TestBank for Abrams Clinical Drug Therapy;Rationale for Nursing Practice 13E by Frandsen

TEST BANK

TEST BANK

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 1: The Foundation of Pharmacology: Quality and Safety 1.A woman has been prescribed paroxetine hydrochloride, which is an antidepressant agent administered in pill form. The medication is administered for her obsessive-compulsive disorder.

This medication will produce which of the following effects A) Curative B) Systemic C) Local D) Parenteral Ans:B Feedback: Drugs that produce systemic effects are taken into the body, circulated through the bloodstream to their sites of action in various body tissues, and eventually eliminated from the body. Curative agents are given to cure a disease process. In this case, paroxetine hydrochloride will control the symptoms but not cure the disorder. Drugs with local effects, such as sunscreen and local anesthetics, act mainly at the site of application. Paroxetine hydrochloride is not administered parenterally. Parenteral agents are administered subcutaneously, intramuscularly, or intravenously 2.A patient has been prescribed an antibiotic. This medication is a naturally occurring substance that has been chemically modified. What is another name for this type of medication A) Synthetic drug B) Semisynthetic drug C)Biotechnology drug D)Prototype drug Ans:B Feedback: Semisynthetic drugs (e.g., many antibiotics) are naturally occurring substances that have been chemically modified. Synthetic drugs are more standardized in their chemical characteristics, more consistent in their effects, and less likely to produce allergic reactions.

Biotechnology drugs involve manipulating DNA and RNA and recombining genes into hybrid molecules that can be inserted into living organisms. Prototype drugs are the first drug of a particular group to be developed 3. A patient is administered morphine. Morphine is a prototypical drug that can be classified in different ways. Which of the following. Do classifications apply to morphine A) Central nervous system depressant B) Central nervous system stimulant C) Anti-inflammatory D) Antihypertensive Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Drugs are classified according to their effects on particular body systems, their therapeutic uses, and their chemical characteristics. For example, morphine can be classified as a central nervous system depressant and a narcotic or opioid analgesic. A central nervous system stimulant increases attention and raises mood. An anti-inflammatory agent decreases inflammation at the site of tissue or joint inflammation. An antihypertensive agent reduces blood pressure 4.A patient is administered amoxicillin (Amoxil). The generic name of this medication indicates that it belongs to which drug group A) Selective serotonin reuptake inhibitors B) Diuretics C) Penicillins D) ACE inhibitors Ans:C Feedback: The generic name often indicates the drug group (e.g., drugs with generic names ending in “cillin” are penicillins). Selective serotonin reuptake inhibitors are medications that have antidepressant effects; SSRI is a broad classification, not a generic name. Diuretics are medications that increase urine output; diuretic is a broad classification, not a generic name. ACE inhibitor is the broad classification for the angiotensin-converting enzyme inhibitors, not the generic name.

5.The administration of diphenhydramine (Benadryl), which is an over-the-counter medication, is regulated by which government agency A)Public Health Service B)Federal Trade Commission C)Occupational Safety and HealthAdministration D)Food and Drug Administration Ans:D Feedback: The Food and Drug Administration approves drugs for over-the-counter availability, including the transfer of drugs from prescription to OTC status, and may require clinical trials to determine the safety and effectiveness of OTC use. The Public Health Service is regulated by the state to maintain the health of individual citizens of the state. The Federal Trade Commission regulates imports and exports throughout the nation. The Occupational Safety and Health Administration regulates safety within the workplace.

6. The administration of anabolic steroids is regulated by which of the following laws A) The Food, Drug, and Cosmetic Act of 1938

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The Comprehensive Drug Abuse Prevention and Control Act C) The Harrison Narcotic Act D) The Shirley Amendment Ans:B Feedback: The Comprehensive Drug Abuse Prevention and Control Act regulates the manufacture and distribution of narcotics, stimulants, depressants, hallucinogens, and anabolic steroids. The Food, Drug, and Cosmetic Act of 1938 revised and broadened FDA powers and responsibilities, giving the FDA control over drug safety. The Harrison Narcotic Act restricted the importation, manufacture, sale, and use of opium, cocaine, marijuana, and other drugs that the act defined as narcotics. The Shirley Amendment of 1912 prohibited fraudulent claims of drug effectiveness.

7. A nurse is responsible for maintaining an accurate count and record of the controlled substances on the nursing unit. This nursing action is regulated by which of the following laws or agencies A)Food, Drug, and Cosmetic Act of 1938 B)Public Health Service C)Drug Enforcement Administration D)Shirley Amendment Ans:C Feedback: The Drug Enforcement Administration enforces the Controlled Substances Act. Under this enforcement, nurses are responsible for storing controlled substances in locked containers, administering them only to the people for whom they are prescribed, recording each dose given, and maintaining an accurate inventory. The Food, Drug, and Cosmetic Act of 1938 revised and broadened FDA powers and responsibilities, giving the FDA control over drug safety. The Public Health Service is regulated by the state to maintain the health of individual citizens of the state.

The Shirley Amendment of 1912 prohibited fraudulent claims of drug effectiveness 8. In Phase I clinical trials, the potential uses, and effects of a new drug are determined by which of the following methods A) Administering doses to healthy volunteers B) Administering doses to people with the disease C) Administering in placebo-controlled design D) Calculating the risk-to-benefit ratio Ans:A Feedback: Phase I studies allow for the administration of the medication to healthy volunteers to determine safe dosages, routes of administration, absorption, metabolism, excretion, and toxicity.

In Phase II studies, a few doses are given to a certain number of subjects with the disease or symptom for which the drug is being studied and responses are compared with those of healthy subjects. Placebo-controlled designs are used in the Phase III studies, in which half of the

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

subjects receive the new drug and half receive the placebo. Calculating the risk-to-benefit ratio is used in Phase II studies to determine whether the potential benefits of the drug outweigh the risks 9. A new medication for the treatment of Alzheimer's disease is being administered to a group of subjects with the disease. The subjects receiving this medication are unaware of whether they are being administered the medication or whether they are receiving a placebo. This testing occurs in which phase of the drug approval process A) Phase I B) Phase II C) Phase III D) Phase IV Ans:C Feedback: In Phase III, the drug is given to a larger and more representative group of subjects. In double-blind, placebo-controlled designs, half of the subjects receive the new drug and half receive a placebo (an inactive substance similar in appearance to the actual drug), with neither subjects nor researchers knowing which subjects receive which formulation. In Phase I, a few doses are given to a certain number of healthy volunteers to determine safe dosages, routes of administration, absorption, metabolism, excretion, and toxicity. In Phase II, a few doses are given to a certain number of subjects with the disease or symptom for which the drug is being studied and responses are compared with those of healthy subjects. In Phase IV, the FDA evaluates the data from the first three phases for drug safety and effectiveness, allows the drug to be marketed for general use, and requires manufacturers to continue monitoring the drug's effects.

10. Which organization is responsible for approving new drugs in the United States A) American Medical Association B) American Pharmaceutical Association C) Food and Drug Administration D) United States Pharmacopeia Ans:C Feedback: The Food and Drug Administration is responsible for approving new drugs in the United States. The American Medical Association represents the physicians of the United States.

The American Pharmaceutical Association represents the pharmacists of the United States. The United States Pharmacopeia was adopted in 1906 and is issued every 5 years under the supervision of a national committee of pharmacists,scientists, and physicians 11. Which of the following reference books provides information from the drug manufacturers' inserts A) American Formulary Service B) Drug Facts and Comparisons C) Physicians' Desk Reference D) Lippincott's Nursing Drug Guide

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: The Physicians' Desk Reference is published yearly and contains manufacturers' published inserts for selected drugs. American Formulary Service is an authoritative source of drug information. Drug Facts and Comparisons is an authoritative source of drug information.

Lippincott's Nursing Drug Guide is an example of a drug handbook, not a compilation of manufacturers' inserts.

12. A nursing student in a pharmacology class should be encouraged to study the medications according to which categorization A) Prototype B) Controlled substance C) Drug use D) Generic names Ans:A Feedback: The nursing student should concentrate on therapeutic classifications and their prototypes. Controlled substances limit the medications studied to one broad classification. Drug use is only one part of the broad classification. Generic names are only one aspect of the medication 13. A patient with a long-standing dermatological health problem has been advised to use a drug with a local effect. The nurse should recognize what characteristic of this drug A) It affects only the organ system in which it is metabolized B) The drug requires application at multiple sites C) It is effective only as long as it is in contact with skin D) The drug acts primarily at the site where it is applied Ans:D Feedback: Drugs with local effects, such as sunscreen lotions and local anesthetics, act mainly at the site of application. Those with systemic effects are taken into the body, circulated through the bloodstream to their sites of action in various body tissues, and eventually eliminated from the body. A drug with local effect does not necessarily have to be applied at multiple sites, and its action may affect tissues long after contact.

14. A patient with an autoimmune disorder has just been prescribed a synthetic drug. Which of the following characteristics is a noted advantage of synthetic drugs

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Synthetic drugs are less likely to cause an allergic reaction than naturally occurring substances B) Synthetic drugs typically require less frequent dosing than naturally occurring substances C) Synthetic drugs are normally available on an over-the-counter basis D) Synthetic drugs are available in a wider variety of administration routes than naturally occurring substances Ans:A Feedback: Synthetic drugs are more standardized in their chemical characteristics, more consistent in their effects, and less likely to produce allergic reactions. They do not necessarily require less frequent dosing and may or may not be available OTC. They are not noted to be available in a wider variety of administration routes than naturally occurring substances.

15. A patient is confused about her care provider's advice and has stated to the nurse, “I wasn't sure whether he recommended Tylenol or whether he recommended acetaminophen.” The nurse should include which of the following information in an explanation of generic and trade names A) Prescribers should refer solely to generic names in their recommendations and written prescriptions B) A generic name is independent of any particular drug manufacturer C) Generic names change frequently, but trade names are more consistent D) Prescribers should refer solely to trade names in their recommendations and written prescriptions Ans:B Feedback: A generic name is related to the chemical or official name and is independent of the manufacturer. Drugs may be prescribed and dispensed by generic or trade name. Generic names do not change, while trade names vary according to time and place.

16. A nurse is aware that American drug laws have a long and complex history, with numerous jurisdictions being involved. What is the primary purpose of drug laws in the United States A) To ensure maximum choice for consumers B) To expedite the workload of care providers C) To protect the safety of the public D) To enhance the efficient delivery of health care

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: The main goal of drugs laws is to protect the public by ensuring that drugs marketed for therapeutic purposes are safe and effective. Efficiency and choice are valid considerations but neither is the primary goal of American drug legislation

17.A nurse who provides care on a postsurgical unit frequently administers Schedule II drugs to patients. Which of the following aspects of administering these drugs falls under the auspices of the Drug Enforcement Agency A)Performing a thorough patient assessment prior to administration B)Recording each dose administration on an agency narcotic sheet C)Informing patients of the potential risks and benefits of Schedule II drugs prior to the first dose D)Assessing the patient shortly after administration to ensure therapeutic effect Ans:B Feedback: Nurses are responsible for storing controlled substances in locked containers, administering them only to people for whom they are prescribed, recording each dose given on agency narcotic sheets and on the patient's medication administration record, maintaining an accurate inventory, and reporting discrepancies to the proper authorities. The other given actions are appropriate nursing activities, but they are not within the scope of the DEA authority 18.

Trials of a new drug are scheduled to soon begin and the testing methodology will integrate the stipulations of the National Institutes of Health (NIH) Revitalization Act According to this act, the manufacturer must A)independently fund the entire testing process B)make the results of the testing process publicly available C)include women and minorities in the testing process D)exclude any potential for financial gain during the testing process Ans:C Feedback: In 1993, Congress passed the National Institutes of Health (NIH) Revitalization Act, which formalized a policy of the NIH that women and minorities be included in human subject research studies funded by the NIH and that women and minorities be included in clinical drug trials. This act does not specifically address the financial structure of testing or the accessibility of information.

19. A hospital nurse is vigilant in ensuring the safe use of medications and consistently applies the rights of medication administration. Which of the following is one of the traditional rights of medication administration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Right to refuse B) Right route C) Right education D) Right evaluation Ans:B Feedback: The traditional rights of medication administration (right drug, right dose, right patient, right route, right time, right reason, and right documentation) now include additional rights that should also be considered (right education, right evaluation, and right to refuse the medication).

20. A patient's current medication administration record includes a drug that the nurse recognizes as an Institute for Safe Medication Practices (ISMP) high-alert medication. This designation signals the nurse to what characteristic of the drug A) It can only be administered by a physician or advanced practice nurse B) Administration must be cosigned by a second registered nurse or practical/vocational nurse C)It is currently undergoing Phase IV testing and is pending full FDA approval D)Administration errors carry a heightened risk of causing significant patient harm Ans:D Feedback: The Institute for Safe Medication Practices (ISMP) identifies drugs that when used in error have a heightened risk of causing significant patient harm. Such drugs are not limited to physician or advanced practice nurse administration. The drug would have completed the testing and approval procedure and administration does not necessarily require a cosignature.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 2 Basic Concepts and Processes 1. Which cellular structure stores hormones and other substances and packages these substances into secretory granules A) Golgi apparatus B) Endoplasmic reticulum C)Mitochondria D)Lysosome Ans:A Feedback: The golgi apparatus stores hormones and other substances. The endoplasmic reticulum contains ribosomes, which synthesize proteins, including enzymes that synthesize glycogen, triglycerides, and steroids and those that metabolize drugs and other chemicals The mitochondria generate energy for cellular activities and require oxygen. Lysosomes are membrane-enclosed vesicles that contain enzymes capable of digesting nutrients (proteins, carbohydrates, fats), damaged cellular structures, foreign substances (bacteri A), and the cell itself 2. A patient is suffering from a cough associated with an upper respiratory infection. Which oral medication will likely produce the most therapeutic effect A) A tablet B) An expectorant C)A topical spray D)A timed-release tablet Ans:B Feedback: Liquid medications are absorbed faster than tablets or capsules. Expectorants are liquid medications. A tablet is an oral medication that has a slower onset of action than a liquid medication. A topical spray can be sprayed to the back of the throat and provides only a local effect. A timed-release tablet is an oral medication that has a slower onset and longer duration of action.

3.A patient is administered an oral contraceptive. Which of the following is the process that occurs between the time the drug enters the body and the time that it enters the bloodstream A) Absorption

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Distribution C) Metabolism D) Excretion Ans:A Feedback: Absorption is the process that occurs from the time the drug enters the body to the time it enters the bloodstream to be circulated Distribution involves the transport of drug molecules within the body. Metabolism is the method by which drugs are inactivated or biotransformed by the body. Excretion refers to elimination of a drug from the body 4. Which of the following sites of drug absorption is considered to have an exceptionally large surface area for drug absorption A) Rectum B) Fundus of the stomach C) Esophagus D) Lungs Ans:D Feedback: The lungs have a large surface area for absorption of anesthetic gases and a few other drugs. The rectum absorbs the medication through the mucous membranes and has a smaller surface area than the lungs. The fundus and esophagus have comparatively small surface areas 5. A nurse is aware of the importance of adhering to the intended route of a medication. Which of the following drugs are formulated to be absorbed through the skin A) Amoxicillin, tetracycline, and penicillin B) Clonidine, fentanyl, and nitroglycerin C) Digoxin, lidocaine, and propranolol D) Insulin, heparin, and morphine Ans:B Feedback: Some drugs are formulated in adhesive skin patches for absorption through the skin Clonidine, fentanyl, and nitroglycerin are examples of drugs that are formulated in adhesive skin patch form to be absorbed through the skin. Amoxicillin, tetracycline, and penicillin are administered orally Digoxin and propranolol are administered orally, and lidocaine can be administered intravenously, subcutaneously, or topically. Insulin and heparin are administered intravenously and subcutaneously. Morphine is administered orally, intramuscularly, and intravenously.

6. An 85-year-old patient has an elevated serum creatinine level, indicating impaired kidney function. When the patient is administered a medication, this patient is at risk for which of the following medication-related effects A) Toxicity B) Increased absorption

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Delayed gastric emptying D) Idiosyncratic effects Ans:A Feedback: An elevated creatinine level is indicative of diminished kidney function, which will result in serum drug toxicity. The creatinine level indicates kidney function, does not affect absorption, and has no effect on gastric emptying.

7. Protein binding is an important aspect of pharmacokinetics. Protein binding ultimately has which of the following effects on drug action A) Increases the drug's speed of action B) Decreases the drug's speed of action C) Increases the rate of excretion D) Averts adverse effects Ans:B Feedback: | Protein binding allows part of a drug to be stored and released as needed. Drugs that are highly bound to plasma proteins or stored extensively in other tissues have a long duration of action. Protein binding does not increase the speed of action, increase the excretion rate, or avert adverse effects Protein binding decreases the speed of action by storing the drug to be released when needed.

8. A patient is taking a medication that is metabolized by the CYP enzymes. Which of the following medications inhibits several of the CYP enzymes A) Cisplatin B) Acebutolol hydrochloride C) Cimetidine D) Dicloxacillin sodium Ans:C Feedback: Cimetidine is a gastric acid suppressor that inhibits several CYP enzymes and can greatly decrease drug metabolism. The other listed drugs do not have this specific effect 9. A nurse is aware that the dosing scheduling of a patient's new medication takes into account the serum half-life of the drug. What is the serum half-life of a medication The time required for IV medications to penetrate the brain tissue B) The time needed for the serum level to fall by 50 C) The safest margin to prevent toxicity D) The dose adjustment that reduces the risk of adverse effects by one half Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Serum half-life is the time required for the serum concentration of a drug to decrease by 50 . Although many IV medications penetrate the brain tissue, this action does not describe the halflife. The safest margin to prevent toxicity depends on the rate of metabolism and excretion. The half-life of the medication does not relate directly to a specific reduction in adverse effects.

10. A patient has increased intracranial pressure and is ordered to receive a diuretic. Which of the following diuretics does not act on receptor sites to produce diuresis A) Furosemide (Lasix) B) Hydrochlorothiazide (HCTZ) C) Spironolactone (Aldactone) D) Mannitol (Osmitrol) Ans:D Feedback: Mannitol (Osmitrol) is an osmotic diuretic that increases the osmolarity of plasma and pulls water out of the tissues into the bloodstream. It does not act on receptor sites.

Furosemide (Lasix) is a loop diuretic that inhibits the reabsorption of sodium and chloride in the loop of Henle Hydrochlorothiazide is associated with drug interference with absorption of sodium ions across the distal renal tubule. Spironolactone acts by competing with aldosterone for cellular receptor sites.

11. A patient older than 65 years is more likely to experience drug reaction than a much younger patient. Which of the following factors accounts for this variation A) Drugs more readily crossing the blood–brain barrier in older people B) Age-related physiologic changes C) Increased drug-metabolizing enzymes in older people D) Diminished immune response Ans:B Feedback: In older adults (65 years and older), physiologic changes may alter all pharmacokinetic processes. Although drugs crossing the blood–brain barrier affect drug reaction, this factor is important in all ages. Increased drug-metabolizing enzymes are key in all ages and do not relate to age variations. A diminished immune response is important in all ages and does not affect all medications.

12. A patient who is 6 feet tall and weighs 280 pounds will require which of the following doses A) Higher dose than a patient who weighs 180 pounds B) Lower dose than a patient who weighs 180 pounds C) Same dose as a patient who weighs 180 pounds

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) A parenteral rather than oral dose Ans: A Feedback: In general, people heavier than average may need larger doses, provided their renal, hepatic, and cardiovascular functions are adequate.

13. A nurse has provided an oral dose of morphine, an opioid agonist, to a woman in early labor.

The nurse should be aware of what characteristic of agonists A) Agonists alter the normal processes of distribution and metabolism B) Agonists counteract the action of specific neurotransmitters C) Agonists block the action of specific neurotransmitters D) Agonists bind to receptors and cause a physiological effect Ans: D Feedback: Agonists are drugs that produce effects similar to those produced by naturally occurring hormones, neurotransmitters, and other substances by activating (not blocking or counteracting) a receptor. Classification of a drug as an agonist does not denote a change to metabolism or distribution.

14. A nurse is preparing to simultaneously administer two drugs to a patient. The nurse knows that the drugs have been ordered to be given together because of their synergistic effect. This means that A) the adverse effects of one of the drugs are nullified by the other drug B) the combined effects are greater than the effects of either one of the drugs alone C) one of the drugs enhances metabolism, while the other drug enhances either distribution or absorption D) both drugs are toxic in isolation but therapeutic when administered together Ans:B Feedback: Synergism occurs when two drugs with different sites or mechanisms of action produce greater effects when taken together. This does not mean that potential toxicity or adverse effects are “canceled out.” The two drugs would not individually affect different aspects of pharmacokinetics.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. A patient has been brought to the emergency department by ambulance, and his friend states that he has overdosed on methadone, a long-acting opioid. The care team is preparing to administer the appropriate antidote, naloxone, which has a shorter half-life than methadone.

What are the implications of this aspect of pharmacokinetics A) Repeated doses of naloxone will likely be necessary B) A different antidote will be required after the serum level of naloxone decreases C) An increased dose of naloxone will be required D) The antidote is unlikely to have a therapeutic effect on the patient's symptoms Ans:A Feedback: When an antidote is used, its half-life relative to the toxin's half-life must be considered. For example, the half-life of naloxone, a narcotic antagonist, is relatively short compared with the half-life of the longer-acting opioids such as methadone, and repeated doses may be needed to prevent recurrence of the toxic state

16. A patient tells the nurse, “I took my sleeping pill yesterday evening, but it didn't seem to work for me like it usually does.” The nurse should consider which of the following variables that can affect drug absorption Select all that apply A) GI function B) Blood flow to the site of administration C) The presence of other drugs D) Route of administration E) The presence of receptor agonists Ans:A, B, C, D Feedback: Numerous factors affect the rate and extent of drug absorption, including dosage form, route of administration, blood flow to the site of administration, GI function, the presence of food or other drugs, and other variables Agonist activity is a relevant variable, but this is not an aspect of absorption.

17. A nurse has administered a dose of a drug that is known to be highly protein bound. What are the implications of this characteristic A) The patient must consume adequate protein in order to achieve a therapeutic effect

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The molecules of the drug that are bound to protein are inactive C) Increased levels of serum protein will increase the effect of the drug D) Each molecule of the drug must bind to a protein molecule to become effective Ans:B Feedback: Drug molecules bound to plasma proteins are pharmacologically inactive because the large size of the complex prevents their leaving the bloodstream through the small openings in capillary walls and reaching their sites of action, metabolism, and excretion. Only the free or unbound portion of a drug acts on body cells. The patient's protein intake or levels of protein are not normally relevant 18. A patient requires a high dose of his new antihypertensive medication because the new medication has a significant first-pass effect This means that the drug A) must pass through the patient's bloodstream several times to generate a therapeutic effect B) passes through the renal tubules and is excreted in large amounts C) is extensively metabolized in the patient's liver D) is ineffective following the first dose and increasingly effective with each subsequent dose Ans:C Feedback: Some drugs are extensively metabolized in the liver, with only part of a drug dose reaching the systemic circulation for distribution to sites of action. This is called the first-pass effect or presystemic metabolism. The first-pass effect is not related to renal function or the need to pass through the bloodstream multiple times.

19. A patient with a diagnosis of bipolar disorder has begun lithium therapy, and the nurse has explained the need for regular monitoring of the patient's serum drug levels. What is the primary rationale for the nurse's instruction A) It is necessary to regularly test for blood–drug incompatibilities that may develop during treatment B) It is necessary to ensure that the patient's drug levels are therapeutic but not toxic C) It is needed to determine if additional medications will be needed to potentiate the effects of lithium D) It is needed in order to confirm the patient's adherence to the drug regimen

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Measuring serum drug levels is useful when drugs with a narrow margin of safety are given, because their therapeutic doses are close to their toxic doses. This is the case during lithium therapy. Serum levels are not commonly taken to monitor adherence to treatment. Blood– drug incompatibilities are not a relevant consideration.

20. A patient in cardiovascular collapse requires pharmacological interventions involving a rapid drug action and response. What route of administration is most likely appropriate A) Intravenous B) Oral C) Rectal D) Topical Ans:A Feedback: For rapid drug action and response, the IV route is most effective because the drug is injected directly into the bloodstream.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 3 Medication Administration and the Nursing Process of Drug Therapy 1. An infant's current weight indicates that the maximum safe dose of Tylenol is 30 mg by mouth. The physician orders 65 mg to be given, and the nurse administers Tylenol 65 mg. Who is legally responsible in the event that the infant has a toxic reaction to the medication A) The nurse B) The pharmacist C) The physician D) The pharmacy technician Ans:A Feedback: When giving medications, the nurse is legally responsible for safe and accurate administration. This regulation means that the nurse may be held liable for not giving a drug or for giving a wrong drug or dose. The pharmacist is responsible for filling the medication order, but if an error exists in the order and the medication is still administered by the nurse, the nurse is the most responsible. If the physician writes the order but does not administer the medication, then the physician is not legally responsible. The pharmacy technician is not legally responsible.

2. An 80-year-old patient with risk factors for thrombophlebitis is to be administered heparin 5000 units subcutaneously. The heparin vial is labeled 10,000 units/mL. How many milliliters will the nurse administer to the patient A) 50 mL B) 1.5 mL C) 5 mL D) 0.5 mL Ans:D Feedback: 5000 units/X = 10,000 units/1 mL. 3. The physician orders potassium chloride 40 mEq to be added to the patient's IV solution. The vial reads 10 mEq/5 mL. How many milliliters will be added to the IV solution A) 0.25 mL B) 20 mL C) 200 mL D) 40 mL Ans:B Feedback: 40 mEq/X mL = 10 mEq/5 mL 4. You have received an order for a medication to be administered buccally. Where is the medication administered

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Eye B) Vagina C) Cheek D) Nose Ans:C Feedback: A medication that has been ordered to be administered buccally is given in the patient's cheek. The eye, vagina, and nose are not considered part of the buccal mucosa.

5. The nurse is repeatedly unsuccessful in starting an IV on a patient who requires antibiotic therapy. The physician then orders the patient to receive an oral antibiotic. What is the major disadvantage of the oral route over the parenteral route A) Slower rate of action B) Greater adverse effects C) Increased risk of tolerance D) Dose must be larger Ans:A Feedback: The oral route of administration has a slower rate of action. Oral antibiotics do not produce greater adverse effects. The risk of tolerance is equal in intravenous and oral antibiotics The dose is not necessarily larger in oral versus intravenous antibiotics.

6. A patient has a gastrostomy tube, and the pharmacy has delivered an extended-release tablet.

What is the most appropriate action taken by the nurse A) Administer the medication orally B) Administer the medication through the tube C) Crush the medication and administer half of it at a time D) Call the pharmacy to obtain an immediate- release form Ans:D Feedback: The most important nursing action is to call the pharmacy to determine whether a liquid or a nonextended-release tablet can be substituted. Extended-release tablets should never be crushed—the patient would be placed at risk for overdose or potentially serious adverse effects or death. If the patient has a gastrostomy tube, then he or she cannot swallow and cannot take the pill orally. The medication cannot be administered through the tube because it will obstruct the tube.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. The nurse has measured a patient's capillary blood glucose and is preparing to administer NPH insulin. Which of the following actions should the nurse perform A) Administer intramuscularly B) Rotate the liquid C) Vigorously shake the vial D) Administer intradermally Ans:B Feedback: When administering NPH insulin, particles of active drug are suspended in a liquid; the liquid must be rotated. NPH insulin is administered subcutaneously, not intramuscularly or intradermally. The vial should be rotated or shaken, but not vigorously shaken.

8. A nurse begins a patient interaction by systematically gathering information on the patient's care and eventually evaluating the outcomes of care. Which of the following represents this continuum of care A) Assessment process B) Outcomes analysis C) Nursing interventions D) Nursing process Ans:D Feedback: The nursing process is a systematic way of gathering and using information to plan and provide individualized patient care and to evaluate the outcomes of care. The assessment, outcomes, and nursing interventions are individual components of the nursing process.

9. Which of the following assessments should be made before administering a new medication A) Determine the patient's past medication history B) Evaluate the patient's health beliefs C) Instruct the patient on the effect of the medication D) Teach the patient about the desired outcomes of drug therapy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Assessment involves collecting data on patient characteristics known to affect drug therapy. This process includes observing and interviewing the patient, interviewing family members, completing a physical assessment, reviewing medical records for pertinent laboratory and diagnostic reports, and other methods. Initially (before drug therapy is started or on first contact), the patient should be assessed for age, weight, vital signs, health status, pathologic conditions, and ability to function in usual activities. It is not necessarily important to evaluate the patient's health beliefs at this point. Education is considered to be an intervention, not an assessment.

10. A patient states that she takes acetaminophen (Tylenol) four to five times daily when she is at home. Which of the following laboratory tests is a relevant response to this practice A) Cardiac enzymes B) Peak and trough C) Liver enzymes D) White blood cell count Ans:C Feedback: Laboratory tests of liver, kidney, and bone marrow function are often helpful because some drugs may damage these organs Cardiac enzymes are assessed in the event that the patient has had myocardial infarction symptoms. The peak and trough indicates the amount of medication when half the medication has been excreted and the serum level of the medication prior to the administration of the next dose. The white blood cell count is indicative in the event of agranulocytosis or infection.

11. A patient who has been diagnosed with type 2 diabetes mellitus is being instructed on her medication regimen, diet, and exercise. She is having difficulty grasping information about when exactly she should administer insulin Which of the following nursing diagnoses is most appropriate for this patient A) Deficient knowledge: drug therapy regimen B) Noncompliance: overuse C) Risk for injury related to adverse effects D) Acute confusion related to insulin regimen Ans:A Feedback: Deficient knowledge: drug therapy regimen is the most accurate nursing diagnosis for this patient. The question does not address noncompliance: overuse. The patient is not necessarily at risk for injury based on the stem of the question. Acute confusion does not relate to a lack of understanding or knowledge.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A patient is diagnosed with pneumonia and has been placed on antibiotics to treat the infection. Which of the following nursing actions will assist in increasing lung capacity A) Promoting hand hygiene B) Increasing rest C) Frequent repositioning D) Promoting deep breathing Ans:D Feedback: Assisting the patient to cough and deep breathe will increase lung capacity and assist in fighting the infection. Promoting hand hygiene is important but will not increase lung capacity. Increasing rest will assist in recovery but will not increase lung capacity. Frequent repositioning does not increase lung capacity.

13. The nurse is providing care for a patient who has rheumatoid arthritis. Which of the following herbal supplements is often combined with chondroitin to repair cartilage A) Ginkgo B) Glucosamine C) St. John's wort D) Saw palmetto Ans:B Feedback: Glucosamine is an herbal supplement that is usually combined with chondroitin to repair cartilage. Ginkgo is used to improve memory and cognitive function in people with Alzheimer's disease. St. John's Wort is used to treat depression. Saw palmetto is used to treat urinary symptoms in men with benign prostatic hyperplasia.

14. The nurse makes an effort to provide high- quality care to patients by obtaining and analyzing the best available scientific research. This activity demonstrates an important component of which of the following A) Evidence-based nursing B) Medical justification C) Nursing data synthesis D) Scientific nursing Ans:A Feedback: Evidence-based nursing practice requires a conscientious and continuing effort to provide high-quality care to patients by obtaining and analyzing the best available scientific evidence from research. Then, the scientific evidence is integrated with the nurse's clinical

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

expertise and the patient's preferences and values to yield “best practices” for a patient with a particular disease process or health problem.

15. A patient has informed the nurse that he has begun supplementing his medication regimen with a series of herbal remedies recommended by his sister-in-law. Which of the following is the most important nursing responsibility regarding herbal supplements A) Research for potential interactions with medications B) Instruct the patient to discontinue them if taking prescription medications C) Instruct the patient to take the supplements 1 hour before prescription medications D) Instruct the patient to take the supplements 3 hours after prescription medications Ans:A Feedback: Two major concerns are that the use of supplements may keep patients from seeking treatment from a health care provider and that products may interact with prescription drugs. Not all herbal supplements should be discontinued in combination with prescription medications. The herbal supplements should be administered in varying quantities and at varying times based on the medication regime. They are not always administered 1 hour before prescription medications or 3 hours after prescription medications.

16. A patient is being administered a selective serotonin reuptake inhibitor to treat depression.

Which of the following herbal supplements is contraindicated A) St. John's wort B) Glucosamine C) Chondroitin D) Melatonin Ans:A Feedback: St. John's wort should not be combined with monoamine oxidase inhibitors or selective serotonin reuptake inhibitor antidepressants.

17. A pediatric nurse confronts many challenges when providing medications to children and infants. Which of the following principles is most appropriate when administering medication to children A) If a child is resistant to taking the medication, the nurse should tell the child that it is candy B) Measurement by teaspoons is as accurate as milliliters

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) If a drug is not supplied in liquid form, the nurse can always crush the pill D) Assess the child's weight prior to initial drug administration Ans:D Feedback: It is imperative to determine a child's weight in order to ensure safe dosage. Never describe the medication to the child as candy. Liquid medications should always be measured by milliliters, not teaspoons. Some, but not all, medications may be safely crushed.

18. An 88-year-old woman has developed syncope (fainting) since an antihypertensive agent was added to her medication regime. The development of syncope may be related to which of the following physiologic processes A) Interaction of other medications B) Ingestion of herbal supplements C) Diminished excretion of the medication D) Increased metabolism of the medication Ans:C Feedback: Adverse effects of medications in an elderly patient are likely because of physiologic changes associated with aging, pathologic changes due to disease processes, multiple drugs for acute and chronic disorders, impaired memory and cognition, and difficulty in complying with drug orders. The question does not address the interaction of other medications. The question does not identify any herbal supplements. Based on physiologic alterations, the patient will not have increased metabolism of the medication.

19. A nurse is preparing to administer a patient's scheduled beta-adrenergic blocker. The nurse is aware that the patient is receiving this drug for the treatment of hypertension. The nurse has addressed which of the following rights of safe medication administration A) Right indication B) Right diagnosis C) Right reason D) Right history Ans:C Feedback: “Right reason” is one of the universally recognized rights of safe drug administration.

The other listed “rights” are not used in practice.

20. A nurse is preparing to administer an intramuscular injection of an older adult's seasonal influenza vaccination. What size needle should the nurse use to administer the injection

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) 16 gauge B) 20 gauge C) 24 gauge D) 28 gauge Ans:B Feedback: Usually, a 25-gauge, 5/8-inch needle is used for Sub-Q injections and a 22- or 20gauge, 1 1/2-inch needle is used for IM injections.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 4 Pharmacology and the Care of Infants and Pediatric Patients Medication Administration in Pediatrics 1. A pediatric nurse is well aware of the many physiological variables that influence safe pharmacotherapy in patients younger than 18. Which of the following principles should the nurse integrate into care A) The physiology of patients older than 15 can be considered to be the same as an adult patient B) The younger the patient, the greater the variation in medication action compared to an adult C) The larger the patient's body mass index, the more his or her physiology varies from that of an adult D) Pediatric patients have a greater potential to benefit from pharmacotherapy than adult patients Ans:B Feedback: The younger the patient, the greater the variation in medication action when compared to an adult. This does not necessarily equate into a greater potential for benefit, however BMI is not the main or sole basis of variations between adults and children.

2. An infant who is 3 weeks old was born at full gestation but was just brought to the emergency department with signs and symptoms of failure to thrive. This pediatric patient will be classified into what pediatric age group A) Full-term baby B) Young infant C) Neonate D) Early postnatal Ans:C Feedback: Neonates are considered to be infants from full-term newborn 0 to 4 weeks of age.

3. A pediatric nurse practitioner is aware that there are many knowledge gaps that still exist in the evidence base that underlies pediatric pharmacology. Many of these knowledge gaps are rooted in A) a lack of scientific understanding of the anatomy and physiology of children and infants B) the historical lack of pediatric participation in the drug testing process C) the fact that research grants in pharmacology have traditionally specified adult participation D) assumptions that there are no physiological differences between adults and children Ans:B Feedback: Historically, researchers used only adults to test medications, and prescribers simply assumed that smaller doses would elicit the same results in smaller patients. The knowledge base

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

surrounding anatomical and physiological differences between adults and children is substantial, and grant funding is not typically limited to adult participation.

4. A 3-year-old Asian American boy has had culture and sensitivity testing performed, and antibiotic treatment is indicated. The prescriber knows that the recommended antibiotic has not been extensively studied in pediatric patients. Consequently, the prescriber will be obliged to do which of the following A) Administer subtherapeutic doses in order to mitigate the potential for adverse effects B) Choose a different antibiotic that has been extensively tested in children C) Apply vigilant clinical judgment when administering the antibiotic to the child D) Have the child's family sign informed consent forms absolving the care team from responsibility for adverse effects Ans:C Feedback: Prescribers must continue to treat pediatric patients with drugs for which they lack information; therefore, they must practice good assessment, dosing, and evaluation during the administration of any medication to a pediatric patient. Alternative drugs are not always an option, and a lack of data does not absolve the care team from responsibility for adverse outcomes.

5. A 9-year-old boy with severe influenza symptoms will be treated with ribavirin (Rebetol), an antiviral that is usually taken by adults twice daily in doses of 600 mg PO. After learning that the child's body surface area (BS A) is 1.10, the nurse will anticipate that the child will likely receive how much ribavirin for each dose A) 110 mg B) 380 mg C) 545 mg D) 660 mg Ans:B Feedback: The prescriber calculates a dose based on a known adult dose by using the following equation: pediatric dose = BSA/1.73 × adult dose. Thus, 1.1 1.73 × 600 = 381.5 mg. This would likely be rounded to 380 mg.

6. Significant pharmacodynamic variations exist between adult patients and pediatric patients.

Which of the following factors are known to contribute to differences in the ways that drugs affect target cells in children and infants? Select all that apply A) Inability of children to accurately describe adverse effects B) Immaturity of children's organ systems C) Differences in the body composition of children

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) The lack of active immunity in children E) Differences in the function of humoral immunity in children Ans:B, C Feedback: Immature organ systems and changing body compositions mean that drugs affect children differently. Causes of pharmacodynamic variability across the lifespan include differences in body composition, immature systems, and genetic makeup. Total body water, fat stores, and protein amounts change throughout childhood and greatly influence the effectiveness of drugs in the pediatric population. Children are indeed less able to describe adverse effects, but this is not a pharmacodynamics variation. Differences in the function of the immune system are not noted to significantly influence pharmacodynamics.

7. A 2-year-old girl with a recent history of idiopathic nausea and vomiting was prescribed promethazine (Phenergan) by her primary care provider. The immaturity of this child's gastrointestinal system will primarily influence what aspect of pharmacokinetics A) Absorption B) Distribution C) Metabolism D) Elimination Ans:A Feedback: Gastric emptying and intestinal motility greatly affect the child's drug absorption. The GI tract is less directly involved in distribution, metabolism, and elimination 8. drug for the treatment of an acute infection The nurse recognizes that the percentage of body water in an infant is significantly higher than that of an adult. What implication does this have for pharmacotherapy of an infant A) The drug will need to be emulsified before administration B) The infant's fluid intake will be reduced before and after administration C) The infant will have a fat-soluble drug substituted D) The infant may require an increased dose of the drug Ans:D Feedback: In adults, total body water is approximately 60 , whereas in newborns, it is 80.This difference means that water-soluble drugs are diluted easily and readily moved into intercellular tissue. As a result, serum drug concentrations are lower, and increased dosages of water-soluble drugs may be necessary to maintain therapeutic drug levels. Substitutes may not be available, and fluid restriction does not compensate for this physiological difference.

9. An infant with recent seizures is being treated in the neonatal intensive care unit with phenytoin (Dilantin). The infant's low plasma protein levels during the first year of life have what consequence

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The infant may have an unpredictable drug response B) The infant may have an increased risk of toxicity C) The infant may experience impaired elimination of the drug D) The infant will have an increased rate of drug metabolism Ans:B Feedback: In infants, immature liver function leads to very low plasma protein levels, which limit the amount of protein binding by drugs Consequently, the serum concentrations of highly protein-bound drugs may be higher, and toxicity may occur. This is not a result of differences in elimination or increased metabolism.

10. Which of the following laboratory tests relates most directly with the impaired drug elimination that is expected in neonates A) C-reactive protein level B) Creatine kinase C) Serum albumin level D) Glomerular filtration rate Ans:D Feedback: Excretion of most drugs occurs via the kidneys, and elimination in the urine follows.

Young children have immature kidneys, a reduced glomerular filtration rate, and slower renal clearance. Neonates are especially prone to increased levels of drugs that are eliminated primarily by the kidneys. CK, albumin, and C-reactive protein levels do not directly relate to this physiological characteristic.

11. The nurse has experienced challenges in administering a 3-year-old boy's oral antibiotics due to the boy's resistance. How can the nurse best ensure that this patient receives his necessary medication A) Convince the boy that the medication is actually a treat, especially reserved for him B) Mix the medication with pleasantly flavored syrup or pureed fruit C) Withdraw some of the child's privileges if he refuses to take his medication D) Distract the child with a toy and then put it in his mouth quickly Ans:B Feedback: To make oral medications more palatable, the nurse may mix them with flavored syrups or fruit purees. It would be inappropriate to use negative reinforcement, and medications should not be characterized as candy or treats. Sneaking the medication into the child's mouth will not ensure that it will be swallowed.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. Oral acetaminophen has been ordered for a young child who has a fever. A liquid form has been obtained by the nurse to increase the chance of problem-free administration. Prior to administration, the nurse is going through the rights of medication administration. When confirming the right dose, what term is most appropriate A) “160 mg” B) “One teaspoon” C) “One third of a tablespoon” D) “5 mL” Ans:A Feedback: To ensure accuracy and safety, the nurse should administer medications based on individual dosages in milligrams, micrograms, or units, not on variables such as tablets, teaspoons, or milliliters, for which the concentration may vary.

13. A nurse is preparing to administer a nebulized bronchodilator to a young child with asthma.

The nurse should be aware that this child's dosage is based primarily on what characteristic of the child A) Weight B) Age C) Body type D) Development stage Ans:A Feedback: Dosages of pediatric medications are calculated based on weight

14. An emergency department nurse is confirming that a child's ordered dose of IV analgesia is congruent with her body surface area (BS A). In order to calculate the child's BSA, the nurse must know which of the following variables?

Select all that apply A) The child's height B) The child's percentage of body water C) The child's weight D) The usual adult dose of the drug E) The child's age in months Ans:A, C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: BSA is calculated using the child's weight and height. The child's age and the normal adult dose are normally relevant to dosing, but not to the calculation of BSA. 15. An infant's antiseizure medication has been ordered after careful consideration of the unique pharmacokinetics among this population. What characteristic of neonates has the greatest bearing on drug metabolism A) The undeveloped state of the blood–brain barrier B) Increased gastric motility in infants C) The infant's undeveloped renal function D) Immaturity of the infant's liver Ans:D Feedback: The enzyme cytochrome P450 (CYP450) in the liver metabolizes most drugs. In neonates, the ability to metabolize drugs is very low because of the immaturity of the liver and the resultant inability to break down drugs Characteristics of the kidneys, the blood– brain barrier, and GI function do not primarily affect metabolism

16. An infant's mother is reluctant for the nurse to administer a suppository to her baby, stating, “It just seems so terribly invasive.” What principle should guide the nurse's use of suppositories in infant patients A) Suppositories are generally avoided unless absolutely necessary, due to the risk of injuring the rectal mucosa B) Suppositories can be an effective means of administering medications to infants, since oral administration is often challenging C) Suppositories should only be administered after the nurse manually clears the infant's rectum D) Suppositories are poorly absorbed in infants due to their immature gastrointestinal tract Ans:B Feedback: Suppositories are an effective way of administering medications to infants. They do not require manual clearing of the rectum prior to administration. Suppositories are well absorbed.

17. A public health nurse is preparing to administer an intramuscular injection of a vaccine to an 8-year-old girl. The nurse recognizes that the child is uncharacteristically quiet and appears tense. The nurse should recognize the possibility of what nursing diagnosis A) Fear related to IM injection B) Acute confusion related to misunderstanding of the necessity of IM injection

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Risk for injury related to IM injection D) Ineffective coping related to reluctance to receive IM injection Ans:A Feedback: IM injections are frightening for older children, and they need praise and encouragement. Fear is a far more likely cause of this child's behavior than confusion or ineffective coping. There is risk for injury associated with IM injections, but the nurse can mitigate this risk through proper technique.

18. A 4-year-old boy is postoperative day one following surgery for trauma suffered in a motor vehicle accident. The boy is in pain, and the nurse is preparing to administer a dose of hydromorphone syrup as ordered. To administer this drug, the nurse should use A) a teaspoon B) a transparent, 2-ounce medication cup C) a parenteral syringe with the needle removed D) an oral syringe Ans:D Feedback: The nurse should administer oral medications only in oral syringes. Other methods have the potential to be inaccurate.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 5 Pharmacology and the Care of Adults and Geriatric Patients 1. An 80-year-old woman has sought care for a dermatological health problem that most often requires treatment with an oral corticosteroid. When considering whether to prescribe steroids to this patient, the care provider should prioritize which of the following questions A) “Should this patient receive a medication that was likely tested on younger adults?”

B) “Do the potential benefits of this medication outweigh the potential harm?”

C) “Are there plausible herbal or complementary alternatives to this medication?”

D) “Is there a younger adult who can oversee this patient's medication regimen?”

Ans:B Feedback: The nurse and the prescriber must carefully consider the risk of associated adverse effects of those medications as well as possible benefits these medications might have in changing physiological processes related to disease. This consideration is a priority over the specifics of the drug's original testing procedure or the presence of herbal alternatives. Not every older adult requires another person to oversee his or her medications.

2. A nurse is teaching an 81-year-old man about the risk for potential adverse effects before he begins a course of antibiotics for an upper respiratory infection. What characteristic of older adults predisposes them to adverse drug reaction A) Increased excretion time due to increased bowel motility B) Impaired distribution due to polypharmacy C) A decrease in overall body surface area D) A decrease in the number of receptors needed for distribution Ans:D Feedback: Older adults are prone to adverse drug reactions because of a decrease in the number of receptors needed for drug distribution. BSA does not change appreciably with age and bowel motility slows with age. Polypharmacy is a valid concern, but this phenomenon does not primarily involve distribution.

3. A nurse is conducting a medication reconciliation of a woman who is newly admitted to a long-term care facility. When appraising the woman's medication regimen in light of the Beers Criteria, the nurse will look for A) drugs that are known to cause adverse effects in older adults B) drugs for which generic equivalents are available at lower cost C) drugs that have been found to be ineffective in older adults D) drugs that are known to exacerbate the aging process

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Dr. Mark Beers developed the Beers Criteria list of potentially inappropriate medications used by the older adult population. The list confirms that toxic medication effects and drug-related problems affect the safety of older adults and names drugs that cause problems in this population.

4. A nurse has noted that an older adult patient on an acute care for elders (ACE) unit has an exceptionally lengthy medication administration record. The nurse has alerted the pharmacist because one of the patient's long-standing medications appears on the Beers list. What medication is the nurse likely addressing A) Low-dose enteric-coated ASA B) Metoprolol (Lopressor) C) Digoxin (Lanoxin) D) Vitamin D Ans:C Feedback: Digoxin appears on the list of Beers Criteria due to the risk of adverse effects in older adults. ASA, metoprolol, and vitamin D do not appear on this list.

5. A nurse has called an elderly patient's surgeon to question the order for meperidine hydrochloride (Demerol) for pain control. The nurse's action is prompted by the possibility of what adverse effect associated with the use of Demerol in older adults A) Confusion B) Blood dyscrasias C) Gastrointestinal bleeding D) Hepatotoxicity Ans:A Feedback: Demerol is associated with confusion in older adults. It is not noted to cause blood dyscrasias, GI bleeding, or hepatotoxicity.

6. A gerontological nurse is aware that older adults' abilities to excrete medications diminish with age. When appraising an older adult's ability to excrete medications, what laboratory or diagnostic finding should the nurse prioritize A) Renal ultrasound B) Complete blood count (CBC) C) Serum bilirubin and albumin levels D) Blood urea nitrogen and creatinine levels Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The nurse should assess an older adult's blood urea nitrogen and creatinine clearance (CrCl) levels to determine the patient's ability to excrete the medications. Renal ultrasound identifies structural abnormalities in the kidneys but is less useful in diagnosing function. The patient's CBC and bilirubin and albumin levels do not help the nurse assess the patient's ability to excrete medications.

7. A 90-year-old patient’s most recent blood work includes the following data: alanine aminotransferase (ALT) 1.99 kat/L (high) and aspartate aminotransferase (AST) 3.1 kat/L (high). What implication do these data have for the patient's pharmacokinetics A) Distribution of drugs may be erratic B) Absorption of drugs may be incomplete C) Excretion of drugs may be delayed D) Metabolism of drugs may be impaired Ans:D Feedback: AST and ALT levels are used to determine the patient's liver function and ability to metabolize drugs.

8. A 72-year-old woman with a 60-pack-year history of cigarette smoking has developed chronic obstructive pulmonary disease (COP D) and has consequently been prescribed albuterol, a beta2-adrenergic agonist. When administering this medication, the nurse should be aware that A) the drug carries a higher potential for hepatotoxicity in this patient than in a younger patient B) the drug may be less effective than in a younger patient due to decreased beta- receptor function C) the patient will need to take a beta-adrenergic blocker concurrently to mitigate the likelihood of adverse effects D) the patient will need to have serial complete blood counts (CBCs) drawn following the initiation of therapy Ans:B Feedback: Beta-adrenergic agonists are less effective in older adults as a result of the decreased function of the beta-receptor system. The potential for hepatotoxicity is not increased, and a betablocker is not indicated. Serial blood work is not necessary.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. The daughter of an 80-year-old woman states that her mother has been taking alendronate (Fosamax) for several years for the treatment of osteoporosis. The daughter tells the nurse that her mother never had any complaints of nausea after taking this medication until recently. How should the nurse respond to the daughter's statement A) “It could be that your mother's stomach empties more slowly than it used to, which is a normal result of aging.”

B) “As your mother gets older, the medication travels down her esophagus more slowly than it used to. This can cause nausea.”

C) “Because your mother processes drugs more slowly than when she was younger, there is more time during which they can cause nausea.”

D) “As your mother ages, she has more of the receptors that trigger nausea. This is a normal change that accompanies the aging process.”

Ans:A Feedback: Diminished gastric emptying also plays a role by causing the medication to be in the stomach for a longer period. This factor increases the risk of developing nausea and vomiting, thus causing elimination of the medication in emesis and promoting fluid volume deficit. This phenomenon is not attributable to receptor changes or decreased esophageal motility.

10. An older adult's most recent blood work reveals that his serum albumin level is 21 g/L (low).

This will most influence what aspect of pharmacokinetics A) Absorption B) Distribution C) Metabolism D) Excretion Ans:B Feedback: Many medications require serum albumin to bind, transport, and distribute the medication to the target organ. In the event that the amount of serum albumin is insufficient, the amount of free drug rises and the effect of the drug is more intense

11. Laboratory testing of an 80-year-old patient who is well-known to the clinic nurse indicates that his liver function has been gradually decreasing over the last several years. How will this age-related physiological change influence drug metabolism A) The patient will metabolize drugs more quickly but derive less of a therapeutic benefit from them

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The liver will sequester drug molecules in the hepatocytes, and they will be released at unpredictable times C) Many of the patient's medications will remain in his body for a longer time D) The patient's kidneys will be forced to metabolize a disproportionate quantity of medications Ans:C Feedback: The hepatic enzymes of the liver are decreased in the older adult, altering the ability to remove metabolic by-products. It is important to understand that because older adults have a reduced metabolism, medications with a long half-life will remain in the body for a greater amount of time. The kidneys do not compensate for this loss of function. Drugs are not normally sequestered in the liver tissue.

12. A gerontological nurse is aware that age is a salient variable that must be considered during pharmacotherapy in adults. However, the nurse knows that many other important variables must also be considered, including ethnicity. Members of which of the following ethnic groups typically require lower doses of many common medications A) Native Americans B) Caucasian Americans C) Asian Americans D) African Americans Ans:C Feedback: Caucasian Americans and African Americans are poor metabolizers of medication compared with Asian Americans; Asian Americans have the ability to metabolize and excrete medications more quickly than those of Caucasian and African descent. This often means that Asian Americans require lower doses.

13. A nurse is reviewing a new patient's admission blood work, which indicates that the patient's glomerular filtration rate is 51 mL/min/1.732 (low). What implication m does this have for the patient's subsequent pharmacotherapy A) The patient may need lower-than-normal doses of some medications

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The patient may require a fluid challenge prior to medication administration C) The patient may need IV administration of a hypotonic solution to aid medication excretion D) The patient may need to receive medications by topical and subcutaneous routes rather than parenteral Ans:A Feedback: With a decreased GFR, it is necessary to reduce the dosage of the medication. IV fluid administration and alternative routes do not adequately compensate for this change in pharmacokinetics.

14. A 69-year-old man has been prescribed a nitrate and a calcium channel blocker for the treatment of unstable angina. When performing health education to promote adherence to his medication regimen, the nurse should emphasize which of the following A) The fact that the patient will likely need medications until he no longer experiences the signs of angina B) The fact that the patient should take his medications as ordered even if he feels well in the short term C) The fact that inconsistent medication use will likely cause the onset of hypertension D) The fact that he should gauge his day's dose based on how he feels that morning Ans:B Feedback: Being asymptomatic may contribute to nonadherence to a medication regimen. Many patients begin to feel better with the initiation of therapy and then discontinue medications altogether or miss individual doses. Patients and their families should be educated about adherence to medication regimens and taught to not skip doses, even if they feel well Inconsistent use of nitrates and calcium channel blockers does not normally lead to hypertension.

15. Mrs. James has been taking a diuretic and a beta-blocker for the treatment of hypertension for the past several months. During her latest clinic visit, she states that she has been measuring her blood pressure regularly at her local drug store and she claims that it is usually in the range of 130/80 mm Hg. As a result, she states that she has cut down on her doses of both drugs. Mrs. James' actions should indicate what nursing diagnosis to the nurse A) Risk for poisoning related to unilateral changes to medication regimen

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Acute confusion related to the necessity for medication adherence C) Readiness for enhanced decision making related to management of drug therapy D) Deficient knowledge related to self- management of drug regimen Ans:D Feedback: Mrs. James is evidently unaware of the need to take her medications consistently.

She is presuming that symptom control means that the medication is no longer indicated. The nurse should address this lack of knowledge. There is no associated risk of poisoning, and the patient's decision making is deficient, a fact that she may or may not be willing to address. Acute confusion denotes a deficit in cognitive processes, not a lack of information.

16. A nurse at a long-term care facility is surprised to learn that a new resident's medication administration record runs four pages in length. The nurse knows that polypharmacy carries which of the following risks for older adults? Select all that apply A) Increased risk of complications B) Decreased continuity of care C) Decreased cognition D) Decreased medication adherence E) Decreased costs of care Ans:A, C Feedback: Polypharmacy and the consequent interactions of medications can lead to greater complications and diminished mental status. It does not necessarily reduce the continuity of care or medication adherence. Costs to the patient are likely to be higher, not lower.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 6 Pharmacology and the Care of Pregnant or Lactating Woman 1. A pregnant woman is experiencing nausea and vomiting in her first trimester of pregnancy.

Which herbal agent has traditionally been used as an antiemetic A) Ginger B) Garlic C) Ginkgo biloba D) Green tea Ans:A Feedback: Ginger has been used to relieve nausea and vomiting during pregnancy. Garlic, Ginkgo biloba, and green tea are not recommended to relieve nausea and vomiting in pregnancy.

2. A pregnant woman asks why she needs to take a folic acid supplement. What is the nurse's best explanation for the administration of folic acid A) “Folic acid prevents the development of contractions.”

B) “Folic acid prevents neural tube birth defects.”

C) “Folic acid builds strong fetal bones.”

D) “Folic acid will decrease nausea and vomiting.”

Ans:B Feedback: Folic acid prevents neural tube birth defects. Folic acid does not prevent contractions.

Folic acid will not build fetal bones. Folic acid will not prevent nausea and vomiting.

3. A woman is being administered IV magnesium sulfate. What is a desired outcome related to the administration of magnesium sulfate A) Increased contractions B) Respiratory rate above 18 C) Decreased blood pressure D) Increased uterine tone Ans:C Feedback: The administration of magnesium sulfate can prevent seizure activity and reduce severe hypertension. Magnesium sulfate is administered for preterm labor to prevent contractions and reduce uterine tone, not to increase respiratory rate 4. A woman who began labor several hours ago is to be administered oxytocin. What is the goal of oxytocin therapy A) Prevent postpartum bleeding B) Decrease fetal hyperactivity

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Augment weak or irregular contractions D) Diminish periods of relaxation Ans:C Feedback: Use of this manufactured hormone induces labor or augments weak, irregular uterine contractions during labor. It is not used in the labor phase to prevent bleeding. It is not administered to decrease fetal hyperactivity. The administration of oxytocin should allow for adequate periods of relaxation between contractions.

5. A woman in labor is being treated with magnesium sulfate intravenously and is beginning to show signs and symptoms of hypermagnesemia. The infusion has been discontinued, and the nurse should anticipate administration of what drug A) Metoprolol (Lopressor) B) Calcium gluconate C) Potassium chloride D) Furosemide (Lasix) Ans:B Feedback: Overdoses of magnesium sulfate may lead to hypotension, muscle paralysis, respiratory depression, and cardiac arrest. Calcium gluconate, the antidote for magnesium sulfate, should be readily available for use if hypermagnesemia occurs.

6. A patient is being administered magnesium sulfate for preterm labor. The patient's serum magnesium level is elevated at 11 mg/dL. With what sign or symptom will the patient likely present A) Tachypnea B) Muscle rigidity C) Tachycardia D) Depressed deep tendon reflexes Ans:D Feedback: Hypermagnesemia will cause depressed deep tendon reflexes. The serum magnesium level of 11 mg/dL would result in depressed respirations. The serum magnesium level of 11 would result in decreased muscle strength. The serum level of 11 mg/dL would result in bradycardia, not tachycardia.

7. A woman in preterm labor has been administered terbutaline sulfate (Brethine). For what potential adverse effects should the nurse assess the patient A) Pruritus (itching) and copious diaphoresis B) Joint pain and numbness in her extremities

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Headache and visual disturbances D) Palpitations and shortness of breath Ans:D Feedback: Terbutaline sulfate (Brethine) is a beta- adrenergic agent that inhibits uterine contractions by reducing intracellular calcium levels. Adverse effects may include hyperkalemia, hyperglycemia, cardiac dysrhythmias, hypotension, and pulmonary edema. Women commonly experience hand tremors, palpitations, and shortness of breath with chest tightness.

8. When administering magnesium sulfate, for what should the nurse assess the patient A) Dry, pale skin B) Respiratory depression C) Agitation D) Tachycardia Ans:B Feedback: Overdoses of magnesium sulfate may lead to hypotension, muscle paralysis, respiratory depression, and cardiac arrest. The nurse would not anticipate dry, pale skin; agitation; or tachycardia.

9. A pregnant woman states that she has been constipated since becoming pregnant. Which medication is most appropriate for preventing constipation related to pregnancy A) Metamucil B) Mineral oil C) Saline cathartic D) Stimulant cathartic Ans:A Feedback: A bulk-producing agent, such as Metamucil, is most physiologic for the mother and safe for the fetus. Mineral oil is not recommended because of the lack of absorption of fatsoluble vitamins. Saline cathartics are not recommended because of hypernatremia Stimulant cathartics are not recommended for the pregnant woman.

10. A woman who is 7 months pregnant is waking up at night with gastroesophageal reflux Which of the following medications is most highly recommended A) Terbutaline (Brethine) B) Diphenoxylate (Lomotil) C) Ranitidine (Zanta C) D) Chlorothiazide (Diuril)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: A histamine2 receptor antagonist, such as ranitidine, is used for gastroesophageal reflux disease. Terbutaline is a tocolytic agent Diphenoxylate is not administered for GERD Chlorothiazide is a diuretic agent antiretroviral therapy (HAART) for HIV/

12. A woman is at 42 weeks of gestation. Which of the following medications will be administered to promote cervical ripening A) Calcium gluconate B) Magnesium sulfate C) Terbutaline (Brethine) D) Dinoprostone (Cervidil) Ans:D Feedback: Cervidil is administered to ripen the cervix in a woman who is at 42 weeks of gestation Calcium gluconate, magnesium sulfate, and terbutaline are not administered to ripen the cervix.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

13. A patient is receiving oxytocin (Pitocin). Which of the following is a maternal adverse effect of Pitocin A) Acute confusion B) Hypertension C) Edema D) Inverted T wave Ans:B Feedback: Hypertension is a maternal adverse effect of Pitocin. Confusion, edema, and inverted T wave are not adverse effects of Pitocin.

14. A woman was administered misoprostol (Cytote C) in an effort to induce labor, but the care team is unsatisfied with the results Consequently, oxytocin will be used. Prior to administering oxytocin, what must occur A) Four hours must elapse after the last dose of misoprostol B) The woman must have a type and cross-match performed C) The woman must receive a bolus of 500-mL normal saline D) The woman must have her electrolytes measured Ans:A Feedback: If the course of treatment changes and oxytocin is to be given after misoprostol, it is essential to wait 4 hours from the last administration of misoprostol before starting oxytocin.

Blood work and IV hydration are not necessary.

15. A patient is being treated for preterm labor. Which beta-adrenergic medication is administered orally to decrease uterine contractions A) Magnesium sulfate B) Oxytocin (Pitocin) C) Nifedipine (Procardi A) D) Terbutaline (Brethine) Ans:D Feedback: Terbutaline is a beta-adrenergic agent that inhibits uterine contractions by reducing intracellular calcium levels; oral doses can be given as maintenance therapy. Magnesium sulfate

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

is administered intravenously and not administered at home. Oxytocin induces labor. Nifedipine is a calcium channel blocker that decreases uterine contractions.

16. A couple have been trying unsuccessfully for nearly a year to become pregnant and have now sought fertility counseling. The nurse should be aware of what potential etiological factors related to infertility? Select all that apply A) Absence of sperm B) Endometriosis C) Vaginitis D) Blocked fallopian tubes E) Fibromyalgia Ans:A, B, D Feedback: In women, the most common causes are ovulation disorders, blocked fallopian tubes, endometriosis, and advanced maternal age, which affects egg quality and quantity. In men, causes include absence of sperm, declining sperm counts, testicular abnormalities, and ejaculatory dysfunction. Vaginitis cannot cause infertility, and fibromyalgia is not noted as a common etiological factor.

17. A woman has been unable to conceive for many months and will soon begin treatment with clomiphene (Clomi D). What health education should the nurse provide to this patient A) Avoid drinking alcohol while taking Clomid B) Perform daily OTC pregnancy tests beginning the day after taking Clomid C) Take her basal temperature between 5 to 10 days after taking Clomid D) Report any numbness or tingling in her hands or lips to her care provider Ans:C Feedback: Ovulation occurs 5 to 10 days after the course of clomiphene treatment has been completed. Prior to beginning the drug regimen, the nurse instructs the woman about taking her basal temperature 5 to 10 days following administration. An incremental rise in temperature is an indication of ovulation There is no specific contraindication against alcohol, and neurological adverse effects are not expected.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse is performing health education with a woman who has just learned that she is pregnant. The nurse has explained the concept of teratogenic drugs and emphasized the need to have her care provider assess any medications she should consider taking. The nurse should teach the woman that drug- induced teratogenicity is most likely to occur at what point in her pregnancy A) During the second half of her third trimester B) In the 7 to 10 days after conception C) In the first trimester during organogenesis D) During 30 to 34 weeks of gestation Ans:C Feedback: Drug-induced teratogenicity is most likely to occur when drugs are taken during the first three months of pregnancy, during organogenesis.

19. A primiparous woman was vigilant in avoiding medications and herbs during her pregnancy and states that she is similarly committed to protecting her baby's health now that she is breastfeeding. What principle should guide the woman's use of medications while breast-feeding A) Very few medications are explicitly contraindicated while breast-feeding B) It is generally safer to use herbs rather than medications while breast-feeding C) Most women can resume their prepregnancy medication regimen after delivery D) Most medications are contraindicated while a woman is breast-feeding Ans:D Feedback: A wide variety of medications are contraindicated during pregnancy, and herbs are not guaranteed to be safe.

20. A woman who is in the first trimester of her pregnancy has told the nurse, “I've stopped taking my blood pressure pill because I know it could harm the baby. Instead, I've started taking natural and herbal remedies.” What nursing diagnosis is suggested by the woman's statement A) Deficient knowledge related to drug and herbal effects during pregnancy B) Health-seeking behaviors related to protection of fetal health

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Acute confusion related to the potential teratogenic effects of herbs D) Effective therapeutic regimen management related to use of herbs rather than drugs Ans:A Feedback: This patient is evidently unaware of the fact that herbs pose risks to her fetus and that such risks are not limited to drugs. The nurse should address this knowledge gap. Acute confusion suggests a deficit in cognitive processes, not a lack of relevant and accurate information.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 7 Pharmacology and Women's Health

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 8 Pharmacology and Men's Health

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 9 Drug Therapy for Coagulation Disorders 1. open heart surgery. The patient tells the home care nurse she has pain in both knees that began this week. The nurse notes bruises on both knees. Based on the effects of her medications and the complaint of pain, what does the nurse suspect is the cause of the pain A) Joint thrombosis B) Torn medial meniscus C) Degenerative joint disease caused by her medication D) Bleeding Ans:D Feedback: The main adverse effect of warfarin (Coumadin) is bleeding. The sudden onset of pain in the knees alerts the nurse to assess the patient for bleeding. Arthritis, torn medical meniscus, and degenerative joint disease could all be symptoms of knee pain, but the onset and combination of anticoagulant therapy is not an etiology of these types of injuries and disease.

2. A patient who has been treated with warfarin (Coumadin) after cardiac surgery is found to have an INR of 9.0. Which medication will be administered to assist in the development of clotting factors A) Vitamin K B) Vitamin E C) Protamine sulfate D) Acetylsalicylic acid (Aspirin) Ans:A Feedback: Vitamin K is the antidote for warfarin overdosage. In this case, the patient may be at the therapeutic level to control thrombus formation, but, due to the injury, it is important to control bleeding. Vitamin E is not used as an antidote for warfarin overdosage. Protamine sulfate is used as an antidote to heparin or low molecular-weight heparin. Acetylsalicylic acid (Aspirin) is used to decrease coagulation as a preventive measure for myocardial infarction.

3. A patient has a history of clot formation. She is scheduled for bowel resection due to colorectal cancer. What anticoagulant agent will be administered prophylactically A) Acetylsalicylic acid (Aspirin) B) Heparin C) Warfarin (Coumadin) D) Streptokinase (Streptase) Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Prophylactically, low doses of heparin are given to prevent thrombus formation in patients having major abdominal surgery. Acetylsalicylic acid is not used to prevent thrombus in patients having major abdominal surgery. Warfarin takes several days for therapeutic effects to occur; thus it is not used prophylactically to prevent thrombus in a patient with abdominal surgery. Streptokinase promotes thrombolysis and is not used to prevent thrombus.

4. A patient has been administered heparin to prevent thromboembolism development status postmyocardial infarction. The patient develops heparin-induced thrombocytopenia. Which of the following medications will be administered A) Argatroban (Acov A) B) Vitamin K C) Calcium gluconate D) Aminocaproic acid (Amicar) Ans:A Feedback: Heparin-induced thrombocytopenia may occur in 1 to 3 of those receiving heparin and is a very serious side effect of heparin. In this patient, all heparin administration must be discontinued and anticoagulation managed with a direct thrombin inhibitor, such as argatroban. The patient is not administered vitamin K, calcium gluconate, or aminocaproic acid.

5. A patient is receiving low molecular weight heparin to prevent thromboembolic complications.

The nursing student asks the nursing instructor the reason why this treatment is given instead of heparin. What is the instructor's best explanation of the rationale for LMWH over heparin A) “LMWH is associated with less thrombocytopenia than standard heparin.”

B) “LMWH is associated with stronger anticoagulant effects than standard heparin.”

C) “LMWH is given to patients who have a history of blood dyscrasia.”

D) “LMWH is more effective than standard heparin for patients with hypertension.”

Ans:A Feedback: Low molecular weight heparins are associated with less thrombocytopenia than standard heparin. Low molecular weight heparin is not stronger than standard heparin. Low molecular weight heparin is administered cautiously in patients with blood dyscrasia and hypertension.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient who is receiving warfarin (Coumadin) has blood in his urinary catheter drainage bag. What medication will likely be ordered by the physician A) Aminocaproic acid (Amicar) B) Platelets C) Protamine sulfate D) Vitamin K Ans:D Feedback: Vitamin K is the antidote for warfarin overdose. Aminocaproic acid is used to control excessive bleeding from systemic hyperfibrinolysis. Platelets are a blood product, not a medication. Protamine sulfate is the antidote for heparin therapy.

7. A patient has experienced the formation of clots and has bruising. It is determined that there is a depletion of the patient's coagulation factors and widespread bleeding. Which of the following medications will be administered A) Aminocaproic acid (Amicar) B) Heparin C) Warfarin (Coumadin) D) Protamine sulfate Ans:B Feedback: The development of clots and widespread bleeding is indicative of disseminated intravascular coagulation. The patient should be administered heparin to slow the formation of clots. The goal of heparin therapy in DIC is to prevent blood coagulation long enough for clotting factors to replenish and control hemorrhage. Aminocaproic acid is used to control excessive bleeding from systemic hyperfibrinolysis. Warfarin is administered orally to decrease clot formation. Protamine sulfate would not be administered.

8. A patient is admitted with thrombophlebitis and sent home on enoxaparin (Lovenox) Which statement indicates a good understanding of why enoxaparin is being administered A) Enoxaparin inhibits the formation of additional clots B) Enoxaparin eliminates certain clotting factors C) Enoxaparin decreases the viscosity of blood D) Enoxaparin will dissolve the existing clots Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Low molecular weight heparins prevent the development of additional clots. They do not eliminate clotting factors. LMWHs do not dissolve the clot or decrease the viscosity of blood.

9. A patient is being discharged from the hospital with warfarin (Coumadin) to be taken at home.

Which of the following foods should the patient be instructed to avoid in his diet A) Eggs B) Dairy products C) Apples D) Spinach Ans:D Feedback: Spinach is a green leafy vegetable that is high in vitamin K and will interact to prevent adequate levels of anticoagulant therapy Eggs, dairy products, and apples are not contraindicated with warfarin.

10. A patient is discharged from the hospital with a prescription of warfarin (Coumadin). Which of the following statements indicates successful patient teaching A) “If I miss a dose, I will take two doses.”

B) “I will avoid herbal remedies.”

C) “I will eat spinach or broccoli daily.”

D) “I will discontinue my other medications.”

Ans:B Feedback: Most commonly used herbs and supplements have a profound effect on drugs for anticoagulation. The patient should never double up on dosing related to a missed dose. The patient should avoid green leafy vegetables due to vitamin K. The patient should not discontinue his or her medications

11. A patient is being administered heparin IV and has been started on warfarin (Coumadin). The patient asks the nurse why she is taking both medications. What is the nurse's most accurate response A) “After a certain period of time, you must start warfarin and heparin together.”

B) “You will need both warfarin and heparin for several days.”

C) “Warfarin takes 3 to 5 days to develop anticoagulant effects, and you still need heparin.”

D) “Warfarin cannot be given without heparin due to the amount of clotting you need.”

Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Anticoagulant effects do not occur for 3 to 5 days after warfarin is started because clotting factors already in the blood follow their normal pathway of elimination. The statement “After a certain period of time, you must start warfarin and heparin together” does not explain clearly the reason for the two medications concurrently. The statement “You will need both warfarin and heparin for several days” does not explain clearly the reason for the two medications. The statement “Warfarin cannot be given without heparin due to the amount of clotting you need” is not accurate.

12. A patient asks the nurse what dose of acetylsalicylic acid (Aspirin) is needed each day for antiplatelet effects to prevent heart attacks. What dose is most appropriate to reduce platelet aggregation A) 10 mg B) 30 mg C) 625 mg D) 1000 mg Ans:B Feedback: A single dose of 300 to 600 mg or multiple doses of 30 mg inhibit cyclooxygenase in circulating platelets almost completely. The dose of 10 mg is too small. The doses of 625 mg and 1000 mg are too large.

