pharm final

During treatment of a patient who has breast cancer, the nurse hears the physician mention that the patient has reached the “nadir.” The nurse knows that this term means the
A. lowest level of neutrophils reached during therapy.
B. highest level of neutrophils reached during therapy.
C. point at which the adverse effects of chemotherapy will stop.
D. point at which the cytotoxic action against cancer cells is the highest.
Rationale: A; The lowest neutrophil count reached after a course of chemotherapy is known as the nadir.
Which statement is not true regarding neutropenia and cancer?
A. The lower the WBC or ANC count is, the poorer the cancer prognosis.
B. The longer the WBC or ANC is low, the higher the risk for infection.
C. Frequent temperatures are necessary with the neutropenic patient.
D. Tylenol should be avoided to prevent hiding signs of infection.
Rationale: A is not true, lower ANC counts mean higher risk for infection not poorer prognosis for cancer treatment. B is true, the longer a patient is neutropenic, the more risk of infection. C is true, temperatures are an indicator for infection. D is true, in cancer patients, fever may be the only early sign of infection.
One adverse effect of excessive immunosuppression is the development of:
A. Liver failure
B. Kidney failure
C. Myocardial infarction
D. Serious infection
D
A nurse is caring for a person undergoing antiemetic drug therapy to prevent nausea. The client reports loss of appetite because of nausea. Which of the following would the nurse implement to enhance the client’s appetite?
A. suggest consumption of milk products.
B. suggest physical exercises to the client.
C. remove items with a strong smell and odor.
D. avoid giving frequent oral rinses to the client.
C
A patient is receiving cisplatin as part of her treatment for ovarian cancer. Which nursing diagnosis is appropriate for this antineoplastic drug?
A. Ineffective tissue perfusion related to cardiotoxicity
B. Ineffective breathing pattern related to the adverse effect of pulmonary toxicity
C. Risk for injury related to effects of neurotoxicity (ataxia, numbness of hands and feet)
D. Impaired urinary elimination pattern related to hyperuricemia
Rationale: C; Risk for injury related to neurotoxicity is an appropriate nursing diagnosis specific to cisplatin. Cisplatin does not cause cardiotoxicity, hyperuricemia, or pulmonary toxicity.
When giving cisplatin, the nurse is aware that the major dose-limiting toxicity of this drug is
A. alopecia.
B. kidney damage.
C. cardiotoxicity.
D. stomatitis.
Rationale: B; Cisplatin may cause nephrotoxicity, and the patient’s renal function must be monitored closely while on this drug. Ensuring hydration will help to prevent nephrotoxicity.
The nurse is developing a plan of care for a patient who is experiencing gastrointestinal adverse effects, including anorexia and nausea, after her first course of antineoplastic therapy. What is an appropriate goal for this patient when dealing with this problem? The patient will
A. eat 3 balanced meals a day within 4 days.
B. return to her normal eating pattern within 1 month.
C. maintain her normal weight by consuming healthful snacks as tolerated.
D. maintain a diet of frequent feedings with a nutrition supplement as a snack within 2 weeks.
Rationale: D; Consuming small, frequent meals and eating slowly; consuming clear liquids; and maintaining a bland diet help to improve nutrition during antineoplastic therapy.
A patient is receiving methotrexate and is experiencing severe bone marrow suppression. The nurse will expect which intervention to be ordered with this drug to reduce this problem?
A. A transfusion of whole blood
B. leucovorin rescue
C. filgrastim (Neupogen) therapy
D. epoetin alfa (Epogen) therapy
Rationale: B; High-dose methotrexate is associated with bone marrow suppression, and it is always given in conjunction with the rescue drug leucovorin, which is an antidote for folic acid antagonists. Basically, leucovorin rescues the healthy cells from methotrexate.
The nurse is reviewing prevention-of-infection measures with a patient who is receiving antineoplastic drug therapy. Which statement by the patient, who is at risk for infection resulting from neutropenic effects of antineoplastic drug therapy, shows that he still needs further teaching about his care?
A. “I should avoid those who have recently had a vaccination.”
B. “I will eat only fresh fruits and vegetables.”
C. “I should report a sore throat, cough, or low-grade temperature.”
D. “It is important for both my family and me to practice good hand washing.”
Rationale: B. Patients who are neutropenic and susceptible to infections should adhere to a low-microbe diet by washing fresh fruits and vegetables and making sure foods are well cooked. The other options are correct.
With each of the following lab data – what would be appropriate nursing interventions?

A. Hemoglobin 7.2

B. ANC 400

C. WBC 4,000

D. Platelets 48,000.

A. Hemoglobin 7.2 Anemia.
Energy conservation strategies – space out activities and provide rest periods.
Assist with ADL’s.

B. ANC 400 severe risk for infection.
Remember WBC counts fall an absolute neutrophil count will be used to accurately portray the patient’s ability to fight infection. No fresh fruit – no raw food – no flowers – no salad – no visitors with diarrhea – no visitors with infection.

C. WBC 4,000 Patient is exhibiting normal immune response.
No special precautions except for standard universal precautions.

D. Platelets 48,000. Thromobocytopenia
The nurse needs to implement bleeding precautions and avoid shaving the patient with a metal razor, use caution with mouth care and avoid using rectal thermometers.

What advice would you give a patient that is experiencing myelosuppression, nausea or hair loss?
Myelosuppression is an expected consequence of chemotherapy. The blood counts will recover after the chemotherapy is stopped. If a patient is experiencing low WBC counts it would be advisable to avoid crowded areas like malls. It would also be advisable to eat cooked meals out and in some cases avoid areas that may be contaminated like buffets or beverage fountains.

Nausea may occur in response to the chemotherapy or in anticipation (anticipatory nausea) of chemotherapy administration. The best thing to do to prevent its occurrence is to eat mild foods and avoid strong smells. Also, eating smaller meals may help as well.

The hair grows back – in fact through months of chemo – the hair will start to grow again and may fall out again. It may be a different texture. Patients should get fitted for wigs prior to starting chemo – so that a natural look can be achieved.

To assure maximal effect from an antiemetic – it is important for the nurse to
administer the antiemetic first, 30 – 60 minutes prior to administer chemotherapy.

Rationale: Once a person begins to vomit – it is difficult to stop it.

When the nurse is preparing to administer chemotherapy, which actions would the nurse implement?
It is important for the nurse to wear special chemotherapy gloves to prevent absorption of the medication through mucus membranes. A gown and a mask may also be used to prevent exposure.

A sign should be placed on the patient’s door to protect family members and other staff from exposure to harmful excreta like urine or stool. A sign should also be placed over the toilet so that the staff will remember to double flush the toilet.

Of course universal precautions should always be used to limit exposure to bodily fluids.

