports this as which type of seizure? a. Myoclonic b. Absence c. Tonic-clonic d. Psychomotor

Chapter 19 Answers: 1. c; 2. b; 3. c; 4. c, d, e; 5. a, b; 6. b; 7. d.

Study Questions Match the seizure type in Column I with its definition in Column II. ________1. Absence seizure ________2. Partial seizure ________3. Generalized seizure ________4. Myoclonic seizure ________5. Simple seizure a. Involves one hemisphere of the brain with no loss of consciousness b. Can be focal or massive with jerky movements lasting 10 seconds or less c. No loss of consciousness and can have a motor, sensory, autonomic, or psychic form d. Loss of consciousness usually lasts less than 10 seconds; also called petit mal seizures e. A seizure that involves both hemispheres of the brain with loss of consciousness Complete the following. 6. To diagnose epilepsy, results of a(n) ______________ are useful. 7. Seventy-five percent of all epilepsy is primary or ______________. 8. The International Classification of Seizures describes the two categories of seizures as ______________ and ______________. 9. Antiseizure drugs suppress abnormal electrical impulses, thus ______________ the seizure, but they (do/do not) eliminate the cause. (Circle correct answer.) 10. Antiseizure drugs (are/are not) used for all types of seizures. (Circle correct answer.) 11. The first anticonvulsant used to treat seizures was ______________, discovered in 1938, and today is the most commonly used drug for seizures. 12. It is strongly recommended that the patient check with the health care provider before taking ______________ products. 13. Administration of phenytoin via the (oral/intramuscular/intravenous) route is not recommended because of its erratic absorption rate. (Circle correct answer.) Review Questions Select the best response. 14. The patient with a history of bipolar disorder recently experienced tonic-clonic seizures. Which drug would the nurse expect to be prescribed for this patient? (Select all that apply.)a. Carbamazepineb. Diazepamc. Ethosuximided. Acetazolamide 15. The patient has a seizure disorder and has just discovered that she is pregnant. At her first prenatal visit, she tells the nurse, "I quit taking all of my drugs because I don't want anything to be wrong with my baby." Which response would be most appropriate by the nurse?a. "You can't do that. You have to take your medications."b. "What drugs have been prescribed for you?"c. "How long have you had seizures?"d. "When was your last seizure?" 16. Which anticonvulsant is appropriate for status epilepticus? (Select all that apply.)a. Fosphenytoinb. Carbamazepinec. Phenobarbitald. Diazepame. Topiramate 17. The patient has just been diagnosed with epilepsy and will be starting phenytoin. The patient's spouse asks how this drug works in the body. Which response is most appropriate by the nurse?a. "It inhibits the enzyme that destroys one of the neurotransmitters."b. "It helps stop the entry of sodium into the cell."c. "It has not been determined exactly how it prevents seizures."d. "It increases the amount of calcium that enters the cell." 18. The patient has just been diagnosed with a seizure disorder and has been started on valproic acid. Which statement by the patient indicates to the nurse more instruction regarding the drug is needed? (Select all that apply.)a. "I just have to remember to take it once a day."b. "I do not have to worry about labs."c. "I need to take it at the same times every day."d. "This drug will cure my seizures." 19. The nurse has received an order to administer an initial dose of intravenous (IV) phenytoin to a patient with new-onset seizures. Which action would the nurse check before administering the first dose? (Select all that apply.)a. Hourly urine outputb. Blood glucose levelsc. Cardiac rhythmd. Blood pressure measurements 20. The patient receiving intravenous (IV) phenytoin for grand mal seizures complains of burning at the IV site. Which nursing action would be most appropriate?a. Call the health care provider immediately to change the drug to oral.b. Continue the infusion and reassure the patient.c. Flush the line with 10 mL of normal saline and continue the infusion.d. Discontinue the IV and restart the IV infusion at a different site. 21. A patient was started on an antiseizure drug for a seizure disorder of unknown cause and asks how long the drug will need to be taken. Which response would be appropriate by the nurse?a. "You will need to take an anticonvulsant of some type for your lifetime."b. "This drug should be taken until you haven't had a seizure for a month."c. "Seizures are unpredictable and so is the duration of the treatment."d. "You will only need to take it for a short period of time because antiseizures will cure the seizure disorder." 22. Which result is within the therapeutic range for phenytoin?a. 8 mcg/mL of bound phenytoinb. 18 mcg/mL of bound phenytoinc. 28 mcg/mL of unbound phenytoind. 38 mcg/mL of unbound phenytoin 23. Which information would the nurse document after witnessing a patient having seizure? (Select all that apply.)a. Types of movementsb. Duration of movementsc. Ability to stop movementsd. Progression of movementse. Preceding events 24. The nurse is preparing discharge teaching for a patient who has been started on phenytoin for a seizure disorder. Which information about the side effects of this drug would the nurse provide to the patient and family member?a. "There may be a green discoloration of the patient's urine."b. "It is best to use a hard-bristle toothbrush for dental care."c. "Nosebleeds and sore throats should be reported to the health care provider."d. "The patient should get up slowly to prevent fainting." 25. Which effect would the nurse expect to see if the patient is experiencing a common side effect of phenytoin?a. Gingival hyperplasiab. Excessive thirstc. Weight gaind. Muscle tremors 26. A patient presents to the emergency department in status epilepticus. Which drug would the nurse anticipate being prescribed first?a. Diazepamb. Midazolamc. Propofold. Phenobarbital 27. Which statement is true about seizures and antiseizure uses in pregnancy? (Select all that apply.)a. Seizures may increase up to 33% in women with history of seizures.b. Many antiseizure drugs have teratogenic properties.c. Antiseizure drug use increases the loss of folic acid.d. Antiseizure drugs increase the effects of vitamin K.e. Valproic acid causes malformation in 40% to 80% of fetuses. 