Pharm Exam 2

6. A patient with chronic gout is admitted to the hospital for treatment for an infection. The patient is receiving allopurinol and ampicillin. The nurse is preparing to administer medications and notes that the patient has a temperature of 101°F and a rash. What will the nurse do? a. Withhold the allopurinol and notify the prescriber of the drug reaction. b. Withhold the ampicillin and contact the provider to request a different antibiotic. c. Request an order for an antihistamine to minimize the drug side effects. d. Suggest giving a lower dose of the allopurinol while giving ampicillin.

ANS: A Allopurinol can cause a hypersensitivity syndrome, which is characterized by a rash and fever. If these occur, the drug should be discontinued immediately. The combination of ampicillin and allopurinol increases the risk of this reaction; if it occurs, the allopurinol, not the ampicillin, should be discontinued. Antihistamines are not indicated. Lowering the dose of allopurinol is not indicated.

A nurse provides teaching for a patient about to begin taking an FGA drug for schizophrenia. Which statement by the patient indicates a need for further teaching about side effects of these drugs? a. "Dry mouth and constipation are uncommon with this medication." b. "I may experience gynecomastia and galactorrhea." c. "I may feel lightheaded or dizzy and should sit or lie down if this occurs." d. "Sedation may occur initially, but will subside in 1 to 2 weeks."

ANS: A Anticholinergic effects are common with FGAs, so this statement indicates a need for further teaching. Neuroendocrine effects, orthostatic hypertension, and sedation can occur with FGAs.

A patient with metastatic cancer has had several fractures secondary to bone metastases. The provider orders denosumab [Xgeva]. What will the nurse teach this patient? a.Denosumab may delay healing of these fractures. b.Denosumab should be given subcutaneously every 12 months. c.Denosumab will improve hypocalcemia. d.Unlike bisphosphonates, denosumab does not increase osteonecrosis of the jaw (ONJ).

ANS: A Because denosumab suppresses bone turnover, fracture healing may be delayed. Denosumab is given every 6 months. Denosumab can exacerbate hypocalcemia. Denosumab can increase the incidence of ONJ.

8. A patient is admitted for treatment of gout that has been refractory to treatment with allopurinol and probenecid. The patient is taking colchicine, and the prescriber orders pegloticase [Krystexxa]. Before administering this drug, the nurse will expect to: a. administer an antihistamine and a glucocorticoid. b. discontinue the colchicine. c. increase the dose of colchicine. d. prepare to administer a bronchodilator if needed.

ANS: A Because pegloticase poses a risk of triggering anaphylaxis, patients should be pretreated with an antihistamine and a glucocorticoid. Colchicine is indicated at the initiation of treatment with pegloticase to reduce the intensity of gout flare-ups. Bronchodilators are not indicated.

A patient taking risedronate IR [Actonel] for osteoporosis reports experiencing diarrhea and headaches. What will the nurse tell this patient? a.These are common side effects of this drug. b.These symptoms indicate serious toxicity. c.The patient should discuss taking risedronate DR [Atelvia] with the provider. d.The medication should be taken after a meal to reduce symptoms.

ANS: A Diarrhea and headaches are common adverse effects of risedronate IR. These symptoms do not indicate toxicity. The side effects of Atelvia are similar to those of Actonel. Taking the medication after a meal will not reduce these effects

A patient newly diagnosed with cancer is admitted to the hospital, and the provider orders oxycodone [OxyContin] every 4 to 6 hours PRN pain. The patient requests pain medication whenever he reports pain as a 7 or 8 on a scale of 1 to 10 (10 being the worst pain), but he tells the nurse the medication is not working well. The nurse will contact the provider to discuss: a. a fixed dosing schedule for the oxycodone. b. intramuscular meperidine [Demerol]. c. intravenous morphine sulfate. d. transdermal fentanyl.

ANS: A Dosing should be done on a fixed schedule to prevent opioid levels from becoming subtherapeutic once patients begin to have more severe pain. IM and IV dosing are more invasive and should not be used unless other methods have failed. Transdermal fentanyl is used for chronic, severe pain in patients tolerant to opioids.

A nurse is providing education to a patient who will begin taking alendronate [Fosamax]. Which complication should the patient be instructed to report immediately? a.Difficulty swallowing b.Dizziness c.Drowsiness d.Pallor

ANS: A Esophagitis is the most serious adverse effect of alendronate, sometimes resulting in ulceration. The nurse should instruct the patient to report difficulty swallowing immediately, because it can be a sign of esophageal injury. Dizziness is not an adverse effect of alendronate. Drowsiness is not a symptom associated with alendronate. Pallor is not a symptom associated with alendronate.

A nurse provides teaching for a patient with a newly diagnosed partial complex seizure disorder who is about to begin therapy with antiepileptic drugs (AEDs). Which statement by the patient indicates understanding of the teaching? a. "Even with an accurate diagnosis of my seizures, it may be difficult to find an effective drug." b. "I will soon know that the drugs are effective by being seizure free for several months." c. "Serious side effects may occur, and if they do, I should stop taking the medication." d. "When drug levels are maintained at therapeutic levels, I can expect to be seizure free."

ANS: A Even with an accurate diagnosis of seizures, many patients have to try more than one AED to find a drug that is effective and well tolerated. Unless patients are being treated for absence seizures, which occur frequently, monitoring of the clinical outcome is not sufficient for determining effectiveness, because patients with convulsive seizures often have long seizure-free periods. Serious side effects may occur, but withdrawing a drug precipitously can induce seizures. Not all patients have seizure control with therapeutic drug levels, because not all medications work for all patients.

A nurse is discussing partial versus generalized seizures with a group of nursing students. Which statement by a student indicates understanding of the teaching? a. "Febrile seizures are a type of generalized tonic-clonic seizure." b. "Generalized seizures are characterized by convulsive activity." c. "Partial seizures do not last as long as generalized seizures." d. "Patients having partial seizures do not lose consciousness."

ANS: A Febrile seizures typically manifest as a tonic-clonic seizure of short duration and are a type of generalized seizure. Generalized seizures may be convulsive or nonconvulsive. Partial seizures may last longer than some types of generalized seizures. Patients with complex partial seizures and secondarily generalized seizures, which are types of partial seizures, may lose consciousness.

A patient who is taking oral contraceptives begins taking valproic acid [Depakote] for seizures. After a week of therapy with valproic acid, the patient tells the nurse that she is experiencing nausea. What will the nurse do? a. Ask the patient if she is taking the valproic acid with food, because taking the drug on an empty stomach can cause gastrointestinal side effects. b. Contact the provider to request an order for a blood ammonia level, because hyperammonemia can occur with valproic acid therapy. c. Suggest that the patient perform a home pregnancy test, because valproic acid can reduce the efficacy of oral contraceptives. d. Suspect that hepatotoxicity has occurred, because this is a common adverse effect of valproic acid.

ANS: A Gastrointestinal effects, including nausea, vomiting, and indigestion, are common with valproic acid and can be minimized by taking the drug with food or using an enteric-coated product. Hyperammonemia can occur when valproic acid is combined with topiramate. Signs of pregnancy usually do not occur within a week, so this is less likely. Hepatotoxicity is a rare adverse effect.

A nurse counsels a patient who is to begin taking phenytoin [Dilantin] for epilepsy. Which statement by the patient indicates understanding of the teaching? a. "I should brush and floss my teeth regularly." b. "Once therapeutic blood levels are reached, they are easy to maintain." c. "I can consume alcohol in moderation while taking this drug." d. "Rashes are a common side effect but are not serious."

ANS: A Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly. Because small fluctuations in phenytoin levels can affect response, maintaining therapeutic levels is not easy. Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be serious and should be reported immediately.

A patient will begin taking hydroxychloroquine [Plaquenil] for rheumatoid arthritis. The patient is currently taking high-dose NSAIDs and methotrexate. What will the nurse teach the patient? a.That an eye exam is necessary at the beginning of therapy with this drug b.That the dose of NSAIDs may be decreased when beginning hydroxychloroquine c.To obtain tests of renal and hepatic function while taking this drug d.To stop taking methotrexate when starting hydroxychloroquine

ANS: A Hydroxychloroquine can cause retinal damage so an eye exam is necessary at the onset of treatment as well as every 6 months during treatment. Patients taking other drugs should continue to take those when beginning treatment with hydroxychloroquine since full therapeutic effects take months to develop. Renal and hepatic toxicity are not concerns. The drug is usually combined with methotrexate.