13. A patient is prescribed eptifibatide (Integrilin), which inhibits platelet aggregation by preventing activation of GP IIb/IIIa receptors on the platelet surface and the subsequent binding of fibrinogen and von Willebrand factor to platelets. Which of the following syndromes are treated with eptifibatide A) Blocked carotid arteries B) Intermittent claudication C) Hypertension D) Unstable angina Ans:D Feedback: Eptifibatide (Integrilin) inhibits platelet aggregation by preventing activation of GP IIb/IIIa receptors on the platelet surface and the subsequent binding of fibrinogen and von Willebrand factor to platelets. Eptifibatide is used for acute coronary syndromes, including unstable angina, myocardial infarction, and non–Q wave MI. Blocked carotid arteries, intermittent claudication, and hypertension are not treated with eptifibatide.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A patient is receiving IV heparin every 6 hours. An activated partial thromboplastin time (aPTT) is drawn 1 hour before the 08:00 dose. The PTT is 92 seconds. What is the most appropriate action by the nurse A) Give the next two doses at the same time B) Give the dose and chart the patient response C) Check the patient's vital signs and give the dose D) Hold the dose and call the aPTT result to the physician's attention Ans:D Feedback: The normal control value is 25 to 35 seconds; therefore, therapeutic values are 45 to 70 seconds, approximately. A result of 92 seconds is a risk for bleeding, and the dose should be held until approval to administer is provided by the physician. The nurse should not give the next two doses at the same time. The nurse should not give the dose and document the patient's response. The nurse should not check the patient's vital signs and give the dose.

15. A patient is taking warfarin (Coumadin) to prevent clot formation related to atrial fibrillation. How are the effects of the warfarin (Coumadin) monitored A) RBC B) aPTT C) PT and INR D) Platelet count Ans:C Feedback: The warfarin dose is regulated according to the INR. The INR is based on the prothrombin time. The red blood cell count is not indicative of warfarin dosage. The aPTT is utilized to determine heparin dose. The platelet count is required to determine warfarin dose.

16. A patient who is recovering in hospital from a bilateral mastectomy has developed minor bleeding at one of her incision sites. During the process of clot formation, plasminogen will become part of a clot by which of the following means A) By binding with fibrin B) By binding with platelets C) By activating plasmin D) By activating factor VII Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: When a blood clot is being formed, plasminogen, an inactive protein present in many body tissues and fluids, is bound to fibrin and becomes a component of the clot.

Plasminogen does not bind to platelets, activate plasmin, or active factor VII.

17. A 55-year-old man has been diagnosed with coronary artery disease and begun antiplatelet therapy. The man has asked the nurse why he is not taking a “blood thinner like warfarin.” What is the most likely rationale for the clinician's use of an antiplatelet agent rather than an anticoagulant A) Antiplatelet agents do not require the man to undergo frequent blood work; anticoagulants require constant blood work to ensure safety B) Antiplatelet agents are more effective against arterial thrombosis; anticoagulants are more effective against venous thrombosis C) Antiplatelet agents are most effective in large vessels; anticoagulants are most effective in the small vessels of the peripheral circulation D) Antiplatelet agents have fewer adverse effects than anticoagulants Ans:B Feedback: Anticoagulants are more effective in preventing venous thrombosis than arterial thrombosis. Antiplatelet drugs are used to prevent arterial thrombosis. CAD has an arterial rather than venous etiology. The rationale for the use of antiplatelet agents in CAD is not likely related to the need for blood work or the presence of adverse effects.

18. A nurse at a long-term care facility is conducting a medication reconciliation for a man who has just moved into the facility. The man is currently taking clopidogrel (Plavix). The nurse is most justified is suspecting that this man has a history of A) hemorrhagic cerebrovascular accident B) hemophilia A C) idiopathic thrombocytopenic purpura (ITP) D) myocardial infarction Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Indications for use of Plavix include reduction of myocardial infarction, stroke, and vascular death in patients with atherosclerosis and in those after placement of coronary stents. It is not indicated in the treatment of ITP, CVA, or hemophilia.

19. A 79-year-old woman has been brought to the emergency department by ambulance with signs and symptoms of ischemic stroke. The care team would consider the STAT administration of what drug A) Low molecular weight heparin B) Vitamin K C) Clopidogrel (Plavix) D) Alteplase (Activase) Ans:D Feedback: Alteplase (Activase) is used as first-line therapy for the treatment of acute ischemic stroke in selected people. Vitamin K would exacerbate the woman's symptoms, and LMWH and Plavix would be ineffective.

20. A 50-year-old man has undergone a bunionectomy and has been admitted to the postsurgical unit. What aspect of the man's medical history would contraindicate the use of heparin for DVT prophylaxis A) The man is morbidly obese B) The man has a diagnosis of ulcerative colitis C) The man had a myocardial infarction 18 months ago D) The man has a diagnosis of type 2 diabetes mellitus Ans:B Feedback: GI ulcerations contraindicate the use of heparin. Obesity, diabetes, and previous MI do not rule out the safe use of heparin.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 10 Drug Therapy for Dyslipidemia 1. An obese patient who has an elevated triglyceride level and reduced high-density lipoprotein cholesterol is seen by her primary care physician. What do these data suggest in this patient A) The development of arthritic syndrome B) The development of metabolic syndrome C) The development of Reye's syndrome D) The development of Tay-Sachs disease Ans:B Feedback: Metabolic syndrome is noted when the patient has elevated waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose. Elevated triglyceride level and reduced high-density lipoprotein cholesterol are not indicative of arthritic syndrome. Reye's syndrome is marked by acute encephalopathy and seen in children under the age of 15 years after an acute viral infection. TaySachs is a genetic disease characterized by neurological deterioration in the first year of life.

2. A patient has an elevated total serum cholesterol of 260 mg/dL. Which of the following aspects of patient teaching of lifestyle changes is most important for the patient A) Eat organic foods B) Stop smoking C) Increase rest periods D) Drink whole milk Ans:B Feedback: Therapeutic lifestyle changes to lower serum cholesterol, including exercise, smoking cessation, change in diet, and drug therapy, are recommended to lower serum cholesterol. The patient with an elevated serum cholesterol should increase exercise and not increase rest periods. The patient should consume low-fat dairy products and avoid whole milk.

Organic foods are not specifically recommended.

3. A patient with a diagnosis of cardiovascular disease is taking atorvastatin calcium (Lipitor) to reduce serum cholesterol. What is the goal of therapy for LDL cholesterol for a patient taking atorvastatin calcium (Lipitor)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) 100 to 115 mg/dL B) 75 to 85 mg/dL C) Less than 60 mg/dL D) Less than 100 mg/dL Ans:D Feedback: In patients with a diagnosis of cardiovascular disease, the goal of therapy is an LDL below 100 mg/dL. 4. A male patient is taking atorvastatin calcium (Lipitor) to reduce serum cholesterol. Which of the following aspects of patient teaching is most important A) Call his physician if he develops muscle pain B) It is unacceptable to eat dietary fats C) Decrease the dose if lethargy occurs D) Eat two eggs per day to increase protein stores Ans:A Feedback: Patients should be advised to notify their health care provider if unexplained muscle pain or tenderness occurs. The patient should avoid saturated fats when taking statins but should not entirely eliminate fats from his diet. The patient should not decrease the dose of statins without the physician's knowledge. The patient should not increase the intake of eggs due to the increase in cholesterol.

5. A patient has begun taking cholestyramine. Which of the following are noted as the most common adverse effects A) Nausea, flatulence, and constipation B) Increased appetite and blood pressure C) Fatigue and mental disorientation D) Hiccups, nasal congestion, and dizziness Ans:A Feedback: Cholestyramine is not absorbed systemically, so the main adverse effects are gastrointestinal (GI) ones (abdominal fullness, flatulence, diarrhea, and constipation) Constipation is especially common, and a bowel program may be necessary to control this problem.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient who has been taking a statin has seen an improvement in his cholesterol laboratory values; however, the low-density lipoprotein remains elevated. What medication will be added to the medication regimen A) Digoxin (Lanoxin) B) Vitamin D C) Cholestyramine (Questran) D) Calcium carbonate Ans:C Feedback: Cholestyramine is administered to patients to reduce LDL cholesterol in patients who are already taking a statin drug. Digoxin is not given to lower LDL cholesterol. Vitamin D is not given to lower LDL cholesterol. Calcium carbonate is not given to lower LDL cholesterol.

7. A patient is taking cholestyramine (Questran) to reduce LDL cholesterol. Cholestyramine will cause a decrease in absorption of which of the following medications A) Digoxin (Lanoxin) B) Ibuprofen (Motrin) C) Aspirin D) Acetaminophen (Tylenol) Ans:A Feedback: Bile acid sequestrants may decrease absorption of digoxin (Lanoxin) Cholestyramine will not decrease the ibuprofen, aspirin, or acetaminophen.

8. A patient is prescribed fenofibrate (TriCor). When providing patient teaching, which of the following accurately describes the action of fenofibrate A) It binds to bile acids in the intestinal lumen B) It increases oxidation of fatty acids in the liver C) It inhibits an enzyme required for hepatic synthesis D) It inhibits mobilization of free fatty acids from peripheral tissues Ans:B Feedback: Fibrates increase oxidation of fatty acids in the liver. Bile acid sequestrants bind to bile acids in the intestinal lumen. HMG-CoA reductase inhibitors inhibit an enzyme required for hepatic synthesis. Niacin inhibits mobilization of free fatty acids from peripheral tissues

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. Which single drug class is known to be most effective in reducing the major types of dyslipidemia A) Statins B) Bile acid sequestrants C) Fibrates D) Niacin Ans:A Feedback: For single-drug therapy, a statin is preferred for the treatment of dyslipidemia. To lower cholesterol and triglycerides, a statin, a cholesterol absorption inhibitor, gemfibrozil, a fibrate, or the vitamin niacin may be used. To lower triglycerides, gemfibrozil, ezetimibe, a cholesterol absorption inhibitor, or niacin may be given.

10. A patient is taking cholestyramine (Questran) and ezetimibe (Zeti A). What administration guideline is most important to teach this patient A) The two medications should be taken together B) The ezetimibe inhibits cholesterol in the liver C) The cholestyramine (Questran) is administered 1 hour after ezetimibe D) The administration of ezetimibe (Zeti A) is 2 hours before cholestyramine Ans:D Feedback: Ezetimibe (Zeti A) should be taken 2 hours before or 4 hours after a bile acid sequestrant. The two medications should not be taken together. Ezetimibe acts in the small intestine to inhibit absorption of cholesterol and decrease the delivery of intestinal cholesterol in the liver. They do not inhibit the absorption of cholesterol. Cholestyramine should not be administered 1 hour after ezetimibe 11. flax seed to lower cholesterol. What should the patient be taught about the use of flax seed and cholestyramine (Questran) A) Cholestyramine absorption will be increased with flax seed B) Cholestyramine absorption will be decreased with flax seed C) Bleeding will be increased with flax seed and cholestyramine D) Hypoglycemia will result from flax seed and cholestyramine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Absorption of cholestyramine is decreased with flax seed. Bleeding is not increased with flax seed and cholestyramine. Hypoglycemia will not result from flax seed and cholestyramine.

12. Which herbal and dietary supplement has shown proven success in lowering LDL and total cholesterol in research studies A) Soy B) Ginkgo biloba C) Green tea D) Garlic Ans:A Feedback: Soy is used as a food source and has been researched extensively to lower cholesterol. Ginkgo biloba, green tea, and garlic do not have extensive scientific research to support the lowering of cholesterol.

13. A patient is scheduled to have her serum triglyceride level assessed. How long should the patient be without food or fluids prior to the serum triglyceride test A) 6 hours B) 8 to 10 hours C) 12 hours D) 24 hours Ans:C Feedback: For accurate interpretation of a patient's lipid profile, blood samples for laboratory testing of triglycerides should be drawn after the patient has fasted for 12 hours.

14. Mr. Burris is a 66-year-old man who leads a sedentary lifestyle and who has recently been diagnosed with dyslipidemia. Mr. Burris is disappointed to learn of this apparent deterioration in his health, stating, “First it was the diabetes and then the arthritis, now this.” The nurse has performed health education with Mr. Burris and has described metabolic syndrome. In addition to his elevated cholesterol levels, what aspect of Mr. Burris' health is congruent with a diagnosis of metabolic syndrome

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Sedentary lifestyle B) Age over 65 coupled with male gender C) Arthritis D) Diabetes mellitus Ans:D Feedback: Diagnostic criteria for metabolic syndrome include a cluster of several cardiovascular risk factors linked with obesity: increased waist circumference, elevated triglycerides, reduced high-density lipoprotein cholesterol, elevated blood pressure, and elevated fasting glucose. Age, gender, and joint disorders are not among these criteria.

15. A male patient has been diagnosed with moderately increased LDL, and his primary care provider wishes to begin him on a statin. What is a potential disadvantage of statins that the care provider should consider? Select all that apply A) Statins are nephrotoxic B) Statins are expensive C) Statins are contraindicated in patients with a history of myocardial infarction D) Statins require regularly scheduled blood work E) Statins have an immunosuppressive effect Ans:B, D Feedback: Because liver enzymes may be elevated during atorvastatin use, patients need liver function tests and repeat lipid profile testing on a routine basis. These drugs are also expensive.

They are not nephrotoxic and do not suppress the immune system. Previous MI is an indication for their use, not a contraindication.

16. A patient will begin taking atorvastatin (Lipitor), and the nurse is conducting relevant health education. The nurse should emphasize the need to report any new onset of A) muscle pain B) dry mouth C) pruritus (itching) D) increased thirst Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Myopathy is an important adverse effect of statins. Statins can injure muscle tissue, resulting in muscle ache or weakness; this should be reported promptly. Dry mouth, pruritus, and thirst are not reported adverse effects of statins.

17. A 74-year-old male patient is being treated in the hospital for a stroke and is undergoing an extended stay on a rehabilitation unit. The patient's wife has been participating actively in his care and performs much of his feeding and hygiene. This evening, the patient's wife has brought in a number of healthy snacks to keep at his bedside. Knowing that the patient's medication regimen includes simvastatin, the nurse would remove which of the following items A) Purple grapes B) Cranberry cocktail C) Grapefruit juice D) Trail mix (salted nuts and seeds) Ans:C Feedback: It is important to avoid taking simvastatin with grapefruit juice. None of the other listed foods is contraindicated.

18. A patient has been largely unsuccessful in achieving adequate control of dyslipidemia through lifestyle changes and the use of a statin. As a result, the patient has been prescribed cholestyramine (Prevalite, Questran). What change in this patient's lipid profile will the nurse identify as the most likely goal of therapy A) Reduction in triglycerides B) Reduction in total serum cholesterol levels C) Increase in HDL levels D) Reduction in LDL cholesterol levels Ans:D Feedback: Cholestyramine (Prevalite, Questran), the prototype bile acid sequestrant, has the ability to reduce LDL cholesterol. It has little or no effect on HDL cholesterol and either no effect or an increased effect on triglyceride levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A 66-year-old woman's most recent physical assessment and diagnostic workup reveal the presence of dyslipidemia. The woman is a candidate for monotherapy with a statin, and she will soon begin treatment with atorvastatin (Lipitor). The nurse should anticipate what order A) “Lipitor 150 mg PO BID” B) “Lipitor 10 mg PO OD” C) “Lipitor 50 mg PO TID with meals” D) “Lipitor 75 mg PO BID” Ans:B Feedback: Lipitor is normally administered PO 10 to 80 mg daily in a single dose

20. An elderly patient with dyslipidemia has had fenofibrate (TriCor) added to her existing medication regimen. In addition to having her lipid profile drawn on a regular basis, the nurse should educate the patient about the need for what ongoing laboratory testing during therapy A) Complete blood count (CB C) B) Liver panel C) INR and aPTT D) Reticulocyte count Ans:B Feedback: Because of the risk for hepatotoxicity, patients taking fenofibrate (TriCor) require serial testing of liver enzyme levels. There is no specific need for follow-up with CBCs, coagulation tests, or reticulocyte counts

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 11 Drug Therapy for Hematopoietic Disorders 1. A patient has a low erythrocyte count. How may a colony-stimulating factor affect the patient's erythrocyte count A) It stimulates growth of red blood cells B) It suppresses T-cell production C) It inhibits protein synthesis D) It stimulates antibody production Ans:A Feedback: Colony-stimulating factors stimulate the production of red blood cells, platelets, granulocytes, granulocyte–macrophages, and monocyte–macrophages. Colony-stimulating factors will not suppress the T-cell production, inhibit protein production, or stimulate antibody production.

2. A patient is exposed to a viral infection. What role will interferon most likely play during this exposure A) It will stimulate B-lymphocyte activity B) It will interfere with stem cell multiplication C) It will stimulate growth of lymphoid cells D) It will interfere with virus replication Ans:D Feedback: Interferons interfere with the ability of viruses in infected cells to replicate and spread to uninfected cells. Interferons will not stimulate B-lymphocyte activity, stem cell multiplication, or growth of lymphoid cells.

3. A patient has developed a decubitus ulcer on the coccyx. What defense mechanism is most affected by this homeostatic change A) The mucous membrane is affected B) The respiratory tract is affected C) The skin is affected D) The gastrointestinal tract is affected Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The body's primary external defense mechanism is intact skin. The development of a decubitus ulcer allows for entry of microbial growth. The mucous membranes, respiratory tract, and gastrointestinal tract are not affected primarily.

4. A patient is being administered chemotherapeutic agents for the treatment of cancer. Which of the following blood cells will be stimulated by the colony-stimulating factors in response to the effects of the chemotherapy A) White blood cells B) Red blood cells C) Phagocytes D) Myocardial cells Ans:B Feedback: Chemotherapeutic agents have the potential to decrease red blood cells and will result in the colony-stimulating factors stimulating the production of red blood cells. The colonystimulating factors do not affect the white blood cell production, phagocytes, or cardiac cells.

5. A patient with chronic renal failure is prescribed filgrastim (Neupogen). What is the major effect of filgrastim (Neupogen) A) Decreases neutropenia related to chemotherapy B) Decreases white blood cells related to infection C) Decreases growth of blood vessels due to ischemia D) Decreases platelet count related to bleeding Ans:A Feedback: Filgrastim (Neupogen) is used to stimulate blood cell production by the bone marrow in places with bone marrow transplantation or chemotherapy-induced neutropenia Filgrastim does not decrease white blood cells in response to infection. Filgrastim increases growth of blood vessels related to ischemic heart disease. Filgrastim does not decrease platelet count related to bleeding.

6. A patient has been diagnosed with chronic renal failure. Which of the following agents will assist in raising the patient's hemoglobin levels A) Epoetin alfa (Epogen, Procrit) B) Pentoxifylline (Pentoxil) C) Estazolam (ProSom) D) Dextromethorphan hydrobromide Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Uses of epoetin include the prevention and treatment of anemia associated with chronic renal failure, hepatic impairment, or anticancer chemotherapy. Pentoxifylline is used for intermittent claudication to maintain the flexibility of red blood cells. Estazolam is a benzodiazepine agent used short term for insomnia. Dextromethorphan hydrobromide is used to relieve cough.

7. A patient is undergoing a bone marrow transplant. Which of the following medications is most effective in stimulating the production of granulocytes and macrophages A) Bacillus Calmette-Guérin (BCG) B) Epoetin alfa (Epogen) C) Aldesleukin (Proleukin) D) Sargramostim (Leukine) Ans:D Feedback: Sargramostim (Leukine) is a formulation of granulocyte colony-stimulating factor (GCSF) and granulocyte macrophage colony- stimulating factor (GM-CSF). Bacillus CalmetteGuérin is a vaccine used to treat bladder cancer. Epoetin alfa stimulates bone marrow production of red blood cells Aldesleukin (Proleukin) is a recombinant DNA version of interleukin-2. It activates cellular immunity.

8. A hospital patient's complex medical history includes a recent diagnosis of kidney cancer.

Which of the following medications is used to treat metastatic kidney cancer A) Filgrastim (Neupogen) B) Aldesleukin (Proleukin) C) Interferon alfa-2b (Intron A) D) Darbepoetin alfa (Aranesp) Ans:B Feedback: Aldesleukin (Proleukin) is used to treat metastatic kidney cancer but is contraindicated in patients with serious pulmonary impairment. Filgrastim is a colonystimulating factor that is not used for the treatment of kidney cancer. Darbepoetin alfa is a hormone that stimulates the production of red blood cells by the bone marrow. Interferon alfa-2b (Intron A) is normally used to treat leukemia.

9. A patient is diagnosed with ischemic heart disease. She is prescribed filgrastim (Neupogen).

What effect will this medication provide in the treatment of ischemic heart disease A) Increase platelets

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Decrease platelets C) Promote angiogenesis D) Prevent thrombus formation Ans:C Feedback: Experts believe that filgrastim promotes the growth of arterioles around blocked areas in coronary arteries. Filgrastim does not increase or decrease platelets. Filgrastim does not prevent thrombus formation.

10. A patient with a diagnosis of renal failure is being treated with epoetin alfa (Epogen) Frequent assessment of which of the following laboratory values should be prioritized before and during treatment A) AST B) C-reactive protein C) CBC D) ALT Ans:C Feedback: With the use of hematopoietic and immunostimulant drugs, a CBC with WBC differential and platelet count should be done before and during treatment to monitor response and prevent avoidable adverse reactions. It is less imperative to monitor liver enzymes or CRP levels.

11. A patient is receiving epoetin alfa (Epogen) for anemia. Which of the following adjunctive therapies is imperative with epoetin alfa A) Potassium supplements B) Sodium restriction C) Iron supplement D) Renal dialysis Ans:C Feedback: When administering darbepoetin and epoetin, an adequate intake of iron is required for drug effectiveness and an iron supplement is usually necessary. It is not necessary to provide the patient with potassium supplements, restrict sodium, or place the patient on renal dialysis.

12. A patient is administered a granulocyte colony-stimulating factor (G-CSF). What is the expected outcome of a G-CSF A) 3 Red blood cell count of 3000 mm B) Decreased number of infections C) Decreased fatigue and increased energy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) 3 White blood cell count of 20,000 mm Ans:B Feedback: G-CSFs help to prevent infection by reducing the incidence, severity, and duration of neutropenia associated with several chemotherapy regimens. The administration of a G-CSF should not lower red blood cell count or raise white blood cell count. They assist in the prevention of infection but do not necessarily resolve fatigue

13. An oncology nurse is providing for an adult patient who is currently immunocompromised.

The nurse is aware of the physiology involved in hematopoiesis and immune function, including the salient role of cytokines. What is the primary role of cytokines in maintaining homeostasis A) Cytokines perform phagocytosis in response to bacterial and protozoal infection B) Cytokines perform a regulatory role in the development of diverse blood cells C) Cytokines can be considered to be the basic “building blocks” of all blood cells D) Cytokines are formed in response to the presence of antibodies Ans:B Feedback: Hematopoietic cytokines are diverse substances produced mainly by bone marrow and white blood cells (WBCs). They regulate many cellular activities by acting as chemical messengers among cells and as growth factors for blood cells. Blood cells are not made up of cytokines, and they do not perform phagocytosis. The presence of antigens, not antibodies, can prompt the expression of certain cytokines.

14. A patient's current medical condition is suggestive of impaired erythropoiesis. Which of the following laboratory studies would be most clinically relevant in diagnosing this health problem A) White blood cell count with differential B) RBC, hemoglobin, and hematocrit C) INR and aPTT D) d-dimer and C-reactive protein Ans:B Feedback: Parameters used to measure erythropoiesis include RBC count, hemoglobin concentration and hematocrit, and mean corpuscular volume. Tests related to immune function, hemostasis, and inflammation are not used to diagnose erythropoiesis.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. An adult patient has developed renal failure secondary to an overdose of a nephrotoxic drug.

Which of the following assessment findings would the nurse recognize as being most suggestive of impaired erythropoiesis A) Frequent infections and low neutrophil levels B) Fatigue and increased heart rate C) Agitation and changes in cognition D) Increased blood pressure and peripheral edema Ans:B Feedback: As RBCs decrease, conditions related to inadequate hematopoiesis develop. Clinical manifestations of inadequate erythropoiesis include anemia. This results in a decrease in the oxygen-carrying capacity of blood and consequently a decreased oxygen availability to the tissues. A compensatory increase in heart rate and cardiac output initially increases cardiac output, offsetting the lower oxygen-carrying capacity of the blood.

16. A patient with a diagnosis of chronic renal failure will soon begin a regimen of epoetin that will administered by the patient at home. Which of the following statements indicates that the nurse's initial health education has been successful A) “I'll make sure to take my Epogen pill on a strict schedule and make sure I never miss a dose.”

B) “I'm glad that Epogen can help to protect me from getting an infection.”

C) “I'm excited that there's a medication that can help my kidneys work better.”

D) “I'm not all that comfortable with giving myself an injection, but I'm sure I'll be able to learn.”

Ans:D Feedback: Epogen is administered parenterally, not orally. It acts by stimulating erythroid progenitor cells to produce RBCs but does not enhance overall renal function. Epogen does not enhance immune function.

17. Which of the following patients would likely be the most appropriate candidate for treatment with filgrastim (Neupogen) A) A patient who has undergone a mastectomy for the treatment of breast cancer B) A patient with acquired immune deficiency syndrome (AIDS) who has been diagnosed with Kaposi's sarcoma C) A patient who developed acute renal failure secondary to rhabdomyolysis D) A patient whose acute myelogenous leukemia necessitated a bone marrow transplant Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Indications for filgrastim include preventing infection in patients with neutropenia induced by cancer chemotherapy or bone marrow transplantation. Surgical patients, patients with AIDS, and patients with renal failure are not typically treated with G-CSFs.

18. A 69-year-old female patient has been diagnosed with malignant melanoma. The care team has collaborated with the patient and her family and agreed on a plan of care that includes administration of interferon alfa-2b. After administering interferon alfa-2b, the oncology nurse should anticipate that the patient may develop which of the following adverse effects A) Profound diaphoresis B) Decreased level of consciousness C) Flu-like symptoms D) Cyanosis and pallor Ans:C Feedback: In the majority of patients, flu-like symptoms (e.g., fever, chills, fatigue, muscle aches, headache, tachycardi A) develop within 2 hours of administration of interferon alfa-2b and last up to 24 hours.

Diaphoresis, changes in LOC, and changes in oxygenation are not associated with the use of interferon alfa-2b.

19. Which of the following nursing diagnoses would provide the most plausible indication for the use of epoetin alfa (Epogen) in a patient with renal failure A) Risk for infection related to decreased erythropoiesis B) Activity intolerance related to decreased oxygen-carrying capacity C) Powerlessness-related sequelae of renal failure D) Ineffective breathing pattern related to inadequate erythropoietin synthesis Ans:B Feedback: The impaired erythropoiesis that accompanies renal failure results in fatigue and decreased stamina, symptoms that can be addressed with the administration of epoetin alfa.

Decreased erythropoiesis does not constitute a risk for infection, and the patient may or may not experience feelings of powerlessness Inadequate erythropoietin synthesis causes impaired oxygenation, but this does not normally manifest as breathing problems.

20. A patient who is undergoing chemotherapy for the treatment of non-Hodgkin's lymphoma will soon begin treatment with epoetin alfa (Epogen). The nurse should be aware that this drug may be administered by which of the following routes? Select all that apply

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Subcutaneous B) Intramuscular C) Oral D) Buccal E) Intravenous Ans:A, E Feedback: Epogen is administered by either IV or sub-Q routes.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 12 Drug Therapy: Immunizations 1. An infant is being administered an immunization. Which of the following provides an accurate description of an immunization A) It should be administered to a pregnant woman prior to the infant's birth B) It is the administration of an antigen for an antibody response C) It produces many adverse reactions, particularly autism, in the infant D) It protects the infant from exposure to infectious antibodies Ans:B Feedback: Immunization involves administration of an antigen to induce antibody formation.

Live, attenuated vaccines should not be administered to the pregnant woman. There are limited adverse effects associated with immunization. The immunization protects the infant from infectious antigens, producing an antibody response. It does not protect from antibodies

2. A patient is scheduled to receive an immunization. In which of the following patients may the administration of a live vaccine be contraindicated A) Patient with renal insufficiency B) Patient with hepatic failure C) Patient taking steroid therapy D) Patient over the age of 65 years Ans:C Feedback: Patients receiving a systemic corticosteroid in high doses (e.g., prednisone 20 mg or equivalent daily) or for longer than 2 weeks should wait at least 3 months before receiving a livevirus vaccine. No evidence supports withholding immunizations related to renal insufficiency or hepatic failure. Patients over the age of 65 should receive immunizations as needed to protect from infectious disease.

3. A patient is to be administered an immunization. The serum contains aluminum phosphate.

What route is most appropriate to administer this immunization A) Intramuscularly B) Subcutaneously C) Intravenously D) Orally

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Products containing aluminum should be given intramuscularly only because they cannot be given intravenously and greater tissue irritation occurs with subcutaneous injections.

Immunizations containing aluminum are not administered orally.

4. A patient has received a rubella immunization. The patient was unaware that she was pregnant. What risk is associated with the administration of the rubella immunization in this patient A) Risk of development of the disease in the newborn B) Risk of low infant birth weight C) Risk of preterm labor D) Risk of birth defects Ans:D Feedback: Rubella during the first trimester of pregnancy is associated with a high incidence of birth defects in the newborn. Rubella is not associated with the development of disease Rubella is not associated with low birth weight or preterm labor.

5. The college health nurse is providing health education for freshmen. Which of the following pieces of information about immunizations is applicable to individuals of this age group A) The oral polio should be updated B) The yearly administration of flu vaccine is recommended C) The tetanus toxoid must be within 2 years D) The administration of hepatitis A vaccine is mandatory Ans:B Feedback: An annual flu vaccine is recommended for all adults. The administration of oral polio will not need to be updated in this population. The administration of tetanus toxoid should be every 10 years. HAV vaccination is not mandatory.

6. A nursing student is scheduled to receive the hepatitis B series. What type of immunity will this immunization provide A) Active immunity B) Passive immunity C) Innate immunity D) Natural immunity

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: The hepatitis B series produces passive immunity. Passive immunity occurs when antibodies are formed by the immune system of another person or animal and transferred to the host. Active immunity is produced by the person's own immune system in response to a disease caused by a specific antigen or administration of an antigen from a source outside the body, usually by injection. Innate or natural immunity, which is not produced by the immune system, includes the general protective mechanisms.

7. It is important for the nurse to stay informed of the most current recommendations for immunizations. Which of the following sources is most accurate regarding immunization guidelines A) American Academy of Pediatrics B) American Academy of Family Physicians C) American Academy of Infectious Disease Physicians D) Centers for Disease Control and Prevention Ans:D Feedback: The best source of information for current recommendations is the Centers for Disease Control and Prevention. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Infectious Disease Physicians are all sources of immunization information, but their information is based on the CDC's information.

8. An infant is seen in the clinic for her first immunizations. When providing patient teaching to the parent, which of the following is no longer recommended for administration A) Rubella and mumps vaccine B) Polio vaccine C) Diphtheria, pertussis, and tetanus vaccine D) Smallpox vaccine Ans:D Feedback: Smallpox has been largely eradicated and is no longer administered to children. By 4 to 6 years of age, children should have received vaccinations for chickenpox, diphtheria, hepatitis A and B, influenza, measles, mumps, pertussis, polio, pneumococcal diseases, rubella, tetanus, and Haemophilus influenzae and rotavirus infections.

9. The nurse is preparing to administer a vaccine to a newborn. Before administering the vaccine, the nurse should A) warm the vaccine to well above room temperature B) vigorously massage the chosen injection site

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) check the infant's temperature D) divide the dose for administration to three injection sites Ans:C Feedback: The nurse should check the infant's temperature before administering any vaccine.

Three injection sites are not normally required, and vigorous massage is not indicated. Warming the vaccine is not normally necessary.

10. A nurse is administering a mumps vaccine to an adolescent. Which of the following medications should be available when administering an immunization A) Diphenhydramine (Benadryl) B) Hydroxyzine (Vistaril) C) Physostigmine D) Epinephrine Ans:D Feedback: The administration of vaccines for immunization possesses the risk of an allergic reaction and anaphylaxis. The nurse should have aqueous epinephrine available in the event of an anaphylactic reaction. The administration of diphenhydramine or hydroxyzine will reduce the allergic reaction but will not be effective in the event of anaphylaxis. Physostigmine is not administered.

11. A public health nurse is responsible for the administration of numerous immunizations.

Which of the following guidelines regarding anaphylaxis should the nurse adhere to A) The patient should be observed for anaphylaxis for 1 minute after administration B) The patient should be observed for anaphylaxis for 5 minutes after administration C) The patient should be observed for anaphylaxis for 30 minutes after administration D) The patient should be observed for anaphylaxis for 90 minutes after administration Ans:C Feedback: The nurse should observe for allergic reactions, which usually occur within 30 minutes. The patient should be observed longer than 1 or 5 minutes, and it is not necessary to observe for longer than 30 minutes.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. When instructing the parents of a child who has received immunization in the vastus lateralis, which reaction is most common in the days after the administration A) Nausea, vomiting, and diarrhea B) Rash and edema C) Weakness and difficulty walking D) Tenderness and redness at the site Ans:D Feedback: Pain, tenderness, and redness at the injection site are associated with the administration of immunizations. Nausea, vomiting, diarrhea, rash, edema, weakness, or difficulty walking are not general reactions to immunizations.

13. A 1-year-old child will receive her scheduled MMR vaccination shortly. The nurse should teach the child's parents that she may develop what possible adverse effect related to the administration of this medication A) Cough and fever B) Pallor and listlessness C) Serum sickness D) Nausea and vomiting Ans:A Feedback: Adverse effects associated with MMR vaccine include fever and cough. Nausea and vomiting, pallor and listlessness, and serum sickness are not among the noted adverse effects of the MMR vaccine.

14. A 70-year-old patient is seen in the family practice clinic. Which of the following vaccines should be administered to prevent shingles A) Zoster vaccine B) Haemophilus influenzae Type b (Hi B) vaccine C) Human papillomavirus (HPV) D) Pneumococcal polyvalent Ans:A Feedback: Zoster vaccine is administered to adults 60 years and older to prevent herpes zoster (shingles). The Haemophilus influenzae Type b is not administered to prevent herpes zoster.

HPV and pneumococcal vaccine do not address the risk factors for shingles 15. vaccine administration, which of the following is most important regarding the schedule for administration A) It is administered at 1 to 2 months

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) It is administered at 3 to 4 months C) It is administered at 5 to 6 months D) It is administered at 12 to 15 months Ans:D Feedback: Measles, mumps, and rubella immunization is administered initially at 12 to 15 months of age. The vaccine is not administered under the age of 1 year.

16. A patient is seen in the emergency room for a laceration sustained on broken glass. The nurse assesses the patient for the last tetanus toxoid he received. How often should the patient be administered a tetanus toxoid A) Every year B) Every 10 years C) Every 2 years D) Every 5 years Ans:B Feedback: The patient should receive a tetanus toxoid every 10 years according to the CDC. It is not necessary to receive tetanus toxoid yearly, every 2 years, or every 5 years.

17. When providing a health promotion presentation to a group of seniors, how often should you instruct the senior group to obtain influenza vaccines A) One time only B) Every 10 years C) Two times per year D) Yearly Ans:D Feedback: The influenza vaccine should be administered yearly. It is not administered as a single dose, every 10 years, or two times per year

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A primiparous woman tells the nurse that she and her partner are highly reluctant to have their infant vaccinated, stating, “We've read that vaccines can potentially cause a lot of harm, so we're not sure we want to take that risk.” How should the nurse respond to this family's concerns A) “Vaccinations are not without some risks, but these are far exceeded by the potential benefits.”

B) “The potential risks of vaccinations have been investigated and determined to be nonexistent.”

C) “Unfortunately, state laws mandate that your child receive the full schedule of vaccines.”

D) “Vaccines indeed cause several serious adverse effects, but these are usually treated at the site where your child receives the vaccination.”

Ans:A Feedback: Mild reactions to vaccinations are common, but serious reactions are rare.

Consequently, the benefits of vaccinations exceed the risks. Parental choice is still respected in most instances.

19. A health care worker has received her annual influenza vaccination and has remained at the clinic after administration so that the nurse may observe for adverse reactions. The worker complains of pain at the site of IM injection. The nurse should recommend which of the following A) ASA B) Acetaminophen C) Meperidine (Demerol) D) Heat application Ans:B Feedback: Most vaccines can cause fever and soreness at the site of injection. Acetaminophen (e.g., Tylenol) can be taken two to three times daily for 24 to 48 hours if needed to decrease fever and discomfort. Aspirin and heat are not explicitly recommended; opioids are not necessary.

20. When teaching new parents about the benefits of adhering to the recommended vaccination schedule, the nurse should cite protection against which of the following diseases Select all that apply A) HIV B) Measles C) Varicella D) Poliomyelitis E) Hepatitis B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B, C, D, E Feedback: Measles, varicella, polio, and HBV are all within the schedule of infant vaccinations There is currently no vaccine against HIV. Chapter 13 Drug Therapy to Decrease Immunity 1. Which of the following is the most likely indication for the use of immunosuppressant agents

A) Intractable seizure disorders B) Increased intracranial pressure C) Organ transplantation D) HIV/AIDS with multiple drug resistance Ans:C Feedback: Immunosuppressant agents are used for inflammatory autoimmune disorders or to prevent or treat tissue rejection reactions in organ transplantation. Immunosuppressant agents are not administered for seizure disorders, increased intracranial pressure, or HIV/AIDS

2. A patient has received a bone marrow transplant. What will occur if the patient receives inadequate immunosuppression after the transplant A) Graft-versus-host disease B) Hepatotoxicity C) Acute kidney injury D) Sepsis Ans:A Feedback: The goal after bone marrow transplantation is to provide adequate immunosuppression. If immunosuppression is inadequate, graft- versus-host disease will occur with bone marrow transplantation. The patient will not suffer from hepatic or renal failure Inadequate immunosuppression will not place the patient at risk for serious infection.

3. A patient with Crohn's disease is given a corticosteroid to decrease inflammation. Which of the following effects will occur with the use of corticosteroids A) Increased joint pain B) Increased C-reactive protein levels C) Increased T-cell counts D) Decreased antibody production Ans:D Feedback: The administration of corticosteroids will decrease T-cell and antibody production.

Corticosteroids do not cause joint pain or increase a patient's C-reactive protein levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

4. A patient is to begin treatment for rheumatoid arthritis with infliximab (Remicade). What potential risk should the nurse identify as being associated with this drug A) Risk for infection B) Risk for decreased level of consciousness C) Risk for nephrotoxicity D) Risk for hepatotoxicity Ans:A Feedback: All TNF-alpha blockers carry a risk for infection. This risk supersedes the risks of kidney or liver damage. Changes in LOC are not typically noted.

5. A patient is administered mycophenolate (CellCept) to prevent rejection of his transplanted heart. It is recommended that he have a CBC drawn weekly. He asks the nurse the reason for the weekly CBC. Which of the following is the nurse's best response A) “The weekly CBC is routine and ordered for all patients.”

B) “The weekly CBC assesses for the development of bleeding.”

C) “The weekly CBC assesses for the development of infection.”

D) “The weekly CBC assesses for changes in your blood’s oxygen carrying capacity.”

Ans:C Feedback: The weekly CBC is to assess for infection, neutropenia, and thrombocytopenia.

Stating to the patient that the CBC is routine is a belittling response that does not provide patient education. The weekly CBC is not indicated to assess for bleeding or a decrease in erythrocytes.

6. A patient is administered cyclosporine (Sandimmune, Neoral) to prevent rejection of a kidney transplant. Which of the following is a major adverse effect of cyclosporine A) Congestive heart failure B) Nephrotoxicity C) Anaphylaxis D) Respiratory arrest Ans:B Feedback: The major adverse effect of cyclosporine is nephrotoxicity. Congestive heart failure is not noted as an adverse effect of cyclosporine Anaphylaxis and respiratory arrest are not common adverse effects of cyclosporine.

7. A patient is receiving immunosuppressant therapy and is preparing for discharge. For which of the following should the patient be educated

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The importance of a high-protein diet B) The need to maximize fluid intake C) The need for regular physical activity D) The importance of keeping the home clean Ans:D Feedback: Meticulous environmental cleansing and personal and hand hygiene will protect from the development of serious infection. The importance of this infection control measure is greater than that of dietary or exercise guidelines.

8. A patient has been discharged from the hospital after a kidney transplant. Which of the following nursing interventions is the first line of defense against the immunosuppressed patient developing an infection A) Ensure visitors do not come to the home B) Teach the patient to wear a mask consistently C) Administer prophylactic antibiotics D) Teach the patient the importance of personal hygiene Ans:D Feedback: With patients who are taking immunosuppressant drugs, a major role of the home care nurse is to assess the environment for potential sources of infection, assist patients and other members of the household to understand the patient's susceptibility to infection, and teach ways to decrease risks of infection. Meticulous environmental cleansing as well as personal and hand hygiene are required. Visitors do not necessarily need to be wholly barred from the home, and a mask is not always required Prophylactic antibiotics are not normally used.

9. A patient has been placed on tacrolimus, and the route will be changed from IV to oral prior to discharge home from the hospital How will this change in administration route affect the patient's plan of care A) The patient's dose of tacrolimus will have to be increased B) The patient will receive the drug QID rather than BID C) The patient will have to be monitored more closely for adverse effects D) The patient will have to take tacrolimus concurrently with an antiemetic

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Tacrolimus, like cyclosporine, is not well absorbed orally, so it is necessary to give higher oral doses than IV doses to obtain similar blood levels. Increased frequency is not necessarily required. Concurrent dosing with an antiemetic is not required. Regardless of the route by which the drug is provided, the patient needs to be closely monitored for adverse effects.

10. A patient is ordered to receive cyclosporine intravenously, and the nurse has explained the need for frequent blood work. This blood work is required because cyclosporine A) decreases erythropoiesis B) has a narrow therapeutic range C) has been linked to spontaneous hemolysis D) can precipitate a thyroid storm Ans:B Feedback: Cyclosporine has a very narrow therapeutic index; therefore, prescribers use serum drug levels to regulate cyclosporine dosing, and close monitoring is necessary. Cyclosporine does not have a significant bearing on RBC production and has not been closely linked to thyroid function of hemolysis.

11. Sirolimus and cyclosporine are being used to prevent renal transplant rejection in an adult patient. What principle should guide the nurse's administration of these two drugs A) Sirolimus should be given orally; cyclosporine should be administered IV B) The two drugs should be administered together to potentiate their effects C) The two drugs should be given at least 4 hours apart D) The drugs should be administered in a single intramuscular injection Ans:C Feedback: Sirolimus may have synergistic effects with cyclosporine because it has a different mechanism of action, and prescribers may order both drugs in combination. However, because the two drugs are metabolized by the same liver CYP3A4 enzymes, cyclosporine can increase blood levels of sirolimus, potentially to toxic levels. Consequently, it is essential that the drugs not be given at the same time; patients should take sirolimus 4 hours after a dose of cyclosporine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A patient is to be administered antithymocyte globulin (ATG) to treat renal transplant rejection. What skin test should be assessed prior to the administration of the first dose of medication A) Allergy to horse serum B) Allergy to ragweed C) Allergy to dust mites D) Tuberculosis Ans:A Feedback: Antithymocyte globulin is obtained from horse serum, and, prior to administration, the patient should be tested for allergy to horse serum. The patient will not need to be assessed for allergy to ragweed. The patient will not be assessed for an allergy to dust mites. The patient will not be assessed for tuberculosis.

13. A patient is receiving omalizumab (Xolair) to treat allergic asthma, which is not relieved by inhaled corticosteroids. Which nursing intervention is appropriate with each dose administration of omalizumab A) Administer high-flow oxygen prior to administration B) Avoid high-fat foods during the course of treatment C) Have epinephrine available during administration D) Administer a corticosteroid prior to administration Ans:C Feedback: Because of the risk of anaphylaxis, the FDA has issued a black box warning for omalizumab. Administration should occur only in a health care setting under direct medical supervision by provider who can initiate treatment of life-threatening anaphylaxis. The patient will not require oxygen therapy with every dose administration. The patient will not need to avoid high-fat foods. The patient will not receive corticosteroid agents.

14. An adult male patient is being administered immunosuppressant agents on a long-term basis. Which of the following assessments should be made routinely with the use of long-term immunosuppressant therapy A) Yearly bronchoscopy B) Yearly skin assessment C) Yearly bladder biopsy

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D) Yearly prostate examination Ans:B Feedback: The most common malignancies among transplant recipients are skin cancers and lymphomas. The patient should be assessed annually for skin cancer. The patient will not require a yearly bronchoscopy. The patient will not require a yearly bladder biopsy. The male patient should have a yearly prostate examination, but this examination is not required for immunosuppressant therapy.

15. A patient is administered methotrexate for the treatment of severe rheumatoid arthritis Administration of this drug should be performed with particular care because of the associated high risk of A) intracapsular bleeding B) thrombophlebitis C) hepatotoxicity D) myocardial infarction or CVA Ans:C Feedback: Even in the low doses used in rheumatoid arthritis and psoriasis, methotrexate may cause hepatotoxicity. Consequently, many clinicians recommend serial liver biopsies for patients on long-term, low-dose methotrexate. This drug is not closely associated with bleeding disorders, MI, or stroke.

16. A 71-year-old woman has experienced a sharp decline in her mobility and quality of life due to severe rheumatoid arthritis. As a result, her care provider has recently prescribed abatacept (Orenci A). This fusion protein inhibitor will achieve a therapeutic effect by what means A) Preventing the activation of T cells B) Increasing antibody production by B cells C) Antagonizing histamine receptors D) Inhibiting the production of mast cells Ans:A Feedback: Abatacept (Orenci

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) is a fusion protein inhibitor synthesized from an IgG antibody fused to a cell protein that binds to antigen- presenting molecules. This action prevents the activation of T lymphocytes and the production of inflammatory cytokines Abatacept does not increase antibody production, antagonize histamine receptors, or inhibit mast cell production.

17. The nurse's medication reconciliation performed on a patient who is newly admitted to the hospital reveals that he regularly takes infliximab (Remicade), a humanized IgG monoclonal antibody. The nurse is justified in suspecting that this patient may have a history of which of the following A) Osteoporosis B) Crohn's disease C) Organ transplant D) Severe seasonal allergies Ans:B Feedback: Infliximab (Remicade) is a humanized IgG monoclonal antibody used to treat rheumatoid arthritis and Crohn's disease.

18. An adult male patient is postoperative day 2 following a kidney transplant, and his regimen of antirejection drugs began just prior to surgery. What nursing action should be integrated into this patient's plan of care A) Place the patient in a single, positive-pressure room B) Arrange for the patient to receive a raw-food, organic diet C) Wash the patient's skin with chlorhexidine twice daily D) Have the patient wear a gown and gloves when outside his room Ans:A Feedback: Patients receiving antirejection therapy are at a greatly heightened risk of infection; protective isolation is warranted. Raw foods are normally contraindicated, and the use of a gown and gloves does not protect the patient sufficiently from infectious microorganisms. It is not necessary to perform twice-daily antiseptic washes.

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19. Following a successful kidney transplant in 1999, a 59-year-old woman has presented to the clinic for one of her regularly scheduled follow-up appointments. The nurse at the clinic should assess the patient in the knowledge that long-term use of antirejection drugs has been associated with A) early onset of dementia B) increased risk of malignancy C) atherosclerosis D) increased risk of venous thromboembolism Ans:B Feedback: As a consequence of long-term survival and chronic immunosuppression, patients on long- term immunosuppressants have an increased risk of developing a malignancy. These drugs have not been linked to dementia, VTE, or atherosclerosis.

20. A transplant nurse is aware of the need to closely monitor a patient's serum levels of cyclosporine. In order to do this, the nurse should ensure that blood is drawn at what time A) 30 minutes before a scheduled dose B) Simultaneous to the administration of a dose C) 2 hours after a dose D) At the halfway point between two scheduled doses Ans:C Feedback: Cyclosporine has a very narrow therapeutic index; therefore, prescribers use serum drug levels to regulate cyclosporine dosing, and close monitoring is necessary. They use blood levels measured 2 hours after a dose for dosage adjustments.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 14 Drug Therapy for the Treatment of Cancer 1. A patient has been diagnosed with a brain tumor and is dealing with this diagnosis by seeking detailed information about cancer. The nurse would explain to the patient that cancer is essentially a result of the disruption of the A) cell cycle B) cell wall C) lymphatic system D) immune system Ans:A Feedback: Malignant cells have lost the normal genetic regulation that controls cell growth, invading normal tissues and taking blood and nutrients away from these tissues. In essence, the cell cycle has been pathologically disrupted.

2. A 49-year-old patient is diagnosed with ovarian cancer. What is a characteristic of malignant cells that differentiates them from normal body cells A) Cancerous cells do not require an energy source in order to proliferate B) Cancerous cells grow in an uncontrollable fashion C) Cancerous cells have a theoretically infinite lifespan D) Cancerous cells are not responsive to the presence of drugs Ans:B Feedback: Malignant cells have lost the normal genetic regulation that controls cell growth, invading normal tissues and taking blood and nutrients away from these tissues. They grow in an uncontrolled fashion without regard to growth regulation signals (e.g., contact with other cells) that stop the growth of normal cells Cancerous cells, like all cells, have a finite lifespan and need energy. Cancerous cells are responsive to drugs; this is the rationale for treatment with antineoplastics.

3. A patient with a diagnosis of bladder cancer is started on a chemotherapeutic regimen that includes three agents. What is the rationale for using multiple antineoplastic agents A) The use of three agents decreases the development of cell resistance

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The use of three agents increases adherence to treatment C) The use of three agents increases the serum levels of one of the agents D) The use of three agents decreases the total adverse effects Ans:A Feedback: Most chemotherapy regimens involve a combination of drugs with different actions at the cellular level, which destroys a greater number of cancer cells and reduces the risk of the cancer developing drug resistance.

4. A patient has undergone an aggressive chemotherapeutic regimen to treat leukemia. The patient develops gastrointestinal upset, hypertension, and paresthesias. What syndrome is the patient developing A) Fröhlich's syndrome B) Epidermal nevus syndrome C) Irritable bowel syndrome D) Tumor lysis syndrome Ans:D Feedback: With the treatment of leukemias and lymphomas, a serious, life-threatening adverse effect called tumor lysis syndrome may occur. This syndrome occurs when large numbers of cancer cells are killed or damaged, releasing their contents into the blood stream. The patient may have metabolic imbalances, which include gastrointestinal upset, hypertension, and paresthesias Fröhlich's syndrome is noted in adolescent boys who have an increase in fat and atrophy of the genitals. Epidermal nevus syndrome is associated with multiple nevi. Irritable bowel syndrome is marked by abdominal pain and disturbances of evacuation.

5. A patient develops tumor lysis syndrome during the administration of chemotherapy agents.

Which of the following treatments is implemented to resolve this health problem A) Administration of potassium IV B) Administration of anti-inflammatory agents C) Limiting of fluid intake and reduction in IV fluid rate D) Administration of IV normal saline and sodium bicarbonate Ans:D Feedback: The patient experiencing lysis syndrome should receive regular insulin and IV sodium bicarbonate. The patient suffers from hyperkalemia and should not be administered

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potassium. The patient would not be administered anti-inflammatory agents. The patient should be aggressively hydrated and thus should not have fluids limited or decreased.

6. A patient is being treated with cyclophosphamide (Cytoxan). Which of the following laboratory values should the nurse follow most closely A) D-dimer B) Complete blood count C) C-reactive protein level D) Arterial blood gases Ans:B Feedback: The patient's complete blood count should be assessed frequently because of the adverse effect of bone marrow depression. The other listed lab values may be important to assess at different points but are not normally as critical as the CBC. 7. A patient with colorectal cancer is being treated with oxaliplatin (Eloxatin). Which of the following potential adverse effects should the nurse explain to the patient A) Dysuria B) Diarrhea C) Insomnia D) Cold-induced neuropathy Ans:D Feedback: Cold-induced neuropathy is an adverse effect of oxaliplatin. Dysuria, diarrhea, and insomnia are not closely associated with Eloxatin.

8. A patient has been administered methotrexate, which is a purine antagonist used to treat a rapidly growing tumor. The patient develops stomatitis. What is the priority nursing diagnosis for a patient suffering from stomatitis A) Impaired skin integrity B) Activity intolerance C) Self-care deficit: hygiene D) Risk for disuse syndrome Ans:A Feedback: Toxic effects of methotrexate include stomatitis, which is an alteration in skin integrity. Disuse syndrome, lack of hygiene, and activity intolerance are less directly related to stomatitis.

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9. A patient is administered bevacizumab (Avastin) to treat tumor growth in a breast tumor.

What is the action of a monoclonal antibody such as bevacizumab (Avastin) A) It changes the RNA of the tumor cell to a normal form B) It binds to the 30S ribosome C) It prevents the activation of intracellular growth factors D) It blocks the cell wall synthesis Ans:C Feedback: Bevacizumab (Avastin) binds to growth factor receptors found on blood vessels to prevent intracellular growth factors from becoming activated and stimulating cell growth Bevacizumab does not change the RNA of the tumor cell. Bevacizumab does not bind to the 30S ribosome or block cell wall synthesis

10. An oncology nurse is preparing to administer cytotoxic chemotherapy medications. Which of the following measures best protects the nurse from harm related to the chemotherapy A) Wearing protective equipment B) Performing thorough hand hygiene C) Mixing medication in a 1000-mL bag D) Administering medication intramuscularly whenever possible Ans:A Feedback: Because of the drugs' toxicity, nurses who administer IV cytotoxic chemotherapy should be specially trained to administer the medications safely and use protective equipment when handling the medication Hand hygiene is important during care but will only minimally protect from harm. The medication is mixed in a variety of solutions and amounts. The medication is not normally administered intramuscularly.

11. A 32-year-old female patient is being treated with a cytotoxic antineoplastic agent. Which of the following is the most important instruction related to the potential for teratogenicity A) The medication will be completely eliminated 24 hours after the administration B) The patient should protect herself from infections and take Bactrim C) The patient should not become pregnant for several months D) The patient will not get pregnant due to the elimination of ova

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Ans:C Feedback: Most cytotoxic antineoplastic drugs are potentially teratogenic, and pregnancy should be avoided during and for several months after drug therapy is stopped. The medication is not completely eliminated in 24 hours. The patient should be protected from infection, but this characteristic is not related to pregnancy. The patient can get pregnant after the medication is administered.

12. Fewer adverse effects are associated with monoclonal antibody therapy than those of cytotoxic drugs. However, some of the potential adverse effects of monoclonal antibodies can be life threatening, including which of the following A) Heart failure and bleeding problems B) Changes in cognition and personality changes C) Ischemic heart disease D) Bronchoconstriction and pulmonary edema Ans:B Feedback: Although some adverse effects of monoclonal antibodies are rare, they are serious (e.g., heart failure, bleeding problems, electrolyte imbalances) and vary with a particular drug.

13. A patient is undergoing a cytotoxic chemotherapy regimen for the treatment of stage III lung cancer. What effect will this regimen likely have on the patient's hemostatic function A) The patient's platelet count will decline B) The patient will be at increased risk of deep vein thrombosis C) The patient will require prophylactic heparin D) The patient will likely experience thrombocytosis Ans:A Feedback: Thrombocytopenia is a common adverse effect of cytotoxic chemotherapy. Heparin is consequently contraindicated, and DVT is not a priority risk.

14. A patient has chosen to receive palliative care after his lung cancer metastasized to his bones and liver. Which of the following is most appropriate during palliative cancer care A) Abrupt cessation of chemotherapy immediately prior to entering palliative care B) Aggressive chemotherapy to reduce malignant cell proliferation C) The use of chemotherapy to reduce pain D) The replacement of chemotherapy with complementary and alternative treatments

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Palliative chemotherapy is used in advanced cancer to prevent or treat pain and obstruction. Chemotherapy does not need to be stopped abruptly or replaced with CAM. Aggressive chemotherapy would not normally be administered in a palliative context.

15. An adult patient has recently begun cancer treatment with methotrexate (MTX). The nurse is aware of the importance of monitoring the patient closely for adverse effects of treatment. When reviewing this patient's laboratory work, the nurse should consequently prioritize assessment of which of the following A) Sodium and potassium B) BUN and creatinine C) Calcium and magnesium D) Arterial blood gases Ans:B Feedback: The antimetabolites may also be nephrotoxic. MTX use in patients with impaired renal function may lead to accumulation of toxic amounts or additional renal damage Evaluation of the patient's renal status should take place before and during MTX therapy. This adverse effect of MTX treatment supersedes the importance of electrolytes and ABGs, though these would also be considered.

16. A patient is being treated on the oncology unit and has developed worsening adverse effects over the past several days of chemotherapy Administration of filgrastim (Neupogen) may aid in achieving what desired outcome A) Resolution of mucositis B) Increased leukocytes C) Increased platelet levels D) Prevention of hemorrhagic cystitis Ans:B Feedback: Severe neutropenia can be prevented or its extent and duration minimized by administering filgrastim or sargramostim to stimulate the bone marrow to produce leukocytes.

Filgrastim does not address the patient's risk for bleeding.

17. A 50-year-old man has just been diagnosed with liver cancer, and the care team is finalizing the chemotherapy regimen that will begin imminently. Administration of chemotherapeutic drugs is best achieved through which of the following

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A) An intramuscular depot B) A peripheral IV in the nondominant forearm C) Peripheral intravenous access in the antecubital fossa D) A central venous catheter Ans:D Feedback: Insertion of an indwelling central venous catheter is often appropriate for patients who have poor peripheral venous access, who require many doses of chemotherapy, or who require continuous infusions. Overall, a CVC is preferable to peripheral access. IM administration is uncommon.

18. A 79-year-old woman has recently moved to a long-term care facility, and the nurse at the facility is conducting a medication reconciliation. The nurse notes that the woman has recently been taking tamoxifen (Nolvadex). The nurse is justified in concluding that the woman has a history of what malignancy A) Ovarian cancer B) Breast cancer C) Malignant melanoma D) Cervical cancer Ans:B Feedback: Tamoxifen is an antiestrogen that has been widely used to prevent recurrence of breast cancer after surgical excision in women aged 40 and older and to treat metastatic breast cancer in postmenopausal women with estrogen receptor–positive disease.

19. An oncology nurse is reviewing the medication administration record of a patient being treated for advanced prostate cancer. In addition to two chemotherapeutic agents, the nurse reads that the patient has been ordered a cytoprotective agent. The goal of this agent is to A) buffer the cytotoxins that result from the metabolism of chemotherapeutic agents B) protect the patient from pathophysiological effects of his malignancy C) potentiate the beneficial effects of chemotherapy D) reduce the incidence or severity of adverse drug effects

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Ans:D Feedback: Cytoprotectant agents reduce the adverse effects of cytotoxic drugs, some of which can be severe, debilitating, or life threatening Cytoprotectant drugs do not potentiate chemotherapy, protect the patient from the effects of cancer, or buffer cytotoxins.

20. A patient's chemotherapy regimen has been deemed successful, but the patient is experiencing debilitating nausea and vomiting. These adverse effects should signal the nurse to the possibility of what nursing diagnosis A) Acute pain B) Adult failure to thrive C) Ineffective therapeutic regimen management D) Imbalanced nutrition: less than body requirements Ans:D Feedback: Nausea and vomiting are major threats to the patient's nutrition. Failure to thrive is typically a chronic, rather than acute, health problem. Pain does not necessarily accompany nausea, and there is no indication that this patient is not maintaining the necessary regimen.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 15 Inflammation, Infection, and the Use of Antimicrobial Agents 1. A female patient has been treated for strep throat with ampicillin by mouth. She visits the occupational health nurse and states she has vaginal itching. What organism is the cause of the vaginal itching A) Klebsiella B) Enterobacter C) Candida albicans D) Proteus Ans:C Feedback: The yeast Candida albicans is a normal resident of the vagina and the intestinal tract.

An antibacterial drug may destroy the normal bacterial flora without affecting the fungal organism. Klebsiella, Enterobacter, and Proteus will not contribute to the development of a yeast infection.

2. An elderly patient is treated for pneumonia with clindamycin (Cleocin). One week after the completion of the medication, she develops diarrhea. What is the most probable cause of the diarrhea A) Change in normal flora B) Food-borne illness C) Crohn's disease D) Incontinence Ans:A Feedback: Much of the normal flora can cause disease under certain conditions, especially in the elderly, debilitated, or immunosuppressed people. The development of infectious diarrhea is related to the change in the normal flora of the bowel. Food-borne illness, Crohn's disease, and incontinence do not contribute to this particular development of diarrhea.

3. A patient with burns has developed a wound infection. This patient is experiencing what type of wound infection A) Fungal infection B) Opportunistic infection C) Nosocomial infection D) Food-borne infection Ans:B

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Feedback: Opportunistic infections are likely to occur in people with severe burns, cancer, human immunodeficiency virus, and indwelling catheters and are often caused by drug- resistant microorganisms, are usually serious, and may be life threatening. The patient may be at risk for a fungal, nosocomial, or food- borne infection, but the risk for all infections is high due to the patient's opportunistic nature of the burn.

4. An elderly man who is a resident of a skilled nursing facility develops methicillin-resistant Staphylococcus aureus. What type of infection has this man developed A) Community acquired B) Postoperative C) Sustained infection D) Nosocomial infection Ans:D Feedback: Nosocomial infections are infections acquired from microorganisms in hospitals and other health care facilities. The patient's infection is not community acquired, postoperative, or sustained.

5. A nurse is instructing a patient on the antibiotic regimen for the treatment of pneumonia.

Which of the following is most important to teach the patient A) Take the medication with orange juice B) Supplement the medication with multivitamins C) Complete the entire prescription of medication D) Administer the medication with dairy products Ans:C Feedback: Interruption or inadequate antimicrobial treatment of infections may also contribute to the emergences of antibiotic-resistant organisms. The administration of an antibiotic with orange juice is not recommended in all instances. The medication does not need to be supplemented with vitamins. Antibiotics need not be administered with dairy products.

6. A patient is to be started on an antibiotic. Which of the following is most important to take into consideration before beginning the antibiotic regimen A) Duration of symptoms B) Culture and sensitivity C) The patient's hydration status

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D) The patient's age and weight Ans:B Feedback: Culture identifies the causative organism, and susceptibility tests determine which drugs are likely to be effective against the organism The duration of symptoms and the patient's hydration status, age, and weight are important, but not imperative, in determining the antibiotic of choice.

7. A patient has presented to the emergency department after suffering a severe laceration to his hand in a workplace accident. During the subsequent process of acute inflammation, what physiological event took place first A) The patient's B cells produced antibodies B) The patient's blood vessels constricted C) Neutrophils migrated to the injury site D) Opsonization occurred Ans:B Feedback: The process of acute inflammation occurs in three stages. The first stage is the vascular stage; notable changes occur in the small blood vessels at the site of the cellular and tissue injury. At the time of the injury, vasoconstriction results, followed by vasodilation of the capillaries and venules to increase capillary blood flow, increasing temperature and redness at the site Opsonization, neutrophil migration, and antibody production take place in later stages of inflammation.

8. A 12-year-old boy was bitten by a dog, and inflammation took place at the site of the injury.

During the process of opsonization, what physiological event occurred A) The boy's blood vessels dilated, allowing rapid peripheral blood flow B) Viscosity of the boy's blood decreased, facilitating the migration of neutrophils C) Antigens were coated, marking them for phagocytosis D) T cells were released from the boy's thymus gland Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The third stage of inflammation involves opsonization, which facilitates phagocytosis. During opsonization, a substance coats the foreign antigens, producing inflammation This inflammation makes the antigens more susceptible to the macrophages and leukocytes, thus increasing phagocytic activity. Opsonization is not characterized by T-cell activity or changes in blood flow and viscosity.

9. An adult patient with an autoimmune disorder regularly takes oral corticosteroids. The nurse knows that corticosteroids can be used in the successful treatment of inflammation but that they also create a risk for A) bleeding B) leukocytosis C) infection D) electrolyte imbalances Ans:C Feedback: Corticosteroids impair phagocytosis by preventing phagocytic cells from leaving the bloodstream. They decrease the amount of lymphocytes, fibroblasts, and collagen needed for tissue repair. This causes a reduction in inflammation but a commensurate increase in the patient's risk for infection.

10. The family members of a geriatric patient are angered that she has been colonized with methicillin-resistant Staphylococcus aureus during her stay in the hospital. The nurse should explain what characteristic of colonization to the members of the family A) The bacteria are present but are not causing infection B) The bacteria are causing an infection, but the infection is not spreading C) The bacteria are causing tissue injury at the site of colonization D) The bacteria are spreading within a clearly defined body region Ans:A Feedback: Colonization is the presence and growth of microorganisms. The microorganisms do not necessarily cause tissue injury or elicit an immune response in the human body.

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11. An adult female patient has been living with human immunodeficiency virus (HIV) for several years but has recently been admitted to the hospital after being diagnosed with herpes simplex. How would this patient's herpes infection most likely be characterized A) Community-acquired infection B) Opportunistic infection C) Secondary infection D) Nosocomial infection Ans:B Feedback: Microorganisms may become pathogens in hosts whose defense mechanisms are impaired. Opportunistic infections are likely to occur in people whose defenses are compromised due to human immunodeficiency virus (HIV) infection. This is not characterized as a nosocomial infection (hospital-acquired infection) or a secondary infection. The infection was likely to have been acquired in the community, but the patient's HIV diagnosis means that it would be considered to be an opportunistic infection.

12. A group of nursing students are learning about the factors that underlie recent increases in the incidence and prevalence of antibiotic- resistant microorganisms. What factor is known to contribute to antibiotic resistance A) Increased survival rates from acute infections B) Increased population density C) Use of antibiotics that are ineffective against the infectious microorganism D) Overuse of antibiotics Ans:D Feedback: Antibiotic overuse can contribute to antibiotic resistance. Resistance is not typically attributable to increased age of patients, increased population density, or the use of ineffective antibiotics.

13. A 4-month-old baby has been brought to the emergency department by her parents, and initial assessment is highly suggestive of bacterial meningitis. Consequently, the baby has been admitted, and empiric antibiotic therapy has been ordered. The nurse should understand what characteristic of this infant's current treatment plan A) Success or failure of treatment will not be apparent for several weeks B) The infant will receive aggressive treatment with a narrow-spectrum antibiotic C) Culture and sensitivity results of the infant's cerebrospinal fluid are still pending

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D) The infant is suspected of having an antibiotic-resistant infection Ans:C Feedback: Empiric therapy is based on an informed estimate of the most likely pathogen(s) given the patient's signs and symptoms and the site of infection, as well as knowledge of communicable diseases currently infecting other people in the community. Because laboratory tests used to definitively identify causative organisms and to determine susceptibility to antibiotics usually require 48 to 72 hours, the prescriber usually initiates treatment with an antimicrobial drug that is likely to be effective. The other listed statements are not true of empiric therapy.

14. A patient with an infection has not responded appreciably to antibiotic therapy, and the nurse suspects antibiotic resistance. What phenomenon is known to contribute to acquired antibiotic resistance A) Bacteria take on genetic material from healthy body cells, reducing antigen recognition B) Microorganisms remain in resting (G0) phase during antibiotic treatment C) Distribution of an antibiotic is insufficient to cause resolution of the infection D) The strongest microorganisms survive antibiotic treatment while the weakest are eradicated Ans:D Feedback: Selective pressure, or natural selection, refers to the survival of the fittest bacteria.

When antibiotic therapy is initially begun, the weakest bacteria are killed first while the strongest bacteria, which are best able to withstand the effects of antibiotic therapy, remain. This contributes to antibiotic resistance. Resistance is not the result of an extended G0 phase, impaired distribution, or bacterial appropriation of human genetic material.

15. When participating in the care of a patient who is being treated with antimicrobials, the nurse can promote the appropriate use of these medications in which of the following ways A) Encouraging the use of narrow-spectrum, rather than broad-spectrum, antibiotics B) Promoting the use of prophylactic antibiotics for patients possessing risk factors for infection C) Initiating empiric therapy for all older adult patients admitted to a health care facility D) Promoting the use of herbal treatment for infection rather than antimicrobial drugs Ans:A Feedback: Guidelines to promote more appropriate use of antimicrobial drugs include using a narrow-spectrum antibacterial drug instead of a broad-spectrum drug, whenever possible, in

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order to decrease the risk of a superinfection. Herbal alternatives are frequently not available.

Antibiotics should not normally be administered in the absence of a diagnosed infection.

16. A critically ill patient has developed a fever of 38.9°C, and blood cultures have been drawn and sent to the laboratory for culture and sensitivity testing. Determination of the culture will tell the care team A) whether the infection is antibiotic resistant B) the exact identity of the infectious microorganism C) the most likely location of the infection D) the most likely origin of the infection Ans:B Feedback: Culture identifies the causative microorganism. It does not necessarily indicate the presence of antibiotic resistance. The origin or location of the infection may often been indirectly determined by the culture, but this is not always the case.

17. A medical nurse on a night shift is reviewing a patient's medication administration record for the following day. The nurse notes that a combination antimicrobial drug is ordered. What is implied by the fact that the patient has been ordered a combination drug A) The patient's infection likely has a fungal or protozoal etiology B) The patient likely has a history of recurrent, multisystemic infections C) The patient may be unable to tolerate treatment with a single antimicrobial D) The patient may have an infection caused by multiple microorganisms Ans:D Feedback: Indications for combination therapy may include infections caused by multiple microorganisms. A fungal or protozoal infection is not implied, and the patient may or may not have a history of recurrent infections. Intolerance of single antibiotics is not normally an indication for combination therapy.

18. A hospital nurse is aware that nosocomial infections pose a significant threat to many patients' health status. In order to reduce the spread of nosocomial infections, the nurse should prioritize which of the following actions

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A) Increased use of empiric antibiotic therapy B) Use of disinfectants when providing patient hygiene C) Vigilant and thorough hand hygiene D) Patient education on the causes of infection Ans:C Feedback: Good hand hygiene is probably the most effective method of preventing infections.

This supersedes the importance of education regarding the causes of infection or the use of disinfectants. Antibiotic therapy should only be used on patients who clearly need this treatment.

19. An 81-year-old female patient has been admitted to the hospital after a urinary tract infection developed into urosepsis. What assessments should the nurse prioritize when monitoring the course of this patient's infection? Select all that apply A) Blood urea nitrogen and creatinine B) White blood cell count C) Heart rhythm D) Temperature E) Liver panel Ans:B, D Feedback: For patients with an infection, the nurse should prioritize assessment of WBCs and temperature. Cardiac, renal, and liver function are important measures of health, but these are less directly affected by the presence of infection.

20. Mr. Garcia has been taking antibiotics at home for the treatment of a respiratory infection for the past 6 days, and there is no evident improvement in his infection. Which of the following nursing assessments is most appropriate A) Assess Mr. Garcia's adherence to his medication regimen B) Assess Mr. Garcia's home hygiene C) Assess Mr. Garcia's understanding of his illness D) Assess Mr. Garcia's use of herbal or alternative remedies Ans:A Feedback: Nonadherence to antibiotic therapy can result in a continuation or exacerbation of the infection. Poor hygiene is a risk factor for the development of infection but is less likely to perpetuate an existing infection that is being treated appropriately with antibiotics. Herbs may be contraindicated but are unlikely to negate the therapeutic effects of an antibiotic. The nurse should gauge the patient's understanding of his illness, but this does not have a bearing on his lack of improvement.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 16 Drug Therapy to Decrease Pain, Fever, and Inflammation 1. A patient is receiving acetaminophen (Tylenol) for fever. The patient also has inflammation in the knees and elbows with pain. Why will acetaminophen (Tylenol) assist in reducing fever but not in decreasing the inflammatory process A) Prostaglandin inhibition is limited to the central nervous system B) Acetaminophen inhibits cyclooxygenase (COX-1 and COX-2) only C) Acetaminophen has an antiplatelet effect to decrease edema D) Prostaglandins decrease the gastric acid secretion Ans:A Feedback: The action of acetaminophen on prostaglandin inhibition is limited to the central nervous system. Aspirin and other nonselective NSAIDs inhibit COX-1 and COX-2 Acetaminophen does not produce an antiplatelet effect. Prostaglandins do not affect gastric secretions

2. A patient suffers from pain in the elbow related to inflammation. What are the chemical mediators of inflammation A) Insulin, thyroid hormone, and calcitonin B) Bradykinin, histamine, and leukotrienes C) Phospholipids, arachidonic acid, and platelets D) Red blood cells, lymph, and serosa Ans:B Feedback: Prostaglandins sensitize pain receptors and increase the pain associated with other chemical mediators of inflammation and immunity, such as bradykinin, histamine, and leukotrienes. Insulin, thyroid hormone, and calcitonin are not chemical mediators of inflammation. Phospholipids, arachidonic acid, and platelets are not chemical mediators of inflammation. Red blood cells, lymph, and serosa are not chemical mediators of inflammation.