28. Which antiseizure drug may also be used as prophylaxis for migraine headaches?a. Diazepamb. Phenytoinc. Valproic acidd. Clorazepate Clinical Judgment Unfolding Case Study Phase 1: Question 1: SLO: Apply knowledge of abnormal test results in patients experiencing seizure activity NGN Item Type: Highlight Text Cognitive Skills: Recognize Cues A 30-year-old female who has a history of type 1 diabetes and emphysema was found unconscious in a swimming pool. Cardiopulmonary resuscitation (CPR) was initiated and continued enroute to the emergency department (ED). With each chest compression, water was expelled from the lungs. After 20 minutes of CPR, the patient's cardiopulmonary status was restored,. While having blood drawn for labs, the patient started having sustained dysrhythmic bilateral muscle contractions. Diazepam 5 mg and phenytoin 30 mg/kg intravenously was administered. Patient weighs 174 pounds. Test results are as follow: • CT of the head was unremarkable • 12-lead electrocardiogram (ECG) showed atrial fibrillation with ventricular rate of 135 beats per minute • Hemoglobin 14 g/dL • Hematocrit 40% • White blood cells 5000 cells/mcL • Serum sodium 130 mEq/L • Serum potassium 3.8 mEq/L • Chest x-ray with ground-glass opacities bilaterally • Abdomen distended • Arterial blood gas revealed pH 7.28, pCO2 52 mmHg, HCO3 18 mEq/L Highlight the assessment findings that require follow up by the nurse. Question 2: SLO: Compare the different seizure classifications and their treatment NGN Item Type: Cloze Cognitive Skills: Analyze Cues A 30-year-old female who has a history of type 1 diabetes and emphysema was found unconscious in a swimming pool. Cardiopulmonary resuscitation (CPR) was initiated and continued enroute to the emergency department (ED). With each chest compression, water was expelled from the lungs. After 20 minutes of CPR, the patient's cardiopulmonary status was restored. While having blood drawn for labs, the patient started having sustained dysrhythmic bilateral muscle contractions. Diazepam 5 mg and phenytoin 30 mg/kg intravenously was administered. Patient weighs 174 pounds. Test results are as follow: • CT of the head was unremarkable • 12-lead electrocardiogram (ECG) showed atrial fibrillation with ventricular rate of 135 beats per minute • Hemoglobin 14 g/dL • Hematocrit 40% • White blood cells 5000 cells/mcL • Serum sodium 130 mEq/L • Serum potassium 3.8 mEq/L • Chest x-ray with ground-glass opacities bilaterally • Abdomen distended • Arterial blood gas revealed pH 7.28, pCO2 52 mmHg, HCO3 18 mEq/L, O2 saturation 86% Choose the most likely options for the missing information from the statements below by selecting from the lists of options provided. Note that not all the responses will be used. Based on the scenario, the patient's abnormal test results are most likely related to her ___1___. Muscle contractions that are dysrhythmic bilaterally indicates the patient is experiencing __2____ seizure activities. ___3___ is an example of a benzodiazepine and __3____ is a hydantoin. The total amount of phenytoin the patient would receive is ___4___ mg. Options for 1Options for 2Options for 3Options for 4EmphysemaTonic-clonicPhenytoin30DiabetesPartialClonidine2373DrowningMyoclonicMorphine2610Cardiopulmonary resuscitation effortsAtoniaDiazepam Phase 2: Question 3: SLO: Prioritize patient care in persons who have seizure disorder NGN Item Type: Multiple Response Select All That Apply Cognitive Skills: Prioritize Hypotheses A 30-year-old female who has a history of type 1 diabetes and emphysema was found unconscious in a swimming pool. After a successful cardiopulmonary resuscitation (CPR), she experienced a tonic-clonic seizure activity in which she was given diazepam 5 mg and fosphenytoin 1186 mg intravenously. Initial CT of the head was unremarkable, and her arterial blood gas revealed acidemia. She is "weak and tired" and complains of "hurting all over." She also has productive cough. She experienced two more episodes of bilateral dysrhythmic muscular contractions and was given additional diazepam and phenytoin IV. Which priority potential complications would the nurse monitor? a. Acute pain b. Anxiety c. Aspiration d. Chronic obstructive pulmonary disease e. Falls f. Hyperglycemia g. Myocardial infarction h. Respiratory depression i. Sepsis j. Tissue hypoxia Question 4: SLO: Determine appropriate actions for patients taking antiseizure drugs NGN Item Type: Matrix Multiple Choice Cognitive Skills: Generate Solutions A 30-year-old female who has a history of type 1 diabetes and emphysema was treated for seizure disorder. She is now 2 days without seizure activity. Phenytoin is converted to oral preparation. The patient tells the nurse that she is getting married in 2 weeks and wants to have children. For each patient's concern/question, select the appropriate nurse's response from the first column. Note that not all responses will be used. Nurse's ResponsePatient's QuestionAppropriate Nurse's Response"Phenytoin can cause blood sugars to increase, not decrease. You may need to increase your insulin dose.""I really do not want to take more medicine for the seizures.""Yes, you will need to decrease your insulin since phenytoin can cause hypoglycemia.""How long will I need to be taking the medicine?""I'm glad you told me about your urine. Tests need to be done to see where you are bleeding.""Will I be able to get pregnant while on the medicine?""Yes you can become pregnant while on this drug. It should not affect your baby.""Will I need to decrease my insulin while on this medicine?""Usually, persons with seizures are on antiseizure medicines for the rest of their life. But, if the person has been seizure free for 3 to 5 years, the doctor may stop the medicine.""My urine is reddish in color. Does this medicine cause me to bleed?""Be sure to discuss this with your doctor. Phenytoin can harm the fetus so a different antiseizure medication may be needed""Phenytoin can cause your urine to turn pinkish-red or reddish-brown in color. This is normal and does not indicate you are bleeding.""As long as you are without seizures, you do not need to take the medicine.""The antiseizure medications help prevent abnormal electrical impulses in your brain." Phase 3: Question 5: SLO: Select the appropriate nursing actions for patients receiving antiseizure drugs NGN Item Type: Matrix Multiple Choice Cognitive Skills: Take Action A 30-year-old female has been in the hospital for 5 days for drowning incident and acute seizure activities. She also has type 1 diabetes and emphysema. The patient is to be discharged and the nurse is planning discharge teaching. The patient is prescribed phenytoin 100 mg orally three times a day. She is to resume her medications prior to hospitalization, which includes insulin, albuterol/ipratropium metered dose inhaler, and oral contraceptive. Use an X for the discharge teaching below that is Indicated (appropriate or necessary), Contraindicated (could be harmful). Discharge TeachingIndicatedContraindicated"Decrease your insulin dosage by 4 units since phenytoin can cause hypoglycemia.""Have dental check-ups on a regular basis. Phenytoin can cause overgrowth of your gums.""You will need routine labs to monitor the drug level.""It is normal if you develop nose bleeds.""You will need to eat a high-fat diet while you are on phenytoin for better drug action.""Check your blood sugars more frequently." Question 6: SLO: Evaluate patient's assessment findings to determine the effectiveness of antiseizure drug NGN Item Type: Matrix Multiple Choice Cognitive Skills: Evaluate Outcomes A 30-year-old female has been in the hospital for 5 days for drowning incident and acute seizure activities. She also has type 1 diabetes and emphysema. The patient is to be discharged and the nurse is planning discharge teaching. The patient is prescribed phenytoin 100 mg orally 3 times a day. She is to resume her medications prior to hospitalization, which includes insulin, albuterol/ipratropium metered dose inhaler, and oral contraceptive. For each assessment finding, use an X to indicate whether nursing and collaborative interventions were Effective (helped meet expected outcomes) or Ineffective (did not meet expected outcomes). Assessment FindingEffectiveIneffectiveFingerstick blood sugar 98 mg/dLPatient states "I do not need to worry about getting pregnant since I am on the pill."Blood pressure 94/50 mm HgPhenytoin drug level 17 mcg/mLAbdomen nondistended, active bowel sounds and nontender.Gait even, smooth, and controlled