A patient has been taking methadone [Dolophine] for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes? a. Prolonged QT interval b. Prolonged P-R interval c. AV block d. An elevated QRS complex

ANS: A Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

An older adult patient who has cancer and Alzheimer's disease is crying but shakes her head "no" when asked about pain. The prescriber has ordered morphine sulfate 2 to 4 mg IV every 2 hours PRN pain. It has been 4 hours since a dose has been given. What will the nurse do? a. Administer 4 mg of morphine and monitor this patient's verbal and nonverbal responses. b. Give 2 mg of morphine for pain to avoid increasing this patient's level of confusion. c. Request an order for a nonopioid analgesic or an antidepressant adjuvant analgesic. d. Withhold any analgesic at this time and reassess the patient in 30 to 60 minutes.

ANS: A Older adult patients often are undertreated for pain, because assessing pain is difficult in patients with cognitive impairment and because practitioners often believe that reduced dosages are necessary to alleviate side effects. This patient does not verbalize pain, but her nonverbal cue (crying) indicates that pain is present. The nurse should give the higher dose, especially because the dosing interval has already been exceeded, and then monitor the patient's response to the medication. Giving 2 mg to avoid side effects is not indicated; patients with Alzheimer's disease will continue to have confusion unrelated to the opioid. Nonopioid analgesics and antidepressants are not indicated. Withholding pain medication is not appropriate, because this patient shows nonverbal signs of pain.

A patient with bone cancer has recently undergone chemotherapy and radiation therapy to reduce the size of the tumor. The patient is taking a large dose of an opioid analgesic, along with acetaminophen and an antidepressant. The nursing student caring for this patient is concerned that the patient is showing drug-seeking behaviors, because the individual requested an increased dose of the opioid. The student discusses this concern with the nurse. Which statement by the student indicates a need for further teaching? a. "It would probably help this patient more to give a larger antidepressant dose." b. "Patients often need more drug to achieve the same effect." c. "Radiation and chemotherapy can damage bone tissue and cause increased pain." d. "The patient's description of pain is the most important part of the assessment of pain." teaching?

ANS: A Pain in cancer patients can arise from the cancer itself and from the treatments. This patient has bone cancer, which causes somatic pain, and the treatments can increase this pain. Although neuropathic pain can occur as well, this patient is more likely to need analgesia for the nociceptive pain, so increasing the antidepressant dose is not indicated. Patients very often require more drug to achieve the same effect as tolerance develops. Radiation and chemotherapy can damage tissue and increase pain. When assessing pain in patients, the patient's own description of pain intensity is the most important.

A nurse is preparing to administer IV calcium chloride to a patient with a low serum calcium level. Which drug on the patient's medication record, administered concurrently, would require additional patient monitoring by the nurse? a.Digoxin [Lanoxin] b.Furosemide [Lasix] c.Lorazepam [Ativan] d.Pantoprazole [Protonix]

ANS: A Parenteral calcium may cause severe bradycardia in patients taking digoxin; therefore, the heart rate should be monitored closely. Concurrent administration of calcium chloride and pantoprazole, lorazepam, or furosemide is not known to lead to drug interactions.

A patient will receive buprenorphine [Butrans] as a transdermal patch for pain. What is important to teach this patient about the use of this drug? a. Avoid prolonged exposure to the sun. b. Cleanse the site with soap or alcohol. c. Remove the patch daily at bedtime. d. Remove hair by shaving before applying the patch.

ANS: A Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

A patient who has developed opioid tolerance will experience which effect? a. Decreased analgesic effect b. Decreased constipation c. Increased euphoria d. Increased respiratory depression

ANS: A Patients who develop tolerance to opioids will develop tolerance to its analgesic, euphoric, and sedative effects and will also develop tolerance to respiratory depression. Very little tolerance develops to constipation.

A patient has begun taking phenobarbital after experiencing several seizures and is currently receiving 60 mg PO twice daily. After two weeks of therapy, the patient has a serum drug level of 30 mcg/mL and reports feeling drowsy much of the day. What will the nurse tell this patient? a. "I will contact your provider to discuss changing your dosing to once daily to minimize the drowsiness." b. "The drug level is low and you may need a higher dose, but taking it three times daily will reduce the drowsiness." c. "This side effect is expected and should decrease over time. You should avoid driving in the meantime." d. "Your lab work shows a higher than normal level of the drug and your provider will probably lower your dose."

ANS: A Phenobarbital has a long half-life and may be given once daily at bedtime to help manage its sedative effects. The serum drug level is within the normal range of 15 to 40 mcg/mL, so the dose does not need to be adjusted. Increasing the dose and the frequency is not necessary since the drug levels are therapeutic and scheduling the drug to three times daily will compound the sedative effects. The sedative side effects do not increase over time.

A nurse is discussing the administration of an intravenous infusion of rituximab (Rituxan) with a nursing student. Which statement by the student indicates a need for further education about the care of a patient receiving this drug? a."Angioedema and hypersensitivity may occur, but they are usually self-limiting and mild." b."I should be prepared to administer epinephrine, glucocorticoids, and oxygen if needed." c."I will administer an antihistamine and acetaminophen before beginning the infusion." d."I will monitor this patient's blood pressure, respiratory rate, and oxygen saturation closely."

ANS: A Rituximab can cause severe infusion-related hypersensitivity reactions. Nurses should be prepared to administer epinephrine, steroids, and O2 if needed. Antihistamines and acetaminophen are given before infusion. Close monitoring of vital signs and oxygenation are indicated.

A patient with severe glucocorticoid-induced osteoporosis will start therapy with teriparatide [Forteo]. What will the nurse expect to administer? a.20 mcg once daily subQ b.20 mcg twice daily subQ c.10 mcg once daily subQ d.10 mcg twice daily subQ

ANS: A The dose of teriparatide for all indications is 20 mcg once daily subQ.

A nurse is preparing a pediatric patient for surgery and is teaching the patient and the child's parents about the use of the patient-controlled analgesia pump. The parents voice concern about their child receiving an overdose of morphine. What will the nurse do? a. Instruct the parents not to activate the device when their child is sleeping. b. Reassure the parents that drug overdose is not possible with PCA. c. Suggest that the child use the PCA sparingly. d. Tell the patient that the pump can be programmed for PRN dosing only.

ANS: A The nurse should instruct parents not to activate the PCA when their child is sleeping because that can lead to drug overdose. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

A patient shows loss of consciousness, jaw clenching, contraction and relaxation of muscle groups, and periods of cyanosis. The nurse correctly identifies this as which type of seizure? a. Tonic-clonic b. Petit mal c. Myoclonic d. Atonic

ANS: A Tonic-clonic seizures (or grand mal seizures) are considered generalized seizures and are manifested by a loss of consciousness, jaw clenching, muscle relaxation alternating with muscle contractions, and periods of cyanosis. Absence seizures (or petit mal seizures) are characterized by loss of consciousness for a brief period and usually involve eye blinking and staring into space. Myoclonic seizures consist of sudden contractions that may be limited to one limb or may involve the entire body. Atonic seizures are characterized by sudden loss of muscle tone.

A patient asks the nurse what can be given to alleviate severe, chronic pain of several months' duration. The patient has been taking oxycodone [OxyContin] and states that it is no longer effective. The nurse will suggest discussing which medication with the provider? a. Fentanyl [Duragesic] transdermal patch b. Hydrocodone [Vicodin] PO c. Meperidine [Demerol] PO d. Pentazocine [Talwin] PO

ANS: A Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

A nurse is discussing the role of vitamin D in calcium regulation with a nursing student. Which statement by the student indicates a need for further teaching? a."Adequate amounts of vitamin D occur naturally in the diet." b."Vitamin D3 is preferred over vitamin D2." c."Vitamin D can promote bone decalcification." d."Vitamin D increases the absorption of calcium and phosphorus from the intestine."