3. A patient is administered acetylsalicylic acid (aspirin) for fever and headache. What is the action of acetylsalicylic acid (aspirin) A) Inhibiting prostaglandin synthesis in the central and peripheral nervous system

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Providing selective action by inhibiting prostaglandin synthesis in the CNS C) Inhibiting the release of norepinephrine to increase blood pressure D) Suppressing the function of the hypothalamus to decrease inflammation Ans:A Feedback: Aspirin inhibits prostaglandin synthesis in the central nervous system and the peripheral nervous system. Acetylsalicylic acid does not provide selective action by inhibiting prostaglandin synthesis in the CNS. Aspirin does not inhibit the release of norepinephrine to increase blood pressure. Aspirin does not suppress the function of the hypothalamus to decrease inflammation

4. When acetylsalicylic acid (aspirin) is administered in low doses, it blocks the synthesis of thromboxane A2. What physiological effect results from this action A) Inflammation is relieved B) Core body temperature is reduced C) Pain is relieved D) Platelet aggregation is inhibited Ans:D Feedback: At low doses, aspirin blocks the synthesis of thromboxane A2 to inhibit platelet aggregation; this lasts for the life of the platelet.

5. A patient began taking acetylsalicylic acid (aspirin) several years ago to prevent platelet aggregation following a myocardial infarction. Which dose of aspirin is most likely appropriate for this patient A) 80 mg B) 180 mg C) 325 mg D) 650 mg Ans:A Feedback: The dose of aspirin given depends mainly on the condition being treated. Low doses (325 mg initially and 80 mg daily) are used for the drug's antiplatelet effects in preventing arterial thrombotic disorders such as myocardial infarction and stroke.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient is suffering from bursitis in the right elbow. Which of the following orally administered medications is most likely to diminish inflammation and assist in relieving pain A) Acetaminophen (Tylenol) B) Morphine sulfate C) Acetylsalicylic acid (aspirin) D) Codeine Ans:C Feedback: Aspirin is widely used to prevent and treat mild to moderate pain and inflammation associated with musculoskeletal disorders. Aspirin is administered orally Acetaminophen (Tylenol) will only relieve pain and not affect inflammation. Morphine sulfate will relieve pain but not affect inflammation. Codeine will relieve pain but not affect inflammation.

7. A patient is diagnosed with familial adenomatous polyposis. Which of the following nonsteroidal anti-inflammatory agents has the potential to reduce the number of polyps and decrease the risk of colon cancer A) Ibuprofen (Motrin) B) Nabumetone (Relafen) C) Celecoxib (Celebrex) D) Probenecid (Benemi D) Ans:C Feedback: Celecoxib (Celebrex), a COX-2 inhibitor, is used to treat familial adenomatous polyposis, in which the drug reduces the number of polyps and may decrease risk of colon cancer. Ibuprofen (Motrin) and nabumetone (Relafen) are not recommended for use in preventing familial adenomatous polyposis. Probenecid (Benemi D) is used to treat gouty arthritis, not for the prevention of adenomatous polyposis.

8. A patient is taking ibuprofen (Motrin) for knee pain. The patient is admitted to the hospital with abdominal pain. Which of the following assessments should the nurse prioritize A) Assessment for diarrhea B) Assessment for occult blood in the patient's stool C) Assessment of the patient's urine for hematuria D) Assessment for hemoptysis Ans:B Feedback: Nonsteroidal anti-inflammatory agents that block COX-1 and COX-2 place the patient at risk for gastrointestinal bleed. Patients who have symptoms of abdominal pain and are taking NSAIDs should be assessed for signs and symptoms of gastrointestinal bleed

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Assessing the patient for diarrhea is not related to ibuprofen (Motrin) administration. Assessing the patient for hematuria or hemoptysis is not a priority.

9. A child has symptoms of influenza, including a fever. Which of the following medications should not be administered to the child because of the risk of Reye's syndrome A) Acetaminophen (Tylenol) B) Acetylsalicylic acid (aspirin) C) Ibuprofen (Motrin) D) Ascorbic Acid (vitamin C) Ans:B Feedback: In children and adolescents, aspirin is contraindicated in the presence of viral infections, such as influenza or chickenpox, because of its association with Reye's syndrome.

Acetaminophen (Tylenol) and ibuprofen (Motrin) are safe to administer for fever reduction and pain relief in children and adolescents. Ascorbic acid (vitamin C) is safe to administer to children but is not used to reduce fever or pain.

10. A perinatal nurse is preparing a dose of IV indomethacin for administration to a neonate.

What is the most plausible indication for this treatment A) Patent ductus arteriosus B) Tetralogy of Fallot C) Patent foramen ovale D) Cardiomyopathy Ans:A Feedback: The FDA has approved IV indomethacin for treatment of patent ductus arteriosus in premature infants.

11. A patient is admitted to a neurological unit with a confirmed cerebrovascular bleed Which of the following medications used to treat inflammation is contraindicated in this patient A) Furosemide (Lasix) B) Hydrochlorothiazide with triamterene C) Digoxin (Lanoxin) D) Ketorolac (Toradol) Ans:D Feedback: Ketorolac (Toradol) should not be administered to a patient with a suspected or confirmed cerebrovascular bleed. Furosemide (Lasix) is administered to reduce fluid volume and is not administered to treat inflammation. Hydrochlorothiazide with triamterene is administered

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

to reduce fluid volume and is not administered to treat inflammation. Digoxin (Lanoxin) is administered to increase cardiac output, not to treat inflammation.

12. An elderly patient has taken ibuprofen (Motrin) 800 mg two times per day for the past 3 years. Which of the following laboratory tests is the priority assessment A) Renin and aldosterone levels B) 24-hour urine for microalbumin C) Blood urea nitrogen and serum creatinine D) Complete blood count Ans:C Feedback: Nonsteroidal anti-inflammatory agents in long-term use can cause renal impairment.

The patient should be assessed for renal impairment with the elevation of the serum BUN and creatinine. NSAIDs do not affect renin and aldosterone levels. A 24-hour urine for microalbumin is not recommended when administering ibuprofen. A complete blood count may not be necessary.

13. A patient is allergic to acetylsalicylic acid (aspirin). Which of the following medications is contraindicated due to cross- hypersensitivity reactions A) Acetaminophen (Tylenol) B) Naproxen sodium (Naprosyn) C) Morphine sulfate (MS Contin) D) Naloxone (Narcan) Ans:B Feedback: In people who have demonstrated hypersensitivity to aspirin, all nonaspirin NSAIDs are contraindicated because cross- hypersensitivity reactions may occur with any drugs that inhibit prostaglandin synthesis Acetaminophen (Tylenol) does not have cross-sensitivity with acetylsalicylic acid (aspirin) because it is not an NSAID. Morphine sulfate (MS Contin) does not have a cross-sensitivity to aspirin because it is an opioid, not an NSAID. Naloxone (Narcan) is an opioid antagonist and does not have cross- sensitivity with aspirin.

14. A patient with osteoarthritis has been prescribed meloxicam (Mobi C). Which of the following instructions should the patient be given A) Take the medication with orange juice B) Crush enteric-coated tablets to aid swallowing C) Take the medication with food

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Take the medication at bedtime Ans:C Feedback: Meloxicam should be taken with food. Enteric-coated tablets are never crushed, and it is not always necessary to take this medication at bedtime. Orange juice is not of particular benefit.

15. A patient enters the emergency room with complaints of visual changes, drowsiness, and tinnitus. The patient is confused and hyperventilating. These symptoms may be attributable to which of the following A) Acute acetaminophen toxicity B) Salicylism C) Ibuprofen overdose D) Caffeine overdose Ans:B Feedback: Salicylism, toxicity due to salicylates that may be associated with chronic use, is characterized by dizziness, tinnitus, difficulty hearing, and mental confusion. Ibuprofen overdose will cause gastric mucosal damage Caffeine overdose will produce tachycardia.

16. A patient is admitted to the emergency department with a suspected overdose of acetaminophen (Tylenol). What adverse effect is most common in acute or chronic overdose of acetaminophen (Tylenol) A) Nephrotoxicity B) Hepatotoxicity C) Pulmonary insufficiency D) Pancreatitis Ans:B Feedback: In acute or chronic overdose of acetaminophen (Tylenol), the patient can develop hepatotoxicity. Nephrotoxicity is not an adverse effect associated with Tylenol overdose.

Pulmonary insufficiency is not an adverse effect associated with Tylenol overdose. Pancreatitis is not an adverse effect associated with Tylenol overdose.

17. A patient suffers from gouty arthritis. Why is probenecid (Benemi D) administered A) To increase urinary excretion of uric acid

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) To decrease the level of liver enzymes C) To diminish the temperature D) To increase protein metabolism Ans:A Feedback: Probenecid (Benemi D) increases the urinary excretion of uric acid. Probenecid (Benemi D) will not decrease the level of liver enzymes, diminish temperature, or increase protein metabolism.

18. A patient is diagnosed with salicylate overdose. Which of the following medications will be administered for the treatment of salicylate overdose A) Intravenous meperidine (Demerol) B) Intravenous sodium bicarbonate C) Intravenous furosemide (Lasix) D) Inhaled acetylcysteine (Mucomyst) Ans:B Feedback: Intravenous sodium bicarbonate produces alkaline urine in which salicylates are more rapidly excreted in patients with salicylism.

19. Which of the following is the antidote for acetaminophen (Tylenol) poisoning A) Acetylcysteine (Mucomyst) B) Allopurinol (Zyloprim) C) Diclofenac sodium (Voltaren) D) Ketorolac (Toradol) Ans:A Feedback: A specific antidote, acetylcysteine (Mucomyst), is a mucolytic agent given for acetaminophen poisoning.

20. A nurse is conducting a medication reconciliation for a 79-year-old man who has just relocated to the long-term care facility. The nurse notes that the man has been taking colchicine (Colcrys) on a regular basis. This aspect of the man's medication regimen should signal the nurse to the possibility that he has a diagnosis of A) osteoarthritis B) gout

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) inflammatory bowel disease D) bursitis or tendonitis Ans:B Feedback: Colchicine (Colcrys), the prototype agent for the treatment and prevention of gout, is the most commonly administered antigout medication. Colchicine is not indicated in the treatment of osteoarthritis, IBD, tendonitis, or bursitis.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 17 Drug Therapy with Corticosteroids 1. A patient is in the admission department prior to outpatient surgery, and she states that she is exceptionally nervous. Which of the following actions increases this patient's stress-related release of cortisol A) Negative feedback mechanism B) Stimulation of the hypothalamus C) Release of epinephrine and norepinephrine D) Atrophy of the adrenal cortex Ans:C Feedback: The stress response activates the sympathetic nervous system to produce more epinephrine and norepinephrine and the adrenal cortex to produce as much as 10 times the normal amount of cortisol. The negative feedback mechanism does not accelerate the stress response. Cortisol production is not based on the stimulation of the hypothalamus. The stress response will not cause atrophy of the adrenal cortex.

2. A patient is diagnosed with an adrenal tumor. With which of the following abnormalities of the adrenal gland will the patient most likely be diagnosed A) Primary adrenocortical insufficiency B) Secondary adrenocortical insufficiency C) Adrenocortical hyperfunction D) Hyperaldosteronism Ans:C Feedback: Adrenocortical hyperfunction (Cushing's disease) may be a result of a primary adrenal tumor. Primary adrenocortical insufficiency is associated with destruction of the adrenal cortex by disorders such as tuberculosis, cancer, or hemorrhage. Secondary adrenocortical insufficiency is produced by inadequate secretion of corticotropin Hyperaldosteronism is a rare disorder caused by adenoma or hyperplasia of the adrenal cortex cells that produce aldosterone.

3. A patient is seen in the primary care provider's office with complaints of polydipsia and polyuria without polyphagia. He has very edematous ankles, and his blood pressure is elevated.

From which disorder of the adrenal cortex is the patient suffering A) Hyperaldosteronism B) Adrenocortical hyperfunction C) Androgen-producing tumors D) Adrenal hyperplasia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Hyperaldosteronism is characterized by hypokalemia, hypernatremia, hypertension, thirst, and polyuria. Adrenocortical hyperfunction causes the secretion of several corticosteroids.

Androgen-producing tumors of the adrenal cortex, which are usually benign, produce masculinizing effects Adrenal hyperplasia results from deficiencies in one or more enzymes required for cortisol production.

4. A patient is receiving hydrocortisone 40 mg PO daily for treatment of severe autoimmune inflammation. Which of the following nursing interventions is most important to implement A) Increase dietary sodium B) Limit dietary protein C) Assess BUN and creatinine regularly D) Implement infection control measures Ans:D Feedback: Corticosteroids create a risk for infection due to immune suppression; infection control measures are a priority. When taking hydrocortisone daily, the patient should limit dietary sodium due to fluid retention. The patient should maintain a diet high in protein. The patient should not alter fluid intake unless the patient shows signs of fluid volume overload. Renal function may or may not be an assessment priority.

5. A male patient has been on chronic corticosteroid therapy for several years and has been scheduled for a colonoscopy. How should the patient's corticosteroid therapy be altered to accommodate this impending stressful event A) The patient should stop taking the corticosteroid 7 days prior to the procedure B) The patient should continue taking the regular dose of his corticosteroid C) The patient should temporarily change to IV administration of his corticosteroid D) The patient should temporarily take a higher dose of his corticosteroid Ans:D Feedback: For people receiving chronic corticosteroid therapy, dosage must be increased during periods of stress or illness. Some common sources of stress for most people include surgery and anesthesia, infections, anxiety, and extremes of temperature.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A 50-year-old male is admitted to the emergency room with a head injury after a motorcycle crash. He is unconscious with one eye dilated and one constricted. He has a widened pulse pressure. What corticosteroid will most likely be administered parenterally A) Cortisone B) Prednisone C) Dexamethasone (Decadron) D) Fluticasone (Flonase) Ans:C Feedback: Dexamethasone is considered the corticosteroid of cerebral edema. It is thought to penetrate the blood–brain barrier more readily and achieve higher concentrations in cerebrospinal fluid. Cortisone is the drug of choice for adrenal insufficiency. Prednisone is the glucocorticoid of choice in nonendocrine disorders in which anti-inflammatory, antiallergic, antistress, and immunosuppressive effects are desired Fluticasone (Flonase) is administered by oral inhalation.

7. A patient is being treated with corticosteroids for chronic adrenocortical insufficiency When should the patient be instructed to take the medication A) Between 06:00 and 09:00 B) 12:00 C) Between 13:00 and 14:00 D) 21:00 Ans:A Feedback: Daily administration of corticosteroids is required in cases of chronic adrenocortical insufficiency. The entire daily dose can be taken each morning, between 06:00 and 09:00 AM. This schedule stimulates normal endogenous corticosteroid secretion.

8. A patient is to be discharged on prednisone to be administered every other day at 9:00 AM. When implementing discharge teaching, what should the nurse explain as the rationale for giving the medication every other day A) It reduces adverse effects B) It prolongs therapeutic effects C) It prevents steroid tolerance D) It increases effectiveness

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Alternate-day therapy allows rest periods so that adverse effects are decreased Alternative-day therapy will not prolong the therapeutic effects, prevent steroid tolerance, or increase effectiveness.

9. A child is prescribed therapy with glucocorticoids. The child is placed on alternate-day therapy. What is the advantage of alternate-day therapy in this child A) The child will have less chance of infection B) It will protect the child from hyperglycemia C) The child will have less chance of hypertension D) Adherence will be increased Ans:A Feedback: Intermediate-acting glucocorticoids are the drugs of choice for alternate-day therapy and will decrease the susceptibility of infection. Alternative-day therapy will not protect from hyperglycemia. Alternate-day therapy will not affect blood pressure. Alternate-day therapy is not used as a strategy for improving adherence.

10. A 71-year-old woman with a history of chronic obstructive pulmonary disease (COP D) and congestive heart failure (CHF) has begun tapering off of prednisone. The nurse should prioritize which of the following assessments during this phase of the woman's care A) Daily weights B) Level of consciousness assessment C) Nonstress cardiac testing D) Positional blood pressure measurement Ans:A Feedback: When caring for a patient with COPD and a history of heart failure who takes a tapering dose of prednisone, it is necessary to instruct the patient to check his or her weight daily.

The patient should also assess his or her extremities for edema. If the patient's weight increases, edema is evident, and shortness of breath develops, the patient should notify the primary health provider. This potential alteration in fluid balance is more likely than blood pressure changes, decreased LOC, or acute cardiac changes.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

11. A patient has long-standing pain in her right hip, and the orthopedic surgeon has prepared an intra-articular injection. How long will it take for the patient to see improvement in her pain and mobility A) Approximately 10 days B) 1 to 3 weeks C) 2 to 8 weeks D) 1 to 4 months Ans:C Feedback: An intra-articular injection of corticosteroid provides decreased pain and improved movement in 2 to 8 weeks.

12. A patient is admitted with an acute asthma attack. He has been using inhaled corticosteroids two times daily. Based on this information in the patient's history, what should you anticipate will be required in his care A) The patient will require an antibiotic to treat infection B) The patient will require high doses of systemic drugs C) The patient will need to be treated with an oral opioid D) The patient will have diminished tidal volume after treatment Ans:B Feedback: The patient who has taken inhaled steroids will require high doses of systemic drugs during acute attacks because aerosols are not effective. The patient will only require antibiotics in the presence of infection. The patient's tidal volume should be increased with the administration of systemic corticosteroids. Opioids are not likely indicated.

13. A patient with a diagnosis of breast cancer is administered a corticosteroid in addition to chemotherapy agents. What effect will the corticosteroids have on this patient's course of recovery A) The corticosteroid will decrease signs and symptoms of cancer B) The corticosteroid will alter the action of the chemotherapy agent C) The corticosteroid will decrease metastasis to distant sites D) The corticosteroid will decrease hepatic effects of the chemotherapy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The administration of corticosteroid agents in cancer will assist in decreasing symptoms associated with cancer. The administration of the corticosteroid will not alter the action of the chemotherapy agent. The corticosteroid will not affect metastasis. The corticosteroid will not decrease hepatic effects.

14. A patient has a tumor of the spinal cord and is administered a corticosteroid. What statement by the patient demonstrates an accurate understanding of this treatment A) “This drug will cause my tumor to be more susceptible to treatment.”

B) “This drug will decrease my chance of infection and meningitis.”

C) “This drug won't cure my cancer, but it may help me feel much better.”

D) “This drug will stop my cancer cells from growing further.”

Ans:C Feedback: Patients tend to feel better when taking corticosteroids, although the basic disease process may be unchanged. The corticosteroid will not allow the tumor to be more susceptible to treatment. The corticosteroid will not prevent meningitis.

15. A patient who is receiving chemotherapy is administered a corticosteroid agent. What is the mostly likely intended effect of this drug administration A) Increased pulmonary function B) Decreased diarrhea C) Decreased infection susceptibility D) Decreased nausea Ans:D Feedback: Corticosteroids have strong antiemetic effects; the mechanism is unknown Corticosteroids diminish pulmonary inflammation, but this reaction is not related to chemotherapy administration. The administration of corticosteroids will decrease gastric inflammation but will not decrease diarrhea. The administration of corticosteroids will diminish the patient's ability to fight infection.

16. An adult patient has been taking oral prednisone for the treatment of an acute dermatological condition. When teaching this patient about this course of treatment, what teaching point should the nurse emphasize A) The need to supplement prednisone with high doses of vitamin D B) The need to avoid drinking grapefruit juice for the duration of treatment C) The importance of gradually reducing rather than abruptly stopping the drug

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) The importance of matching each day's dose to the severity of symptoms Ans:C Feedback: Gradually tapering the dose is necessary for any systemic corticosteroid. It is not imperative to avoid grapefruit juice or take vitamin D supplements. Daily doses are not normally adjusted on the basis of short-term symptoms.

17. A patient has questioned why she cannot stop taking her prescribed corticosteroid as soon as she achieves relief of her symptoms. The nurse should explain the rationale for the patient's regimen based on which of the following A) The serum half-life of many corticosteroids can exceed 3 months B) Corticosteroids are sequestered in hepatocytes and released over several weeks C) The HPA axis does not normally resume full function for several months D) Abrupt cessation of corticosteroid therapy can cause nephrotoxicity Ans:C Feedback: When steroids are given for purposes other than replacement and then discontinued, the HPA axis usually recovers within several weeks to months, but recovery may take a year. The necessity for tapering is not based on the half-life of the drugs, storage in the liver, or the potential for nephrotoxicity.

18. An adult patient is preparing to begin corticosteroid treatment for rheumatoid arthritis.

When teaching this patient about the appropriate use of corticosteroids, the nurse should include what teaching point A) “You will likely gain some weight after you start taking this drug.”

B) “Try to eat as many organic and natural foods as possible while taking this drug.”

C) “You might have some slight bleeding in your stool after you start this drug.”

D) “Ensure that you vary the times that you take your drug in order to maximize effectiveness.”

Ans:A Feedback: An initial weight gain is likely to occur with steroid treatment and is usually attributed to increased appetite. Organic foods are not necessary, and a consistent schedule of administration is imperative. Bleeding is not expected.

19. A 12-year-old boy was recently diagnosed with asthma, and his primary care provider has prescribed a corticosteroid to be administered by metered-dose inhaler. This drug achieves a therapeutic effect by which of the following means

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) By increasing the number of beta-adrenergic receptors B) By increasing the muscle tone in the smooth muscle of the trachea C) By increasing the permeability of the alveolar membrane D) By increasing the number of binding sites on erythrocytes Ans:A Feedback: Corticosteroids increase the number of beta- adrenergic receptors and increase or restore responsiveness of beta receptors to beta- adrenergic bronchodilating drugs. They do not influence the permeability of alveoli, muscle tone, or the structure of red blood cells.

20. A 22-year-old male patient has been living with Crohn's disease for several years and is experiencing an exacerbation of symptoms. The nurse should anticipate the use of what corticosteroid A) Oral fludrocortisone (Florinef) B) Topical hydrocortisone C) Oral dexamethasone (Decadron) D) Oral prednisone Ans:D Feedback: In moderate Crohn's disease, oral prednisone, 40 mg daily, is usually given until symptoms subside. The other listed corticosteroids are not normally used in the treatment of IBD.

Chapter 18 Drug Therapy With Beta-Lactam Antibacterial Agents 1. A patient is administered penicillin V orally for a strep throat. What is the mechanism of action of this medication A) It inhibits protein synthesis B) It lowers the pH of cellular contents C) It causes mutations D) It inhibits cell wall synthesis Ans:D Feedback: Beta-lactam antibacterial drugs inhibit synthesis of bacterial cell walls by binding to proteins in bacterial cell membranes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Penicillin V does not inhibit protein synthesis, cause mutations, or lower the pH of a bacterium's cellular contents.

2. A patient previously experienced an anaphylactic reaction to penicillin G. Which of the following medications should not be administered to this patient due to the potential for crosssensitivity A) Lactulose (Chronula C) B) Ketoconazole (Nizoral) C) Kanamycin (Kantrex) D) Cefadroxil (Duricef) Ans:D Feedback: Cefadroxil (Duricef) is a cephalosporin. Administration of cephalosporins or carbapenems should be avoided if possible in people with life-threatening allergic reactions to penicillin. Lactulose reduces blood ammonia by resident intestinal bacteria. It is not contraindicated in the event of penicillin anaphylaxis. Ketoconazole is an antifungal and does not possess cross-sensitivity to penicillin. Kanamycin is an aminoglycoside and does not possess cross-sensitivity to penicillin.

3. An adult patient has a history of rheumatic fever. Which of the following medications should be administered as prophylaxis for rheumatic fever A) Cyclacillin (Cyclapen) B) Amoxicillin (Augmentin) C) Dicloxacillin D) Penicillin G benzathine (Bicillin L A) Ans:D Feedback: Penicillin G benzathine (Bicillin L A) is administered as prophylaxis for rheumatic fever. Cyclacillin, amoxicillin, and dicloxacillin are not routinely administered for prophylaxis of rheumatic fever.

4. A patient has been prescribed an oral penicillin for an infection caused by gram- negative bacilli. When conducting health education for this patient, the nurse should emphasize which of the following A) The need to take the medication on an empty stomach B) The fact that a mild rash frequently follows the first few doses C) The need to increase fluid intake for the duration of treatment D) The fact that the drug should be discontinued once symptoms subside

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Most penicillins should be best taken on an empty stomach. Increased fluid intake is not normally necessary. A rash is an unexpected finding that should be reported promptly. The patient should take the full course of antibiotics.

5. Unasyn is being administered to a patient with an infection caused by Staphylococcus aureus.

What type of anti-infective is Unasyn A) Extended-spectrum antipseudomonal penicillin B) Penicillin–beta-lactamase inhibitor combination C) Cephalosporin D) Aminopenicillin Ans:B Feedback: Unasyn is a penicillin–beta-lactamase inhibitor combination. It is ampicillin and sulbactam. Unasyn is not classified as an extended-spectrum antipseudomonal penicillin, cephalosporin, or aminopenicillin.

6. A patient is administered Augmentin (amoxicillin and clavulanate potassium) to treat otitis media. How does a beta-lactamase inhibitor agent achieve a therapeutic effect A) It extends the spectrum of antibacterial activity of penicillin B) It extends the spectrum of the beta-lactamase inhibitor C) It decreases the side effects of high-dose penicillin D) It increases the absorption of the penicillin Ans:A Feedback: When combined with a penicillin, the beta- lactamase inhibitor protects the penicillin from destruction by the enzymes and extends the penicillin's spectrum of antimicrobial activity.

Augmentin does not extend the spectrum of beta-lactamase inhibitor Augmentin does not decrease the side effects of high-dose penicillin. Augmentin does not increase the absorption of penicillin.

7. A patient is administered a third-generation cephalosporin. Which of the following microorganisms are cephalosporins most effective in treating A) Gram-positive B) Gram-negative

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Fungi D) Virus Ans:B Feedback: Cephalosporins are broad-spectrum agents with activity against both gram-positive and gram-negative bacteria. Compared with penicillins, they are, in general, less active against gram-positive organisms but more active against gram-negative ones Cephalosporins are not effective against fungi or viruses.

8. A patient is diagnosed with infective endocarditis. Which of the following medications is most effective in treating this patient A) Dicloxacillin B) Ampicillin C) Nafcillin D) Oxacillin Ans:B Feedback: Health care providers use ampicillin in the treatment or prophylaxis of infective endocarditis. Dicloxacillin, nafcillin, and oxacillin are typically used to treat methicillin-resistant Staphylococcus aureus.

9. A patient with septicemia is administered cefotaxime sodium (Claforan), a second- generation cephalosporin. How is this medication excreted A) It is excreted by the lungs B) It is excreted by the liver C) It is excreted by the kidneys D) It is excreted through the GI tract Ans:C Feedback: Cefotaxime sodium, like all cephalosporins, is excreted by the kidneys. Cefotaxime is not excreted by the lungs, liver, or GI tract 10. A patient is scheduled for a vaginal hysterectomy. Which of the following medications is the drug of choice for surgical prophylaxis A) Cefadroxil (Duricef) B) Cefazolin sodium (Ancef) C) Cephalexin (Keflex) D) Cephradine (Velosef)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Cefazolin sodium (Ancef) is the drug of choice for surgical prophylaxis in most surgical procedures. Cefadroxil, cephalexin, and cephradine are all first-generation cephalosporins, but they are not utilized as the drug of choice for surgical prophylaxis.

11. A patient is diagnosed with B. fragilis, an anaerobic organism resistant to most drugs. What is the drug of choice to treat this microorganism A) Cefaclor (Ceclor) B) Cefamandole nafate (Mandol) C) Cefoxitin (Mefoxin) D) Cefuroxime sodium (Zinacef) Ans:C Feedback: Cefoxitin (Mefoxin) is active against B. fragilis, an anaerobic organism resistant to most drugs. Cefaclor, cefamandole nafate, and cefuroxime sodium are all second-generation cephalosporins but not the drug of choice for B. fragilis.

12. A patient is to receive imipenem–cilastatin (Primaxin) IM to treat P. aeruginosa. What should imipenem–cilastatin be mixed with prior to administering intramuscularly A) Meropenem (Merrem) B) Gentamicin (Garamycin) C) Lidocaine D) Epinephrine Ans:C Feedback: When preparing imipenem–cilastatin for IM injection, lidocaine is added to decrease pain. Meropenem, gentamicin, and epinephrine are not added to imipenem–cilastatin.

13. A patient is administered imipenem–cilastatin for the treatment of an E. coli infection. The nurse should be aware that cilastatin is combined with the imipenem for what purpose A) To eliminate adverse effects of imipenem administration B) To inhibit the destruction of imipenem C) To potentiate the therapeutic effects of imipenem D) To allow imipenem to cross the blood–brain barrier Ans:B Feedback: Cilastatin inhibits the destruction of imipenem, increasing the urinary concentration of imipenem and reducing its potential renal toxicity. It does not allow the drug to cross the blood–brain barrier, and cilastatin does not eliminate all adverse effects.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A patient is administered aztreonam (Azactam). What is the major advantage of this monobactam over the aminoglycosides in treating P. aeruginosa A) It is a lower-cost medication B) It is administered orally C) It causes less GI distress D) It has lower risk for hearing loss Ans:D Feedback: Aztreonam is effective against gram-negative bacteria similar to aminoglycosides, but the drug does not cause kidney damage or hearing loss. Aztreonam is not a lower-cost medication. Aztreonam is not administered orally. Aztreonam does not cause less GI upset.

15. A 71-year-old man with a history of osteoarthritis is scheduled for hip replacement surgery, and the surgeon has ordered a first- generation cephalosporin to be administered before and after surgery as prophylaxis Which of the following drugs is a first- generation cephalosporin A) Cefotetan (Cefotan) B) Cefoxitin (Mefoxin) C) Ceftriaxone (Rocephin) D) Cefazolin (Ancef) Ans:D Feedback: Cefazolin (Ancef) is a first-generation cephalosporin. Cefotetan (Cefotan) and cefoxitin (Mefoxin) belong to the second generation, and ceftriaxone (Rocephin) is a thirdgeneration cephalosporin.

16. Oral ampicillin has been ordered for a female patient whose urinary tract infection will be treated in a home setting. When teaching this patient about her antibiotic, the nurse should instruct the patient to do which of the following A) Take the first dose together with diphenhydramine to reduce the chance of an allergic reaction B) Take the drug immediately before a meal, unless the meal will contain large amounts of fat

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Drink a full glass of water when taking a dose of the drug D) Taper off the drug rather than abruptly stopping it Ans:C Feedback: Patients taking penicillins should take oral doses with a full glass of water. The drugs should otherwise be taken on an empty stomach. Tapering is unnecessary, and it is not advised to take the drug with diphenhydramine in an effort to reduce the allergy risk.

17. An older adult patient has just been diagnosed with community-acquired pneumonia and aztreonam (Azactam) has been ordered. What action should the nurse perform before administering the first dose A) Administer a 500 mL bolus of normal saline B) Confirm the patient's allergy status C) Swab the patient's nares for the presence of MRSA D) Teach the patient to expect discolored urine during treatment Ans:B Feedback: As with all antibiotics, it is important to assess the patient's allergy status prior to drug administration. This is especially important before the initial dose. An IV bolus is unnecessary, and discoloration of urine is not expected. MRSA testing is not relevant to aztreonam administration.

18. An intensive care unit (ICU) nurse is preparing to administer an intravenous dose of imipenem–cilastatin to a patient who is being treated for sepsis. What aspect of this patient's history would contraindicate the use of this drug A) The patient has a history of type 1 diabetes mellitus B) The patient is showing signs and symptoms of fluid volume excess C) The patient's most recent creatinine level was 140 D) The patient has a documented allergy to penicillin Ans:D

mol/L (high)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: It is important to avoid administering imipenem–cilastatin and the other carbapenems to people with life-threatening allergic reactions to penicillin. Diabetes, slightly increased creatinine levels, and fluid overload do not necessarily contraindicate the use of imipenem– cilastatin.

19. A nurse has established intravenous access in a patient whose infection necessitates treatment with IV cefazolin. What potential adverse reaction is most likely during this patient's course of treat A) Gastrointestinal upset B) Dry skin and pruritus C) Drowsiness D) Orthostatic hypotension Ans:A Feedback: Adverse effects to cefazolin and the other cephalosporins are similar to those of most other antibiotics: abdominal pain, diarrhea, gastritis, nausea, and vomiting Integumentary, neurological, and blood pressure changes are atypical.

20. A 69-year-old female responded well to inpatient treatment with a third-generation cephalosporin. After being largely symptom free for 48 hours, the woman has developed a fever of 38.6°C and an elevated white cell count. What phenomenon may account for this patient's current clinical presentation A) The patient may be infected with microorganisms that were resistant to the cephalosporin B) The patient may be experiencing a delayed (type IV) hypersensitivity reaction to the cephalosporin C) The patient may be developing glomerulonephritis secondary to the nephrotoxic cephalosporin D) The cephalosporin may have initially caused leukopenia and made the patient susceptible to secondary infection Ans:A Feedback: Patients treated with cephalosporins may be vulnerable to superinfections (infection after a previous infection, typically caused by microorganisms that are resistant to the antibiotics used earlier). Delayed hypersensitivity and renal involvement are highly unlikely. Antibiotics do not cause leukopenia.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 19 Drug Therapy With Aminoglycosides and Fluoroquinolones 1. A patient is diagnosed with an infection attributable to the gram-negative microorganism Pseudomonas. Which of the following anti-infective agents is most reliable in treating this microorganism A) Aminoglycoside B) Antifungal C) Aminopenicillin D) GABA analog Ans:A Feedback: Aminoglycosides are used to treat infections caused by gram-negative microorganisms, such as Pseudomonas. Antifungal and aminopenicillin agents are not used to treat Pseudomonas. A GABA analog is used to treat pain related to neuropathy.

2. A patient is diagnosed with a gram-negative infection and is prescribed an aminoglycoside.

What is the action of an aminoglycoside A) It blocks protein synthesis of the cell wall B) It blocks DNA replication C) It destroys the integrity of the cell wall structure D) It increases white blood cell viability Ans:A Feedback: Aminoglycosides penetrate the cell walls of susceptible bacteria and bind irreversibly to 30S and 50S ribosomes, intracellular structures that synthesize proteins Aminoglycosides do not block DNA replication, destroy cell wall structure, or increase white blood cells.

3. The nurse is preparing to administer gentamicin (Garamycin) to a patient when he mentions that he has recently been experiencing diminished hearing. What action should the nurse take based on this statement A) Administer the dosage and notify the physician of the alteration in hearing B) Hold the dosage and notify the physician of the alteration in hearing

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Administer the dosage and report the alteration in hearing to the audiologist D) Hold the dosage and document the finding in the nurses' notes Ans:B Feedback: Aminoglycosides accumulate in high concentrations in the inner ear, damaging sensory cells in the cochlea and vestibular apparatus. The medication should be held and alteration in hearing reported to the physician. The administration of the medication will only cause more damage to the cochlea and vestibular apparatus. Holding the medication and documenting the information in the nurses' notes will not allow for a new anti- infective to be administered and for the hearing to be assessed.

4. A patient is diagnosed with multidrug- resistant tuberculosis. Which of the following aminoglycoside medications is used in a 4- to 6-drug regimen A) Tetracycline hydrochloride (Achromycin) B) Amoxicillin (Amoxil) C) Sulfadiazine (Sulfisoxazole) D) Streptomycin (Sulfate) Ans:D Feedback: Streptomycin may be used as part of a 4- to 6- drug regimen for treatment of multidrug- resistant tuberculosis. Tetracycline, amoxicillin, and sulfadiazine are not aminoglycosides or drugs of choice for multidrug-resistant tuberculosis.

5. A patient is scheduled for a bowel resection. He is to receive neomycin sulfate (Neo- Fradin) by mouth. The patient asks the nurse the purpose of this medication. What is the most appropriate response the nurse can provide to the patient A) “The administration by mouth will prevent renal damage.”

B) “The administration by mouth will prevent ototoxicity.”

C) “The administration will decrease the risk of contamination.”

D) “The administration decreases the risk of airborne contamination.”

Ans:C Feedback: Neomycin can be given before bowel surgery to suppress intestinal bacterial growth.

The administration of neomycin will not prevent renal damage or ototoxicity. It will also not affect the risk of airborne contamination.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient has been administered an aminoglycoside. It is time for his next dose, and the nurse learns his creatinine level is elevated at 3.9 mg/dL. What action should the nurse take regarding this assessment A) Administer the medication and report the creatinine level B) Hold the dose until another creatinine level is assessed C) Administer the medication with 100 mL of fluids D) Hold the medication and assess the urine output Ans:D Feedback: Aminoglycosides are nephrotoxic and should not be administered in the presence of renal impairment. It is important to hold the medication, assess the urine output, and notify the physician. The medication should not be administered. The medication should be held, but the creatinine level cannot be reassessed without a doctor's order. The administration with fluids will not protect the patient from renal impairment.

7. A patient has a genitourinary infection and is being treated with a fluoroquinolone. What is the advantage of a fluoroquinolone over an aminoglycoside A) The fluoroquinolone does not have adverse effects B) The fluoroquinolone can be given orally C) The fluoroquinolone has a nearly immediate peak D) The fluoroquinolone has a broader spectrum Ans:B Feedback: Fluoroquinolones are often given orally. Like all drugs, they have adverse effects.

Peak levels are not immediately achieved, and they do not have a broader spectrum than an aminoglycoside.

8. A patient is receiving gentamicin (Garamycin) to treat meningitis. The physician has ordered a peak serum level be drawn in association with the 07:00 dose, which will finish infusing at 07:30. When should the peak serum level be drawn A) 08:00 B) 09:00 C) 10:00

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) 12:00 Ans:A Feedback: With conventional dosing, it is necessary to take gentamicin peak levels 30 minutes after the end of a 30-minute IV infusion. Thus, 8:00 AM is the optimal peak time to assess the serum level of gentamicin.

9. A patient has been prescribed a once-daily aminoglycoside. What is the advantage of this method of administration A) It is associated with less hepatotoxicity B) It is significantly more cost-effective C) It reduces the risk of nephrotoxicity D) It increases adherence to treatment Ans:C Feedback: The use of once-daily aminoglycoside dosing has replaced the common multiple daily dosing. The rationale for this dosing approach is a potential increase in efficacy with a reduced incidence of nephrotoxicity.

10. A patient is prescribed ciprofloxacin (Cipro). Which of the following nursing interventions will best prevent crystalluria A) The nurse should limit oral fluids to 500 mL/ day B) The nurse should administer 2000 mL of oral fluids per day C) The nurse should insert a urinary catheter D) The nurse should administer phenazopyridine (Pyridium) Ans:B Feedback: Guidelines to decrease the incidence and severity of adverse effects include keeping patients well hydrated to decrease drug concentrations in serum body tissues. The administration of 500 mL is not a sufficient amount to prevent crystalluria. The administration of Pyridium will not prevent crystalluria. A urinary catheter is not indicated.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

11. A nurse has informed the laboratory technician that a patient's gentamicin has finished infusing and the technician will soon draw a blood sample to determine the patient's serum drug concentration. Why is assessment of gentamicin levels necessary A) To identify possible changes in the patient's serum osmolality B) To identify whether the drug is at a therapeutic level C) To identify whether the drug is causing hepatotoxicity D) To identify possible hemolysis following administration Ans:B Feedback: Measurement of both peak and trough levels of gentamicin helps maintain therapeutic serum levels without excessive toxicity Gentamicin is nephrotoxic, not hepatotoxic. Hematological changes are not assessed by measuring serum drug levels.

12. An adult male patient with a diagnosis of osteomyelitis will soon begin treatment with gentamicin. Which of the following schedules is most likely to maximize efficacy and minimize nephrotoxicity A) Gentamicin 500 mg IV OD at 1200 B) Gentamicin 250 mg PO BID at 07:30 and 19:30 C) Gentamicin 500 mg PO TID at 08:00, 12:00, and 17:00 D) Gentamicin 125 mg IV QID at 06:00, 1200, 18:00, and 24:00 Ans:A Feedback: The ODA method uses higher doses (e.g., 4 to 7 mg/kg) to produce high initial drug concentrations, with no repeat dosing until the serum concentration is quite low (typically 24 hours later). The rationale for this dosing approach is a potential increase in efficacy with a reduced incidence of nephrotoxicity Gentamicin is not administered orally.

13. A medical nurse is aware of the need to assess for potential ototoxicity in patients who are being treated with gentamicin. Which of the following patients is likely most susceptible to developing ototoxicity secondary to gentamicin A) A man who received his first dose of IV gentamicin 12 hours ago B) A man who has required repeated courses of gentamicin over the past several months C) A woman who has a Pseudomonas infection but who has a hypersensitivity to penicillins D) A woman who is immunocompromised and who is being treated with gentamicin Ans:B Feedback: Ototoxicity (auditory or vestibular) may develop after extended use of gentamicin and may not be reversible. Penicillin allergies and immunocompromised status are not risk factors for ototoxicity.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A patient with sepsis is being treated with gentamicin, and her medication regimen takes into account the phenomenon of postantibiotic effects. What are postantibiotic effects A) The tendency for patients to exhibit symptoms mimicking hypersensitivity after drug administration B) The tendency for adverse effects of a drug to be masked during administration C) The ability of microorganisms to proliferate between doses of antibiotics D) The ability of an antibiotic to kill bacteria even when serum concentrations are low Ans:D Feedback: Postantibiotic effects mean that aminoglycosides continue killing microorganisms even at low serum concentrations.

15. Extreme caution would be necessary with the use of gentamicin in which of the following patients A) A patient who is morbidly obese and who has primary hypertension B) A patient who has chronic renal failure secondary to diabetes mellitus C) A patient who has bipolar disorder and who is on long-term lithium therapy D) A patient who has an atrioventricular block Ans:B Feedback: Gentamicin is nephrotoxic, and with impaired renal function, a reduction in dosage is essential. Heart blocks, obesity, and lithium therapy do not severely complicate, or contraindicate, the use of an aminoglycoside.

16. A patient has been prescribed ciprofloxacin after being diagnosed with a sinus infection.

Which of the following should the patient avoid taking concurrently with ciprofloxacin A) Antacids B) Calcium channel blockers C) Beta-adrenergic blockers D) Diuretics Ans:A Feedback: Patients should space out ciprofloxacin administration 4 to 6 hours with any of the following: antacids, multivitamins, sucralfate, or other products containing calcium, iron, or zinc.

Absorption of ciprofloxacin may be impaired when these substances are administered together with ciprofloxacin, resulting in a decreased antibiotic effect.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

17. An older adult patient is recovering in hospital from an ischemic stroke and has a feeding tube in place due to dysphagia. The patient has developed an infected pressure ulcer, and ciprofloxacin suspension has been ordered as empiric therapy. How should the nurse follow up this order A) The nurse should flush the patient's feeding tube with free water before and after administration of the ciprofloxacin suspension B) The nurse should dilute the suspension thoroughly before administration C) The nurse should liaise with the care provider to provide an alternative route of administration D) The nurse should administer small, frequent doses of the drug to minimize GI upset Ans:C Feedback: Administration of the oral suspension of ciprofloxacin via feeding tubes should not occur, because the oil-based formulation tends to adhere to the feeding tube. An alternative route is consequently necessary.

18. A hospital patient has been prescribed ciprofloxacin IV for the treatment of cellulitis. After initiating the infusion of the patient's first scheduled dose, the patient develops a pronounced rash to her chest and arms. How should the nurse respond to this event A) Discontinue the infusion and inform the care provider promptly B) Slow down the rate so that the infusion takes place over 2 hours C) Administer oral diphenhydramine to the patient during the infusion D) Administer a STAT dose of acetylcysteine Ans:A Feedback: Severe hypersensitivity reactions have occurred with the administration of fluoroquinolones. The nurse discontinues the antibiotic immediately if skin rash or other signs or symptoms occur. Administration of acetylcysteine or diphenhydramine is not indicated.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 20: Drug Therapy With Tetracyclines, Sulfonamides, and Urinary Antiseptics 1. A patient has been prescribed phenazopyridine (Pyridium) for urinary tract symptoms related to the infection. The patient asks why she is taking this medication. What is the most appropriate response by the nurse A) “This medicine is used to treat urinary retention.”

B) “This medicine will stop the blood in your urine.”

C) “This medicine will decrease the pain of your infection.”

D) “This medicine will prevent hesitancy when you’re passing urine.”

Ans:C Feedback: Phenazopyridine (Pyridium) is given to relieve pain associated with urinary tract infection. It is not administered for urinary retention, hematuria, or hesitancy.

2. A patient is given tetracycline (Sumycin) to treat acne-related skin eruptions. How does tetracycline work A) It binds to the 30S ribosome to inhibit protein synthesis.

B) It reduces central nervous system stimulation C) It is a beta-lactam antibiotic inhibiting cell wall synthesis D) It works on the final stage of cell wall synthesis Ans: A Feedback: Tetracycline binds with the 30S ribosome to inhibit protein synthesis. It has no effect on the central nervous system. The penicillin agents are beta-lactam antibiotics. Ampicillin works in the final stage of cell wall synthesis.

3. A patient is seen in the clinic after a bite from a tick. She has a rash over her arms and legs and arthritic pain in the joints. What is the drug of choice for Lyme's disease A) Ibuprofen (Motrin) B) Tetracycline (Sumycin) C) Phenazopyridine (Pyridium) D) Nitrofurantoin (Macrodantin) Ans:B Feedback: Tetracyclines are useful in treating some animal bites and Lyme's disease. Ibuprofen is administered for the inflammation associated with the arthritic pain, but not to treat the

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

infection. Phenazopyridine is not administered for Lyme's disease. Nitrofurantoin is administered for urinary tract infections.

4. A teenager asks the nurse how tetracycline (Sumycin) will improve her acne. Which of the following is the best statement the nurse can provide to the patient regarding the action of tetracycline A) “Tetracycline decreases redness and swelling of the pustules.”

B) “Tetracycline treats the Chlamydia organism that causes acne.”

C) “Tetracycline is used in combination with doxycycline to treat acne.”

D) “Tetracycline interferes with the production of free fatty acids.”

Ans:D Feedback: Tetracyclines interfere with the production of free fatty acids and decrease Corynebacterium in sebum. Tetracycline will decrease redness and swelling, but this response is not the direct action of the medication. Tetracycline treats Chlamydia but is not the cause of acne. Tetracycline is not combined with doxycycline.

5. A patient has sustained a burn from a gas grill. She has been prescribed a sulfonamide to prevent a burn infection. What route is preferred in the prevention of a burn infection A) Intrathecal B) Topical C) Parenteral D) Oral Ans:B Feedback: Topical sulfonamides are used in prevention of burn wound infections. Sulfonamides are not administered intrathecally. Parenteral and oral administrations are not recommended for the prevention of a burn infection.

6. A 70-year-old woman is assessed in the clinic for signs and symptoms of chronic bronchitis related to pneumococci. Which of the following is a sulfonamide that will most likely be prescribed A) Trimethoprim–sulfamethoxazole (Bactrim) B) Tetracycline (Sumycin) C) Doxycycline (Vibramycin) D) Demeclocycline (Declomycin) Ans:A Feedback: Trimethoprim–sulfamethoxazole is used to treat chronic bronchitis due to pneumococci. Tetracycline, doxycycline, and demeclocycline are not sulfonamides.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient is being treated for a urinary tract infection with trimethoprim– sulfamethoxazole (Bactrim). What assessment should the nurse make prior to the administration of the medication A) Assessing for the presence of asthma B) Assessing for hypertension C) Assessing for diabetes mellitus D) Assessing for renal insufficiency Ans:D Feedback: Both tetracyclines and sulfonamides are contraindicated in patients with renal failure.

These medications are not contraindicated in patients with asthma, hypertension, or diabetes mellitus.

8. A patient has been prescribed doxycycline (Vibramycin). Which of the following teaching instructions is a priority with this medication A) Avoid sun exposure B) Avoid unprotected sexual activity C) Administer with an antacid D) Chew the tablets Ans:A Feedback: The administration of doxycycline increases photosensitivity, which is a common side effect. Avoidance of sexual activity is not taught. The medication should not be administered with an antacid; the administration of an antacid will result in diminished absorption of the medication. The doxycycline tablets should not be chewed 9. A patient is started on sulfamethoxazole– trimethoprim (Bactrim) for a urinary infection.

What would contraindicate the use of Bactrim with this patient A) Liver failure B) Rheumatoid arthritis C) Bone marrow depression D) Congestive heart failure Ans:A Feedback: Hepatic disease contraindicates the use of Bactrim. The other listed health problems do not necessarily preclude the safe use of Bactrim.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

10. A patient is administered a sulfonamide for a urinary tract infection. Which of the following nursing interventions is most appropriate to increase the alkalinity of the patient's urine A) Provide at least 2000 mL of water daily B) Administer sodium bicarbonate C) Recommend a tub bath every evening D) Provide orange juice daily Ans:B Feedback: The urine can be alkalinized by giving sodium bicarbonate. The administration of water is important but will not increase alkalinity. The taking of tub baths is not recommended due to the fact that doing so increases the risk of urinary tract infection. The administration of orange juice increases acid, not alkalinity.

11. What is the rationale for not administering tetracycline (Sumycin) to children under the age of 8 years A) It will not treat the infection B) It will increase the risk of heart failure C) It will interfere with enamel development D) It will increase the risk for future infections Ans:C Feedback: Tetracyclines should not be used in children younger than 8 years because of their effects on teeth and bones. In teeth, the drugs interfere with enamel development. The medication can treat the infection Tetracycline does not increase the risk of heart failure. The administration of tetracycline will not increase the risk of future infections.

12. A 64-year-old female patient sought care for the treatment of a urinary tract infection, and her primary care provider prescribed nitrofurantoin. What change in the patient's health status would prompt the use of an alternative medication A) The patient develops a fluid volume deficit B) Urinalysis reveals the presence of ketones

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) The patient develops leukocytosis D) The patient's UTI progresses to urosepsis Ans:D Feedback: Urinary antiseptics may be bactericidal for sensitive organisms in the urinary tract because these drugs are concentrated in renal tubules and reach high levels in urine. They are not used in systemic infections because they do not attain therapeutic plasma levels. Consequently, the development of urosepsis would necessitate a systemic antibiotic. Fluid deficit, ketones in the urine, and elevated white cells would not necessarily contraindicate the use of nitrofurantoin.

13. A public health nurse interacts with many members of the community who are at risk for sexually transmitted infections (STIs). The nurse should anticipate the use of tetracycline in a patient who is diagnosed with what STI A) Vaginitis B) Chlamydia C) Human papillomavirus D) Trichomoniasis Ans:B Feedback: Tetracycline is effective for treating Mycoplasma, Chlamydia, and Rickettsia. It is not efficacious in the treatment of trichomoniasis, HPV, or vaginitis.

14. A nurse is preparing to administer a patient's first scheduled dose of tetracycline. The nurse should first ensure that the patient has not recently eaten A) dairy products B) leafy green vegetables C) any high-fat foods D) acidic foods Ans:A Feedback: It is important not to take tetracycline with dairy products, antacids, or iron supplements.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. A young adult patient's acne has responded well to treatment with tetracycline. However, the patient has now returned to the clinical with signs and symptoms of oral candidiasis. The nurse should recognize that this patient's current health problem is likely attributable to which of the following A) A delayed (type IV) hypersensitivity reaction B) The fact that the patient may have chewed the capsules prior to swallowing them C) Superinfection following the eradication of normal oral flora D) A type I hypersensitivity reaction Ans:C Feedback: Candidal superinfections may result from the use of tetracycline. The superinfection results from the elimination of normal flora and is not a hypersensitivity reaction. This is not the result of physical contact between the drug and the oral mucosa 16. pertussis. The pediatric nurse is processing the boy's admission orders and notes that IV demeclocycline (Declomycin) has been ordered. After beginning this treatment, the nurse should confirm the results of what laboratory test A) Mean corpuscular volume (MCV) B) D-dimer C) Bilirubin D) Blood urea nitrogen (BUN) Ans:D Feedback: When administering demeclocycline, it is important to monitor the patient's BUN. Increases in the BUN are secondary to antianabolic effects. D-dimer and MCV values are not relevant. Bilirubin levels would only be important in the presence of liver toxicity.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 21 Drug Therapy With Macrolides and Miscellaneous Anti-infective Agents 1. A patient is admitted to the emergency room with a diagnosis of Legionnaires' disease and is placed on isolation. Which of the following medications is the drug of choice for Legionnaires' disease A) Erythromycin (Ery-Ta B) B) Loxapine hydrochloride (Loxitane) C) Meclizine (Antivert) D) Pravastatin (Pravachol) Ans:A Feedback: Erythromycin is the prototype macrolide used to treat Legionnaires' disease.

Loxapine hydrochloride is an antipsychotic agent. Meclizine (Antivert) is used to treat nausea and dizziness. Pravastatin is used to treat hypercholesterolemia

2. The nurse is administering telithromycin (Ketek) to a child with Streptococcus pneumoniae infection. What nursing intervention is implemented when administering this medication A) Administer the medication with or without food B) Administer the medication with grapefruit juice C) Increase the dose in the event of QT elongation D) Administer the medication with lovastatin Ans:A Feedback: When administering telithromycin, food does not affect the absorption of the medication The administration of the medication with grapefruit juice may increase the plasma concentration and cause adverse effects. Telithromycin can cause an elongation of the QT interval; thus, the dose should not be increased. The administration of telithromycin and lovastatin can cause an increase in the QT interval.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A patient is allergic to penicillin and has been diagnosed with a genitourinary infection caused by Chlamydia trachomatis. Which of the following medications will most likely be administered A) Acamprosate calcium (Campral) B) Atazanavir (Reyataz) C) Erythromycin (Ery-Ta B) D) Flumazenil (Mazicon) Ans:C Feedback: A patient who is diagnosed with a genitourinary infection that is caused by trachomatis and who is allergic to penicillin should be administered erythromycin (Ery- Ta B). Acamprosate calcium is administered as a substance abuse deterrent, not in place of penicillin. Atazanavir (Reyataz) is an antiviral agent that is used to treat HIV infection, not Chlamydia trachomatis. Flumazenil is a benzodiazepine antagonist and not used for Chlamydia trachomatis.

4. A patient is diagnosed with peptic ulcer disease. He has been prescribed clarithromycin (Biaxin). Which of the following organisms is this medication used to treat A) Streptococcus pneumoniae B) Haemophilus influenzae C) Mycobacterium avium complex D) Helicobacter pylori Ans:D Feedback: Clarithromycin is approved to treat H. pylori infections associated with peptic ulcer disease. Clarithromycin is also approved to treat Streptococcus pneumoniae, Haemophilus influenza, and Mycobacterium avium complex, but these organisms do not cause peptic ulcer disease.

5. A patient is administered telithromycin (Ketek) to treat a community-acquired pneumonia. A change in what blood level may necessitate a reduction in the dosage A) Creatinine B) AST and ALT C) CPK D) Differential Ans:A Feedback: For patients who have renal impairment, together with hepatic impairment, it is essential to reduce the dosage to 400 mg once daily. Alterations in CPK, white cell differential, and liver enzymes may not require a change in the dosage.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient has been prescribed chloramphenicol (Chloromycetin) for vancomycin-resistant enterococci. How is this medication eliminated from the body A) Through the liver B) Exhaled through the lungs C) Excreted in the urine D) Excreted in the bile Ans:C Feedback: Chloramphenicol is metabolized in the liver and excreted in the urine. It is not eliminated in the liver, exhaled through the lungs, or excreted in the bile.

7. Which of the following miscellaneous antibacterial drugs is administered topically in the treatment of acne A) Chloramphenicol (Chloromycetin) B) Clindamycin (Cleocin) C) Daptomycin (Cubicin) D) Tigecycline (Tygacil) Ans:B Feedback: Clindamycin is administered topically for the treatment of acne. Chloramphenicol, daptomycin, and tigecycline are not administered topically for the treatment of acne

8. A patient is administered daptomycin (Cubicin) to treat a gram-negative infection caused by Staphylococcus aureus. Which of the following symptoms should be reported immediately to the physician based on the known adverse effects of daptomycin A) Weakness of the legs and arms B) Decreased wound drainage C) Hematuria D) Shortness of breath Ans:A Feedback: The nurse should report weakness of legs and arms due to increased serum creatine kinase levels. Decrease in wound drainage, hematuria, and shortness of breath are not adverse effects of daptomycin.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient has been diagnosed with a community-acquired skin infection and has been prescribed linezolid (Zyvox). Which of the following foods should not be eaten during the administration of this medication A) Pasta B) Garlic C) Green leafy vegetables D) Cheddar cheese Ans:D Feedback: Because linezolid is a weak monoamine oxidase inhibitor, patients should avoid food high in tyramine content, such as aged cheeses. Pasta, garlic, and green leafy vegetables are not contraindicated with linezolid.

10. A patient has developed Clostridium difficile associated with pseudomembranous colitis.

Which of the following medications is effective in the treatment of Clostridium difficile A) Linezolid (Zyvox) B) Cladribine (Leustatin) C) Clarithromycin (Biaxin) D) Metronidazole (Flagyl) Ans:D Feedback: Metronidazole (Flagyl) is indicated for use in the treatment of Clostridium difficile Linezolid (Zyvox) is not used to treat C. difficile. Cladribine (Leustatin) is an antineoplastic agent that is not used for C. difficile. Clarithromycin (Biaxin) is not used to treat C. difficile.

11. A patient returns from a trip to the Caribbean and is suffering from severe diarrhea related to E. coli. Which of the following medications is the drug of choice for traveler's diarrhea A) Rifaximin (Xifaxan) B) Spectinomycin (Trobicin) C) Chloramphenicol (Chloromycetin) D) Erythromycin (Ery-Ta B) Ans:A Feedback: Rifaximin (Xifaxan) is administered for the treatment of traveler's diarrhea related to E. coli. Spectinomycin is used to treat gonococcal infections. Chloramphenicol is not administered to treat traveler's diarrhea related to E. coli. Erythromycin is not used to treat traveler's diarrhea related to E. coli.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A patient who is being administered metronidazole (Flagyl) to treat Clostridium difficile will also be administered which medication orally to assist in restructuring the flora of the intestinal tract A) Spectinomycin (Trobicin) B) Rifaximin (Xifaxan) C) Vancomycin (Vancocin) D) Quinupristin–dalfopristin Ans:C Feedback: Oral vancomycin is used to treat pseudomembranous colitis caused by C. difficile.

Spectinomycin (Trobicin), rifaximin (Xifaxan), and quinupristin–dalfopristin are not administered to treat pseudomembranous colitis caused by C. difficile.

13. A patient who is being treated in the intensive care unit has been diagnosed with ventilatorassociated pneumonia. Culture and sensitivity testing of the patient's sputum indicates that erythromycin is a treatment option. The nurse knows that this drug is likely contraindicated for what reason A) Erythromycin inhibits normal liver function B) Erythromycin is associated with gastrointestinal upset C) Erythromycin is nephrotoxic D) Erythromycin cannot be administered orally Ans:A Feedback: Erythromycin is seldom used in critical care settings, partly because broader spectrum bactericidal drugs are usually needed in critically ill patients and partly because it inhibits liver metabolism and slows elimination of several other drugs Erythromycin is not nephrotoxic. The drug is administered orally, and GI upset does not contraindicate use.

14. An adult patient has been diagnosed with bacterial sinusitis, and her care provider has prescribed oral erythromycin. The nurse has cautioned the patient against taking the drug together with antacids because this practice A) delays metabolism of the drug B) can exacerbate nausea and reflux

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) causes a dangerous rise in gastric pH D) decreases the absorption of the drug Ans:D Feedback: People should not take erythromycin after taking antacids. Antacids decrease the absorption of both the tablet and suspension form of erythromycin. Antacids do not cause a dangerous rise in pH, exacerbate GI upset, or delay the metabolism of the drug.

15. A 22-year-old college student is allergic to penicillin. Consequently, her current chlamydial infection is being treated with oral erythromycin. What assessment should the nurse prioritize during this patient's course of treatment A) Assessment of the patient's apical heart rate B) Assessment of the patient's hearing C) Assessment of the patient's peripheral pulses D) Assessment of the patient's renal function Ans:B Feedback: With erythromycin, it is important to assess the patient's hearing. The loss of hearing is reversible with the discontinuation of the medication. Erythromycin does not typically affect renal function or circulation. The IV form has been associated with dysrhythmias, but this is not the case with the oral form.

16. An older adult patient has been prescribed telithromycin for community-acquired pneumonia. The nurse has contacted the patient's primary care provider because the patient is on replacement corticosteroid therapy. Why is concomitant use of telithromycin and corticosteroids contraindicated A) The woman may be unable to adequately metabolize her corticosteroid B) The effect of the corticosteroid may be greatly increased C) The woman may have an increased risk of thromboembolism D) The corticosteroid may negate the efficacy of the telithromycin Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Telithromycin is a potent CYP3A4 inhibitor. Combination of this drug with several medications, including corticosteroids, results in an increased serum concentration of these other drugs.

17. A patient states that he has been taking his prescribed clindamycin as ordered, but that it has been causing him to have frequent diarrhea. How should the nurse best respond to this patient's statement A) Reemphasize the importance of taking clindamycin with food B) Encourage the patient to temporarily use an over-the-counter antidiarrheal C) Encourage the patient to increase his fluid intake until the course of treatment is complete D) Liaise with the patient's care provider to have the drug discontinued Ans:D Feedback: The FDA has issued a black box warning for clindamycin regarding the potential of severe and possible fatal colitis. If diarrhea develops in a patient receiving clindamycin, discontinuation of the drug is essential.

18. Numerous residents of a long-term care facility have developed Clostridium difficile– associated diarrhea over the past week. The nurses at this facility would anticipate that many residents would require which of the following drugs A) Linezolid (Zyvox) B) Daptomycin (Cubicin) C) Metronidazole (Flagyl) D) Chloramphenicol (Chloromycetin) Ans:C Feedback: Clinical indications for metronidazole include prevention or treatment of anaerobic bacterial infections (e.g., in colorectal surgery, intra- abdominal infections) and treatment of C. difficile infections associated with pseudomembranous colitis. The other listed antibiotics are not used for the treatment of Clostridium difficile–associated diarrhea.

19. A nurse has returned to a patient's hospital room for a follow-up assessment during the intravenous infusion of vancomycin. What assessment finding would signal the nurse to the possibility that the patient's infusion is running too quickly A) The patient is flushed and has a visible skin rash

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) The patient's apical heart rate is irregular C) The patient is difficult to rouse and has dilated pupils D) The patient complains of pain at the intravenous access site Ans:A Feedback: It is very important to give IV infusions slowly, over 1 to 2 hours, to avoid an adverse reaction characterized by hypotension, flushing, and skin rash. This reaction, sometimes called red man syndrome, is attributed to histamine release.

20. A nurse is preparing a patient's scheduled dose of oral vancomycin. This patient's current illness was most likely manifested by what sign or symptom A) Vomiting B) Inflamed, swollen skin C) Shortness of breath D) Diarrhea Ans:D Feedback: Oral vancomycin is useful only to treat staphylococcal enterocolitis and pseudomembranous colitis caused by C. difficile. These illnesses are always characterized by diarrhea, not vomiting, skin inflammation, or shortness of breath.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 22 Drug Therapy for Tuberculosis and Mycobacterium avium Complex Disease 1. A patient seen in the clinic has symptoms of persistent cough, fever, and night sweats. He recently entered the United States from the Philippines. Which of the following is the most plausible explanation for the patient's condition A) Latent tuberculosis B) Bacterial pneumonia C) Active tuberculosis D) Emphysema Ans:C Feedback: Emigration from countries where the disease occurs, such as the Philippines, places patients at risk for tuberculosis. Active tuberculosis is characterized by symptoms of cough, fever, and night sweats. Patients with latent tuberculosis exhibit no symptoms and do not feel sick. Bacterial pneumonia is not commonly noted with night sweats Emphysema is not noted with fever.

2. A college student has a TB test prior to starting the semester. The tuberculin test site is noted with a reddened, raised area. What condition will the student be diagnosed with if the chest radiograph is negative A) Transmission B) Primary infection C) Latent tuberculosis D) Active tuberculosis Ans:C Feedback: People with inactive or latent TB have no symptoms and do not feel sick. The transmission of the infection occurs when an uninfected person inhales infected airborne particles that are exhaled by an infected person. Primary infection occurs 6 to 8 weeks after exposure. The patient has a mild, pneumonia-like illness that often is undiagnosed. Active tuberculosis is a result from reactivation of a latent infection.

3. A patient is hospitalized with active tuberculosis. The patient is receiving antitubercular drug therapy and is not responding to the medications. What do you suspect the patient is suffering from A) Human immunodeficiency virus B) Drug-resistant tuberculosis C) Methicillin-resistant Staphylococcus aureus

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Vancomycin-resistant Staphylococcus aureus Ans:B Feedback: A patient who is being treated with antitubercular drug therapy and is not responding to the medication regime is most likely experiencing drug-resistant tuberculosis. Human immunodeficiency virus causes tuberculosis to move more rapidly This scenario does not provide any indication that the tuberculosis is related to the diminished patient response. The scenario does not identify methicillin- or vancomycin- resistant Staphylococcus aureus.

4. A patient being treated for tuberculosis is determined to be drug resistant. Which of the following medications will the patient be resistant to in the treatment of the tuberculosis A) Isoniazid (INH) and rifampin B) Carbamazepine (Tegretol) and phenytoin (Dilantin) C) Dextroamphetamine (Dexedrine) and doxapram (Dopram) D) Propranolol (Inderal) and sotalol (Betapace) Ans:A Feedback: Isoniazid (INH) and rifampin are used to treat tuberculosis. In multidrug resistance, the most effective drugs the patient is resistant to are isoniazid and rifampin. Carbamazepine and phenytoin are used to control seizures Dextroamphetamine and doxapram are central nervous system stimulants. Propranolol and sotalol are beta-adrenergic blocking agents.

5. A patient who was frequently homeless over the past several years has begun a drug regimen consisting solely of isoniazid (INH) What is this patient's most likely diagnosis A) Active tuberculosis B) Latent tuberculosis C) Mycobacterium avium complex D) Human immunodeficiency virus Ans:B Feedback: Although use of INH by itself for treatment of latent TB is appropriate, use with other anti- TB drugs is essential for treatment of active TB. INH would not be used exclusively in the treatment of HIV or MAC. 6. A patient is administered isoniazid (INH) for tuberculosis. Which of the following adverse effects will result in discontinuation of the medication A) Weight gain

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Jaundice C) Fever D) Arthralgia Ans:B Feedback: Potentially serious adverse effects of INH include hepatotoxicity and peripheral neuropathy. Hepatotoxicity may be manifested by symptoms of hepatitis (e.g., anorexia, nausea, fatigue, malaise, jaundice) or elevated liver enzymes. Weight gain, fever, and arthralgia are not the most known adverse effects of isoniazid (INH).

7. A patient receiving isoniazid (INH) and rifampin (Rifadin) has a decreased urinary output and decreased sensation in his great toes. Which laboratory values should be assessed A) Hematocrit and hemoglobin B) ALT and AST C) Urine culture and sensitivity D) Erythrocyte count and differential Ans:B Feedback: Hepatotoxicity and peripheral neuropathy are important adverse effects of isoniazid and rifampin. The ALT/AST will assess liver function. The hematocrit and hemoglobin are not indicated with the described symptoms. Erythrocyte count and differential are not indicated with these symptoms.

8. A nursing student is learning about the effects of bactericidal agents. How does rifampin (Rifadin) achieve a therapeutic action against both intracellular and extracellular tuberculosis organisms A) It is metabolized in the liver B) It binds to acetylcholine C) It inhibits synthesis of RNA D) It causes phagocytosis Ans:C Feedback: Rifampin kills Mycobacterium by inhibiting synthesis of RNA. It is metabolized in the liver, but this characteristic does not represent its action. It does not bind to acetylcholine. It does not cause phagocytosis.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient is administered rifampin (Rifadin). Which of the following facts should the patient be taught A) When taking it with warfarin (Coumadin), an increased anticoagulant effect occurs B) It decreases hepatic enzymes and decreases metabolism of drugs C) It has an increased serum half-life, so it is more effective than rifabutin (Mycobutin) D) The urine, tears, sweat, and other body fluids will be a discolored red-orange Ans:D Feedback: The patient's urine, tears, sweat, and other body fluids will be a discolored redorange. This adverse effect is harmless, but the patient should be instructed on this adverse effect The administration of this medication with warfarin will decrease the anticoagulant effect. The medication increases hepatic cytochrome P450 3A4 enzyme and decreases serum concentrations.

The serum half-life of rifampin is shorter than that of the medication rifabutin.

10. A patient who is being administered isoniazid (INH) for tuberculosis has a yellow color in the sclera of her eye. What other finding would lead you to believe that hepatotoxicity has developed A) Diarrhea B) Numbness C) Diminished vision D) Light-colored stools Ans:D Feedback: The presence of light-colored stools is suggestive of hepatotoxicity. Diarrhea, numbness, and diminished vision are not related to hepatotoxicity of isoniazid (INH).

11. A patient is being treated for active tuberculosis with ethambutol (Myambutol). The patient states to the nurse that he cannot identify the red and green on the traffic lights when he is driving. Based on this finding, what medical intervention is most appropriate A) Assess for photosensitivity B) Discontinue ethambutol (Myambutol) C) Decrease the ethambutol (Myambutol) dose

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Administer vitamin B12 Ans:B Feedback: The administration of ethambutol should be discontinued if optic neuritis develops.

Optic neuritis is an inflammatory, demyelinating disorder of the optic nerve that decreases visual acuity and ability to differentiate red and green. The inability to distinguish red and green is not indicative of photosensitivity. The ethambutol should not be decreased. There is no indication for the administration of vitamin B12.

12. A patient is hospitalized due to nonadherence to an antitubercular drug treatment. Which of the following is most important for the nurse to do A) Observe the patient taking the medications B) Administer the medications parenterally C) Instruct the family on the medication regime D) Count the number of tablets in the bottle daily Ans:A Feedback: Directly observed therapy in which a health care provider observes the patient taking each dose of anti-TB drugs is recommended for all drug regimens and is considered mandatory in this case. The medications are not administered parenterally. The family should be instructed on the medication regime, but this action is not imperative in maintaining compliance.

Tablets missing from the bottle may not necessarily have been taken correctly by the patient.

13. A patient with HIV has been infected with Mycobacterium avium complex from an indoor pool. Which of the following medications is the recommended treatment for MAC A) Clarithromycin B) Isoniazid (INH) C) Rifabutin D) Azithromycin Ans:A Feedback: The main drugs used in prevention of MAC disease in patients with HIV are the macrolides azithromycin and clarithromycin.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A homeless man was screened for tuberculosis (T B) during a health consultation at a shelter, and the results indicate latent TB. The community health nurse who is liaising with the providers of the shelter would anticipate what component of this man's plan of care A) The man will undergo conservative treatment for TB using adjuvant medications B) The man will be treated for TB using first-line antitubercular drugs C) The man will be monitored closely to determine if treatment is necessary D) The man will be screened again in 10 to 12 weeks to determine whether he has developed active TB Ans:B Feedback: Patients with latent TB cannot spread the disease to others, but treatment of the latent disease prevents progression of the disease to an active state. It is particularly important to treat latent TB in those patients who are at high risk for progression to active TB. Homelessness is a major risk factor for active TB.

15. A female patient has been diagnosed with tuberculosis and begun multiple-drug therapy. The woman has asked the nurse why it is necessary for her to take several different drugs instead of one single drug. How should the nurse best respond to the patient's question A) “Multiple drugs are used because doctors aren't sure which drug will kill a particular TB strain.”

B) “The use of multiple drugs prevents the development of drug-resistant TB.” C) “Multiple drugs are prescribed because the final testing results for TB can take up to 3 months.”

D) “Multiple drugs are used in order to speed up the course of treatment.”

Ans:B Feedback: Use of multiple drugs to treat TB is necessary to prevent the development of drugresistant TB. This approach to treatment is not necessitated by delays in testing, questionable diagnostic results, or the need to hasten the course of treatment.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

16. A patient is being treated for latent tuberculosis on an outpatient basis and tells the nurse during a scheduled follow-up visit, “I've been feeling pretty good lately, so I haven't actually been all that consistent with taking my drugs.” Subsequent health education should focus on what subject A) The fact that nonadherence to treatment exacerbates the risks of adverse effects B) The need to consistently take the prescribed drugs in order to cure TB C) The need to match drug dosages carefully to signs and symptoms D) The fact that nonadherence will necessitate the use of antiretrovirals Ans:B Feedback: Consistent adherence to treatment is imperative to ensure successful treatment of TB. Nonadherence leads to resistance and unsuccessful treatment, not increased adverse effects.

Antivirals are ineffective against TB. 17. A patient has been diagnosed with tuberculosis and will soon begin first-line drug treatment.