A client with cancer is taking cisplatin (Platinol). What nursing intervention is essential during the course of treatment?
It is important for the nurse to assure that the client is receiving adequate hydration. Specifically with cisplatin (Platinol) causes hemorrhagic cystitis.
A patient is receiving lithium carbonate (Eskalith). While this medication is being administered, it is important that the nurse perform which of the following actions?
A. test the clients urine weekly.
B. restrict the client’s sodium intake.
C. monitor the clients blood level regularly.
D. withhold the client’s other medications for one week.
Rationale: C is correct because lithium levels are typically checked more often when the patient starts lithium. A is incorrect because lithium levels are not measured with urine testing. B is incorrect because patients taking lithium actually need adequate amounts of sodium to keep their lithium level safe and not toxic. Remember with low sodium levels your body preserves lithium in an attempt to keep sodium levels normal. D is correct and this is not a nursing action to withhold all other drugs for one week.
The nurse is assessing a patient’s plasma level of lithium carbonate. The nurse notes that the lithium blood level is 1.8 mEq/L. At this time the nurse would:
A. Continue the usual dose of lithium and note any adverse reactions
B. Discontinue the drug until the lithium serum level drops to 0.5 mEq/L
C. ask the physician to increase the dose of lithium because the blood lithium level is too low.
D. hold the drug and notify the physician because the blood lithium level may be toxic.
Rationale: D is correct because this lithium level is toxic. A is incorrect because the nurse would not continue a medication with an obviously high level. C is incorrect because this level is to high, so it would not make this suggestion. D is incorrect; there are two cues as to why D is incorrect. First nurses would not discontinue a medication and secondly, 0.5 mEq/L is much too low for a lithium level.
To quickly reverse the sedative effects of benzodiazepines, the nurse would anticipate administering
A. Naloxone (Narcan)
B. Methadone
C. Flumazenil (Romazicon)
D. Chlorpromazine
C
A patient with fibromyalgia is starting amitriptyline hydrochloride (Elavil) and the nurse is providing medication instructions. Which statement by the patient indicates that teaching has been effective?
A. “It’s important for me to avoid cheese products.”
B. “This medicine can be taken as needed for pain relief.”
C. “This medication may make it hard for me to fall asleep.”
D. “I can chew sugarless gum if my mouth feels dry.”
D
Rationale: this tricyclic antidepressant can cause anticholinergic effects
The lithium level in a client taking lithium carbonate (Lithium) is 2.3 mEq/L. In light of this findings, which assessment finding would the nurse expect to note in the client based on this laboratory value?
A. Flaccidity
B. Constipation
C. Stable mood
D. Blurry vision
The nurse is devising a care plan for a patient with schizophrenia. Which of the following is not an appropriate goal for a patient receiving antipsychotics?
A. The client will not hit other patients.
B. The client will not call out to visual hallucinations.
C. The client will participate in unit activities.
D. The client will express interest in hobbies.
E. The client will state they feel less depressed.
A,B
Rationale: Antipsychotic drugs in schizophrenia are most useful at decreasing positive symptoms, and at reducing acute delusions, and hallucinations. C, D, and E are not appropriate goals.
The nurse is caring for a patient receiving imipramine (Tofranil). Which of the following actions would the nurse perform?
A. assess for slowed respirations.
B. advise the patient not to eat cheddar cheese.
C. instruct the patient to assess for vision changes.
D. assess for signs of tolerance.
Rationale: C is correct because glaucoma may occur (this is an anticholinergic adverse effect). A is not correct because tricyclic antidepressants do not slow respirations. B is not correct because aged cheeses react with MAO inhibitors not tricyclics. D is not correct because patients do not develop tolerance to tricyclic antidepressants.
A nurse is evaluating the medications for a group of patients on a psychiatric unit. Which of the following medications will the nurse need a blood level on?
A. Lorazepam (Ativan)
B. Sertraline (Zoloft)
C. Valproic acid (Depakote)
D. Risperidone (Risperdol)
Rationale: A is incorrect because the presence of benzodiazepines is only checked in the event of unexplained signs and symptoms or overdose typically seen in an emergency department or in the setting of a motor vehicle accident. B and D are incorrect because routine levels of these drugs are not monitored
Lorazepam (Ativan) has been prescribed for a client for management of anxiety. Which finding in the client history would indicate the nurse the need to confer with the healthcare provider before administering this medication?
A. Diabetes
B. Coronary artery disease
C. Hypothyroidism
D. Narrow angle glaucoma
D
A nurse assesses a client hospitalized with schizophrenia for whom risperidone (Risperdal) has been prescribed. Which laboratory test result should the nurse check before administering the first dose of this medication?
A. Platelet count
B. Liver function tests
C. Clotting studies
D. International normalized ratio (INR)
B
A client with diabetes who has been taking lithium (Eskalith) and furosemide (Lasix). Which is the major concern for this drug combination?
A. Respiratory depression
B. Intensification of action
C. Increased danger of lithium toxicity
D. Decreased action of both drugs
Rationale: C is correct because any situation that would cause a sodium level to decrease may cause lithium toxicity. In situations of hyponatremia, lithium is conserved by the body (not eliminated) in an attempt to maintain homeostasis; thus lithium is retained by the body.
A client is started on tranylcypromine (Parnate). After noticing that the client became dizzy after assisting them to ambulate, the nurse assesses for other signs of adverse effects including
A. Dry mouth an constipation
B. Uncoordinated movement of extremities and tremors
C. Minimal use of nonverbal expression
D. Flat affect and reluctance to converse
Rationale: A is incorrect because these are signs and symptoms of anticholinergic effects. C is incorrect because these may be clinical features of depression and not indicate any signs of adverse effects. D is incorrect because these are signs and symptoms of schizophrenia.
Which of the following is considered a late appearing, potentially irreversible extrapyramidal symptom?
A. Acute dystonia
B. Ptosis
C. Tardive dyskinesia
D. Hyporeflexia
Rationale: C is correct because when these movement disorders occur they may be irreversible. Movements such as lip smacking, jaw movements, tongue protruding (sticking in and out of the mouth) and head bobbing are all considered extrapyramidal symptoms. A is incorrect because it happens early with use of traditional antipsychotics like haloperidol. B and D are incorrect because they are not extrapyramidal symptoms.
The physician orders imipramine (Tofranil) for a client. An appropriate nursing action when administering this drug is to
A. Avoid administering narcotics with this drug
B. Warn the client not to eat cheddar cheese
C. Observe the client for increased tolerance so that the level can be maintained
D. Instruct the client to be alert of signs an symptoms of glaucoma
Rationale: D is correct because glaucoma may occur (this is an anticholinergic adverse effect). A is not correct because there opioids do not impact tricyclic antidepressants. B is not correct because aged cheeses react with MAO inhibitors not tricyclics. C is not correct because patients do not develop tolerance to tricyclic antidepressants.
The psychiatric facility is having a holiday party on the unit. Several families have brought in food items to share with hospitalized patient. It would be a priority for the nurse to evaluate the food items if the client was taking which of the following medications?
A. sertraline (Zoloft)
B. phenelzine (Nardil)
C. bupropion (Wellbutrin)
D. lithium (Eskalith)
Rationale: B is the correct because clients taking MAO inhibitors must avoid foods that are high in tyramine to avoid hypertensive crisis. A, C and D are incorrect because there are no food and drug interactions that the nurse needs to be assess for.
A patient who is depressed has been put on an antidepressant. The patient wants to know when the drug will take effect. Which response by the nurse demonstrates knowledge of this drugs action?
A. 24 – 48 hours
B. 8 – 10 days
C. 2 – 3 weeks
D. One month
C
The nursing assessment of a patient who is on haloperidol (Haldol) reveals smacking lips and head bobbing up and down. What would be an appropriate nursing evaluation of these specific effects?
A. Dystonia
B. Akathesia
C. Extrapyramidal symptoms (EPS)
D. pseudoparkinsonism
Rationale: B is the answer. A is incorrect because dystonia refers to specific symptoms involving muscular spasms, tongue protrusion, and oculogyric crisis. D is incorrect because these behaviors include shuffling gait, drooling, and blank facial expression.
A nurse in a long term care facility is assessing a patient that has received haloperidol (Haldol) for three weeks. The nurse notes that the patient is squirming in a wheelchair. The nurse notes these movements as which of the following?
A. Akinesia
B. Akathesia
C. Parkinsonism
D. Torticollis
Rationale: B is the answer akathesia refers to continuous motor movements, restless, fidgeting, and pacing. A is incorrect because it is the opposite of movement; it includes fatigue and muscular weakness. C is incorrect because this involves fine tremors, shuffling gait. D is incorrect because this term means neck spasms.
As part of home care for a patient on haloperidol (Haldol), the nurse should assess for which of the following common side effects?
A. extrapyramidal symptoms (EPS)
B. hypoglycemia
C. high blood pressure
D. involuntary movements
Rationale: A is the answer EPS includes involuntary movements (akathesia, dystonia, pseudoparkinsonism. B is not correct because hypoglycemia is not a side effect of this medicine. C is incorrect because hypertension (not hypotension) is the side effect associated with haloperidol. D. is true, however A is the more inclusive answer in this question.
Discharge teaching for a patient with bipolar disorder includes explaining how lithium interacts with diet. The nurse would instruct the client to:
A. Maintain a table salt free diet to reduce edema
B. Main a reduced table salt free diet since lithium is a salt
C. Maintain a regular sodium diet to reduce lithium toxicity
D. Not worry about table salt, because it does not affect lithium levels
D
Rationale: to cross the neuron membrane, the lithium needs to be transported with sodium, so a normal amount of salt should be included in the diet. A, B and C are incorrect because adequate sodium intake is important.
A nurse reviews the laboratory results of a client taking lithium carbonate (Lithobid). Which serum electrolyte value would the nurse identify as a precipitating factor for lithium toxicity?
A. Sodium 130 mEq/L
B. Sodium 145 mEq/L
C. Calcium 8.4 mg/dL
D. Calcium 10.2 mg/dL
A
Rationale: Hyponatremia precipitate lithium toxicity
What is a possible consequence of sudden withdrawal to diazepam (Valium)?
A. Drowsiness
B. Ataxia
C. Confusion
D. seizures
D
Rationale: A, B and C are incorrect because these are side effects while on valium. D is correct because seizures are what occurs when the patient suddenly stops taking valium. In this case you could miss this question because of missing the word withdrawal. Always be sure to look for key words in the stem of the question.
Antianxiety medications, such as benzodiazepines, produce a calming effect by:
A. Depressing the CNS
B. Decreasing levels of norepinephrine and serotonin in the brain
C. Decreasing levels of dopamine in the brain
D. Inhibiting production of the enzyme MAO
A
The nurse is assessing a patient that is started on lithium. The nurse knows that symptoms of toxicity are more likely to occur if the patient’s drug level is higher than which of the following?
A. 0.15 mEq/L
B. 1.5 mEq/L
C. 15 mEq/L
D. 150 mEq/L
B
There is a very narrow margin between the therapeutic and toxic levels of lithium
carbonate. Symptoms of toxicity are most likely to appear if the serum levels exceed:
A. 0.15 mEq/L
B. 1.5 mEq/L
C. 15 mEq/L
D. 150 mEq/L
B
Initial symptoms of lithium toxicity include:
A. Constipation, dry mouth, drowsiness, oliguria.
B. Dizziness, thirst, dysuria, arrhythmias.
C. Ataxia, tinnitus, blurred vision, diarrhea.
D. Fatigue, vertigo, anuria, weakness.
C
Antipsychotic medications are thought to decrease psychotic symptoms by:
A. Blocking reuptake of norepinephrine and serotonin.
B. Blocking the action of dopamine in the brain.
C. Inhibiting production of the enzyme MAO.
D. Depressing the CNS.
B
If the foregoing extrapyramidal symptoms should occur, which of the following would
be a priority nursing intervention?
A. Notify the physician immediately.
B. Administer prn trihexyphenidyl (Artane).
C. Withhold the next dose of antipsychotic medication.
D. Explain to the client that these symptoms are only temporary and will disappear
shortly.
A concern with children on long-term therapy with CNS stimulants for ADHD is:
A. Addiction
B. Weight gain
C. Substance abuse
D. Growth suppression
D
If a patient does not follow dietary restrictions while taking parnate, they may develop which of the following adverse effects?
A. Generalized urticarial
B. Occipital headache
C. Severe muscle spasms
D. Severe hypotension
Rationale: B is the correct answer. Tyramine is a catecholamine found in over-the-counter decongestants and foods such as aged cheeses, wine (especially red wine), beer, preserved meats, coffee, chocolate, and soy sauce. Normally, the body deactivates it, but MAO inhibitors interfere with this process. The result is potent vasoconstriction. D is not the correct answer because the food – drug interaction causes hypertension not hypotension.
What is neuroleptic malignant syndrome? Signs and symptoms,
A rare complication of antipsychotic drugs with a rapid onset of 1 – 2 days. It is a serious medical condition caused by dopamine blockade. Signs and symptoms include: Elevated temperature, blood pressure, muscular rigidity. Labs will be altered (increase CPK (creatinine kinase, increased potassium. Treatment includes stopping the offending drug immediately and administering dopamine enhancing drugs.
What are clinical features of benzodiazepine or Lorazepam (Ativan) toxicity? And what is the treatment for this condition?
Confusion and slurred speech occur with lorazepam toxicity. Flumazenil (Romazicon) is the antidote to benzodiazepine overdose. Overdose can occur intentionally or by accident.
Describe the key nursing assessments that must happen after a client is started on antidepressants?
• Evaluate for the risk of suicide. Once a patient that is depressed begins to feel better – they are most at risk for committing suicide; this is the utmost concern for the RN.
• Physiological parameters are the next most important assessment a nurse could make. Some medications cause alterations in vital signs, things like orthostatic hypotension.
• Are they taking the medicine as prescribed?
• Are they able to perform ADL’s? Are they able to get to work etc? Family function?
. What is the pathophysiology of psychosis? How do the antipsychotics drugs alleviate the symptoms of psychosis? How do we know that antipsychotic drugs are working?
Elevated levels of dopamine are implicated in the pathophysiology of psychosis. This explains why some illegal drugs like amphetamines and cocaine cause psychosis (amphetamines and cocaine increase levels of dopamine in the brain). This also explains why medications for Parkinson’s disease (where the aim is to give medications that increase dopamine) can cause hallucinations.