ANS: A Vitamin D does not occur naturally in the diet. Adequate amounts are gained through fortified foods, supplements, and exposure to sunlight. Vitamin D3 is preferred. If calcium intake is not sufficient, vitamin D can promote bone decalcification. Vitamin D acts to increase the absorption of calcium and phosphorus from the intestine.

A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.) a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids c. Monitoring the patient's blood pressure closely for hypertension d. Palpating the patient's lower abdomen every 4 to 6 hours e. Requesting an order for methylnaltrexone [Relistor] to prevent constipation

ANS: A, B, D Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient's abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

Which side effects are more common in second-generation antipsychotic medications than in first-generation antipsychotic medications? (Select all that apply.) a. Agranulocytosis b. Anticholinergic effects c. Extrapyramidal symptoms d. Metabolism by CYP3A4 e. Prolactin elevation

ANS: A, B, D SGAs are more likely than FGAs to cause agranulocytosis and anticholinergic effects and are metabolized by CYP3A4 enzymes. They are not more likely to cause extrapyramidal effects or prolactin elevation.

A parent reports being afraid that a child may have schizophrenia because of disorganized speech and asocial behaviors. The nurse will tell this parent that which of the following must also be present to make a diagnosis? (Select all that apply.) a. A decrease in self-care, job, or school function b. A history of substance abuse c. A 1-month duration of active phase symptoms d. Continuous signs of disturbance for longer than 6 months e. The presence of manic episodes

ANS: A, C, D Patients must have at least two symptoms with 1-month duration of active symptoms. One symptom must be delusions, hallucinations, or disordered speech. Patients must have continuous signs of disturbance for longer than 6 months. A history of substance abuse and manic episodes are not associated with schizophrenia.

Which drugs are approved for treating osteoporosis in men? (Select all that apply.) a.Alendronate [Fosamax] b.Calcitonin c.Raloxifene [Evista] d.Teriparatide [Forteo] e.Zoledronate [Reclast]

ANS: A, D, E Only five drugs have been approved to treat osteoporosis in men, including alendronate, teriparatide, and zoledronate. Calcitonin has been tried, but without proof of efficacy. Raloxifene is a SERM, used in women only.

A patient with cancer is admitted to the hospital. The nurse obtains an admission history and learns that the patient has been taking oxycodone and a nonsteroidal anti-inflammatory drug (NSAID) for a year. The patient reports a recent increase in the intensity of pain, along with a new pain described as "burning" and "shooting." The nurse anticipates that the prescriber will order:

ANS: B As pain increases in severity, more powerful opioids should be used. This patient has been taking oxycodone, which is a moderate-strength opioid; fentanyl is stronger. Because the pain is chronic and is now severe and because the patient has opioid tolerance, a transdermal patch may be used. Long-term use of NSAIDs is not recommended because of the risk of thrombotic events. The patient also is describing neuropathic pain, which can be treated with an adjuvant analgesic. Fixed-dose combination drugs are not recommended for increasing pain. NSAIDs are not recommended long term. Intramuscular medications are not recommended because of the pain associated with administration.

A patient is to begin taking phenytoin [Dilantin] for seizures. The patient tells the nurse that she is taking oral contraceptives. What will the nurse tell the patient? a. She may need to increase her dose of phenytoin while taking oral contraceptives. b. She should consider a different form of birth control while taking phenytoin. c. She should remain on oral contraceptives, because phenytoin causes birth defects. d. She should stop taking oral contraceptives, because they reduce the effectiveness of phenytoin.

ANS: B Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient's dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.

4. A patient who will begin taking colchicine for gout reports taking nonsteroidal anti-inflammatory drugs, simvastatin, amoxicillin, and digoxin. What will the nurse do? a. Contact the provider to discuss using a different antibiotic while this patient is taking colchicine. b. Notify the provider about the potential risk of muscle injury when simvastatin is taken with colchicine. c. Request an order for cardiorespiratory monitoring, because the patient is taking digoxin. d. Suggest that the nonsteroidal anti-inflammatory drugs (NSAIDs) be withdrawn during colchicine therapy.

ANS: B Colchicine can cause rhabdomyolysis, and this risk is increased in patients who also take simvastatin or other statin drugs. Amoxicillin does not interact with colchicine. The side effects of digoxin are not increased by concurrent use with colchicine. NSAIDs can safely be taken with colchicine.

1. A patient who is hospitalized for an acute gout attack has received several doses of hourly oral colchicine but still reports moderate to severe pain. As the nurse prepares to administer the next dose, the patient begins vomiting. What will the nurse do? a. Contact the provider to discuss giving a lower dose of colchicine. b. Hold the medication and notify the prescriber. c. Explain that this is a common side effect that will soon stop. d. Request an order for an antiemetic so that the next dose of colchicine may be given.

ANS: B Colchicine should be discontinued immediately, regardless of the status of the joint pain, if gastrointestinal (GI) symptoms occur. The patient's symptoms indicate injury to the GI endothelium. Once damage begins to occur, lowering the dose is not indicated. GI toxicity will not abate over time. An antiemetic may be useful for stopping the vomiting; however, continued administration of the drug can lead to further damage to the GI endothelium.

A patient who has been diagnosed with rheumatoid arthritis (RA) for 1 month and has generalized symptoms is taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) and an oral glucocorticoid. The provider has ordered methotrexate [Rheumatrex]. The patient asks the nurse why methotrexate is necessary since pain and swelling have been well controlled with the other medications. The nurse will tell the patient that: a.a methotrexate regimen can reduce overall costs and side effects of treatment. b.starting methotrexate early can help delay joint degeneration. c.starting methotrexate now will help increase life expectancy. d.with methotrexate, doses of NSAIDs can be reduced to less toxic levels. .

ANS: B Current guidelines for treatment of RA recommend starting a disease-modifying antirheumatic drug (DMARD) early—within 3 months of diagnosis for most patients—in order to delay joint degeneration. Methotrexate may take up to 3 to 6 weeks to be at therapeutic levels, so NSAIDs and glucocorticoids should be continued until this occurs. Methotrexate is expensive and has more toxic side effects. Patients taking methotrexate have been shown in some data to have decreased life expectancy. Patients may eventually be able to stop taking NSAIDs altogether

An 8-year-old child with advanced cancer has an order for oxycodone [OxyContin] PO, PRN for moderate to severe pain. The nurse notes that the child is constantly playing computer games and repeatedly denies having pain. What will the nurse do? a. Administer the oxycodone at regular intervals around the clock. b. Contact the provider to discuss using patient-controlled analgesia (PCA). c. Reassure the child's parent that the child will ask for pain medication as needed. d. Tell the child to notify the nurse when pain is present.

ANS: B For a number of reasons, even children who can verbalize pain correctly often underreport it. The child may fear that reporting pain may lead to painful procedures or may worry caregivers, or the child may be unaware that pain can be alleviated. Children involved in activities such as computer games may actually be using the activity to distract themselves from the pain, so such an activity is not an indication that the child is comfortable. This child has advanced cancer and is likely to have severe pain. A PCA device would give the child control and provide adequate pain relief. The oxycodone order is for PRN dosing, so the nurse cannot administer it around the clock without a prescriber's order to do so. Also, because this child is more likely to have severe pain, a PCA would be more effective. Reassuring the parent that the child will report pain and asking the child to report pain do not take into account the fact that children often hide pain for the reasons previously mentioned.

A nurse is caring for a patient who has been taking an antiepileptic drug for several weeks. The nurse asks the patient if the therapy is effective. The patient reports little change in seizure frequency. What will the nurse do? a. Ask the patient to complete a seizure frequency chart for the past few weeks. b. Contact the provider to request an order for serum drug levels. c. Reinforce the need to take the medications as prescribed. d. Request an order to increase the dose of the antiepileptic drug.

ANS: B If medication therapy is not effective, it is important to measure serum drug levels of the medication to determine whether therapeutic levels have been reached and to help monitor patient compliance. Patients should be asked at the beginning of therapy to keep a seizure frequency chart to help deepen their involvement in therapy; asking for historical information is not helpful. Until it is determined that the patient is not complying, the nurse should not reinforce the need to take the medication. Until the drug level is known, increasing the dose is not indicated.