Chapter 19: Antiseizure Drugs 1. d 2. a 3. e 4. b 5. c 6. electroencephalogram (EEG) 7. idiopathic 8. generalized; partial 9. preventing; do not 10. are not 11. phenytoin 12. over-the-counter 13. intramuscular 14. a, b. Carbamazepine and diazepam are given for tonic-clonic seizures. Ethosuximide and acetazolamide are indicated for absence seizures. 15. b. Although it is important to know the patient's medical history regarding seizures, the best response is asking about the drugs that have been prescribed. Most antiseizure drugs have teratogenic properties. Women with seizure history are at increased risk for seizures during pregnancy. The risk versus the benefits need to be discussed. Abruptly stopping antiseizure drugs can also increase the risk of seizures. 16. a, c, d. Hydantoins, such as fosphenytoin, barbiturates, such as phenobarbital, and benzodiazepines, such as

1. Which of the following assessment findings would the nurse see in a patient with Parkinson disease? (Select all that apply.) a. Abrupt onset of symptoms b. Muscle rigidity c. Involuntary tremors d. Bradykinesia e. Bilateral muscle weakness

Chapter 20 Answers: 1. b, c, d; 2. d; 3. d; 4. c; 5. b; 6. a, b, c, e; 7. a, b, c.

Study Questions Match the description in Column I with the letter of the reference in Column II. Column IColumn II________1. Acetylcholinesterase (AChE) inhibitor________2. Dopamine agonist________3. Dystonic movement________4. Bradykinesia________5. Pseudo parkinsonisma. Stimulates dopamine receptorsb. Drug-induced parkinsonismc. Allows more acetylcholine in the neuron receptorsd. Involuntary abnormal movementse. Slowed movements Complete the following. 6. The two neurotransmitters within the neurons of the striatum of the brain that have opposing effects are ______________ and ______________. 7. Which of the neurotransmitters is deficient in Parkinson disease? ______________ 8. A drug used in a combination therapy to treat Parkinson disease by replacing the neurotransmitter is ____________. 9. The substance that inhibits the enzyme dopa decarboxylase and allows more levodopa to reach the brain is ______________. 10. An example of an acetylcholinesterase inhibitor is ______________. 11. Acetylcholinesterase inhibitors ___________ transmission at the cholinergic synapses. 12. The drug ____________ prolongs action of levodopa and can decrease "on-off" fluctuations in patients with parkinsonism. 13. The drugs that are a combination of dopaminergic and a catechol-O-methyltransferase (COMT) inhibitor that provides the greatest dosing flexibility include ______________, ______________, and _______________. 14. An example of a Food and Drug Administration (FDA)-approved anticholinergic drug used for Parkinson disease is __________________. Review Questions Select the best response. 15. A patient taking carbidopa-levodopa tablets for parkinsonism is complaining of dizziness, diarrhea, anxiety, and nasal stuffiness. Which complaints would the nurse recognize as a possible side effect of carbidopa-levodopa?a. Dizzinessb. Diarrheac. Anxietyd. Nasal stuffiness 16. The nurse is teaching a patient with parkinsonism about extended-release carbidopa-levodopa. Which statement by the patient indicates the need for further teaching? (Select all that apply.)a. "This drug may make my movements smoother."b. "My skin may turn yellow if I miss too many doses."c. "If I have trouble swallowing, I can crush my drug and mix it with applesauce."d. "I must take this medicine on an empty stomach."e. "I need to check my blood sugar regularly while taking this drug." 17. The nurse is helping a family prepare for a grocery shopping trip for a patient who has been prescribed selegiline for Parkinson disease. Which food item would the family avoid purchasing? (Select all that apply.)a. Aged cheesesb. Chocolatec. Peanut butterd. Wheat breade. Yogurt 18. A patient with Alzheimer disease is taking rivastigmine and has also been started on a drug for depression. Which medication would the nurse question before administering the new drug?a. Atypical antidepressantb. Monoamine oxidase inhibitor (MAOI) antidepressantc. Selective serotonin reuptake inhibitor (SSRI) antidepressantd. Tricyclic antidepressant 19. A patient with parkinsonism currently takes carbidopa-levodopa, and the patient's health care provider adds entacapone to the drug regimen. Which change in the dosing of carbidopa-levodopa would the nurse expect to occur?a. There should be no change in the drug dosage.b. Both carbidopa and levodopa dosages should be decreased.c. Only the levodopa dosage should decrease.d. Only the carbidopa dosage should decrease. 20. Anticholinergics are contraindicated for patients with which disorder?a. Glaucomab. Shinglesc. Urinary frequencyd. Diabetese. Angina 21. A patient who was prescribed antiparkinson medication is brought into the emergency department after the family reports the patient is talking to "rabbits coming out of the walls" at home. Which drug would the nurse suspect may be causing this symptom? (Select all that apply.)a. Bromocriptineb. Selegilinec. Pramipexoled. Tolcapone 22. A patient's wandering and hostility levels have increased per family reports. Which dosing information would concern the nurse in this patient who is taking memantine 10 mg/day?a. The dose is too high a daily dose to maintain mental status.b. The patient has taken an overdose of the drug.c. The patient is not taking enough of the drug.d. A combination of memantine and amantadine may be needed. 