How will rifampin most likely be administered to this patient by the nurse A) Orally, with food B) Orally, on an empty stomach C) Intramuscularly D) Intravenously, as bolus Ans:B Feedback: Rifampin should be taken on an empty stomach, either 1 hour before or 2 hours after a meal. IV administration is possible, but this takes place as a three-hour infusion, not as a bolus.

Rifampin is not administered IM. 18. The nurse is providing care for a patient who is taking isoniazid and rifampin (Rifadin) for the treatment of active tuberculosis. The patient should be taught that an improvement in symptoms will likely be noticed within A) 48 hours B) a week to 10 days C) 2 to 3 weeks D) 4 to 6 weeks Ans:C Feedback: Therapeutic effects are usually apparent with the first 2 to 3 weeks of drug therapy for active TB.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A patient with a diagnosis of active TB has begun second-line therapy that includes the use of pyrazinamide. When monitoring this patient, the nurse should suspect that adverse effects of this drug may account for which of the following laboratory values A) Low hematocrit and mean corpuscular volume (MCV) B) Increased INR and aPTT C) Increased blood urea nitrogen and creatinine D) Increased AST, ALT, and GGT Ans:D Feedback: The most severe adverse effect of pyrazinamide is hepatotoxicity. Consequently, liver enzymes such as GGT, ALT, and AST should be monitored. Changes in erythrocytes, coagulation, and renal function are less likely to result from pyrazinamide therapy.

20. A 40-year-old man has been living with HIV for several years but experienced a significant decrease in his CD4+ levels a few months ago. The patient has just been diagnosed with Mycobacterium avium complex disease. The nurse should anticipate administering which of the following medications? Select all that apply A) Clarithromycin B) Pyrazinamide C) Rifapentine (Priftin) D) Azithromycin E) Bactrim Ans:A, D Feedback: The main drugs used in prevention of MAC disease in patients with HIV are the macrolides azithromycin and clarithromycin. Pyrazinamide, Bactrim, and Priftin are not used to treat MAC.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 23 Drug Therapy for Viral Infections 1. A patient is prescribed acyclovir (Zovirax) for the treatment of genital herpes. What is the expected outcome of this medication A) Decreased testosterone production B) Decreased libido C) Decreased viral shedding D) Decreased bacterial replication Ans:C Feedback: Acyclovir is used to treat genital herpes, in which it decreases viral shedding and the duration of skin lesions and pain. Acyclovir does not decrease testosterone or libido Acyclovir is used to treat viral, not bacterial, infections.

2. A patient suffers from an autoimmune disorder. Which of the following represents a potential result of a viral infection in a patient with an autoimmune disorder A) Lymphocytes recognize the host's tissue as foreign B) Erythrocytes destroy the T cells in the host C) The involution of the thymus gland increases infection cause D) The differential decreases the sedimentation rate Ans:A Feedback: Autoimmune diseases may be caused by viral alteration of host cells so that lymphocytes recognize the host's own tissues as being foreign

3. failure is admitted to the hospital with herpes simplex. The acyclovir (Zovirax) is to be administered parenterally. When preparing to administer this medication, what would the nurse expect in regard to the dose A) The dose is smaller due to the herpes simplex B) The dose is smaller based on the patient's kidney function C) The dose is higher in treating genital herpes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) The dose is higher if the creatinine is above 4.0 mg/dL Ans:B Feedback: Oral and IV acyclovir are excreted in the urine, and the dose should be decreased in patients who are older or have renal impairment. The dose is not smaller due to herpes simplex.

The dose is not higher in treating genital herpes. The dose should be lower if the creatinine level is above 4.0 mg/ dL.

4. A patient who has been diagnosed with human immune deficiency syndrome is given ganciclovir (Cytovene) to prevent cytomegalovirus. The patient develops granulocytopenia. How long will it take for the granulocytes to regenerate after the ganciclovir is discontinued A) 5 days B) 7 days C) 10 days D) 14 days Ans:B Feedback: Ganciclovir causes granulocytopenia and thrombocytopenia in 20 to 40 of recipients, often during the first 2 weeks of therapy. If severe bone marrow depression occurs, ganciclovir should be discontinued; recovery usually occurs within a week of stopping the drug.

Five days after discontinuing the drug is too soon to see a change in granulocytopenia. Ten to fourteen days is too long for change to occur. It should have occurred within 1 week.

5. A patient has been diagnosed with cytomegalovirus (CMV). Which of the following drugs would be ineffective in the treatment of this disease A) Ribavirin (Rebetol) B) Ganciclovir (Cytovene) IV C) Foscarnet (Foscavir) IV D) Valganciclovir hydrochloride (Valcyte) Ans:A Feedback: Ribavirin is administered to treat respiratory syncytial virus. Ganciclovir, foscarnet, and valganciclovir are used in the treatment of CMV.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A 21-year-old male is being started on zidovudine (AZT) for treatment of HIV/ AIDS. Which of the following statements made by the patient indicates that he has understood the patient teaching A) “AZT inactivates the virus and prevents recurrence of the disease.”

B) “AZT therapy may result in the development of AZT-resistant strains.”

C) “AZT slows the progression of the disease but does not cure it.”

D) “AZT prevents the occurrence of opportunistic infections.”

Ans:C Feedback: Zidovudine slows the progression of the disease but does not cure the disease Zidovudine does not inactivate the virus. Zidovudine does not result in resistant strains.

Zidovudine does not prevent the occurrence of opportunistic infections.

7. A patient is administered a nucleotide reverse transcriptase inhibitor in combination with a nonnucleotide reverse transcriptase inhibitor. What is the main rationale for administering these medications together A) They facilitate increased adherence to treatment B) They decrease the length of illness C) They have synergistic antiviral effects D) They prevent the development of opportunistic infections Ans:C Feedback: Because the two types of drugs inhibit reverse transcriptase by different mechanisms, they may have synergistic antiviral effects. The use of two medications may decrease adherence because of the burden of taking two medications. The use of two medications will not decrease the length of the illness. They will not decrease all opportunistic infections.

8. A patient is prescribed zanamivir (Relenz A) to treat influenza B. The patient has a history of asthma. For which of the following symptoms should the nurse assess A) Bradycardia B) Pneumonia C) Bronchospasm D) Pulmonary embolism Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A patient is administered zanamivir for the treatment of influenza B. The patient has asthma and should be observed or assessed for decreased respiratory function, including bronchospasm. Bradycardia, pneumonia, and pulmonary embolism are not adverse effects the nurse should expect.

9. A neonatal intensive care unit nurse is caring for an infant with RSV. What route of delivery will the nurse use when ribavirin (Virazole) is administered A) Oral suspension B) Topical C) Intravenous D) Inhaled Ans:D Feedback: Ribavirin is inhaled systemically.

10. A young woman is seen in the physician's office and wants to ensure that she is vaccinated against hepatitis. Vaccines are available for which of the following types of hepatitis? Select all that apply A) Hepatitis A virus B) Hepatitis B virus C) Hepatitis C virus D) Hepatitis D virus E) Hepatitis G virus Ans:A, B Feedback: Vaccines are available for hepatitis A and B. 11. A patient is prescribed indinavir sulfate (Crixivan) for the treatment of HIV infection. What patient teaching should be provided regarding renal function A) Drink grape juice daily for antioxidants B) Drink grapefruit juice to enhance absorption C) Assess for pulmonary edema D) Consume at least 48 ounces of fluid per day Ans:D Feedback: When taking indinavir, the patient should be instructed to consume 48 ounces of water or fluid per day to prevent nephrolithiasis. The consumption of grape juice with

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

antioxidants will assist in preventing nephrolysis but must be in sufficient amounts. The consumption of grapefruit juice is usually contraindicated The nurse would not need to assess for pulmonary edema.

12. A patient has sought care from her primary care provider after feeling “under the weather” for several days. The care provider suspects that the patient is suffering from a viral illness. What signs and symptoms typically accompany viral infections? Select all that apply A) Increased white cell count B) Idiopathic bleeding C) Malaise D) Fever E) Headache Ans:C, D, E Feedback: Symptoms usually associated with acute viral infections include fever, headache, cough, malaise, muscle pain, nausea and vomiting, diarrhea, insomnia, and photophobia. White blood cell counts usually remain normal, and bleeding is uncharacteristic.

13. A young adult male who has had multiple sex partners in the preceding months has been diagnosed with hepatitis B virus (HBV) and begun treatment with lamivudine (Epivir) Shortly after beginning treatment, the man complains of a 24-hour history of intense abdominal pain. The nurse should recognize the possibility of what adverse effect of lamivudine therapy A) Gastroenteritis B) Gastroesophageal reflux disease C) Bowel obstruction D) Pancreatitis Ans:D Feedback: A main adverse effect of lamivudine is pancreatitis. GERD, obstruction, and gastroenteritis do not typically result from lamivudine therapy. As well, these problems do not typically manifest with intense and sudden abdominal pain.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. An influenza outbreak has spread through a long-term care residence, affecting many of the residents with severe malaise, fever, and nausea and vomiting. In an effort to curb the outbreak, the nurse has liaised with a physician to see if residents may be candidates for treatment with what drug A) Saquinavir mesylate B) Oseltamivir phosphate C) Lamivudine D) Ribavirin Ans:B Feedback: Oseltamivir phosphate (Tamiflu) is used to treat active influenza. Saquinavir mesylate is a protease inhibitor. Lamivudine is used to treat hepatitis B. Ribavirin treats RSV. 15. A patient who is undergoing treatment for cytomegalovirus received his first dose of IV ganciclovir 3 days ago. When reviewing this patient's most recent blood work, what abnormality should the nurse most likely attribute to the use of this drug A) Hemoglobin 17 g/dL (high normal) B) INR 3.8 (high) C) Platelet count 118,000/mm3 (low) D) 3 Leukocytes 11,900/mm (high) Ans:C Feedback: Ganciclovir causes granulocytopenia and thrombocytopenia in 20 to 40 of recipients, often during the first 2 weeks of therapy. Leukocytosis, increased hemoglobin, and hypocoagulation are not typical adverse effects associated with ganciclovir.

16. A 42-year-old female patient with HIV has been receiving antiretroviral therapy for several years, and her care team has recently added raltegravir (Isentress) to her drug regimen. When appraising the success or failure of this change in treatment and the patient's ability to fight infection, the nurse should prioritize which of the following laboratory values A) The patient's C-reactive protein levels B) The patient's erythrocyte sedimentation rate (ESR) C) The patient's viral load D) The patient's CD4 count Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The nurse assesses for an increase in T-helper CD4 cells. The CD4 count measures the ability to fight against infections. CD4 count is more important than viral load in this regard.

CRP levels and ESR do not reflect the patient's immune function.

17. When administering the fusion protein inhibitor enfuvirtide (Fuzeon) to a patient with HIV, the nurse should A) have the patient gargle with normal saline immediately after taking the drug B) flush the patient's central venous catheter with 100 Unit/mL heparin prior to administration C) inject the drug into the patient's ventrogluteal site using the z-track method D) regularly rotate the subcutaneous injection sites that are used Ans:D Feedback: The nurse injects enfuvirtide subcutaneously into the upper arm, abdomen, or anterior thigh. Injection of the drug into blood vessels, navel, moles, scars, or other areas of skin change should never occur. Rotation of injection sites and assessment of the sites for reactions are necessary.

18. A patient's antiretroviral therapy has not been as efficacious as her care team had predicted, and maraviroc (Selzentry) has consequently been added to her drug regimen. The nurse should recognize this drug as belonging to what category of antiretroviral A) Fusion protein inhibitors B) Protease inhibitors C) CCR5 antagonists D) Integrase strand transfer inhibitors Ans:C Feedback: Currently, maraviroc is the only member of the class of CCR5 antagonists.

19. A school nurse is meeting with a high school student who mentions that she is frustrated with her repeated outbreaks of cold sores. The student states that she tried an over-the- counter topical cream but that it failed to produce an appreciable improvement. The nurse should recognize that this student used what drug A) Ganciclovir B) Valacyclovir (Valtrex)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Famciclovir (Famvir) D) Docosanol (Abrev A) Ans:D Feedback: Docosanol (Abrev A) is an over-the-counter topical antiviral agent that works in the early stages of intracellular events of viral entry into the target cells. Famciclovir (Famvir) is an oral antiviral agent administered for herpes zoster and recurrent genital herpes Valacyclovir (Valtrex) is not an over-the- counter medication. Cold sores are not treated with ganciclovir.

20. A patient began antiretroviral therapy several weeks ago for the treatment of HIV, and he has now presented to the clinic for a scheduled follow-up appointment. He states to the nurse, “I've been pretty good about taking all my pills on time, though it was a bit hit and miss over the holiday weekend.” How should the nurse best respond to this patient's statement A) “Remember that if you miss a dose, you need to take a double dose at the next scheduled time.”

B) “It's acceptable to miss an occasional dose as long as your symptoms don't get worse, but it's not really recommended.”

C) “Remember that your antiretroviral drugs will only be effective if you take them very consistently.”

D) “If you're not consistent with taking your medications, you're likely to develop more side effects.”

Ans:C Feedback: Effective treatment of HIV infection requires close adherence to drug therapy regimens involving several drugs and daily doses Missing as few as one or two doses can decrease blood levels of antiretroviral drugs and result in increased HIV replication and development of drug-resistant viral strains.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 24 Drug Therapy for Fungal Infections 1. vaginal vault while taking an anti-infective to treat strep throat. What fungal agent has most likely caused the burning and itching A) Cryptococcus neoformans B) Candida albicans C) Aspergillus D) Dermatophytes Ans:B Feedback: Growth of Candida organisms is normally restrained by intact immune mechanisms and bacterial competition of nutrients. When these restraining forces are altered (antibacterial drug therapy), fungal overgrowth and opportunistic infection can occur Cryptococcus neoformans organisms evade normal immune defense of phagocytosis Aspergillus organisms produce protease Dermatophytes grow on cool body surfaces.

2. A patient is being treated with amphotericin B for a fungal infection of the urinary tract What is the action of amphotericin B A) It binds to ergosterol and forms holes in the membrane B) It binds to an enzyme required for synthesis of ergosterol C) It disrupts the fungal cell walls rather than the cell membrane D) It inhibits glucan synthetase required for glucan synthesis Ans:A Feedback: Amphotericin B binds to ergosterol and forms holes in the membrane, causing leakage of fungal cell contents and lysis of the cell. The azole drugs bind to an enzyme that is required for synthesis of ergosterol. This action causes production of a defective cell membrane, which allows leakage of intracellular contents and destruction of the cell. Echinocandins disrupt fungal cell walls rather than fungal cell membranes. They inhibit glycan synthetase, an enzyme required for synthesis of glucan

3. A patient is being treated for a severe fungal infection with amphotericin B. What is the expected length of treatment for this patient

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) 1 to 2 weeks B) 3 to 6 weeks C) 4 to 12 weeks D) 15 to 18 weeks Ans:C Feedback: Because of the toxicity of amphotericin B, the drug is used only for serious infections. It is usually given for 4 to 12 weeks. Amphotericin B is not given for 1 to 2 weeks, 3 to 6 weeks, or 15 to 18 weeks.

4. A patient is given Abelcet instead of amphotericin B. What is the advantage of Abelcet over amphotericin B A) It is a newer medication with a lower cost B) It is the same as amphotericin B in hepatotoxicity C) It reaches higher concentration in diseased tissue D) It constricts afferent renal arterioles to reduce blood flow Ans:C Feedback: Lipid formulations, such as Abelcet, reach higher concentrations in diseased tissues than in normal tissues, so larger doses can be given to increase therapeutic effects. Abelcet does not cost less than amphotericin B. Abelcet has fewer side effects than amphotericin B. Amphotericin B constricts afferent renal arterioles to reduce blood flow.

5. A child with a serious fungal infection is receiving amphotericin B parenterally. Which of the following minerals will the patient most likely be required to receive A) Chloride B) Magnesium C) Glucose D) Sodium Ans:B Feedback: Hypomagnesemia may occur, which will require the administration of magnesium.

The patient is less at risk for changes in chloride, glucose, or sodium.

6. A patient is receiving oral nystatin suspension for a fungal infection of the mouth. Which of the following adverse effects is most likely to be experienced with this form of nystatin

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Local irritation B) Burning C) Nausea D) Urinary urgency Ans:C Feedback: Oral use of nystatin produces the following adverse effects: nausea, vomiting, and diarrhea. The vaginal application of nystatin produces the following adverse effects: local irritation and burning. Urinary urgency is not an adverse effect associated with nystatin.

7. A woman is seen in the clinic for vaginal itching and discharge. Which of the following medications can be administered in a single dose to treat her discomfort and vaginal discharge A) Caspofungin (Cancidas) B) Terbinafine (Lamisil) C) Ketoconazole (Nizoral) D) Fluconazole (Diflucan) Ans:D Feedback: Fluconazole (Diflucan) is used for vaginal candidiasis in a single oral dose of 150 mg. Caspofungin is not used for vaginal candidiasis, but for invasive aspergillosis. Terbinafine is used for interdigital tinea pedis. Ketoconazole is used for patients with organ transplants.

8. A patient has been diagnosed with a fungal infection and is to be treated with itraconazole (Sporanox). Prior to administration, the nurse notes that the patient is taking carbamazepine (Tegretol) for a seizure disorder. Based on this medication regime, which of the following will be true regarding the medications A) The serum level of carbamazepine will be increased B) The patient's carbamazepine should be discontinued C) The patient's antiseizure medication should be changed D) The patient will require a higher dosage of itraconazole (Sporanox) Ans:D Feedback: Drugs that induce drug-metabolizing enzymes (e.g., carbamazepine, phenytoin, rifampin) decrease serum concentrations of itraconazole. The serum level of carbamazepine will not need to be increased. The carbamazepine should not be discontinued or changed.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient is being treated with caspofungin for a systemic fungal infection related to Aspergillus. Prior to the administration of the first parenteral dose, the nurse notes that the patient's AST and ALT levels are elevated How will these serum hepatic enzymes affect the administration of caspofungin A) The dose will need to be increased B) The dose will need to be decreased C) The dose will require a serum trough D) The medication should not be given Ans:B Feedback: The dose of caspofungin will need to be reduced due to the risk of hepatotoxicity. The dose of caspofungin should not be increased. The peak and trough are not as vital as the reduction of the dose. The medication should be administered at a lower dose.

10. A patient is being treated for a fungal infection with IV amphotericin B. In order to prevent drug discomfort, the nurse should consistently monitor the patient's levels of A) sodium B) hemoglobin C) calcium D) leukocytes Ans:A Feedback: It is essential to assess the sodium balance throughout the administration of amphotericin. By maintaining the serum sodium level within normal range, the patient has decreased symptoms of drug discomfort.

11. A patient is receiving intravenous amphotericin. Which of the following assessments warrants the discontinuation of the antifungal agent A) Sodium of 138 mEq/L

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Hematocrit of 39 C) Blood urea nitrogen of 60 mg/dL D) AST 10 Unit/L Ans:C Feedback: If the patient's BUN exceeds 40 mg/dL or serum creatinine exceeds 3 mg/dL, the drug should be stopped or dosage should be reduced until renal function recovers. The hematocrit is in normal range and will not affect the medication administration. The AST and sodium levels are within normal range and will not affect the administration

12. A patient is being treated with amphotericin B. Which of the following statements indicates that the patient has understood the patient teaching A) “The medication may cause diabetes.”

B) “The medication will cause liver necrosis.”

C) “The medication may cause kidney damage.”

D) “The medication will cause pancreatitis.”

Ans:C Feedback: The main concern with the administration of amphotericin B is the risk of nephrotoxicity. Thus, the statement that the medication may cause kidney damage is the most appropriate. The medication will not cause diabetes, liver necrosis, or pancreatitis.

13. Amphotericin B is being used in the treatment of cryptococcosis in a patient who has HIV. When assessing for potential signs and symptoms of cryptococcosis, the nurse should prioritize what assessment A) Neurological assessment B) Functional assessment C) Nutritional assessment D) Cardiac assessment Ans:A Feedback: Cryptococcosis may involve the lungs, skin, and other body organs. In patients with AIDS or other immunosuppressant disorders, it often involves the CNS and produces mental status changes, headache, dizziness, and neck stiffness. Neurological assessment is consequently a priority

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. An adult patient was recently diagnosed with a tinea infection, and her primary care provider promptly began treatment with griseofulvin. During a scheduled clinic visit, the patient states to the nurse, “I'm pretty good at reading my body's signals, so I make sure to take a bit extra when I think my infection is getting worse.” This patient's statement is suggestive of what nursing diagnosis A) Deficient knowledge related to correct use of griseofulvin B) Effective therapeutic regimen management related to symptom identification C) Disturbed thought processes related to appropriate use of griseofulvin D) Ineffective coping related to self-medication Ans:A Feedback: In order to achieve maximum therapeutic benefit, it is important for the patient to take the drug exactly as ordered. The patient's statement suggests that she does not appreciate or understand this fact. There is no evidence of pathological thought patterns or ineffective coping.

15. A patient with systemic candidiasis has been prescribed flucytosine. The nurse should be aware of the need to administer this drug with which of the following A) Vitamin D and calcium supplements B) Fluconazole (Diflucan) C) Amphotericin B D) Penicillin G Ans:C Feedback: Flucytosine is used as an adjunctive agent with amphotericin B for the treatment of systemic fungal infections caused by Candida and Cryptococcus

16. An adult patient has begun treatment with fluconazole. The nurse should recognize the need to likely discontinue the drug if the patient develops which of the following signs or symptoms A) Jaundice B) Weight gain C) Iron deficiency anemia D) Hematuria Ans:A Feedback: The azoles may cause hepatotoxicity, and the development of jaundice usually accompanies liver damage, which may necessitate discontinuing the drug. Fluconazole is not associated with weight gain, anemia, or hematuria.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

17. An older adult patient has asked her primary care provider for a prescription that will help to resolve her “warped toenails.” The care provider has diagnosed the woman with onychomycosis.

The nurse should anticipate that this patient will be treated with what drug A) Micafungin (Mycamine) B) Terbinafine (Lamisil) C) Voriconazole (Vfen D) D) Fluconazole (Diflucan) Ans:B Feedback: Terbinafine (Lamisil) is used for the treatment of onychomycosis of the fingernails or toenails.

18. A 43-year-old man has tested positive for systemic candidiasis, and the care team has decided on IV fluconazole as a first-line treatment. When administering this medication, the nurse should A) administer the drug with lactated Ringer's B) infuse the drug no faster than 200 mg/h C) avoid administering the drug through a peripheral IV D) administer prophylactic heparin prior to the fluconazole Ans:B Feedback: Continuous infusion of fluconazole occurs at a maximum rate of 200 mg/h. The drug is not administered with lactated Ringer's or heparin. A peripheral IV may be used.

19. When administering the azoles in the home setting, the home health nurse should prioritize educational interventions that address what nursing diagnosis A) Risk for injury related to antifungal therapy B) Risk for acute confusion related to antifungal therapy C) Risk for infection related to antifungal therapy D) Risk for falls related to antifungal therapy Ans:C Feedback: When administering the azoles in the home setting, it is important that the home care nurse instruct the patient and family on the management of the environment with the

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

implementation of good hand hygiene, household cleanliness, removal of potted plants and fresh flowers, and the use of air conditioning and air filtration systems. The nurse should also tell the patient and family about measures to prevent the reinfection and spread of the fungal infection.

Falls, confusion, and injury are less likely consequences of using the azoles in the home setting.

20. Caspofungin has been ordered in the treatment of a patient who is being treated in the acute medicine unit for invasive aspergillosis. The nurse should teach the patient to promptly report what symptoms A) Cardiac symptoms B) Diaphoresis C) Dry mouth D) Muscle pain Ans:A Feedback: Caspofungin is administered in the acute care setting. The patient should receive instruction about the histamine reaction to the medication and the necessity of reporting any cardiac symptoms. Diaphoresis, dry mouth, and muscle pain are not normally associated with the administration of caspofungin.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 25 Drug Therapy for Parasitic Infections 1. A child who attends a day care center has been admitted to the pediatric unit with diarrhea and abdominal cramping. He has been diagnosed with giardiasis. How long does it take for the symptoms of giardiasis to develop after ingestion of cysts A) 12 to 24 hours B) 3 to 5 days C) 1 to 2 weeks D) 2 to 3 months Ans:C Feedback: Giardia infections occur 1 to 2 weeks after the ingestion of the cysts and may be asymptomatic or produce diarrhea, abdominal cramps, and distention.

2. A teacher in a preschool is diagnosed with giardiasis. Which of the following medications will be administered to treat the diarrhea and abdominal distention A) Sulfasalazine (Azulfidine) B) Metronidazole (Flagyl) C) Trimethoprim–sulfamethoxazole (Bactrim) D) Doxycycline (Vibramycin) Ans:B Feedback: Adults and children older than 8 years of age with symptomatic giardiasis are usually treated with oral metronidazole. The administration of sulfasalazine is used to treat ulcerative colitis. Trimethoprim– sulfamethoxazole is used to treat urinary tract infections.

Doxycycline is a tetracycline agent. It is not used for giardiasis.

3. A group of nursing students and their professor are engaged in a service learning project and will be caring for patients in Haiti. What medication should be administered to prevent the development of malaria A) Metronidazole (Flagyl) B) Oprelvekin (Neumeg A) C) Chloroquine phosphate (Aralen) D) Chloroprocaine hydrochloride (Nesacaine) Ans:C Feedback: Chloroquine phosphate (Aralen) is administered to prevent malaria when traveling to the countries where malaria is a risk because of infected mosquitoes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Metronidazole is not administered to prevent malaria. Oprelvekin is used in the prevention of severe thrombocytopenia with antineoplastic chemotherapy. Chloroprocaine hydrochloride is a local anesthetic agent.

4. A woman is diagnosed with Trichomonas vaginalis. She is being treated with metronidazole (Flagyl) orally. What factor is most important in the care of this patient A) Instruct her on safe sex B) Instruct her to drink red wine C) Instruct her to take two tablets if a dose is missed D) Instruct her to have her partner treated Ans:D Feedback: The woman should be instructed that her partner should also be treated. Because trichomoniasis is transmitted by sexual intercourse, partners should be treated simultaneously to prevent reinfection Although instruction on safe sexual practices is always important, it will not prevent reinfection, and the partner is infected asymptomatically. The patient should not drink while taking metronidazole. The woman should not double the dose if it is missed.

5. A home care nurse visits a patient who is bed bound and lives in a 12-story high rise apartment complex. Her daughter states that she has small red skin lesions over her body and she has been itching. What parasite is most likely responsible for this patient's skin lesions A) Sarcoptes scabiei B) Pediculosis corporis C) Pediculosis pubis D) Toxoplasma gondii Ans:A Feedback: Scabies are parasitic infestations of the skin. Scabies is caused by the itch mite (Sarcoptes scabiei), which burrows into the skin and lays eggs that hatch in 4 to 8 days.

Pediculosis corporis is body lice. Pediculosis pubis is diagnosed by the presence of nits in the pubic and genital areas. Toxoplasma gondii is a parasite spread by ingesting undercooked meat or other food containing encysted forms of the organism.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. The administration of benzene hexachloride (Lindane) for the treatment of scabies is applied in small quantities. What is the rationale for instructing the patient to apply the medication in small quantities A) Excessive applications will lead to central nervous system toxicity B) Excessive applications will cause irritation, rash, and inflammation C) Excessive applications will cause headaches, dizziness, and diarrhea D) Excessive applications will lead to anorexia and cachexia Ans:A Feedback: Lindane is applied topically, and substantial amounts are absorbed through intact skin. Central nervous toxicity has been reported with excessive use. The application of Lindane will not cause irritation, rash, or inflammation. The application of Lindane will not cause headaches, dizziness, or diarrhea The application of Lindane will not lead to anorexia or cachexia.

7. A patient is receiving chloroquine (Aralen) for extraintestinal amebiasis. Which of the following medications should be administered with chloroquine A) Iodoquinol (Yodoxin) B) Metronidazole (Flagyl) C) Metyrosine (Demser) D) Carbamazepine (Tegretol) Ans:B Feedback: Chloroquine is used mainly for its antimalarial effects. When used as an amebicide, the drug is effective in extraintestinal amebiasis, but usually ineffective in intestinal amebiasis.

Treatment is usually combined with an intestinal amebicide. Metronidazole is an intestinal amebicide. Iodoquinol is an iodine compound that acts against amebae in the intestinal lumen.

Metyrosine is an enzyme inhibitor Carbamazepine is an antiseizure medication.

8. A patient has been prescribed iodoquinol (Yodoxin). Prior to administering iodoquinol (Yodoxin), what assessment should the nurse make A) Assess for allergy to iodine B) The time the patient ate C) Assess for skin eruptions

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Assess for ophthalmic symptoms Ans:A Feedback: Iodoquinol (Yodoxin) is an iodine compound; so, prior to administration, the nurse should assess the patient for an iodine allergy. The administration of this medication is not dependent on the time the patient ate. The nurse should assess for skin eruptions after the administration of the medication. The nurse should assess for ophthalmic symptoms after the administration of the medication.

9. A nurse is educating a patient on the administration of tinidazole (Tindamax). Which of the following indicates that the patient understands the administration of tinidazole A) “I will report to the doctor if I have a slow heart rate.”

B) “The medicine will leave a bitter or metallic taste in my mouth.”

C) “I will report urinary urgency and incontinence.”

D) “The medication is given in two doses every day.”

Ans:B Feedback: Tinidazole (Tindamax) will produce a bitter or metallic taste in the mouth. Tinidazole will cause tachycardia as an adverse effect Tinidazole will cause urinary retention, not urgency. Tinidazole should be administered in one dose, not two doses.

10. A 9-year-old boy's mother is anxious about the fact that he will soon begin treatment for worms using mebendazole. The mother asks the nurse about the way in which the drug will eradicate her son's parasitic worms. How should the nurse best respond to the mother A) “Mebendazole will stop the worms from being able to reproduce.”

B) “Mebendazole robs the worms of the glucose they need to survive.”

C) “This drug will prompt your son's body to expel the worms.”

D) “This drug causes the cells in each worm's body to burst.”

Ans:B Feedback: Mebendazole blocks glucose uptake by susceptible helminths. The drug depletes glycogen stores that the worms need for survival and reproduction, resulting in their death.

11. A young adult has been diagnosed with hookworm and has begun taking mebendazole.

When monitoring this patient's health status during treatment, what diagnostic value should the nurse prioritize A) Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) B) White blood cell differential

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) International normalized ratio (INR) and activated partial thromboplastin time (aPTT) D) Hemoglobin, hematocrit, and red blood cell levels Ans:A Feedback: Because mebendazole is potentially hepatotoxic, it is important to assess the hepatic enzymes AST and ALT for elevations leading to hepatic failure. The other listed laboratory values are relevant indicators of the patient's health status, but neither relates directly to the specific risks of mebendazole.

12. A school nurse is teaching the mother of a 7- year-old girl how to safely and effectively apply permethrin after her daughter was diagnosed with head lice. The nurse should teach the mother to do which of the following A) Apply permethrin twice daily until the lice are eradicated B) Avoid using shampoo for the duration of treatment C) Apply the cream only to those locations where nits or lice are visible D) Wear gloves when applying the permethrin cream Ans:D Feedback: When administering permethrin for head lice, it is necessary to wear gloves.

Administration should occur again in 1 week if lice and nits are present. The cream should be applied to the entire scalp, and there is no need to avoid using shampoo.

13. Ivermectin (Stromectol) appears on a list of a patient's recent medications. The nurse who is reviewing the medications is justified in suspecting that the patient may have been receiving treatment for a parasitic infection with A) Entamoeba histolytica B) Giardia lamblia C) Strongyloides stercoralis D) Plasmodium falciparum Ans:C Feedback: Ivermectin (Stromectol), which is used for numerous parasitic infections, is most active against strongyloidiasis (caused by the roundworm Strongyloides stercoralis) Entamoeba histolytica causes amebiasis Plasmodium falciparum causes malaria, and Giardia lamblia causes giardiasis.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A 24-year-old man is planning a trip to Southeast Asia and has obtained a prescription for chloroquine for malaria prophylaxis. While taking this drug, the nurse should likely encourage the patient to avoid A) soy products B) unpeeled vegetables C) high-fat food D) alcohol Ans:D Feedback: When chloroquine is combined with alcohol, the risk of GI distress increases. There is no particular need for this patient to avoid soy, dietary fat, or unpeeled vegetables.

15. A nature photographer will be embarking on a trip to sub-Saharan Africa and is beginning a protocol for malaria prophylaxis involving 500 mg of chloroquine phosphate (Aralen) What instruction should the nurse include in this patient's health education A) “Make sure you take your pill on the same day each week.”

B) “It's not unusual to develop a rash on your trunk and arms, but this isn't cause for concern.”

C) “You'll need to plan ahead so that you take your chloroquine on an empty stomach.”

D) “We'll need to provide you with enough syringes and teach you how to inject the drug.”

Ans:A Feedback: For malaria prophylaxis, chloroquine is taken weekly. It is administered orally and may be taken with food. A rash is not expected and would necessitate further follow-up.

16. A child has been taking mebendazole for the past 3 weeks after being diagnosed with roundworm. The nurse will determine the efficacy of the child's treatment by referencing what diagnostic test A) Liver enzymes B) Stool for ova and parasites C) Colonoscopy or sigmoidoscopy D) Rectal swab for culture Ans:B Feedback: The nurse obtains a stool sample for culture for ova and parasites after 3 weeks of drug administration. A negative stool culture is the optimum outcome of drug therapy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Colonoscopy, liver enzyme levels, and rectal swabs are not used to ascertain whether treatment has been successful.

17. A primary care provider has completed an assessment of a patient who recently returned from a trip to Nepal with a nongovernmental organization. The care provider has liaised with the nurse to create a plan of care that will focus on treatment for amebiasis. What signs and symptoms most likely prompted this patient to initially seek care A) Malaise and fatigue B) Severe diarrhea C) Intermittent fever D) Dizziness and confusion Ans:B Feedback: Trophozoites (active amebae) produce an enzyme that allows them to invade body tissues. They may form erosions and ulcerations in the intestinal wall with resultant diarrhea.

This is a characteristic symptom of amebiasis.

18. A patient who is taking metronidazole for the past 4 days for the treatment of a parasitic infection reports to the nurse that his most recent dose made him “flushed, sweaty, and sick in the stomach.” What assessment is most likely to address the cause of this phenomenon A) “Do you know if you've ever had an allergic reaction to penicillin?”

B) “Did you drink any alcoholic beverages around the time of taking the drug?”

C) “Did you take this dose on an empty stomach?”

D) “Are you taking any over-the-counter antihistamines?”

Ans:B Feedback: Flushing, headache, nausea, sweating, and vomiting may occur if alcohol is ingested with metronidazole. This reaction is unlikely attributable to an allergy, since he has been taking the drug for 4 days. Taking Flagyl on an empty stomach or with antihistamines would not likely have this effect.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 26 Drug Therapy for Hypertension 1. A community health nurse is facilitating a health promotion session to a group of seniors.

Which of the following is most important to instruct regarding hypertension A) Hypertension will increase the risk of cancer B) An increase in sodium is recommended with hypertension C) Vigorous exercise will increase the risk of hypertension D) Hypertension will increase the risk of heart disease Ans:D Feedback: Hypertension increases risks of myocardial infarction, heart failure, cerebral infarction and hemorrhage, and renal disease Hypertension does not increase the risk of cancer. An increase in sodium in a patient's diet is not recommended with hypertension. Exercise will decrease the risk of hypertension.

2. A patient is diagnosed with high blood pressure. Which of the following events occurs in a patient with hypertension A) The kidneys excrete more fluid in response to increased blood pressure B) Fluid loss increases blood volume in the patient with hypertension C) Decreased blood volume increases blood pressure D) Cardiac output increases and in turn causes an increase in blood pressure Ans:A Feedback: When arterial blood pressure is elevated, the kidneys excrete more fluid. The loss of fluid will reduce, not increase, blood volume. The decreased blood volume will decrease cardiac output. The decreased cardiac output decreases blood pressure.

3. A patient has had multiple blood pressure readings that indicate he has hypertension. How is hypertension defined A) Systolic pressure above 140 mm Hg or diastolic pressure above 90 mm Hg B) Systolic pressure above 160 mm Hg or diastolic pressure above 110 mm Hg

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Systolic pressure above 130 mm Hg or diastolic pressure above 95 mm Hg D) Systolic pressure above 150 mm Hg or diastolic pressure above 100 mm Hg Ans:A Feedback: Hypertension is defined as a systolic pressure above 140 mm Hg or a diastolic pressure above 90 mm Hg on multiple blood pressure measurements. The blood pressure of 160/110 mm Hg is considered hypertensive but does not define hypertension. The blood pressure of 130/95 mm Hg is hypertensive but does not define hypertension. The blood pressure of 150/100 mm Hg is hypertensive but does not define hypertension.

4. A patient has recently been diagnosed with hypertension. Which of the following outcomes is most important in this patient A) Verbalization of an understanding of medical regimen B) Compliance with antihypertensive medications C) Multiple diastolic blood pressure readings <90 mm Hg D) Compliance with a low-sodium diet Ans:C Feedback: The diastolic blood pressure below 90 mm Hg is the most important outcome in this patient. Verbalization of understanding of the medical regime is a patient-related outcome that is important but not the most important outcome. Compliance with antihypertensive medications is important but does not confirm a decreased blood pressure. Compliance with a low-sodium diet will assist in decreasing blood pressure but will not confirm that the blood pressure is decreased.

5. A patient is diagnosed with hypertension and is being treated with captopril (Capoten) Which of the following patients should be administered captopril as the first-line treatment A) A patient with diabetes mellitus B) A patient with asthma C) A patient with glaucoma D) A patient with angina pectoris Ans:A Feedback: Captopril (Capoten) is the first-line agent for treating hypertension in diabetic patients, particularly those with type 1 diabetes Captopril can be used for hypertension in patients with asthma, glaucoma, and angina pectoris but is not the first-line agent, as noted in diabetes mellitus.

6. A patient with diabetes mellitus is prescribed captopril (Capoten) to treat hypertension What electrolyte imbalance might the patient be prone to develop A) Hyperkalemia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Hypokalemia C) Hypernatremia D) Hypermagnesemia Ans:A Feedback: Hyperkalemia may develop in patients who have diabetes mellitus or renal impairment. Hypokalemia is not a risk in patients with diabetes mellitus. Hypernatremia is not a major risk in patients with diabetes who are taking captopril. Hypermagnesemia is not a risk in patients with diabetes who are taking captopril.

7. A patient is prescribed losartan (Cozaar). The medication alone is not effective in controlling blood pressure. What medication will best increase the effectiveness of blood pressure control in this patient A) Atorvastatin calcium (Lipitor) B) Hydrochlorothiazide (HCTZ) C) Hydralazine hydrochloride D) Digoxin (Lanoxin) Ans:B Feedback: If losartan alone does not control blood pressure, a low dose of diuretic may be added. Hydrochlorothiazide is a diuretic agent Atorvastatin calcium is not a diuretic agent. Hydralazine is not a diuretic agent. Digoxin is not a diuretic agent.

8. A patient who is malnourished and has hypertension is being treated with losartan (Cozaar).

How should the dose of the medication be adjusted in this patient A) The dose should be higher than normal B) The dose should be lower than normal C) The dose should remain the same as normal D) The medication should be combined with a diuretic Ans:B Feedback: Both losartan and the metabolite are highly bound to plasma albumin, and losartan has a shorter duration of action. Due to malnutrition, a low dose of losartan should be prescribed.

The dose should not be higher than normal due to possible toxicity. The dose should not be the same as normal due to possible toxicity. The medication will not be combined with a diuretic unless the blood pressure is not controlled.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient is prescribed trandolapril (Mavik). What adverse effect should the patient be instructed on that can occur with angiotensin- converting enzyme (ACE) inhibitors A) Sedation B) Persistent cough C) Tachycardia D) Rash Ans:B Feedback: A persistent cough can develop with the use of ACE inhibitors. Sedation, tachycardia, and rash are not noted with ACE Inhibitors.

10. A patient is being administered enalapril maleate (Vasote C). Which of the following diuretics can be combined with ACE inhibitors to increase effectiveness in decreasing blood pressure A) Loop diuretics B) Osmotic diuretics C) Potassium-sparing diuretics D) Thiazide diuretics Ans:D Feedback: ACE inhibitors may be used alone or in combination with other antihypertensive agents, such as thiazide diuretics. ACE inhibitors are not routinely combined with loop, osmotic, or potassium-sparing diuretics 11. the care team is establishing the best medication regimen to match the patient's decreased level of function. Which of the following medications can be administered by transdermal patch A) Amlodipine (Norvas C) B) Candesartan (Atacan D) C) Enalapril (Vasote C) D) Clonidine (Catapres) Ans:D Feedback: Clonidine is available as a transdermal patch. Enalapril, candesartan, and amlodipine are not available by this route.

12. An African American patient is being treated for a new diagnosis of hypertension. What antihypertensive agent is the most likely drug of choice for this patient

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Diuretic B) Vasodilator C) Calcium channel blocker D) Beta-adrenergic blocker Ans:A Feedback: In African Americans, diuretics are effective and recommended as initial drug therapy.

13. A patient is prescribed a potassium-sparing diuretic. What electrolyte imbalance would the patient be prone to develop A) Hypernatremia B) Hyponatremia C) Hypokalemia D) Hyperkalemia Ans:D Feedback: Potassium-sparing diuretics may precipitate hyperkalemia. Potassium-sparing diuretics would not precipitate hypernatremia, hyponatremia, or hypokalemia 14. When providing dietary instruction on a low- sodium diet, which dietary choice is most appropriate for a patient with hypertension A) Hot dog, baked beans, and coleslaw B) Grilled hamburger, french fries, and cola C) Grilled chicken, green salad, and apple D) Ham sandwich, potato chips, and cookie Ans:C Feedback: Therapeutic regimes include sodium restriction. The grilled chicken, green salad, and apple represent low-sodium dietary choices. Hot dog, baked beans, and coleslaw are high in sodium. Grilled hamburger, french fries, and cola are high in sodium. Ham sandwich, potato chips, and cookie are high in sodium.

15. A patient of Asian descent has been diagnosed with hypertension. He is placed on a betablocker. Why is the dose lower than in most other patients A) Asians metabolize and excrete beta-blockers slower B) Asians metabolize beta-blockers in the small intestine C) Asians have a diminished renal excretion of beta-blockers D) Asians are more likely to have a lower albumin level

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Asians in general need much smaller doses of beta-blockers because they metabolize and excrete beta-blockers slowly. They do not metabolize beta-blockers in the small intestine.

They do not have diminished renal excretion of beta-blockers. They do not have a lower albumin level 16. care provider. The patient has been diagnosed with hypertension following several elevated blood pressure readings. The nurse at the clinic should recognize which of the following drug regimens as being most likely A) Monotherapy with a loop diuretic B) Monotherapy with an ACE inhibitor C) A beta-blocker combined with a calcium channel blocker D) A thiazide diuretic combined with a beta- blocker Ans:D Feedback: The JNC 7 guidelines suggest thiazide diuretics be used as first-line therapy, either alone (monotherapy) or with a beta-blocker, ACE inhibitor, ARB, or calcium channel blocker.

Consequently, the other listed drug regimens are less likely to be implemented.

17. An elderly man who resides in a care facility has been prescribed antihypertensives for the first time following many years of generally good health. When administering the first dose of the prescribed medications, the nurse should recognize what nursing diagnosis A) Risk for falls related to antihypertensive medications B) Risk for infection related to antihypertensive medications C) Risk for acute confusion related to antihypertensive medications D) Risk for impaired oxygenation related to antihypertensive medications Ans:A Feedback: Initiation of antihypertensive therapy creates a risk of acute hypotension and consequent falls. Infection, confusion, or impaired oxygenation is much less likely 18. his daily dose of metoprolol (Lopressor) that he has been taking for the treatment of hypertension for several years. Prior to administering this drug, the nurse should assess and document which of the following? Select all that apply A) Oxygen saturation level B) Heart rate C) Potassium level D) Blood pressure E) Capillary refill Ans:B, D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Beta-blockers reduce heart rate and blood pressure; both parameters should be assessed prior to administration. Beta-blockers do not significantly affect potassium levels, oxygen levels, or peripheral circulation.

19. A nurse is working with an adult patient who has recently been diagnosed with hypertension and begun combination therapy. Which of the patient's following statements would suggest a need for further health education A) “I'm going to make up a schedule for checking my blood pressure on a regular basis.”

B) “I'll only need to take these drugs on days when my blood pressure is particularly high.”

C) “My wife and I are thinking of ways that we can cut down the amount of salt in our diet.”

D) “I've made plans with my best friend to start going for walks in the morning four times a week.”

Ans:B Feedback: Antihypertensive drug therapy is usually long term and is taken regularly, except in instances of hypotension or bradycardia Therapy should not be seen as a response to short-term hypertensive readings. The other listed statements are appropriate responses to diagnosis and treatment

20. A patient started taking ramipril earlier in the week for the treatment of hypertension. At her latest clinic visit, she has stated that she now has a “nagging, dry cough.” How should the nurse best follow up the patient's statement A) Inform the patient that the drug should be immediately discontinued B) Inform the patient that this is an adverse effect of the medication that may lead to pneumonitis C) Explain why it will be necessary to obtain a sputum sample D) Explain that drugs like ramipril often cause a cough Ans:D Feedback: ACE inhibitors may precipitate a cough and may necessitate discontinuation of the drug. This is not, however, an emergency or an indication of lung infection or lung inflammation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 27 Drug Therapy for Dysrhythmias 1. A nurse is teaching a cardiac patient about the ability of the heart to generate an electrical impulse. Which of the following teaching points should the nurse convey to the patient A) “There are many different parts of your heart that can initiate an electrical impulse.”

B) “Electrical signals travel along the blood vessels that provide oxygen to your heart.”

C) “Your heart depends on your brainstem to initiate electrical signals.”

D) “The lining of your left ventricle is the site where electrical signals usually originate.”

Ans:A Feedback: Any part of the conduction system can spontaneously start an impulse, but the sinoatrial (S A) node normally has the fastest rate of automaticity and therefore the faster rate of spontaneous impulse formation. The SA node is located in the right atrium. The brain does not initiate the electrical signal Conduction does not exclusively follow blood vessels.

2. A patient is administered medications for the treatment of a rapid dysrhythmia. What is the mechanism of action for these medications A) Reducing automaticity B) Increasing conduction C) Repolarizing myocardial cells D) Reducing refractory period Ans:A Feedback: Drugs used for the treatment of rapid dysrhythmias mainly reduce automaticity. They slow the conduction of electrical impulses through the heart. They spontaneously depolarize myocardial cells. They prolong the refractory period of myocardial cells.

3. A patient is being treated with quinidine to reduce automaticity. The nurse should advocate for a lower-than-normal dose if the patient has a history of A) type 1 or type 2 diabetes B) primary hypertension C) liver disease D) chronic obstructive pulmonary disease

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Hepatic impairment increases the plasma half- life of several antidysrhythmic drugs, including quinidine, and patients with hepatic impairment usually receive a reduced dosage 4. (Norpace) to treat chronic ventricular tachycardia. The nurse's subsequent cardiac assessments and monitoring should be planned in the knowledge that this drug has the potential to cause what health problem A) New-onset chest pain B) Mitral valve regurgitation C) Acute renal failure D) New dysrhythmias Ans:C Feedback: For disopyramide, the Food and Drug Administration (FD A) has issued a black box warning because of the drug's known prodysrhythmic properties. It is not specifically linked to chest pain, valvular regurgitation, or renal failure.

5. A patient is admitted to the emergency room with a ventricular dysrhythmia associated with an acute myocardial infarction. The physician has ordered a bolus of lidocaine IV. What assessment should the nurse make prior to administering this medication A) Assess for lidocaine administration in the patient's history B) Determine the patient's ability to swallow C) Assess the patient's nutritional history for allergies D) Determine if the patient has had a reaction to local anesthesia Ans:D Feedback: Lidocaine is contraindicated in patients allergic to local anesthetic agents. It is important to determine if the patient has been administered lidocaine in the past, but it is imperative to ascertain any untoward effects. The medication will be administered intravenously, so it is not necessary to assess the patient's ability to swallow. However, swallowing can be impaired after administration and should be assessed. It is not necessary to do a nutritional assessment at this time

6. A physician has ordered lidocaine IV for a patient with a ventricular dysrhythmia. The nurse has administered a bolus of lidocaine. What is the recommended rate for continuous infusion of lidocaine IV A) 0.25 to 0.75 mg/min

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) 10 to 20 mg/min C) 1 to 4 mg/min D) 6 to 8 mg/min Ans:C Feedback: A continuous infusion of lidocaine IV after a bolus is 1 to 4 mg/min. The administration of 0.25 to 0.75 mg/min would be too small of a dosage. The administration of 10 to 20 or 6 to 8 mg/min would be too large.

7. A patient is receiving an antidysrhythmic medication intravenously. How often should the patient's blood pressure be assessed A) Once per shift B) Every 1 to 5 minutes C) Every 15 minutes D) Every 2 hours Ans:B Feedback: During intravenous administration of antidysrhythmic drugs, maintain continuous cardiac monitoring and check blood pressure every 1 to 5 minutes depending on the onset of action. Assessment of the blood pressure one time per shift, every 15 minutes, and every 2 hours would be too limited for safe nursing practice

8. Intravenous verapamil has been ordered STAT in the treatment of a patient with a supraventricular tachycardia. In order to ensure patient safety, the nurse should be aware that concurrent use of which of the following medications is absolutely contraindicated A) Sodium bicarbonate B) Propranolol C) Diltiazem D) Lidocaine Ans:B Feedback: Use of IV verapamil with IV propranolol should not take place; it may result in potentially fatal bradycardia and hypotension.

9. An adult male patient with a long-standing dysrhythmia has been taking oral propranolol for the last several months, resulting in acceptable symptom control. What is a priority teaching point for the nurse to communicate to this patient A) The need to measure his radial pulse for 1 minute prior to each dose of propranolol B) The importance of not stopping the medication abruptly

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) The need to avoid taking over-the-counter antacids D) The need to limit his intake of high-potassium foods Ans:B Feedback: Patients need to realize that they should not stop taking propranolol abruptly because this action can cause the dysrhythmia to worsen. There is no need to restrict potassium intake, to avoid antacids, or to measure his radial pulse prior to each dose of propranolol

10. A patient is admitted to the emergency department in ventricular fibrillation. The patient is administered amiodarone hydrochloride (Cordarone). What is a major effect of this medication A) It produces skeletal muscle relaxation B) It decreases automaticity in the ventricles C) It stimulates the sympathetic nervous system D) It slows the process of repolarization Ans:D Feedback: Potassium channel blockers such as amiodarone prolong duration of the action potential, slow repolarization, and prolong the refractory period in both the atria and ventricles.

Amiodarone blocks the effects of the sympathetic nervous system instead of stimulating it.

Amiodarone and the other potassium channel blockers do not directly decrease automaticity.

11. A patient is administered amiodarone (Cordarone) intravenously. Which of the following assessments should the nurse consequently prioritize A) Assess urine output every 5 minutes B) Assess blood pressure at least every 5 minutes C) Assess for increased bronchovesicular lung sounds D) Assess for muscle rigidity Ans:B Feedback: The nurse should assess the blood pressure every 5 minutes with the IV administration of amiodarone and other antidysrhythmics. It is important to assess urine output, but it is not necessary to assess it every 5 minutes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Amiodarone may diminish lungs sounds, but it will not cause an increase in lung sounds. The effect of amiodarone is to decrease muscle strength, not cause rigidity 12. amiodarone (Cordarone) is normally reserved for use in patients with life-threatening dysrhythmias. In some cases, however, low- dose amiodarone may be used to prevent recurrence of A) atrial fibrillation B) angina pectoris C) ventricular hypertrophy D) mitral valve regurgitation Ans:A Feedback: Low-dose amiodarone may be a pharmacologic choice for preventing recurrent atrial fibrillation after electrical or pharmacologic conversion. Potassium channel blockers are not used to prevent valvular disorders, ventricular hypertrophy, or angina.

13. A patient is admitted in atrial flutter. Which of the following nonpharmacological interventions will best assist in long-term maintenance of a normal sinus rhythm A) Implantation of a cardioverter–defibrillator B) Initiation of an isometric exercise program C) A high-potassium diet D) Surgical intervention with a new mitral valve Ans:A Feedback: The implantable cardioverter–defibrillator provides nonpharmacological management of atrial flutter to maintain normal sinus rhythm. Surgical intervention with a new mitral valve will not prevent atrial flutter. Exercise and potassium intake will ensure NSR. 14. A patient is diagnosed with acute supraventricular tachycardia, and a critical care nurse is contributing to his plan of care. Which of the following class IV calcium channel blockers is exclusively administered to treat acute supraventricular tachycardia A) Bethanechol chloride (Urecholine) B) Chlorambucil (Leukeran) C) Diltiazem (Cardizem) D) Midazolam hydrochloride Ans:C Feedback: Diltiazem is administered intravenously to treat acute supraventricular tachycardia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Bethanechol is used to treat neurogenic bladder. Chlorambucil (Leukeran) is an antineoplastic agent used to treat chronic lymphocytic leukemia. Midazolam hydrochloride is administered to reduce anxiety.

15. A patient is administered diltiazem (Cardizem) IV, which is followed by propranolol (Inderal) IV. The nurse should assess for what potential effect of this medication combination A) Hypertensive crisis B) Anaphylaxis C) Valve regurgitation D) Impaired contractility Ans:D Feedback: If diltiazem is used with propranolol or digoxin, it is necessary to exercise caution to avoid further impairment of myocardial contractility. The administration of IV diltiazem and propranolol will not produce hypertensive crisis, anaphylaxis, or valve regurgitation.

16. A patient has been diagnosed with digitalis- induced dysrhythmia. The patient is administered magnesium sulfate IV to resolve a low potassium level. What effect does hypomagnesemia have A) Decreased QRS complex B) Increased stroke volume C) Myocardial irritability D) Elevated ST segment Ans:C Feedback: Hypomagnesemia increases myocardial irritability. Magnesium deficit prolongs the QRS complex instead of decreasing the QRS complex. Hypomagnesemia does not increase stroke volume. Hypomagnesemia will depress the ST segment, not elevate the ST segment.

17. The electrocardiogram of a patient in distress reveals the presence of paroxysmal supraventricular tachycardia. The cardiologist has consequently ordered adenosine, an unclassified antidysrhythmic that is specific to the treatment of this disorder. The nurse should prepare to facilitate what intervention A) Cardiac catheterization B) Inserting a central venous catheter C) Holter monitoring D) Nonstress testing

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Adenosine has a very short duration of action (serum half-life of less than 10 seconds) and a high degree of effectiveness. It must be given by a rapid bolus injection, preferably through a central venous line. Cardiac catheterization is not indicated in this patient's care. Holter monitoring and nonstress testing are not used in the immediate assessment of patients in cardiac decompensation.

18. A 48-year-old male patient with no known history of cardiovascular disease has presented to the emergency department in atrial flutter. The on-call cardiologist has ordered propafenone PO 150 mg every 8 hours for 24 hours. What is the cardiac care nurse's priority assessment during this period A) Every 1 hour monitoring of potassium levels B) Blood pressure monitoring every 10 minutes C) Echocardiography D) Continuous ECG monitoring Ans:D Feedback: Propafenone may cause new dysrhythmias or aggravate preexisting dysrhythmias, sometimes causing sustained ventricular tachycardia or ventricular fibrillation. As a result, continuous ECG monitoring is necessary at the initiation of treatment. This is a priority over serial potassium levels or echocardiography. Blood pressure should ideally be monitored more frequently than every 10 minutes.

19. A 59-year-old man with a history of coronary artery disease is undergoing cardiac catheterization. The procedure has been proceeding as planned, but the patient suddenly begins exhibiting ventricular tachycardia. What drug should the nurse most likely prepare for administration A) Lidocaine B) Magnesium sulfate C) Digoxin D) Epinephrine Ans:A Feedback: Lidocaine is the drug of choice for treating serious ventricular dysrhythmias associated with acute myocardial infarction, cardiac catheterization, cardiac surgery, and

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

digitalis- induced ventricular dysrhythmias. Digoxin, MgSO4, and epinephrine are not used in this clinical situation.

20. Oral quinidine has been ordered for a patient who has a diagnosis of chronic ventricular tachycardia without heart block. In order to assess for the safety and efficacy of this treatment, the nurse should prioritize assessment of the patient's A) radial and brachial pulse B) level of consciousness C) serum drug levels D) blood pressure Ans:C Feedback: While all of the listed assessments are relevant and appropriate, the nurse must assess the patient's serum quinidine level to ensure it is between 2 and 6 mcg/mL.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 28 Drug Therapy for Coronary Heart Disease 1. A patient has substernal chest pain that radiates to the neck. The pain lasts 5 minutes and then subsides with relaxation. What is the most likely cause of the chest pain A) Myocardial infarction B) Intermittent claudication C) Hypertension D) Angina pectoris Ans:D Feedback: Classic angina pain related to angina pectoris is substernal chest pain that can radiate to the jaw. Chest pain that lasts longer than 5 minutes is not associated with angina but is associated with myocardial infarction Hypertension is usually a condition in which the patient is pain free. Intermittent claudication is not associated with chest pain.

2. A patient is experiencing episodes of chest pain. He smokes one pack of cigarettes per day and has done so for many years. When teaching him about the effect of smoking on the cardiovascular system, the nurse will teach the patient about the effects of nicotine, including which of the following A) It increases catecholamines to increase heart rate B) It diminishes the blood's ability to clot C) It increases myocardial contractility of the heart D) It increases high-density lipoproteins Ans:A Feedback: Nicotine increases catecholamines to increase heart rate and blood pressure. It increases platelet adhesiveness and aggregation to increase, not decrease, clotting. It decreases myocardial contractility. It does not increase myocardial contractility. It decreases good cholesterol, which is the high-density lipoprotein.

3. The nurse is teaching the patient about angina pectoris. Which of the following statements by the patient indicates that he has understood the teaching A) “I will avoid exercise because it will precipitate my angina.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) “As long as I take my medicines, I will not need to decrease my fat intake.”

C) “My high blood pressure has no effect on my episodes of chest pain.”

D) “High fat in the diet and smoking can cause my episodes of chest pain.”

Ans:D Feedback: A diet high in fat and calories will precipitate episodes of chest pain. The implementation of an exercise routine prevents cardiac pain and should be adhered to. The patient will need to alter his lifestyle to maintain heart health High blood pressure will affect episodes of chest pain.

4. A patient is admitted to the emergency department with chest pain that is unrelieved with sublingual organic nitrates. What medication will most likely be administered A) Intravenous morphine sulfate B) Intravenous nitroglycerin C) Oral nonsteroidal anti-inflammatory agents D) Duragesic topical patch Ans:B Feedback: Intravenous nitroglycerin is used to manage angina that is unresponsive to organic nitrates via other routes. The use of intravenous morphine sulfate will decrease pain but will not increase blood flow. Oral nonsteroidal anti-inflammatory agents will not assist in decreasing pain or increasing blood flow. The application of a Duragesic patch will not increase blood flow.

5. A patient with a history of angina has sustained a mild head injury in a motor vehicle accident.

He has nitroglycerin tablets for chest pain and asks the nurse for one due to chest pain. What effect will the nitroglycerin have on the patient's current status A) Nitroglycerin will raise the patient's blood pressure B) Nitroglycerin will cause decreased cerebral edema C) Nitroglycerin will increase intracranial pressure D) Nitroglycerin will decrease blood glucose Ans:C Feedback: Nitroglycerin should be used cautiously in the presence of a head injury or cerebral hemorrhage because it may increase intracranial pressure. Nitroglycerin will lower blood

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

pressure. Nitroglycerin can increase cerebral edema. Nitroglycerin does not have a direct effect on blood glucose.

6. A patient is diagnosed with erectile dysfunction. He asks what effect sildenafil (Viagr A) has because he is taking nitroglycerin for chest pain. What is the best explanation for why nitrates are contraindicated with sildenafil (Viagr A) A) “Nitroglycerin and Viagra cause a severe decrease in blood pressure.”

B) “Nitroglycerin and Viagra can lead to prostate cancer.”

C) “Nitroglycerin decreases the effect of Viagra for erectile dysfunction.”

D) “Nitroglycerin and Viagra will diminish the effectiveness of chest pain relief.”

Ans:A Feedback: Nitrates and phosphodiesterase enzyme type 5 inhibitors decrease blood pressure, and the combined effect can produce profound, life- threatening hypotension.

7. A patient is experiencing chest pain and administers her nitroglycerin sublingually. When should the patient expect to notice relief of her chest pain A) 1 to 3 minutes B) 5 to 10 minutes C) 15 to 20 minutes D) 30 to 60 minutes Ans:A Feedback: When given sublingually, nitroglycerin is absorbed directly into the systemic circulation and acts within 1 to 3 minutes. If the medication has not produced an effect in 5 minutes, it should be repeated. The nitroglycerin tablets have an onset of action of 1 to 3 minutes, not 5 to 60 minutes.

8. When instructing a patient on the use of a nitroglycerin patch, what should the patient be taught regarding the advantage of the nitroglycerin patch A) It is only administered one time per week B) It is more effective than the tablets C) It has a longer duration of action D) It has a faster action than the tablets

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: When applied topically, nitroglycerin is absorbed directly into the systemic circulation. Absorption occurs at a slower rate and has a longer duration of action. The topical form is usually administered more frequently than one time per week. It is not more effective than the tablets. It does not have a faster action.

9. A patient is beginning therapy with isosorbide dinitrate (Isordil). When will the nurse know that the patient has maximal tolerance A) When nausea develops B) When halos are seen around lights C) When a headache develops D) When the heart rate increases to 100 Ans:C Feedback: Isosorbide dinitrate's effective dose is usually determined by increasing the dose until the patient experiences a headache, which will indicate maximum tolerable dose. The development of nausea does not indicate maximum tolerable dose. The patient should not see halos around lights with isosorbide dinitrate. The patient will not have an increase in heart rate.

10. A patient with a long-standing diagnosis of asthma is prescribed a beta-blocker for the treatment of angina. The nurse should consequently prioritize assessment for what health problem A) Bronchospasm B) Hyperglycemia C) Pleural effusion D) Pneumonia Ans:A Feedback: Patients with asthma should be observed for bronchospasm from blockage of beta2 receptors in the lung. The patient will not likely experience hyperglycemia, pleural effusion, or pneumonia.

11. A patient with angina is prescribed propranolol (Inderal). Following absorption of the drug, the nurse should expect to assess A) relief of fatigue B) increased oxygen saturation levels C) mild to moderate drowsiness D) decreased heart rate

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Beta-blockers cause a slowing of the heart rate. They do not normally result in drowsiness, short-term relief from fatigue, or a notable increase in SaO2.

12. A patient is prescribed ranolazine (Ranex A) to treat chronic angina. Which of the following electrocardiogram changes will contraindicate the use of ranolazine A) Normal ST segment B) Inverted P wave C) Shortened QRS D) QT prolongation Ans:D Feedback: Ranolazine is contraindicated in patients with preexisting QT prolongation. It is not contraindicated with a normal ST segment, inverted P wave, or shortened QRS. 13. A medical nurse has administered an oral dose of 30 mg nifedipine long-acting to a patient with a diagnosis of angina. What principle should guide the nurse's follow-up assessment after administering this drug A) Nifedipine has the potential to induce prodysrhythmic effects B) Nifedipine does not affect heart rate, so assessment after administration is not normally necessary C) The patient's heart rate will be at its lowest approximately 45 minutes to 1 hour after oral administration of nifedipine D) The patient's blood pressure, heart rate, and oxygen saturation level should be assessed 30 minutes after administration of nifedipine Ans:B Feedback: Nifedipine inhibits the influx of calcium entering through slow channels, producing vasodilation of the peripheral blood vessels and coronary arteries. However, the drug has a minimal effect on the sinoatrial and atrioventricular nodes. Therefore, it does not affect the heart rate.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. Oral atenolol has been ordered for a resident of a long-term care facility who has a diagnosis of angina. Which of the following assessment findings would prompt the nurse to withhold a scheduled dose of the drug Select all that apply A) Heart rate of 68 beats per minute B) Blood pressure of 88/49 mm Hg C) Heart rate of 58 beats per minute D) Blood pressure of 141/92 mm Hg E) Oxygen saturation of 90 on room air Ans:B, C Feedback: It is important to withhold atenolol and notify the prescriber for a resting heart rate of 60 beats per minute and/or systolic blood pressure less than 90 mm Hg. Low SaO2 does not require withholding atenolol.

15. An elderly patient has begun taking bisoprolol (Zebet A) 10 mg PO once daily for the treatment of angina. The nurse should administer this drug in the knowledge that it achieves a therapeutic effect in what way A) Decreasing heart rate B) Increasing the force of myocardial contractions C) Prolonging the QT interval D) Shortening the time required for repolarization Ans:A Feedback: Bisoprolol reduces the workload of the heart and decreases myocardial oxygen demand by decreasing heart rate and the force of myocardial contractions. It does not prolong the QT interval or shorten the time required for repolarization.

16. A 69-year-old woman has been diagnosed with angina pectoris, and her primary care provider has prescribed nifedipine (Adalat, Procardi A). After administering a dose of the drug at 08:00, the nurse should anticipate maximum effect at what time A) Between 08:30 and 09:00 B) 09:00 to 10:00 C) Between 12:00 and 14:00 D) 11:30 to 12:30 Ans:B Feedback: Except for sustained release forms, nifedipine reaches peak plasma levels within 1 to 2 hours.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

17. A 59-year-old male patient has a long history of heavy alcohol use and was diagnosed with liver cirrhosis several months earlier. The patient's medical history includes numerous other health problems, including angina When considering the use of nifedipine in the management of this patient's angina, what consideration should the nurse be aware of A) The patient is likely to experience an increased effect of the medication B) This patient will require a higher dose than a patient without this medical history C) Nifedipine is contraindicated because it is highly hepatotoxic D) The patient's increased albumin levels will negate the therapeutic effect Ans:A Feedback: In patients with cirrhosis, bioavailability of oral drugs is greatly increased and metabolism (of both oral and parenteral drugs) is greatly decreased. Both of these effects increase plasma levels of drug from a given dose (essentially an overdose).

18. An older adult patient whose medical history includes angina is gardening outside his home when he experiences a sudden onset of chest pain. This patient would most likely administer a dose of nitroglycerin by what route A) Subcutaneous injection B) Oral sustained-release tablet C) Nebulized inhalation D) Transmucosal spray Ans:D Feedback: For relief of sudden-onset angina, fast-acting preparations of nitroglycerin include SL and chewable tablets and transmucosal spray Sub-Q injections, sustained-release tablets, and nebulizers are not used.

19. A patient with coronary artery disease is prescribed nitroglycerin ointment. When teaching the patient to safely administer this medication, the nurse should convey which of the following instructions A) “The backs of your hands and the tops of your feet are ideal sites for applying the ointment.”

B) “Make sure you squeeze the ointment on to a paper measuring scale before applying it.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) “Massage the ointment into your skin for 10 to 15 seconds after applying it.”

D) “Don't apply the ointment unless you're experiencing chest pain at the time.”

Ans:B Feedback: Application of nitroglycerin ointment requires using the dose-measuring application papers supplied with ointment. It is necessary to squeeze the ointment onto a measuring scale printed on paper. The ointment should be applied onto a nonhairy area of skin; distal extremities should be avoided. The area should not be massaged.

20. A nurse has administered a scheduled dose of 50-mg atenolol PO for the treatment of angina.

Following administration, the nurse should prioritize what assessment A) Level of consciousness B) Blood pressure C) SaO2 D) Oral temperature Ans:B Feedback: Atenolol and other beta-blockers have an antihypertensive effect. They are unlikely to affect temperature, LOC, or oxygen saturation levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 29 Drug Therapy for Shock and Hypotension 1. A patient is experiencing anaphylaxis. Which of the following medications will most likely be administered A) Epinephrine B) Norepinephrine C) Acetylcysteine (Mucomyst) D) Dantrolene sodium (Dantrium) Ans:A Feedback: Epinephrine is the adrenergic drug of choice for relief of anaphylactic shock, the most serious allergic reaction, as well as in treatment of cardiac arrest. Norepinephrine is not administered. Acetylcysteine (Mucomyst) is used for acetaminophen overdose Dantrolene sodium is used to treat malignant hyperthermia.

2. A patient is suffering from hypovolemic shock. Which agents are administered if fluid volume replacement does not restore sufficient blood pressure A) First-line agents B) Second-line agents C) Beta-blockers D) Antianginal drugs Ans:B Feedback: In hemorrhagic or hypovolemic shock, the drugs are second-line agents that may be used if adequate fluid volume replacement does not restore sufficient blood pressure and circulation to maintain organ perfusion. First- line agents are not used; the first-line therapy is fluid replacement. Beta-blockers decrease heart rate and are not administered with hypovolemic shock. Antianginals are not administered in hypovolemia.

3. A patient has been diagnosed with narrow- angle glaucoma. What ocular effect will be produced if the patient is prescribed an adrenergic agent A) Hypothyroidism B) Decreased heart rate C) Mydriasis D) Hypertension Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Narrow-angle glaucoma is a contraindication to adrenergic agents because the drugs result in mydriasis, closure of the filtration angle of the eye, and increased intraocular pressure.

Hypothyroidism will not occur with the administration of adrenergic agents Decreased heart rate will not occur with the administration of adrenergic agents and is not an ocular effect. Hypertension is not an ocular effect.

4. A patient is administered epinephrine in conjunction with a local anesthetic. What effect will epinephrine produce A) Decreased cerebral circulation B) Decreased coronary circulation C) Increased vasoconstrictive effects D) Increased bronchoconstriction Ans:C Feedback: Epinephrine is added to local anesthetics for vasoconstrictive effects, which include prolonging the action of the local anesthetic drug, preventing systemic absorption, and minimizing bleeding. Epinephrine will not decrease cerebral circulation or coronary circulation.

Epinephrine will not increase bronchoconstriction.

5. An emergency department nurse enters a patient's room with an order to administer epinephrine subcutaneously to treat his asthma attack. The patient's wife asks the nurse why it could not be given by mouth. Which of the following is the best response by the nurse A) “The medication he is to receive is only given by an injection in the arm.”

B) “The medication is administered this way because it works faster than by mouth.”

C) “The medication is given many ways, but this is the way it was ordered.”

D) “The medication will not absorb in the GI tract if given by mouth.”

Ans:D Feedback: Epinephrine is not given orally because enzymes in the GI tract and liver destroy it.

The medication can be given through inhalation, intravenously, and subcutaneously. The medication will work more quickly in a parenteral form but is not given orally. Stating to the patient that this method is the way the physician ordered it to be given will belittle the patient and not provide adequate patient teaching.

6. A patient suffers from bronchial asthma. Which of the following medications is a mixedacting adrenergic drug that may be administered A) Epinephrine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Ephedrine C) Pseudoephedrine D) Isoproterenol Ans:B Feedback: Ephedrine is a mixed-acting adrenergic drug that acts by stimulating alpha1 and beta receptors and causing release of norepinephrine from presynaptic terminals. It is used in the treatment of bronchial asthma. Epinephrine is not a mixed-acting adrenergic drug.

Pseudoephedrine is a related drug, stimulating alpha1 and beta receptors. It is used as a nasal decongestant. Isoproterenol is a synthetic catecholamine that acts on beta1- and beta2-adrenergic receptors.

7. A home care nurse is visiting a patient, and the assessment will include blood pressure and heart rate. The patient's grandson has a large amount of pseudoephedrine (Sudafe D) in the kitchen. For what might the nurse suspect the patient's grandson is using the pseudoephedrine A) Methamphetamine production B) Treatment of bronchial asthma C) Treatment of sinusitis D) To increase appetite Ans:A Feedback: Pseudoephedrine and ephedrine are ingredients used in making methamphetamine, a highly addictive and illegal drug of abuse. Pseudoephedrine is used in the treatment of bronchospasm but is not the drug of choice. Pseudoephedrine is used in the treatment of sinusitis, but, in large quantities, the nurse should suspect methamphetamine production Pseudoephedrine will increase basal metabolic rate but is not the drug of choice to increase appetite.

8. A patient suffers from bradycardia. Which of the following medications is a synthetic catecholamine for the treatment of bradycardia A) Isoproterenol (Isuprel) B) Pseudoephedrine (Sudafe D) C) Ephedrine D) Epinephrine Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Isoproterenol (Isuprel) is a synthetic catecholamine that acts on beta1- and beta2adrenergic receptors to stimulate heart rate. Pseudoephedrine (Sudafe D) is not a synthetic catecholamine. Ephedrine and epinephrine are not synthetic catecholamines.