A patient is taking hydrocodone and ibuprofen for cancer pain and is admitted to the hospital for chemotherapy. The nurse anticipates that the prescriber will ____ ibuprofen. a. reduce the dose of b. discontinue the c. increase the dose of d. order aspirin (ASA) instead of

ANS: B NSAIDs are contraindicated in patients undergoing chemotherapy because of decreased platelet production caused by bone marrow suppression. Any NSAID further increases the risk of bruising and bleeding. ASA is especially dangerous, because it causes irreversible inhibition of platelet aggregation. Ibuprofen should be discontinued, not reduced or increased.

A patient who has diabetes mellitus is diagnosed with schizophrenia and the provider orders thioridazine. The patient asks the nurse why the provider hasn't ordered olanzapine [Zyprexa], which the patient has seen advertised on television. Which response by the nurse is the most important reason that this patient is not receiving olanzapine? a. "Olanzapine is more expensive than thioridazine." b. "Olanzapine causes more metabolic side effects than thioridazine." c. "Thioridazine has fewer side effects than olanzapine." d. "Thioridazine has a faster onset of action than olanzapine."

ANS: B Olanzapine is an SGA and, although it has fewer extrapyramidal side effects than the FGA the provider has ordered, it has an increased risk of metabolic side effects, which is contraindicated in patients with diabetes. It is more expensive, but this is not the most important reason for not prescribing it. Thioridazine has more side effects than olanzapine, but the side effects caused by olanzapine are more critical for this patient. Thioridazine does not have a faster onset of action.

A patient in whom drug therapy has failed several times in the past is readmitted to a hospital to begin therapy for schizophrenia. What will the nurse do to help improve adherence? a. Encourage the patient to take responsibility for medication management. b. Teach the patient about drug side effects and how to manage them. c. Tell the patient that an abstinence syndrome will occur if the drug is stopped. d. Tell the patient that the drug may be taken as needed to control symptoms.

ANS: B One way to promote adherence to a medication regimen is to teach patients about drug side effects and how to minimize undesired responses. Family members should be encouraged to oversee medication management for outpatients, because patients themselves may fail to appreciate the need for therapy or may be unwilling to take prescribed medications. It is not true that an abstinence syndrome occurs when these drugs are withdrawn. These drugs are not used PRN; they must be given on a regular basis.

A patient with moderate to severe chronic pain has been taking oxycodone [OxyContin] 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss: a. administering a combination opioid analgesic/acetaminophen preparation. b. changing the medication to a continued-release preparation. c. confronting the patient about drug-seeking behaviors. d. withdrawing the medication, because physical dependence has occurred.

ANS: B Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

A patient who has cancer asks the nurse about using acupuncture to manage cancer pain. What will the nurse tell this patient? a. "Acupuncture is not an effective treatment for cancer pain and should not be used." b. "Studies to date do not clearly indicate effectiveness of acupuncture for alleviating cancer pain." c. "Transcutaneous electrical nerve stimulation (TENS) has been shown to be more effective than acupuncture." d. "There is good evidence to suggest that acupuncture is an effective adjunct treatment for cancer pain."

ANS: B Studies regarding acupuncture for treatment for cancer pain have been few and not well designed, so there is insufficient evidence to support its use. However, there have not been definitive studies showing that it does not work. TENS has not been well-studied, so findings about its use are inconclusive.

A patient who takes teriparatide [Forteo] administers it subcutaneouslywith a prefilled pen injector. The patient asks why she must use a new pen every 28 dayswhen there are doses left in the syringe. Which is the correct response by the nurse? a."Go ahead and use the remaining drug; I know it is so expensive." b."The drug may not be stable after 28 days." c."You are probably not giving the drug accurately." d."You should be giving the drug more frequently.

ANS: B Teriparatide is supplied in 3-mL injectors. The pen should be stored in the refrigerator and discarded after 28 days, even if some drug remains in the syringe. Although the drug is expensive, it is not correct to use what is in the syringe after 28 days. Drug may be left in the syringe even with correct dosing.

A nurse and a nursing student are discussing the plan of care for a patient with schizophrenia. The patient, who has been taking a high-potency FGA for 2 months, has become restless and constantly needs to be in motion. Which statement by the student indicates a need for further education? a. "Anticholinergic medications may help control these symptoms." b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA." c. "The provider may try a low-potency FGA instead of the high-potency FGA." d. "This patient may need to take a benzodiazepine or a beta blocker."

ANS: B The patient is showing signs of akathisia, which can resemble an exacerbation of psychosis. If the two are confused and the provider orders more of the FGA, the symptoms may actually increase. Anticholinergic medications may be used, a low-potency FGA may be ordered, or a benzodiazepine or beta blocker may be prescribed.

A patient who is taking a first-generation antipsychotic (FGA) drug for schizophrenia comes to the clinic for evaluation. The nurse observes that the patient has a shuffling gait and mild tremors. The nurse will ask the patient's provider about which course of action? a. Administering a direct dopamine antagonist b. Giving an anticholinergic medication c. Increasing the dose of the antipsychotic drug d. Switching to a second-generation antipsychotic drug

ANS: B The patient is showing signs of parkinsonism, an extrapyramidal effect associated with antipsychotic medications. Anticholinergic medications are indicated. A direct dopamine antagonist would counter the effects of the antipsychotic and remove any beneficial effect it has. Increasing the dose of the antipsychotic medication would only worsen the extrapyramidal symptoms. A second-generation antipsychotic medication may be used if parkinsonism is severe, since the risk of parkinsonism is lower than with the FGAs. This patient is exhibiting mild symptoms, so this is not necessary at this point.

A nursing student caring for a patient with cancer tells the nurse that the patient seems to be exaggerating when reporting the degree of pain. Which statement by the nurse is an appropriate response to this concern? a. "Evaluation of the patient's vital signs can help you tell if this patient is exaggerating." b. "It is important to give pain medication as ordered for the degree of pain the patient reports." c. "We may need to evaluate the patient for the development of metastasis or infection." d. "You should monitor this patient's behavior and facial expressions for a more accurate assessment."

ANS: B The patient's description of his or her pain is the cornerstone of assessment. Pain is a personal experience, and caregivers must act on what the patient says, even if they suspect the patient is exaggerating or not telling the truth. Evaluation of vital signs can be used to monitor responses to pain medication, as can assessments of behaviors and facial expressions, but they are not determinants of the level of pain in initial assessments. Patients with pain in new locations should be evaluated for metastases or infection or other causes.

A nurse is assessing a patient who becomes motionless and seems to stare at the wall and then experiences about 60 seconds of lip smacking and hand wringing. What should the nurse do? a. Ask the patient about a history of absence seizures. b. Contact the provider to report symptoms of a complex partial seizure. c. Notify the provider that the patient has had a grand mal seizure. d. Request an order for intravenous diazepam [Valium] to treat status epilepticus.

ANS: B This patient showed signs of a complex partial seizure, characterized by impaired consciousness beginning with a period of motionlessness with a fixed gaze, followed by a period of automatism. The entire episode generally lasts 45 to 90 seconds. Absence seizures are characterized by loss of consciousness for a brief period (about 10 to 30 seconds) and may involve mild, symmetric motor activity or no motor signs. A grand mal seizure is characterized by jaw clenching and rigidity followed by alternating muscle relaxation and contraction and then periods of cyanosis, all with a loss of consciousness. Status epilepticus is a seizure that persists for 30 minutes or longer.

A nurse provides teaching for a woman who will begin taking supplemental calcium. Which statement by the woman indicates understanding of the teaching? a."Chewable calcium tablets are not absorbed well and are not recommended." b."I should not take more than 600 mg of calcium at one time." c."I should take enough supplemental calcium to provide my total daily requirements." d."If I take calcium with green, leafy vegetables, it will increase absorption."

ANS: B To help ensure adequate absorption of calcium, no more than 600 mg should be consumed at one time. Chewable calcium tablets are recommended because of their more consistent bioavailability. The amount of supplemental calcium should be enough to compensate for what is not consumed in the diet and should not constitute the total amount needed per day. Green, leafy vegetables reduce the absorption of calcium.