The antipsychotic drugs act by blocking the receptor site for dopamine (and some newer agents also impact serotonin). Other neurotransmitters are thought to be involved but this hasn’t been proven yet in studies.

The standard by which antipsychotics are measured for effectiveness is control of the positive symptoms, like delusions and paranoid ideation.

Clozaril (Clozapine) is good to use for patients with _________ because it has less _________ when compared to conventional (typical) drugs. The major adverse effect that limits the use of clozaril (clozapine) use is_________ and this is assessed by _________.
Clozaril (Clozapine) is good to use for patients with psychosis_________ because it has less extrapyramidal symptoms when compared to conventional (typical) drugs. The major adverse effect that limits the use of clozaril (clozapine) use is agranulocytosis and this is assessed by _evaluating WBC count.
A client has been given diazepam (Valium) IM. What are the important nursing considerations?
Keep the patient safe from harm. After administering a medication from this class (benzodiazepine) it is important to note sedations – the patient is at high risk for falls.
When a nurse is documenting a patient’s condition and they are receiving antidepressants – what points are important to assess for and to document?
Remember to assess for risk of committing suicide – patients are at highest risk for suicide once they start to feel better. It is always important to check for compliance, it is not uncommon to have patients decide to stop taking antidepressants once they start feeling better. The relapse rate (return of depression symptoms) is very high in these cases.
What is the difference between acute dystonia and tardive dyskinesia?
Acute dystonia happens early and the classic clinical sign is a neck spasm.

Tardive dyskinesia is potentially irreversible. It occurs late. Sometimes medical staff will decrease the dosage of the typical / conventional drugs to help decrease symptoms. Often times – medications such as clonazepam (Klonopin) a long acting benzodiazepine, is given to treat the teeth grinding and neck movement which can be incapacitating.

How would you assess for anticholinergic side effects? Considering the anticholinergic side effects which age group (children, middle aged or old) are most susceptible to anticholinergic adverse effects?
Acetylcholine is a neurotransmitter—a chemical messenger that helps cells communicate. Anticholinergic drugs blocks the action of acetylcholine, which is an essential neurotransmitter.
Blind as a bat (blurred vision)
Dry as a bone (dry mouth and mucous membranes)
Red as a beet (flushing)
Mad as a hatter (confusion)
Hot as a hare (hyperthermia)
Can’t see (vision changes)
Can’t pee (urinary retention)
Can’t (do something that rhymes with “spit”, constipation)
What are the essential differences between the different categories of antidepressants? (for example compare an SSRI to bupropion (Wellbutrin.) How does the mechanism of action account for the side effects?
Some work by blocking the reuptake of neurotransmitters. Sertraline (Zoloft) impacts serotonin. Serotonin is responsible in our body for regulating sleep and hunger. So an excess of serotonin may result in GI disturbance, and sexual dysfunction.

Other antidepressants work by impacting norepinephrine and serotonin. Bupropion (Wellbutrin) acts by preventing uptake of norepinephrine and dopamine. Norepinephrine is responsible for the sympathetic nervous system, and dopamine is responsible for fine muscle movements and it stimulates the hypothalamus (to release sex, adrenal and thyroid hormones). The exaggeration of these neurotransmitters accounts for the adverse effects and warnings.

What do you predict would happen if a patient received phenylzine (Nardil) and one week later received sertraline (Zoloft)?
Life threatening increase in blood pressure. Phenylzine is a powerful inhibitor of MAO; MAO is the chemical responsible for “breaking down” serotonin. If the patient takes phenyzline they will be unable to break down serotonin. Therefore, if the patient ingests sertaline (Zoloft) the patient would be unable to reuptake or reabsorb serotonin. This would result in an increase in serotonin at the synapse
The nurse plans care for a client with Parkinson’s disease. What will the best plan of the nurse include?