23. Which statement by the patient indicates an understanding of how to relieve some of the side effects associated with the use of benztropine mesylate?a. "I can suck on hard candy or chew sugarless gum to prevent dry mouth."b. "I need to take my drug every 6 hours so I don't get constipated."c. "I should decrease the doses of all of my other drugs so I don't get dizzy."d. "I should urinate after meals so I do not retain urine." Clinical judgment unfolding case study Question 1: SLO: Differentiate between Parkinson and Alzheimer disease NGN Item Type: Highlight Text Cognitive Skills: Recognize Cues An 88-year-old male, who lives alone in an assisted living facility, told his daughter that he fell but did not "hurt anything." Because of the daughter's concerns of her father's fall, she accompanies him to his appointment with his health care provider. The nurse documents the following assessment: • Awake, alert, oriented • Blood pressure 123/72 mm Hg • Heart rate 87 beats per minute • History of 3 falls in the last 6 months with ecchymoses to legs and arms • Masked facial expressions • Mild resting tremors to hands bilaterally • Patient reports his feet "drags the floor" • Positive for cogwheel rigidity Highlight the assessment finding that would require follow-up by the nurse. Question 2: SLO: Apply knowledge of Parkinson disease and its neurotransmitters causing changes to patient's physical movement. NGN Item Type: Drop-Down Cloze Cognitive Skills: Analyze Cues An 88-year-old male, who lives alone in an assisted living facility, told his daughter that he fell but did not "hurt anything." Because of the daughter's concerns of her father's fall, she accompanies him to his appointment with his health care provider. The nurse documents the following assessment: • Awake, alert, oriented • Blood pressure 123/72 mm Hg • Heart rate 87 beats per minute • History of 3 falls in the last 6 months with ecchymoses to legs and arms • Masked facial expressions • Mild resting tremors to hands bilaterally • Patient reports his feet "drags the floor" • Positive for cogwheel rigidity Based on the assessment, the nurse determines the patient's symptoms are related to an imbalance of the neurotransmitters _____1_____ (inhibitory) and ____2_____ (excitatory). The levels of dopamine are____3____ and acetylcholine are ____4___, which stimulates the release of ____5____. Options for 1Options for 2Options for 3Options for 4Options for 5AcetylcholineAcetylcholineAbsentAbsentAcetylcholineDopamineDopamineDecreasedDecreasedDopamineGamma-aminobutyric acidGamma-aminobutyric acidIncreasedIncreasedGamma-aminobutyric acidLevodopaLevodopaLevodopa Phase 2: Question 3: SLO: Prioritize nursing care for patients with Parkinson Disease NGN Item Type: Multiple Response Select All That Apply Cognitive Skills: Prioritize Hypotheses An 88-year-old male, who lives alone in an assisted living facility, had multiple falls due to movement disorders. The patient is diagnosed with Parkinson disease and was started on carbidopa-levodopa 25 mg/100 mg daily. His medical history includes hypertension and diabetes type 2. Medications he routinely takes include lisinopril/hydrochlorothiazide 10/12.5 mg daily, calcium/vitamin D supplements, metformin ER 500 mg daily. His blood pressure is 123/72 mm Hg and his heart rate is 87 beats per minute. Labs which include complete blood count and chemistry panel were unremarkable except for mild anemia and serum glucose of 110 mg/dL. When teaching to the patient and his daughter, the nurse would place a priority to which potential complications? Select all that apply. • Diarrhea • Falls • Functional ability • Gastrointestinal distress • Hyperglycemia • Hypotension Questions 4: SLO: Plan actions when caring for patients prescribed antiparkinson drugs NGN Item Type: Multiple Response Select All That Apply Cognitive Skills: Generate Solutions An 88-year-old male, who lives alone in an assisted living facility, had multiple falls due to movement disorders. The patient is diagnosed with Parkinson disease and was started on carbidopa-levodopa 25 mg/100 mg daily. While preparing the medication, the patient reports having "nausea 30 minutes after taking the medicine" and that his "sweat seems to be darker." Which nursing action would be indicated for patients taking carbidopa-levodopa? Select all that apply. • Administer antinausea medication 30 minutes prior to administering antiparkinson drug • Administer the medication with small amount of food • Assess for orthostatic hypotension • Instruct the patient to notify the nurse if urine becomes dark • Monitor blood pressure for hypertension • Observe patient's ability to perform activities of daily living, such as brushing teeth • Obtain a finger stick blood sugar prior to administering the medicine • Place patient as "high fall risk" Phase 3: Question 5: SLO: Determine appropriate nursing actions for patients prescribed antiparkinson drugs NGN Item Type: Matrix Multiple Response Cognitive Skills: Take Action An 88-year-old male, who lives alone in an assisted living facility, had multiple falls due to movement disorders. The patient is diagnosed with Parkinson disease and was started on carbidopa-levodopa 25 mg/100 mg daily. His home medications he routinely takes include lisinopril/hydrochlorothiazide 10/12.5 mg daily, calcium/vitamin D supplements, and metformin ER 500 mg daily. For each potential complication in the second column, select the appropriate nursing action from the first column. Note that not all responses will be used. Nursing ActionPotential ComplicationAppropriate Nursing Action for ComplicationAdminister medicine with high protein foodPatient reports increased dizzinessAdminister antinausea medicationFallsInform the patient this is harmlessDarkened area to clothing around the axillary regionCheck glucose for hyperglycemiaPatient report of increased head bobbingConsult case worker to assess home environmentIncreased nausea with medicineNotify healthcare providerProvide small low-protein snackCheck blood pressure with position changes Question 6: SLO: Evaluate the effectiveness of nursing interventions for patients on antiparkinson drugs NGN Item Type: Highlight Text Cognitive Skills: Evaluate Outcomes Highlight the assessment findings in the progress note that would indicate the patient is not progressing as indicated. Progress Notes: An 88-year-old male patient is seen in the clinic for a 2-week follow-up post hospitalization due to frequent falls. The patient was prescribed carbidopa-levodopa 25 mg/100 mg daily. Routine home medications of lisinopril/hydrochlorothiazide 10/12.5 mg daily, calcium/vitamin D supplements, and metformin ER 500 mg daily were resumed upon discharge. Daughter is present during the visit. Daughter reports patient with decreased appetite and has been "preparing protein shakes." Patient denies any dizziness or unusual weakness. Denies difficulty sleeping. Sitting blood pressure 132/88 mmHg and pulse 64 beats per minute; standing blood pressure 110/62 mmHg and pulse 80 beats/minute. Patient needing moderate assistance to stand. Flat facial expression, "pill-rolling" bilaterally, and head bobbing noted while in sitting position. Lungs clear throughout area. Heart with no extra heart tones. Apical pulses irregular with 60-84 beats/minute.