9. A patient has been using phenylephrine (Neo- Synephrine) for nasal congestion. He states to the nurse that he is using more every day because his nose is so congested. What effect is the medication producing A) Reflex bradycardia B) Mucosal hemorrhage C) Tachycardia D) Rebound congestion Ans:D Feedback: Overuse of nasal decongestants leads to decreased effectiveness (tolerance), irritation and ischemic changes in the nasal mucosa, and rebound congestion. These effects can be minimized by using small doses only when necessary and for no longer than 3 to 5 days.

Phenylephrine will not produce reflex bradycardia, mucosal irritation, or tachycardia.

10. A pediatric patient is administered epinephrine to treat bronchospasm as a result of acute asthma. What effect should the patient be monitored for A) Edema B) Syncope C) Bradycardia D) Hemorrhage Ans:B Feedback: Epinephrine is mainly used in children for treatment of bronchospasm due to asthma or allergic reactions. Parenteral epinephrine may cause syncope when given to asthmatic children. Epinephrine will not increase edema or cause bradycardia or hemorrhage.

11. A nurse is participating in a “code blue” response to a patient who lost consciousness after a short period of distress. The physician leading the code has ordered the administration of IV epinephrine. When preparing this drug for administration, the nurse should recognize what goal of this treatment A) Increased cardiac contractility B) Increased blood flow to the heart and brain C) Increased peripheral blood circulation

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Increased release of dopamine Ans:B Feedback: Epinephrine is often administered during cardiopulmonary resuscitation (CPR). The most important action of epinephrine during cardiac arrest is constriction of peripheral blood vessels, which shunts blood to the central circulation and increases blood flow to the heart and brain. The goal of epinephrine administration is not increased contractility or dopamine release.

12. Epinephrine is indicated in the treatment of a 79-year-old patient whose blood pressure has plummeted in the postanesthesia recovery room following prostate surgery. Epinephrine should be used with caution in a patient of this age because of the risk of A) exacerbating chronic cardiac conditions B) causing cerebral ischemia C) increasing intracranial pressure D) causing Stevens-Johnson's syndrome Ans:A Feedback: Clinicians use adrenergic agents to treat asthma, hypotension, shock, cardiac arrest, and anaphylaxis in older adults. These drugs stimulate the heart to increase rate and force of contraction and blood pressure. Because older adults often have chronic cardiovascular conditions (e.g., angina, dysrhythmias, heart failure, coronary artery disease, hypertension, peripheral vascular disease) that are aggravated by adrenergic drugs, careful monitoring by the nurse is required.

13. A teenage boy has been brought to the emergency department (E D) by his football coach, who states that the boy has not responded to his normal rescue inhaler.

The care team has opted for the administration of subcutaneous epinephrine. The ED nurse should anticipate what assessment finding subsequent to the administration of this drug A) Increased level of consciousness within 2 to 5 minutes B) Immediate bronchodilation C) An immediate decrease in respiratory rate D) Bronchodilation within 5 to 10 minutes Ans:D Feedback: For acute asthma attacks, subcutaneous (Sub- Q) administration of epinephrine usually produces bronchodilation within 5 to 10 minutes; maximal effects may occur within 20 minutes. An increase in LOC is not a priority, and respiratory rate would not likely decrease.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A clinic nurse is teaching the parents of toddler about the safe and effective use of an EpiPen after the child was diagnosed with severe nut allergies. What instruction should the nurse convey to the parents A) “It's prudent to administer a small dose of epinephrine if you want to prevent a future reaction.”

B) “Only use your EpiPen if you've tried oral medications and they've been ineffective.”

C) “The thigh is usually the ideal place to inject the EpiPen.” D) “Keep administering repeated doses of epinephrine until your child's symptoms abate.”

Ans:C Feedback: The thigh is the preferred site for autoinjection, providing more rapid absorption and higher blood levels of epinephrine than the arm in children and adults for either intramuscular or subcutaneous administration. Epinephrine is not administered as a prophylactic treatment.

Emergencies preclude the use of oral medications, and repeated injections may result in toxicity

15. treatment of an adult hospital patient. In anticipation, the nurse has reviewed the patient's current medication regimen. The presence of a drug from which of the following drug categories would contraindicate the safe use of epinephrine A) Potassium-wasting diuretics B) Sulfonamide antibiotics C) Selective serotonin reuptake inhibitors (SSRIs) D) Monoamine oxidase (MAO) inhibitors Ans:D Feedback: It is essential not to give MAO inhibitors with adrenergic drugs because the combination may cause death. Use of adrenergics with diuretics, SSRIs, or sulfa antibiotics is not necessarily contraindicated.

16. A 19-year-old has been brought to the emergency department (E D) by ambulance after a suspected overdose of a herbal preparation that contained ephedra. Due to the risk of seizures and intracranial hemorrhage, the nurse should prioritize what assessment A) Continuous oxygen saturation monitoring B) Blood pressure monitoring C) Respiratory auscultation D) Assessing extremities for color, warmth, movement, and sensation Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Ephedrine and ephedra-containing herbal preparations (e.g., ma huang, herbal ecstasy) are often abused as an alternative to amphetamines. The primary clinical manifestation of this adrenergic drug toxicity is severe hypertension, which may lead to headache, confusion, seizures, and intracranial hemorrhage. Vigilant blood pressure monitoring is thus a high priority 17. and symptoms of hypovolemic shock. How will the patient's compromised hepatic function affect the possible use of epinephrine A) The patient will require a higher-than-normal dose B) The patient's hepatic function is not a priority consideration C) The patient should not receive epinephrine by a parenteral route D) The patient should receive a small fraction of the normal dose Ans:B Feedback: Liver disease is not usually considered a contraindication to administering adrenergic drugs. Dosages do not normally need to be adjusted.

18. A patient has been resuscitated using epinephrine following an episode of asystole and is now being monitored in the intensive care unit (ICU). When monitoring the patient's status, the nurse should anticipate which of the following effects of epinephrine administration? Select all that apply A) Decreased urine output B) Hyperglycemia C) Increased serum potassium levels D) Hypercapnia E) Increased blood pressure Ans:A, B, E Feedback: Administration of epinephrine is associated with decreased urine output, increased blood glucose, hyperkalemia, and increased blood pressure. Excess CO2 levels are not anticipated.

Chapter 30 Drug Therapy for Heart Failure 1. The home care nurse sees a patient for the first time. The patient has crackles in the lower lobes of the lungs, an audible S3, and pitting edema in the feet and ankles. What condition is the patient most likely experiencing

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Pneumonia B) Liver disease C) Heart failure D) Myocardial infarction Ans:C Feedback: The cardinal manifestations of heart failure are dyspnea and fatigue, which can lead to exercise intolerance and fluid retention. Fluid retention results in the development of pulmonary congestion and peripheral edema. An audible S3 is often present. The patient is not presenting with myocardial infarction symptoms.

2. A patient is diagnosed with heart failure. She asks the nurse for further details about heart failure. Which of the following statements is most accurate A) “Heart failure can be caused by atherosclerotic plaque due to high-fat diets.”

B) “Hypothyroidism will result in decreased heart rate and development of heart failure.”

C) “The administration of diuretics increases blood volume, causing symptoms to abate.”

D) “The use of digoxin will slow heart rate to make your heart more efficient.”

Ans:D Feedback: Endothelial dysfunction allows processes that narrow the blood vessel lumen and lead to blood clot formation and vasoconstriction that further narrow the blood vessel lumen.

These are major factors in coronary artery disease and hypertension, the most common conditions leading to heart failure Hyperthyroidism, not hypothyroidism, is a cause of heart failure. The administration of diuretics decreases fluid volume, which prevents the symptoms of heart failure. The use of digoxin increases the force of myocardial contraction and prevents the development of congestive heart failure in patients whose heart cannot pump blood to meet tissue needs. A high-fat diet does not directly cause heart failure.

3. A patient states that he is seeing halos around lights. The patient takes digoxin (Lanoxin) by mouth every day. The physician orders the patient to have serum digoxin level drawn. At what digoxin level would the care team first suspect that the patient is experiencing toxicity A) 0.5 ng/mL B) 1.5 ng/mL C) 3.0 ng/mL D) 6.0 ng/mL Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The therapeutic serum digoxin level is 0.8 to 2.0 ng/mL. 4. A patient has an elevated BUN and creatinine. The patient has been prescribed digoxin (Lanoxin) for heart failure. What aspect of care is the priority regarding this patient A) The patient should be taught to increase sodium in her diet B) The dose should be increased when her heart rate is below 60 C) The dose should be decreased in this patient D) The dosage should be 1.0 mg PO daily Ans:C Feedback: The dose must be reduced in the presence of renal failure because most of the digoxin is excreted unchanged by the kidneys, leading to drug accumulation and toxicity. The patient should be taught to limit sodium intake in the diet. The patient's heart rate should remain above 60. If the heart rate falls below 60, the digoxin should be held. The dose of 1.0 mg is too large for a patient with altered renal function.

5. A patient with a history of heart failure is being treated with digoxin (Lanoxin). The nurse knows that this medication increases the force of contractions of the heart. What effect improves the contractility of the heart A) Positive chronotropic effect B) Positive inotropic effect C) Negative inotropic effect D) Negative dromotropic effect Ans:B Feedback: In heart failure, digoxin exerts cardiotonic or positive inotropic effect that improves the contractility and pumping ability of the heart. A positive chronotropic effect accelerates the rate of the heart, which is not recommended in a patient with heart failure. A negative inotropic effect accelerates the heart, which is not recommended in a patient with heart failure. A negative dromotropic effect changes the conductivity of muscle fiber, increasing heart rate.

6. A patient is admitted to the intensive care unit with an electrolyte imbalance. Which of the following imbalances will contraindicate the administration of digoxin (Lanoxin) A) Hyperkalemia B) Hypokalemia C) Hypermagnesemia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Hypocalcemia Ans:B Feedback: Digoxin is contraindicated in patients with hypokalemia. Digoxin is not contraindicated in patients with hyperkalemia, hypermagnesemia, or hypocalcemia.

7. A patient with heart failure is admitted to the emergency department. The physician orders digoxin (Lanoxin) intravenously. What is the onset of action when digoxin (Lanoxin) is administered intravenously A) 5 minutes B) 10 minutes C) 45 minutes D) 1 hour Ans:B Feedback: Digoxin administered intravenously will have an onset of action within 10 to 30 minutes Five minutes after administration is too soon to provide an onset of action. Forty-five minutes to one hour is after the onset of action.

8. A patient is in the intensive care unit to be digitalized. This patient is to be digitalized rapidly.

What is the total dose range of digoxin (Lanoxin) for rapid digitalization A) 0.75 to 1.5 mg B) 2.0 to 2.5 mg C) 3.75 to 4 mg D) 0.125 to 0.05 mg Ans:A Feedback: Digitalization may be accomplished rapidly by giving a total dose of 0.75 to 1.5 mg of digoxin in divided doses. A digoxin dose range of 2.0 to 4.0 mg is too large. A digoxin dose range of 0.125 to 0.5 mg is too small

9. In the last 3 months, she has noticed she is tired all the time, her heart rate is very slow, and she is always cold. The nurse assessing the patient notes her blood pressure at 88/50 and pulse rate is 44. The nurse instructs the patient not to take her digoxin. What condition may the patient be suffering from that would contraindicate the administration of digoxin A) Hypothyroidism B) Myocardial infarction C) Cerebrovascular accident

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Intermittent claudication Ans:A Feedback: Hypothyroidism slows digoxin metabolism and further slows the heart rate. The patient is presenting with signs and symptoms of hypothyroidism. The patient is not experiencing characteristic signs and symptoms of myocardial infarction, cerebrovascular accident, or intermittent claudication.

10. A patient who has been prescribed digoxin (Lanoxin) is also taking furosemide (Lasix) 20 mg daily. Which of the following electrolyte imbalances will precipitate the development of digoxin toxicity A) Hyperkalemia B) Hypokalemia C) Hypermagnesemia D) Hyponatremia Ans:B Feedback: Hypokalemia will contribute to the patient developing digoxin toxicity.

Hyperkalemia, hypermagnesemia, and hyponatremia will not contribute to the development of digoxin toxicity

11. A patient is admitted to the emergency department with severe heart failure. Milrinone (Primacor) is administered IV. For what adverse effect should the patient be assessed A) Hypertension B) Bradycardia C) Atrial dysrhythmias D) Lethargy Ans:C Feedback: Dose-limiting adverse effects of the drugs include tachycardia, atrial or ventricular dysrhythmias, and hypotension Hypertension, bradycardia, and lethargy are not adverse effects of milrinone.

12. A patient has been administered nesiritide (Natrecor) to manage symptoms of acute heart failure. How does the drug act A) Nesiritide (Natrecor) exhibits mild inotropic action and decreased platelet aggregation B) Nesiritide (Natrecor) compensates for cardiac deterioration by reducing preload and afterload

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Nesiritide (Natrecor) corrects hyperthyroidism by inhibiting synthesis of the thyroid hormone D) Nesiritide (Natrecor) increases the concentration of acetylcholine to potentiate the action of ACE Ans:B Feedback: Nesiritide (Natrecor) compensates for cardiac deterioration by reducing preload and afterload. Dipyridamole (Persantine) exhibits mild inotropic action and decreased platelet aggregation. It would not be used in acute heart failure. Methimazole (Tapazole) corrects hyperthyroidism by inhibiting synthesis of the thyroid hormone. Physostigmine (Antilirium) increases the concentration of acetylcholine to potentiate the action of ACE on the skeletal muscle

13. When instructing a patient on a no-added-salt diet, the nurse should instruct the patient on foods with hidden salt. Which of the following foods has hidden salt and should be avoided A) Ice cream B) Dehydrated apple chips C) Bread D) Canned soup Ans:D Feedback: Canned soup is very high in sodium and should be avoided. Ice cream contains a small amount of sodium but should be avoided due to the fat content. Dehydrated apple chips are an acceptable food. Bread is an acceptable food.

14. A patient is being treated for heart failure Which of the following is most indicative of improved health status A) Decreased pedal edema B) Increased skin turgor C) Heart rate of 52 D) Improved sensorium Ans:A Feedback: Decreased pedal edema improves cardiac output due to the fact that the patient has diminished fluid volume. Increased skin turgor indicates that the patient is well hydrated and does not have fluid volume excess. A heart rate of 52 is too slow to provide good contractility.

Improved sensorium indicates adequate perfusion but is not the most indicative of improved heart failure status.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. A patient is being administered digoxin (Lanoxin) for treatment of heart failure. At what level should the serum potassium level be maintained A) 1.5 to 2.0 mEq/L B) 3.5 to 5.0 mEq/L C) 6.0 to 8.0 mEq/L D) 8.5 to 10 mEq/L Ans:B Feedback: Electrolyte imbalance must be monitored during digoxin therapy, and the potassium level should be maintained at 3.5 to 5.0 mEq/ L. A potassium level of 1.5 to 2.0 mEq/L is too low. Potassium levels of 6.0 to 8.0 and 8.5 to 10 mEq/L are too high.

16. A patient is experiencing nausea and visual disturbances when taking digoxin (Lanoxin).

Which of the following medications will be administered A) Acetylsalicylic acid (aspirin) B) Nesiritide (Natrecor) C) Felbamate (Felbatol) D) Digoxin immune fab (Digibin D) Ans:D Feedback: A patient who has nausea and visual changes while taking digoxin will most likely be administered digoxin immune fab (Digibin D). Acetylsalicylic acid is not administered for digoxin toxicity. Nesiritide is not administered when the patient is experiencing digoxin toxicity. Felbamate is administered for the treatment of seizures.

17. A 77-year-old patient was diagnosed with heart failure 3 years ago, and he had achieved reasonable symptom control with digoxin. In the last several months, his cardiac function has decreased significantly and his cardiologist has prescribed nesiritide during his current admission. What aspect of this patient's health status would potentially contraindicate the administration of nesiritide A) Blood pressure of 88/50 mm Hg B) Jaundice C) Presence of +2 peripheral edema D) Irregular apical heart rate Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Nesiritide should not be administered if the systolic blood pressure is less than 90 mm Hg. The presence of jaundice, edema, or an irregular heart rate does not necessarily contraindicate the use of this drug.

18. An older adult patient has been receiving treatment for heart failure and has been experiencing frequent episodes of peripheral edema. As a result, her care provider has added furosemide (Lasix) to her medication regimen. What assessment should the nurse perform on a daily basis for the duration of treatment A) Body weights B) Arterial blood gases C) Magnesium level D) Pupillary response Ans:A Feedback: When a patient is being treated with furosemide, the nurse weighs the patient daily and reports any increase in weight of greater than 2 pounds in 24 hours to the health care provider. Electrolyte levels must be assessed, but sodium and potassium levels are the priority.

There is no particular need to assess ABGs or pupillary response.

19. A nurse has poured a hospital patient's scheduled dose of hydrochlorothiazide (HCTZ). The nurse should know that this drug reduces preload by which of the following means A) Exerting a direct relaxant effect on the vascular smooth muscle B) Increasing renal excretion of sodium and water C) Increasing the contractility of myocardial fibers D) Stimulating the SA node to fire more frequently Ans:B Feedback: Hydrochlorothiazide inhibits the reabsorption of sodium and chloride in the distal renal tubule, increasing the excretion of sodium and water by the kidneys. Thiazide diuretics do not relax smooth muscle, increase contractility, or stimulate the SA node.

20. A gerontological nurse is aware that increased aldosterone is a major factor in the pathophysiology of heart failure. Which of the following medications reduces aldosteroneinduced retention of sodium and water A) Hydrochlorothiazide B) Enalapril maleate C) Spironolactone

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Losartan potassium Ans:C Feedback: Spironolactone (Aldactone) is an aldosterone antagonist that reduces aldosteroneinduced retention of sodium and water and impaired vascular function. Thiazide diuretics, ACE inhibitors, and angiotensin II–receptor blockers do not have this mechanism of action.

Chapter 31 Drug Therapy for Nasal Congestion and Cough 1. A patient presents at the clinic with sneezing and coughing. He is diagnosed with the common cold. Which type of microorganism causes the common cold A) Gram-positive bacteria B) Gram-negative bacteria C) Virus D) Fungus Ans:C Feedback: The common cold, a viral infection of the upper respiratory tract, is the most common respiratory tract infection. The common cold is not caused by gram-negative or gram- positive bacteria. Fungal infections are not the cause of the common cold.

2. You are the school nurse educating a group of parents on the prevention of the common cold among their children. Which of the following preventive measures is most important to teach the parents A) Frequent handwashing B) Maintaining vaccinations C) Taking 1200 mg of vitamin C D) Taking Echinacea daily Ans:A Feedback: Because of the way cold viruses are spread, frequent and thorough hand hygiene is the most important protective and preventive measure. There is vaccine against the common cold. The ingestion of vitamin C and Echinacea is not the most effective preventive measure for the common cold.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A 3-year-old child is seen in the pediatric office for a dry, hacking cough. The mother is requesting a prescription for dextromethorphan. In providing patient education, which of the following provides the most effective teaching regarding the use of dextromethorphan in children A) Dextromethorphan suppresses cough in children B) Dextromethorphan is ineffective in children C) Dextromethorphan must be combined with codeine D) Dextromethorphan raises blood pressure in children Ans:B Feedback: Although antitussives continue to be used and adults report beneficial effect in reducing cough, antitussives, particularly dextromethorphan, have not been demonstrated to be effective in children and adolescents. Adverse effects of dextromethorphan in children include behavioral disturbances and respiratory depression, not high blood pressure.

4. A patient is using oxymetazoline (Afrin) to relieve nasal congestion. Which of the following conditions would contraindicate the use of this drug A) Nasal congestion B) Cough C) Hypertension D) Skin rash Ans:C Feedback: Oxymetazoline is contraindicated in patients with severe hypertension or coronary artery disease because of its cardiac stimulating and vasoconstricting effects. Oxymetazoline is prescribed for nasal congestion Oxymetazoline is not contraindicated in cough or skin rash.

5. A patient is admitted to the emergency room after consuming 50 acetaminophen tablets in a suicide attempt. What medication will be administered to counteract the effect of the acetaminophen A) Oxymetazoline hydrochloride (Afrin) B) Acetylcysteine (Mucomyst) C) Daptomycin (Cubicin) D) Darbepoetin alfa (Aranesp) Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Acetylcysteine is effective in the treatment of acetaminophen overdose.

Oxymetazoline hydrochloride is used for nasal congestion, not acetaminophen overdose.

Daptomycin and darbepoetin alfa are not used for acetaminophen overdose.

6. A patient is taking a nasal decongestant. Which of the following medications may dangerously increase the effects of nasal decongestants A) Anti-infective agents B) Anti-inflammatory agents C) Proton pump inhibitors D) Thyroid preparations Ans:D Feedback: The administration of thyroid preparations should be done cautiously with nasal decongestants due to their increased effects. PPIs, anti-infectives, and anti-inflammatories do not have this effect.

7. A patient is prescribed an antitussive agent with codeine. Which of the following statements by the patient indicates that the nurse's teaching has been effective A) “I will take this medication whenever I am coughing.”

B) “This medication may make me anxious and nervous.”

C) “I will call my physician if I develop diarrhea when I take it.”

D) “This medication will cause drowsiness, and I will not drive.”

Ans:D Feedback: Antitussive agents suppress cough by depressing the cough center in the medulla oblongata or the cough receptors in the throat, trachea, or lungs. Since they are combined with codeine, they will also depress the CNS and induce drowsiness. The medication should not be given every time the patient coughs. The medication will not cause anxiety and nervousness. The medication will cause constipation, not diarrhea.

8. A patient has hypertension and wants to take a nasal decongestant for cold symptoms. Which of the following statements by the nurse best describes the effect of decongestants on blood pressure A) “The administration of a nasal decongestant will increase blood pressure due to vasoconstriction of blood vessels.”

B) “The administration of a nasal decongestant will cause bradycardia and increase peripheral blood pressure.”

C) “The administration of a nasal decongestant will decrease the thyroid production and increase blood pressure.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) “The administration of nasal decongestant will act on the central nervous system to cause vasodilation of blood vessels.”

Ans:A Feedback: “The administration of nasal decongestants will increase blood pressure due to vasoconstriction of blood vessels” is indicative of good patient teaching. Nasal decongestants do not cause bradycardia to increase blood pressure. The administration of nasal decongestants will not decrease thyroid production and increase blood pressure. The administration of a nasal decongestant does not act on the central nervous system

9. A patient has expressed frustration at the fact that he has been taking Sudafed for several days and “it still hasn't really cured my cold.” What teaching point should the nurse convey to the patient A) “Drugs like this can often relieve some of the symptoms of a cold, but they won't cure it.”

B) “Most people find that cold medications are essentially ineffective.”

C) “It usually takes between 6 and 8 days for Sudafed to cure your cold.”

D) “Sudafed can sometimes mask the effects of your cold, essentially prolonging it.”

Ans:A Feedback: Patients should be made aware that cold medications do not cure the common cold; they only relieve some symptoms. Such medications do not inhibit healing by masking symptoms.

10. An elderly patient has presented to the clinic for a scheduled visit and states that he has been taking a combination antitussive/ decongestant/expectorant for several weeks in order to prevent the common cold. The nurse should cite which of the following effects of long-term use of OTC cold remedies? Select all that apply A) Chronic epistaxis B) Anticholinergic effects C) Chronic congestion D) Damage to the nasal mucosa E) Hepatotoxicity Ans:C, D Feedback: Over-the-counter (OT C) cold remedies should not be used longer than 1 week. Do not use nose drops or sprays more often or longer than recommended. Excessive or prolonged use may damage nasal mucosa and produce chronic nasal congestion. These drugs are not associated with chronic epistaxis, anticholinergic effects, or hepatotoxicity

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

11. An adult patient has asked the nurse to recommend an OTC cold remedy because she is unsure which of the many options available is most appropriate. Before making a recommendation, the nurse should do which of the following A) Consult with a pharmacist or pharmacy technician B) Assess the patient's understanding of the epidemiology of the common cold and upper respiratory infections C) Assess the patient for health problems that may contraindicate the use of a particular remedy D) Ensure that the patient has tried some of the more common herbal and natural remedies Ans:C Feedback: Before recommending a particular product, the nurse needs to assess the intended recipient for conditions or other medications that contraindicate the product's use. Herbal options do not need to precede pharmaceuticals, and the nurse does not necessarily need to consult with a pharmacist or pharmacy technician. The patient's understanding of the epidemiology of the common cold is not a high priority.

12. A community health nurse is cautious when recommending the use of OTC cold remedies to patients. The use of pseudoephedrine would most likely be contraindicated in which of the following patients A) A woman who is breast-feeding B) A man with a history of angina and hypertension C) A man who has diagnoses of chronic obstructive pulmonary disease and diabetes D) A woman who has myasthenia gravis Ans:B Feedback: Contraindications to pseudoephedrine use include severe hypertension or coronary artery disease because of the drug's cardiac stimulating and vasoconstricting effects Breast-feeding does not necessarily contraindicate the use of pseudoephedrine, though caution would be warranted. The other listed medical diagnoses do not contraindicate the use of pseudoephedrine.

13. A 30-year-old woman with two preschoolers has sought the nurse's advice because she has heard conflicting reports about the safety and efficacy of cough and cold products in young children. The nurse should inform the woman that A) cough and cold remedies are generally safe and effective for children over the age of 2

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) there are concerns among health professionals about how safe and effective these medications are C) media reports about the risks of cough and cold medications in children have greatly exaggerated the risks D) it is imperative to use age-specific preparations of cough and cold remedies Ans:B Feedback: Certain organizations have expressed caution about the use of pseudoephedrine in young children. The use of age-specific preparations does not guarantee safety or effectiveness.

14. A 55-year-old male patient has been living with type 1 diabetes for many years and has begun to experience diabetic nephropathy over the past year. How will this patient's current health status influence the possible use of pseudoephedrine in the treatment of cold symptoms A) The patient should monitor his blood glucose levels more frequently when taking pseudoephedrine B) The use of pseudoephedrine is absolutely contraindicated by the fact that the patient has diabetes and takes insulin C) The patient may require a higher-than-average dose of pseudoephedrine because of excess fluid volume secondary to renal failure D) The patient should use caution and will likely require a lower dose of pseudoephedrine because of his impaired renal function Ans:D Feedback: Because pseudoephedrine is excreted primarily via the kidneys, caution in patients with renal impairment is important. It may be necessary to reduce the dosage to avoid potential drug accumulation and drug toxicity. The presence of diabetes warrants caution, but it is not an absolute contraindication.

15. A patient has asked the nurse if it would be appropriate to use dextromethorphan to treat her cough. What type of cough is best suited to treatment with dextromethorphan A) An occasional, productive cough

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) A cough that is nearly continuous and that is accompanied by copious secretions C) A cough that occurs when the patient is exposed to airborne irritants D) A dry, nonproductive cough Ans:D Feedback: The major clinical indication for use of dextromethorphan is a dry, hacking, nonproductive cough that interferes with rest and sleep. It is not desirable to suppress a productive cough because the secretions need to be removed.

16. A 17-year-old boy has been brought to the emergency department by his mother who is distraught by the fact that she caught him and his friend “guzzling cough syrup.” What assessment finding is suggestive of an overdose of dextromethorphan A) Hallucinations B) Dysrhythmias C) Kussmaul's respirations D) Profound diaphoresis Ans:A Feedback: The nurse observes for excessive suppression of the cough reflex (inability to cough effectively when secretions are present) or hallucinations with dosages that exceed recommendations of dextromethorphan Kussmaul's respirations, dysrhythmias, and diaphoresis are not characteristic adverse effects.

17. A patient with a persistent and debilitating cough is confused that his physician has prescribed codeine. He tells the nurse, “I was sure that codeine was a narcotic that people take for pain.” The nurse should cite what mechanism of action when describing this use of codeine A) Depression of the cough center in the medulla oblongata B) Vasodilation of the alveolar capillaries C) Stimulation of the reticular activating system (RAS) D) Desensitization of the cough receptors in the sinuses and trachea Ans:A Feedback: Antitussives such as codeine suppress cough by depressing the cough center in the medulla oblongata. They do not influence blood flow or desensitize peripheral cough receptors.

The RAS is not involved in the cough reflex.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse has taught an adult patient about the fact that guaifenesin is not necessarily an effective way of liquefying secretions. To help liquefy the patient's secretions, the nurse should encourage which of the following measures A) Reducing salt intake B) Deep breathing and exercises C) Gargling with normal saline D) Increasing fluid intake Ans:D Feedback: Drinking plenty of water while taking guaifenesin may help loosen mucus in the lungs. Deep breathing, gargling with normal saline, and reducing salt intake do not necessarily help liquefy and mobilize secretions.

19. A critically ill patient with a diagnosis of ventilator-associated pneumonia has been administered acetylcysteine by inhalation. The critical care nurse knows that this medication helps to liquefy secretions in the respiratory tract by A) increasing the osmolality of mucus B) decreasing the osmolality of mucus C) breaking the protein bonds that exist in mucus D) drawing increased amounts of water from interstitial spaces into mucus Ans:C Feedback: Mucolytics such as acetylcysteine are drugs that liquefy mucus in the respiratory tract by attacking the protein bonds of the mucus.

20. A patient has purchased an OTC cold remedy that advertises a “nondrowsy” formulation The nurse should recognize that this produce likely contains which of the following A) A nasal decongestant but not an antihistamine B) An expectorant, a mucolytic, and a benzodiazepine C) An expectorant but not a decongestant D) A narcotic analgesic and a decongestant Ans:A Feedback: “Nondrowsy” or “daytime” cold formulas typically contain a nasal decongestant but not an antihistamine. Such medications would not contain an opioid or a benzodiazepine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 32 Drug Therapy to Decrease Histamine Effects and Allergic Response 1. A patient is stung by a bee. What is the chemical mediator released in immune and inflammatory response to the bee sting A) Norepinephrine B) Mast cells C) Epinephrine D) Histamine Ans:D Feedback: Histamine is the chemical mediator released in immune and inflammatory response to the bee sting.

2. A patient is experiencing allergy symptoms after being exposed to environmental dust. This reaction involves the action of histamine, which is released by what cells A) Lymphocytes B) CD4 T cells C) Basophils D) Platelets Ans:C Feedback: Histamine is discharged from mast cells and basophils in response to certain stimuli, such as allergic reactions, cellular injury, and extreme cold. Lymphocytes and platelets do not release histamine.

3. A patient is being administered epinephrine for the treatment of anaphylaxis. This patient is experiencing what type of hypersensitivity reaction A) Type I B) Type II C) Type III D) Type IV Ans:A Feedback: Anaphylaxis is a type I response, which can be mild or life threatening.

4. An elderly patient is given diphenhydramine (Benadryl) for allergic response to mold. The nurse should consequently assess the patient for A) anticholinergic effects B) dysrhythmias

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) increased muscle tone D) respiratory depression Ans:A Feedback: Diphenhydramine (Benadryl) is the prototype of first-generation antihistamines and causes a high incidence of drowsiness and anticholinergic effects. It is not associated with dysrhythmias, increased muscle tone, or respiratory depression.

5. A second-generation H1 receptor antagonist antihistamine formulated as a nasal spray for topical use is A) chlorpheniramine (Chlor-Trimeton) B) clemastine (Tavist) C) cyproheptadine (Periactin) D) azelastine (Astelin) Ans:D Feedback: Azelastine (Astelin) and olopatadine (Patanol) are second-generation H1 receptor antagonists that have been formulated as nasal sprays for topical use. Each of the other listed drugs is a first-generation H1 receptor antagonist

6. A patient is instructed to take diphenhydramine (Benadryl) after an allergic reaction. Which of the following statements by the patient indicates successful teaching concerning the safe and effective use of diphenhydramine A) “I will still be able to have my after-dinner drink with this medication.”

B) “I will eat a diet low in sodium while taking this medication.”

C) “I should not drive my car after taking this medication.”

D) “I can take this medication every 2 hours until I feel better.”

Ans:C Feedback: The administration of diphenhydramine (Benadryl) causes drowsiness, and the patient should not operate machinery, such as driving. The patient should not combine diphenhydramine with alcohol due to central nervous system depression. The patient will not need to limit sodium with this medication. The patient should adhere to the dosing schedule and not take the medication every 2 hours.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient is having an allergic reaction to mold. The patient describes chest tightness and difficulty breathing. Which of the following body effects is occurring A) Contraction of smooth muscle in the bronchi B) Suppression of the vagus nerve endings producing tachycardia C) Decreased permeability of the veins and capillaries D) Decreased secretion of the mucous glands Ans:A Feedback: An allergic reaction produces contraction of the smooth muscle in the bronchi and bronchioles. The patient will have stimulation, not suppression, of the vagus nerve endings. The patient will have increased, not decreased, permeability of the veins and capillaries. The patient will have increased secretion from the mucous glands, producing nasal congestion.

8. A patient is diagnosed with allergic rhinitis. What type of hypersensitivity reaction is causing allergic rhinitis A) Type I B) Type II C) Type III D) Type IV Ans:A Feedback: A type I response to cell-mediated invasion is mild and characterized by allergic rhinitis Type II response is mediated by IgG or IgM generating direct damage to the cell surface. The patient with hemolytic anemia is having a type II response. Type III is an IgG- or IgM- mediated reaction characterized by formation of antigen–antibody complexes that induce an acute inflammatory reaction in tissues. Type IV hypersensitivity is a delayed hypersensitivity.

9. A patient has been suffering from repeated sinus infections and is diagnosed with allergic rhinitis. The patient is prescribed a first- generation H1 receptor antagonist. What is one of the effects of this medication A) It depletes norepinephrine and serotonin B) It decreases capillary permeability C) It catalyzes the enzymatic oxidation of uric acid D) It raises the seizure threshold by impairing vitamin D Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Decreased capillary permeability is among the effects of first-generation drugs. H1 receptor antagonists do not affect vitamin D, uric acid, or neurotransmitters.

10. A patient has been taking cephalexin (Keflex) for an upper respiratory infection. On the seventh day of treatment, the patient develops myalgia and fever. What reaction is the patient likely having A) The patient has developed a new infection B) The patient has developed an autoimmune disease C) The patient has become septic D) The patient has serum sickness Ans:D Feedback: Serum sickness is a delayed hypersensitivity reaction most often caused by drugs, such as antimicrobials. Within initial exposure to the antigen, symptoms usually develop within 7 to 10 days and include urticaria, lymphadenopathy, myalgia, arthralgia, and fever. Although the patient has a fever, the patient does not present with all the symptoms of a new infection or sepsis. An autoimmune disease is not likely.

11. A patient is scheduled to receive one unit of packed red blood cells. The patient states that she has had an allergic reaction to a transfusion in the past. What class of medication will assist in preventing a reaction to the packed red blood cell transfusion A) Antipyretics B) Antimicrobials C) Antianginals D) Antihistamines Ans:D Feedback: Premedication with an antihistamine may be used to prevent allergic reactions with the administration of a transfusion of packed red blood cells. The administration of antimicrobial or antianginal is not recommended for a transfusion reaction.

12. A hospital patient is complaining of nausea and vomiting that has failed to respond to firstline antiemetics. Which of the following medications may be administered for the treatment of nausea and vomiting A) First-generation antihistamine agent: chlorpheniramine (Chlor-Trimeton) B) First-generation antihistamine agent: hydroxyzine (Vistaril)

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C) Second-generation antihistamine agent: loratadine (Claritin) D) Second-generation antihistamine agent: cetirizine (Zyrte C) Ans:B Feedback: Hydroxyzine is a first-generation H1 receptor antagonist that can be administered as an antiemetic agent. Chlorpheniramine is not administered as an antiemetic agent Loratadine and cetirizine are not administered as antiemetic agents.

13. A patient who suffers from allergies to grass and mold is getting ready to cut grass. Prior to cutting grass, he takes cetirizine (Zyrte C) When will the patient expect the medication to reach maximum effects A) 1 hour B) 2 to 3 hours C) 8 to 12 hours D) 12 to 24 hours Ans:A Feedback: Cetirizine (Zyrte C) reaches maximal serum concentration in 1 hour

14. A child is experiencing severe flu-like symptoms with nausea and vomiting and is admitted to the hospital. Which disorder in children will contraindicate the administration of promethazine A) Chickenpox B) Endocarditis C) Reye's syndrome D) Hypertensive crisis Ans:C Feedback: Promethazine should not be used in children with hepatic disease or Reye's syndrome. The use of promethazine is not contraindicated with chickenpox, endocarditis, or hypertensive crisis. Promethazine would not be treated with chickenpox unless nausea or vomiting was noted. Endocarditis would not be treated with promethazine. This drug would not be administered with hypertensive crisis.

15. Antihistamines are used to treat nasal congestion. Which of the following patients should not be administered an antihistamine A) A male patient with Parkinson's disease

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) A female patient with asthma C) A male patient with diabetes mellitus D) A male patient with prostatic hypertrophy Ans:D Feedback: Antihistamines are contraindicated in patients with prostatic hypertrophy.

Antihistamine agents can be administered to patients with Parkinson's disease, asthma, and diabetes mellitus

16. An unlicensed care provider administered Benadryl to an elderly resident who has been suffering from seasonal pollen allergies Which of the following assessment findings should prompt the nurse at the facility to suspect that the resident is experiencing anticholinergic effects of this drug A) Blurry vision B) Tinnitus C) Wheezing on expiration D) Urticaria Ans:A Feedback: First-generation H1 receptor antagonists are associated with anticholinergic effects such as dry mouth, urinary retention, constipation, and blurred vision. Wheezing, urticaria, and tinnitus are not anticholinergic effects.

17. An adult patient has questioned whether fexofenadine (Allegr A) would be preferable to the first-generation H1 receptor antagonists that he has long taken in the treatment of his environmental allergies. When describing the benefits of second-generation drugs such as Allegra, the nurse should cite what advantage A) Lower cost B) Decreased sedation C) Absence of adverse effects D) Once-weekly dosing Ans:B Feedback: Unlike the first-generation H1 receptor antagonists, the second-generation H1 receptor antagonists do not readily enter the brain from the blood. This selectivity significantly reduces the occurrence of adverse drug reactions, such as drowsiness and sedation, while still providing effective relief of allergic conditions. Adverse effects are not wholly absent, however.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Duration of action is 12 to 24 hours, and these drugs are more expensive than first-generation drugs.

18. A gerontological nurse has encouraged a group of caregivers who work with older adults to avoid administering first-generation H1 receptor antagonists to these patients. The nurse's cautionary message is an acknowledgment of what possible nursing diagnosis A) Risk for infection related to adverse effects of antihistamines B) Risk for falls related to sedation C) Risk for deficient fluid volume related to diuresis D) Risk for impaired skin integrity related to urticaria Ans:B Feedback: First-generation antihistamines cause drowsiness and impaired cognition that can result in falls. These drugs do not cause diuresis, impaired skin integrity, or infection.

19. An adult patient has complained to the nurse that she has been experiencing a dry mouth and urinary retention after several nights of taking an OTC sleep aid. The nurse should suspect that this medication contains what antihistamine A) Loratadine (Claritin) B) Promethazine (Phenergan) C) Diphenhydramine (Benadryl) D) Olopatadine (Patanol) Ans:C Feedback: The active ingredient in OTC sleep aids is a sedating antihistamine, usually diphenhydramine (Benadryl).

20. A patient with a long-standing history of seasonal allergies has sought care during the spring and been advised to take a second- generation antihistamine. Which of the patient's following statements suggests a need for the nurse to perform health education A) “I know these can be a bit expensive, but hopefully it will be worth it for me.”

B) “I'm really hoping that these pills will cure my allergies before summer starts.”

C) “I'll check with my doctor to make sure that the diet supplements I'm taking are okay to take at the same time as these pills.”

D) “It's handy that I don't necessarily have to take these pills at bedtime.”

Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Antihistamines mitigate the signs and symptoms of allergies, but they do not cure the problem. Second-generation antihistamines are more expensive than earlier drugs. It is prudent to screen for potential interactions with herbal remedies. Because second-generation drugs do not cause sedation, they may generally be taken at any time.

Chapter 33 Drug Therapy for Asthma and Bronchoconstriction 1. A patient has been diagnosed with asthma Which of the following health education topics is most important A) “Do not become fatigued. It will trigger asthma attacks.”

B) “Exposure to cold temperatures can trigger asthma.”

C) “Do not consume foods high in sodium.”

D) “Prolonged exposure to direct sunlight will trigger asthma.”

Ans:B Feedback: Exposure to cold air can exacerbate asthma symptoms due to the bronchoconstriction of airways. Fatigue is not a direct trigger of asthma. The consumption of high quantities of sodium will not trigger asthma. The exposure to direct sunlight will not trigger asthma.

2. A patient with asthma has been taking ibuprofen (Advil) twice daily for 2 weeks after an ankle injury. The patient calls her health care provider and states she is bothered by shortness of breath and rapid breathing What will the patient's health care provider suspect A) The patient is having an anxiety attack B) The patient has a sensitivity to the drug C) The patient is experiencing hypoglycemia D) The patient is suffering from a myocardial infarction Ans:B Feedback: In about 25 of patients with asthma, aspirin and other nonsteroidal anti-inflammatory drugs can precipitate an asthma attack. The patient is experiencing a hypersensitivity reaction. The patient is not experiencing hypoglycemia or a myocardial infarction.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A patient is using an albuterol (Proventil) inhaler, which is a bronchodilator. Which of the following patient teaching interventions is a priority for the patient who experiences shortness of breath related to constriction of airways A) Administer insulin to decrease hand shaking B) Administer ibuprofen (Advil) to decrease inflammation C) Exercise should be limited to one time per week D) Stop smoking due to the bronchoconstriction Ans:D Feedback: Cigarette smoking will increase bronchoconstriction, so the patient should be encouraged to stop. The albuterol causes hand shaking. Insulin will not decrease hand shaking.

The patient will not require ibuprofen (Advil). The patient should be encouraged to exercise, and it should not be limited to one time per week.

4. A patient is started on albuterol (Proventil). Of what adverse reaction should the patient be warned A) Polydipsia B) Tachycardia C) Hypotension D) Diarrhea Ans:B Feedback: The symptoms of cardiac stimulation, including tachycardia, are noted with the administration of albuterol. The patient will not experience polydipsia, hypotension, or diarrhea.

5. A patient is admitted to the emergency room with inspiratory stridor and air hunger after a bee sting. Which of the following medications will the nurse prepare for administration A) Ipratropium bromide (Atrovent) B) Epinephrine (Adrenalin) C) Cromolyn (Intal) D) Pseudoephedrine Ans:B Feedback: Epinephrine may be injected subcutaneously in an acute attack of bronchoconstriction

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ipratropium is administered by inhalation for maintenance therapy of bronchoconstriction related to chronic bronchitis and inflammation. It is not administered for an acute attack of bronchoconstriction Cromolyn stabilizes mast cells and prevents the release of bronchoconstrictive and inflammatory substances when mast cells are confronted with allergens and other stimuli. It is not used for acute attacks. Pseudoephedrine is not administered for acute bronchoconstriction.

6. A patient is instructed on the administration of inhaled corticosteroid agents to treat asthma.

How do inhaled corticosteroid agents assist in the treatment of asthma A) Inhaled corticosteroid agents will depress the central nervous system B) Inhaled corticosteroid agents will reduce respiratory rate C) Inhaled corticosteroid agents will reduce bronchodilation D) Inhaled corticosteroid agents will reduce airway inflammation Ans:D Feedback: Inhaled corticosteroid agents suppress the release of inflammatory mediators, block the generations of cytokines, and decrease the recruitment of airway eosinophils. Inhaled corticosteroid agents do not depress the central nervous system. Inhaled corticosteroid agents do not affect bronchodilation or constriction.

7. A patient is prescribed an adrenergic bronchodilator for airway constriction. Which of the following conditions will require it to be administered cautiously A) Liver failure B) Renal failure C) Respiratory constriction D) Seizure disorder Ans:D Feedback: The administration of adrenergic bronchodilators should be used cautiously in patients with hypertension, hyperthyroidism, diabetes mellitus, and seizure disorders. The patient with liver failure and renal failure can be administered adrenergic bronchodilators. The patient with respiratory constriction should receive adrenergic bronchodilators.

8. A patient is experiencing an acute asthma attack. Which of the following medications is contraindicated for the treatment of acute bronchospasm A) Aminophylline

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Cromolyn (Intal) C) Albuterol (Proventil) D) Formoterol (Foradil) Ans:B Feedback: Cromolyn stabilizes mast cells and is not used in acute bronchospasm. Aminophylline is used in limited cases but is administered for acute asthma attack. Albuterol and formoterol are used for acute asthma attack.

9. A child is prescribed an inhaled corticosteroid agent to decrease respiratory inflammation The child's parent administers high doses of the drug after 2 days of administration. What is the patient at risk for A) Adrenal insufficiency B) Tachycardia C) Edema D) Hypoglycemia Ans:A Feedback: Adrenal insufficiency is most likely to occur with systemic or high doses of inhaled corticosteroids. The patient is not at risk for tachycardia, edema, or hypoglycemia unless related to adrenal insufficiency.

10. A patient is experiencing an acute asthma attack. What is the most common first-line therapy for relief of an acute asthma attack A) Inhaled steroid B) Leukotriene modifier C) Beta2-adrenergic agonist D) Xanthine Ans:C Feedback: A patient experiencing an acute asthma attack should be administered a beta2adrenergic agonist. The patient can receive an inhaled steroid, but it is not the first-line therapy Leukotriene modifiers are used for maintenance in asthma, not during acute exacerbation.

Xanthines are not the drug of choice in acute asthma attack.

11. Albuterol (Proventil) is administered to a patient to promote bronchodilation Administration of this beta2-adrenergic agonist results in increased production of A) leukotrienes B) cortisol

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) cyclic AMP D) glucagon Ans:C Feedback: Beta-adrenergic drugs increase the production of cyclic AMP to produce bronchodilation They do not increase the release of leukotrienes, cortisol, or glucagon 12. A patient is being assessed by the home care nurse on the appropriate use of her metereddose inhalers. Which of the following will assist in proper administration of the inhaler A) Use of a spacer B) Administration of a corticosteroid first C) Pushing fluids D) Exhaling immediately after administration Ans:A Feedback: The patient should be instructed to use a spacer to increase compliance and accuracy of administration. The corticosteroid should be administered after the bronchodilator. The increase in fluids will not affect the administration of the inhaler. The patient should hold her breath for several seconds after administration of the inhaler.

13. A patient is admitted to the intensive care unit with status asthmaticus. The patient is administered high doses of nebulized albuterol (Proventil). What electrolyte imbalance should the nurse assess for this patient A) Hyperkalemia B) Hypermagnesemia C) Hypocalcemia D) Hypokalemia Ans:D Feedback: High doses of nebulized albuterol have been associated with tachycardia, hypokalemia, and hyperglycemia. The patient will not have alterations of magnesium or calcium levels.

14. A patient is bothered with nighttime episodes of bronchoconstriction related to asthma Which of the following medications can be administered to decrease the nighttime episodes and prevent asthma attacks A) Xanthines B) Beta2-adrenergic agonists C) Anticholinergics

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Leukotriene modifiers Ans:D Feedback: The leukotriene modifiers improve symptoms and pulmonary function tests, decrease nighttime symptoms, and decrease the use of beta2-adrenergic drugs. Xanthines treat acute attacks but do not prevent asthma from occurring. Beta2-adrenergic agonists treat acute attacks but do not prevent asthma from occurring. Anticholinergics block the action of acetylcholine in bronchial smooth muscle when given by inhalation.

15. A patient has begun taking antiasthmatic drugs. The patient should avoid excessive intake of what beverage A) Coffee B) Grapefruit C) Green tea D) Acai juice Ans:A Feedback: Patients taking antiasthmatic drugs should generally avoid excessive intake of caffeine- containing fluids such as coffee, tea, and cola drinks. These beverages may increase bronchodilation but also may increase heart rate and cause palpitations, nervousness, and insomnia with bronchodilating drugs.

16. A patient with a recent diagnosis of asthma is anxious because she experienced an asthma attack and was unable to relieve the symptoms despite taking several puffs of her prescribed salmeterol (Serevent). How should the nurse respond to the patient's concerns A) “Remember that your Serevent isn't effective when you take it at the time of an asthma attack.”

B) “It's important to take your Serevent as soon as you feel the first sensation of an asthma attack.”

C) “Unfortunately, Serevent can take up to 15 minutes to relieve your difficulty breathing.”

D) “It's best to take repeated doses of Serevent, every 5 minutes, until your symptoms subside.”

Ans:A Feedback: Formoterol (Foradil) and salmeterol (Serevent) are long-acting beta2-adrenergic agonists used only for prophylaxis of acute bronchoconstriction. They are not effective in acute attacks because they have a slower onset of action than the short-acting drugs.

17. A patient with asthma has been prescribed ipratropium (Atrovent) 2 puffs QID. The nurse should recognize which of the following as the most likely goal of this treatment A) Promoting short-term relief of acute asthma symptoms

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B) Relieving acute bronchoconstriction C) Promoting long-term management of asthma symptoms D) Promoting blood flow in the alveolar capillaries Ans:C Feedback: The anticholinergic bronchodilators are most useful in the long-term management of asthma and other conditions producing bronchoconstriction. These drugs are not used in the management of acute exacerbations of asthma. They do not promote alveolar blood flow

18. A hospital patient's medication administration record specifies concurrent doses of nebulized ipratropium and albuterol at 08:00 and 20:00. When administering these drugs, which of the following statements is true A) The two drugs should be administered at least 30 minutes apart, with ipratropium administered first B) The two drugs can be mixed in the nebulizer immediately before administration C) The two drugs should be administered at least 30 minutes apart, with albuterol administered first D) The nurse should contact the prescriber due to the increased risk of adverse effects when these drugs are administered concurrently Ans:B Feedback: It is appropriate to mix ipratropium bromide inhalation solution in the nebulizer with albuterol or metaproterenol if the mixture is used within 1 hour. These drugs have a synergistic effect.

19. A patient with a long-standing history of asthma has failed to achieve adequate symptom control with first-line drugs. As a result, her care provider has prescribed theophylline. The nurse is aware of the narrow therapeutic range of this drug and has taught the patient to recognize the signs and symptoms of toxicity. These include which of the following A) Polyuria and polyphagia B) Confusion and decreased level of consciousness C) Agitation and dysrhythmias D) Chest pain and shortness of breath

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Ans:C Feedback: Signs and symptoms of theophylline overdose include anorexia, nausea, vomiting, agitation, nervousness, insomnia, tachycardia and other dysrhythmias, and tonic–clonic convulsions. Ventricular dysrhythmias or convulsions may be the first sign of toxicity. Chest pain, shortness of breath, polyuria, polyphagia, and decreased level of consciousness do not accompany theophylline overdose.

20. An adult patient with a diagnosis of asthma has been prescribed montelukast (Singulair). The nurse should teach the patient that this drug will help relieve symptoms by A) reducing the muscle tone in the alveoli and facilitating gas exchange B) relaxing smooth muscle in the bronchi and bronchioles C) preventing the bronchoconstriction and inflammation that is caused by leukotrienes D) preventing mast cells from releasing histamine Ans:C Feedback: Montelukast prevents leukotrienes from binding to its receptors reducing the bronchoconstriction and ultimate inflammation caused by leukotrienes.

Chapter 34 Drug Therapy for Fluid Volume Excess 1. The physician has ordered the patient hydrochlorothiazide. What assessment should the nurse make before administering the first dose of hydrochlorothiazide A) Pulse rate B) Hemoglobin level C) Sulfonamide allergy D) Neutrophil level Ans:C Feedback: Thiazide diuretics must be used cautiously in patients allergic to sulfonamide drugs because there is a known cross-sensitivity of some sulfonamide-allergic patients to sulfonamide nonantibiotic. It is not imperative to assess pulse, hemoglobin, or neutrophil levels.

2. A patient has edema of the lower extremities and abdomen. What is the reason for administering a stronger diuretic than a thiazide diuretic to this patient A) A thiazide diuretic will reabsorb potassium in the distal tubule B) A thiazide diuretic will be ineffective for immediate diuresis

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) A thiazide diuretic will provide peak effects in 2 hours D) A thiazide diuretic will be excreted in more than 72 hours Ans:B Feedback: Thiazide diuretics are ineffective when immediate diuresis is required. A thiazide diuretic acts to reabsorb sodium, not potassium, in the distal convoluted tubule. A thiazide diuretic reaches its peak in 4 to 6 hours. A thiazide diuretic is excreted in 72 hours maximum.

3. A patient is admitted to the hospital with a diagnosis of heart failure. The patient is ordered to receive furosemide (Lasix) 40 mg IV. How soon after administration should the nurse expect to see evidence of diuretic effects A) 1 minute B) 5 minutes C) 30 minutes D) 2 hours Ans:B Feedback: After IV administration, diuretic effects occur within 5 minutes. The diuretic effect is not seen in 1 minute. The peak of the action occurs in 30 minutes, not the onset of action. The duration of action is 2 hours, not the onset of action.

4. A patient is administered furosemide (Lasix) 20 mg PO every morning. What effect will a diet high in sodium have on the patient A) Decreased blood pressure B) Decreased diuresis C) Hyperkalemia D) Hyperglycemia Ans:B Feedback: A high dietary intake of sodium can cause sodium retention and reduce or cancel the diuretic-induced sodium loss. A high dietary intake of sodium will not increase diuresis. A high dietary intake of sodium will not cause hyperkalemia. A high dietary intake of sodium will not cause hyperglycemia.

5. A patient is switched from furosemide (Lasix) to spironolactone (Aldactone). The patient asks the nurse why she has been switched to a new medicine. What is the nurse's best response A) “You will lose less potassium with spironolactone than with furosemide.”

B) “You will have greater potassium losses with spironolactone than with furosemide.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) “You will have greater water losses with spironolactone than with furosemide.”

D) “You will have greater sodium losses with spironolactone than with furosemide.”

Ans:A Feedback: Spironolactone promotes retention of sodium and water and excretion of potassium by stimulating the sodium–potassium exchange mechanism in the distal tubule. The patient will not have greater potassium losses, water losses, or sodium losses with spironolactone rather than furosemide.

6. A patient is taking spironolactone (Aldactone). When providing patient teaching about this medication, what foods should the patient be instructed to avoid A) Fish B) Apples C) Crackers D) Bananas Ans:D Feedback: Bananas are high in potassium and should be avoided with potassium-sparing diuretics. It is acceptable for the patient to eat fish, apples, and crackers.

7. A patient is admitted to the emergency department and is unconscious as a result of a head injury. The patient's intracranial pressure is increased. What type of diuretic will the nurse most likely administer to the patient A) Loop diuretic B) Potassium-sparing diuretic C) Thiazide diuretic D) Osmotic diuretic Ans:D Feedback: An osmotic diuretic is used to reduce intracranial pressure related to a head injury.

Loop diuretics, potassium-sparing diuretics, and thiazide diuretics do not reduce intracranial pressure 8. A patient with hypertension has been prescribed a combination diuretic. What is the major purpose in administering a combination diuretic agent A) It prevents sodium imbalance B) It is less expensive than two medications C) It prevents potassium imbalance D) It prevents allergic reactions

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: The major purpose of the diuretic combinations is to prevent potassium imbalances.

The combination products do not prevent sodium imbalance. The combination products are not less expensive than taking two medications. The combination products do not prevent allergic reactions.

9. A patient asks the nurse why she has to take two diuretics when her friend only takes one with a combination medication. The patient takes hydrochlorothiazide 75 mg every day with a potassium-sparing diuretic. What is the nurse's best response A) “Maybe you should speak with your doctor about the combination.”

B) “I do not know why your doctor prefers that you take two medications.”

C) “It could be that you need a larger dose than is available in the combination medications.”

D) “The combination medications are not as effective as two medications.”

Ans:C Feedback: The fixed-dose combination of hydrochlorothiazide and a potassium-sparing diuretic contains 50 mg of hydrochlorothiazide, and this patient requires 75 mg of hydrochlorothiazide. The statement “It could be that you need a larger dose than is available in the combination medications” is the best answer. The statement “Maybe you should speak with your doctor about the combination” does not provide adequate teaching. The statement “I do not know why your doctor prefers that you take two medications” does not provide adequate patient education. The combination medications are very effective, and the statement that they are not as effective is inaccurate.

10. A patient has edema of the lower extremities with crackles in the lung bases. What diuretic is the nurse most likely to administer A) Hydrochlorothiazide B) Furosemide C) Spironolactone D) Mannitol Ans:B Feedback: Acute pulmonary edema is an indication for the use of Lasix. HCTZ, spironolactone, and mannitol are not used for this purpose, largely due to their slower onset of action.

11. A patient has been prescribed digoxin (Lanoxin) and furosemide (Lasix) for treatment of congestive heart failure. What is the patient at risk for developing with this combination of medications

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Hyperkalemia B) Hyperglycemia C) Tachycardia D) Digoxin toxicity Ans:D Feedback: When digoxin and diuretics are used concomitantly, the risk of digoxin toxicity is increased. The patient is at risk for hypokalemia, not hyperkalemia. The patient is not at a particular risk for hyperglycemia or tachycardia.

12. A patient is receiving furosemide (Lasix) and a potassium supplement. When monitoring daily laboratory values, what should the potassium level be for this patient A) 1.5 to 3.0 mEq/L B) 3.5 to 5.0 mEq/L C) 5.0 to 7.5 mEq/L D) 6.0 to 6.5 mEq/L Ans:B Feedback: The normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 1.5 to 3.0 mEq/L is too low. A serum potassium level of 5.0 to 7.5 mEq/L is indicative of hyperkalemia. A serum potassium level of 6.0 to 6.5 mEq/L is indicative of hyperkalemia.

13. An elderly patient with a history of heart failure has presented to the emergency department in respiratory distress. Assessment reveals the presence of pulmonary edema, and an infusion of IV furosemide (Lasix) has been ordered. For the duration of treatment, the nurse should prioritize assessments related to what nursing diagnosis A) Risk for deficient fluid volume related to diuretic administration B) Risk for decreased cardiac output related to adverse effects of furosemide C) Ineffective health maintenance related to pulmonary edema D) Functional urinary incontinence related to diuretic administration Ans:A Feedback: Increased diuresis creates a risk of deficient fluid volume. Impaired health maintenance and urinary incontinence are not priorities at this time. Lasix will not reduce cardiac output.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A hospital patient with a diagnosis of liver failure has been prescribed a low dose of spironolactone in order to treat ascites. The nurse who is providing this patient's care should prioritize assessments for the signs and symptoms of what health problem A) Peritonitis B) Liver cancer C) Cirrhosis D) Hepatic encephalopathy Ans:D Feedback: Spironolactone is used in the treatment of ascites. However, it should be used cautiously and carefully monitored in patients with significant hepatic impairment because a rapid change in fluid and electrolyte balance may lead to hepatic coma. It is important to monitor susceptible patients carefully for signs and symptoms of hepatic encephalopathy. There is no risk for liver cancer, cirrhosis, or peritonitis that results directly from the use of spironolactone.

15. A clinical nurse educator on a nephrology and dialysis unit is reviewing renal physiology with a nursing student who is completing a preceptorship on the unit. The student should be aware that a majority of reabsorption takes place in what anatomical location A) Ureters B) Proximal tubule C) Efferent arteriole D) Afferent arteriole Ans:B Feedback: Most reabsorption occurs in the proximal tubule. Almost all glucose and amino acids are reabsorbed; about 80 of water, sodium, potassium, chloride, and most other substances is reabsorbed. Arterial blood enters the glomerulus by the afferent arteriole, and blood that does not become part of the glomerular filtrate leaves the glomerulus through the efferent arteriole. The ureters connect the kidneys to the bladder.

16. A hospital patient with peripheral edema has been prescribed furosemide (Lasix). How should the nurse best determine the extent of the patient's desired fluid loss A) Assess the patient's skin turgor on a daily basis B) Test the osmolarity of the patient's urine regularly C) Weigh the patient daily D) Auscultate the patient's chest each morning

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: The nurse should measure and record weights to assist in determining the amount of mobilization of excess fluid. This is a more accurate gauge of changes in fluid status than skin turgor, urine osmolarity, or chest auscultation.

17. An adult patient with a diagnosis of hypertension has had oral Lasix added to his medication regimen by his primary care provider. The nurse is planning a brief health education session with the patient in light of this change in his treatment plan. What goal should the nurse specify when planning this teaching session A) The patient will identify strategies for limiting his sodium intake B) The patient will describe the rationale for increasing his fluid intake C) The patient will be able to demonstrate correct technique for blood glucose monitoring D) The patient will accurately describe the basic structure and functions of the kidneys Ans:A Feedback: The reason for furosemide use should guide patient teaching. In most instances, it is necessary to initiate measures to limit sodium intake. Key considerations should include not adding salt to food during preparation or at the dinner table, reading food labels carefully to be aware of hidden sources of sodium, and avoiding processed or high-sodium foods Blood glucose monitoring is not indicated, and there is no need for increased fluid intake. Renal anatomy and physiology are not priority teaching points.

18. An older adult patient has a complex medical history that includes heart failure, type 1 diabetes, and diabetic nephropathy. The nurse has questioned a care provider's order for oral spironolactone because the patient's health problems would contribute to a high risk of A) metabolic acidosis B) hypocalcemia C) hemolytic anemia D) hyperkalemia Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The presence of renal insufficiency is also a contraindication to the use of spironolactone because use of spironolactone may cause hyperkalemia through the inhibition of aldosterone and the subsequent retention of potassium. This patient does not face a greatly increased risk of anemia, hypocalcemia, or acidosis

19. A nurse is reviewing a newly admitted patient's medication administration record and notes that the patient takes a loop diuretic as well as a thiazide diuretic. The nurse understands what primary rationale for the concurrent use of these two drugs A) Increased diuretic effect B) Reduced risk of potassium imbalances C) Decreased blood pressure without a risk of bradycardia D) Increased adherence to treatment Ans:A Feedback: When an inadequate diuretic response occurs with one drug, people sometimes take two potassium-losing diuretics concurrently. The combination of a loop and a thiazide diuretic has synergistic effects because the drugs act in different segments of the renal tubule Thus, the rationale for this particular combination is not rooted in prevention of potassium imbalances, increased adherence, or maintenance of a normal heart rate.

20. A patient has been taking an ACE inhibitor and a beta-blocker for the treatment of hypertension but has been consistently obtaining blood pressure readings in the vicinity of 145/90 mm Hg. As a result, the patient's primary care provider has prescribed furosemide (Lasix). What order would be most consistent with this patient's health needs A) Lasix 125 mg PO OD B) Lasix 40 mg IV TID C) Lasix 20 mg IV OD D) Lasix 40 mg PO BID Ans:D Feedback: For hypertension, Lasix is commonly given as 40 mg PO twice daily and gradually increased if necessary Chapter 35 Nutritional Support Products, Vitamins, and Mineral Supplements 1. A patient has suffered from several infections in the last 6 months and unexplained impaired wound healing.

What assessment should the nurse prioritize A) Assess for pain

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Assess for nutritional deficiencies C) Assess genetic tendency for infection D) Assess for edema and decreased hemoglobin Ans:B Feedback: Nutritional deficiencies may impair the function of essentially every body function.

Signs and symptoms include unintended weight loss, increased susceptibility to infection, and impaired wound healing. The development of infection and impaired wound healing would require assessment for pain but would not provide evidence of cause. The nurse would not be able to assess genetic tendency. Edema and decreased hemoglobin would not explain the etiology of suffering infections and impaired wound healing.

2. An adult patient is experiencing deficiencies in folic acid and vitamin B12. This patient's compromised health status creates a risk for which of the following A) Hyperuricemia B) Hepatitis C) Non-Hodgkin's lymphoma D) Megaloblastic anemia Ans:D Feedback: Deficiency states of both vitamin B12 and folic acid present similarly as megaloblastic anemia (characterized by abnormally large, immature red blood cells). These deficiencies do not contribute to hyperuricemia, hepatitis, or lymphoma 3. status has necessitated the use of a nutritional formula. When reviewing this patient's laboratory findings, the nurse should prioritize which of the following values A) Erythrocyte sedimentation rate (ESR) B) Serum albumin C) GGT, AST, and ALT D) Blood urea nitrogen Ans:B Feedback: For patients receiving nutritional formulas, the nurse observes for weight gain and increased serum albumin. In a patient with compromised nutrition, there is less emphasis placed on BUN, liver enzymes, and ESR.

4. A patient with a history of atrial fibrillation has been brought to the emergency department (E

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) by his wife after inadvertently taking 22 mg of warfarin rather than 2 mg, which is the patient's prescribed daily dose. The ED nurse should anticipate the administration of A) vitamin K B) vitamin B12 C) vitamin A D) vitamin B1 Ans:A Feedback: Vitamin K is used to reverse the effects of warfarin (Coumadin).

5. When providing nutritional teaching to adolescent girls, which aspect of teaching is most important A) Limit the amount of foods high in fiber B) Increase potassium chloride in the diet C) Calcium intake should be 1300 mg daily D) Increase sodium in the diet Ans:C Feedback: Adolescent females should consume 1000 to 1300 mg of calcium per day.

Adolescent females should not limit fiber or increase potassium chloride or sodium in the diet.

6. A patient is admitted to the hospital with hyperkalemia. The patient is prescribed sodium polystyrene sulfonate (Kayexalate). How does this medication lower the patient's potassium level A) It decreases the absorption of exogenous potassium B) It increases urinary excretion of potassium C) It combines with potassium ions for elimination D) It releases sodium to acidify urine with potassium Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, administered orally, removes potassium from the body in the stool. Kayexalate does not decrease the absorption of potassium. Kayexalate does not increase urinary excretion of potassium.

Kayexalate does not release sodium to acidify urine with potassium.

7. A patient has an increased serum potassium level and has developed a cardiac arrhythmia.

How do insulin and glucose assist in decreasing the serum potassium level A) Insulin and glucose drive potassium into the cells B) Insulin and glucose bind potassium to sodium C) Insulin and glucose increase urinary excretion of potassium D) Insulin and glucose increase fecal excretion of potassium Ans:A Feedback: Insulin and glucose lower serum potassium levels by driving potassium into the cells. Insulin and glucose do not bind potassium to sodium or increase urinary excretion of potassium or fecal excretion of potassium.

8. A 4-year-old child has eaten many of his mother's prenatal vitamins. Which medication is indicated for iron toxicity A) Deferoxamine (Desferal) B) Penicillamine (Cuprimine) C) Sucralfate (Carafate) D) Magnesium sulfate Ans:A Feedback: Deferoxamine is a parenteral drug used to remove excess iron from storage sites in the body. Penicillamine, sucralfate, and magnesium sulfate are not administered for iron toxicity.

9. A patient with thalassemia requires frequent blood transfusions. The patient develops iron overload. Which of the following medications will be administered A) Calcium gluconate B) Deferoxamine (Desferal) C) Sodium polystyrene sulfonate (Kayexalate) D) Deferasirox (Exjade) Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Deferasirox (Exjade) is an oral iron chelating agent that is used to treat chronic iron overload in patients who require frequent blood transfusions for severe chronic anemia. Calcium gluconate, deferoxamine (Desferal), and sodium polystyrene sulfonate (Kayexalate) are not used to treat chronic iron overload

10. A toddler lives in a home that was built in the 1960s. The child has been diagnosed with lead poisoning after eating chips of flaking paint. Which medication will be administered to decrease lead levels A) Succimer (Chemet) B) Folic acid C) Deferoxamine (Desferal) D) Deferasirox (Exjade) Ans:A Feedback: Succimer (Chemet) chelates lead to form water-soluble complexes that are excreted in the urine. Succimer is used to treat lead poisoning in children. Folic acid is not used to treat lead poisoning. Deferoxamine is not used to treat lead poisoning. Deferasirox is not used to treat lead poisoning.

11. A new mother asks why her baby receives vitamin K IM at birth. What is the best statement to explain the need for vitamin K in a newborn A) “The administration of vitamin K prevents her from bleeding.”

B) “Your infant will need multiple injections of vitamin K to prevent health problems.”

C) “Your infant will need the conjugated iron in vitamin K to protect her from infection.”

D) “Vitamin K helps boost her nutrition until she's able to feed more efficiently.”

Ans:A Feedback: A single IM dose of vitamin K is given to newborn infants to prevent hemorrhagic disease of newborns. The infant does not need multiple injections of vitamin K to prevent hemorrhage. The administration of vitamin K will not protect from infection. Vitamin K is not used to enhance nutrition

12. A woman in her last trimester of pregnancy is diagnosed with toxemia. The patient is admitted to labor and delivery and suffers a seizure. What medication will be administered parenterally A) Magnesium oxide B) Magnesium sulfate C) Potassium chloride

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Calcium gluconate Ans:B Feedback: Magnesium sulfate is given parenterally for convulsions related to pregnancy.

Magnesium oxide is given orally for mild hypomagnesemia. Potassium chloride is not given for convulsions related to pregnancy Calcium gluconate is not given for convulsion related to pregnancy.

13. A patient's fluid overload has required several doses of furosemide (Lasix). Which medication will be administered if the patient's serum potassium level is 2.8 mEq/L A) Potassium chloride B) Calcium gluconate C) Potassium carbonate D) Sodium polystyrene sulfonate (Kayexalate) Ans:A Feedback: Furosemide is a potassium-depleting diuretic in which potassium chloride will be administered to prevent hypokalemia Calcium gluconate and zinc gluconate will not be administered to the patient. Sodium polystyrene sulfonate would be administered with hyperkalemia not hypokalemia.

14. A patient with alcoholism has been admitted to the hospital following an injury Assessment of the patient's overall health reveals significant nutritional deficits. The patient is likely to require which of the following due to inadequate dietary intake A) Sodium B) Vitamin A C) Vitamin K D) Thiamine Ans:D Feedback: Thiamine deficiency is common in patients with alcoholism because of inadequate dietary intake and use of large amounts of thiamine to metabolize ethanol. Sodium, vitamin A, and vitamin K are important but not as crucial to this particular patient as thiamine.

15. A patient diagnosed with pernicious anemia asks why vitamin B12 is administered by injection. What is the best response to the patient A) “Oral forms of vitamin B12 will not be absorbed.”

B) “Oral ingestion of vitamin B12 causes irritation and bleeding.”

C) “Pernicious anemia causes changes in the mucous membrane.”

D) “In severe pernicious anemia, vitamin B12 is not effective.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: In pernicious anemia, vitamin B12 must be given by injection because oral forms are not absorbed from the GI tract. Vitamin B12 is not administered orally and thus will not cause irritation and bleeding. Pernicious anemia causes changes in the mucous membrane, but these changes do not explain why vitamin B12 is administered by injection.

16. A 3-year-old child has been diagnosed with an acute gastrointestinal infection that has caused her severe diarrhea for the past 36 hours. The pediatric nurse should anticipate the use of A) magnesium gluconate B) Pedialyte C) sodium bicarbonate D) 50 dextrose Ans:B Feedback: Oral electrolyte solutions (e.g., Pedialyte) contain several electrolytes and a small amount of dextrose. They are especially useful in children for treatment of diarrhea and may prevent severe fluid and electrolyte depletion. Magnesium gluconate, 50 dextrose, and sodium bicarbonate are not typically used for this purpose.

17. A middle-aged woman with a family history of breast cancer has told the nurse that she has begun taking 250 mg of vitamin E each day in an effort to prevent cancer. How should the nurse best respond to this woman's statement A) “Good for you. You're to be commended for being so proactive with your health.”

B) “If you do this, it's best to take several smaller doses during the day rather than one big dose.”

C) “Unfortunately, high doses of vitamins haven't been shown to protect against disease.”

D) “This is actually quite a dangerous practice, and might increase, rather than decrease, your cancer risk.”

Ans:C Feedback: People should never self-prescribe megavitamins, large doses of vitamins in excess of the recommended dietary allowance (RD A). This practice does not, however, increase an individual's risk of cancer.

18. A patient with a history of homelessness has been diagnosed with nutritional deficits that include a vitamin E deficiency. What aspect of the patient's current health status would contraindicate the safe and effective use of vitamin E supplements

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Cirrhosis B) Thrombocytopenia C) Low serum albumin D) IV opioid abuse Ans:B Feedback: Patients with a history of bleeding disorders or thrombocytopenia should not take vitamin E. Opioid use and liver disease do not necessarily contraindicate the use of vitamin E supplements.

19. A patient with iron deficiency anemia has begun taking daily supplements of oral ferrous sulfate. The nurse who is planning this patient's care should add what nursing diagnosis to the nursing care plan A) Risk for excess fluid volume related to use of iron supplements B) Risk for unstable blood glucose related to use of iron supplements C) Risk for constipation related to use of iron supplements D) Risk for peripheral neurovascular dysfunction related to use of iron supplements Ans:C Feedback: Constipation is a common adverse effect of iron supplements. Neurovascular dysfunction, fluid volume excess, and unstable blood glucose are unlikely to result from iron supplements.