A. Monitor the client for psychotic symptoms.
B. Limit exercise to decrease the possibility of fractures.
C. Monitor the client for the ability to chew and swallow.
D. Check peripheral circulation for thrombophlebitis.

C
Rationale: In Parkinson’s disease, muscle function is lost, and the client’s ability to chew and swallow to prevent aspiration becomes a safety issue. Psychosis is possible; however this is not the primary concern. Activity is important to maintain as much muscle tone as possible, and should not be limited. Thrombophlebitis is not related to Parkinson’s disease.
The client receives levodopa and carbidopa (Sinemet). What will the best teaching of the nurse include as relates to this medication?
A. Take the medication with meals.
B. Take the medication on an empty stomach.
C. Take the medication with a protein food.
D. Avoid drinking caffeinated beverages.
Rationale: Levodopa and carbidopa (Sinemet) is best absorbed on an empty stomach. Food decreases absorption. Levodopa and carbidopa (Sinemet) should not be taken with a protein food; this will decrease absorption. There isn’t any significant relationship between caffeine and Levodopa and carbidopa (Sinemet).
A client receives benztropine (Cogentin) and tells the nurse he is going on a cruise. Which statement would be included in the best plan of the nurse?
A. “Limit your activity while on the cruise.”
B. “Be sure to take a hat and sunglasses.”
C. “Take a multivitamin for additional energy.”
D. “If you forget a few doses, that is all right.”
B
Rationale: Benztropine (Cogentin) can cause photophobia; the client needs sunglasses. There isn’t any need to limit activity. A multivitamin is not necessary. The dosage schedule should be maintained.
The client receives trihexyphenidyl (Artane) for Parkinson’s disease. Which assessment data will the nurse report to the physician?

A. Dry mouth
B. Urinary retention
C. Hypertension
D. Anorexia

B
Rationale: Urinary retention is a serious side effect that must be reported to the physician. Dry mouth is a common side effect of trihexyphenidyl (Artane) that does not need reporting. Hypertension is not a side effect of trihexyphenidyl (Artane). Anorexia is not a side effect of trihexyphenidyl (Artane).
Carbidopa / levodopa (Sinemet) is preferred over regular levodopa in drug treatment of Parkinson disease because it
A. is better absorbed from the GI tract
B. induces fewer CNS adverse effects
C. allows more dopamine to reach the brain
D. can be administered once a day
C
Rationale: C is correct because the carbidopa prevents peripheral conversion of levodopa. A is incorrect because combining the two drugs does not change absorption of the medication. B is incorrect because the CNS effects are from the disease itself and the CNS benefits of the drug are the same with levodopa or carbidopa / levodopa (Sinemet). D is incorrect because the dosing of dopaminergic agents (this means drugs that contain dopamine) are given more than once a day.
Carbidopa / levodopa (Sinemet) works by

A. blocking the action of acetylcholine.
B. blocking the action of dopamine.
C. increasing the activation of dopamine receptors in the brain.
D. Increasing activation of acetylcholine receptors in the brain.

C
Rationale: Medications for Parkinson’s are used to increase the amount of dopamine. This is helpful in treating Parkinson’s because dopamine is the neurotransmitter implicated in muscular movement. However, on high enough doses of this medication nausea is often the result because excess dopamine is also implicated with nausea.
A client is taking carbidopa/levodopa (Sinemet). While assessing the client, which of the following statements made by the client would require the nurse to intervene?

A. “I just love avocado’s! I could eat them everyday.”
B. “I tend to watch my meat intake because it just bothers my stomach.”
C. “I eat bran flakes every morning.”
D. “I drink at least 8 glasses of water a day.”