Chapter 20: Drugs for Parkinsonism and Alzheimer Disease 1. c 2. a 3. d 4. e 5. b 6. dopamine; acetylcholine 7. dopamine 8. levodopa 9. carbidopa 10. donepezil or rivastigmine 11. enhance 12. selegiline 13. carbidopa, levodopa, entacapone 14. trihexyphenidyl (also benztropine) 15. a. Dizziness is a common side effect of carbidopa-levodopa. Constipation is a side effect, not diarrhea. Anxiety and nasal stuffiness are not a side effect of carbidopa-levodopa. 16. b, c, d, e. Carbidopa-levodopa may make the patient's movements smoother, although at high doses, dyskinesia may be noted. Jaundice will not result from missing doses. Extended release drugs should not be crushed or cut; if the patient is unable to swallow tablets, then other preparations, such as liquid or oral disintegrating tablets, are available. Nausea and vomiting are side effects, so taking the drug with meals may be beneficial. There is no indication that carbidopa-levodopa affects glucose levels. 17. a, b, e. Tyramine rich foods should be avoided, such as, aged cheeses, chocolate, and yogurt. These foods should be avoided when taking selegiline to prevent a hypertensive crisis from occurring. Peanut butter and wheat bread are not high in tyramine. 18. d. An order for tricyclic antidepressant should be questioned. Tricyclic antidepressants decrease the effect of rivastigmine. 19. c. The nurse understand that levodopa only will be decreased. When taken with levodopa, COMT inhibitors like entacapone will increase the levodopa combination in the brain. 20. a. Anticholinergic drugs are contraindicated in persons with glaucoma. Extreme caution is warranted for persons with heart problems and those with urinary retention, not urinary frequency. Shingles and diabetes are not contraindications. 21. a, c. Most medications used to treat persons with Parkinson disease can cause hallucinations. The dopamine agonists stimulate the dopamine agonist receptors and provide relief from Parkinson disease symptoms. Bromocriptine and pramipexole are two drugs that are classified as dopamine agonists. Selegiline is a monoamine oxidase B inhibitor and tolcapone is a catechol-O-methyltransferase inhibitor. 22. c. Memantine is prescribed for the treatment of mild to severe Alzheimer disease. Increased wandering and hostility can indicate that the disease is progressing and an increase in the dose may be beneficial. The maximum dose for memantine is 20 mg per day. 23. a. Sucking on hard candy or chewing sugarless gum may help with dry mouth associated with anticholinergic drugs such as benztropine mesylate. This drug is initially taken at bedtime and twice per day in divided doses as a maintenance dose. The nurse would remind the patient that all drug adjustments need to be made by the health care provider. Urinary retention is a side effect of anticholinergic drugs; however, the nurse would encourage the patient to urinate when the urge is felt and not on a set schedule. Clinical Judgment Unfolding Case Study Question 1 • History of 3 falls in the last 6 months with ecchymoses of variegated colors to legs and arms • Masked facial expressions • Mild resting tremors to hands bilaterally • Patient reports his feet "drags the floor" • Positive for cogwheel rigidity Rationale: Falls, especially among older adults, need further investigation to determine the cause of the falls. Variegated skin colors indicate different stages of healing. Older ecchymoses would have yellowish tinge while new ecchymoses are red. Masked facies, resting tremors, cogwheel rigidity, and feet dragging the floor can indicate Parkinson disease. Major features of Parkinson disease include rigidity (abnormal increased muscle tone), bradykinesia (slow movement), gait disturbances, and tremors. Rigidity increases with movement. Postural changes caused by rigidity and bradykinesia include the chest and head thrust forward with the knees and hips flexed, a shuffling gait, and the absence of arm swing. Other characteristic symptoms are masked facies (no facial expression), involuntary tremors of the head and neck, and pill-rolling motions of the hands. The tremors may be more prevalent at rest. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 229 Question 2 Options for 1Options for 2Options for 3Options for 4Options for 5DopamineAcetylcholineDecreasedIncreasedGamma-aminobutyric acid Rationale: Two main neurotransmitters within the brain that controls movement are dopamine and acetylcholine (ACh). Some of the motor neurons, which are dopaminergic neurons, of the brain have degenerated resulting in an imbalance between dopamine and acetylcholine. Dopamine is an inhibitory neurotransmitter, while ACh is an excitatory neurotransmitter. The degeneration of the motor neuron results in a decreased level of dopamine. Dopamine "controls" and maintains ACh. Without dopamine, ACh level and its activities are not hindered. With less DA production, the excitatory response of ACh exceeds the inhibitory response of dopamine. An excessive amount of ACh stimulates neurons that release gamma-aminobutyric acid (GABA). With increased stimulation of GABA, the symptomatic movement disorders of Parkinson disease occur. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 229-234 Phase 2 Question 3 • Falls • Functional ability • Gastrointestinal distress • Hypotension Rationale: Parkinson disease is a disorder that primarily affects the motor neurons. Carbidopa-levodopa is a dopaminergic drug than enhances the dopamine levels in the brain. Some of the side effects of this drug includes dizziness and orthostatic hypotension; which can cause falls. Since the patient also takes lisinopril and hydrochlorothiazide for hypertension, carbidopa-levodopa can enhance the action of the antihypertensives, further exacerbating the risk for falls. As Parkinson disease progresses, the functional capability declines. Also, the dopaminergic can cause worsening involuntary movements and dyskinesia. Carbidopa-levodopa can cause gastrointestinal distress, such as nausea and vomiting. It has the tendency to cause constipation, not diarrhea. Fluctuations of blood glucose are not a common side effect of carbidopa-levodopa. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 228-237 Question 4 • Administer the medication with small amount of food • Assess for orthostatic hypotension • Observe patient's ability to perform activities of daily living, such as brushing teeth • Place patient as "high fall risk" Rationale: Since the patient is complaining of "nausea 30 minutes after taking the medicine," it would be logical for the nurse to provide a low protein snack to take with the drug. Food high in protein can decrease the absorption of levodopa. Carbidopa-levodopa can cause orthostatic hypotension. The nurse would not administer antinausea medication since it is not known if the patient has antinausea medication prescribed. The nurse would need to assess the patient's blood pressure for hypotension, especially with position changes. It is common for sweat and urine to become dark when exposed to air while taking carbidopa-levodopa. It is not necessary for the patient to notify the nurse. However, the patient should be informed clothing can be stained because of darker sweat and/or urine. It is not necessary to obtain fingerstick blood sugar prior to administering carbidopa-levodopa. Patients with Parkinson disease has difficulty in motor coordination, which includes having shuffling gait, involuntary tremors of the limbs, rigidity of muscles, and slowness of movement that can increase them to falls. These patients should be designated as "high fall risk." Additionally, nurses would need to assess the ability for patients to perform their activies of daily living, such as brushing teeth. The involuntary tremors and rigidity of muscles should decrease within 30 to 60 minutes of dosing; thereby, improving their function. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 228-237 Phase 3: Question 5 Nursing ActionPotential ComplicationAppropriate Nursing Action for ComplicationCheck blood pressure with position changesConsult case worker to assess home environmentInform the patient this is harmlessNotify healthcare providerProvide small low-protein snackEncourage sugar-free candy Rationale: Carbidopa can enhance the effects of antihypertensives, such as lisinopril and hydrochlorothiazide. Patient and his daughter should be informed what signs and symptoms, such as dizziness, to report to their health care provider. Dizziness can indicate orthostatic hypotension and the dose of the antihypertensives may need to be decreased. Changing positions slowly is important to prevent orthostasis hypotension, thereby, reducing incidences of falls. Consulting a case worker to assess home environment may be necessary. Persons with Parkinson disease are at an increased risk of falls due to mobility issues. Home environment should be assessed and decrease potential obstacles, such as area rugs, to minimize falls. Carbidopa-levodopa may cause patients to sweat more and/or the color of their sweat may become dark and can stain clothing. Patients and family members must be informed that this is harmless and is nothing to be concerned about. To maximize absorption of carbidopa-levodopa, it is best for patients to take the medicine on an empty stomach. However, a common side effect of carbidopa-levodopa is gastrointestinal distress. If this occurs, the medication can be taken with a small amount of food. Sugar-free candy can be encouraged to relieve dry mouth due to a common side-effect from carbidopa-levodopa. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 288-237 Question 6 Progress Notes: • Preparing protein shakes. • Sitting blood pressure 132/88 mmHg and pulse 64 beats per minute; standing blood pressure 110/62 mmHg and pulse 80 beats/minute. Patient needing moderate assistance to stand. Flat facial expression, "pill-rolling" bilaterally, and head bobbing noted while in sitting position. • Apical pulses irregular with 60-84 beats/minute. Rationale: Carbidopa-levodopa should be taken on an empty stomach. If gastric distress, such as nausea, occurs, then the medication can be taken with small amount of low-protein food. High protein diet, such as protein shakes, decreases the rate of absorption which would decrease the amount of available drug for therapeutic effects. Changes in the blood pressure from sitting to standing indicate orthostatic hypotension. This finding in addition to continued signs of Parkinson disease would need to be provided to the health care provider. Symptoms of Parkinsonism usually decreases within 30 to 60 minutes of dosing with carbidopa-levodopa. Continue masked facies, "pill-rolling", and head bobbing are indication that carbidopa-levodopa is not effective. Cardiac dysrhythmia as indicated by an apical pulse being irregular with 60-80 beats/minute can be a sign of cardiac toxicity. The patient most likely will need an alternative antiparkinson drug. Reference: McCuisition, L.E., DiMaggio, K.V., Winton, M.B., & Yeager, J.J. (2023). Pharmacology: A patient-centered nursing process approach, 11th ed. St. Louis, MO:Elsevier. pp. 288-237