A patient who has been taking phenobarbital for epilepsy begins taking valproic acid [Depakote] as adjunct therapy. The nurse notes that the patient is very drowsy. What will the nurse do? a. Explain to the patient that tolerance to sedation eventually will develop. b. Notify the prescriber, and request an order to reduce the dose of phenobarbital. c. Notify the prescriber of the need to increase the dose of valproic acid. d. Request an order for liver function tests to monitor for hepatotoxicity.

ANS: B Valproic acid competes with phenobarbital for drug-metabolizing enzymes and can increase plasma levels of phenobarbital by approximately 40%. When this combination is used, the dose of phenobarbital should be reduced. Increasing the dose of valproic acid would compound the problem. Patients taking phenobarbital alone experience sedation, which diminishes as tolerance develops. Liver toxicity is a rare adverse effect of valproic acid and is marked by symptoms of nausea, vomiting, and malaise, not drowsiness.

A 65-year-old female patient tells a nurse that she has begun taking calcium supplements. The nurse learns that the patient consumes two servings of dairy products and takes 1200 mg in calcium supplements each day. The patient's serum calcium level is 11.1 mg/dL. What will the nurse tell this patient? a.She should increase her dietary calcium in addition to the supplements b.The amount of calcium she takes increases her risk for heart attack and stroke c.To continue taking 1200 mg of calcium supplement since she is over age 50 d.To supplement her calcium with 10,000 units of vitamin D each day

ANS: B Women older than 50 years need 1200 mg of calcium per day. Patients should take only enough supplemental calcium to make up for the difference between what the diet provides and the RDA. This patient is getting 1800 mg/day. Excess supplemental calcium can increase risks for vascular calcification, MI, stroke, and kidney stones. She does not need to increase calcium intake. Supplementing with 10,000 units of vitamin D is indicated for documented vitamin D deficiency, which is not evident in this case.

Which nonpharmacologic therapies are effective in reducing cancer pain? (Select all that apply.) a. Acupuncture b. Cold c. Exercise d. Heat e. Transcutaneous electrical nerve stimulation (TENS)

ANS: B, C, D Cold, heat, and exercise have been shown to reduce pain. Acupuncture and TENS have not been demonstrated to be effective, although in theory they should work.

Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.) a. Biliary colic b. Cough suppression c. Suppression of bowel motility d. Urinary retention e. Vasodilation

ANS: B, C, E Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

Over time, patients taking opioid analgesics develop tolerance to which side effects? (Select all that apply.) a. Constipation b. Euphoria c. Physical dependence d. Respiratory depression e. Sedation

ANS: B, D, E With continuous use, tolerance develops to most side effects of opioids, except to constipation and physical dependence.

A child who has juvenile idiopathic arthritis and who has been taking methotrexate [Rheumatrex] will begin a course of abatacept [Orencia]. What will the nurse include when teaching the child's family about this drug? a.That abatacept and methotrexate must both be taken to be effective b.To continue getting vaccinations during therapy with abatacept c.That signs of infection may warrant immediate discontinuation of abatacept d.That a tumor necrosis factor (TNF) antagonist may be added if this therapy is not effective

ANS: C Abatacept suppresses immune function and can increase the risk of serious infection. Parents should report any signs of infection, which may warrant discontinuation of abatacept. Abatacept may be taken alone. Abatacept may blunt the effectiveness of vaccines, and vaccines should be up-to-date prior to therapy and may need to be delayed until 3 months after therapy. Live vaccines should be avoided. Abatacept should not be given with TNF antagonists because of the increased risk of serious infections.

A patient who has developed postmenopausal osteoporosis will begin taking alendronate [Fosamax]. The nurse will teach this patient to take the drug: a.at bedtime to minimize adverse effects. b.for a maximum of 1 to 2 years. c.while sitting upright with plenty of water. d.with coffee or orange juice to increase absorption.

ANS: C Alendronate can cause esophagitis, and this risk can be minimized if the patient takes the drug with water while in an upright position. Taking the drug at bedtime is not indicated. The drug may be taken up to 5 years before re-evaluation is indicated. Coffee and orange juice reduce the absorption of alendronate and should be delayed for 30 minutes after taking the drug

A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol [Haldol] and finds the patient having facial spasms. The patient's head is thrust back, and the patient is unable to speak. What will the nurse do? a. Administer the haloperidol as ordered. b. Discuss increasing the haloperidol dose with the provider. c. Request an order to give diphenhydramine. d. Request an order to give levodopa.

ANS: C An early reaction to antipsychotic drugs is acute dystonia. Initial treatment consists of an anticholinergic medication, such as diphenhydramine. Administering more antipsychotic medication would increase the symptoms and could be life threatening. Levodopa is not given for extrapyramidal symptoms, because it could counteract the beneficial effects of antipsychotic treatment.

A patient who has had cancer for 1 year uses a fentanyl transdermal patch for pain relief. The patient reports having three or four episodes of pain (which she rates as 8 or 9 on a scale of 1 to 10) each day, and each episode lasts 15 to 30 minutes. The nurse will contact the provider to: a. discuss the use of an adjuvant analgesic. b. request an order for an NSAID. c. request a strong, short-acting opioid PRN. d. suggest increasing the dose of fentanyl.

ANS: C Breakthrough pain can occur in patients who otherwise have well-controlled pain, and it should be managed with extra doses of short-acting, strong opioids. This pain is moderate to severe and is not neuropathic, so adjuvant analgesics or NSAIDs are not useful. Increasing the dose of the long-acting opioid would not alleviate breakthrough pain.

A patient with cancer who has been receiving an opioid analgesic reports having pain at a new location even though the previous pain is well controlled. The nurse will contact the provider to discuss: a. breakthrough pain. b. drug-seeking behavior. c. infection or metastasis. d. tolerance to drug therapy.

ANS: C Caregivers should be alert for new pain; this usually results from a new cause, such as metastasis, infection, or fracture, and should be investigated. Breakthrough pain is pain that occurs even when adequate levels of analgesics are given. Drug-seeking behavior refers to patients who use drugs for euphoric effects instead of for intended effects. Tolerance occurs when more drug is required to receive the same effect.

A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine [Clozaril]. The nurse teaches the family about the medication and its side effects. Which statement by a family member indicates a need for further teaching about this drug? a. "Blood counts are necessary for several weeks after discontinuation of the drug." b. "Fever, sore throat, and sores in the mouth should be reported immediately." c. "If the ANC is less than 3000, the drug will be discontinued permanently." d. "Use of this drug requires weekly evaluation of blood work."

ANS: C Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal of the drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported immediately.

A patient will begin taking etanercept [Enbrel] for severe rheumatoid arthritis. The patient has been taking methotrexate [Rheumatrex]. The patient asks if the etanercept is stronger than the methotrexate. The nurse will tell the patient that etanercept ____ methotrexate. a.has synergistic effects with b.helps reduce adverse effects associated with c.is better at delaying progression of joint damage than d.has fewer adverse effects than

ANS: C Etanercept has been shown to reduce symptoms in patients with moderate to severe RA who have not responded to methotrexate. It does not have synergistic effects with methotrexate or reduce adverse effects of methotrexate. It has many adverse effects.

A child who receives valproic acid [Depakote] begins taking lamotrigine [Lamictal] because of an increase in the number of seizures. The nurse will observe this child closely for which symptom? a. Angioedema b. Hypohidrosis c. Rash d. Psychosis

ANS: C Lamotrigine can cause life-threatening rashes, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, and this risk increases with concurrent use of valproic acid. Angioedema is an adverse effect associated with pregabalin. Hypohidrosis and psychosis are associated with topiramate.