A
Rationale: The question is asking the nurse to figure out which food is not good to eat with carbidopa / levodopa (Sinemet) and the guidelines are low proteins foods. A is correct because this food is high in protein. B is incorrect, because although meat is high in protein and avoiding it would be useful, the exam item is stating the patient avoids meat. C and D are incorrect because they are irrelevant with carbidopa / levodopa (Sinemet).
The wife of a patient with Parkinson’s disease state “Will my husband have to take this medication forever?
All patients with Parkinson’s disease will require medication therapy to allow for muscular movement. This is a chronic condition. Other signs and symptoms such as postural instability are not as treatable with medications
What is the goal of treatment for Parkinson’s Disease?
Knowing why we are treating PD is important for patient teaching so patients know what to expect. The drugs improve ADL’s only that is they help the patient eat, drink, ambulate. The drugs do not prevent muscle wasting that might occur due to declining activity or stop the tremors that eventually occur. The drugs also do not treat the depression that may occur with Parkinson’s disease.
What is the difference between “wearing off” and “on – off” syndrome?
Wearing off syndrome occurs when the patient experiences a recurrence of the signs and symptoms of Parkinson’s Disease. It is caused by low drug levels and thus it occurs at predictable times – when the drug level is the lowest. The physician should be notified because the physician may change the medication dosage.
As patient with PD progresses and their condition deteriorates the medications become less effective, an ‘On’ / ‘Off’ syndrome may develop. The period of time when the medication does not work (the ‘OFF’ period) becomes longer with a corresponding reduction in the time when it does work (the ‘ON’ period). The ‘On’ period is often marked by an increased instance of dyskinesia while dystonia can be experienced during the change from one status to the other. During the ‘Off’ period the true Parkinsonian symptoms of tremor, rigidity, and slow movement are experienced. The severity of the symptoms is determined by the level to which the condition has progressed. On – off syndrome occurs at random times because it is not related to drug levels.
The client has epilepsy and receives valproic acid (Depakote). The client has been seizure-free, and asks the nurse why he still needs blood tests when he is not having seizures. What is the best response by the nurse?
A. “Because Depakote can deplete your system of potassium.”
B. “Because Depakote can cause Stevens-Johnson syndrome, which will show up in the blood tests.”
C. “Because Depakote has a very narrow range between a therapeutic dose and a toxic dose.”
D. “Because Depakote can cause blood-thinning in some clients.”
C
Rationale: Depakote has a very narrow range between a therapeutic dose and a toxic dose; blood levels must be monitored to ensure a therapeutic level and to prevent toxicity. There isn’t any evidence to support that Depakote causes potassium depletion. Stevens-Johnson Syndrome is not associated with Depakote. Depakote is not an anticoagulant, and does not cause thinning of the blood.
The physician is initiating a new order for intravenous phenytoin (Dilantin). The client is also receiving 5% dextrose in water (D5W) intravenously (IV). The nurse plans which of the following interventions?
A. Flush the intravenous (IV) line with saline.
B. Monitor the client for hypertension.
C. Administer the dose in the smallest bore IV
D. Monitor the client for Stevens-Johnson Syndrome.
A
Rationale: A – Intravenous lines of 5% dextrose in water (D5W) must be flushed with saline, as traces of dextrose can cause microscopic precipitate formations that become emboli, if infused. Phenytoin (Dilantin) is a soft-tissue irritant that will cause local tissue damage if extravasation occurs, so a large vein must be used for infusion not a small vessel. Clients receiving phenytoin (Dilantin) are at risk for hypotension, not hypertension. Stevens-Johnson Syndrome is a side effect of phenytoin (Dilantin), but it takes days to occur.
What should be part of the teaching plan for a child with a seizure disorder being discharged on phenytoin (Dilantin)?
A. drinking plenty of liquids
B. brushing teeth after each meal
C. having someone be with the child during waking hours
D. reporting signs of infection
B
Rationale: B is correct because phenytoin (Dilantin) can cause gingival hyperplasia. Children taking Dilantin should brush their teeth after every meal and at bedtime and visit the dentist on a regular basis. Drinking plenty of liquids is not required while taking Dilantin. C is not correct because a child on Dilantin does not need to be observed during waking hours because seizures should be controlled. D is not correct because infections do not occur with increased incidence in patients receiving Dilantin.
When teaching a patient about taking a newly prescribed AED at home, the nurse should include which instruction?
A. Driving will be allowed after 2 weeks of therapy.
B. If seizures recur, take a double dose of the medication.
C. Antacids can be taken with the AED to reduce gastrointestinal adverse effects.
D. Regular, consistent dosing is important for successful treatment.
D
84.
A patient has a 9-year history of a seizure disorder that has been managed well with oral phenytoin (Dilantin) therapy. He is to be NPO (consume nothing by mouth for surgery in the morning. What will the nurse do about his morning dose of phenytoin?
A. Give the same dose intravenously.
B. Give him the morning dose with a small sip of water.
C. Contact the prescriber for another dosage form of the medication.
D. Notify the operating room that the medication has been withheld.
C
The nurse is giving an intravenous dose of phenytoin (Dilantin). Which action will the nurse perform to administer the drug?
A. Give the dose as a fast intravenous (IV) bolus.
B. Mix the drug with normal saline and give it as an IV piggyback.
C. Mix the drug with dextrose (D5W) and give it as an IV piggyback.
D. Mix the drug with any available solution as long as the drip rate is correct.
B
A patient is experiencing status epilepticus. The nurse prepares to give which drug of choice for the treatment of this condition?
A. diazepam (Valium)
B. midazolam (Versed)
C. valproic acid (Depakote)
D. carbamazepine (Tegretol)
A
Phenytoin (Dilantin) has a narrow therapeutic index. The nurse recognizes that this characteristic means that
A. the safe and the toxic plasma levels of the drug are very close to each other.
B. phenytoin has a slim chance of being effective.
C. there is no difference between safe and toxic plasma levels.
D. a very small dosage can result in the desired therapeutic effect.
A
A patient has been taking an AED for several years as part of his treatment for partial seizures. His wife has called because he ran out of medication this morning and wonders if he can go without it for a week until she has a chance to go to the drugstore. What is the nurse’s best response?
A. “He is taking another antiepileptic drug, so he can go without the medication for a week.”
B. “Stopping this medication abruptly may cause withdrawal seizures. A refill is needed right away.”
C. “He should temporarily increase the dosage of his other antiseizure medications.”
D. “He can probably stop all medication because he has been treated for several years now.”
B
During a routine appointment, a patient with a history of seizures is found to have a phenytoin (Dilantin) level of 18 mcg/mL. What concern should the nurse have, if any?
A. The patient is at risk for seizures because the drug level is not at a therapeutic level.
B. The patient’s seizures should be under control because this is a therapeutic drug level.
C. The patient’s seizures should be under control if she is also taking a second antiepilepsy drug.
D. The drug level is at a toxic level, and the dosage should be reduced.
B
Which statements about AED therapy are true? Select all that apply.
A. AED therapy can be stopped when seizures are under control.
B. AED therapy is usually lifelong.
C. Consistent dosing is key to controlling seizures.
D. A dose may be skipped if the patient is experiencing adverse effects.
E. AED therapy should never be abruptly discontinued because doing so may precipitate rebound seizure activity
B,C, E
When teaching a patient what has started valproic acid (Depakene) about possible side effects of this medication, the nurse would include which of the following in the teaching plan?
A. increased urination
B. slowed thinking
C. sedation
D. weight loss
C
Rationale: C is correct because this medication causes sedation as well as nausea, vomiting and indigestion. Sedation is important because the patient needs to be cautioned about driving or operating heavy machinery. A and B are incorrect because depakene does not cause increased urination or slowed thinking. D is incorrect because some patients may experience weight gain not weight loss.
Which of the following statements by a client taking valproic acid (Depakene) indicates that further teaching is necessary?
A. “I need to take the pills at the same time every day.”
B. “I can chew the pills if necessary.”
C. “I can take the pills with food.”
D. “I need to call my doctor if I bruise easily.”
B
Rationale: If the patient makes the statement “B” it indicates further teaching is necessary because chewing can cause mouth and throat irritation and is contraindicated. A does not need correction because the medications should be taken at the same time each day. C does not need correction because taking the medication with food can decrease GI irritation. D does not need correction because valproic acid (Depakene) can cause clotting disorders.
A patient is taking valproic acid (Depakene) twice daily. Which adverse effect is least associated with this medication?
A. tremors
B. Hair loss
C. gastrointestinal upset
D. anorexia
D
Rationale: D is not associated with valproic acid. Adverse effects include tremors, transient hair loss, GI upset and weight gain.
A patient with Alzheimer’s disease is started on low dose lorazepam (Ativan) because of agitation and sleep disturbance. While monitoring the patient for possible adverse effects, the nurse should expect to find which of the following as the most common?
A. Confusion and nighttime agitation
B. Extrapyramidal side effects
C. Vomiting and profuse sweating
D. Anticholinergic side effects
A
Rationale: A is correct because in the cognitively impaired patient, benzodiazepines such as lorazepam (Ativan) can increase confusion and nighttime agitation. B is not correct because extrapyramidal side effects are more common with antipsychotic drugs. C is not correct because these are signs and symptoms of acute benzodiazepine withdraw. D is not correct because Anticholinergic side effects are more common with antipsychotics and tricyclic antidepressants.
The nurse is preparing to administer phenytoin (Dilantin) intravenous push. The client has an IV D5W at 50 mL / hour. Select all that apply.
A. Consult a drug reference book looking at compatibilities
B. Apply a cold pack to the IV site to limit vascular damage
C. Assess the patency of the IV access with a normal saline flush
D. Dilute the medication with normal saline
E. Select a central venous access site
A, C, E
What teaching points are very important with phenytoin (Dilantin)?
Take the medication every day and do not skip days
No grapefruit juice as this food impairs metabolism of the drug and may result in toxicity.
Advise the patient to look for rashes

While injecting phenytoin (Dilantin) it should be slow, for example no faster than 50 mg./min. A central line should also be used and it should not be injected into the hand. The IV access should be flushed with saline only.

Nurses should place patient’s on cardiac monitors if they are administering a loading dose (typically 1 gram). In contrast, 100 mg is given either IV or orally on medical surgical floors.

Also any other medication that is considered a CNS depressant for example morphine or lorazepam (Ativan) may have an additive effect.

When giving Carbamazepine (Tegretol) – what physical and hematological adverse effects are you looking for
Nystagmus and ataxia are physical signs of adverse effects of carbamazepine (Tegretol). This medication also causes hematological effects such as low white count, platelet count
Case study: A 28 year old student complains to friends that he doesn’t feel well and that he smells burning food. A minute later this student falls to the ground. The medics arrive and note dilated pupils, hyperventilation, arched back and neck and urinary incontinence. After arriving in the emergency department a loading dose of intravenous phenytoin (Dilantin) is started and a stat dose of diazepam (valium) is administered.

Medical Orders For The Medical Surgical Floor:
• Phenytoin (Dilantin) 100 mg PO TID
• Carbamazepine (Tegretol) 200 mg PO BID
• CBC and chemistry daily

A. What would be appropriate nursing actions when administering the Phenytoin (Dilantin) loading dose?
What would be appropriate questions to ask in a social history?
Why would the provider order levels for CBC, glucose, sodium, calcium and a drug screen?
What is the purpose of diazepam (Valium)?
E. After arrival to the medical surgical floor – what assessments are a priority?
F. What client education is vital for this patient?

The patient should be on a cardiac monitor and the medicine should be administered on an infusion pump slowly to avoid cardiac dysrhythymias. The intravenous access should be located in the upper arm and not the hand because phenytoin (Dilantin) can cause vascular damage in the hands.

It would be important to assess for alcohol history. Alcohol withdraw can precipitate seizures.

A CBC would be performed to assess WBC count for infection which can cause seizures. Hypoglycemia can also precipitate seizures.
All of the benzodiazepines enhance GABA which is the major inhibitory neurotransmitter in the brain. Enhanced GABA will decrease electrical transmission.
The nurse would perform frequent neurological assessments. In addition to assessing for further seizure activity, the patient would need to be treated for decreased level of consciousness and weakness as these are side effects of Phenytoin (Dilantin) initially.

The patient should take the medication at the same time every day and not skip any doses. The patient should not abruptly stop taking any seizure medication. Compliance with seizure medications is below average with approximately 30% of patients missing at least one dose of their medication every month!