1. What is the nurse's best explanation of the pathophysiology of myasthenia gravis? a. Degeneration of cholinergic neurons and a deficit in acetylcholine lead to neuritic plaques and neurofibrillary tangles. b. A decreased amount of acetylcholine to cholinergic receptors produces weak muscles and reduced nerve impulses. c. Myelin sheaths of nerve fibers in the brain and spinal cord develop lesions or plaques affecting the nervous system. d. An imbalance of dopamine and acetylcholine leads to degeneration of neurons in midbrain and extrapyramidal motor tracts.

Chapter 21 Answers: 1. b; 2. b; 3. c; 4. d; 5. a; 6. a, c, d; 7. b, c, d, e; 8. c; 9. a, b, d, e.

1. A patient tells the nurse that he has started to take an over-the-counter antihistamine, diphenhydramine. In teaching about side effects, what is most important for the nurse to tell the patient? a. To avoid insomnia, do not to take this drug at bedtime. b. Avoid driving a motor vehicle until stabilized on the drug. c. Nightmares and nervousness are more likely in an adult. d. Medication may cause excessive secretions.

Chapter 38 Answers: 1. b; 2. c; 3. d; 4. b; 5. d; 6. b, c, d, e.

Study Questions Match the drug class in Column I to the description in Column II. Column IColumn II________1. Antihistamines________2. Antitussives________3. Decongestants________4. Expectorantsa. Act on the cough-control center in the medullab. Loosen bronchial secretions so they can be removed by coughingc. H1 blockers or H1 antagonistsd. Stimulate the alpha-adrenergic receptors, producing vascular constriction in the nasal capillaries Complete the following. 5. Antihistamines are _____________ antagonists that have effects on the _____________ muscles. 6. Many over-the-counter (OTC) cold remedies contain a _____________ _____________ antihistamine that can cause side effects such as _____________ _____________ and _____________. 7. Second-generation antihistamines are considered _____________ and have fewer _____________ side effects. 8. Frequent use of nasal decongestants can result in _____________ and _____________ _____________ _____________, which can occur in as little as _____________ _____________. 9. Nasal decongestants stimulate the _____________ receptors that cause _____________, which can also cause _____________. Match the antihistamine in Column I to the correct generation in Column II. The generation in Column II may be used more than once. Column IColumn II________10. Diphenhydramine________11. Cetirizine________12. Loratadine________13. Chlorpheniramine________14. Azelastine________15. Clemastine fumaratea. First generationb. Second generation Review Questions 16. Antihistamines are another group of drugs used for the relief of cold symptoms. Which properties of these drugs result in decreased secretions?a. Analgesicb. Anticholinergicc. Antitussived. Cholinergic 17. Compared to first-generation antihistamines, second-generation antihistamines have a lower incidence of which side effect?a. Drowsinessb. Headachec. Tinnitusd. Vomiting 18. The U.S. Food and Drug Administration has ordered removal of all cold remedies containing which drug?a. Dextromethorphanb. Guaifenesinc. Histamined. Phenylpropanolamine 19. The patient has seasonal allergies and asks the student health nurse about the appropriate dose of diphenhydramine. Which amount is the recommended dosage of diphenhydramine?a. 25-50 mg q4-6hb. 25-50 mg dailyc. 50-100 mg q4-6hd. 100 mg daily 20. Which effect is a therapeutic effect for diphenhydramine?a. Anticoagulantb. Anticonvulsantc. Antihypertensived. Antitussive 21. Which advice would the nurse provide to a breastfeeding patient who is also taking diphenhydramine?a. Breastfeeding provides allergy relief to the infant.b. Large amounts of the drug pass into breast milk; breastfeeding is not recommended.c. Small amounts of the drug pass into breast milk; breastfeeding is contraindicated.d. The drug does not affect breastfeeding. 22. Which statement indicates an advantage of systemic decongestants over nasal sprays and drops?a. Fewer side effectsb. Less costlyc. Preferred by older patientsd. Provide longer relief 23. Which expectorant is frequently an ingredient in cold remedies?a. Dextromethorphanb. Ephedrinec. Guaifenesind. Promethazine 24. Which group of drugs is used to treat cold symptoms? (Select all that apply.)a. Antihistaminesb. Antitussivesc. Decongestantsd. Expectorantse. Xanthines 25. Decongestants are contraindicated or to be used with extreme caution for patients with which condition? (Select all that apply.)a. Cardiac diseaseb. Diabetes mellitusc. Hypertensiond. Hyperthyroidisme. Obesity 26. Which priority information would be included in teaching a patient who is taking drugs for a common cold and has a history of atrial fibrillation and depression? (Select all that apply.)a. Administer 4 puffs of nasal spray for a full 10 days.b. Antibiotics are also needed to fight a common cold virus.c. Do not drive during initial use of a cold remedy containing an antihistamine.d. Read labels of over-the-counter drugs for any interactions with current drugs.e. Take cold remedies with a decongestant for a better night's sleep. Case Study: Critical Thinking Read the scenario and answer the following questions on a separate sheet of paper. An adult executive is preparing to fly across the country for a conference and presents to the health care provider with nasal stuffiness. The patient tells the provider "I hate to fly when my nose is this way. It just makes the trip all that much longer." A decongestant, oxymetazoline, is ordered. 1. What is the purpose of oxymetazoline, and how does it work? 2. What is the standard dosage for this drug? 3. Describe rebound congestion. What other side effects might be expected, and how can they be prevented? Are there any other options for a decongestant?

Chapter 38: Upper Respiratory Disorders 1. c 2. a 3. d 4. b 5. H1, smooth 6. first-generation; dry mouth; drowsiness 7. nonsedating; anticholinergic 8. tolerance; rebound nasal congestion; 3 days 9. alpha-adrenergic; vasoconstriction; hypertension 10. a 11. b 12. b 13. a 14. b 15. a 16. b. Antihistamines block H1 receptors found in the extravascular smooth muscles resulting in an anticholinergic effect. This antagonist effect can cause dryness of the mouth and decreased secretions. Antihistamines can also decrease nasal itching. Antihistamines do not have an analgesic (pain relieve) property. Antitussives suppress cough rather than decrease secretions. Antihistamines have an anticholinergic, not cholinergic, effects. 17. a. Second generation antihistamines have fewer anticholinergic effects than first generation antihistamines. Drowsiness is less with second generation antihistamines. 18. d. Phenylpropanolamine was discontinued in all over-the-counter cold remedies and weight-loss aids because of an increased risk of stroke, hypertension, renal failure, and cardiac dysrhythmias. 19. a. The recommended dose to treat allergies with diphenhydramine is 25-50 mg every 4-6 hours, with a maximum dose of 300 mg per day. 20. d. Diphenhydramine is a H1 antagonist and is one of the most frequently used over-the-counter antihistamine. Diphenhydramine has antitussive effects, in addition to treating allergic rhinitis, sneezing, pruritus, urticaria, and to treat motion sickness. 21. c. Breastfeeding patients need to be instructed that small amounts of diphenhydramine can pass into breast milk. Since children are more susceptible to the antihistamine effects, use of diphenhydramine while breastfeeding is contraindicated. 22. d. Both nasal and systemic decongestants have different mechanism of actions. Nasal decongestants have sympathomimetic actions which stimulate the alpha-adrenergic receptors that cause vasoconstriction. Frequent use of nasal decongestants can have a rebound effect. Systemic decongestants are alpha-adrenergic agonists primarily used for allergic rhinitis. The advantage of systemic over nasal decongestants is that they last longer. But, nasal decongestants have quicker action. 23. c. Expectorant reduces the viscosity of secretions so that they can be eliminated by coughing. The most common ingredient in cold remedies is guaifenesin. However, the best way to help loosen mucus is by maintaining hydration. 24. a, b, c, d. The class of drugs used to treat cold symptoms include antihistamines (H1 blockers for vasoconstriction), decongestants (vasoconstriction), antitussives (control cough), and expectorants (to thin secretions). 25. a, b, c, d. Decongestants are not contraindicated in obesity unless the patient also has any of the other diagnoses. 26. c, d. Antihistamines may cause drowsiness. Diphenhydramine is a common ingredient in OTC sleeping preparations. Should the patient choose to take any OTC drugs, the patient should be instructed to read the label carefully to check for interactions. The best option, however, is to check with the health care provider or pharmacist. Decongestants taken at bedtime may cause insomnia or jitteriness. Antibiotics are ineffective against a virus. Case Study: Critical Thinking 1. Oxymetazoline is a decongestant nasal spray that is used to help constrict the vessels within the nasal cavity. The nasal mucous membranes shrink, and it is easier for the patient to exchange air through the nose. 2. The correct dose for this patient would be 2 or 3 sprays in each nostril, morning and night. It should not be used for longer than 3-5 days because of the potential for rebound congestion. 3. Rebound congestion occurs because of irritation of the nasal mucosa leading to vasodilation instead of vasoconstriction. Use of nasal decongestants can also lead to nasal dryness and, if overused, epistaxis. Some brands of oxymetazoline are listed as moisturizing. Another option is to use saline nasal drops, although this will only moisturize and not serve as a decongestant. Oral decongestants such as phenylephrine or pseudoephedrine may also be used. Also important with this patient is to determine the cause of the nasal congestion. Allergies may be treated with intranasal glucocorticoids and first- or second-generation antihistamines. A common cold will not be treated with glucocorticoids.