A patient with rheumatoid arthritis is taking leflunomide [Arava] and an oral contraceptive. She tells the nurse she would like to get pregnant. What will the nurse tell her? a.That leflunomide is not dangerous during the first trimester of pregnancy b.That plasma levels of leflunomide will drop rapidly when she stops taking it c.To ask her provider about an 11-day course of cholestyramine d.To stop taking leflunomide when she stops using contraception

ANS: C Leflunomide is contraindicated during pregnancy. Patients desiring pregnancy must follow a three-step protocol that includes stopping the drug, taking cholestyramine to chelate the leflunomide, and ensuring that leflunomide drug levels are below 20 mcg/L before getting pregnant. Leflunomide is teratogenic and is not safe during pregnancy. Plasma levels of leflunomide may take 2 years to drop without using cholestyramine. It is not correct to stop taking leflunomide without following the protocol.

A child is diagnosed with absence seizures, and the prescriber orders ethosuximide [Zarontin]. When teaching the child's parents about dosage adjustments for this drug, the nurse will stress the importance of: a. frequent serum drug level monitoring. b. learning as much as possible about the disorder and its treatment. c. recording the number of seizures the child has each day. d. reporting dizziness and drowsiness to the provider.

ANS: C Measurements of plasma drug levels are less important than observation of seizure activity for determining effective dosages for absence seizures, because this type of seizure is characterized by as many as several hundred occurrences a day. Keeping a chart of seizure activity is the best way to monitor drug effectiveness when treating absence seizures. Frequent drug level monitoring is important when side effects occur to ensure that drug toxicity is not occurring. Learning about the disorder is an important part of adherence. Dizziness and drowsiness are common side effects that diminish with continued use.

A patient who has biliary colic reports a pain level of 8 on a 1 to 10 pain scale with 10 being the most severe pain. The patient has an order for ibuprofen as needed for pain. Which action by the nurse is correct? a. Administer the ibuprofen as ordered. b. Contact the provider to discuss nonpharmacologic pain measures. c. Request an order for meperidine [Demerol]. d. Request an order for morphine sulfate.

ANS: C Opioids can induce spasm of the common bile duct and can cause biliary colic. For patients with existing biliary colic, morphine may intensify the pain. It is important to treat pain, however, and certain opioids, such as meperidine, which cause less smooth muscle spasm, may be given. Ibuprofen is used for mild to moderate pain and is not appropriate for this patient. Nonpharmacologic methods are appropriate when used as adjunctive therapy with an opioid.

A nurse is providing teaching to a patient newly diagnosed with partial seizures who will begin taking oxcarbazepine [Trileptal]. The patient also takes furosemide [Lasix] and digoxin [Lanoxin]. Which statement by the patient indicates understanding of the teaching? a. "I may need to increase my dose of Trileptal while taking these medications." b. "I may develop a rash and itching, but these are not considered serious." c. "I should report any nausea, drowsiness, and headache to my provider." d. "I should use salt substitutes instead of real salt while taking these drugs."

ANS: C Oxcarbazepine can cause clinically significant hyponatremia in 2.5% of patients. If oxcarbazepine is combined with other drugs that reduce sodium, the patient should be monitored. Signs of hyponatremia include nausea, drowsiness, confusion, and headache, and patients should be taught to report these symptoms. Increasing the dose of oxcarbazepine is not indicated. Rashes can indicate a serious drug reaction, and providers should be notified so that the oxcarbazepine can be withdrawn. Salt substitutes would compound the problem of hyponatremia.

A postmenopausal patient develops osteoporosis. The patient asks the nurse about medications to treat this condition. The nurse learns that the patient has a family history of breast cancer. The nurse will suggest discussing which medication with the provider? a.Estrogen estradiol b.Pamidronate [Aredia] c.Raloxifene [Evista] d.Teriparatide [Forteo]

ANS: C Raloxifene is a selective estrogen receptor modulator (SERM) that has estrogenic effects in some tissues and antiestrogenic effects in others. It can preserve bone mineral density while protecting against breast and endometrial cancers. Estrogen promotes breast cancer and would not be indicated. Pamidronate and teriparatide are not protective against breast cancer.

A patient with schizophrenia receives a dose of risperidone [Risperdal Consta] IM. The nurse teaching this patient about this medication will make which statement? a. "You will experience therapeutic levels of this drug in 1 to 2 weeks." b. "You will need injections of this drug every 6 weeks." c. "You will need to take an oral antipsychotic drug for 3 weeks." d. "You probably will not have extrapyramidal symptoms with this drug."

ANS: C Risperidone given intramuscularly is a depot preparation used for long-term therapy. Significant release of the drug does not occur until 2 to 3 weeks after injection; therefore, patients must take an oral antipsychotic medication until drug levels are raised. Therapeutic levels are reached 4 to 6 weeks after injection. Patients need injections every 2 weeks. With IM dosing, the incidence of extrapyramidal symptoms is substantial.

A patient has severe Paget's disease of the bone. The patient asks the nurse what can be done to alleviate the pain. The nurse will suggest that the patient discuss the use of which medication with the provider? a.Alendronate [Fosamax] b.Calcifediol [25-Hydroxy-D3] c.Calcitonin-salmon [Miacalcin] d.Long-acting NSAIDs

ANS: C Salmon calcitonin is the drug of choice for rapid relief of pain associated with Paget's disease. Alendronate, calcifediol, and NSAIDs are not indicated.

A patient with a form of epilepsy that may have spontaneous remission has been taking an AED for a year. The patient reports being seizure free for 6 months and asks the nurse when the drug can be discontinued. What will the nurse tell the patient? a. AEDs must be taken for life to maintain remission. b. Another AED will be substituted for the current AED. c. The provider will withdraw the drug over a 6- to 12-week period. d. The patient should stop taking the AED now and restart the drug if seizures recur.

ANS: C The most important rule about withdrawing AEDs is that they should be withdrawn slowly over 6 weeks to several months to reduce the risk of status epilepticus (SE). AEDs need not be taken for life if seizures no longer occur. Substituting one AED for another to withdraw AED therapy is not recommended. Stopping an AED abruptly increases the risk of SE.

A patient who has cancer reports pain as "burning" and "shooting" alternating with feelings of numbness and coldness. The nurse will contact the provider to discuss the use of which medication? a. Acetaminophen b. Ibuprofen c. Imipramine [Tofranil] d. Oxycodone [OxyContin]

ANS: C This patient is describing neuropathic pain, which results from injury to peripheral nerves. This type of pain responds poorly to opioid analgesics but does respond to adjuvant analgesics, which include antidepressants such as imipramine. Acetaminophen and ibuprofen are used for mild nociceptive pain, and oxycodone is used for more severe nociceptive pain.

A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient? a. PRN dosing of the drug may be more effective. b. The risk of respiratory depression increases over time. c. The patient should discuss increasing the dose with the provider. d. The patient should request the addition of a benzodiazepine to augment pain relief.

ANS: C This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, because they increase the risk of oversedation.

A patient with a seizure disorder is admitted to the hospital and has a partial convulsive episode shortly after arriving on the unit. The patient has been taking phenytoin [Dilantin] 100 mg three times daily and oxcarbazepine [Trileptal] 300 mg twice daily for several years. The patient's phenytoin level is 8.6 mcg/mL, and the oxcarbazepine level is 22 mcg/mL. The nurse contacts the provider to report these levels and the seizure. What will the nurse expect the provider to order? a. A decreased dose of oxcarbazepine b. Extended-release phenytoin c. An increased dose of phenytoin d. Once-daily dosing of oxcarbazepine

ANS: C This patient's phenytoin level is low; the therapeutic range is 10 to 20 mcg/mL. An increase in the phenytoin dose is necessary. The oxcarbazepine level is within the normal range of 3 to 40 mcg/mL, so changing the dose is not necessary. Extended-release phenytoin is absorbed more slowly and would not increase this patient's serum phenytoin level. The dosing of oxcarbazepine does not need to be changed.

A woman in labor receives meperidine [Demerol] for pain. The nurse caring for the infant will observe the infant closely for: a. congenital anomalies. b. excessive crying and sneezing. c. respiratory depression. d. tremors and hyperreflexia.