Inform the patient that the tiredness and lethargy they feel on the medications initially will eventually subside as the patient is on the medication for a while.
The patient should anticipate returning to their provider’s office for periodic checks on their plasma medication level which is important for both Phenytoin (Dilantin) and carbamazepine (Tegretol). In addition, CBC and platelet counts are important because decreases in WBC and platelet counts are possible with carbamazepine (Tegretol).
The unpredictability of seizures is a major issue. Several lifestyle precautions are recommended for patients. Safety must be balanced with the risk for seizures. A patient with many poorly controlled, diurnal seizures might exercise more caution than a patient who has only nocturnal seizures.
Recommendations for driving vary depending on state laws and on whether the patient has seizures that occur exclusively during sleep. Recommendation for driving cars and trucks extends to the operation any motor vehicles such as quads, boats, motorcycles etc. Patients a seizure disorder should not swim alone and should swim with a lifeguard present that can pull them out of the water if required. Life jackets are important in boats. Even taking a bath may be risky as a person can drown in one inch of water. Patient should also be careful around heights, fire and power tools (auto shut off is recommended).

A home health nurse provides instructions to the spouse of a client taking tacrine (Cognex) for the management of moderate dementia associated with Alzheimer’s disease. Which information should the nurse provide to the spouse?

A. “If a dose is missed, double up the next dose.”
B. “Administer the medication with food.”
C. “If flu like symptoms occur, notify the healthcare provider immediately.”
D. “If you see a change in the color of the skin and stool, notify the healthcare provider.”

D
Rationale: The most common side effect of tacrine is an increase in LFT’s. When a patient starts taking tacrine, blood is drawn on a weekly basis to measure ALT. If there is an increase in blood ALT, the dosage of tacrine can be reduced.
The client has been diagnosed with Alzheimer’s disease. What is the best medication education the nurse gives to the client’s husband?

A. “Her symptoms will improve as long as she takes the medication.”
B. “Her symptoms should begin improving in a few days.”
C. “The medication may help her symptoms for a little while.”
D. “The medication has serious side effects if used for a long time.”

C
Rationale: Medications will only slow the progression of the disease. Improvement with medication usually only lasts a matter of months. It takes a minimum of 1 to 4 weeks to begin to see improvement. The medications do not have serious side effects and are usually not used over a long period of time.
The client has been diagnosed with Alzheimer’s disease. What is the best medication education that the nurse gives to the client’s husband?

A. “Her symptoms will improve as long as she takes the medication.”
B. “Her symptoms should begin to improve in a few days.”
C. “The medication may help her symptoms for awhile.”
D. The medication has serious side effects if used for a long time.”

C
Rationale: Current medications will only decrease symptoms for a little while. There are drugs that will decrease symptoms for a short period of time. Drugs will not control symptoms for many years. The drugs for treatment of Alzheimer’s disease are no more dangerous than other drugs used for a long period of time.
The client receives tacrine (Cognex) as treatment for Alzheimer’s disease. Which laboratory test(s) will the nurse primarily assess?

A. Renal function tests
B. Serum amylase levels
C. Complete blood count
D. Liver function tests

D
Rationale: C – tacrine (Cognex) is hepatotoxic and requires monitoring of liver function tests (LFTs) in any client who is receiving this drug. Tacrine (Cognex) does not affect renal function; so monitoring of renal function tests is not required. Tacrine (Cognex) does not affect pancreatic function; so monitoring of serum amylase levels is not required. Tacrine (Cognex) does not affect blood counts; so monitoring of complete blood counts (CBC) is not required.
Which statement is the most accurate regarding acetylcholinesterase inhibitors when used for Alzheimer’s disease?
A. They intensify the effect of acetylcholine at the receptor.
B. They increase synthesis of acetylcholine.
C. They increase enzymatic breakdown, leading to increased neuronal production.
D. They reverse the structural damage within the brain.
Rationale: Acetylcholinesterase inhibitors intensify the effect of acetylcholine at the receptor. They do not increase acetylcholine synthesis or enzymatic breakdown. Currently no drugs can reverse the structural damages associated with Alzheimer’s disease.
At which of the following times should the nurse instruct the patient to take ibuprophen (Motrin) prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
A. at bedtime
B. on arising
C. immediately after a meal
D. On an empty stomach
Rationale: C is correct drugs that can cause gastric irritation such as ibuprophen are best taken after or with a meal when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will need to gastric irritation.
When preparing a teaching plan for a client receiving celecoxib (Celebrex) the nurse expects to explain that the major advantage of this medication over [ibuprophen (Motrin) or diclofenac (Volaren)] is that celecoxib is less likely to produce which of the following?
A. hepatotoxicity
B. renal toxicity
C. GI bleeding
D. Nausea and vomiting
C
Rationale: C is the correct answer, the major advantage of celecoxib a newer generation of COX-2 inhibitors, over diclofenac (or Motrin/ ibuprophen) a COX-1 inhibitor is that celecoxib is less likely to produce GI problems such as ulcers and bleeding. B, C and D are not correct because there is no evidence of less hepatotoxicity, renal toxicity or nausea and vomiting.
A 75 year old woman has been given an NSAID for the treatment of rheumatoid arthritis. The nurse is reviewing the patient’s medication history and notes that which type of medication could have an interaction with this NSAID?
A. antibiotics
B. decongestants
C. anticoagulants
D. beta blockers
C
An elderly patient tells the nurse that he uses aspirin for “anything that ails me.” The nurse will assess for which most common sigs of chronic salicylate intoxication in adults?
A. photosensitivity
B. tinnitus and hearing loss
C. acute gastrointestinal bleeding and anorexia
D. hyperventilation and central nervous system effects
D
A patient with gout has been treated with allopurinol for 2 months. The nurse will monitor laboratory results for which therapeutic effect?
A. decreased uric acid levels
B. adequate prothrombin time
C. increased white blood cell count
D. increased hemoglobin and hematocrit
A
The nurse is teaching a patient who is taking colchicine for the treatment of gout. Which instruction should be included during the teaching session?
A. “fluids should be restricted while on colchicine therapy.”
B. “colchicine should be taken with meals.”
C. “the drugs should be discontinued when symptoms are reduced.”
D. “call your doctor if you have increased pain or blood in the urine.”
D
The client takes calcium supplements. What is the best instruction by the nurse?
A. “Take them on an empty stomach.”
B. “Take three tablets at one time.”
C. “Take your calcium with a meal.”
D. “It does not matter if Vitamin D is added.”
C
Rationale: Calcium is best absorbed if taken with a meal. Calcium should be taken with food for best absorption. Calcium is best absorbed if the pills are taken in divided doses. Vitamin D facilitates absorption of calcium.
The nurse has taught the client with osteoporosis about how to manage the illness. Which statement by the client indicates that she needs additional teaching?
A. “I will walk for 30 minutes every day.”
B. “I will avoid drinking alcohol.”
C. “I will take my calcium at bedtime.”
D. “I will drink milk regularly.”
C
Rationale: Calcium should be taken with meals, not at bedtime. Walking will help with osteoporosis. Avoiding alcohol will help with osteoporosis. Drinking milk will help with osteoporosis
The client receives alendronate (Fosamax) as treatment for osteoporosis. Which symptoms, caused by an adverse effect of the medication, does the nurse teach should be reported to the physician?
A. Severe abdominal pain and diarrhea
B. Hot and dry skin
C. Muscle spasms and facial twitching
D. Vision changes and photophobia
C
Rationale: Muscle spasms and facial twitching indicate a low calcium level, which can be caused by alendronate (Fosamax), and should be reported immediately before the client has seizures. Severe abdominal pain and diarrhea are not adverse effects of alendronate (Fosamax). Hot and dry skin are symptoms of hyperglycemia, which is not an adverse effect of alendronate (Fosamax). Vision changes and photophobia are not adverse effects of alendronate (Fosamax).
A 51-year-old woman will be taking selective estrogen receptor modulators (SERMs) as part of the treatment for postmenopausal osteoporosis. The nurse reviews potential adverse effects with this patient, including the possible occurrence of
A. pregnancy.
B. breast cancer.
C. stress fractures.
D. venous thromboembolism.
D
Rationale: D; SERMs such as raloxifene increase the risk for venous thromboembolism. Postmenopausal women taking raloxifene were no more likely to develop breast, uterine, or ovarian cancer than were women taking a placebo. The other options are not correct.
During a follow-up visit, a patient who has been on estrogen therapy admits that she has continued to smoke cigarettes. The nurse will remind the patient that smoking while on estrogen may lead to increased
A. incidence of nausea.
B. tendency to bleed during menstruation.
C. levels of triglycerides.
D. risk for thrombosis.
D
Rationale: D; Smoking should be avoided during estrogen therapy because it adds to the risk for thrombosis formation. The other options are not correct.
What of the following is an important hormonal medication for postmenopausal women limits bone loss?
A. vitamin D
B. raloxifene (estrogen)
C. calcitonin
D. osteocalcin
B
Rationale: B is correct because estrogen replacement therapy reduces bone loss
When teaching about the best sources of calcium, you know that what ingredient found in milk is essential for calcium absorption?
A. vitamin D
B. fructose
C. lactose
D. carbonate
A
Adalimumab (Humira) is prescribed for a patient with severe RA. The nurse checks the patient’s medical history, knowing that this medication is contraindicated if which disorder if present?
A. Hypertension
B. Urinary tract infection
C. Hypothyroidism
D. anemia
B
A patient has an order for the monoclonal antibody adalimumab (Humira). The nurse notes that the patient does not have a history of cancer. What is another possible reason for administering this drug?
A. Severe anemia
B. Rheumatoid arthritis
C. Hypothyroidism
D. osteoporosis
B
A patient complains of a severe burning sensation in her chest. She is concerned that she is having a heart attack. When a medication history is being obtained, she mentions that she has just started a new “bone medication.” Which one of the following agents is most likely to be the cause of her symptoms?
A. Alendronate
B. Calcium
C. Calcitonin
D. Ergocalciferol
A
Parkinson Disease
Neurodegenerative disorder of the extrapyramidal system associated with disruption of neurotransmissions within the striatum
Dopamine vs Acetylcholine
acetylcholine makes body move. Dopamine controls movement.
PD Therapeutic goal:
Therapeutic goal
Improve activities of daily living (ADL)
Drug selection and dosages are determined by ADL performance
1. Dopamine “preservers”: Selegiline (Eldepryl)