20. An older adult has been admitted to the hospital with failure to thrive. Assessment suggests that the patient is in a severely malnourished state. Which of the following assessment findings is most suggestive of a vitamin A deficiency A) Night blindness B) Manic episodes C) Nonblanching erythema D) Petechiae Ans:A Feedback: Night blindness is characteristic of vitamin A deficiency. Mania and integumentary changes are not normally associated with this vitamin deficiency.

Chapter 36 Drug Therapy for Weight Management 1. A patient has a body mass index of 27 and weighs 160 pounds. What is this patient considered to be A) Underweight B) Overweight

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Obese D) Desired weight Ans:B Feedback: Overweight is defined as a body mass index 2 of 25 to 29.9 kg/m . The patient is not underweight, obese, or at the desired weight. Obesity cannot be determined solely on the basis of body weight.

2. When the nurse is educating a women's group on obesity and healthy eating, which of the following statements is most accurate A) Consuming 3500 extra calories in a week will result in 1 pound of fat B) Extra calories are converted to amino acids or protein C) Food that contains large amounts of fat stimulates energy D) Women will typically expend more energy than men because of muscle tissue Ans:A Feedback: Consuming an extra 500 calories each day for a week results in 3500 excess calories, or 1 pound of fat. Excess calories are converted to triglycerides, not amino acids. Foods that contain carbohydrates and protein stimulate energy expenditure. Men expend more energy than women.

3. A school nurse is in the planning stages of a health promotion campaign that will address childhood obesity. Of the following, which is an environmental factor believed to have contributed most to increased weight in children A) Playing video games B) Genetic changes C) Increased social acceptance of obesity D) Increased incidence of depression Ans:A Feedback: For both adults and children, increased time watching television, playing video and computer games, and working on computers contributes to less physical activity and promotes weight gain. Depression, social factors, and genetic factors are not environmental influences.

4. A nurse is instructing parents about health and nutrition. The nurse should state that overweight children are more likely than normal-weight children to develop which disease process

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Glaucoma B) Migraine headache C) Scoliosis D) Diabetes mellitus Ans:D Feedback: Overweight and obese children are at risk for developing type 2 diabetes.

Overweight children are not particularly prone to developing glaucoma, migraine headache, or scoliosis.

5. A patient is prescribed phentermine (Ionamin) in an effort to promote weight loss. What is the most common adverse effect of phentermine A) Dry mouth B) Hypernatremia C) Fatigue D) Hypoglycemia Ans:A Feedback: The most commonly reported adverse effects of phentermine are nervousness, dry mouth, constipation, and hypertension Hypernatremia, fatigue, and hypoglycemia are not adverse effects of phentermine.

6. An obese patient has asked her nurse practitioner to prescribe sibutramine. What variable will most affect the nurse's decision A) Sibutramine has been taken off the market due to adverse cardiovascular effects B) Sibutramine is prohibitively expensive and is not covered by most insurers C) The use of sibutramine requires weekly blood work D) Sibutramine must be combined with an anticholinergic drug in order to potentiate its effects Ans:A Feedback: Until recently, health care providers used sibutramine, a drug that suppresses appetite by inhibiting the reuptake of the neurotransmitters norepinephrine and serotonin, in the management of obesity. The drug is no longer available in the United States because a clinical study demonstrated an increased risk of cardiovascular events such as heart attack and stroke with its use.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. Which of the following patients would be the most appropriate candidate for treatment with orlistat A) A 31-year-old woman who has been unable to lose her “baby fat” in the months following the birth of her child B) A patient with a body mass index of 25.5 C) A man who is morbidly obese and who has osteoarthritis in his knees D) A 66-year-old man who was previously healthy but who has been gradually gaining weight since retirement Ans:C Feedback: Orlistat is intended for people who are clinically obese, not for those who want to lose a few pounds. A patient with a BMI of 25.5 is nominally overweight.

8. A patient is prescribed orlistat (Xenical) to promote weight loss. What is the action of orlistat A) It increases central nervous system stimulation B) It inhibits the reuptake of serotonin and norepinephrine C) It decreases fat absorption, which leads to decreased caloric intake D) It decreases appetite because of the caffeine contained in the medication Ans:C Feedback: Orlistat decreases fat absorption, which leads to decreased caloric intake. Orlistat does not increase central nervous system stimulation. Orlistat does not inhibit reuptake of serotonin and norepinephrine. Orlistat does not decrease appetite because of the caffeine contained in the medication.

9. A 40-year-old patient has a body mass index that classifies him as being severely obese. For several months, the patient has been working with an interdisciplinary team in an effort to lose weight, but he has experienced nominal success. His physician has proposed the use of orlistat, and the nurse has conducted appropriate health education. What statement by the patient indicates a need for further teaching A) “They explained to me that I have to take the medicine with my meals.”

B) “I'm excited that I won't have to cut down on my favorite fried foods anymore.”

C) “It still amazes me that you can take a pill that will actually help you lose weight.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) “If I understand correctly, these pills will help me lower my cholesterol as well as lose weight.”

Ans:B Feedback: It is necessary to decrease consumption of high-fat foods when taking orlistat because total caloric intake is a major determinant of weight, and adverse effects (e.g., diarrhea; fatty, malodorous stools) worsen with consumption of a large amount of fat. The patient's other listed statements are accurate

10. A mother is distraught that her 13-year-old son weighs 260 pounds and continues to gain weight. She has asked her family's primary care provider if her child would be a candidate for treatment with orlistat, which she read about on the Internet. What fact should primarily guide the care provider's decision A) Orlistat is not approved for use in children under the age of 18 B) Orlistat can only be administered to children in an inpatient setting C) Alternatives such as increased activity and decreased caloric intake should first be exhausted D) The drug is not likely to be effective until the boy completes puberty Ans:C Feedback: Although experts do not generally recommend drug therapy for treatment of childhood obesity, the FDA has approved orlistat for use in children aged 12 and older and considers the drug to be safe and effective for weight reduction in overweight adolescents.

Orlistat is not limited to inpatient use, and puberty does not negate efficacy.

11. A team of community health nurses have been commissioned to plan and implement a community-based health promotion initiative aimed at addressing obesity. During the planning stages, the nurses should be aware that the prevalence of obesity is highest in which of the following groups A) Caucasian women B) Caucasian men C) African American women D) African American men Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: African American women and Mexican American men and women have the highest rates of overweight and obesity in the United States

12. An obese patient has been receiving extensive health education prior to beginning treatment with phentermine. The nurse has taught the patient about the varied factors that contribute to obesity. Which of these factors is addressed by the use of phentermine A) Psychosocial factors B) Environmental factors C) Genetic factors D) Physiologic factors Ans:D Feedback: Because phentermine inhibits the reuptake of both serotonin and norepinephrine, it directly affects physiologic factors related to obesity.

13. A nurse who works with patients in a bariatric clinic is teaching a man about the potentially beneficial effects of phentermine. How should the nurse best explain this drug's mechanism of action A) “This drug will cause you to have less of an appetite.”

B) “This drug will cause you to absorb less of the fat that you eat.”

C) “This drug will cause you to burn more calories than you normally do.”

D) “This drug prevents fat from being deposited in your tissues.”

Ans:A Feedback: Phentermine inhibits the reuptake of both serotonin and norepinephrine. It is an anorexiant, causing appetite suppression, which is thought to result from direct stimulation of the satiety center in the hypothalamic and limbic region. It does not increase calorie metabolism or fat deposition 14. tells the nurse, “The pills seemed to work wonders for me for the first few weeks, but now I feel like they don't really make much of a difference.” The nurse should anticipate that the prescriber will take what action A) Increasing the daily dosage of the drug by approximately 50 B) Ordering blood work to ascertain the serum level of phentermine C) Discontinuing the drug D) Changing the route and schedule of administration Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Tolerance to phentermine usually occurs within 4 to 6 weeks and is an indication for discontinuing drug administration. Continued administration or use of large doses does not maintain appetite-suppressant effects. Instead, it increases the incidence of adverse effects Blood work is unnecessary, and changing the route is not an option.

15. An adult patient with long-standing obesity has been deemed an appropriate candidate for treatment with phentermine. When teaching the patient to safely and effectively administer the drug, the nurse should convey what message to the patient A) Take phentermine with food, preferably at mealtimes B) Take the medication on an empty stomach C) Take the medication 15 minutes after meals to reduce fat absorption D) Take an increased dose of phentermine if a large meal is anticipated Ans:B Feedback: It is necessary to take phentermine on an empty stomach. Recipients should take single-dose drugs in the early morning; they should take multiple-dose preparations 30 minutes before meals, with the last dose of the day about 6 hours before going to bed. Doses are not increased when large meals are anticipated. Phentermine does not affect fat absorption.

16. A female patient with obesity will soon begin treatment with orlistat. The nurse should teach the patient that A) there will be fat present in her stools B) her appetite will decline over the next 48 hours C) she will have to increase her fiber intake D) she will need to temporarily eliminate fats from her diet Ans:A Feedback: Fatty stools are a notable adverse effect of orlistat. This drug does not reduce appetite. A reduced-fat diet may be of benefit, but it is not necessary to wholly eliminate fats from the diet.

17. A nurse educator is working with a patient of a bariatric clinic who has just begun taking orlistat. The nurse should encourage the patient to supplement her diet with which of the following

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) An iron supplement B) A multivitamin C) An omega-3 fatty acid supplement D) A potassium supplement Ans:B Feedback: Because orlistat prevents absorption of the fat-soluble vitamins A, D, E, and K, people who take it should also take a multivitamin daily 2 hours before or after orlistat. Iron supplements, potassium supplements, and omega-3 fatty acid supplements are not necessarily required.

18. A 34-year-old woman with a body mass index of 56 has recently started to take orlistat. The nurse has educated the patient about the common adverse effects of this medication, including the potential for diarrhea and flatulence. Which of the following meals would be most likely to exacerbate the adverse effects of orlistat A) A Cobb salad with romaine lettuce, boiled egg, chicken breast, tomato, and cheese B) A tomato, green pepper, and ham omelet C) A salami, sausage, and pepperoni pizza topped with mozzarella and parmesan D) A bowl of beef chili con carne topped with diced onions Ans:C Feedback: To minimize GI effects, the nurse encourages patients to distribute fat calories over the three main meals and to avoid high-fat meals. The fat content of a meat-laden pizza exceeds that of a Cobb salad, omelet, or bowl of chili.

19. A young adult man is despondent that he has been unable to lose weight and keep it off Now that his weight has crested 350 pounds, he has sought advice from the nurse. He states that obesity runs in his family but that his mother had great success in losing weight with the use of amphetamines in the late 1970s. The nurse should explain to the man that this is not a treatment option because A) amphetamines have been shown to be largely ineffective in clinical studies B) amphetamines have been superseded by more modern lipase inhibitors C) amphetamines carry a high risk of dependence and abuse

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) amphetamines are prohibitively expense and are not covered by most health insurers Ans:C Feedback: Experts do not recommend using amphetamines because they are controlled substances (Schedule II) with a high potential for abuse and dependence. Amphetamines do not inhibit lipase.

20. A nurse has begun the assessment process with an obese patient who states that he is highly motivated to lose weight. How can the nurse most accurately gauge the patient's normal eating and drinking patterns A) Have the patient keep a detailed food diary for 2 or 3 days B) Ask the patient to describe a typical meal and snack C) Check laboratory reports of total and LDL cholesterol, triglycerides, and blood sugar D) Have the patient describe the differences between a healthy meal and an unhealthy meal Ans:A Feedback: The best way to assess dietary habits is to ask the patient to keep a food diary for 2 or 3 days. If food intake is not written down, people tend to underestimate the amount and caloric content. Blood work is a relevant assessment datum but does not necessarily indicate the patient's eating and drinking habits. Having the patient describe a healthy or unhealthy meal does not allow the nurse to assess eating habits.

Chapter 37 Drug Therapy for Peptic Ulcer Disease and Hyperacidity 1. A patient is taking nonsteroidal anti- inflammatory agents for arthritis of the knees and hips.

Which of the following diseases is a result of cellular destruction of the gastrointestinal tract from this medication A) Esophageal cancer B) Bowel obstruction C) Liver cancer D) Peptic ulcer disease Ans:D Feedback: Cell destruction will occur from the ingestion of NSAIDs, which can lead to the development of peptic ulcer disease

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Nonsteroidal anti-inflammatory agents do not cause esophageal cancer, bowel obstruction, or liver cancer.

2. A patient has Maalox ordered for administration as needed. Which of the following conditions contraindicates the administration of Maalox A) Hypertension B) Heart rate of 68 C) Renal dysfunction D) Stress ulcer Ans:C Feedback: Magnesium-based antacids are contraindicated in patients with renal failure.

Magnesium-based antacids are not contraindicated with hypertension, regular heart rate, or stress ulcer.

3. A patient is diagnosed with peptic ulcer disease complicated by H. pylori. What is the rationale for adding bismuth to the patient's medication regimen A) Increases pepsin activity B) Decreases gastrin secretion C) Prevents metabolic alkalosis D) Protects gastric mucosa from stomach acid Ans:D Feedback: Health care providers use bismuth subsalicylate to coat ulcers, protecting them from stomach acid to treat H. pylori. Bismuth does not increase pepsin activity, decrease gastrin secretion, or prevent metabolic alkalosis.

4. A patient is in the intensive care unit and being administered ranitidine (Zanta C) parenterally. How long will it take for ranitidine (Zanta C) to reach peak blood levels A) 15 minutes B) 30 minutes C) 1 hour D) 2 hours Ans:A Feedback: Parenteral ranitidine reaches peak blood level in 15 minutes. Parenteral ranitidine reaches its peak prior to 30 minutes, 1 hour, and 2 hours.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

5. The nurse practitioner instructs the patient to use over-the-counter ranitidine (Zanta C) instead of cimetidine (Tagamet). What risk is decreased when using ranitidine rather than cimetidine A) Headache B) Drug-to-drug interaction C) Diarrhea D) Bradycardia Ans:B Feedback: Unlike cimetidine, ranitidine (Zanta C), famotidine (Pepcid, Pepcid RP D), and nizatidine (Axi D) do not affect the cytochrome P450 drug-metabolizing system in the liver and therefore do not interfere with the metabolism of other drugs. Use of these other drugs may be preferable in patients who are critically ill because they often require numerous other drugs with which cimetidine may interact.

6. A patient is taking cimetidine (Tagamet) for increased gastric pain and hypersecretion.

Nurses should use extreme caution when administering cimetidine to patients with which of the following conditions A) Hepatic disease B) Cancer C) Hypertension D) Diabetes mellitus Ans:A Feedback: No absolute contraindications exist, but cimetidine should be used cautiously in patients with impaired hepatic and renal function. The patient with cancer, hypertension, and diabetes mellitus can take cimetidine safely.

7. A male patient is taking cimetidine (Tagamet). Which adverse effect is more likely to occur with cimetidine than with other histamine2 receptor antagonists A) Hypoxia B) Hypertension C) Gynecomastia D) Seizures Ans:C Feedback: Gynecomastia is an adverse effect that is more likely to occur with cimetidine than with other histamine2 antagonists. Hypoxia, hypertension, and seizures are not adverse effects of cimetidine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

8. A patient is prescribed a proton pump inhibitor to treat erosive gastritis. How soon will the patient's symptoms most likely be abolished A) 1 to 2 weeks B) 4 weeks C) 1 month D) 6 weeks Ans:A Feedback: The symptoms of gastroesophageal reflux disease will be abolished in 1 to 2 weeks after the start of the proton pump inhibitor medication regime. It will not take 4 weeks, 1 month, or 6 weeks to see a change with the proton pump inhibitor.

9. A 23-year-old female patient is prescribed misoprostol (Cytote C). Which of the following patient teaching interventions is most important A) Supplement therapy with magnesium antacids B) Report postmenopausal bleeding C) Use effective contraceptive measures D) Administer the drug one time per day Ans:C Feedback: Misoprostol (Cytote C) is used to prevent NSAID gastric ulcer development. The medication can cause spontaneous abortion; thus, the medication should be administered with a good form of birth control. It should not be administered with magnesium antacids. It is not necessary for a patient aged 23 years to report postmenopausal bleeding. The medication should be administered two to four times per day.

10. A 62-year-old man is surprised to learn that his recurrent indigestion has been attributed to a new diagnosis of peptic ulcer disease. The patient states, “I've never been a really anxious type of person, so I never thought I'd develop ulcers.” The nurse has responded with health education addressing the etiology of peptic ulcer disease. What causative factors should the nurse cite?

Select all that apply

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Physiologic or psychological stress B) Diabetes mellitus C) Cigarette smoking D) Infections E) Nonsteroidal anti-inflammatory drugs Ans:A, C, D, E Feedback: There are multiple etiologic factors implicated in PUD. These include smoking, H. pylori infection, NSAID use, and stress. Diabetes is not an identified cause.

11. A critically ill patient is being treated in a burn unit following a workplace accident. The patient's current treatment includes an intragastric drip of an antacid through a nasogastric tube.

How should the critical care nurse most accurately titrate the dose and frequency of administration A) By assessing the pH of a 24-hour urine sample B) By aspirating stomach contents and measuring the pH C) By measuring the pH of urine after each void D) By swabbing the patient's buccal mucosa and testing for pH daily Ans:B Feedback: For patients with a nasogastric tube in place, antacid dosage may be titrated by aspirating stomach contents, determining pH, and then basing the dose on the pH. Accurate measurement of gastric pH cannot be determined from the buccal mucosa or urine.

12. An adult patient has been taking Titralac (Tums) on an increasingly frequent basis. When teaching this patient, the nurse should include suggestions for the prevention of which of the following adverse effects A) Constipation B) Urinary frequency C) Fatty stools D) Nausea Ans:A Feedback: With the antacid Titralac (Tums), which contains calcium, it is important to observe for constipation. Combining this antacid with other antacids containing magnesium may prevent this effect. Frequency, fatty stools, and nausea are not noted adverse effects.

13. A patient who has been experiencing heartburn has begun taking OTC ranitidine (Zanta

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C). The nurse who is working with this patient should be aware that this drug achieves a therapeutic effect by which of the following means A) Raising the pH of gastric secretions B) Inhibiting the secretion of gastric acid C) Binding to proton pumps D) Decreasing gastric motility Ans:B Feedback: The histamine2 receptor antagonists (H2RAs) inhibit both basal secretion of gastric acid and the secretion stimulated by histamine, acetylcholine, and gastrin. These drugs, such as ranitidine, do not change the pH of secretions, bind to the proton pumps, or decrease gastric motility.

14. A patient has sought care for follow-up to his recent diagnosis of peptic ulcer disease. The patient states that he has achieved adequate symptom relief with the use of OTC antacids but has asked the nurse about the optimal schedule for taking these drugs. What should the nurse recommend A) Taking the drugs at the earliest appearance of symptoms B) Immediately prior to each meal and at bedtime C) Every 4 hours during all waking hours D) One hour and three hours after each meal and at bedtime Ans:D Feedback: For treatment of peptic ulcer disease, patients should take antacids 1 and 3 hours after meals and at bedtime (four to seven doses daily), 1 to 2 hours before or after other medications.

15. A patient has been prescribed omeprazole by her primary care provider. When questioned by the nurse about her perceived effectiveness of the drug, the patient states, “I think it's working quite well, and I've gotten in the routine of taking it every morning before breakfast.” How should the nurse respond A) “That's good, but remember that you shouldn't take it on days when you're not having any symptoms.”

B) “I'm glad it's working for you, but you'll probably find it works even better if you take it after eating.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) “That's great. If you find later that it's not working as well, you might want to try taking it at bedtime.”

D) “I'm glad to hear that. It sounds like you're taking it exactly like it should be taken.”

Ans:D Feedback: It is important that omeprazole be administered before food intake. Once-daily dosing is typical. The drug is not taken solely as a response to acute symptoms.

16. A patient with a complex medical history states that his primary care provider has changed his proton pump inhibitor from omeprazole (Prilose C) to esomeprazole (Nexium). The patient is unsure of the rationale for this change in medication and has raised this question with the nurse. What rationale is most plausible A) Nexium has fewer adverse effects B) Nexium can be used long term C) Nexium has fewer drug interactions D) Nexium can be taken on an outpatient basis Ans:C Feedback: The actions and pharmacokinetics of the other PPIs—esomeprazole (Nexium), lansoprazole (Prevaci D), pantoprazole (Protonix), and rabeprazole (AcipHex)—are similar to those of omeprazole.

However, the drug interactions associated with omeprazole reportedly do not occur with these other PPIs. 17. A patient who has a diagnosis of peptic ulcer disease has begun taking sucralfate (Carafate).

The nurse should caution the patient against the concurrent use of A) antacids B) NSAIDs C) acetaminophen D) probiotics Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Antacids decrease the effects of sucralfate, and people should not take them within 30 minutes before or after administration of sucralfate.

18. A patient with ulcers has asked the nurse if it would be acceptable for him to take bismuth subsalicylate. Before recommending an OTC formulation of this drug, the nurse should assess the patient's A) immunization history B) allergy status C) cognition D) normal bowel pattern Ans:B Feedback: Because it is a salicylate, this drug can cause serious bleeding problems when used alone in patients with ulcers. People with an allergy to aspirin or other salicylates should not take bismuth subsalicylate. The patient's bowel pattern, immunization history, and cognition are not central considerations.

Chapter 38 Drug Therapy for Nausea and Vomiting 1. A patient is experiencing nausea and vomiting as a response to radiation therapy. Which of the following antiemetic agents is a phenothiazine administered to control nausea and vomiting A) Prochlorperazine (Compazine) B) Metoclopramide (Reglan) C) Mesna (Mesnex) D) Dexamethasone Ans:A Feedback: Prochlorperazine (Compazine) is a commonly used phenothiazine administered for nausea and vomiting related to radiation therapy Metoclopramide is a prokinetic agent that increases GI motility and the rate of gastric emptying by increasing the release of acetylcholine from nerve endings in the GI tract. Mesna is used for thrombocytopenia Dexamethasone is a corticosteroid.

2. A pregnant woman suffers from morning sickness. Which of the following should be considered a first-line treatment

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Vitamin B6 B) Promethazine (Phenergan) C) Vitamin E D) Diphenhydramine (Benadryl) Ans:A Feedback: For pregnant women, taking pyridoxine (vitamin B6) 30 to 75 mg daily in three divided doses with or without the antihistamine doxylamine 12.5 mg every 8 hours as needed is considered a first-line treatment option that is safe and effective. Phenergan is not a first-line treatment for morning sickness. Benadryl and vitamin E are not used to treat nausea.

3. A patient with Parkinson's disease develops nausea and vomiting. Promethazine may be contraindicated because it depletes levels of what neurotransmitter A) Acetylcholine B) Serotonin C) Dopamine D) Adenosine Ans:C Feedback: Promethazine and other phenothiazines have widespread effects on the body. The therapeutic effects in nausea and vomiting are attributed to their ability to block dopamine from receptor sites in the brain and CTZ. This blockage of dopamine has the potential to exacerbate parkinsonian effects.

4. What is a nonpharmacological measure that is effective in treating nausea and vomiting in pregnant women A) Ginkgo biloba B) Ginger C) Garlic D) Ginseng Ans:B Feedback: Clinical trials indicate that ginger can effectively reduce nausea and vomiting associated with motion sickness, pregnancy, and surgery.

5. A patient is administered promethazine (Phenergan) for nausea and vomiting. Which of the following is an adverse effect of promethazine (Phenergan) A) Urinary incontinence B) Tachycardia C) Taste alteration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Extrapyramidal symptoms Ans:D Feedback: Extrapyramidal symptoms are adverse effects of promethazine. Urinary retention is an adverse effect, not urinary incontinence Tachycardia is not an adverse effect of promethazine. Taste alteration is not an adverse effect of promethazine.

6. A patient is administered an antihistamine for nausea. Which of the following is an adverse effect of this classification of medication A) Diarrhea B) Prolonged QRS complex C) Urinary retention D) Inverted T wave Ans:C Feedback: Adverse anticholinergic effects of antihistamines are dizziness, confusion, dry mouth, and urinary retention. Diarrhea, prolonged QRS complex, and inverted T wave are not adverse effects of antihistamines.

7. A patient is administered a phenothiazine for nausea and vomiting. What is the action of phenothiazine A) Increases gastric motility B) Antagonizes dopamine receptors C) Blocks histamine receptors D) Antagonizes serotonin receptors Ans:B Feedback: Phenothiazines act on the CTZ and vomiting center by blocking dopamine. They do not increase gastric motility. Phenothiazines do not block histamine receptors. Phenothiazines do not antagonize serotonin receptors.

8. A patient has been administered hydroxyzine for the treatment of nausea. Which of the following statements indicates that she has understood the teaching provided by the nurse A) “I will take repeated doses of this medication until my nausea resolves.”

B) “I may experience drowsiness with this medication.”

C) “I should eat before I take this medication.”

D) “I will need to take potassium with this medication.”

Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Hydroxyzine will produce drowsiness in the patient. Repeated doses are unsafe. The patient should not eat with nausea. The patient does not need to take potassium with hydroxyzine.

9. A pediatric patient is receiving chemotherapy. What is the recommended treatment of nausea and vomiting with pediatric chemotherapy agents A) Corticosteroids and 5-HT3 receptor antagonists B) Phenothiazines and benzodiazepines C) Proton pump inhibitors and antacids D) Prokinetic agents and antihistamines Ans:A Feedback: 5-HT3 receptor antagonists and corticosteroids are used to treat nausea and vomiting in pediatric oncology patients.

10. A 1-year-old postoperative patient has been experiencing repeated vomiting. What antiemetic drug has a black box warning against use in a patient of this age A) Promethazine (Phenergan) B) Benzquinamide (Emete-Con) C) Buclizine (Bucladin-S) D) Cyclizine (Marezine) Ans:A Feedback: A black box warning alerts nurses that promethazine is contraindicated in children younger than 2 years of age because of the risk of potentially fatal respiratory depression.

Benzquinamide, buclizine, and cyclizine do not have such warnings.

11. An adult patient is administered hydroxyzine for nausea. What adverse effect is most likely with this medication A) Thrombocytopenia B) Palpitations C) Hypertonic muscle tone D) Dry mouth Ans:D Feedback: Anticholinergic effects, including dry mouth, can result from the use of hydroxyzine.

This drug is not associated with thrombocytopenia, palpitations, or hypertonicity.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. An 85-year-old patient is administered dimenhydrinate (Dramamine). Which of the following is the priority nursing intervention A) Encourage fluids with this patient B) Have the patient void after administration C) Maintain IV access D) Protect from injury Ans:D Feedback: Dimenhydrinate (Dramamine) causes drowsiness, especially in older adults, and therefore should be used cautiously. The nurse should protect the patient from injury. The nurse should not force fluids. The patient will not require IV access unless fluid replacement is ordered.

13. A patient is administered promethazine. The patient has an elevated creatinine level Which of the following is important when administering promethazine to this patient A) Administer the routine dose B) Administer a lower dose C) Administer a higher dose D) Hold the medication Ans:B Feedback: A dose reduction may be necessary in patients with renal impairment to avoid the possibility of adverse effects, toxicity, or increased sensitivity to phenothiazines A patient who is scheduled to begin

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. An adult hospital patient has been experiencing intractable nausea and vomiting for several hours, so the nurse has obtained an order for an antiemetic from the primary care provider. The order reads: “Promethazine 25 mg sub-Q every 6 hours PRN.” The nurse should contact the care provider to question what aspect of this order A) The drug B) The dose C) The route D) The frequency Ans:C Feedback: A black box warning alerts nurses that promethazine is contraindicated for subcutaneous administration. The other parameters of the order are within recommendations.

16. An older adult's physician has recommended the occasional use of hydroxyzine for relief of nausea. Following administration, the nurse should assess the patient for A) pruritus B) drowsiness C) urinary frequency

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) bradycardia Ans:B Feedback: The use of hydroxyzine is associated with drowsiness. Antihistamines do not typically cause pruritus, frequency, or bradycardia.

17. A patient has been admitted to the postsurgical unit from postanesthetic recovery following a transurethral prostatic resection. The patient is experiencing nausea subsequent to anesthesia.

What antiemetic is the most common first-line drug for the treatment of postoperative nausea and vomiting A) Ondansetron (Zofran) B) Dronabinol (Marinol) C) Dimenhydrinate (Dramamine) D) Hydroxyzine (Vistaril, Atarax) Ans:A Feedback: The 5-HT3 receptor antagonists are usually considered drugs of first choice for postoperative nausea and vomiting Ondansetron (Zofran) is the prototype of the 5-HT3 receptor antagonists

18. A patient is undergoing a course of radiotherapy for the treatment of leukemia. Treatments in the past have caused the patient severe nausea and vomiting. The oncology nurse should normally administer antiemetics on what schedule A) Simultaneous with radiation treatment B) The night before a scheduled radiation treatment C) 30 to 60 minutes before the treatment D) 10 to 15 minutes before the treatment Ans:C Feedback: The nurse should normally administer antiemetic drugs 30 to 60 minutes before a nausea-producing event, when possible.

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19. When reviewing a newly admitted patient's previous medication record, the nurse notes that the patient has previously been treated with aprepitant (Emen D). The nurse is justified is suspecting that this patient's medical history includes which of the following A) Placement of a nasogastric tube B) Chemotherapy C) Endoscopy D) Radiation therapy Ans:B Feedback: Prescribers often order aprepitant as part of combination therapy along with a 5-HT3 receptor antagonist and corticosteroids to treat both acute and delayed nausea and vomiting associated with chemotherapy. NG tube insertion, radiation therapy, and endoscopy are not typical indications for the use of aprepitant.

20. A hospital patient has a standing order for aprepitant on an as-needed basis. The patient should be encouraged to request a dose of the drug A) when she anticipates that she will become nauseous B) at the same time each day C) as soon as she senses the onset of nausea D) when her nausea results in vomiting Ans:A Feedback: The nurse instructs patients to take aprepitant as prescribed before the onset of nausea and vomiting. It does not need to be taken on a regular schedule and should not be withheld until the onset or peak of symptoms.

Chapter 39 Drug Therapy for Constipation and Elimination Problems 1. Defecation is normally stimulated by what physiologic trigger A) Movements and reflexes in the gastrointestinal tract B) Stimulation from the medulla oblongata C) Synthesis and release of digestive enzymes D) Changes in the osmolarity of bowel contents Ans:A Feedback: Defecation is normally stimulated by movements and reflexes in the gastrointestinal tract. It does not result from changes in osmolarity, CNS stimulation, or the release of enzymes.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

2. Constipation is defined as A) the passage of fewer than three stools in any 7-day period B) the passage of fewer than five stools in any 7- day period C) the infrequent and painful expulsion of hard, dry stools D) a subjective sensation of bowel fullness Ans:C Feedback: Constipation is the infrequent and painful expulsion of hard, dry stools. It is not defined by a particular number of stools or in terms of an individual's subjective sensation.

3. A patient is using psyllium hydrophilic mucilloid (Metamucil) to promote evacuation of stool.

What is the action of this medication A) It reduces the surface tension of bowel contents B) It irritates the intestinal mucosa, thus increasing intestinal motility C) It increases mass and water content of stool, promoting evacuation D) It creates a barrier between the colon wall and feces Ans:C Feedback: Bulk-forming laxatives increase mass and water content of the stool, promoting evacuation. Bulk-forming laxatives do not reduce surface tension of bowel contents. Bulkforming laxatives do not irritate the intestinal mucosa to increase intestinal motility. Bulkforming laxatives do not create a barrier between the colon wall and feces.

4. Which of the following statements by your patient leads you to believe that he has understood how to safely and effectively use bulk-forming laxatives A) “I will mix the medication with around a cup of fluid and then drink the mixture.”

B) “I will mix the dry medication with applesauce and then eat prunes before bedtime.”

C) “I will use milk of magnesia in conjunction with Metamucil until I have a bowel movement.”

D) “I will decrease the roughage in my diet while I am taking the bulk-forming laxative and eat rice.”

Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Bulk-forming laxatives increase mass and water content of the stool, promoting evacuation. Mixing the bulk-forming laxative with applesauce will not provide the needed fluid, and the applesauce can have a binding effect. It is not necessary to mix milk of magnesia with Metamucil. The patient should not decrease roughage in the diet or eat rice, which is binding.

5. Your patient is taking psyllium hydrophilic mucilloid (Metamucil) daily. What information should be included in the discharge plan A) Drink at least 8 ounces of fluid with the medication B) Mix the medication with your food at the evening meal C) Combine all of your medications with the mucilloid D) Discontinue the mucilloid if you do not have a bowel movement daily Ans:A Feedback: Bulk-forming laxatives increase mass and water content of the stool, promoting evacuation. The patient should drink at least 8 ounces of fluid with the medication. The patient should not mix the medication with food or other medications. The mucilloid should not be discontinued if the patient does not have a bowel movement.

6. When assessing a patient's bowel habits, which of the following descriptions is the best indication of normal bowel elimination A) One bowel movement daily in the AM B) One bowel movement daily in the PM C) Soft, formed stool D) Liquid stool Ans:C Feedback: Normal bowel elimination should produce soft, formed stool. One bowel movement in the AM or PM may not be a regular bowel pattern for all patients. Liquid stool is not an indication of normal bowel elimination.

7. A patient is suffering from constipation. He is a truck driver and does not always have access to a toilet. When providing patient teaching, what will result when the patient fails to respond to the defecation reflex A) Involuntary evacuation B) Increased defecation reflex C) Decreased defecation reflex

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Diarrhea Ans:C Feedback: In people who often inhibit the defecation reflex or fail to respond to the urge to defecate, constipation develops as the reflex weakens. The patient will not have involuntary evacuation. The patient will not have increased sensory stimulation. The patient will not have diarrhea.

8. The nurse has an order to administer a saline cathartic to a patient who has a history of congestive heart failure. Why is this type of cathartic contraindicated with this patient A) The patient is at risk for hypomagnesemia B) The patient is at risk for excess fluid volume C) The patient is at risk for third spacing D) The patient is at risk for hyperphosphatemia Ans:B Feedback: Patients with congestive heart failure are at risk for fluid retention and edema with sodium-containing laxatives. The patient is not at risk for hypomagnesemia, hypochloremia, or hyperphosphatemia 9. A patient is scheduled for a colonoscopy in the morning. Which laxative is most likely prescribed the evening before the colonoscopy A) Psyllium (Metamucil) B) Polyethylene glycol–electrolyte solution (NuLYTELY) C) Castor oil D) Lactulose (Cephula C) Ans:B Feedback: Polyethylene glycol–electrolyte solution (NuLYTELY) is a nonabsorbable oral solution that induces diarrhea within 30 to 37 minutes and rapidly evacuates the bowel, usually within 4 hours for a colonoscopy. Psyllium is not strong enough for a colonoscopy preparation.

Castor oil is not the most commonly prescribed preparation for a colonoscopy. Lactulose is normally used only when the serum ammonium level is elevated.

10. A patient is administered a stimulant cathartic. Which of the following is the most common adverse effect of a stimulant cathartic A) Nausea

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Vomiting C) Diarrhea D) Rectal bleeding Ans:C Feedback: The stimulant cathartics are the strongest and most abused laxative products. These drugs act by irritating the GI mucosa and pulling water into the bowel lumen. As a result, feces are moved through the bowel too rapidly to allow colonic absorption of fecal water, so a watery stool is eliminated. Nausea, vomiting, and rectal bleeding should not routinely occur

11. A patient with alcoholism and chronic liver failure is admitted to the medical unit. He is confused and has an elevated serum ammonia level. What laxative will the nurse administer to lower the serum ammonia level A) Docusate sodium (Colace) B) Polyethylene glycol–electrolyte solution (NuLYTELY) C) Lactulose (Cephula C) D) Sorbitol Ans:C Feedback: Lactulose decreases production of ammonia in the intestine. Lactulose is a disaccharide that is not absorbed from the GI tract. It is used to treat hepatic encephalopathy Docusate sodium only provides stool softening and has no effect on serum ammonia levels.

Polyethylene glycol– electrolyte solution (NuLYTELY) is not used to decrease serum ammonia.

Sorbitol is not used to decrease serum ammonia.

12. An older adult's constipation has not responded to first-line laxatives, so lactulose has been prescribed. The nurse should know that this medication achieves a therapeutic effect by which of the following means A) Decreasing the viscosity of intestinal contents in the duodenum B) Pulling water into the intestinal lumen by osmotic pressure C) Irritating the intestinal mucous membrane D) Relaxing the muscle tone of the ileocecal valve and anal sphincter Ans:B Feedback: Lactulose (Chronulac, Cephula C) is a disaccharide that is not absorbed from the GI tract. It exerts laxative effects by pulling water into the intestinal lumen. It does not change muscle tone, change the viscosity of bowel contents, or irritate the intestinal epithelium

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

13. A hospice patient is receiving opioids for treatment of cancer pain. Which laxative will best assist in the prevention of constipation A) Lactulose (Cephula C) B) Stimulant C) Saline D) Bulk-forming Ans:B Feedback: Stimulant laxatives are the most commonly used laxative with these patients.

Lactulose is not usually recommended. Saline laxatives are not recommended due to electrolyte imbalance. Bulk-forming laxatives are not usually recommended for patients with cancer because they may not be able to drink adequate amounts of fluid required with these medications.

14. You are the nurse educating new parents on prevention and treatment of constipation with infants. What is the most effective and safest way to treat constipation in infants prior to bowel training A) Milk of magnesia B) Sorbitol C) Dulcolax suppositories D) Glycerin suppositories Ans:D Feedback: Glycerin suppositories are often effective in infants and children. Milk of magnesia, sorbitol, and Dulcolax suppositories are not recommended.

15. Which of the following patients is at highest risk for alteration in bowel elimination A) A patient who is paralyzed from a spinal cord injury B) A patient who has a diagnosis of type 2 diabetes C) A patient who has hypertension D) A patient who takes thyroid replacements Ans:A Feedback: Spinal lesions can often result in constipation. Thyroid replacements, high blood pressure, and hypertension are not risk factors for constipation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

16. A middle-aged patient is frustrated by her increasingly frequent episodes of constipation.

She tells the nurse that she is highly reluctant to take medications. What nonpharmacologic measure should the nurse recommend A) Adoption of a low-fat diet B) Use of a fiber supplement C) Daily consumption of 6 to 8 L of fluids D) Use of a ginger or ginseng supplement Ans:B Feedback: There is some evidence that fiber supplements improve the frequency and consistency of stools. No effectiveness data support increasing fluids beyond normal intake. Low fat intake, ginger, and ginseng are not noted to benefit patients with constipation.

17. An older adult has told the nurse practitioner that she has regularly drunk mineral oil to treat occasional episodes of constipation. The nurse should encourage the patient to explore other treatments because the use of oral mineral oil can result in A) edema from changes in intestinal solute content B) paralytic ileus C) rebound constipation D) decreased absorption of drugs and vitamins Ans:D Feedback: Oral use of mineral oil may cause potentially serious adverse effects, including decreased absorption of fat-soluble vitamins and some drugs and lipid pneumonia if aspirated into the lungs. Thus, mineral oil is not an oral laxative of choice in any condition. It is not noted to cause rebound constipation, paralytic ileus, or edema.

18. A surgical patient's postoperative orders include the twice-daily administration of docusate sodium. The patient is concerned about developing diarrhea from this medication, so the nurse has begun patient education. What should the nurse teach the patient about docusate sodium A) “This medication will soften your stools over the next couple of days.”

B) “You'll usually have a bowel movement within 2 to 3 hours of taking this.”

C) “This medication will cause your bowels to contract more strongly than they normally do.”

D) “This drug will help you pass regular stools while you're in the hospital, but you should not take it for more than 5 days.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Surfactant laxatives (e.g., docusate calcium or docusate sodium) decrease the surface tension of the fecal mass to allow water to penetrate into the stool. They also act as a detergent to facilitate admixing of fat and water in the stool. As a result, stools are softer and easier to expel.

These agents have little, if any, laxative effect. Their main value is to prevent straining while expelling stool. They usually act within 1 to 3 days and should be taken daily

19. A community health is conducting a health promotion session with a group from a local seniors' center. The nurse has addressed the issue of laxative overuse in this population. The nurse should highlight what consequence of the overuse of laxatives A) Dependence B) Impaired absorption of water-soluble vitamins C) Fecal incontinence D) Abdominal pain Ans:A Feedback: Overuse of laxatives results in dependence. This is a significant problem among older adults and is more common than fecal incontinence, impaired vitamin absorption, or abdominal pain.

20. An adult resident of an assisted living facility has not responded appreciably to bulk- forming laxatives so the primary care provider has prescribed bisacodyl. The nurse who oversees the care at the facility should know that this drug may be administered by what routes? Select all that apply A) Oral B) Intravenous C) Subcutaneous injection D) Suppository E) Intramuscular injection Ans:A, D Feedback: Bisacodyl can be administered orally or by suppository. Parenteral administration is not possible.

Chapter 40 Drug Therapy for Diarrhea 1. A patient with anorexia nervosa has taken a saline cathartic to lose weight. What is the patient at risk for

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Constipation B) Diarrhea C) Bowel obstruction D) Hyponatremia Ans:B Feedback: A patient who uses laxatives, such as saline laxatives, and suffers from anorexia nervosa will be prone to diarrhea. The patient who takes a saline laxative will not suffer from constipation. The patient who takes a saline laxative will not be at risk for bowel obstruction.

The patient who takes a saline cathartic will be at risk for hypernatremia, not hyponatremia.

2. A grade school has an outbreak of gastroenteritis and vomiting with nearly half of the school—both students and staff— affected. Which organism is most likely the cause A) Norwalk-like virus (calicivirus) B) Clostridium difficile C) Vibrio vulnificus D) E. coli Ans:A Feedback: An outbreak of gastroenteritis that is accompanied by vomiting and that affects both staff and students is most predominately caused by the Norwalk-like virus (calicivirus).

Clostridium difficile is a nosocomial diarrhea that would not be characteristic of this population.

Vibrio vulnificus is contamination of raw shellfish and would not be the cause of gastroenteritis E. coli is a less likely cause.

3. A cancer patient has intractable diarrhea that is not of an infectious nature. Which of the following medications will most likely be prescribed A) Bismuth B) Pepto-Bismol C) Psyllium D) Opioids Ans:D Feedback: Opioids are the most effective agents for symptomatic treatment of diarrhea. Bismuth and Pepto-Bismol are the same agents and would not be used for intractable, severe diarrhea.

Psyllium would not be administered for diarrhea, except if there were a need to absorb toxins.

4. An older adult patient is experiencing diarrhea. Which of the following is a likely cause of diarrhea A) Fluid volume deficit

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Antihypertensive agents C) Laxative abuse D) Anemia Ans:C Feedback: Laxative abuse is associated with diarrhea. This phenomenon is particularly common among older adults. Antihypertensive agents and anemia are not associated with diarrhea. Fluid volume deficit is a result, not cause, of diarrhea.

5. The physician orders bismuth subsalicylate (Pepto-Bismol) for your patient. What assessment is most important to make before administering this medication A) Assess for pain B) Assess electrolytes C) Assess for allergy to aspirin D) Assess for allergy to opioids Ans:C Feedback: Bismuth salts have antibacterial and antiviral activity. Bismuth subsalicylate contains salicylate, and the patient should be assessed for an aspirin allergy before administration. It is important to assess for pain and electrolyte balance, but this is not the primary assessment to be made. The nurse would not need to assess for allergy to opioids because bismuth does not contain opioids.

6. A patient diagnosed with HIV/AIDS has diarrhea that is not responding to antidiarrheal agents. Which medication will best assist in treating this patient's diarrhea A) Bismuth salts (Pepto-Bismol) B) Ciprofloxacin (Cipro) C) Cholestyramine (Questran) D) Octreotide acetate (Sandostatin) Ans:D Feedback: Octreotide acetate (Sandostatin) is a synthetic form of somatostatin that is effective in diarrhea related to HIV/AIDS. Bismuth salts are not used for diarrhea that does not respond to other agents. Ciprofloxacin will not be used to treat diarrhea. Cholestyramine will not be used to treat diarrhea.

7. A patient who has been experiencing liquid stools is prescribed polycarbophil (FiberCon).

What is the reason for administering a bulk- forming laxative A) Polycarbophil absorbs large amounts of water and decreases fluidity of stools

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Polycarbophil will diminish the absorption of intestinal fiber and water C) Polycarbophil will provide pain relief and decrease cramping and bloating D) Polycarbophil will increase bile and diminish bacterial flora in the intestines Ans:A Feedback: Polycarbophil is an adsorbent drug that works by absorbing large amounts of water and produces stools of gelatin-like consistency Polycarbophil will not diminish the absorption of intestinal fiber and water. Polycarbophil will cause abdominal discomfort and bloating. Polycarbophil has no effect on bacterial flora in the intestines.

8. A patient with Crohn's disease is experiencing diarrhea during an exacerbation of symptoms.

What medication will the nurse most likely administer A) Bismuth salts (Pepto-Bismol) B) Ciprofloxacin (Cipro) C) Cholestyramine (Questran) D) Octreotide acetate (Sandostatin) Ans:C Feedback: Bile-binding drugs, such as cholestyramine (Questran) or colestipol, are useful in treating diarrheas due to bile salt accumulation in conditions such as Crohn's disease. Bismuth salts, ciprofloxacin, and octreotide are not typically administered to the patient with Crohn's disease.

9. A 20-month-old child is experiencing diarrhea. When planning the child's care, the nurse should prioritize assessments related to what health problem A) Electrolyte deficiencies B) Anorectal bleeding C) Anal fissures D) Nausea Ans:A Feedback: If severe or prolonged, acute diarrhea may lead to serious fluid and electrolyte depletion, especially in young children and older adults 10. A patient is discharged with octreotide (Sandostatin) and has been given minimal patient teaching. What is the most important aspect of patient teaching for this patient A) The importance of maintaining a diet high in fiber B) The administration of subcutaneous injections

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) The concurrent use of bismuth subsalicylate and octreotide D) The administration of morphine to decrease pain Ans:B Feedback: If octreotide is taken at home, the home care nurse may need to teach the patient or a caregiver how to administer subcutaneous injections; this drug is not available orally. The patient should limit the intake of fiber. The patient would not be administered bismuth subsalicylate with octreotide. The patient would not be administered morphine to decrease pain related to diarrhea.

11. A woman is seen in the primary care provider's office with chronic severe diarrheapredominant irritable bowel syndrome, which has not responded to conventional therapy Which medication should the nurse anticipate administering A) Rifaximin (Xifaxan) B) Nitazoxanide (Alini A) C) Alosetron (Lotronex) D) Cholestyramine (Questran) Ans:C Feedback: Alosetron (Lotronex) is a selective 5-HT3 receptor antagonist indicated for treating women with chronic severe diarrhea- predominant irritable bowel syndrome that has not responded to conventional therapy. Rifaximin (Xifaxan) is a nonsystemic antibiotic that would not be prescribed for this patient. Nitazoxanide (Alini A) is an antiprotozoal agent used for Giardia lamblia. Cholestyramine (Questran) is a bilebinding drug and is not the drug of choice for this patient.

12. A patient has been treated successfully for diarrhea and has had only one loose bowel movement during the day. Which of the following foods should be introduced back into the diet first A) Chicken breast B) Beef stew C) Baked potato D) Lentils Ans:C Feedback: Following diarrhea, bland foods should be introduced back into the diet, such as baked potato. The patient should not resume a diet with chicken, beef stew, or lentils until later.

13. A patient is experiencing diarrhea and being treated with diphenoxylate (Lomotil). The presence of which condition requires that diphenoxylate (Lomotil) be administered cautiously

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Edema B) Hepatorenal disease C) Congestive heart failure D) Cardiovascular insufficiency Ans:B Feedback: Diphenoxylate should be used with extreme caution in patients with severe hepatorenal disease because hepatic coma may be precipitated. Edema, congestive heart failure, and cardiovascular insufficiency are not conditions in which cautious administration with diphenoxylate is needed.

14. A middle-aged female has presented to the emergency department (E D) after 36 hours of severe diarrhea that shows no sign of abating. The patient's family members are asking that the care team provide medications to resolve her diarrhea. The ED nurse should be aware that the use of diphenoxylate (Lomotil) would be contraindicated in which of the following circumstances A) The patient has a documented history of laxative abuse B) The patient's diarrhea is caused by the ingestion of toxins C) The patient's diarrhea is attributable to psychosocial stress D) The patient has an allergy to aspirin Ans:B Feedback: Contraindications to the use of diphenoxylate with atropine include diarrhea caused by toxic materials, microorganisms that penetrate intestinal mucosa (e.g., pathogenic E. coli, Salmonella, Shigell A), and antibiotic- associated colitis. Laxative abuse, allergies to aspirin, and the presence of stress do not contraindicate the safe use of Lomotil.

15. An older adult patient has received his third dose of diphenoxylate (Lomotil) and the nurse is monitoring the patient's bowel patterns closely. In addition to monitoring the number and consistency of the patient's stools, the nurse should prioritize what assessment A) Assessment of cognition and neurological status B) Assessment of oxygen saturation and respiratory rate C) Assessment of nutritional status D) Assessment of fluid and electrolyte balance

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: After drug administration, the nurse monitors the number and consistency of stools and fluid and electrolyte balance. The patient's fluid and electrolyte balance is more vulnerable during prolonged diarrhea than neurological, nutritional, or respiratory status.

16. A patient has contacted the clinic, stating to the nurse, “I've been taking Imodium for the past day-and-a-half, and my diarrhea shows no signs of slowing down.” The nurse should respond to the patient in the knowledge that Imodium should be discontinued if her diarrhea does not improve in the next A) 12 hours B) 2 days C) 3 to 4 days D) week Ans:A Feedback: In general, it is necessary to discontinue loperamide after 48 hours if clinical improvement has not occurred.

17. Which of the following patients with diarrhea would be most likely to be prescribed octreotide (Sandostatin) A) A child who has been diagnosed with E. coli infection B) An older adult who has been abusing laxatives for several months C) A teenage patient who has been diagnosed with ulcerative colitis D) A patient with HIV/AIDS who has developed intractable diarrhea Ans:D Feedback: Diarrhea secondary to HIV/AIDS is an indication for treatment with octreotide.

Laxative abuse, IBS, and E. coli infections would likely be treated with alternative antidiarrheal medications.

18. A patient's severe diarrhea has necessitated treatment with polycarbophil (FiberCon). The nurse should caution the patient about the possibility of what adverse effect A) Nausea and vomiting

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Headache and visual disturbances C) Abdominal fullness and bloating D) Gastroesophageal reflux Ans:C Feedback: Polycarbophil may cause abdominal discomfort and bloating and may reduce the absorption of coadministered medications. It is not noted to cause nausea and vomiting, reflux, or headache.

19. When reviewing a patient's medication history, the nurse observes that the patient has recently completed a course of treatment with nitazoxanide (Alini A). The nurse is justified in suspecting that the patient was infected with what microorganism A) Giardia lamblia B) E. coli C) Salmonella D) Campylobacter jejuni Ans:A Feedback: Nitazoxanide (Alini A) is an antiprotozoal agent used specifically for treating diarrhea resulting from infection with Giardia lamblia or Cryptosporidium parvum. It is not used in the treatment of diarrhea associated with E coli, Salmonella, or Campylobacter jejuni 20. Cholestyramine (Questran) and colestipol (Colesti D) are useful in treating diarrhea due to which of the following causes A) Gram-positive bacterial infection B) Bile salt accumulation C) Retroviruses D) Autoimmune processes Ans:B Feedback: Cholestyramine (Questran) and colestipol (Colesti D) are useful in treating diarrhea due to bile salt accumulation in conditions such as Crohn's disease or surgical excision of the ileum.

Chapter 41 Drug Therapy for Diabetes Mellitus 1. A patient with a diagnosis of diabetes is prescribed pramlintide (Symlin). How will this drug assist in controlling the patient's blood sugar A) It slows gastric emptying B) It blocks the absorption of food

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) It is absorbed by insulin D) It increases the release of insulin Ans:A Feedback: Pramlintide slows gastric emptying, helping to regulate the postprandial rise in blood sugar. Pramlintide does not block the absorption of food. Pramlintide is not absorbed by insulin.

Pramlintide does not increase the release of insulin.

2. A patient is diagnosed with type 1 diabetes What distinguishing characteristic is associated with type 1 diabetes A) Blood glucose levels can be controlled by diet B) Exogenous insulin is required for life C) Oral agents can control blood sugar D) The disease always starts in childhood Ans:B Feedback: Type 1 diabetes will result in eventual destruction of beta cells, and no insulin is produced. The blood glucose level can only be controlled by diet in type 2 diabetes. In type 2 diabetes, oral agents can be administered. Type 1 diabetes is diagnosed at many ages, not only in childhood.

3. A patient is in diabetic ketoacidosis. The patient blood glucose level is over 600 mg/ dL. The physician has ordered the patient to receive an initial dose of 25 units of insulin intravenously.

What type of insulin will most likely be administered A) NPH insulin B) Lente insulin C) Ultralente insulin D) Regular insulin Ans:D Feedback: Regular insulin has rapid onset of action and can be given via IV. It is the drug of choice for acute situations, such as diabetic ketoacidosis. Isophane insulin (NPH) is used for long-term insulin therapy. Lente insulin is an intermediate-acting insulin. Ultralente insulin is a long-acting insulin.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

4. During a teaching session on the care of the diabetic patient, a family member asks why her daughter has a different insulin than her best friend. The nurse should make which of the following statements to explain the differences in insulin A) “Insulin is prescribed based on the insurer's criteria for reimbursement.”

B) “Insulin is prescribed based on the patient's age.”

C) “Insulins have different onsets and durations of action.”

D) “Insulin type is matched with the appropriate oral hypoglycemic agent.”

Ans:C Feedback: When insulin therapy is indicated, the physician may choose from several preparations that vary in composition, onset, duration of action, and other characteristics. Insulin is not prescribed based solely on cost. Insulin is not prescribed based solely on the patient's age.

Insulin is not usually matched with oral hypoglycemic agents.

5. A patient asks the nurse why a quick-acting sugar given by mouth is better in the regulation of insulin than the use of intravenous glucose for a low blood sugar. Which of the following statements by the nurse represents the most appropriate response to this question A) “The ingestion of food allows the digestive tract to stimulate vagal activity and the release of incretins.”

B) “The combination of insulin and food will yield a higher blood sugar than intravenous glucose.”

C) “Both food and intravenous glucose will produce changes similarly in the gastrointestinal tract to increase blood sugar.”

D) “You are mistaken. The intravenous glucose yields a higher blood glucose through the release of incretins.”

Ans:A Feedback: Oral glucose is more effective than intravenous glucose because glucose or food in the digestive tract stimulates vagal activity and induces the release of gastrointestinal hormones called incretins. The combination of insulin and food does not yield a higher blood glucose than intravenous insulin. Food stimulates the vagal nerve activity, but intravenous glucose does not. A statement that indicates that the patient is mistaken will belittle the patient and should be rephrased 6. with diabetes since age 14 states he has pain in his feet and hands. What is this pain most likely a result of A) A diabetes-related infectious process B) Peripheral neuropathy C) An autoimmune disorder D) Hypertension resulting from diabetes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Pain in the feet and hands is related to changes in small blood vessels resulting in neuropathy. The long-term effect of diabetes can result in an infectious process, but the pain described is not indicative of an infection. Latent autoimmune diabetes of the adult has an onset in adulthood and thus is not a long-term disorder. Hypertension is a long- term chronic effect of diabetes but is not what has been described with pain in the feet and hands.

7. A patient is to be administered glipizide (Glucotrol). Which of the following factors would contraindicate the administration of glipizide (Glucotrol) to this patient A) A diagnosis of hypertension B) The ingestion of carbohydrates C) Allergy to sulfonamides D) Increase in alkaline phosphatase Ans:C Feedback: Sulfonylureas are contraindicated in patients with hypersensitivity to them, with severe renal or hepatic impairment, and who are pregnant. A diagnosis of hypertension does not cause contraindication of sulfonylureas. The patient should consume carbohydrates in association with the oral hypoglycemic agent. An increase in alkaline phosphatase does not result in the contraindication of glipizide (Glucotrol) 8. A patient has been prescribed acarbose (Precose). What is the advantage of acarbose over alternative drugs A) It can replace the use of insulin B) The patient does not have to limit food intake C) It delays the digestion of complex carbohydrates D) It prevents alkalosis Ans:C Feedback: Acarbose delays the digestion of complex carbohydrates into glucose and other simple sugars. Acarbose may be combined with insulin or an oral agent, usually a sulfonylurea.

The patient will still need to remain on a diabetic dietary regime. The drug does not directly prevent acid–base imbalances.

9. A patient who regularly takes metformin has developed a severe infection. How will the infection change his diabetic regimen A) Metformin is contraindicated in the presence of an infection

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Metformin will be given more frequently to decrease blood sugar C) Metformin will result in better regulation of blood sugar D) Metformin will allow the patient to decrease the absorption of glucose Ans:A Feedback: Metformin is contraindicated in patients with diabetes complicated by fever, severe infections, severe trauma, major surgery, acidosis, and pregnancy. Metformin will not be given more frequently to decrease blood sugar. Metformin should be discontinued and is not administered for better regulation of blood sugar. Metformin will not decrease the absorption of glucose in this patient 10. Sitagliptin (Januvi A) is prescribed for a patient who has been diagnosed with type 2 diabetes. What is the action of sitagliptin (Januvi A) A) It blocks the S phase of the cell cycle B) It slows the rate of inactivation of the incretin hormones C) It is a synthetically prepared monosodium salt D) It inhibits hydrogen, potassium, and ATPase Ans:B Feedback: Sitagliptin (Januvi A) minimizes the rate of inactivation of the incretin hormones to increase hormone levels and prolong their activity. Sitagliptin does not block the S phase of the cell cycle. Sitagliptin is not a synthetically prepared monosodium salt Sitagliptin does not inhibit hydrogen, potassium, and ATPase.

11. A patient of Italian descent has been prescribed antidiabetic medications. Heavy intake of which of the following herbs should be avoided by this patient A) Garlic B) Anise C) Basil D) Oregano Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Garlic has been known to cause hypoglycemia when taken with antidiabetic medications. Anise, basil, and oregano are not noted to carry this risk.

12. A patient has suffered from hypoglycemia twice in the past week. She states she eats one meal per day and snacks the rest of the day What patient education will you provide for this patient A) She should limit her alcohol with meals B) She should increase her caloric intake C) She should increase her protein intake during snacks D) She should not eat at sporadic times Ans:D Feedback: A regular dietary intake associated with the administration of insulin or oral hypoglycemic will prevent episodes of hypoglycemia. The patient should limit her alcohol consumption, but alcohol consumption does not contribute to hypoglycemia. The patient should not necessarily increase her caloric or protein intake. The patient should coordinate her exercise with her dietary intake, but dietary intake is not the cause of her hypoglycemia.

13. An 8-month-old infant is admitted to the pediatric floor of the community hospital with a new diagnosis of diabetes. The patient is to receive 1 unit of regular insulin subcutaneously. How will that 1 unit be administered A) It is administered orally B) It is administered as U-5 C) It is administered with a TB syringe D) It is administered as U-10 Ans:D Feedback: An infant should receive the dosage in a dilution strength of U-10. It is not administered orally, as U-5, or in a TB syringe.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

14. A patient in his mid-30s has received a diagnosis of type 2 diabetes. Following his diagnosis, he has been meeting with a nurse regularly as well as performing extensive online research.

Which of the patient's statements should prompt the nurse to perform further teaching A) “I don't like getting this diagnosis, but I know that treatment now can prevent future health consequences.”

B) “I'm disappointed, but I take some solace in the fact that I won't ever have to have insulin injections.”

C) “People always tried to encourage me to lose weight, and I suppose they might have been right.”

D) “From what I've learned, I know that the basic problem is that my pancreas can't keep up with my insulin needs.”

Ans:B Feedback: Among people with type 2 diabetes, 20 to 30 require exogenous insulin at some point in their lives. Obesity is a major cause, and vigilant treatment can prevent future sequelae. The essence of type 2 diabetes is the pancreas' inability to meet insulin needs.

15. A nurse educator is explaining the pathophysiology of diabetes to a newly diagnosed patient.

The patient does not understand why she had a “constant, insatiable thirst” in the months preceding her diagnosis. What phenomenon should the nurse describe A) “The excess glucose in your blood accumulates in your blood vessels and neurons, including the neurons that control thirst.”

B) “Excess glucose pulled more water through your kidneys and the increased urination caused thirst.”

C) “Increased thirst is your body's attempt to dilute your blood because it contains too much glucose.”

D) “When your body cells are starved for useful glucose, they signal your body to increase food and fluid intake.”

Ans:B Feedback: When large amounts of glucose are present, water is pulled into the renal tubule.

This results in a greatly increased urine output (polyuri A). The excessive loss of fluid in urine leads to increased thirst (polydipsi A). Glucose does not directly affect the thirst center.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

16. A hospital patient with a diagnosis of type 1 diabetes is ordered Humulin R on a sliding scale. Based on the patient's blood glucose reading, the nurse administered 8 units of insulin at 07:45. The nurse recognizes the need to follow up this intervention and will reassess the patient's blood glucose level when the insulin reaches peak efficacy. The nurse should consequently check the patient's blood glucose level at what time A) 08:15 B) Between 08:45 and 09:45 C) Between 09:45 and 10:45 D) Between 11:15 and 11:45 Ans:C Feedback: Humulin R peaks between 2 and 3 hours after administration.

17. A patient's medication administration record specifies that the patient is to receive 20 units of NPH insulin at 08:00. Before administering this medication, the nurse must do which of the following A) Massage the chosen injection site B) Assess the patient's understanding of diabetes C) Assess the patient's urine for the presence of glucose D) Have a colleague confirm the dosage Ans:D Feedback: Before administering insulin, patient safety requires that two nurses always check the dosage. Assessing the patient's understanding of the disease may or may not be appropriate or necessary at this time. Injection sites are not massaged before administration. It is not necessary to assess urine for the presence of glucose.

18. A hospital patient is to receive 4 units of regular insulin prior to lunch. The nurse knows that the lunch trays are usually distributed at approximately 12:15. The nurse should plan to administer the patient's insulin at what time A) 12:15 B) 12:10 C) 11:45 D) 11:15 Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: With regular insulin before meals, it is very important that the medication be injected 30 to 45 minutes before meals so that the insulin is available when blood sugar increases after meals.

19. A patient will soon begin treatment for diabetes using glyburide. Which of the following conditions must be met in order for treatment to be effective A) The patient must have functioning pancreatic beta cells B) The patient must have hemoglobin A1C of

7

C) The patient must not have hyperglycemia D) The patient must be able to self-administer the medication Ans:A Feedback: Because glyburide stimulates pancreatic beta cells to produce more insulin, it is effective only when functioning pancreatic beta cells are present. The presence of normal blood glucose levels would render the medication unnecessary. Self-administration is common but not absolutely necessary.

20. A 69-year-old woman has been taking metformin for the treatment of type 2 diabetes for several years. Which of the following changes in the woman's laboratory values may demonstrate a need to discontinue the medication A) A decrease in hemoglobin and hematocrit B) A decrease in glomerular filtration rate C) A decrease in potassium accompanied by an increase in sodium D) An increase in white blood cells Ans:B Feedback: It is essential to discontinue metformin if renal impairment occurs. The other listed changes in laboratory values do not necessarily indicate that metformin should be discontinued.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 42 Drug Therapy for Hyperthyroidism and Hypothyroidism 1. A child is born with cretinism. What element was lacking in the mother's diet during pregnancy A) Potassium B) Iodine C) Sodium D) Magnesium Ans:B Feedback: Cretinism is uncommon in the United States but may occur with a lack of iodine in the mother's diet. A lack of potassium, sodium, and magnesium in the mother's diet will not cause cretinism

2. A patient suffers from hyponatremia, hypoglycemia, and lactic acidosis. What condition is most consistent with this clinical presentation A) Myxedema coma B) Psychotic depression C) Cretinism D) Congenital hypothyroidism Ans:A Feedback: Myxedema coma is severe, life-threatening hypothyroidism characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders, such as hyponatremia, hypoglycemia, and lactic acidosis.

3. A woman is started on propylthiouracil (PTU). What is the primary mode of action for propylthiouracil A) Destroys part of the thyroid gland B) Inhibits production of thyroid hormone C) Suppresses the anterior pituitary hormones D) Stimulates the thyroid cells Ans:B Feedback: The thioamide drugs inhibit synthesis of thyroid hormone. Iodine preparations inhibit the release of thyroid hormones and cause them to be stored within the thyroid gland.

Propylthiouracil does not destroy part of the thyroid gland. Propylthiouracil does not suppress the anterior pituitary hormones

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Propylthiouracil does not sedate the central nervous system or suppress the cardiac output.

4. A patient with hypothyroidism is started on levothyroxine (Synthroi D). What should the patient be taught regarding medication administration in the home setting A) Take medication with milk or food B) Do not exercise with the medication C) Take the medication on an empty stomach D) Levothyroxine has a short half-life Ans:C Feedback: Levothyroxine (Synthroi D) should be taken on an empty stomach to increase absorption. The medication should not be taken with food Exercise has no effect on the administration of the medication. Levothyroxine has a long half-life of about 6 to 7 days.

5. A 5-year-old child is diagnosed with hypothyroidism. What will the patient likely develop if the condition is left untreated A) Mental retardation B) Renal dysfunction C) An immune disorder D) Paralytic ileus Ans:A Feedback: If cretinism is untreated until the child is several months old, permanent mental retardation is likely to result. The patient will not suffer from renal dysfunction, an immune disorder, or paralytic ileus.

6. A patient has been diagnosed with myxedema. She currently takes ibuprofen (Motrin) for knee pain. For what is this patient at increased risk A) Nephrotoxicity B) Pulmonary congestion C) Tachycardia D) Apnea Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A patient diagnosed with myxedema cannot metabolize and excrete drugs, so she is at an increased risk of developing nephrotoxicity. Pulmonary congestion, tachycardia, and apnea are not adverse effects related to myxedema or the administration of ibuprofen (Motrin).

7. A patient is scheduled for a thyroidectomy to treat thyroid cancer. What is the medication of choice administered preoperatively A) Sodium iodide 131 (Iodotope) I B) Methimazole (Tapazole) C) Propylthiouracil (PTU) D) Propranolol (Inderal) Ans:C Feedback: Propylthiouracil (PTU) is administered preoperatively for thyroidectomy. Sodium 131 iodide(Iodotope) is a radioactive iodide that is used to destroy thyroid tissue. Methimazole (Tapazole) is similar to PTU but is not the drug of choice preoperatively Propranolol (Inderal) is used to treat cardiovascular conditions, such as hypertension. It is not used in the preoperative phase of thyroidectomy.

8. A patient is to receive a medication that the nurse recognizes as an expectorant that is normally administered for the treatment of hyperthyroidism. Which medication will be administered A) Propylthiouracil (PTU) B) Methimazole (Tapazole) C) Saturated solution of potassium iodide (SSKI) D) Sodium iodide131 (Iodotope) I Ans:C Feedback: Saturated solution of potassium iodide (SSKI) is more often used as an expectorant but may be given as a preparation for thyroidectomy. Propylthiouracil (PTU) is not administered as an expectorant. Methimazole (Tapazole) is not administered as an expectorant. Sodium iodide 131 (Iodotope) is not administered as I an expectorant.

9. A patient has been diagnosed with hyperthyroidism. She is scheduled to receive a medication to destroy the thyroid gland Which medication will be administered A) Propylthiouracil (PTU) B) Methimazole (Tapazole) C) Saturated solution of potassium iodide (SSKI) D) Sodium iodide 131 (Iodotope) I

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Sodium iodide 131 (Iodotope) is a I radioactive isotope of iodine. Therapeutic doses act by emitting beta and gamma rays, which destroy thyroid tissue and thereby decrease the production of thyroid hormones. Propylthiouracil (PTU) is not administered to destroy thyroid tissue. Methimazole (Tapazole) is not administered to destroy thyroid tissue. Saturated solution of potassium iodide (SSKI) is not administered to destroy thyroid tissue.

10. A patient is being administered propranolol (Inderal) to treat hypertension related to hyperthyroidism. Which condition will warrant the tapering and discontinuation of the propranolol (Inderal) A) Hyperthyroidism B) Hypertension C) Angina pectoris D) Euthyroid state Ans:D Feedback: When the patient becomes euthyroid and hyperthyroid symptoms are controlled by definitive treatment measures, propranolol should be tapered and discontinued Hyperthyroidism, hypertension, and angina pectoris all warrant the administration of propranolol (Inderal).

11. A patient is started on levothyroxine (Synthroi D) for treatment of hypothyroidism. During patient teaching, how frequently can the dosage be increased until symptoms are relieved A) Every 3 to 5 days B) Weekly C) Every 2 weeks D) Monthly Ans:C Feedback: Dosage is influenced by the choice of drug. As a general rule, initial dosage is relatively small. Dosage is gradually increased at approximately 2-week intervals until symptoms are relieved. The dosage is not increased in 3 to 5 days. The dosage is not increased in 1 week.

The dosage is not increased monthly.

12. A patient is being treated for hypothyroidism and has developed symptoms of adrenal insufficiency. What medication will be added to the patient's medication regimen A) Anti-infective agent B) Corticosteroid agent C) Nonsteroidal anti-inflammatory agent

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Antiadrenergic agent Ans:B Feedback: When hypothyroidism and adrenal insufficiency coexist, the adrenal insufficiency should be treated with a corticosteroid drug before starting thyroid replacement. Anti- infective agents, nonsteroidal anti- inflammatory agents, or antiadrenergic agents are not administered for adrenal insufficiency.

13. A patient has been diagnosed with hypothyroidism and admits to the nurse that she has heard of her thyroid gland but does not know the function of thyroid hormone. The nurse should explain the fact that thyroid hormone is responsible for A) regulating the levels of most other hormones in the body B) stimulating the brain and sex organs C) controlling the rate of cell metabolism throughout the body D) regulating levels of glucose in the blood and body tissues Ans:C Feedback: Thyroid hormones control the rate of cellular metabolism and thus influence the functioning of virtually every cell in the body. The heart, skeletal muscle, liver, and kidneys are especially responsive to the stimulating effects of thyroid hormones. The brain, spleen, and gonads are less responsive Thyroid hormone does not primarily influence glucose levels or the function of the endocrine system.

14. Following the completion of diagnostic testing, an adult patient has received a diagnosis of hyperthyroidism. What nursing diagnosis should the nurse prioritize in this patient's care A) Risk for hypothermia related to hyperthyroidism B) Constipation related to hyperthyroidism C) Risk for imbalanced nutrition: less than body requirements related to hyperthyroidism D) Anxiety related to hyperthyroidism Ans:D Feedback: Anxiety is characteristic of a hyperthyroid state. Constipation, cold intolerance, and loss of appetite are associated with hypothyroidism.

15. A 55-year-old female patient was successfully treated for thyroid storm earlier in the year. In subsequent health education, the nurse should caution the patient against excessive intake of what foods

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Seafood and kelp B) Leafy green vegetables and beef C) Purine-rich foods D) Red wine and aged cheeses Ans:A Feedback: Iodine is associated with thyroid storm and is present in foods (especially seafood and kelp) and in radiographic contrast dyes. Reports of iodine-induced hyperthyroidism have been reported after ingestion of dietary sources of iodine.

16. Laboratory testing reveals that a patient is in a severely hyperthyroid state and propylthiouracil (PTU) has been prescribed When providing health education related to this drug, what should the nurse teach the patient A) “You'll need to take these pills every 8 hours.”

B) “I'm going to show you how to perform your daily injection.”

C) “At first, you'll come to the outpatient clinic for your IV infusion once per day.”

D) “It's best to inject PTU into your abdomen rather than your arm.”

Ans:A Feedback: PTU is well absorbed with oral administration. Because the half-life in the thyroid is relatively short, PTU must be given every 8 hours.

17. A patient is scheduled to begin a drug regimen for the treatment of hyperthyroidism. Prior to administering propylthiouracil (PTU), the nurse has reviewed the relevant black box warning and should teach the patient about the need for what form of follow-up A) Serial complete blood counts B) Routine liver function testing C) Daily nonfasting blood glucose testing D) Chest radiographs every 3 months Ans:B Feedback: The FDA has issued a black box warning for PTU stating that severe liver injury resulting in death or acute liver failure may occur within 6 months of treatment. All patients should receive instructions about the signs and symptoms of acute liver failure. Routine liver function testing to assess for liver failure is important. There is no specific need for chest radiographs, CBCs, or glucose monitoring.