ANS: C Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

A 20-kg child has been taking valproic acid [Depakote] for 1 week to treat a seizure disorder. The child is receiving 200 mg PO twice daily. The child's parents report no improvement in seizure activity. The nurse will anticipate that the provider will order which change in this child's drug regimen? a. Adding another seizure medication to supplement the valproic acid b. Changing to phenytoin [Dilantin] since the valproic acid is not effective c. Increasing the dose of valproic acid to 300 mg PO twice daily d. Increasing the dose of valproic acid to 200 mg three times daily

ANS: C Valproic acid is given initially at a dose of 5 to 15 mg/kg/day, administered in two divided doses. This child is receiving 400 mg/day, which is 10 mg/kg/day. The dosage should be increased by 5 to 10 mg/kg/day each week until optimal levels are achieved up to a maximum dose of 60 mg/kg/day. At this point, adding another AED or changing to another AED is not recommended. Increasing the dose to three times daily is not recommended.

A patient with schizophrenia has been taking an oral FGA for 1 week. The patient has been taking the drug daily in two divided doses. The individual complains of daytime drowsiness. The patient's family reports a decrease in the person's hostility and anxiety but states that the patient remains antisocial with disordered thinking. What will the nurse tell the patient and the family? a. An increased dose of the drug may be needed. b. Intramuscular dosing may be needed. c. Some symptoms take months to improve. d. The entire dose may be taken at bedtime.

ANS: C When patients begin therapy with antipsychotic medications, some symptoms resolve sooner than others. During the first week, agitation, hostility, anxiety, and tension may resolve, but other symptoms may take several months to improve. It is not necessary to increase the dose in the first week. IM dosing is indicated for patients with severe, acute schizophrenia and for long-term maintenance. Sedation is normal, and once an effective dose has been determined, the entire dose can be taken at bedtime, but not in the initial days of therapy.

A 55-year-old female patient asks a nurse about calcium supplements. The nurse learns that the patient consumes two servings of dairy products each day. The patient's serum calcium level is 9.5 mg/dL. The serum vitamin D level is 18 ng/mL. The nurse will recommend adding ____ daily and ____ IU of vitamin D3 each day. a.1200 mg of calcium once; 10,000 b.1500 mg of calcium twice; 1000 c.600 mg of calcium once; 10,000 d.600 mg of calcium twice; 2000

ANS: C Women older than 50 years need 1200 mg of calcium per day. This patient is getting 600 mg/day. She should add 600 mg/day to compensate for what she does not get in her diet, because the amount of a supplement should be enough to make up the difference. Her vitamin D level is low, so she needs a vitamin D supplement. To treat deficiency, adults older than 19 years should get 10,000 IU/day. An additional intake of 1200 mg of calcium once daily is too much calcium. An additional intake of 1500 mg of calcium twice daily is too much calcium, and 1000 IU of vitamin D is not enough to treat deficiency. An additional intake of 600 mg of calcium twice daily is too much calcium, and 2000 IU of vitamin D is not sufficient to treat deficiency.

A nurse is providing teaching for a patient with osteoporosis who has just switched from alendronate [Fosamax] to zoledronate [Reclast]. Which statement by the patient indicates a need for further teaching? a."I will need to have blood tests periodically while taking this drug." b."I will only need a dose of this medication every 1 to 2 years." c."This drug is less likely to cause osteonecrosis of the jaw." d."This drug is only given intravenously."

ANS: C Zoledronate has an increased risk of osteonecrosis of the jaw, as does alendronate. The patient is correct to identify the need for periodic blood tests. Zoledronate is given only every 1 to 2 years and is given only intravenously.

A nurse in a mental health hospital finds a patient with schizophrenia who takes haloperidol [Haldol] lying rigid in bed with a temperature of 41.3°C. A cardiac monitor shows cardiac dysrhythmias. What will be included in the treatment of this patient? (Select all that apply.) a. Anticholinergic medications b. Beta blockers c. Dantrolene d. Intravenous fluids e. Withdrawal of haloperidol

ANS: C, D, E Neuroleptic malignant syndrome is characterized by "lead pipe" rigidity, sudden high fever, and autonomic instability. Treatment requires supportive measures, drug therapy, and immediate withdrawal of the antipsychotic medication. Dantrolene is used to relax muscles and reduce heat production. Intravenous fluids are used to maintain hydration. Anticholinergic medications and beta blockers are not helpful.

What are negative symptoms of schizophrenia? (Select all that apply.) a. Delusions b. Disordered thinking c. Poor judgment d. Poor self-care e. Poverty of speech

ANS: C, D, E Poor judgment, poor self-care, and poverty of speech are all negative symptoms of schizophrenia. Delusions and disordered thinking are positive symptoms.

A patient is taking alendronate [Fosamax] to treat Paget's disease. The patient asks the nurse why calcium supplements are necessary. The nurse will tell the patient that calcium supplements are necessary to: a.reduce the likelihood of atrial fibrillation. b.maximize bone resorption of calcium. c.minimize the risk of esophageal cancer. d.prevent hyperparathyroidism.

ANS: D Alendronate can induce hyperparathyroidism in patients with Paget's disease; calcium supplementation can prevent this effect. Giving calcium does not reduce the incidence of atrial fibrillation, maximize bone resorption of calcium, or minimize the risk of esophageal cancer.

5. A patient is being treated with warfarin [Coumadin] to prevent thrombus. The patient develops hyperuricemia, and the provider orders allopurinol [Zyloprim]. The nurse will contact the provider to discuss ____ the ____ dose. a.increasing; allopurinol b. increasing; warfarin c. reducing; allopurinol d. reducing; warfarin

ANS: D Allopurinol can inhibit hepatic drug-metabolizing enzymes and thus delay the inactivation of other drugs. This is a particular concern in patients taking warfarin; therefore, the warfarin dose should be reduced when allopurinol is also used. It is not correct to increase the allopurinol dose, increase the warfarin dose, or reduce the allopurinol dose.

9. A patient who has gout will begin taking febuxostat [Uloric] and colchicine. What will the nurse include when teaching this patient about this drug regimen? a. "You are taking both drugs in order to prevent hepatic side effects." b. "You may stop taking the febuxostat after your uric acid levels decrease." c. "You will have to take both drugs indefinitely to treat your symptoms." d. "You will stop taking the colchicine within 6 months after starting therapy."

ANS: D At the beginning of therapy with fevuxostat, symptoms of gout may flare, so colchicine or NSAIDS are given for up to 6 months to alleviate this. The combination does not prevent effects on the liver. The febuxostat will be given indefinitely.

A nursing student asks the nurse why the provider has ordered a combination product containing an opioid analgesic and an NSAID for a patient who has cancer. Which response by the nurse is correct? a. "There are decreased effects of NSAIDs on the GI tract when a combination product is used." b. "There are fewer adverse effects from both drugs when used in a combination product." c. "There is a decreased likelihood of opioid dependence when it is given in combination with an NSAID." d. "There is increased pain relief with the combination than when either product is used alone."

ANS: D Because the two types of drugs work by different mechanisms, use of a combination product yields greater pain relief than either agent alone. The combination does not decrease the incidence of GI effects from NSAIDs or the incidence of other adverse effects from either drug and does not decrease the likelihood of opioid dependence.

A patient who has a seizure disorder is admitted to the hospital after an increase in seizure frequency, and the prescriber orders carbamazepine [Tegretol] 100 mg twice daily to be added to the patient's medication regimen. The nurse reviewing the patient's medical history notes that the patient is already taking lamotrigine [Lamictal] 375 mg twice daily. The nurse will contact the provider to discuss which action? a. Reducing the carbamazepine dose to 50 mg twice daily b. Reducing the lamotrigine dose to 225 mg twice daily c. Increasing the carbamazepine dose to 200 mg twice daily d. Increasing the lamotrigine dose to 500 mg twice daily

ANS: D Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which lamotrigine and other drugs are metabolized; therefore, patients taking any of these drugs would need an increased dose. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.

2. A patient with gout who has increasingly frequent acute gouty attacks will begin receiving allopurinol [Zyloprim] and colchicine. The nurse will include which statement when teaching the patient about this drug regimen? a. "Allopurinol helps reduce the gastrointestinal side effects of colchicine." b. "Allopurinol reduces the likelihood of gouty episodes that usually occur with initial colchicine therapy." c. "The colchicine is given to enhance the effects of the allopurinol." d. "You will take both drugs initially and then stop taking the colchicine."