1. Fluticasone propionate and salmeterol combination inhalation is ordered for a patient with chronic obstructive pulmonary disease. What does the nurse know about this medication? (Select all that apply.) a. It can be used to treat an acute attack. b. It is delivered as a dry-powder inhaler. c. It contains a beta1 agonist and cromolyn. d. It is taken as one puff two times a day. e. It promotes bronchodilation.

Chapter 39 Answers: 1. b, d, e; 2. b; 3. c; 4. c; 5. a.

Study Questions Match the drug in Column I with its category in Column II. Drugs may belong to more than one category. Column IColumn II________1. Acetylcysteine________2. Zafirlukast________3. Albuterol________4. Ipratropium bromide________5. Dexamethasone________6. Epinephrine________7. Arformoterol tartrate________8. Tiotropiuma. Alpha-adrenergic agonistb. Beta-adrenergic agonistc. Glucocorticoidd. Mucolytice. Leukotriene receptor antagonistf. Anticholinergic Complete the following. 9. The substance responsible for maintaining bronchodilation is ____________________ ____________________. 10. In an acute bronchospasm caused by anaphylaxis, the nonselective sympathomimetic drug administered subcutaneously to promote bronchodilation and elevate the blood pressure is _____________________. 11. The first line of defense in an acute asthmatic attack are the drugs categorized as ___________ __________. 12. Sympathomimetics cause dilation of the bronchioles by increasing _____________________. 13. Theophylline (increases/decreases) the risk of digitalis toxicity. (Circle correct answer.) 14. When theophylline and beta2-adrenergic agonists are given together, a(n) _____________________ effect can occur. 15. The half-life of theophylline is (shorter/longer) for smokers than for nonsmokers. (Circle correct answer.) 16. Aminophylline, theophylline, and caffeine are _____________________________ derivatives used to treat _____________________. 17. The drugs commonly prescribed to treat unresponsive asthma are _____________________. 18. Cromolyn is used as a _____________________ treatment for bronchial asthma. It acts by inhibiting the release of _____________________. 19. A serious side effect of cromolyn is _____________________ _____________________. 20. The newer drugs for asthma are more selective for _____________________ receptors. 21. The leukotriene receptor antagonist (is/is not) considered safe for use in children 6 years and older. (Circle correct answer.) 22. The preferred time of day for the administration of leukotriene receptor antagonists is _____________________. 23. The usual dose of montelukast for an adult is _____________________. 24. A group of drugs used to liquefy and loosen thick mucous secretions is _____________________. 25. With infection resulting from retained mucous secretions, a(n) _____________________ may be prescribed. Review Questions 26. A patient is being treated for chronic obstructive pulmonary disease (COPD) with a drug that is delivered via a metered-dose inhaler. Related health teaching would include which priority information?a. Hold the inhaler upside down.b. Refrigerate the inhaler.c. Shake the inhaler well just before use.d. Test the inhaler each time to see if the spray works. 27. When compared to oral drugs for asthma, which information regarding a drug administered by a metered-dose inhaler would the nurse be aware? (Select all that apply.)a. Inhaled dose will deliver more of the drug directly to the lungs.b. There are fewer side effects with an inhaled drug.c. Inhaled drug is longer-lasting.d. Inhaled drug has a more rapid onset.e. Some oral and inhaled drugs can be taken together. 28. A patient expresses not having the time to wait between taking an inhaled beta agonist and an inhaled steroid for asthma. Which response would be appropriate by the nurse?a. "The inhaled beta agonist allows the bronchioles to dilate so the steroid works better."b. "This is done so you remember which one comes first."c. "The inhaled beta agonist will make your heart circulate the steroid faster."d. "The steroid may make your nose stuffy, so you take the inhaled beta agonist first." 29. Which condition is a side effect of long-term use of glucocorticoids? (Select all that apply.)a. Impaired immune responseb. Insomniac. Hyperglycemiad. Vomitinge. Weight loss 30. Which anticholinergic drug has few systemic effects and is administered by aerosol?a. Albuterolb. Ipratropiumc. Isoproterenold. Tiotropium 31. A patient who has been taking theophylline for asthma has also been taking ephedra to stay alert while finishing a project at work. Heart rate is 124 beats/min, respiratory rate 18 breaths/min, blood pressure 170/90 mm Hg, and oxygen saturation 99% on room air. Fingerstick blood glucose is 210 mg/dL and the theophylline level is 26 mcg/mL. Which side effect or reaction would the nurse suspect may be the cause of the patient's symptoms?a. Acute allergic reactionb. Asthma attackc. Stevens-Johnson syndromed. Theophylline toxicity 32. The patient has exercise-induced bronchospasm and is being treated with a short-acting beta2 agonist. Which priority information would the nurse include in a review of inhaler administration? (Select all that apply.)a. "Cleanse all washable parts of inhaler equipment daily."b. "Hold your breath for a few seconds, remove mouthpiece, and exhale slowly."c. "Keep your lips secure around the mouthpiece and inhale while pushing the top of the canister once."d. "Monitor your heart rate while taking this medication."e. "Wait 5 minutes and repeat the procedure if a second inhalation is needed." 33. Which medication when prescribed with theophylline would concern the nurse? (Select all that apply.)a. Beta blockersb. Digitalisc. Lithiumd. Stool softenerse. Phenytoin 34. Which statement by a patient who is prescribed cromolyn indicates the need for more education?a. "I must take this drug every day."b. "It will stop an asthma attack when taken immediately."c. "I can rinse my mouth out with water to get rid of the taste."d. "It is important for me to take this exactly as directed." 35. A patient is taking theophylline, and the nurse is reviewing the lab results. Which level of theophylline would fall in the therapeutic range?a. 2 mcg/mLb. 8 mcg/mLc. 14 mcg/mLd. 23 mcg/mL Case Study: Critical Thinking Read the scenario, and answer the following questions on a separate sheet of paper. An adult patient has recently been diagnosed with asthma and has been prescribed albuterol, montelukast sodium, and fluticasone propionate/salmeterol 100/50 mcg. 1. Identify the classifications for each of the drugs. 2. Describe the mechanisms of action for each drug. 3. Identify the priority teaching points for this patient with a new diagnosis of asthma.