18. A nurse who provides care at a long-term care facility is preparing to administer a resident's scheduled dose of levothyroxine (Synthroi D). What assessment should the nurse perform prior to administration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Level of consciousness and orientation B) Oxygen saturation level C) Heart rate D) Respiratory rate Ans:C Feedback: Regular monitoring of blood pressure and pulse is essential in older adults receiving Synthroid. As a general rule, levothyroxine should not be given if the resting heart rate is more than 100 beats per minute.

19. A home care nurse observes that a client's supply of Synthroid has run out in less than half the time that it should have. What assessment findings would be most consistent with overuse of Synthroid A) Constipation and abdominal distention B) Hyperactivity and insomnia C) Bradycardia and hypotension D) Joint pain and decreased mobility Ans:B Feedback: Adverse effects of levothyroxine include signs and symptoms of hyperthyroidism.

Other more serious adverse effects are tachycardia, cardiac dysrhythmias, angina pectoris, myocardial infarction, and heart failure. Nervousness, hyperactivity, insomnia, diarrhea, abdominal cramps, nausea, vomiting, weight loss, fever, and an intolerance to heat have also been reported Bradycardia and constipation are associated with hypothyroidism.

20. An older adult patient has been using levothyroxine (Synthroi D) for several years on an outpatient basis. The patient has recently sought care, with complaints that are consistent with hypothyroidism. To which of the patient's following statements may the nurse attribute the decreased effect of Synthroid A) “I've been using a lot of antacids lately because of my indigestion.”

B) “My daughter and I have started the Atkin's diet to try to lose some weight.”

C) “Overall, I'd say that I'm under a lot of stress lately.”

D) “I've stopped taking aspirin for my arthritis and started using Tylenol.”

Ans:A Feedback: Antacids may decrease the effect of levothyroxine. Acetaminophen, stress, and high protein intake do not have this effect.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 43 Drug Therapy for Pituitary and Hypothalamic Dysfunction 1. A patient is scheduled for an exploratory surgery for cancer. What will cause the release of adrenocorticotropic hormone in response to this patient's psychological and physiological stress A) Growth hormone release–inhibiting hormone (Somatostatin) B) Corticotropin-releasing hormone or factor (CRH or CRF) C) Growth hormone–releasing hormone (GHRH) D) Thyrotropin-releasing hormone (TRH) Ans:B Feedback: Corticotropin-releasing hormone or factor (CRH or CRF) causes release of corticotropin (adrenocorticotropic hormone) in response to stress and threatening stimuli.

Growth hormone release–inhibiting hormone (somatostatin) inhibits release of growth hormone.

Growth hormone–releasing hormone causes the release of growth hormone in response to low blood levels of GH. Thyrotropin-releasing hormone causes the release of TSH in response to stress, such as cold.

2. A patient has had surgery. After the surgical procedure, the patient starts to shiver and chill.

What hormone will be released in response to the reaction to cold A) Thyroid-stimulating hormone B) Luteinizing hormone C) Corticotropin D) Somatostatin Ans:A Feedback: Thyroid-stimulating hormone is released in response to stress, such as exposure to cold. Luteinizing hormone is released in response to gonadotropin-releasing hormone Corticotropin stimulates the adrenal cortex to produce corticosteroids. Somatostatin inhibits the release of growth hormone.

3. A patient is suspected of having Cushing's disease. What hormone is used in the diagnosis of this disorder A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Corticotropin-releasing hormone can be used in the diagnosis of Cushing's disease.

Growth hormone is released in response to low blood levels of growth hormone. Corticotropinreleasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

4. A young man has begun weight training. Which hormone will be released in response to the increase in the size and number of muscle cells A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:A Feedback: Growth hormone stimulates the growth of body tissues, including growth of muscle cells. Corticotropin-releasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

5. An adult is diagnosed with an increased low- density lipoprotein cholesterol level. What hormone level may be low based on this diagnosis A) Adrenocorticotropic hormone (ACTH) B) Oxytocin C) Growth hormone D) Somatostatin Ans:C Feedback: In adults, deficient growth hormone can cause increased fat, reduced skeletal and heart muscle mass, reduced strength, reduced ability to exercise, and worsened cholesterol levels (increased low-density lipoprotein cholesterol). Adrenocorticotropic hormone, oxytocin, and somatostatin do not affect low- density lipoprotein.

6. When teaching young women about the hormones of reproduction, the nurse explains how the follicle matures and ruptures in ovulation. Which hormone is needed for this change A) Luteinizing hormone (LH) B) Thyrotropin (TSH) C) Follicle-stimulating hormone (FSH) D) Leydig's cells Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: LH is important in the maturation and rupture of the ovarian follicle. TSH regulates the secretion of thyroid hormones. FSH stimulates the functions of sex glands Leydig's cells are stimulated by LH in men to secrete androgens.

7. A patient has been involved in a motor vehicle accident. Which hormone will be released in response to his blood loss A) Luteinizing hormone (LH) B) Antidiuretic hormone (ADH) C) Oxytocin D) Melanocyte-stimulating hormone Ans:B Feedback: Antidiuretic hormone is also called vasopressin and is released in response to blood loss. Luteinizing hormone is important in ovulation. Oxytocin functions in childbirth and lactation. Melanocyte-stimulating hormone plays a role in skin pigmentation.

8. A patient has been diagnosed with acromegaly. Which of the following medications may be ordered to treat this endocrine disorder A) Gonadorelin hydrochloride (Factrel) B) Octreotide (Sandostatin) C) Nafarelin (Synarel) D) Gonadorelin acetate (Lutrepulse) Ans:B Feedback: Prescribers order octreotide for patients with acromegaly to reduce levels of GH. Gonadorelin hydrochloride, nafarelin, and gonadorelin acetate are not administered to treat acromegaly.

9. A patient is suspected of having adrenal insufficiency. Which hormone may be administered to diagnose Addison's disease A) Corticotropin (ACTH) B) Somatotropin (Humatrope) C) Octreotide (Sandostatin) D) Leuprolide (Lupron) Ans:A Feedback: Corticotropin (ACTH) is sometimes used as a diagnostic test to differentiate primary adrenal insufficiency (Addison's disease) Somatotropin is therapeutically equivalent to endogenous growth hormone. Octreotide (Sandostatin) is used for acromegaly

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Leuprolide causes a decrease in testosterone and estrogen.

10. A patient is diagnosed with infertility. What medication may the nurse administer for the treatment of infertility A) Thyrotropin alfa (Thyrogen) B) Pegvisomant (Somavert) C) Menotropins (Pergonal) D) Somatotropin (Humatrope) Ans:C Feedback: Menotropins (Pergonal) is administered in combination with HCG to induce ovulation. Thyrotropin alfa (Thyrogen) is a synthetic formulation of TSH used as a diagnostic adjunct for serum thyroglobulin. Pegvisomant (Somavert) is a growth hormone receptor antagonist used in the treatment of acromegaly in adults. Somatotropin (Humatrope) is administered to children for impaired growth.

11. An adolescent is being treated with growth hormone. When assessing for potential adverse effects, what assessment should the nurse prioritize A) Deep tendon reflexes B) Level of anxiety C) Respiratory rate D) Blood glucose Ans:D Feedback: Somatropin decreases insulin sensitivity, resulting in hyperglycemia. Patients most at risk for increased insulin sensitivity are those with obesity, Turner's syndrome, or a family history of diabetes mellitus. Growth hormone can cause anxiety, but is not a priority assessment in this case. The respiratory rate is not the most important objective assessment in this case.

12. An adult patient has been diagnosed with a posterior pituitary lesion that has resulted in diabetes insipidus. The characteristic sign of this health problem is A) blood glucose levels 400 mg/dL B) copious urine production C) hyperglycemia that is unresponsive to exogenous insulin D) hematuria Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Characteristic features of DM include polyuria, with excretion of dilute urine ranging from 4 L to as much as 30 L. Hematuria does not normally occur, and blood glucose levels are not directly affected.

13. A patient with a traumatic head injury and a diagnosis of diabetes insipidus is being treated with intravenous vasopressin (Pitressin). What change in the patient's status would prompt the immediate cessation of the drug infusion A) Infiltration at the IV site B) A sudden decrease in urine output C) The appearance of blood in the patient's urine D) A rapid increase in blood glucose Ans:A Feedback: When administering vasopressin intravenously, it is essential to use extreme caution due to the risk of extravasation of the medication, leading to tissue necrosis Decreased urine output is a goal of treatment Blood in the urine and changes in blood glucose levels are atypical events.

14. Somatropin has been prescribed for a child who has been diagnosed with growth hormone deficiency. When providing health education to the child's parents, what teaching point should then nurse prioritize A) The correct technique for daily injections of the drug B) The importance of regular blood pressure monitoring C) The rationale for not crushing the extended- release tablet D) The need to limit the child's activity level for the duration of treatment Ans:A Feedback: Somatropin is administered by daily injections. Blood pressure monitoring and activity limitations are not necessary.

15. A girl who is 7 1/2 years old has received a diagnosis of precocious puberty from the pediatric endocrinologist. The nurse who collaborates with this physician should anticipate the administration of what drug A) Menotropins (Pergonal) B) Thyrotropin alfa (Thyrogen) C) Cosyntropin (Cortrosyn D) Leuprolide acetate (Lupron) Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Leuprolide is useful for the treatment of central precocious puberty in children.

Menotropins (Pergonal) stimulates ovulation. Cosyntropin (Cortrosyn) stimulates the adrenal cortex to synthesize and secrete adrenocortical hormones. Thyrotropin alfa (Thyrogen) stimulates the secretion of thyroglobulin.

16. A 13-year-old boy who is in the first percentile of height for his age has been referred for care. Which of the following assessment findings would contraindicate the safe and effective use of somatropin to treat his growth deficiency A) The boy has not yet begun puberty B) The boy has low serum albumin levels C) The epiphyses of the boy's long bones have closed D) The sutures of the boy's skull have not yet fully closed Ans:C Feedback: Somatropin is ineffective when impaired growth is present after puberty, when the epiphyses of the long bones have closed. Low albumin is not a contraindication to the use of somatropin. The sutures of the skull close early in life.

17. A patient's current drug regimen includes intranasal administration of desmopressin acetate (DDAVP, Stimate). In this patient's plan of nursing care, what is the most likely desired outcome of treatment A) The patient's urine output will not exceed 80 mL/h B) The patient will gain 2 cm in height over the next 6 months C) The patient will ovulate at least once over the next 8 weeks D) The patient's vertical growth will cease in the next 4 weeks Ans:A Feedback: Desmopressin acetate (DDAVP, Stimate) is the prototype posterior pituitary hormone medication. It is used to treat diabetes insipidus. Consequently, reduced urine output is the primary goal of treatment. The drug does not influence growth or ovulation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse reviews the current medication administration record of a patient who has recently been prescribed octreotide. The nurse performs this important safety action in order to prevent drug interactions that could result in A) increased growth B) anaphylaxis C) cardiac complications D) respiratory arrest Ans:C Feedback: Numerous medications combine with octreotide to result in a prolonged QT interval with an increased risk of ventricular dysrhythmia and cardiac arrest. Increased growth, anaphylaxis, and respiratory arrest are not noted adverse effects or the result of drug interactions with octreotide.

19. A child has been referred to a pediatric endocrinologist and has begun treatment with octreotide acetate. What nursing diagnosis should be noted in the child's plan of nursing care A) Delayed growth and development B) Excess fluid volume C) Risk for deficient fluid volume D) Altered growth and development Ans:D Feedback: Acromegaly is the major clinical indication for the use octreotide. In this condition, growth is excessive, not delayed. Fluid volume is not directly affected

20. A patient who is being cared for in the intensive care unit (ICU) is receiving desmopressin.

In light of the black box warning that accompanies this drug, the ICU nurse should prioritize the assessment of which of the patient's laboratory values A) Hematocrit B) Platelets C) Sodium D) Calcium Ans:C Feedback: The FDA has issued a black box warning stating that patients taking desmopressin can develop hyponatremia, leading to seizures. Consequently, assessment of sodium levels takes precedence over hematocrit, calcium, and platelet levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 44 Drug Therapy to Regulate Calcium and Bone Metabolism 1. An elderly patient has been diagnosed with Paget's disease. Which serum electrolyte is altered in this disease process A) Sodium B) Potassium C) Chloride D) Calcium Ans:D Feedback: Disorders of calcium and bone metabolism include hypocalcemia, hypercalcemia, osteoporosis, Paget's disease, and bone breakdown associated with breast cancer and multiple myeloma. Sodium, potassium, and chloride alterations are not primarily associated with Paget's disease 2. A patient has been diagnosed with hyperplasia of the parathyroid gland. Which of the following alterations in blood values will you expect to observe A) Hypercalcemia B) Hypoparathyroidism C) Hyperthyroidism D) Hypocalcemia Ans:A Feedback: Hyperparathyroidism is most often caused by a tumor or hyperplasia of a parathyroid gland. Hypoparathyroidism, hyperthyroidism, and hypothyroidism are not associated with hyperplasia of the parathyroid gland. Clinical manifestations and treatment of hyperparathyroidism are the same as those of hypercalcemia.

3. When a patient has an increased serum level of ionized calcium, which hormone will be released A) Insulin B) Estrogen C) PTH D) Calcitonin Ans:D Feedback: Calcitonin is a hormone from the thyroid gland whose secretion is controlled by the concentration of ionized calcium in the blood flowing through the thyroid gland. When the serum level of ionized calcium is increased, secretion of calcitonin is increased. The serum level of calcium will not affect the release of insulin or estrogen. PTH is a response to low calcium levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

4. A patient has a decreased calcium level. Which of the following will participate in raising the patient's calcium level A) Vitamin D B) Vitamin C C) Ferrous sulfate D) Vitamin B12 Ans:A Feedback: Vitamin D is a fat-soluble vitamin that plays an important role in calcium and bone metabolism. Vitamin C, ferrous sulfate, and vitamin B12 do not play a role in calcium and bone metabolism.

5. A 55-year-old woman is diagnosed with a vitamin D deficit. What disorder results from this deficit A) Chondromalacia B) Chondritis C) Osteomalacia D) Osteopenia Ans:C Feedback: In adults, vitamin D deficiency causes osteomalacia, a condition characterized by decreased bone density and strength Chondromalacia is characterized as a softening of the patella. Chondritis is an inflammation of the cartilage. Osteopenia is a decrease in bone tissue.

6. The nurse is providing health education to an 80-year-old woman who has just been diagnosed with osteoporosis. Which of the following represents an accurate statement when teaching her about this diagnosis A) “Osteoporosis is usually a result of a bone injury.”

B) “Osteoporosis causes a risk for fractures.”

C) “Osteoporosis results from nonmodifiable risk factors.”

D) “Osteoporosis occurs only in women.”

Ans:B Feedback: Osteoporosis results when bone strength is impaired, leading to increased porousness and vulnerability to fracture. Osteoporosis is not a result of fracture. Osteoporosis is partially preventable. Osteoporosis is not limited to the female gender.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient suffers from numbness and tingling around the mouth and has a positive Trousseau's sign after a thyroidectomy. Which of the following medications will be administered A) Parenteral normal saline B) Parenteral potassium chloride C) Parenteral digoxin (Lanoxin) D) Parenteral calcium gluconate Ans:D Feedback: The patient has acute hypocalcemia as evidenced by numbness and tingling around the mouth and a positive Trousseau's sign. An intravenous calcium salt, such as calcium gluconate, is given for acute symptomatic hypocalcemia. Parenteral normal saline may be administered, but it will not increase the calcium level. The administration of potassium chloride parenterally must be diluted and will not affect the calcium level. Parenteral digoxin (Lanoxin) will not be administered.

8. A 75-year-old patient with overall good health is to begin taking vitamin D supplements What is the recommended supplement for her age A) 100 International Units daily B) 200 International Units daily C) 600 International Units daily D) 800 International Units daily Ans:D Feedback: The recommended dietary allowance, or RDA, for vitamin D is 600 International Units for people 1 to 70 years of age and 800 International Units daily for adults 71 years and older to prevent and treat osteoporosis.

9. An older adult patient has been on oral corticosteroids to decrease the symptoms of chronic obstructive pulmonary disease. What is the patient at risk for developing A) Osteoporosis B) Osteoarthritis C) Oat cell carcinoma D) Paget's disease Ans:A Feedback: Drugs used for hypercalcemia, such as corticosteroids, place the patient at risk for developing osteoporosis due to the demineralization of the bone. The patient is not at risk for developing osteoarthritis or oat cell carcinoma. Paget's disease is an inflammatory condition and is not caused by corticosteroid use.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

10. A patient has been prescribed alendronate (Fosamax). Which of the following instructions should the patient be given regarding the administration of this medication A) Take the medication with whole milk B) Take the medication and lie down for 30 minutes C) Take the medication on an empty stomach D) Take the medication to increase bone resorption Ans:C Feedback: Alendronate (Fosamax) must be taken on an empty stomach. Alendronate (Fosamax) should not be taken with milk or food. The patient should be sitting up or ambulatory for 30 minutes after taking the medication. The medication decreases bone resorption, not increases it.

11. A patient has undergone a thyroidectomy in which his parathyroid glands were also inadvertently removed. The patient's morning blood work reveals a serum calcium level of 3.1 mg/dL (normal 8.5 to 10.5 mg/dL). The nurse should consequently assess this patient's A) muscle tone B) level of consciousness C) respiratory rhythm D) respiratory rate Ans:A Feedback: Low calcium levels can result in tetany. Decreased LOC and altered respiratory function are not characteristic of hypocalcemia.

12. A community health nurse is leading a health promotion workshop during a community health fair. A participant has asked the nurse for advice on the necessity of calcium supplements.

The nurse should respond in the knowledge that which of the following demographic groups frequently have low calcium levels? Select all that apply A) Elementary-aged children B) Young women

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Middle-aged men D) Middle-aged women E) Older women Ans:B, E Feedback: Experts believe that the diets of most people of all ages, but especially of young women and older adults, are deficient in calcium

13. An older adult resident of a long-term care facility has been prescribed calcium citrate to address her decreasing bone density. The nurse should review the resident's medication administration record knowing that what medication may decrease the effects of calcium A) Hydrochlorothiazide B) Ibuprofen C) Prednisone D) Diltiazem (Cardizem) Ans:C Feedback: Corticosteroids reduce the effects of calcium by various mechanisms. Thiazide diuretics have the opposite effect. NSAIDs and calcium channel blockers do not appreciably affect the pharmacokinetics of calcium supplements.

14. A patient's low ionized calcium levels have necessitated an infusion of an IV calcium preparation. During the administration of this medication, the nurse should prioritize what assessment A) Oxygen saturation levels B) Cardiac monitoring C) Assessment of cognition D) Assessment for visual changes Ans:B Feedback: Calcium imbalances can result in alterations in heart rate and rhythm; cardiac monitoring is thus necessary. The patient is less likely to experience alterations in respiratory function, cognition, or vision

15. A middle-aged patient is proud of the fact that she is proactive with her health maintenance and tells the nurse that she has been taking 2400 International Units of vitamin D daily, stating,

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

“More is better when it comes to vitamins.” The nurse should provide health teaching to the patient because her current vitamin D intake creates a risk for A) hypercalcemia B) hyperphosphatemia C) hypocalcemia D) tetany Ans:A Feedback: It is important to take vitamin D supplements cautiously and not overuse them; excessive amounts can cause serious problems, including hypercalcemia. Tetany is associated with hypocalcemia. Hypophosphatemia typically accompanies hypercalcemia.

16. A 72-year-old woman has been diagnosed with osteoporosis and has begun taking alendronate (Fosamax). The nurse should be aware that this drug can increase the woman's bone density by which of the following means A) Decreasing renal excretion of calcium B) Increasing the binding of vitamin D to calcium ions C) Suppressing the function of osteoclasts D) Enhancing the function of osteoblasts Ans:C Feedback: Alendronate suppresses osteoclast activity on newly formed resorption surfaces, which reduces bone turnover. This means that bone formation exceeds resorption at remodeling sites, leading to progressive gains in bone mass. Fosamax does not enhance osteoblast function or affect the renal excretion of calcium. It does not influence the chemical interaction between vitamin D and calcium

17. An 80-year-old woman has experienced recent declines in bone density and has consequently been deemed a candidate for treatment with alendronate (Fosamax). During health education, what teaching point should the nurse emphasize A) “Your Fosamax will be most effective if you couple it with an increase in your consumption of dairy products.”

B) “It's important that you not lie down for half an hour after taking your Fosamax.”

C) “Make sure to let your care provider know promptly if you experience bone pain.”

D) “You'll have less stomach upset if you take your Fosamax with some bland food.”

Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The person must remain upright (with head elevated 90 degrees if in bed, sitting upright in a chair, or standing) for at least 30 minutes after administration of Fosamax. It is always necessary to take the drug with a full glass of water, not juice or coffee, at least 30 minutes before breakfast and before taking other drugs. Bone pain is a possible adverse effect, but prevention of esophageal ulceration is a priority. Increased dairy consumption is not vital.

18. A 79-year-old woman has been diagnosed with osteoporosis, and the nurse is reviewing the risks and benefits of Fosamax, which her care provider has prescribed. The patient should be instructed to seek prompt medical attention if she develops which of the following A) Esophageal bleeding B) Fever C) Sudden fatigue D) Musculoskeletal pain Ans:A Feedback: Esophageal erosion and ulcers can result in hemorrhage, which is a medical emergency. Fever, fatigue, and musculoskeletal pain warrant follow-up, but none is an emergency.

19. A patient has been admitted in acute hypercalcemia and has been determined to have a serum calcium level of 12.9 mg/dL. The emergency department nurse's priority intervention is A) administration of IV calcitonin B) administration of IV normal saline C) oxygen supplementation D) subcutaneous administration of exogenous parathyroid hormone (PTH) Ans:B Feedback: Acute hypercalcemia is a medical emergency, and rehydration is a priority; it is essential to administer an IV saline solution. Calcitonin is not administered by the IV route. PTH is not administered exogenously and would exacerbate hypercalcemia.

20. An elderly adult woman has been diagnosed with postmenopausal osteoporosis and has been prescribed calcitonin. The nurse should anticipate administration by what route A) Oral

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Topical C) Intranasal D) Intravenous Ans:C Feedback: Calcitonin can be administered by the intranasal route for the treatment of osteoporosis. It is not given orally, topically, or intravenously.

Chapter 45 Drug Therapy for Addison's Disease and Cushing's Disease 1. days, and she describes herself as feeling “shaky.” Random blood glucose testing reveals a glucose level of 38 mg/dL, but the woman denies any significant change in her diet. The care team should suspect the possibility of what health problem A) Chronic renal failure B) Acute renal failure C) Cushing's disease D) Adrenal insufficiency Ans:D Feedback: Any patient with unexplained severe hypoglycemia requires assessment for adrenal insufficiency. Cushing's disease and kidney disease do not result in hypoglycemia.

2. A patient who has been taking oral prednisone for several months abruptly ceased treatment several days ago on the advice of a family member. The patient has now been admitted to the emergency department with signs and symptoms that are characteristic of addisonian crisis.

When assessing this patient, the nurse should prioritize what assessment A) Assessment of urine for ketones B) Assessment of serum potassium levels C) Assessment for adventitious lung sounds D) Assessment for venous thromboembolism Ans:B Feedback: In addisonian crisis, the loss of sodium leads to retention of potassium, resulting in symptoms of hyperkalemia. As a result, vigilant monitoring of serum potassium levels is more important than respiratory effects, urinalysis, or hypercoagulation

3. A 38-year-old patient has been living with Addison's disease for many years and has achieved adequate symptom control through lifestyle modifications and drug therapy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

However, the patient has now been admitted to the hospital in addisonian crisis. Which of the nurse's following assessment questions is most appropriate A) “Have you been under an unusual amount of stress lately?”

B) “How would you describe your diet over the last few days?”

C) “When was the last time that you drank any alcohol?”

D) “Has your urine output been typical for the past few days?”

Ans:A Feedback: Acute adrenal crisis, or addisonian crisis, is a life-threatening condition that occurs when Addison's disease is the underlying problem and the patient is exposed to minor illness or increased stress. Diet, alcohol use, and impaired urinary function are less likely contributors.

4. A patient's recent symptoms of unexplained fatigue and listlessness have prompted a referral to the endocrinology department. A plasma corticotropin (ACTH) stimulation test for adrenal insufficiency is being performed. Following the administration of ACTH, what finding would confirm the suspected diagnosis A) Low cortisol levels B) Stupor C) Increased levels of CRH D) Signs of Cushing's disease Ans:A Feedback: Confirming the diagnosis of adrenocortical insufficiency requires a short plasma corticotropin (ACTH) stimulation test. The examiner administers corticotropin in the morning, and a subnormal blood cortisol level in the morning and afternoon confirms the diagnosis. CRH is a precursor to ACTH, and would not be directly affected. Cushing's disease is adrenocortical excess, with high cortisol levels.

5. A patient with suspected adrenal insufficiency has been administered 1 mcg of cosyntropin (Cortrosyn) as an IV bolus. Serum testing 30 minutes later reveals a markedly elevated level of cortisol. What conclusion should the nurse infer from this finding A) The patient has normal adrenocortical function B) The patient has primary adrenal insufficiency C) The patient has secondary adrenal insufficiency D) The patient has Addison's disease

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The low-dose test involves the administration of 1 mcg of cosyntropin (Cortrosyn) as an IV bolus. In people with normal adrenocortical function, an increase in cortisol occurs in 20 minutes.

6. A 26-year-old woman's gradual development of a “moon face,” coupled with protracted weight gain, has caused the nurse practitioner to suspect the possibility of Cushing's disease.

When explaining this health problem to the patient, how should the nurse describe it A) “Cushing's disease happens when your pituitary gland doesn't stimulate your other glands enough.”

B) “Cushing's disease is a result of an overproduction of steroid hormones by your kidneys.”

C) “Cushing's disease most often happens when people are taking corticosteroid medications and stop them abruptly.”

D) “Cushing's disease often results from a growth on your kidney that causes inadequate production of steroids.”

Ans:B Feedback: The cause of Cushing's disease is adrenocortical excess. Cessation of exogenous steroids can precipitate addisonian crisis Dysfunction of pituitary gland is an atypical cause. Tumors may cause overproduction, not underproduction, of corticosteroids.

7. A patient with a diagnosis of Cushing's disease has been admitted to the emergency department after taking a fall on the sidewalk outside her apartment building. This patient's underlying disease process creates increased risks of A) hemorrhage and impaired hemostasis B) fractures and impaired wound healing C) neurovascular complications and rhabdomyolysis D) bruising and hematoma Ans:B Feedback: Cushing's disease results in low bone density and impaired wound healing. It does not typically cause impaired hemostasis or neurovascular problems.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

8. The results of a young man's plasma corticotropin (ACTH) stimulation test have confirmed a diagnosis of Addison's disease. The nurse has consequently provided health education around the necessity of hormone replacement therapy. The patient has asked the nurse, “How long am I going to have to take these medications?” How should the nurse best respond A) “You'll need to take these for the rest of your life.”

B) “You'll have to take these until you can pass the corticotropin stimulation test without them.”

C) “You'll have to take these until your kidneys regain their normal level of function.”

D) “You'll need to take these until your symptoms have been stable for at least 6 months.”

Ans:A Feedback: Lifetime hormone replacement is necessary in persons with Addison's disease.

9. A child has received a diagnosis of Addison's disease, and the nurse is providing health education to the child's family around hormone replacement therapy. When planning this child's care, the nurse should know that hormone replacement therapy constitutes a risk for what nursing diagnosis A) Latex allergic response B) Deficient fluid volume C) Delayed growth and development D) Impaired gas exchange Ans:C Feedback: Hydrocortisone may affect growth velocity. It is unlikely to affect allergy response, or respiration. Fluid volume excess, not deficit, is a possibility.

10. Hydrocortisone has been prescribed to a patient for the treatment of Addison's disease, and the patient will soon be discharged. The nurse should encourage the patient to take this medication A) at least 30 minutes before or 2 hours after meals B) at bedtime C) before 9 AM D) with an antacid Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Administration of hydrocortisone should take place every morning before 9 AM. This minimizes HPA suppression. People should take the oral preparation with food to decrease gastric irritation.

11. A patient will soon begin long-term treatment with hydrocortisone after being diagnosed with Addison's disease. In order to mitigate the potentially adverse effect of this treatment regimen, the nurse should encourage the patient to increase her intake of what nutrient A) Water B) Calcium C) Sodium D) Potassium Ans:B Feedback: Due to the potential for reduced bone density, patients should be encouraged to increase calcium intake if hydrocortisone is administered for a prolonged period Increased sodium, potassium, and water intake are not recommended.

12. A patient with a long-standing diagnosis of Addison's disease has been taking hydrocortisone for several years, achieving adequate symptom control. In recent weeks, the patient has experienced profound stress resulting from the collapse of his small business and subsequent conflict with his business partner. How might the presence of these stressors affect the patient's medication regimen A) The patient should take his scheduled hydrocortisone later in the day B) The ratio of mineralocorticoids to glucocorticoids should be adjusted C) The patient's hydrocortisone should be temporarily withheld D) The patient may temporarily require a higher dose of hydrocortisone Ans:D Feedback: During times of increased stress, the dosage of the medication may need to be increased. There would be no need to change the ratio of mineralocorticoids to glucocorticoids or to take the medications later in the day.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

13. A patient with a diagnosis of Addison's disease has had fludrocortisone acetate (Florinef Acetate) added to his medication regimen by his endocrinologist. What is the most plausible rationale for this change in treatment A) The patient's anterior pituitary gland is overstimulated B) The patient requires increased mineralocorticoid supplementation C) The patient's adrenal cortex has become resistant to hydrocortisone D) The patient's GI tract is unable to tolerate hydrocortisone Ans:B Feedback: If a patient with Addison's disease requires additional mineralocorticoid supplementation, then fludrocortisone acetate (Florinef Acetate) may be indicated. Pituitary dysfunction, GI intolerance, and resistance to hydrocortisone are not plausible rationales.

14. A patient with Cushing's disease will soon begin treatment with ketoconazole. When planning the patient's care, the nurse should be cognizant of the black box warning for this drug and consequently monitor what laboratory values A) White blood cell differential B) Blood urea nitrogen and creatinine C) AST, ALT, and GGT D) Hemoglobin, hematocrit, and red blood cell count Ans:C Feedback: The FDA has issued a black box warning stating that ketoconazole can cause hepatotoxicity. As a result, monitoring of liver function may be a priority over assessment of white cells, red cells, and renal function.

15. When assessing for therapeutic effects of mitotane in a patient with adrenocortical carcinoma, the nurse should expect to identify A) a decrease in agitation B) an audible S3 C) a decrease in blood pressure D) a decrease in urine output Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A decrease in blood pressure is an expected therapeutic effect of mitotane. An audible S3 is not expected. Mitotane does not address agitation or high urine output

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 46 Physiology of the Autonomic and Central Nervous Systems and Indications for the Use of Drug Therapy 1. A patient is scheduled for an exploratory surgery for cancer. What will cause the release of adrenocorticotropic hormone in response to this patient's psychological and physiological stress A) Growth hormone release–inhibiting hormone (Somatostatin) B) Corticotropin-releasing hormone or factor (CRH or CRF) C) Growth hormone–releasing hormone (GHRH) D) Thyrotropin-releasing hormone (TRH) Ans:B Feedback: Corticotropin-releasing hormone or factor (CRH or CRF) causes release of corticotropin (adrenocorticotropic hormone) in response to stress and threatening stimuli.

Growth hormone release–inhibiting hormone (somatostatin) inhibits release of growth hormone.

Growth hormone–releasing hormone causes the release of growth hormone in response to low blood levels of GH. Thyrotropin-releasing hormone causes the release of TSH in response to stress, such as cold.

2. A patient has had surgery. After the surgical procedure, the patient starts to shiver and chill.

What hormone will be released in response to the reaction to cold A) Thyroid-stimulating hormone B) Luteinizing hormone C) Corticotropin D) Somatostatin Ans:A Feedback: Thyroid-stimulating hormone is released in response to stress, such as exposure to cold. Luteinizing hormone is released in response to gonadotropin-releasing hormone Corticotropin stimulates the adrenal cortex to produce corticosteroids. Somatostatin inhibits the release of growth hormone.

3. A patient is suspected of having Cushing's disease. What hormone is used in the diagnosis of this disorder A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Corticotropin-releasing hormone can be used in the diagnosis of Cushing's disease.

Growth hormone is released in response to low blood levels of growth hormone. Corticotropinreleasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

4. A young man has begun weight training. Which hormone will be released in response to the increase in the size and number of muscle cells A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:A Feedback: Growth hormone stimulates the growth of body tissues, including growth of muscle cells. Corticotropin-releasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

5. An adult is diagnosed with an increased low- density lipoprotein cholesterol level. What hormone level may be low based on this diagnosis A) Adrenocorticotropic hormone (ACTH) B) Oxytocin C) Growth hormone D) Somatostatin Ans:C Feedback: In adults, deficient growth hormone can cause increased fat, reduced skeletal and heart muscle mass, reduced strength, reduced ability to exercise, and worsened cholesterol levels (increased low-density lipoprotein cholesterol). Adrenocorticotropic hormone, oxytocin, and somatostatin do not affect low- density lipoprotein.

6. When teaching young women about the hormones of reproduction, the nurse explains how the follicle matures and ruptures in ovulation. Which hormone is needed for this change A) Luteinizing hormone (LH) B) Thyrotropin (TSH) C) Follicle-stimulating hormone (FSH) D) Leydig's cells Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: LH is important in the maturation and rupture of the ovarian follicle. TSH regulates the secretion of thyroid hormones. FSH stimulates the functions of sex glands Leydig's cells are stimulated by LH in men to secrete androgens.

7. A patient has been involved in a motor vehicle accident. Which hormone will be released in response to his blood loss A) Luteinizing hormone (LH) B) Antidiuretic hormone (ADH) C) Oxytocin D) Melanocyte-stimulating hormone Ans:B Feedback: Antidiuretic hormone is also called vasopressin and is released in response to blood loss. Luteinizing hormone is important in ovulation. Oxytocin functions in childbirth and lactation. Melanocyte-stimulating hormone plays a role in skin pigmentation

8. A patient has been diagnosed with acromegaly. Which of the following medications may be ordered to treat this endocrine disorder A) Gonadorelin hydrochloride (Factrel) B) Octreotide (Sandostatin) C) Nafarelin (Synarel) D) Gonadorelin acetate (Lutrepulse) Ans:B Feedback: Prescribers order octreotide for patients with acromegaly to reduce levels of GH. Gonadorelin hydrochloride, nafarelin, and gonadorelin acetate are not administered to treat acromegaly.

9. A patient is suspected of having adrenal insufficiency. Which hormone may be administered to diagnose Addison's disease A) Corticotropin (ACTH) B) Somatotropin (Humatrope) C) Octreotide (Sandostatin) D) Leuprolide (Lupron) Ans:A Feedback: Corticotropin (ACTH) is sometimes used as a diagnostic test to differentiate primary adrenal insufficiency (Addison's disease)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Somatotropin is therapeutically equivalent to endogenous growth hormone. Octreotide (Sandostatin) is used for acromegaly Leuprolide causes a decrease in testosterone and estrogen.

10. A patient is diagnosed with infertility. What medication may the nurse administer for the treatment of infertility A) Thyrotropin alfa (Thyrogen) B) Pegvisomant (Somavert) C) Menotropins (Pergonal) D) Somatotropin (Humatrope) Ans:C Feedback: Menotropins (Pergonal) is administered in combination with HCG to induce ovulation. Thyrotropin alfa (Thyrogen) is a synthetic formulation of TSH used as a diagnostic adjunct for serum thyroglobulin. Pegvisomant (Somavert) is a growth hormone receptor antagonist used in the treatment of acromegaly in adults. Somatotropin (Humatrope) is administered to children for impaired growth.

11. An adolescent is being treated with growth hormone. When assessing for potential adverse effects, what assessment should the nurse prioritize A) Deep tendon reflexes B) Level of anxiety C) Respiratory rate D) Blood glucose Ans:D Feedback: Somatropin decreases insulin sensitivity, resulting in hyperglycemia. Patients most at risk for increased insulin sensitivity are those with obesity, Turner's syndrome, or a family history of diabetes mellitus. Growth hormone can cause anxiety, but is not a priority assessment in this case. The respiratory rate is not the most important objective assessment in this case.

12. An adult patient has been diagnosed with a posterior pituitary lesion that has resulted in diabetes insipidus. The characteristic sign of this health problem is A) blood glucose levels 400 mg/dL B) copious urine production C) hyperglycemia that is unresponsive to exogenous insulin D) hematuria

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Characteristic features of DM include polyuria, with excretion of dilute urine ranging from 4 L to as much as 30 L. Hematuria does not normally occur, and blood glucose levels are not directly affected.

13. A patient with a traumatic head injury and a diagnosis of diabetes insipidus is being treated with intravenous vasopressin (Pitressin). What change in the patient's status would prompt the immediate cessation of the drug infusion A) Infiltration at the IV site B) A sudden decrease in urine output C) The appearance of blood in the patient's urine D) A rapid increase in blood glucose Ans:A Feedback: When administering vasopressin intravenously, it is essential to use extreme caution due to the risk of extravasation of the medication, leading to tissue necrosis Decreased urine output is a goal of treatment. Blood in the urine and changes in blood glucose levels are atypical events.

14. Somatropin has been prescribed for a child who has been diagnosed with growth hormone deficiency. When providing health education to the child's parents, what teaching point should then nurse prioritize A) The correct technique for daily injections of the drug B) The importance of regular blood pressure monitoring C) The rationale for not crushing the extended- release tablet D) The need to limit the child's activity level for the duration of treatment Ans:A Feedback: Somatropin is administered by daily injections. Blood pressure monitoring and activity limitations are not necessary.

15. A girl who is 7 1/2 years old has received a diagnosis of precocious puberty from the pediatric endocrinologist. The nurse who collaborates with this physician should anticipate the administration of what drug A) Menotropins (Pergonal) B) Thyrotropin alfa (Thyrogen) C) Cosyntropin (Cortrosyn D) Leuprolide acetate (Lupron)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Leuprolide is useful for the treatment of central precocious puberty in children.

Menotropins (Pergonal) stimulates ovulation. Cosyntropin (Cortrosyn) stimulates the adrenal cortex to synthesize and secrete adrenocortical hormones. Thyrotropin alfa (Thyrogen) stimulates the secretion of thyroglobulin.

16. A 13-year-old boy who is in the first percentile of height for his age has been referred for care. Which of the following assessment findings would contraindicate the safe and effective use of somatropin to treat his growth deficiency A) The boy has not yet begun puberty B) The boy has low serum albumin levels C) The epiphyses of the boy's long bones have closed D) The sutures of the boy's skull have not yet fully closed Ans:C Feedback: Somatropin is ineffective when impaired growth is present after puberty, when the epiphyses of the long bones have closed. Low albumin is not a contraindication to the use of somatropin. The sutures of the skull close early in life.

17. A patient's current drug regimen includes intranasal administration of desmopressin acetate (DDAVP, Stimate). In this patient's plan of nursing care, what is the most likely desired outcome of treatment A) The patient's urine output will not exceed 80 mL/h B) The patient will gain 2 cm in height over the next 6 months C) The patient will ovulate at least once over the next 8 weeks D) The patient's vertical growth will cease in the next 4 weeks Ans:A Feedback: Desmopressin acetate (DDAVP, Stimate) is the prototype posterior pituitary hormone medication. It is used to treat diabetes insipidus. Consequently, reduced urine output is the primary goal of treatment. The drug does not influence growth or ovulation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse reviews the current medication administration record of a patient who has recently been prescribed octreotide. The nurse performs this important safety action in order to prevent drug interactions that could result in A) increased growth B) anaphylaxis C) cardiac complications D) respiratory arrest Ans:C Feedback: Numerous medications combine with octreotide to result in a prolonged QT interval with an increased risk of ventricular dysrhythmia and cardiac arrest. Increased growth, anaphylaxis, and respiratory arrest are not noted adverse effects or the result of drug interactions with octreotide.

19. A child has been referred to a pediatric endocrinologist and has begun treatment with octreotide acetate. What nursing diagnosis should be noted in the child's plan of nursing care A) Delayed growth and development B) Excess fluid volume C) Risk for deficient fluid volume D) Altered growth and development Ans:D Feedback: Acromegaly is the major clinical indication for the use octreotide. In this condition, growth is excessive, not delayed. Fluid volume is not directly affected.

20. A patient who is being cared for in the intensive care unit (ICU) is receiving desmopressin.

In light of the black box warning that accompanies this drug, the ICU nurse should prioritize the assessment of which of the patient's laboratory values A) Hematocrit B) Platelets C) Sodium D) Calcium Ans:C Feedback: The FDA has issued a black box warning stating that patients taking desmopressin can develop hyponatremia, leading to seizures. Consequently, assessment of sodium levels takes precedence over hematocrit, calcium, and platelet levels

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 47 Drug Therapy for Myasthenia Gravis, Alzheimer's Disease, and Urinary Retention 1. A patient has atony of the smooth muscle of the gastrointestinal tract. Which type of medication may be administered to increase smooth muscle strength A) Anticholinergic drugs B) Cholinergic drugs C) Muscle relaxants D) Selective serotonin reuptake inhibitors Ans:B Feedback: Cholinergic drugs are used to treat atony of the smooth muscle of the gastrointestinal tract and urinary systems. Anticholinergic agents will decrease muscle strength. Muscle relaxants will decrease muscle strength Selective serotonin reuptake inhibitors are not used for atony of the smooth muscle of the gastrointestinal tract.

2. A patient is diagnosed with Alzheimer's disease. The nurse should anticipate administering which of the following medications A) Bethanechol (Urecholine) B) Neostigmine (Prostigmin) C) Donepezil (Aricept) D) Physostigmine salicylate (Antilirium) Ans:C Feedback: Donepezil (Aricept) is used to treat mild to moderate Alzheimer's disease.

Bethanechol (Urecholine) produces smooth muscle contractions and is not used to treat Alzheimer's disease. Neostigmine (Prostigmin) is not used to treat Alzheimer's disease; it is used to treat myasthenia gravis. Physostigmine is not used to treat Alzheimer's disease; it is an antidote for overdose of anticholinergic drugs

3. A patient with myasthenia gravis is administered neostigmine (Prostigmin). How does this drug produce its therapeutic effect A) It stimulates the sympathetic nervous system B) It stimulates the parasympathetic nervous system C) It stimulates the cardiac smooth muscle

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) It stimulates the respiratory system Ans:B Feedback: Neostigmine (Prostigmin) stimulates the parasympathetic nervous system. It does not stimulate the sympathetic nervous system, cardiac system, or respiratory system.

4. A patient is administered edrophonium (Tensilon) to confirm the diagnosis of myasthenia gravis. What effect will the edrophonium (Tensilon) have 30 minutes after the medication administration, which will confirm the diagnosis A) Improved breathing B) Decreased fatigue C) Decreased muscle spasms D) Increased urinary output Ans:A Feedback: Edrophonium (Tensilon) is used to diagnose myasthenia gravis. After administration, it will improve breathing in patients who have myasthenia gravis. Edrophonium will not decrease fatigue. Edrophonium will not decrease muscle spasms or increase urinary output.

5. A patient with myasthenia gravis is administered pyridostigmine (Mestinon) for the first time.

She asks the nurse the reason why she has been changed to this medication. Which of the following is the nurse's best response A) “Pyridostigmine (Mestinon) will allow you to awaken with the ability to swallow.”

B) “Pyridostigmine (Mestinon) can be taken every other day.”

C) “Pyridostigmine (Mestinon) is a faster-release form of cholinergic agent.”

D) “Pyridostigmine (Mestinon) is taken one time per day for better control.”

Ans:A Feedback: Pyridostigmine is a slow-release form that is taken at bedtime and allows the patient the ability to swallow in the morning Pyridostigmine is usually taken two times per day, not every other day. Pyridostigmine is a slowrelease form, not a fast-release form Pyridostigmine is taken two times per day, not one time per day.

6. A patient is diagnosed with a paralytic ileus Which of the following medications will be administered to treat a paralytic ileus A) Neostigmine (Prostigmin) B) Donepezil (Aricept)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Bethanechol (Urecholine) D) Ambenonium (Mytelase) Ans:C Feedback: Bethanechol (Urecholine) produces smooth muscle contractions and is used for obstructive conditions of the gastrointestinal tract. Neostigmine is used to treat myasthenia gravis. Donepezil is used to treat Alzheimer's disease. Ambenonium is used to treat myasthenia gravis.

7. When administering anticholinesterase drugs, what assessment finding would indicate the patient is experiencing a toxic effect of the medication A) Loss of consciousness B) Abdominal distention C) Hypertension D) Muscle weakness Ans:D Feedback: The administration of anticholinesterase medications can result in profound muscle weakness. Decreased LOC, abdominal distention, and hypertension are not characteristic adverse effects of the anticholinesterase medications.

8. A patient has been receiving bethanechol (Urecholine) for 1 week. One hour after the dose is administered, he develops sweating, flushing, abdominal cramps, and nausea What is the rationale for the development of these symptoms A) Myasthenic crisis B) Cholinergic overdose C) Anaphylactic reaction D) Pulmonary edema Ans:B Feedback: A patient who suffers cholinergic overdose will experience sweating, flushing, abdominal cramps, and nausea. An accurate diagnosis may be determined from timing in relation to medication. Signs and symptoms having an onset within approximately 1 hour after a dose of anticholinesterase drug are likely to be caused by cholinergic crisis. Signs and symptoms beginning 3 hours or more after a drug dose are more likely to be caused by myasthenic crisis.

These symptoms are not the result of anaphylaxis or pulmonary edema.

9. A patient who is being treated for myasthenia gravis is receiving neostigmine, and her pulse drops to 50 after the administration. Which medication should be administered to treat the bradycardia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Atropine B) Pseudoephedrine C) Propranolol (Inderal) D) Bethanechol (Urecholine) Ans:A Feedback: Atropine will reverse the muscarinic effects of cholinergic crisis. Pseudoephedrine will not affect bradycardia in this patient Propranolol (Inderal) will not affect the bradycardia. Bethanechol will increase the bradycardia.

10. Which of the following medications is administered for ingestion of clitocybe mushrooms A) Pyridostigmine (Mestinon) B) Donepezil (Aricept) C) Rivastigmine (Exelon) D) Atropine sulfate Ans:D Feedback: Atropine sulfate is the specific antidote for mushroom poisoning. Pyridostigmine, donepezil, and rivastigmine are all cholinergic agents that would contribute to the symptoms of toxicity.

11. A 33-year-old female patient with a recent history of visual disturbances and dysphagia has just been diagnosed with myasthenia gravis. The nurse should recognize that this patient's health problem is ultimately attributable to what pathophysiological process A) Idiopathic overproduction of anticholinesterase B) Autoimmune destruction of acetylcholine receptors C) Demyelination of parasympathetic nerve pathways D) Deficient synthesis of dopamine by the substantia nigra Ans:B Feedback: Myasthenia gravis occurs when antibodies produced by the body's own immune system block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, which prevents muscle contraction from occurring. The disease does not involve dopamine deficits, demyelination, or excess anticholinesterase.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A 40-year-old woman has received a diagnosis of myasthenia gravis (MG) and is scheduled to begin treatment with oral neostigmine in her home. When providing relevant health education, the nurse should emphasize that successful control of MG symptoms will primarily depend on A) matching each dose of neostigmine to the severity of symptoms at that time B) making lifestyle modifications to prioritize a healthy diet and regular activity C) adhering strictly to the prescribed administration schedule D) developing acceptance of the functional deficits that result from MG Ans:C Feedback: Strict adherence to timely medication administration promotes optimal blood levels of neostigmine and optimal symptom control. Doses are not typically matched to short-term symptom severity, except in emergencies Lifestyle modifications and acceptance may be of benefit, but pharmacologic therapy is of paramount importance in the treatment of MG. 13. An accidental overdose of neostigmine has prompted the emergency administration of atropine. When assessing the patient, the emergency department nurse should take into account that this intervention will not relieve the effects of neostigmine on A) skeletal muscle B) smooth muscle C) the heart D) glands Ans:A Feedback: Atropine reverses only the muscarinic effects of cholinergic drugs, primarily in the heart, smooth muscle, and glands. Atropine does not interact with nicotinic receptors and therefore cannot reverse the nicotinic effects of skeletal muscle weakness due to overdose of indirect anticholinergic drugs.

14. A middle-aged female patient has been admitted to the outpatient treatment unit of the hospital for an edrophonium (Tensilon) test. Shortly after the administration of the medication, the patient reports that her muscle strength is significantly weaker than before the test. The nurse who is participating in the test should recognize that this finding is suggestive of what diagnosis

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Alzheimer's disease B) Anticholinergic crisis C) Myasthenia gravis D) Cholinergic crisis Ans:D Feedback: If the edrophonium test makes the patient even weaker, the diagnosis is cholinergic crisis.

15. Following recent changes in memory and personality, a 72-year-old man is undergoing neurological testing to rule out Alzheimer's disease. The nurse is aware that this disease is characterized by what pathophysiological phenomena? Select all that apply A) Meningiomas B) Neuritic plaques C) Neurofibrillary tangles D) Arteriovenous malformations (AVMs) E) Gliomas Ans:C, D Feedback: The neuropathologic hallmarks of Alzheimer's disease are neuritic plaques and neurofibrillary tangles. Gliomas, meningiomas, and AVMs are not associated with Alzheimer's disease.

16. An 80-year-old man has been diagnosed with early-stage Alzheimer's disease and has begun treatment with donepezil (Aricept). When providing health education to the patient and his wife, the nurse should identify what goal of treatment A) Remission of Alzheimer's disease B) Cure of Alzheimer's disease C) Improvement of cognition and function D) Resolution of memory and cognitive deficits Ans:C Feedback: The goal of drug therapy for Alzheimer's disease is to slow the loss of memory and cognition, thus preserving the independence of the individual person for as long as possible.

Remission, cure, and resumption of preillness levels of memory and cognition are unrealistic goals.

17. An older adult patient with a diagnosis of moderate Alzheimer's disease will soon return home with her husband. How can the nurse best facilitate the safe and effective administration of donepezil in the home setting

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Have the patient explain the rationale for drug therapy repeatedly before discharge B) Provide a detailed drug monograph to the patient and her husband and offer to answer any questions C) Assess the patient's need for home care D) Teach the patient's husband to administer the medication in a timely and safe manner Ans:D Feedback: It is important for the home care nurse to work with responsible family members in such cases to ensure accurate drug administration. Assessing the family's need for home care may be warranted, but this action does not necessarily ensure safe drug administration. The presence of moderate Alzheimer's disease may preclude effective patient teaching. Written teaching materials must normally be supplemented by other forms of teaching.

18. A nurse is conducting health education with a man who has Alzheimer's disease and his daughter, who is his primary caregiver. The man has been deemed to be a good candidate for treatment with donepezil (Aricept) and will soon begin taking this medication. What teaching point should the nurse convey A) “Aricept should be taken 1 hour before or 2 hours after any dairy products.”

B) “It's important to take this medication at bedtime.”

C) “Aricept should be taken with food to reduce the chance of stomach upset.”

D) “If you don't notice any cognitive improvement within 2 weeks, the drug should be discontinued.”

Ans:B Feedback: Aricept should normally be taken at bedtime. It does not have to be taken with food.

Dairy does not interfere with pharmacokinetics. The drug should be continued even if improvement is not noticeable.

19. A man with a neurogenic bladder secondary to a spinal tumor has been taking bethanechol.

The patient has illuminated his call light, and the nurse has found him anxious, diaphoretic, and visibly flushed. Following a safety assessment, what action should the nurse take A) Prepare to administer an IV dose of epinephrine to mitigate the effects of acetylcholine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Contact the physician as the patient may be experiencing a cholinergic crisis C) Insert a Foley catheter as the patient may have excessive urine in his bladder D) Assess the volume of the patient's bladder contents using a bladder ultrasound Ans:B Feedback: The presence of sweating and skin flushing in a patient taking bethanechol is suggestive of a cholinergic crisis. This is a medical emergency that warrants prompt intervention by the care team. This problem is not treated with epinephrine. Assessing the patient's bladder or inserting a Foley catheter is not sufficient.

20. A military nurse is part of a team reviewing the appropriate response to chemical weapons attacks, including sarin, tabun, and soman When reviewing the physiology of a response to such drugs, the nurse should identify what goal of treatment A) Restore anticholinesterase function B) Restore GABA function C) Restore dopamine function D) Increase serotonin reuptake Ans:A Feedback: These drugs are irreversible anticholinesterase agents. The goal of treatment, such as atropine administration, is to restore normal function of anticholinesterase and rid synapses of excessive acetylcholine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 48 Drug Therapy for Parkinson's Disease, Urinary Spasticity, and Disorders Requiring Anticholinergic Drug Therapy 1. states he sustained several head injuries playing football. Based on this information, what do you suspect the patient is suffering from A) Seizure disorder B) Degenerative joint disease C) Amyotrophic lateral sclerosis D) Parkinson's disease Ans:D Feedback: Parkinson's disease is a chronic, progressive, degenerative disorder of the central nervous system characterized by resting tremor, bradykinesia, rigidity, and postural instability.

The patient is not experiencing degenerative joint disease. The patient is not showing signs of symptoms of a seizure disorder. The patient has rigidity with tremors, not the signs of muscle weakness that are found in amyotrophic lateral sclerosis.

2. A patient has developed symptoms of rigidity and bradykinesia. Which of the following medications has been linked to secondary parkinsonism A) Haloperidol B) Furosemide (Lasix) C) Psyllium hydrophilic mucilloid (Metamucil) D) Valproic acid (Valproate) Ans:A Feedback: Drugs that deplete dopamine stores or block dopamine receptors, including the older antipsychotic drugs (phenothiazines and haloperidol), reserpine, and metoclopramide, can produce movement disorders such as secondary parkinsonism. Furosemide does not deplete dopamine stores. Psyllium does not deplete dopamine stores. Valproic acid does not deplete dopamine stores

3. A patient is being treated for Parkinson's disease and has been prescribed both levodopa (Ldop A) and carbidopa (Lodosyn). Why is this course of combination treatment most effective A) Levodopa restores dopamine and carbidopa decreases peripheral breakdown of levodopa B) Levodopa decreases the toxic effects of carbidopa to reduce the extrapyramidal reaction

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Carbidopa increases the peripheral breakdown of levodopa to hasten its onset and peak D) Levodopa and carbidopa, when combined, enhance voluntary movement to improve gait Ans:A Feedback: Levodopa restores dopamine levels and, in combination with carbidopa, decreases the peripheral breakdown of levodopa and allows more to reach the brain. Levodopa does not decrease the toxic effects of carbidopa to reduce the extrapyramidal reaction. Carbidopa does not increase the peripheral breakdown of levodopa to increase its effectiveness Levodopa and carbidopa combined do not exacerbate abnormal voluntary movement to increase gait.

4. A patient who suffers from Parkinson's disease is being treated with levodopa/ carbidopa.

Which of the following disorders will result in the discontinuation of this drug based on a disease-related contraindication A) Human immune deficiency virus B) Human papillomavirus C) Transient ischemic attacks D) Narrow-angle glaucoma Ans:D Feedback: Since levodopa can dilate pupils and raise intraocular pressure, it is contraindicated in narrow-angle glaucoma. Levodopa is not contraindicated in patients with human immune deficiency virus. Levodopa is not contraindicated in patients with human papillomavirus.

Levodopa is not listed as a contraindication with TIAs. 5. A patient with long-standing Parkinson's disease has been prescribed entacapone (Comtan).

The patient asks the nurse to describe exactly how this medication works. Which of the following responses is most appropriate A) “Entacapone is best given parenterally to relieve symptoms.”

B) “Entacapone inhibits COMT so that dopamine is active for a longer time.”

C) “It increases the metabolism of levodopa in the bloodstream.”

D) “It increases the amount of dopamine that your brain creates.”

Ans:B Feedback: Entacapone is a COMT inhibitor. COMT plays a role in brain metabolism of dopamine. Entacapone is administered orally, not parenterally. Entacapone does not increase the metabolism of dopamine in the bloodstream. It inhibits the metabolism of levodopa in the blood stream. Entacapone is 90 excreted in the biliary tract and feces and 10 in the urine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient with Parkinson's disease is being treated with rasagiline (Azilect). This medication inhibits the metabolism of dopamine by monoamine oxidase. Which of the following foods should the patient be instructed to avoid A) Cheddar cheese and Polish sausage B) Ham and rye bread C) Roast beef and horseradish D) Dairy products Ans:A Feedback: Cheddar cheese and Polish sausage are high in tyramine, which produces a lifethreatening reaction of hypertension when combined with rasagiline. The other listed foods are not high in tyramine.

7. A patient with Parkinson's disease has been prescribed rasagiline. When educating this patient on this medication, which herbal supplement has the potential to produce hyperpyrexia and death with rasagiline A) Ginger B) Dextromethorphan C) Garlic D) St. John's wort Ans:D Feedback: Rasagiline administered with the herbal supplement St. John's wort will enhance the stimulation of serotonergic receptors to cause hyperpyrexia and death. Dextromethorphan can produce the same reaction but is not an herbal supplement. Ginger and garlic are herbal supplements but will not produce hyperpyrexia and death.

8. An 80-year-old patient has been prescribed an anticholinergic agent for treatment of Parkinson-related symptoms. What patient education should be provided A) “Avoid high environmental temperatures.”

B) “Anticholinergics increase mental alertness.”

C) “It is safe to take Sudafed for a cold.”

D) “You may experience urinary incontinence.”

Ans:A Feedback: Anticholinergic drugs decrease sweating and may cause heat stroke. The patient should be instructed to avoid high environmental temperatures. Anticholinergic agents will decrease mental alertness. Sudafed will produce anticholinergic effects and should not be administered. Anticholinergic agents produce urinary retention, not incontinence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A 77-year-old male patient with Parkinson's disease will soon begin treatment with levodopa, carbidopa, and entacapone (Stalevo). Prior to starting this course of treatment, the nurse must ensure that A) the patient has committed to having weekly blood work drawn for the next 2 months B) the patient has completed an anticholinergic challenge in a clinical setting C) the patient's existing dose of levodopa has been reduced D) the patient has a prognosis for complete recovery from Parkinson's disease Ans:B Feedback: Patients whose medication regime is being changed to Stalevo should be administered levodopa and the adjunctive entacapone. The levodopa dose should be adjusted prior to the conversion to Stalevo therapy. Weekly blood work and the completion of an anticholinergic challenge are not necessary. Complete recovery from Parkinson's disease is not a realistic goal.

10. The nurse is teaching a woman who has Parkinson's disease about the dietary implications of her upcoming treatment with levodopa/carbidopa. What should the nurse teach this patient A) “It's important to take this medication on a full stomach so that it doesn't make you nauseous.”

B) “Most people find that it's best to take this medication at bedtime, provided you haven't snacked in the evening.”

C) “If possible, try to eat extra protein when you're taking this medication.”

D) “Dairy products will make this medication ineffective, so make sure you don't take them at the same time.”

Ans:A Feedback: Levodopa/carbidopa is administered with or just after food or following a meal to reduce nausea and vomiting. Levodopa/carbidopa is not administered with a high-protein diet Dairy products do not interfere with pharmacokinetics.

11. A woman is admitted to the emergency department with a diagnosis of sinus bradycardia.

The patient has been prescribed atropine 0.5 mg IV. How often can atropine be administered A) Every 24 hours B) Every 6 hours C) Every 30 minutes D) Every 3 to 5 minutes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Atropine 0.5 mg should be administered IV every 3 to 5 minutes and may be repeated up to 3 mg. Atropine can be administered every 24 hours, but this administration is not the recommended therapy for bradycardia Atropine can be administered every 6 hours, but this administration is not the recommended therapy for bradycardia Atropine can be given in 30 minutes, but this administration is not the recommended therapy for bradycardia.

12. A patient is administered atropine to increase the heart rate. What is the action of atropine A) It blocks the parasympathetic vagal stimulation B) It exacerbates the parasympathetic vagal stimulation C) It provides long-acting antihistamine blockage D) It blocks cell wall synthesis of gram-negative bacilli Ans:A Feedback: Moderate to large doses of atropine increase the heart rate by blocking parasympathetic vagal stimulation. The exacerbation of the parasympathetic vagal stimulation is opposite the effect of atropine. The blockage of histamine is seen with the antihistamine medications, not anticholinergic agents Atropine does not block cell wall synthesis.

13. A patient has been administered atropine for sinus bradycardia. Which of the following symptoms is noted with large doses of atropine A) Pallor B) Flushing C) Edema D) Incontinence Ans:B Feedback: Large doses of atropine cause facial flushing because of dilation of blood vessels in the neck. Pallor, edema, and incontinence are not caused by dilation of blood vessels in the neck.

14. A patient is scheduled for a hemithyroidectomy. She has been prescribed an anticholinergic agent prior to surgery. Why is it important to administer the anticholinergic agent in the preoperative phase

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) It will prevent tachycardia B) It will decrease respiratory secretions C) It will decrease gastric motility D) It relaxes the detrusor muscle Ans:B Feedback: In preoperative patients, the nurse assesses for diminished secretions, particularly when an anticholinergic is administered for head and neck surgery. The administration of an anticholinergic agent will not prevent tachycardia. Anticholinergic agents do decrease gastric motility, but this rationale is not a reason for administration in the preoperative phase. The anticholinergic agents cause relaxation of the detrusor muscle, but this rationale is not the reason for administration of the medication in the preoperative phase.

15. The physician orders benztropine mesylate (Cogentin). What disease process would contraindicate the administration of this anticholinergic medication A) Diabetes mellitus B) Myocardial infarction C) Narrow-angle glaucoma D) Hyperparathyroidism Ans:C Feedback: Narrow-angle glaucoma will result in increased intraocular pressure, and the patient should not receive the anticholinergic agent. Patients who suffer from diabetes mellitus, myocardial infarction, or hyperparathyroidism can normally be administered anticholinergic agents.

16. The physician has ordered scopolamine transdermally for motion sickness. Which of the following statements by the patient indicates an understanding of the medication's administration guideline A) “I will place it on my chest each morning.”

B) “I will use it when I am sick to my stomach.”

C) “I will change the patch every 4 hours.”

D) “I will change the patch every 3 days.”

Ans:D Feedback: Scopolamine is used for motion sickness. The disk (Transderm-V) protects against motion sickness for 72 hours. The scopolamine patch is applied behind the ear, not to the chest.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

The patch is used prior to the patient experiencing nausea. The patch is not changed every 4 hours.

17. A patient with myasthenia gravis is experiencing rhinorrhea. Which of the following medications should not be administered to the patient A) Azelastine hydrochloride (Astelin) B) Ipratropium (Atrovent) C) Fexofenadine (Allegr A) D) Nedocromil sodium (Tilade) Ans:B Feedback: Ipratropium (Atrovent) is administered for rhinorrhea, but is contraindicated in patients who have been diagnosed with myasthenia gravis because of its anticholinergic effects.

Azelastine hydrochloride (Astelin), fexofenadine (Allegr A), and nedocromil sodium (Tilade) are not contraindicated for patients with myasthenia gravis.

18. A patient is suffering from urinary urgency and frequency. Which of the following medications will assist in treating the patient's symptoms of urinary frequency A) Belladonna tincture B) Homatropine hydrobromide C) Hyoscyamine (Anaspaz) D) Ipratropium (Atrovent) Ans:C Feedback: Hyoscyamine (Anaspaz) is a belladonna alkaloid used in genitourinary disorders characterized by spasm, increased secretion, and increased motility. Belladonna tincture is used for GI disorders because of its antispasmodic effect. Homatropine hydrobromide is used as an eyedrop to produce mydriasis and cycloplegia Ipratropium (Atrovent) is used to treat rhinorrhea.

19. A patient has been diagnosed with chronic obstructive pulmonary disease. The patient is to be administered tiotropium bromide (Spiriva HandiHaler). The patient's creatinine level is 25.

What is the patient at risk for developing A) Drug toxicity B) Pneumonia C) Hepatotoxicity D) Central nervous system depression Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The patient has an elevated creatinine level. Tiotropium bromide is eliminated by the renal system, and patients with moderate to severe renal dysfunction should be carefully monitored for drug toxicity.

20. A patient has been administered chlorpromazine (Thorazine) for many years to treat his psychotic disorder. He has recently developed extrapyramidal symptoms related to long-term administration of this drug Which of the following medications can be administered to assist in relieving these symptoms A) Diazepam (Valium) B) Darifenacin (Enablex) C) Trihexyphenidyl (Trihexy) D) Trospium chloride (Sanctur A) Ans:C Feedback: Trihexyphenidyl (Trihexy) is used in the treatment of parkinsonism and extrapyramidal reactions caused by antipsychotic drugs Valium is a benzodiazepine and is not used for this purpose. Darifenacin is used for the treatment of overactive bladder. Trospium chloride (Sanctur A) reduces the tone of the smooth muscle in the bladder.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 49 Drug Therapy With Opioids 1. A surgical patient has highly elevated AST and ALT levels. Standard orders specify that she is to receive morphine sulfate 10 mg postoperatively. What action should the nurse take prior to administering the medication A) Draw up half of the medication for administration B) Notify the physician for a reduced dosage C) Assess the patient's respiratory status D) Assess the patient's pain tolerance Ans:B Feedback: Morphine and meperidine form pharmacologically active metabolites. Thus, liver impairment can interfere with metabolism, and kidney impairment can interfere with excretion.

Drug accumulation and increased adverse effects may occur if dosage is not reduced. The nurse cannot administer half of the medication without a physician's order. It is important to assess the patient's respiratory status before administration, but this action is not the primary intervention in this case. Narcotics prior to surgery are administered to increase pain tolerance during the surgical procedure, not during the preoperative phase.

2. An outpatient has been prescribed hydrocodone for back pain related to a compression fracture. Which of the following interventions should the patient be taught regarding the medication administration A) Consume a diet high in fiber B) Decrease activity due to pain C) Elevate the lower extremities D) Take aspirin with the medication Ans:A Feedback: Hydrocodone is an opioid, which, in the gastrointestinal tract, slows motility. To prevent constipation, the patient should consume a diet high in fiber. A decrease in activity due to pain will increase constipation. Elevating the lower extremities will not increase or decrease pain. Hydrocodone should not be routinely combined with aspirin unless prescribed by the physician.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A hospice patient has been ordered morphine (Roxanol) 5 mg sub-Q every 2 hours Roxanol contains 10 mg/mL. How many milliliters will be administered A) 0.25 mL B) 0.5 mL C) 1 mL D) 2 mL Ans:B Feedback: 5 mg/X = 10 mg/mL. The calculation results in 0.5 mL. The administration of 0.25, 1, or 2 mL is incorrect.

4. A patient who suffers from cancer pain is receiving morphine every 2 hours. For which of the following should the family be taught to assess while the patient is on morphine A) Diarrhea B) Respiratory depression C) Lung sounds D) Urinary incontinence Ans:B Feedback: The administration of morphine can result in respiratory depression. The family should be taught to assess the patient for respiratory depression. Morphine sulfate can be administered to treat severe diarrhea. The patient's lung sounds are important to assess, but only after the nurse assesses for respiratory depression. Morphine does not cause urinary incontinence.

5. A patient is admitted to the surgical division after a mastectomy. The patient has a PCA pump and states to you that she is fearful she will overdose on morphine. Which of the following interventions is most appropriate to teach the patient A) “The pump will administer all of the doses, so you don't have to worry.”

B) “If you follow the instructions, that won't happen to you.”

C) “The device is preset, so you cannot receive more than you need.”

D) “The device will give you a placebo when you press it often.”

Ans:C Feedback: PCA pumps deliver a basic amount of analgesic by continuous infusion, with the patient injecting additional doses when needed. The amount of the drug is preset and limited. The pump will administer a basal rate, but the patient can administer the medication at preset intervals. Telling the patient not to worry is not effective teaching or use of therapeutic communication. Telling the patient to follow the instructions is not effective teaching or use of

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

therapeutic communication. Instructing the patient on a placebo is not effective teaching or use of therapeutic communication

6. A patient has been given MS Contin. You enter the room and the patient is unresponsive. His respirations are 6 breaths per minute. What medication will be ordered for the patient A) Naloxone (Narcan) B) Capsaicin (Zostrix) C) Butorphanol (Stadol) D) Nalbuphine (Nubain) Ans:A Feedback: Naloxone (Narcan) has long been the drug of choice to treat respiratory depression caused by an opioid. Capsaicin is made from cayenne pepper and applied topically for pain relief Butorphanol (Stadol) is a synthetic, Schedule IV agonist similar to morphine in analgesic effects and ability to cause respiratory depression. Nalbuphine (Nubain) is a synthetic analgesic used for moderate to severe pain.

7. A patient has been administered an opioid For which of the following effects should the patient be assessed A) Oliguria B) Decreased level of consciousness C) Edema D) Tachycardia Ans:B Feedback: Opioids will produce decreased LOC. Oliguria is not a result of the administration of an opioid. Edema is not a result of the administration of an opioid. Tachycardia is not a result of the administration of an opioid.

8. A nurse is teaching a patient about her prescription for Tylenol #3 that she will take at home.

This medication consists of acetaminophen and what other drug A) Codeine B) Acetylsalicylic acid (aspirin) C) Methadone (Dolophine) D) Tramadol (Ultram) Ans:A Feedback: Tylenol #3 is acetaminophen (Tylenol) and codeine. Acetylsalicylic acid (aspirin) is not combined with acetaminophen (Tylenol)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Methadone (Dolophine) is not combined with Tylenol. Tramadol (Ultram) is not combined with Tylenol.

9. A patient is near the end of life and has developed increased respiratory secretions and labored breathing. The physician is likely to order which of the following medications to decrease these symptoms A) Meclizine (Antivert) B) Ampicillin C) Naloxone (Narcan) D) Morphine sulfate Ans:D Feedback: Morphine is used for the treatment of acute pulmonary edema. Meclizine (Antivert) is given for dizziness. Ampicillin is used to treat infection. Naloxone (Narcan) is the opioid antidote.

10. A patient has been receiving morphine sulfate 5 mg IV every 4 hours for the past several days. She states that the pain is not being relieved as well as it was in the past. What is the reason for this development A) She has developed a dependency on the morphine B) She has metastatic cancer and is dying C) She has greater pain with inactivity D) She has developed tolerance to morphine Ans:D Feedback: Larger-than-usual doses of morphine are required to treat pain in opiate-tolerant people. The patient has not developed a dependence on morphine. A patient with metastatic cancer will require increasing pain management, but this feature is not the rationale for the patient's statement. The increased pain is not related to inactivity.

11. In which of the following patients should the nurse question the physician's order for IV morphine A) An 88-year-old female with failure to thrive B) A 45-year-old female, 1-day postoperative mastectomy C) An 8-year-old male with a fractured femur D) A 17-year-old female, 1-day postoperative appendectomy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Opioid analgesics should be used cautiously in older adults, especially if they are debilitated. Treatment with morphine 1 day after mastectomy is appropriate for pain management. The treatment of pain with morphine is appropriate for a patient with a fractured femur. The treatment of pain with morphine is appropriate for a patient who is 1-day postoperative for an appendectomy.

12. A 30-year-old male patient has been ordered Demerol 75 mg IM every 4 hours after a fractured femur. What action should the nurse take A) Give the medication as ordered B) Administer half the dose C) Call the physician for a smaller dose D) Give the dose by mouth Ans:A Feedback: The patient should be administered the full dose of medication, which is within dosing recommendations. A male patient with a fractured femur who has adequate hepatic and renal function should not receive a lower dose of Demerol and should not receive the medication by mouth.

13. A nurse is instructing a patient on the administration of an opioid medication. What medication effect will most likely develop A) Lower extremity paresthesia B) Drowsiness C) Occipital headache D) Polyuria Ans:B Feedback: Drowsiness and sedation are results of central nervous system depression. The patient will not develop lower extremity paresthesia, occipital headache, or polyuria. If these effects develop, they are not related to the opioid medication.

14. A patient has been ordered a fentanyl patch known as Duragesic for chronic pain. What patient teaching should be provided to the patient and family A) Remove the patch every 3 days

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Apply it to the chest only C) Apply it for breakthrough pain D) Remove it daily and clean skin Ans:A Feedback: Duragesic has a slow onset of action, but lasts about 72 hours. Duragesic can be applied to other areas of the skin, not solely on the chest. Duragesic is not applied for breakthrough pain. Duragesic is not removed daily 15. What is the most effective way to evaluate the patient's pain response after administering an opioid analgesic A) Observe the patient when he/she is not aware you are assessing him/her B) Ask another nurse to assess the patient's response to the medication C) Using a pain scale, ask the patient to describe the pain D) Ask the family to determine the patient's response to the pain Ans:C Feedback: Asking the patient to describe the pain using a pain scale is the most effective assessment of pain response. Observing the patient when he/ she is unaware is an objective assessment and does not represent a true pain experience Asking another nurse to assess the patient's response will not provide accurate data Asking the family to determine the patient's response will not provide accurate data.