2. Dopaminergic agents: promote activation of dopamine
Levodopa-Carbidopa (Sinemet)

3. Anticholinergic agents
Prevent activation of cholinergic receptors (inhibits cholinergic receptors)
Benztropine (Cogentin) and entacapone (Comtan)

Selegiline
Eldepryl–
Keeps dopamine from being broken down
MAO-B
the enzyme inactivates dopamine in striatum Preserves dopamine by inhibiting the enzyme that breaks it down
MAO-B Inhibitor
Selegine (Eldepryl, Carbex)
Therapeutic uses: Neuroprotective
Mechanism of action:
MAO-B is the enzyme inactivates dopamine in striatum Preserves dopamine by inhibiting the enzyme that breaks it down
Adverse effects: Principle effect is insomnia
Nursing care:
Improvement in early PD
Improvement in “On-Off” and “Wearing Off”
(Deactivates dopamine)
Levodopa-Carbidopa
Sinemet
Mechanism of action
Promotion of dopamine synthesis and release
Prevention of dopamine degradation
Pharmacokinetics:
Levodopa converted to dopamine
Carbidopa works in gut and tissues to prevent breakdown of levodopa
(Protein binds to sinemet)

Adverse effects:
Nausea and vomiting
Dyskinesias
Cardiac stimulation
Orthostatic hypotension
Psychosis

(Wakes up people who have had tragic injuries, short term alone)

Nursing care
Administer with food
Monitor the BP
Instruct clients about signs of postural hypotension; change positions slowly
Monitor vitals, ECG, tachycardia
Advise clients to avoid pyridoxine (B6)
Evaluate therapeutic effects
On-off phenomena
Wearing off effect

Dopamine Agonist
Pramipexole (Mirapex), Ropinirole (Requip)
Therapeutic uses:
used early in disease – and later in combination with other agents
Mechanism of action:
Binds selectively to D2 and D3 receptors

Adverse effects:
***Nausea
***Dizziness
***Daytime somnolence
Insomnia
Orthostatic hypotension

Nursing Care:
Advise clients to take medication with food
Advise clients of the potential for drowsiness and to avoid hazardous activities.
Advise clients to avoid other CNS depressants such as alcohol

Myasthenia gravis
Disease that makes you unable to move muscles.
Fluctuating muscle weakness and rapid fatigue
Symptoms: ptosis, dysphagia, weakness
Autoimmune process in which antibodies attack nicotinicM receptors on skeletal muscle
Edrophonium
Tensilon
Given to diagnose MG
Myasthenia gravis treatment
Neostigmine (prostigmine)
Irreversible cholinesterase inhibitors
(Prevent Acetylcoline breakdown. Continous dose of med)
Neostigmine
Prostigmin
Mechanism of action
Pharmacologic effects
Therapeutic administration – muscarinic receptors
Neuromuscular effects
Therapeutic dose – increases force of contraction in skeletal muscle
Toxic levels – decrease force of contraction
Central nervous system
Therapeutic levels – mild stimulation
Toxic levels – depress the CNS
Neostigmine therapeutic uses
Prostigmin
Therapeutic uses: myasthenia gravis
Adverse effects/acute toxicity
Excessive muscarinic stimulation
Neuromuscular blockade
Treatment with antagonist
Precautions and contraindications
Obstruction of GI or urinary tract
Peptic ulcer disease
Asthma
Coronary insufficiency
Hyperthyroidism
(Pt. can lose muscle control at high levels.)
Alzheimer’s Disease
Pathophysiology:
Amyloid plaques
Neurofibrillary tangles
Goals:
ADL’s, behavior, cognition
Acetylcholinesterase Inhibitors
Stops tremors
Donepezil (Aricept),
galantamine (Reminyl), rivastigmine (Exelon)
Mechanism of action:
Inhibits acetylcholinesterase
Side effects: anorexia, nausea and vomiting, constipation
Adverse effects:
Seizure, bradycardia, orthostatic hypotension, cataracts, MI, heart failure

Contraindicated: liver, renal disease, urinary tract obstruction, orthostatic hypotension, bradycardia
Nursing care:
Assess for history CV, renal, liver or respiratory disease
Implementation:
Assess for mood change, mental status
CBC and LFT’s
Monitor effectiveness
Instruct patient to take with food or fluid
Instruct patient to increase fiber

Lorazepam
Ativan
For seziure
Phenytoin
Dilantin
Seziure
Seizure disorders
Excessive neuron stimulation in CNS
Most can be seizure free with meds
Important to treat acute seizures rapidly to prevent status epilepticus
Lorazepam (Ativan)
Phenytoin (Dilantin)
Antiepileptic Drugs
Suppress neuronal discharge at the seizures focus and suppress propagation of seizure activity from the focus to other areas of the brain
Mechanism of action:
Suppression of sodium influx
Suppression of calcium influx
Potentiation of GABA
Phenytoin- Dilantin
Fosphenytoin (Cerebxy), phenytoin (Dilantin)
Mechanism of action:
selective inhibition of sodium channels
Therapeutic uses:
Partial and tonic clonic seizures

Pharmacokinetics:
Half life 8-60 hours
Level: 10-20 mcg/mL
Dosage individualized

Drug Interactions:
Urine may turn a harmless pink color
Adverse effects:
CNS
Intravenous – hypotension and dyshythmias
Gingival hyperlplasia
(Purple glove syndrome)

Wearing off
Not therapeutic in system
On-Off
Random effects, Sometime meds work and other times meds may not work at all
Diazepam
Valium (benzo)
Fosphenytoin
cerebxy (phenytoin)
GABA
Neurotransmitter that promotes calm
Benzodiazepines
Carbamazepine
Tegretol
(seizure and bipolar)
Mechanism of action:
Suppress high frequent neuronal firing discharge
Pharmacokinetics:
Hepatic elimination
Decreases half life d/t induction of hepatic drug induces metabolism
Therapeutic uses:
Seizures
Bipolar disorder
Trigeminal & glossopharyngeal neuralgias
Adverse effects:
CNS symptoms – nystagmus and ataxia
Anemia
Leukopenia: less than 3,000 mm3
Thrombocytopenia: less 150,000 – 450,000
Nursing care:
Assess for signs of infection
Assess for neurological signs and symptoms
Nystagmus
Twitching eye balls
Valporic Acid (0-100)
Depakote
Mechanism of action:
Therapeutic uses:
Seizure disorder
Bipolar disorder and migraine
Adverse effects:
Hepatotoxicity
Pancreatitis
GI – N&V
Nursing care:
Take the drug with food to reduce GI upset.
Immediately report any severe or persistent heartburn, upper GI pain, nausea, or vomiting.
Valporic acid
Depakote
Tegretol
Carbamazepine
Glutamergic Inhibitors (Memantine)
Namenda (Alzheimer)
Mechanism of action: reduces high levels of glutamate
Nursing care:
Monitor respiratory and CV status
Assess for and report S&S of focal neurologic deficits (TIA, ataxia, vertigo).
Monitor periodic Hct & Hgb, na, Alk Phos, blood glucose.
Monitor diabetics for loss of glycemic control
Selegine
Eldepryl, Carbex
Pramipexole
Mirapex (dopamine Agonist)
Parkinson’s
Therapeutic uses:
used early in disease – and later in combination with other agents
Mechanism of action:
Binds selectively to D2 and D3 receptors