Chapter 39: Lower Respiratory Disorders 1. d 2. e 3. b 4. f 5. c 6. a, b 7. b 8. f 9. cyclic adenosine monophosphate (cAMP) 10. epinephrine 11. beta2-adrenergic agonists 12. cAMP 13. increases 14. synergistic 15. shorter 16. methylxanthine (xanthine); asthma 17. glucocorticoids 18. prophylactic; histamine 19. rebound bronchospasm 20. beta2 21. is 22. evening 23. 10 mg/day 24. mucolytics 25. antibiotic 26. c. The inhaler should be shaken well before each use. Inhalers do not require refrigeration. By testing the inhaler each time to see if the spray works, the patient is losing a dose of the medication. 27. a, b, d, e. Inhaled doses of drugs for asthma have a more rapid onset and fewer side effects than oral preparations. They are shorter-acting. Some inhaled and oral drugs can be taken together. 28. a. The bronchodilator helps open the airway which increases the effectiveness of the inhaled steroid. Beta agonist can cause tachycardia, but it is not the reason to take the beta agonist before the inhaled steroid. 29. a, c. Long-term use of glucocorticoids can cause impaired immune response, hyperglycemia, fluid retention, electrolyte imbalance, hypertension, thinning of the skin, abnormal subcutaneous fat distribution, and purpura. Insomnia, vomiting, and weight loss can be seen with short-term use. 30. b. Ipratropium is an anticholinergic drug that is administered via meter dose inhaler (MDI). It can also be administered via aerosol nebulizer treatment. Unlike albuterol, ipratropium has few side effects which include headache, blurred vision, tachycardia, urinary retention, and constipation. 31. d. Taking theophylline and ephedra together may increase the risk of theophylline toxicity. Hyperglycemia is a sign of theophylline toxicity. 32. a, b, c, d. It is not necessary to wait 5 minutes between inhalations. 33. a, b, c, e. Beta blockers increase the half-life of theophylline. Theophylline increases the risk of digitalis toxicity and decreases the effects of lithium. Phenytoin decreases theophylline levels. 34. b. Cromolyn sodium is used as a prophylactic medication to prevent asthma attacks by preventing the release of histamine and suppressing inflammation in the bronchioles. It will not stop an attack once it has started and is not a bronchodilator. 35. c. The therapeutic range for theophylline is 10-20 mcg/mL. Case Study: Critical Thinking 1. Albuterol is a selective beta2 agonist. It is considered a "rescue inhaler" and can be used on an as-needed basis during an acute asthma attack. Montelukast sodium is a leukotriene modifier. Fluticasone propionate/salmeterol 100/50 is a glucocorticoid combination drug that contains fluticasone propionate 100 mcg and salmeterol 50 mcg. 2. Albuterol is a fast-acting selective beta2 agonist and provides bronchodilation. It has fewer side effects than with nonselective beta agonists. Leukotrienes are chemical mediators that cause airway edema and increase mucous production. Leukotriene modifiers, such as montelukast sodium, decrease inflammation. They must be taken daily and are not effective to treat an acute asthma attack. Glucocorticoids, such as fluticasone propionate/salmeterol, have antiinflammatory properties, and they work synergistically with beta2 agonists. 3. Patients should be encouraged to keep all appointments as scheduled and to contact the health care provider before taking any over-the-counter drugs. If the patient smokes, information on smoking cessation programs should be given. Female patients should be advised to notify the health care provider if contemplating pregnancy. Patients with asthma should be encouraged to stay hydrated and report any increased use of "rescue inhalers" like albuterol. A patient with asthma should also be encouraged to wear a medical identification bracelet or necklace to indicate the drugs being taken.

J.Z., a 72-year-old woman, has difficulty staying asleep. She asks the nurse whether she should take a sleeping medication, such as lorazepam, before bedtime. 1. Before J.Z. takes any sleep aid or hypnotic, what nursing assessments should be made? 2. Describe a nursing plan that may help alleviate J.Z.'s sleep disturbance. 3. Would J.Z. be a candidate for taking a benzodiazepine? Explain your answer. 4. What follow-up plan should the nurse have related to J.Z.'s sleep problem?

1. Assessment includes activities and types of drinks before bedtime and nonpharmacologic measures used (see text). 2. Using nonpharmacologic measures; avoiding alcohol and central nervous system-stimulating drugs; avoiding caffeinated drinks after 5 or 6 pm; and others. 3. The patient should avoid benzodiazepine drugs because of her age and the drugs' side effects. In older adults, metabolism of drugs is slower; thus, accumulative effects are likely to occur. Hangover (residual drowsiness) is common with barbiturates and benzodiazepines. Withdrawal symptoms might occur if these drugs were discontinued abruptly. 4. The patient should keep appointments with the health care provider. Evaluating the response of nonpharmacologic measures and prescribed drug therapy should be ongoing.

A 79-year-old man was diagnosed with Parkinson disease 10 years ago. During his early treatment, he took selegiline. The drug dosage was increased to alleviate symptoms. 1. How does selegiline alleviate symptoms of Parkinson disease? 2. Which dietary changes are most important to adhere to when a patient is prescribed selegiline? The patient has developed nausea, depression, and ataxia to selegiline. The HCP stops selegiline and orders carbidopa-levodopa. 3. What are the similarities and differences between selegiline and carbidopa-levodopa? 4. What are the advantages of carbidopa-levodopa? The family knows of a patient with Parkinson disease who takes the antiviral drug amantadine and does well. They ask whether amantadine is the same as carbidopa-levodopa and, if not, whether their family member can take amantadine instead of carbidopa-levodopa. 5. What is the effect of amantadine on symptoms of Parkinson disease? 6. What would be an appropriate response to the family's question concerning the use of amantadine? 7. What are the uses for dopamine agonists and COMT inhibitors? 8. Certain anticholinergic drugs may be used to control Parkinson disease symptoms. What is the action of these drugs, and what are their side effects? These anticholinergic drugs are usually prescribed for parkinsonism symptoms resulting from what?

1. Selegiline inhibits monoamine oxidase B (MAO B), thus prolonging the action of levodopa. Levodopa, a precursor of dopamine, crosses the blood-brain barrier and is converted to dopamine in the brain. Levodopa decreases symptoms of Parkinson disease, such as rigidity and tremors. 2. The patient should avoid foods high in tyramine such as aged cheese, red wine, and bananas. 3. Both carbidopa-levodopa and selegiline are used for Parkinson disease and parkinsonism. Selegiline is used for early-onset Parkinson disease and may delay use of carbidopa-levodopa therapy by 1 year. Both drugs may cause side effects and adverse effects of dizziness, headache, nausea, vomiting, diarrhea, impulse control symptoms, depression, suicidal ideation, orthostatic hypotension, gastrointestinal ulceration, hyperhidrosis, hypersalivation, bruxism, and elevated hepatic enzymes. In addition, carbidopa-levodopa may cause peripheral neuropathy and angioedema, and selegiline may cause agranulocytosis, thrombocytopenia, hyperkalemia, hyponatremia, and hypercholesterolemia. 4. Carbidopa inhibits the enzyme dopa decarboxylase in the periphery, allowing more levodopa to reach the brain. Advantages of carbidopa-levodopa include (1) more dopamine reaches the basal ganglia, (2) a single dose per day is administered instead of multiple doses, and (3) smaller doses of levodopa are required. 5. Amantadine is an antiviral drug that acts on the dopamine receptors (a dopamine antagonist). 6. Amantadine may be taken as the only drug in treating Parkinson disease, or it may be taken in combination with levodopa or anticholinergic drugs for Parkinson disease. Amantadine can be used for drug-induced parkinsonism. 7. Dopamine agonists stimulate the dopamine receptors. These agents may be taken in combination with levodopa or anticholinergic and antiparkinson drugs. The catechol O-methyltransferase (COMT) inhibitors inhibit the enzyme that inactivates dopamine. 8. Anticholinergic drugs control rigidity and some tremors associated with Parkinson disease. Anticholinergics inhibit the release of acetylcholine, thus preventing muscle contraction. Frequently, anticholinergic and antiparkinson drugs are prescribed for drug-induced parkinsonism (pseudoparkinsonism).