ANS: D Colchicine is used for prophylaxis when urate-lowering drugs, such as allopurinol, are initiated, because gouty episodes have a tendency to increase during this time. Patients start with both drugs, and ultimately the colchicine is withdrawn. Allopurinol does not affect the GI side effects caused by colchicine. Allopurinol may precipitate an acute gouty attack when treatment is begun; colchicine is given to prevent a gouty episode. Colchicine does not enhance the effects of allopurinol

A patient who is taking a fixed-dose combination drug with an opioid and acetaminophen for cancer pain reports increased muscular pain. The patient asks the nurse if the pain medication dose can be increased. What will the nurse tell this patient? a. An adjuvant analgesic medication will probably be used to help with this pain. b. An additional dose of acetaminophen can be used to enhance pain relief. c. Increasing the dose is possible, because there is no ceiling to opioid pain relief. d. The provider will prescribe separate dosing of the opioid and acetaminophen.

ANS: D Fixed-dose combination products are not useful as pain increases, because the side effects of the nonopioid drug become intolerable as the dosage increases. As pain becomes more severe, the components of the combined regimen should be given separately. Adjuvant analgesics are used for neuropathic pain and not nociceptive pain (which this patient has described). Acetaminophen doses should not be increased. Increasing the dose of a fixed-dose combination drug is not recommended.

A postmenopausal patient is at high risk for developing osteoporosis. The patient's prescriber orders raloxifene [Evista], and the nurse provides teaching about this drug. Which statement by the patient indicates understanding of the teaching? a."I may experience breast tenderness while taking this drug." b."I may experience fewer hot flashes while taking this drug." c."I should discontinue this drug several weeks before any surgery." d."I should walk as much as possible during long airline flights."

ANS: D Like estrogen, raloxifene increases the risk of deep vein thrombosis. Patients taking this drug should be cautioned to take walks on long flights or whenever they must sit for long periods. The drug does not increase breast tenderness or decrease hot flashes. There is no need to discontinue this drug before surgery

A patient taking an FGA medication develops severe parkinsonism and is treated with amantadine [Symmetrel]. The amantadine is withdrawn 2 months later, and the parkinsonism returns. The nurse will expect the provider to: a. give anticholinergic medications. b. make a diagnosis of idiopathic parkinsonism. c. resume the amantadine indefinitely. d. try a second-generation antipsychotic (SGA).

ANS: D Neuroleptic-induced parkinsonism is treated with some of the same drugs used for idiopathic parkinsonism, such as amantadine. If parkinsonism is severe, switching to an SGA may help, because the risk of parkinsonism is much lower with these drugs. An anticholinergic medication may be used initially. A recurrence of parkinsonism when the drug is withdrawn does not indicate idiopathic parkinsonism. These drugs should not be used indefinitely.

A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are dilated and that the patient is drowsy and lethargic. The patient's heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do? a. Discuss possible opiate dependence with the patient's provider. b. Encourage the patient to turn over and cough and take deep breaths. c. Note the effectiveness of the analgesia in the patient's chart. d. Prepare to administer naloxone and possibly ventilatory support.

ANS: D Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine [Talwin]. The nurse will monitor the patient for: a. euphoria. b. hypotension. c. respiratory depression. d. yawning and sweating.

ANS: D Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.

7. A patient with chronic gout has an acute gouty episode and is admitted to the hospital. The patient has been taking nonsteroidal anti-inflammatory drugs for several months. The prescriber plans to begin therapy with probenecid. What will the nurse do? a. Give the medication as ordered and observe the patient closely for gastrointestinal side effects. b. Request an order to lower the dose of the nonsteroidal antiinflammatory drug. c. Restrict the patient's fluid intake to minimize the risk of renal injury. d. Suggest delaying the probenecid therapy until the acute episode has subsided.

ANS: D Probenecid may exacerbate acute episodes of gout, so treatment with this drug should be delayed until the acute attack has passed. Probenecid has mild GI effects. Lowering the dose of the NSAID is not recommended. Patients should increase their fluid intake to minimize the risk of renal injury.

A nurse is teaching a group of nursing students about the differences between pure opioid agonists and agonist-antagonist opioids. Which statement by a student indicates understanding of the teaching? a. "Agonist-antagonist opioids act as agonists at mu receptors only." b. "Agonist-antagonist opioids are effective for treating cancer pain." c. "Agonist-antagonist opioids enhance the effects of pure agonists." d. "Pure agonists act as agonists at both mu receptors and kappa receptors."

ANS: D Pure agonists are agonists at mu and kappa receptors. Agonist-antagonist opioids are agonists at kappa, not mu, receptors. At mu receptors, agonist-antagonists act as antagonists. Agonist-antagonists are not recommended for treating cancer pain; because of their antagonist effect, they block access of the pure agonists to mu receptors and thus block their actions.

A patient about to begin therapy with etanercept has a positive tuberculin skin test. A chest radiograph is negative. The nurse will expect this patient to: a.begin taking antituberculosis drugs at the beginning of treatment with etanercept. b.have periodic chest radiographs during treatment with etanercept. c.have regular monitoring of symptoms to detect active tuberculosis. d.undergo tuberculosis treatment prior to beginning etanercept treatment.

ANS: D Since tuberculosis (TB) in a patient taking etanercept is often extrapulmonary and disseminated, it is important to test all patients for TB. Those who test positive for latent TB should be treated for TB before etanercept treatment is begun. It is not correct to begin TB treatment concurrently with etanercept treatment. Latent TB must be treated and not monitored.

A patient is taking an FGA for schizophrenia. The nurse notes that the patient has trouble speaking and chewing and observes slow, wormlike movements of the patient's tongue. The nurse recognizes which adverse effect in this patient? a. Acute dystonia b. Akathisia c. Parkinsonism d. Tardive dyskinesia

ANS: D Tardive dyskinesia can occur in patients during long-term therapy with FGAs. This patient shows signs of this adverse effect. Acute dystonia is characterized by severe spasm of muscles in the face, tongue, neck, or back and by opisthotonus. Akathisia is characterized by constant motion. Parkinsonism is characterized by bradykinesia, drooling, tremor, rigidity, and a shuffling gait.

A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient's arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient's pupils are dilated. The nurse recognizes these symptoms as signs of: a. a mild opioid overdose. b. decreased opioid drug levels. c. improved ventilation. d. worsening hypoxia.

ANS: D The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

3. A patient has had three gouty flare-ups in the past year. Which drug class will the nurse expect the provider to order for this patient? a. Colchicine b. Glucocorticoids c. Nonsteroidal anti-inflammatory drugs d. Urate-lowering drugs

ANS: D The provider will order a urate-lowering drug for this patient. The medication should be diluted and administered with 20 mL of sterile sodium chloride and administered over 5 minutes or longer.

A patient newly diagnosed with cancer reports having pain at a level of 7 to 8 on a scale of 10. Which type of pain management will be used initially to treat pain in this patient? a. Acetaminophen [Tylenol] b. Ibuprofen [Motrin] c. Nonpharmacologic measures d. Opioid analgesics

ANS: D Traditionally, patients have been given opioid analgesics only after a trial with nonopioids has failed. NCCN guidelines recommend selecting drugs based on pain intensity, even in newly diagnosed patients. Patients reporting pain in the 4 to 10 range should be given an opioid

A patient reports experiencing weakness, fatigue, nausea, vomiting,constipation, and nocturia. Total serum calcium is 10.5 mg/dL. A dipstick urinalysis shows a positive result for protein. When questioned, the patient reports taking vitamin D and calcium supplements. The nurse will counsel the patient to: a.reduce the amount of vitamin D and stop taking the calcium. b.discuss taking calcitonin-salmon [Fortical] with the provider. c.stop both supplements and discuss the use of a diuretic with the provider. d.stop taking vitamin D, reduce the amount of calcium, and increase the fluid intake.

ANS: D Vitamin D toxicity can occur, and early responses include the symptoms described. Patients should be counseled to stop taking vitamin D, reduce their calcium intake, and increase their fluid intake. It is not correct to reduce the vitamin D intake and the calcium intake. Calcitonin-salmon is not indicated. A diuretic is indicated when hypercalciuria is severe.