Adverse effects:
***Nausea
***Dizziness
***Daytime somnolence
Insomnia
Orthostatic hypotension
Nursing Care:
Advise clients to take medication with food
Advise clients of the potential for drowsiness and to avoid hazardous activities.
Advise clients to avoid other CNS depressants such as alcohol

Ropinirole
Requip (Dopamine Agonist)
Parkinson’s
Therapeutic uses:
used early in disease – and later in combination with other agents
Mechanism of action:
Binds selectively to D2 and D3 receptors
Adverse effects:
***Nausea
***Dizziness
***Daytime somnolence
Insomnia
Orthostatic hypotension
Nursing Care:
Advise clients to take medication with food
Advise clients of the potential for drowsiness and to avoid hazardous activities.
Advise clients to avoid other CNS depressants such as alcohol
Benztropine
Cogentin (IAnticholinergic Agents)
Parkinson’s
Therapeutic use:
Reduce tremor and rigidity
No effect on bradykinesia
Mechanism of action:
Block muscarinic cholinergic receptors in the striatum

Nursing care:
Assess for history of glaucoma, GI dysfunction, urinary retention, angina, myasthenia gravis
Implementation:
Monitor vitals, urine output, bowel sounds
Instruct patient may relive dry mouth with hard candy, ice chips or sugarless gum
Instruct patient to use sunglasses for possible photophobia
Instruct patient to increase fluids and ingest foods high in fiber

Trihexyphenidyl
Artane (Anticholinergic Agents)
Parkinson’s
Therapeutic use:
Reduce tremor and rigidity
No effect on bradykinesia
Mechanism of action:
Block muscarinic cholinergic receptors in the striatum

Nursing care:
Assess for history of glaucoma, GI dysfunction, urinary retention, angina, myasthenia gravis
Implementation:
Monitor vitals, urine output, bowel sounds
Instruct patient may relive dry mouth with hard candy, ice chips or sugarless gum
Instruct patient to use sunglasses for possible photophobia
Instruct patient to increase fluids and ingest foods high in fiber

entacapone
Comtan (COMT inhibitors)- prolong activity of dopamine
Parkinson’s
Mechanism of action:
Inhibit metabolism of levodopa in the peripheral tissues and intestine
Used in conjunction to prolong its half life

Adverse effects:
Constipation, dry mouth, sweating
Hallucinations
Nausea
Dyskinesias
Hypotension
Sleep disturbances

Nursing care:
Evaluate response – improvement in motor ability
Entacapone (Comtan) – assess for hyperactivity, hallucinations, or uncontrollable movements of tongue, lips, or face

tolcapone
Tasmar (COMT Inhibitors)- prolong activity of dopamine

Parkinson’s
Mechanism of action:
Inhibit metabolism of levodopa in the peripheral tissues and intestine
Used in conjunction to prolong its half life

Adverse effects:
Constipation, dry mouth, sweating
Hallucinations
Nausea
Dyskinesias
Hypotension
Sleep disturbances

Nursing care:
Evaluate response – improvement in motor ability

tolcapone (Tasmar) – assess for signs of liver damage

Amyloid plaques
Plaque in brain that effects nerotransmitters and synapse.
osteoblasts vs ostoclasts
blast- build
clast- destroy
Osteoprorsis
Rate of bone resorption exceeds bone formation
Bone mass is decreased
HOrmone replacement
Premarin
Estrace
Therapeutic use: prevention
Mechanism of action:
Estrogen inhibits osteoclast activity; resulting in decreased bone loss
Selective Estrogen Receptor Modulator
Raloxifene (Evista)
Mechanism of action:
Estrogenic effects on bone (bone preserving)
Antagonistic toward estrogen receptors in the endometrium and breast
Contraindication: nursing women or pregnancy
Adverse effects:
Venous thromboembolism
Nursing care:
Etidronate
Alendronate –Bisphosphonates
(Didronel)
(Fosamax)
Mechanism of action:

Adverse effects:
Upper GI irritation / acid reflux (common)
Esophageal ulceration
Hypocalcemia
Jaw necrosis (IV – higher uptake)
Nursing care:
Assessment: patients must be able to sit up for at least 30 minutes when taking this medication
Monitor for calcium level 9 – 10 mg / dL
Report signs of hypocalcemia
Trousseau’s sign: pump a BP cuff up; a positive sign occurs when the hand goes into spasm
Chvostek’s sign: tap on facial nerve; a positive positive sign occurs when the lip twitches in the corner

hypocalcemia
– testing
Trousseau’s sign: pump a BP cuff up; a positive sign occurs when the hand goes into spasm
Chvostek’s sign: tap on facial nerve; a positive positive sign occurs when the lip twitches in the corner
Methotrexate
RA
Therapeutic use:
RA
Adverse effects:
Hepatic fibrosis
Bone marrow suppression
GI ulceration
Pneumonitis
Nursing care:
Side effects
Loss of hair, HA, mood and mental changes
Administer at the same time every day
May administer with milk
Adalimumab
Inflixamab– Immunomodulators
Humira
Remicade–
Immunomodulators
Mechanism of action:
Tumor necrosis factor inhibition
Adverse effects:
Serious infection
Malignancy
Nursing Care:
Assess: monitor CBC, creatinine and LFT’s
Obtain negative tuberculosis test prior to starting, hepatitis C
Implementation:
Infliximab infused over 2 hours
Adalimumab administered subcutaneously
Instruct patient to avoid live vaccinations
Instruct patient to report severe infections
Instruct patient to report dizziness, chills, dyspnea, seizures or fatigue or rash immediately
Short acting: Hydrocortisone Intermediate acting: Methylprednisolone ( and prednisone Long acting: dexamethasone
Corticosteroids
Short acting: Cortef
Intermediate acting: Solu-Medrol and Deltasone
Long acting: Decadron
Corticosteroids
Therapeutic use: induce remission
Adverse effects:
Sodium and water retention
Muscle wasting (high doses of steroids)
Drug interactions:
Diuretics
NSAIDs and Aspirin
Nursing care:
Assess baseline history of glaucoma, cataracts, peptic ulcer, psychiatric problems, DM
Assess baseline K,
Nursing diagnoses:
Risk for infection
Risk for imbalanced nutrition (weight gain)
Excess fluid volume
Nursing care:
Implementation:
Monitor vitals signs
Monitor weight
Assess for signs of hypokalemia: nausea, vomiting, muscular weakness, abdominal weakness, irregular heart rate
Monitor older adults for osteoporosis
Nursing care:
Implementation: Teaching
Monitor blood glucose
Caution patient not to abruptly stop taking the drug
Take the medication with food; consume foods high in potassium
Avoid persons with respiratory illness
To report signs of drug overdose or Cushing’s syndrome (moon face, puffy eyelids, edema in feet, increased bruising, dizziness, bleeding, menstrual irregularity
GoutIII
Pathophysiology: accumulation of uric acid crystals in joint
Caused by either
Decreased excretion of uric acid
Increased metabolism of nucleic acids
Goal:
Terminate acute attack
Prevent future attacks
Avoid high purine foods:
Meats, alcohol, mushrooms, oatmeal, legumes
NSAID’s can be used for pain relief
Colchicine
Therapeutic use: intermittent use
Adverse effects:
Severe diarrhea – 17%
Serious adverse effects – myelosuppression, coagulation issues
Nursing care:
Take on an empty stomach at symptom onset
Monitor labs for anemia
Assess for signs of toxicity
Encourage fluids
Assess for renal impairment