16. Nonopioid analgesics may sometimes be added to a narcotic analgesic. What action will result A) Antagonism B) Additive effect C) Interference D) Increased excretion Ans:B Feedback: Aspirin and Tylenol are added to narcotic analgesics for additive effects of pain relief without the addition of narcotic adverse effects. Aspirin and Tylenol do not provide an antagonistic effect. Aspirin and Tylenol do not cause an interference of action. Aspirin and Tylenol will not increase excretion

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

17. A 16-year-old has been brought to the emergency department by his football coach after twisting his ankle during a practice drill. Diagnostic testing reveals a fracture. This patient is experiencing what type of pain A) Acute somatic pain B) Acute cutaneous pain C) Visceral pain D) Neuropathic pain Ans:A Feedback: Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in skin, bone, muscle, and soft tissue. Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues. Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system.

Cutaneous pain is not a recognized category.

18. A patient with traumatic injuries describes his current pain as being “unbearable.” The pathophysiology of pain begins with a signal from A) myelin sheaths B) nociceptors C) baroceptors D) synapses Ans:B Feedback: For a person to feel pain, the signal from nociceptors in peripheral tissues must be transmitted to the spinal cord, then to the hypothalamus and cerebral cortex in the brain. Myelin sheaths, synapses, and baroceptors are not directly involved in pain transmission

19. A 54-year-old woman is being admitted to the postsurgical unit following a transverse rectus abdominis myocutaneous (TRAM) flap. The patient's care plan specifies the use of preemptive analgesia. This approach to pain control will involve A) frequent administration of high-dose opioids B) simultaneous use of analgesics from different drug classes C) alternating administration of opioid antagonists with opioid agonists

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) patient-controlled analgesia Ans:B Feedback: Preemptive analgesia is used to reduce postsurgical pain by simultaneously administering medications from different drug classes to suppress pain by blocking multiple pain pathways. It is not synonymous with PCA and does not require alternation between opioid agonists and antagonists.

20. Following the administration of pentazocine (Talwin) to a patient with moderate pain, the nurse should assess for what change in the patient's vital signs A) Increased blood pressure B) Decreased oxygen saturation C) Increased temperature D) Increased respiratory rate Ans:A Feedback: Talwin may cause increased blood pressure. It does not typically cause deoxygenation, fever, or tachypnea.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 50 Drug Therapy With Local Anesthetics 1. A patient has suffered a severe laceration to his thumb and index finger during a workplace accident, and local anesthetic is to be utilized to facilitate suturing. Which of the patient's following statements should prompt the nurse to provide further health education A) “I have to admit I'm relieved that they'll be freezing my hand before they stitch it up.”

B) “I'm feeling pretty queasy about getting stitches, so I'm glad they'll be knocking me out.”

C) “They told me that it will take a few hours before I can feel my hand again.”

D) “If I understand correctly, I won't be able to move my hand normally for a while after getting the anesthesia.”

Ans:B Feedback: Local anesthesia is differentiated from general anesthesia in that there is no loss of consciousness. “Freezing” is an accurate description. Normal motor control and sensation return after a period of time.

2. Spinal anesthesia will be used to perform a patient's scheduled bunionectomy. What should the nurse teach the patient about the administration of this form of anesthesia A) It will cause a significant, but temporary, decrease in level of consciousness B) It will be injected at the level of C7 to T2 C) It will be injected between T8 and T9 D) It will be injected into the cerebrospinal fluid Ans:D Feedback: Spinal anesthesia involves injecting the anesthetic agent into the cerebrospinal fluid, usually in the lumbar spine. It does not cause a significant decrease in level of consciousness

3. Resetting of a patient's fracture will take place under local anesthetic. These anesthetics reduce movement and sensation by decreasing the permeability of the nerve cell membrane to ions.

What is the most important ion that participates in this process A) Calcium B) Magnesium C) Sodium D) Potassium

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Local anesthetics decrease the permeability of the nerve cell membrane to ions, especially sodium.

4. A patient who suffered a laceration while doing woodwork in his garage will have his wound treated under local anesthesia achieved using lidocaine and epinephrine. The nurse who will assist with the procedure should recognize that epinephrine performs what function in this situation A) Promoting vasodilation B) Prolonging the effects of lidocaine C) Preventing adverse effects of lidocaine D) Blocking the afferent nerve pathways Ans:B Feedback: Lidocaine has a rapid effect, and, when combined with epinephrine, this effect is prolonged. Epinephrine can promote vasoconstriction, not vasodilation, and it neither prevents adverse effects nor blocks afferent nerve pathways.

5. A patient's chronic venous ulcer on the lower lateral surface of his leg requires incision and debridement (I & D). The nurse should anticipate that lidocaine will be administered by which of the following routes A) Intravenous B) Topical C) Injection D) Nebulized Ans:C Feedback: Injectable lidocaine is used for infiltration of the skin or subcutaneous administration prior to minor surgical procedures, such as I & D. Nebulized administration of lidocaine is reserved for lung procedures. Topical administration would be insufficient, and IV administration is not warranted.

6. A patient with hand trauma following a gunshot wound currently has bier block anesthesia with lidocaine. What assessment finding should signal the nurse to the possibility that the patient has local anesthetic systemic toxicity (LAST)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The patient has become intensely anxious and agitated B) The patient has complained of nausea and had an episode of blood-tinged emesis C) The patient's heart rate has become bradycardic and irregular D) The patient states that he still has sensation in his hand Ans:A Feedback: Initial symptoms of LAST may include analgesia, circumoral numbness, metallic taste, tinnitus or auditory changes, and agitation. Nausea, dysrhythmias, and continued sensory nerve function do not suggest LAST. 7. An older adult patient has sought care for the treatment of hemorrhoids, and the care provider has prescribed topical lidocaine. The nurse should teach the patient that full pain relief will normally be achieved how long after application of lidocaine A) 5 to 10 minutes B) 15 to 30 minutes C) 20 to 60 minutes D) 90 minutes to 2 hours Ans:C Feedback: Following topical administration of lidocaine, the area becomes numb in 20 to 60 minutes.

8. A patient undergoing chemotherapy for the treatment of lung cancer has developed stomatitis.

Oral lidocaine viscous has consequently prescribed by the primary caregiver. To minimize the patient's chance of aspiration, the nurse should encourage the patient to A) take small bites of food and small sips of fluid after administration B) adopt a minced and pureed diet for the duration of treatment C) remain in a high Fowler's position for 90 minutes following the use of lidocaine viscous D) avoid eating or drinking for 1 hour following the use of lidocaine viscous Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Patients should not drink fluids or eat after gargling with viscous lidocaine for at least 60 minutes due to risk of aspiration. Upright positioning will not mitigate this risk. A textured diet is unnecessary.

9. A patient has been administered lidocaine in anticipation of a bronchoscopy and lung biopsy.

What change in status would the nurse recognize as a potential hypersensitivity to lidocaine A) Audible wheeze B) Pleural pain C) Audible S3 D) Hemoptysis Ans:A Feedback: It is necessary to assess the respiratory status and lung sounds for signs of bronchospasm related to hypersensitivity after lidocaine administration. An audible wheeze is suggestive of bronchospasm. Pleural pain, audible S3, and hemoptysis are less likely to be a direct result of hypersensitivity.

10. A woman who is in her second trimester of pregnancy has suffered burns to her forearm from a steaming kettle. What amide local anesthetic can the nurse safely administer by the topical route during pregnancy A) Lidocaine B) Mepivacaine (Carbocaine, Polocaine) C) Bupivacaine (Marcaine, Sensorcaine) D) Dibucaine (Nupercainal) Ans:D Feedback: Dibucaine (Nupercainal) is local anesthetic administered topically to the affected area to induce pain relief. It is not absorbed systemically; therefore, it is considered safe during pregnancy. The other amides are not approved for use during pregnancy.

11. A hospital patient's medication administration record specifies the parenteral administration of lidocaine before a tissue biopsy to be performed later in the day. What action should the nurse take in response to this order A) Obtain an order for epinephrine in order to potentiate the action of lidocaine B) Contact the prescriber because administration should be performed by a physician or nurse anesthetist C) Administer a 500 mL bolus of normal saline to ensure adequate vascular volume

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Assess the patient's need for an antihistamine to be on hold during administration of the lidocaine Ans:B Feedback: A physician or nurse anesthetist administers the injectable form of lidocaine. A fluid bolus, an antihistamine, and epinephrine are not necessarily indicated.

12. Spinal anesthesia using procaine has been ordered for a patient prior to revision of the patient's ankle hardware. This drug achieves anesthesia by A) preventing the influx of sodium into nerve cells B) increasing the action of anticholinesterase in nerve synapses C) antagonizing nociceptors D) agonizing opioid receptors in the CNS Ans:A Feedback: Procaine decreases the influx of sodium into the nerve cell and depresses depolarization to prevent conduction of the nerve impulse. It does not alter the function of nociceptors, opioid receptors, or anticholinesterase.

13. The nurse is assessing a patient who was recently administered procaine for local anesthesia. Which of the following assessment findings would suggest the possibility of adverse effects A) Increased temperature B) Increased heart rate C) Decreased blood pressure D) Lethargy Ans:B Feedback: Following administration of procaine, the nurse assesses the CNS for excitability and the cardiovascular status for tachycardia and hypertension, leading to cardiovascular collapse.

Lethargy, hypotension, and fever are not typical adverse effects 14. anesthesia. The nurse recognizes that there is a risk to the patient who has local anesthesia due to what nursing diagnosis A) Disturbed sensory perception B) Autonomic dysreflexia C) Self-care deficit D) Latex allergy response

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The absence of sensory perception means that patients are at risk for injuring the anesthetized body part without their knowledge. Autonomic dysreflexia and latex allergy response are not plausible risks. The brief action of local anesthetics means that self-care deficit is rarely an issue.

15. A woman's prolonged epistaxis (noseblee D) following a basketball injury has created a need for anesthesia and vasoconstriction of the nasal mucous membranes. These therapeutic effects can best be achieved with what drug A) Prilocaine B) Procaine hydrochloride C) Bupivacaine D) Cocaine hydrochloride Ans:D Feedback: Topical cocaine is an anesthetic administered to the ear, nose, or throat to produce adequate anesthesia and vasoconstriction of the mucous membranes. The other listed anesthetics are not typically used for this purpose.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 51 Drug Therapy with General Anesthetics 1. Prior to her elective hip replacement surgery, the nurse is explaining the basic characteristics of general anesthesia to the patient. The nurse should perform this education in the understanding that general anesthesia is best understood as A) a nonreversible, temporary state of unresponsiveness B) a state of reversible unconsciousness C) stage N2 non–rapid eye movement sleep D) stage N3 non–rapid eye movement sleep Ans:B Feedback: General anesthesia is defined as a medication- induced reversible unconsciousness with loss of protective reflexes. There is the misconception that general anesthesia is a deep sleep.

2. A perioperative nurse is explaining the process of general anesthesia in anticipation of the adult patient's imminent bowel resection. When describing the phase of induction, the nurse should explain that this is usually achieved by what means A) Intramuscular injection of anesthetics and benzodiazepines B) Intravenous administration of opioid analgesics C) Subcutaneous injection of a rapid-acting anesthetic D) Intravenous administration of anesthetics Ans:D Feedback: The administration of a general anesthetic can be divided into three phases. The first phase is induction, which is rendering the patient unconscious by using inhalation anesthetics, intravenous anesthetics, or both. Adult patients usually receive a rapid-acting intravenous anesthetic medication. IM medications, sub-Q medications, and opioids are not used.

3. An adult patient who is currently undergoing rhinoplasty has developed the characteristic signs and symptoms of malignant hyperthermia. The operating room nurse should anticipate what intervention A) Hemodialysis B) Tracheal intubation C) IV administration of naloxone (Narcan) D) IV administration of dantrolene sodium (Dantrium)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: The treatment for malignant hyperthermia consists of intravenous dantrolene sodium (Dantrium), oxygenation and hyperventilation, hydration, and body cooling. The patient will already be intubated. Narcan and dialysis are not indicated.

4. The operating room nurse is reading the anesthesiologist's consult of a 30-year-old female patient who will undergo surgical repair of a meniscus tear later that day. The nurse reads that total intravenous anesthesia (TIV A) is indicated. What is the most likely rationale for this intervention A) The patient has a diagnosis of chronic obstructive pulmonary disease (COP D) B) The patient's insurer does not reimburse for inhaled anesthesia C) The patient has previously experienced severe postoperative nausea and vomiting D) The patient is in the first trimester of pregnancy Ans:C Feedback: In patients who have history of severe postoperative nausea and vomiting, the anesthetist may substitute the inhalation anesthetic with a technique called total intravenous anesthesia (TIV A). TIVA is not necessarily indicated in patients who are pregnant or who have COPD. Insurance considerations would not normally be an absolute indication for the use of TIVA

5. A certified registered nurse anesthetist is describing the minimum alveolar concentration (MA C) of isoflurane. How will the addition of nitrous oxide or IV anesthetics affect the MAC of isoflurane A) The MAC will remain the same B) The MAC will decrease C) The MAC of isoflurane will not be relevant D) The MAC will be more difficult to calculate

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: With the addition of other medications such as opioids, intravenous anesthetics, or nitrous oxide, the MAC values decrease.

6. A patient is scheduled to undergo craniofacial surgery, a procedure that will necessitate the use of propofol. The operating use nurse should be aware that alternative medications will be absolutely necessary in order to produce what effect in the patient A) Amnesia B) Euphoria C) Analgesia D) Hypnosis Ans:C Feedback: Propofol produces amnesia, euphoria, and hypnosis. It therefore blocks the perception of pain. It does not, however, provide analgesia.

7. The anesthesiologist has specified that ketamine will be included in a surgical patient's balanced anesthesia. When in postanesthetic recovery, the nurse should assess for what adverse effect of this medication A) Labile blood pressure B) Increased intracranial pressure C) Hyperventilation and respiratory alkalosis D) Delirium and agitation Ans:D Feedback: Ketamine can produce emergence delirium, hallucinations, and unpleasant dreams Symptoms of this effect may include confusion, agitation, and nystagmus. The drug preserves blood pressure and does not cause hyperventilation or increased ICP. 8. Vecuronium will be administered to a surgical patient to facilitate intubation and achieve balanced anesthesia. This medication induces paralysis by A) antagonizing acetylcholine receptors at neuromuscular junctions B) potentiating the effects of acetylcholinesterase in synapses C) crossing the blood–brain barrier and agonizing cerebellar function D) binding with serotonin and inhibiting its neuromuscular effects

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Because vecuronium is structurally similar to ACh, it binds to the receptors on the muscle and prevents normal function of ACh, producing skeletal muscle paralysis. The drug does not influence the physiology of serotonin, the cerebellum, or acetylcholinesterase.

9. A 39-year-old patient has been diagnosed with thyroid cancer and will have a thyroidectomy performed. During surgery in this nerve-rich and highly vascular region of the body, the patient may require vecuronium. What will be the primary purpose of this medication A) To ensure that the patient does not move during surgery B) To prevent intraoperative vomiting C) To protect the patient's airway during surgery D) To induce hypnosis and amnesia Ans:A Feedback: Delicate repairs, such as neck surgery and neurosurgery, may require the use of neuromuscular agents to prevent movement and subsequent damage. Vecuronium is not used to prevent nausea and vomiting, to protect the patient's airway, or to induce hypnosis and amnesia.

10. A surgical patient's balanced anesthesia includes the use of vecuronium. What nursing action should the operating room nurses prioritize A) Monitoring the patient for signs of increased level of consciousness B) Assessing and protecting the patient's airway C) Protecting the patient's skin integrity D) Monitoring the patient's deep tendon reflexes Ans:B Feedback: The maintenance of the patient's airway and respiratory function following the administration of neuromuscular blocking agents such as vecuronium is the most important nursing implication. The importance of airway protection supersedes that of DTR assessment, assessing LOC, and maintaining skin integrity, though each of these is a valid consideration.

11. A patient will undergo an endoscopy with conscious sedation using midazolam (Verse D). The nurse who is participating in this procedure should monitor the patient closely for signs of A) increased intracranial pressure B) respiratory depression

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) hemorrhage D) rhabdomyolysis Ans:B Feedback: Following administration of midazolam, continuous monitoring for respiratory depression is required, and if necessary, age- specific resuscitative measures should be implemented. Increased ICP, rhabdomyolysis, and hemorrhage are less likely than respiratory depression.

12. A 55-year-old woman will have a partial mastectomy performed as treatment for breast cancer. The anesthesiologist has informed the operating room nurse that opioids will be used to supplement anesthesia. What opioid is most likely to be utilized A) Codeine B) Oxycodone C) Fentanyl D) Meperidine Ans:C Feedback: A synthetic opioid that is about 100 times more potent than morphine sulfate, fentanyl can be used to supplement sedation, regional techniques, and general anesthesia. Codeine, meperidine, and oxycodone do not have intraoperative applications.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 52 Drug Therapy for Migraines and Other Headaches 1. A patient has been diagnosed with migraines after experiencing headaches of increasing severity. When providing health education to this patient about her new diagnosis, what should the nurse convey A) The etiology of migraines is thought to have a genetic component B) Migraines are typically the result of prolonged psychosocial stress C) Migraines can be a precursor to transient ischemic attacks (TIAs) or stroke D) The pathophysiology of migraine headaches involves a disruption in the limbic system Ans:A Feedback: Migraines demonstrate a familial pattern, and authorities believe that they are inherited as autosomal dominant traits with incomplete penetrance. Stress may precipitate a migraine, but this is not an aspect of the etiology. They are not a precursor to TIAs or stroke, and they do not involve disruption of the limbic system.

2. A middle-aged patient describes her headaches as “utterly debilitating” and tells the nurse, “It's hard to explain, but I just know when one is coming, and I'm never wrong.” This patient's statement suggests that she has what diagnosis A) Migraines B) Cluster headaches C) Tension headaches D) Ischemic headaches Ans:A Feedback: The severity of her headaches coupled with the fact that she experiences a prodrome suggests that she experiences migraines. This clinical presentation is not typical of cluster headaches or tension headaches. Ischemic headache is not a recognized subtype.

3. A young man has been diagnosed with migraines, and the nurse is teaching him about abortive therapy. The primary goal of this form of therapy will be to A) permanently correct the patient's brain physiology B) ensure that the patient experiences fewer migraine headaches C) relieve the symptoms of the patient's migraines

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) foster coping skills that will allow the patient to live with his migraines Ans:C Feedback: Abortive therapy is the administration of medications to treat the symptoms of migraine headache. These medications do not provide a permanent correction of pathophysiological neurological function, and they are not preventative. Coping skills are not provided through medications.

4. A patient who lives with migraines has been prescribed naproxen. The nurse should recognize that this drug achieves a therapeutic effect through which of the following means A) Demyelinizing pain fibers in the CNS B) Selectively antagonizing opioid receptors in the CNS C) Inhibiting the synthesis of COX-1 and COX-2 D) Slowing the reuptake of serotonin and acetylcholine in brain synapses Ans:C Feedback: Naproxen is a nonselective inhibitor of cyclooxygenase resulting in the inhibition of prostaglandin synthesis of COX-1 and COX-2. It does not involve serotonin, acetylcholine, or opioid receptors.

5. A nurse has administered a scheduled dose of naproxen to a hospital patient who has been taking the drug for several weeks. What assessment finding should cause the nurse to suspect that the patient is experiencing adverse effects of this drug treatment A) There is an increase in the patient's neutrophils but no increase in temperature B) The patient's stool tests positive for occult blood C) The patient complains of itchy, dry skin D) The patient has peripheral edema and there is a steady increase in the patient's weight Ans:B Feedback: GI bleeding is a significant adverse effect of naproxen. This drug does not typically cause leukocytosis, dry skin, or fluid imbalances.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. The nurse at a long-term care facility is assessing a new resident's current medication regimen, and the resident states that she often takes an OTC remedy when she experiences a migraine. She has brought the bottle with her, and the nurse notes it to be Anacin Advanced Headache Formula. The nurse should document that the patient takes which drugs Select all that apply A) Codeine B) Acetaminophen C) Aspirin D) Caffeine E) Naproxen Ans:B, C, D Feedback: Anacin Advanced Headache Formula and other similar OTC formulations include acetaminophen, aspirin, and caffeine.

7. A patient who is well-known to the clinic asked if it would safe for him to take Excedrin Extra Strength for the treatment of a severe headache. The nurse is well aware of this patient's medical history and should advise against using this medication based on what aspect of his current health status A) The patient has not adhered to previous treatment regimens B) The patient has a chronic venous ulcer on his lower leg C) The patient has a diagnosis of liver cirrhosis D) The patient is a smoker Ans:C Feedback: People with hepatic impairment should not receive this combination agent on an ongoing basis. They may not metabolize acetaminophen in this combined medication effectively, leading to hepatotoxicity. Lack of previous adherence, cigarette smoking, and the presence of skin ulcers do not necessarily contraindicate the use of this drug.

8. A young woman who is 14 weeks pregnant has sought care because she has been experiencing migraine headaches with increasing severity and frequency in recent months. She states, “My headaches used to be something I could live with, but now they're affecting every

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

other part of my life.” The patient has conducted online research and requested a prescription for ergotamine. How will this patient's current health status affect the clinician's response to this request A) The patient can safely use ergotamine but must be monitored for blood dyscrasias B) The patient must use a reduced dose of ergotamine until she has given birth C) The patient must wait until she has given birth before taking ergotamine D) The patient cannot safely take ergotamine until she has weaned her infant Ans:D Feedback: Pregnancy and lactation are contraindications to the use of ergotamine.

9. A patient has been treated for migraines on an ongoing basis and the care provider has just prescribed sumatriptan. Which of the following is the priority intervention for patient education A) “You might get dizzy and lightheaded after you take sumatriptan, but this is normal.”

B) “It's important that you never take Tylenol within 12 hours of sumatriptan.”

C) “Make sure that you stop taking ergotamine before you get this prescription filled.”

D) “You will likely experience a brief worsening of your migraine before this drug relieves the pain.”

Ans:C Feedback: It is important to ask the patient about recent administration ergot alkaloids. The ergot alkaloids should not be given within 24 hours of the administration of triptans. Signs of low blood pressure should be reported promptly, and there is no particular reason to avoid acetaminophen. Triptans do not make symptoms worse before they provide relief.

10. A nurse is teaching a patient how to take Imitrex in the home setting in order to maximize therapeutic benefit while reducing the risk of adverse effects. The nurse should teach the patient to take Imitrex A) before breakfast each day B) on days when migraines may be anticipated C) as soon as the earliest symptoms of migraine are sensed D) when the pain of a migraine becomes too much to bear Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: It is important to administer sumatriptan at the onset of migraine symptoms. The drug is not taken on a daily, scheduled basis and is not used as a preventative treatment.

11. A middle-aged patient has not achieved adequate symptom relief of migraines with first-line therapies, and the clinician is considering the use of frovatriptan (Frov A). The patient's concurrent use of what medication would contraindicate the safe use of frovatriptan A) Albuterol (Ventolin) B) Metformin C) Atorvastatin (Lipitor) D) Fluoxetine (Proza C) Ans:D Feedback: Frovatriptan (Frov A) interacts unfavorably with selective serotonin reuptake inhibitors and may lead to serotonin syndrome Ventolin, metformin, and Lipitor do not present a risk for interactions.

12. A woman in her 40s has been living with migraines for many years, and these have only just been identified as being linked to her menstrual cycles. Estradiol has been prescribed, which the nurse will administer A) intravenously B) transcutaneously C) intramuscularly D) sublingually Ans:B Feedback: Estradiol for the treatment of migraines is administered by the transcutaneous route.

13. A nurse in surgical daycare is completing a preoperative assessment of a woman who will undergo hip arthroplasty. The nurse has questioned the woman about her daily use of gabapentin

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

(Neurontin), and the woman has stated that she takes this drug to treat her migraines. What role does this drug play in migraine treatment A) It reduces the intensity of menstrual migraines B) It prevents migraines from occurring C) It relieves acute migraine pain D) It lengthens the aura that precedes a migraine Ans:B Feedback: Studies have shown that gabapentin is effective in reducing the frequency of migraines. Gabapentin is not an abortive treatment

14. on a frequent basis and has had oral prochlorperazine (Compazine) added as an adjuvant medication to abortive therapy When teaching the patient to take this drug safely in the home setting, the nurse should emphasize what teaching point A) The importance of taking the pill whole and not crushing or splitting it B) The importance of having a bimonthly complete blood count (CB C) drawn C) The need to avoid taking the drug after eating fatty food D) The need to be aware of the potential for hypotension Ans:A Feedback: When taking prochlorperazine orally, it is important to swallow it whole and not chew or crush the tablets. Blood work is not warranted, and there is no need to avoid fatty food prior to taking the drug. Compazine is not noted to cause hypotension.

15. Mrs. Gonzaga is a 60-year-old woman who first began having headaches during the onset of menopause and who has subsequently been diagnosed with migraines. She tearfully explains to the nurse how her husband downplays her health condition and tells her that she needs to “just push through a headache.” She describes how her migraines have limited her ability to provide

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning Mrs. Gonzaga's care A) Ineffective health maintenance related to migraine headaches B) Ineffective role performance related to migraine headaches C) Situational low self-esteem related to migraine headaches D) Spiritual distress related to migraine headaches Ans:B Feedback: Many nursing diagnoses likely apply to this patient's situation, but there is evidence that she grieves her inability to perform a caregiving role for her grandchildren. There is no evidence that the patient's health maintenance is inadequate or that she has low self-esteem.

Spiritual distress is also not in evidence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 53 Drug Therapy for Seizure Disorders and Spasticity 1. A patient has a left temporal brain tumor. He smells an odor of ammonia prior to experiencing rapid rhythmic jerking movements. What is the odor of ammonia classified as A) Chemical agent evoked by the tumor B) An aura prior to the seizure activity C) The metastatic process of tumor growth D) The inhibition of serotonin and acetylcholine Ans:B Feedback: The smell of ammonia is an aura, which is a warning prior to seizure activity. The tumor will not evoke a chemical agent prior to the seizure. The metastatic process will not evoke a chemical smell. The chemical smell is not related to the inhibition of serotonin and acetylcholine.

2. A patient has been taking phenytoin (Dilantin) for a seizure disorder. He has recently run out of his medication and has not obtained a refill What is the patient at risk for developing A) Hypotension B) Migraine headaches C) Status epilepticus D) Depression Ans:C Feedback: In a person taking medications for a diagnosed seizure disorder, the most common cause of status epilepticus is abruptly stopping AEDs. Abruptly stopping phenytoin will not cause hypotension. Abruptly stopping phenytoin will not cause migraine headaches. Abruptly stopping phenytoin will not cause depression.

3. A patient is admitted to the emergency room in status epilepticus. What medication may be administered intravenously to assist in reducing seizure activity A) Diazepam (Valium) B) Hydromorphone (Dilaudi D) C) Insulin D) Meperidine (Demerol) Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: IV diazepam is an adjunctive skeletal muscle relaxant administered for the treatment of severe recurrent convulsive seizures and status epilepticus. Ethosuximide (Zarontin) is not administered for status epilepticus Meperidine (Demerol) and insulin are not administered for status epilepticus.

4. An 80-year-old patient has severe pain after a case of shingles. The pain is noted along the shoulder and back. He states the pain is so severe he cannot sleep. What is the primary medication that will relieve this pain A) Meperidine (Demerol) B) Morphine sulfate (MS Contin) C) Naproxen sodium (Naprosyn) D) Gabapentin (Neurontin) Ans:D Feedback: Gabapentin is the first oral medication approved by the FDA for the management of postherpetic neuralgia. Meperidine will provide pain relief but is not effective in postherpetic neuralgia. Morphine sulfate will provide pain relief but is not effective in postherpetic neuralgia.

Naproxen sodium will decrease inflammation but is not effective for postherpetic neuralgia.

5. A patient who has been taking valproic acid (sodium valproate) for a seizure disorder is asking the nurse about getting pregnant. Why is pregnancy discouraged in women who are being treated for seizure disorders A) Seizure disorders are genetic B) Seizure disorders are familial C) Antiepilepsy drugs decrease fertility D) Antiepilepsy drugs are teratogenic Ans:D Feedback: Antiepileptic drugs such as valproic acid must be used cautiously during pregnancy because they are teratogenic. Seizure disorders are not normally genetic or familial. Antiepilepsy medications do not decrease fertility.

6. A patient is being treated for a seizure disorder with phenytoin (Dilantin). He is admitted to the emergency room with sinus bradycardia. What action will occur regarding his antiepileptic agent A) Phenytoin (Dilantin) dose will be reduced

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Phenytoin (Dilantin) will be discontinued C) Phenytoin (Dilantin) will be given every other day D) Phenytoin (Dilantin) dose will be increased Ans:B Feedback: Phenytoin should be discontinued immediately because it is contraindicated in patients with sinus bradycardia. Reducing the frequency of administration would likely be insufficient.

7. A patient is admitted to the hospital with severe dehydration and also has decreased albumin levels. What effect will the patient's current status have if a prescribed dose of phenytoin (Dilantin) is administered A) Potentially toxic serum level B) Reduced serum level C) Increased seizure activity D) Thromboembolism Ans:A Feedback: Phenytoin is highly bound to plasma proteins and only a fraction is not bound to albumin; hypoalbuminemia will result in toxic serum levels of phenytoin. A reduced serum level of phenytoin will not be seen with hypoalbuminemia. The patient will not suffer from increased seizure activity. The patient will not suffer from thromboembolism.

8. The nurse has been educating the patient on the self-administration of phenytoin (Dilantin).

Which of the following statements by the patient demonstrates an understanding of the medication A) “I'll only take the drug when I feel an impending seizure.”

B) “I'll reduce my dose if I remain seizure free.”

C) “I'll make sure to take the drug with food.”

D) “I'll stop taking the drug if I don't have a seizure for 8 weeks.”

Ans:C Feedback: Phenytoin should be taken with food to reduce the chance of stomach upset. It should be taken on a regular basis, and not only when a seizure occurs. The patient should not arbitrarily reduce his or her dose of phenytoin. Abrupt cessation can cause seizures.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient suffers from trigeminal neuralgia. What antiepileptic agent may be used to treat this disorder A) Phenytoin (Dilantin) B) Carbamazepine (Tegretol) C) Fosphenytoin (Cerebyx) D) Ethosuximide (Zarontin) Ans:B Feedback: Carbamazepine (Tegretol) is prescribed to treat trigeminal neuralgia. Phenytoin is not administered for trigeminal neuralgia Fosphenytoin is not administered for trigeminal neuralgia. Ethosuximide is not administered for trigeminal neuralgia.

10. A child suffers from absence seizures and has been prescribed acetazolamide (Diamox). The nurse should know that this medication is an adjuvant medication useful in the treatment of seizures. What is the therapeutic action of Diamox A) It slows the action potential of neurons B) It slows the reuptake of acetylcholine C) It suppresses the limbic and reticular systems D) It controls fluid secretion in the CNS Ans:D Feedback: The sulfonamide diuretic acetazolamide (Diamox) controls fluid secretion in the CNS; it is thought to inhibit CNS carbonic anhydrase to decrease neuronal excitability 11. activity. The patient is being treated with gabapentin (Neurontin). After administering the medication, the nurse should assess the patient because of the potential for what adverse effect A) Tetany B) Hypersensitivity C) Paradoxical seizures D) CNS depression Ans:D Feedback: The most common adverse effects of gabapentin are associated with CNS depression and include dizziness, somnolence, insomnia, and ataxia. The drug has not been noted to cause tetany, hypersensitivity reactions, or paradoxical seizures.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A patient with impaired liver function is suffering from a seizure disorder that most often results in partial seizures. Which of the following AEDs may be administered to a patient with impaired liver function A) Oxcarbazepine (Trileptal) B) Fosphenytoin (Cerebyx) C) Carbamazepine (Tegretol) D) Levetiracetam (Keppr A) Ans:D Feedback: Levetiracetam (Keppr A) is not primarily metabolized in the liver. Oxcarbazepine (Trileptal) is metabolized in the liver Fosphenytoin (Cerebyx) is metabolized in the liver. Carbamazepine (Tegretol) is metabolized in the liver.

13. A patient is admitted to the hospital for severe back spasms and pain. Which of the following skeletal muscle relaxants will act peripherally on the muscle itself A) Cyclobenzaprine (Flexeril) B) Carisoprodol (Som A) C) Methocarbamol (Robaxin) D) Dantrolene sodium (Dantrium) Ans:D Feedback: Dantrolene is the only skeletal muscle relaxant that acts peripherally on the muscle itself; it inhibits the release of calcium in skeletal muscle cells, thereby decreasing the strength of muscle contraction. The other listed drugs act centrally.

14. A patient is recovering from a stroke and has developed severe muscle contractions. Which of the following medications will inhibit the release of calcium in skeletal muscle cells A) Dantrolene sodium (Dantrium) B) Baclofen (Lioresal) C) Carisoprodol (Som A) D) Cyclobenzaprine (Flexeril) Ans:A Feedback: Dantrium relieves spasticity by inhibiting the release of calcium in skeletal muscle cells Lioresal, Soma, and Flexeril act centrally.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. A patient with multiple sclerosis is admitted to the medical division for treatment of severe spasticity. What medication is used to treat spasticity and is administered intrathecally A) Baclofen (Lioresal) B) Carisoprodol (Som A) C) Diazepam (Valium) D) Dantrolene (Dantrium) Ans:A Feedback: Baclofen is used to treat spasticity in MS and spinal cord injuries. It can be administered intrathecally. Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. Diazepam is used to relieve muscle spasms but not used intrathecally.

Dantrolene is used to treat malignant hyperthermia but not multiple sclerosis.

16. A patient is admitted with acute, painful muscle spasms and suffers from intermittent porphyria, an inherited enzyme deficiency. Which of the following muscle relaxants is contraindicated due to the patient's history of porphyria A) Baclofen (Lioresal) B) Carisoprodol (Som A) C) Diazepam (Valium) D) Dantrolene (Dantrium) Ans:B Feedback: Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. It is contraindicated in patients with intermittent porphyria. Baclofen is not known to be contraindicated with porphyria Diazepam is not known to be contraindicated with porphyria. Dantrolene is not known to be contraindicated with porphyria.

17. A patient with muscle spasms is administered cyclobenzaprine (Flexeril). Which adverse effect should the nurse assess for with this medication A) Muscle spasms B) Insomnia C) Drowsiness D) Urinary incontinence Ans:C Feedback: A common adverse effect with cyclobenzaprine (Flexeril) is drowsiness. The patient will not experience muscle spasms, insomnia, or urinary incontinence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A patient has been started on dantrolene (Dantrium). What is the most serious adverse effect about which the patient should be instructed A) Metabolic acidosis B) Hypercarbia C) Renal calculi D) Hepatitis Ans:D Feedback: The most serious adverse effect of oral dantrolene is fatal hepatitis. Metabolic acidosis, hypercarbia, and renal calculi are not adverse effects of oral dantrolene.

19. A patient has been started on cyclobenzaprine (Flexeril). For the duration of treatment, the nurse should teach the patient to avoid A) OTC vitamin supplements B) alcohol C) stool softeners D) fatty foods Ans:B Feedback: Increased CNS depression occurs when cyclobenzaprine is combined with alcohol or other CNS depressants. There is no particular need for the patient to avoid fatty foods, stool softeners, or vitamin supplements.

20. A patient is taking tizanidine (Zanaflex) to treat spasticity from multiple sclerosis. Which of the following adverse effects of muscle relaxants is most pronounced with this medication A) Hypotension B) Dark black urine C) Excessive salivation D) Eczema Ans:A Feedback: Hypotension is the most significant adverse effect of tizanidine. Dark black urine, excessive salivation, and eczema are not adverse effects of tizanidine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 54 Drug Therapy for Anxiety and Insomnia 1. A patient is having seizure activity, and the physician has ordered diazepam (Valium) to be given parenterally. If this medication is administered intravenously, when will its onset of action be observed A) 1 to 5 minutes B) 7 to 10 minutes C) More than 10 minutes D) Less than 1 minute Ans:A Feedback: Intravenous diazepam (Valium) is administered intravenously to decrease seizure activity and has a 1- to 5-minute onset of action. Diazepam (Valium) decreases seizure activity in less than 7 to 10 minutes Diazepam (Valium) should decrease seizure activity in less than 10 minutes. Diazepam (Valium) will take more than 1 minute to begin working.

2. A patient suffers from insomnia and is prescribed flurazepam. This medication has a longer half-life than 24 hours. Which of the following contributes to the long half-life of this medication and other benzodiazepines A) Metabolism by cytochrome P450 B) Presence of active metabolites C) Excretion by the renal system D) Movement of calcium in the cell Ans:B Feedback: Benzodiazepines differ mainly in their plasma half-lives, production of active metabolites, and clinical uses. Drugs with half-lives longer than 24 hours form active metabolites that also have long half-lives and tend to accumulate, especially in older adults and people with impaired liver function Flurazepam is not metabolized by cytochrome P450. Flurazepam is excreted in the renal system but does not contribute to the effect on the half-life. Flurazepam does not contribute to movement of calcium in the cell.

3. A patient is given midazolam (Verse D) in combination with an opioid in the preoperative phase before a laparoscopic cholecystectomy. What does the administration of midazolam (Verse D) assist in minimizing A) Oral secretions

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Anxiety C) Hypotension D) Muscle tone Ans:B Feedback: Midazolam (Verse D) provides preoperative sedation and mechanical ventilation. It does not reduce secretions, increase blood pressure, or reduce muscle tone.

4. A patient's medication regimen for treatment of anxiety has been changed from a benzodiazepine. The patient asks the nurse what likely prompted his care provider to change his medication. What is the nurse's best response A) “Your doctor may have been concerned about causing depression.”

B) “Your doctor may have been worried about the possibility of convulsions.”

C) “Long-term use of benzodiazepines can result in dependency.”

D) “Long-term use of benzodiazepines can cause insomnia.”

Ans:C Feedback: Although benzodiazepines are effective anxiolytics, long-term use is associated with concerns over tolerance, dependency, withdrawal, lack of efficacy for treating the depression that often accompanies anxiety disorders, and the need for multiple daily dosing with some agents.

They do not cause insomnia, convulsions, or depression.

5. A patient has developed excessive sedation and respiratory depression. The patient has been taking a benzodiazepine and has diminished liver function. Which of the following medications will reduce the effects of sedation and respiratory depression in this patient A) Olmesartan medoxomil (Benicar) B) Pancrelipase (Pancrease) C) Pamidronate disodium (Aredi A) D) Flumazenil (Romazicon) Ans:D Feedback: Toxic effects of benzodiazepines include excessive sedation, respiratory depression, and coma. Flumazenil (Romazicon) is a specific antidote that competes with benzodiazepines for benzodiazepine receptors and reverses toxicity. Olmesartan medoxomil (Benicar) is an angiotensin II receptor antagonist that is used to treat hypertension. Pancrelipase (Pancrease) is used for enzyme replacement therapy. Pamidronate disodium is used as a bone metabolism regulator.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient is being observed for acute benzodiazepine withdrawal symptoms. Which of the following symptoms is characteristic of this problem A) Bradycardia B) Agitation C) Lethargy D) Diaphoresis Ans:B Feedback: Common signs and symptoms of withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Bradycardia, lethargy, and diaphoresis are uncharacteristic.

7. A patient is administered a benzodiazepine for anxiety. Which of the following will place the patient at risk for benzodiazepine toxicity A) Decreased albumin B) Increased calcium C) Decreased potassium D) Low bicarbonate Ans:A Feedback: Patients with liver disease are at risk for adverse effects with drugs that are highly bound to plasma proteins. Increased calcium will not contribute to benzodiazepine toxicity.

Decreased potassium will not have a direct impact on benzodiazepine toxicity. The normal bicarbonate will not contribute to benzodiazepine toxicity.

8. An older adult patient suffers from generalized anxiety disorder. The use of benzodiazepines in this patient population creates a risk for what adverse effect A) Seizures B) Falls C) Dysrhythmias D) Sexual dysfunction Ans:B Feedback: Adverse effects of benzodiazepines may contribute to falls and other injuries unless patients are carefully monitored and safeguarded. Seizures, dysrhythmias, and sexual dysfunction are not characteristic adverse effects

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A 77-year-old patient is suffering from insomnia. Which of the following medications can be most safely administered to this patient to induce sleep A) Alprazolam (Xanax) B) Clonazepam (Klonopin) C) Diazepam (Valium) D) Temazepam (Restoril) Ans:D Feedback: Temazepam (Restoril) is eliminated by conjugation with glucuronide. Thus, temazepam (Restoril) is the drug of choice for patients who are elderly, have liver disease, or are taking drugs that interfere with hepatic drug–metabolizing enzymes. Alprazolam (Xanax) is not administered for insomnia Clonazepam (Klonopin) is not administered for insomnia. Diazepam (Valium) is not administered for insomnia.

10. A child with night terrors is administered a benzodiazepine agent. Why must the nurse follow the child's health status closely A) The child is more likely to develop insomnia B) The child is more likely to develop dependence C) The child is more vulnerable to adverse effects D) The child is more vulnerable to hepatotoxicity Ans:C Feedback: Children may be more sensitive to its effects of this drug, namely mood and/or mental changes. Hepatotoxicity, insomnia, and dependence are not among the most common adverse effect.

11. When administering benzodiazepines, which of the following medications should be considered the drug of first choice A) Lorazepam (Ativan) B) Estazolam (Prosom) C) Temazepam (Restoril) D) Triazolam (Halcion) Ans:A Feedback: Lorazepam (Ativan) is probably the benzodiazepine of first choice. The drug provides rapid tranquilization of patients experiencing agitation. Administered intravenously, it

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

reduces nausea and vomiting as well as anxiety and induces procedural amnesia. Lorazepam has a slow onset of action (5 to 20 minutes) because of delayed brain penetration but an intermediate to prolonged duration.

12. A patient is admitted to the intensive care unit with a diagnosis of septicemia. In addition to relieving agitation and anxiety, what is a rationale for using benzodiazepines in the treatment of a critically ill patient A) Increased diffusion and perfusion B) Decreased cardiac workload C) Increased level of consciousness D) Decreased blood pH Ans:B Feedback: Antianxiety and sedative–hypnotic drugs are often useful in critically ill patients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. They do not decrease blood pH, increase diffusion and perfusion, or increase LOC. 13. A patient is scheduled to undergo a bronchoscopy for the investigation of a bronchial mass.

What benzodiazepine should the clinic nurse anticipate administering for conscious sedation A) Triazolam (Halcion) B) Midazolam (Verse D) C) Oxazepam (Serax) D) Chlordiazepoxide (Librium) Ans:B Feedback: Midazolam (Verse D) is frequently used for conscious sedation during invasive procedures. Halcion, Serax, and Librium are not typically used for this purpose.

14. A middle-aged woman has become increasingly debilitated by anxiety, to the extent that she has sought medical help. After a thorough assessment, her care provider has diagnosed her with an anxiety disorder. The etiology of anxiety involves which of the following physiological processes A) Stimulation of the parasympathetic nervous system

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Stimulating effects of somatotropin C) Increased activation of the autonomic nervous system D) Adrenocortical suppression Ans:C Feedback: Clinical manifestations of anxiety include overactivity of the autonomic nervous system, such as dyspnea, palpitations, tachycardia, sweating, dry mouth, dizziness, nausea, and diarrhea. Somatotropin is not directly involved, and the adrenal cortex is not suppressed during times of anxiety. The parasympathetic nervous system is not stimulated during times of anxiety.

15. A patient's current medical status includes multiple comorbidities. In recent months, the patient has been complaining of insomnia that has begun to have a significant impact on his quality of life. What aspect of this patient's health is most likely to cause insomnia A) The patient has hypothyroidism B) The patient is morbidly obese C) The patient has chronic pain D) The patient has type 2 diabetes Ans:C Feedback: Chronic pain is commonly associated with insomnia. Diabetes, obesity, and hypothyroidism are not normally associated with insomnia.

16. In the 18 months following the death of his wife, a middle-aged man has been taking benzodiazepines on a daily basis. He has expressed to the nurse his desire to stop taking these medications. In order to minimize the chances of withdrawal symptoms, the nurse knows that the patient will likely be advised to A) taper down his dose of benzodiazepines over a prolonged period of time B) replace the benzodiazepine with a herbal supplement in anticipation of stopping the medication C) replace the immediate-acting form of the drug with a long-acting form D) replace the benzodiazepine with an anticonvulsant

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: To avoid withdrawal symptoms, it is necessary to taper benzodiazepines gradually before discontinuing them completely. Long- acting benzodiazepines, anticonvulsants, and herbal remedies are not recommended in the effort to prevent withdrawal

17. A patient with a history of alcoholism is being treated in the intensive care unit for multiple trauma following a motor vehicle accident The patient is currently being treated with lorazepam (Ativan) to treat signs of alcohol withdrawal as well as hydromorphone (Dilaudi D) for the pain of injuries. The intensive care nurse should prioritize what assessments A) Arterial blood gases B) Respiratory rate and oxygen saturation C) Deep tendon reflexes and pupillary response D) Cardiac rate and rhythm Ans:B Feedback: The combination of opioids and benzodiazepines creates a significant risk for CNS depression; respiratory function is consequently an important focus of assessment. It would likely supersede other assessments, even though each may be warranted.

18. A 77-year-old woman who experiences significant anxiety has been taking diazepam for several months. She was brought to the clinical earlier this week by her daughter, who stated that her mother had been behaving in an uncharacteristically confused manner. The clinician discontinued the patient's diazepam. Three days later, the daughter states that her mother has still been having problems with impaired memory and confusion. The nurse should consider what possible explanation for the patient's current status A) Benzodiazepines can occasionally cause permanent alterations in personality and level of consciousness B) The patient may have decreased liver function C) The patient may have been experiencing a hypersensitivity to the drug, rather than an adverse effect D) The adverse effects of benzodiazepines can persist for several days after stopping the drug

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued Hypersensitivity and decreased liver function are unlikely. Benzodiazepines do not cause permanent changes in cognition.

19. A patient's severe family tragedy 1 year ago resulted in depression and insomnia. Which of the following hypnotics may be safely taken for longer-term treatment of insomnia A) Lorazepam (Ativan) B) Eszopiclone (Lunest A) C) Chloral hydrate D) Oxazepam (Serax) Ans:B Feedback: Eszopiclone (Lunest A) is the first oral nonbenzodiazepine hypnotic to receive FDA approval for long-term use ( 12 months).

20. A nurse has noted that a newly admitted patient has been taking ramelteon (Rozerem) for the past several weeks. The nurse is justified in suspecting that this patient was experiencing what problem prior to starting this drug A) Somnambulism (sleepwalking) B) Difficulty falling asleep at night C) Early morning waking D) Frequent nighttime awakenings Ans:B Feedback: Ramelteon (Rozerem), the newest oral nonbenzodiazepine hypnotic, has received FDA approval for the long-term treatment of insomnia characterized by difficulty with sleep onset.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 55 Drug Therapy for Depression and Mood Stabilization 1. A woman has a history of long periods of depression interspersed with hypomanic episodes.

What mood disorder is the patient most likely suffering from A) Bipolar disorder type I B) Bipolar disorder type II C) Situational depression D) Coping disorder Ans:B Feedback: Bipolar disorder type II is characterized by episodes of major depression plus hypomanic episodes and occurs more frequently in women. Bipolar disorder type I is characterized by episodes of major depression plus mania and occurs equally in men and women.

Situation depression lasts a shorter amount of time and is related to life events. A coping disorder is not related to hypomania.

2. A patient is admitted for assessment because of his history of inappropriately flamboyant and extroverted behavior coupled with risk- taking behaviors. The wife states he has also had periods of major depression but refuses to seek help. From what mood disorder is the patient most likely suffering A) Schizophrenia B) Depression C) Bipolar disorder type I D) Bipolar disorder type II Ans:C Feedback: Bipolar disorder type I is characterized by episodes of major depression plus mania and occurs equally in men and women Schizophrenia results from abnormal brain synapses and includes a wide variety of diseases.

Depression is a mood disorder, but does not exhibit periods of mania. Bipolar disorder type II is characterized by episodes of major depression plus hypomanic episodes and occurs more frequently in women.

3. A patient suffers from depression and states feelings of gloom and inability to perform the activities of daily living. The normal function of which neurotransmitter is most likely impaired A) Acetylcholine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Epinephrine C) Insulin D) Serotonin Ans:D Feedback: Serotonin helps regulate several behaviors that are disturbed in depression.

Acetylcholine is a neurotransmitter with action in the cardiac and skeletal muscle. Acetylcholine has a limited impact in depression. Epinephrine is not associated with depression, though norepinephrine is implicated. Insulin is released by the pancreas to regulate blood sugar.

4. A patient has been taking a selective serotonin reuptake inhibitor for the treatment of depression. Which of the following represents the action of the medication A) Selective serotonin reuptake inhibitors block GABA B) Selective serotonin reuptake inhibitors prevent serotonin from being reabsorbed C) Selective serotonin reuptake inhibitors increase serotonin synthesis D) Selective serotonin reuptake inhibitors increase the number of serotonin binding sites Ans:B Feedback: Fluoxetine and the other SSRIs block the reabsorption of the neurotransmitter serotonin in the brain. This helps elevate mood. SSRIs do not increase serotonin synthesis or the number of binding sites. They do not influence the role of GABA. 5. An 8-year-old child is being seen in the clinic. The mother states he suffers from bed-wetting at least four times per week. What medication is effective in treating enuresis in children A) Amitriptyline (Elavil) B) Duloxetine (Cymbalt A) C) Imipramine (Tofranil) D) Venlafaxine (Effexor) Ans:C Feedback: Imipramine (Tofranil) is approved for treating childhood enuresis in children older than 6 years. Amitriptyline (Elavil) is a tricyclic antidepressant but is not used for childhood enuresis. Duloxetine (Cymbalt A) is a serotonin–norepinephrine reuptake inhibitor that is used for depression. Venlafaxine (Effexor) is a serotonin–norepinephrine reuptake inhibitor that is used for depression.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. An elderly patient is admitted to the medical unit after a fall. At home he is taking amitriptyline (Elavil) 20 mg three times per day. What adverse effect could be related to the patient's fall A) Urinary frequency B) Urinary retention C) Visual disturbances D) Orthostatic hypotension Ans:D Feedback: Orthostatic hypotension is an adverse effect related to amitriptyline (Elavil). Urinary retention (not frequency) is an adverse effect of amitriptyline but is not related to the falls. Visual disturbances are not a common adverse effect.

7. A 40-year-old man has been prescribed fluoxetine (Proza C). The patient states he has not continued the prescribed therapy even though his depression improved. What assessment is most important for the nurse to make A) Assess for sexual dysfunction B) Assess for hypotension C) Assess for pain and discomfort D) Assess for cardiac dysrhythmia Ans:A Feedback: Fluoxetine (Proza C) produces adverse effects, such as sexual dysfunction. It is imperative that the nurse assess for sexual dysfunction, which is a major reason for noncompliance in men. The assessment of hypotension is not accurate without symptoms of hypotension. The assessment of pain or discomfort is not accurate in this patient. The assessment of cardiac dysrhythmia is not accurate in this patient.

8. A patient is to be switched from fluoxetine (Proza C) to isocarboxazid (Marplan). What patient education is most important when changing from fluoxetine (Proza C) A) Wait 5 days before starting isocarboxazid (Marplan) B) Wait 1 week before starting isocarboxazid (Marplan)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Wait 2 weeks before starting isocarboxazid (Marplan) D) Wait 5 weeks before starting isocarboxazid (Marplan) Ans:D Feedback: If a patient is taking fluoxetine (Proza C) and is being switched to isocarboxazid (Marplan), the fluoxetine should be discontinued at least 5 weeks before starting the MAO inhibitor Waiting less time than this before starting the isocarboxazid (Marplan) will place the patient at risk for serotonin syndrome.

9. Duloxetine (Cymbalt A) is being considered in the treatment of a patient's depression. Which of the following laboratory values would prevent the patient from being treated with this medication A) Decreased hemoglobin level B) Decreased potassium level C) Increased ALT D) Increased erythrocyte sedimentation rate Ans:C Feedback: Duloxetine (Cymbalt A) is highly protein bound, extensively metabolized by CYP2D6 and CYP1A2 enzymes in the liver, and excreted by the kidneys. It is not recommended for use in patients with severe renal or any degree of liver impairment. Low hemoglobin, elevated potassium, and increased ESR do not necessarily preclude the use of Cymbalta.

10. A patient has been prescribed phenelzine sulfate (Nardil), which is an MAO inhibitor. Which of the following foods should the patient avoid eating A) Mashed potatoes and roast beef B) Aged Swiss cheese and bratwurst C) Tortellini in cream sauce D) Anise cookies and milk Ans:B Feedback: When taking an MAO inhibitor, the following foods should be avoided: aged cheeses and meats, concentrated yeast extracts, sauerkraut, and fava beans. None of the other listed foods is problematic.

11. A patient has been prescribed mirtazapine (Remeron). How will it decrease migraine headaches and depression

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) It increases concentration of endogenous epinephrine B) It blocks the presynaptic alpha2-adrenergic receptors C) It acts on the dopamine only receptors in the brain D) It inhibits norepinephrine and serotonin reuptake Ans:B Feedback: Mirtazapine blocks presynaptic alpha2- adrenergic receptors (which increase the release of norepinephrine), serotonin receptors, and histamine H1 receptors. Consequently, the drug decreases anxiety, agitation, insomnia, and migraine headaches as well as depression.

12. A patient suffers from insomnia secondary to temporomandibular joint pain. Which of the following selective serotonin reuptake inhibitors is most effective for treating insomnia A) Fluoxetine (Proza C) B) Olanzapine (Zyprex A) C) Citalopram hydrobromide (Celex A) D) Trazodone (Desyrel) Ans:D Feedback: Trazodone (Desyrel) is administered more often for sedation and sleep than depression. Fluoxetine (Proza C) is not administered for sleep. Olanzapine (Zyprex A) is not administered for sleep. Citalopram hydrobromide is not administered for sleep.

13. A patient is being treated for bipolar disorder with lithium carbonate (Eskalith). He also suffers from congestive heart failure and hypertension. The patient has an increased fluid volume and has recently had difficulty breathing. What laboratory value will most affect the action of the patient's lithium carbonate A) Increased hematocrit B) Increased sodium level C) Increased potassium level D) Increased white blood cell count

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: A sodium excess causes more lithium to be excreted and may lower lithium levels to nontherapeutic ranges. An increased lithium level would not be noted with a patient who has fluid volume excess and hypertension. An increased potassium level is unlikely with fluid volume excess. An increased white blood cell count is indicative of infection, from which the patient does not suffer.

14. A patient with a diagnosis of depression states to the nurse that she has started taking St John's wort to help her feel better and tolerate the demands of parenting. The patient has been taking an SSRI for the past several months. The nurse should teach that patient that this combination may result in A) worsened symptoms of depression B) blood dyscrasias C) dangerous drug interactions D) hemostatic instability Ans:C Feedback: Combining St. John's wort with antidepressants can cause serious adverse effects.

These effects do not typically include worsened depression, alterations in coagulation, or dyscrasias.

15. A patient has been taking lithium carbonate (Eskalith) for many years to treat bipolar disorder. Which of the following diets will require the dose of lithium carbonate (Eskalith) be reduced A) Low calorie B) Low carbohydrate C) Low sodium D) Low residue Ans:C Feedback: A low-salt (sodium) diet will impair lithium secretion, so the dose of lithium should be reduced. The administration of a low-calorie diet will not affect the dose of lithium. The administration of a low-carbohydrate diet will not affect the dose of lithium. The administration of a low-residue diet will not affect the dose of lithium.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

16. A patient treated for bipolar disorder with lithium carbonate (Eskalith) is scheduled for a lithium blood level. What is the therapeutic serum lithium level A) 0.5 to 1.2 mEq/L B) 1.5 to 2.0 mEq/L C) 2.7 to 2.9 mEq/L D) 2.75 to 3.25 mEq/L Ans:A Feedback: The therapeutic serum lithium level is 0.5 to 1.2 mEq/L. A serum lithium level of 2.7 to 2.9 mEq/L is toxic. A serum lithium level of 1.5 to 2.0 mEq/L is toxic. A serum lithium level of 2.75 to 3.25 mEq/L is toxic

17. depression several weeks ago and began taking citalopram (Celex A) 10 days ago. He has now scheduled an appointment at the clinic and has told the nurse that he intends to stop taking the drug, stating, “I don't feel any less depressed than I did before I started taking these pills.” How should the nurse best respond to the patient's statement A) “I'll pass that information along to your care provider; a different drug might be more appropriate for you.”

B) “I'd encourage you to continue with the drug; it can take several weeks before it improves your mood.”

C) “People who take this drug often think they don't feel better because the changes in mood are incremental and subtle.”

D) “It could be that one of the other medications or supplements you're taking is negating the effects of Celexa.”

Ans:B Feedback: Steady-state blood levels of SSRIs are achieved slowly, over several weeks. This aspect of pharmacokinetics is more likely than a possible drug interaction. The patient should expect to sense an eventual improvement in mood, and it would be premature to change medications.

18. A high school–aged girl has been suffering from major depression for several months, and she has begun treatment with an SSRI. In light of the black box warning accompanying SSRIs, the nurse should prioritize which of the following assessments A) Assessment for venous thromboembolism (VTE) B) Assessment of cardiac rate and rhythm C) Assessment for hypomanic state D) Assessment for suicidal ideation

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: The FDA has issued a black box warning alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications. VTE, arrhythmias, and hypomania are not likely adverse effects.

19. A patient with a diagnosis of major depression has failed to respond to treatment with SSRIs, and the use of venlafaxine is being considered. The psychiatric nurse would recognize that this drug may have a therapeutic effect by which of the following means A) Slowing the reuptake of endorphins in the CNS B) Increasing levels of serotonin and norepinephrine C) Stimulating synthesis and potentiating the action of dopamine D) Slowing the reuptake of acetylcholine in brain synapses Ans:B Feedback: Venlafaxine increases the levels of serotonin and norepinephrine in the brain by preventing the reuptake of these neurotransmitters known to play an important part in mood. It does not directly affect endorphins or acetylcholine The drug weakly inhibits dopamine reuptake.

20. An elderly woman tells the nurse that she was successfully treated with phenelzine (Nardil) during a bout of severe depression in the 1970s. Her mood has been worsening in recent years as she has dealt with the death of her husband and functional declines. As a result, she has asked the nurse if her care provider is likely to prescribe this same drug. What fact should underlie the nurse's response to the patient A) Cognitive behavioral therapy has been found to be more effective than MAO inhibitors, so they are rarely prescribed B) In most situations, MAO inhibitors have been largely superseded by tricyclic antidepressants C) The risks of serious drug interactions and food interactions mean that MAO inhibitors are rarely used D) MAO inhibitors are rarely used because serum levels must be monitored with blood work every 2 weeks

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: MAO inhibitors are rarely used in clinical practice today, mainly because they may interact with some foods and drugs to produce severe hypertension and possible heart attack or stroke. Serum levels do not need to be monitored. The potential benefits of cognitive behavioral therapy do not affect prescribers' decisions to use MAO inhibitors. SSRIs have become the first line of treatment for depression, replacing tricyclic antidepressants.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 56 Drug Therapy for Psychotic Disorders 1. A person is seen wandering the streets and talking in an animated way to people who are not there. From what disorder do you suspect the person is suffering A) Confusion B) Delusions C) Psychosis D) Depression Ans:C Feedback: The patient is suffering from psychosis, which is a severe mental disorder characterized by disordered thought processes. Delusions are false beliefs that persist in the absence of reason or evidence and are also a symptom of a psychosis. Depression is a disorder and symptom that is not as severe as a psychotic disorder. Confusion is a more generic term that denotes a lack of clear thinking.

2. A patient is admitted to the hospital for cardiac surgery and has just come up to the postsurgical unit from the recovery room. He develops unprecedented confusion and states, “I see bugs up and down the walls. They are going to get me.” The nurse suspects the patient is suffering from what symptom A) Depression B) Delusions C) Delirium D) Schizophrenia Ans:C Feedback: The patient is suffering from delirium as a postoperative complication. Delusions are false beliefs that persist in the absence of reason or evidence. Schizophrenia is a variety of disorders and not a single symptom.

3. A teenage boy has begun to exhibit the characteristic signs and symptoms of schizophrenia.

During his mother's pregnancy, during what time in development could she have experienced an intrauterine insult A) Conception B) First trimester C) Second trimester

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Third trimester Ans:C Feedback: The neurodevelopmental model proposes that schizophrenia results when abnormal brain synapses are formed in response to an intrauterine insult during the second trimester of pregnancy, when neuronal migration is normally taking place. At conception, no implantation in the uterus has occurred. The first trimester is prior to neuronal migration. The third trimester is after neuronal migration.

4. A patient is experiencing an episode of psychosis. He is belligerent, loud, and abusive when you enter the room. What is the best response by the nurse during future interactions A) Respond to him in an assertive tone B) Use a calm, soft voice C) Delegate care to the technician D) Place him in the quiet room Ans:B Feedback: The most therapeutic communication technique for this patient is to use a calm, soft voice. To respond to the patient in a loud tone will increase his agitation. Delegating care to the patient care technician can increase the patient's agitation based on the fact that the unlicensed caretaker may not possess strong therapeutic communication skills. Placing the patient in a quiet room will not affect any changes in his behavior and may increase his hallucinations.

5. A patient who has a diagnosis of schizophrenia is likely to have which of the following pathophysiologic effects A) Increased dopamine B) Increased serum potassium C) Decreased numbers of glutamate receptors D) Decreased interaction with GABA Ans:A Feedback: The patient suffering from schizophrenia has increased dopamine activity in the brain. The amount of potassium would cause other physiological symptoms, but not affect schizophrenic symptoms. The patient with schizophrenia will have widespread glutamate receptors, not decreased glutamate receptors. In addition, the glutamatergic system interacts with the dopaminergic and gamma- aminobutyric acid systems and possibly other neurotransmission systems.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient has been prescribed an antipsychotic agent to relieve psychotic symptoms. Which of the following goals of care is the priority A) The patient will demonstrate independent health maintenance B) The patient will interact therapeutically with peers C) The patient will participate in activities of daily living D) The patient will remain safe Ans:D Feedback: Safety is a priority over other goals. Goals such as participation in ADLs, health maintenance, and participation in relationships are valid, but safety is a priority.

7. A patient in her 60s has been living with schizophrenia since she was a young woman and was treated with chlorpromazine for many years. The nurse who is meeting the patient for the first time observes that the patient continually smacks her lips and appears to be chewing. The nurse should recognize that this patient is likely experiencing what problem A) Tardive dyskinesia B) Akathisia C) Dystonias D) Neuroleptic malignant syndrome Ans:A Feedback: Tardive dyskinesia occurs as the result of long-term use of chlorpromazine. Patients may experience lip smacking, tongue protrusion, and facial grimaces and may have choreic movements of trunk and limbs Akathisia is a form of restlessness, and dystonias are uncoordinated movements. Neuroleptic malignant syndrome is an acute complication.

8. An elderly patient with a long-standing history of schizophrenia has been admitted to the hospital for treatment of hyponatremia The nurse reviews the patient's medical chart and reads that the patient was previously treated with phenothiazine antipsychotics

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

What medication may this patient have been treated with A) Aminophylline (Theophylline) B) Acetylsalicylic acid (aspirin) C) Chlorpromazine (Thorazine) D) Dantrolene sodium (Dantrium) Ans:C Feedback: Chlorpromazine (Thorazine) is the prototype phenothiazine. Aminophylline (Theophylline) is a xanthine agent administered to increase bronchioles. Acetylsalicylic acid (aspirin) and dantrolene sodium (Dantrium) are not phenothiazines.

9. A patient who was diagnosed with schizophrenia in 1962 was prescribed chlorpromazine (Thorazine). The patient has been taking the medication for more than 40 years. What adverse effect will the patient most likely experience A) Hypertension B) Extrapyramidal effects C) Central nervous system agitation D) Urinary frequency Ans:B Feedback: A patient who has taken chlorpromazine (Thorazine) on a long-term basis will be at risk for late extrapyramidal effects Hypertension is not an adverse effect of chlorpromazine, but hypotension is an adverse effect.

Central nervous system agitation is not an adverse effect of chlorpromazine, but central nervous system depression is an adverse effect. Urinary frequency is not an adverse effect of chlorpromazine, but urinary retention is an adverse effect.

10. A child suffers from tics and verbal outbursts in the classroom and while he is awake. The patient is prescribed haloperidol (Haldol) What disease process is haloperidol (Haldol) used to treat A) Muscular dystrophy B) Early-onset dementia C) Tourette's syndrome D) Myasthenia gravis Ans:C Feedback: Haloperidol (Haldol) is used in treating Tourette's syndrome, which is a disorder characterized by involuntary movements and vocalizations. Muscular dystrophy is not treated with atypical antipsychotics Alzheimer's disease is not normally treated with atypical antipsychotics. Myasthenia gravis is not treated with atypical antipsychotics.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

11. A patient is prescribed clozapine (Clozaril). The patient and family should be instructed on the adverse effects of this medication What laboratory test is most important in the first months of the medication regime A) Weekly liver enzymes B) Daily INR C) Monthly creatinine levels D) Regular complete blood counts Ans:D Feedback: Clozapine (Clozaril) is associated with life- threatening decrease in white blood cells (agranulocytosis). It is essential to monitor the complete blood count due to this risk. Weekly liver enzymes are not recommended when administering clozapine. Monthly creatinine levels and INR monitoring are not recommended with clozapine therapy.

12. A patient is prescribed olanzapine (Zyprex A) for the treatment of schizophrenia. The patient tells the nurse he is voiding three times each night and is always thirsty. Based on the adverse effects of this medication, what should the nurse suspect the patient has developed A) Urinary tract infection B) Diabetes mellitus C) Renal calculi D) Hyperthyroidism Ans:B Feedback: The development of polyuria and polydipsia is indicative of diabetes mellitus.

Olanzapine has been associated with weight gain, hyperglycemia, and initiation or aggravation of diabetes mellitus. Urinary tract infection is not considered an adverse effect with olanzapine.

Renal calculus is not an adverse effect of olanzapine. Hyperthyroidism is not an adverse effect of olanzapine.

13. A patient diagnosed with schizophrenia is being seen by the home care nurse. What is the most important aspect of patient teaching with this patient A) Maintain the medication regimen B) Report signs of neuralgia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Stop medications if weight gain occurs D) Limit alcohol intake to two drinks per day Ans:A Feedback: The patient should be instructed to maintain the medication regime to control symptoms of schizophrenia. Reporting signs of neuralgia is not taught because the medication does not have this effect. The medications will cause weight gain and should not be stopped in the event that weight gain develops. The use of alcohol is strictly prohibited with antipsychotic agents.

14. A patient with schizophrenia has been taking haloperidol for several years. The care team and the patient have collaborated and chosen to transition the patient to an atypical antipsychotic in an effort to reduce adverse effects and maximize therapeutic effects. In order to reduce the patient's risk of extrapyramidal effects during this transition, the care team should do which of the following A) Gradually taper the dose of haloperidol B) Have a 2- to 3-week “drug holiday” between stopping the haloperidol and starting the atypical antipsychotic C) Administer haloperidol and the atypical antipsychotic drug concurrently for 6 to 8 weeks D) Arrange for weekly electroconvulsive therapy during the time of transition Ans:A Feedback: When discontinuing haloperidol, it is essential to taper the dosage to prevent extrapyramidal symptoms. If the medication is abruptly discontinued, the patient is at risk for this condition. A drug holiday would exacerbate symptoms, and ECT is not indicated Concurrent administration of two drugs has the potential to exacerbate adverse effects

15. A psychiatric nurse is discussing the advantages of atypical antipsychotics with the parents of a teenage girl who has been diagnosed with schizophrenia. When comparing these drugs with the older, typical antipsychotics, what advantage should the nurse cite A) Lower cost B) The possibility of oral administration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Reduced adverse effects D) Absence of black box warnings Ans:C Feedback: Atypical antipsychotics may be more effective in relieving some symptoms than typical antipsychotics, and they usually produce milder adverse effects. A major drawback is the high cost of these drugs. All antipsychotics are available for the oral route. There are several black box warnings relating to atypical antipsychotics.

16. A 22-year-old man's increasingly bizarre behavior has culminated in a diagnosis of schizophrenia. In light of current treatment modalities for schizophrenia, the nurse should anticipate that the patient is most likely to be prescribed what drug A) Chlorpromazine (Thorazine) B) Olanzapine (Zyprex A) C) Haloperidol (Haldol) D) Prochlorperazine (Compazine) Ans:B Feedback: The "atypical" antipsychotics, such as olanzapine, are the drugs of choice, especially for patients who are newly diagnosed with schizophrenia

17. A psychiatric nurse is providing care for a female patient with schizophrenia whose medication regimen includes oral chlorpromazine. When administering this medication, the nurse should do which of the following A) Have the patient hold the drug under her tongue for at least 30 seconds B) Administer the drug 1 to 2 hours before bedtime C) Administer the drug on alternating days D) Instruct the patient to avoid dairy products for 1 hour before and 2 hours after administration Ans:B Feedback: For oral administration of chlorpromazine, the nurse should give doses 1 to 2 hours before bedtime; peak sedation occurs in about 2 hours. The drug is not given on alternating days, and there is no need to avoid dairy products. It is unnecessary for the patient to hold the drug under her tongue.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A patient has been achieving an acceptable reduction in his positive and negative signs of schizophrenia after several weeks of treatment with clozapine. The patient has asked the nurse if it is acceptable for him to have “a few drinks from time to time.” How should the nurse best respond to the patient's inquiry A) “If you notice that your symptoms are worsening when you drink, you should stop doing it.”

B) “That shouldn't present a problem, provided you make sure that you're safe when you do it.”

C) “That's okay in most cases, but it's advisable to limit it to beer and wine and to avoid spirits.”

D) “When you're taking clozapine, it's best to avoid drinking alcohol altogether.”

Ans:D Feedback: Alcohol increases central nervous system depression in patients taking clozapine; patients should ideally abstain from drinking alcohol.

19. A patient's medication administration record orders the IM administration of chlorpromazine. When administering this drug, the nurse should A) observe the patient while he or she self- administers the drug B) administer the drug into the deltoid muscle with a 1 1/2-inch needle C) have the patient massage the injection site for 1 to 2 minutes after the injection D) have the patient lie down for 30 to 60 minutes after the injection Ans:D Feedback: For IM administration of chlorpromazine, the nurse should have the patient lie down for 30 to 60 minutes after the injection to prevent orthostatic hypotension. Massage is unnecessary, and the ventrogluteal site is used. Self-administration is not the norm.

20. Parenteral haloperidol has been ordered for a patient who is experiencing an acute psychotic episode. The nurse should recognize what primary goal of treatment A) Increased insight into delusional thinking B) Increased sophistication of thinking C) Decreased agitation and combativeness D) Decreased CNS stimulation Ans:C Feedback: When haloperidol is given for acute psychotic episodes, the nurse observes for sedation, decreased agitation, combativeness, and psychomotor activity. Insight, clarity of

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

thinking, and decreased CNS stimulation are not short-term priorities during an acute psychotic episode

Chapter 57 Drug Therapy for Attention Deficit Hyperactivity Disorder and Narcolepsy

1. A 4-year-old child is brought to the pediatric clinic by his mother. She states, “I don't know what to do with him. He is in constant motion. He won't sit for more than a few seconds and he is doing something else. He often throws his toys and yells loudly, even compared with other kids his age.” The child is diagnosed with attention deficit hyperactivity disorder Which of the following medications will most likely be administered in conjunction with treatment A) ACE inhibitors B) SSRIs C) Central nervous system stimulants D) MAO inhibitors Ans:C Feedback: ADHD is characterized by persistent hyperactivity, short attention span, difficulty completing tasks, restlessness, and impulsivity. The diagnosis has increased in recent years, with a concomitant increase in the use of prescribed CNS stimulants for its treatment. SSRIs, ACE inhibitors, and MAOIs are not typically used.

2. A patient visits the occupational health office of the factory in which he works. He has fallen asleep on the line and has a history of muscle weakness. This instance is not the first time he has fallen asleep on the line. From what disease process does the occupational health nurse suspect the patient is suffering A) Sleep apnea B) Insomnia C) Narcolepsy D) Substance abuse Ans:C Feedback: Narcolepsy is characterized by daytime sleep attacks in which the person goes to sleep at any place or at any time. Sleep apnea is episodes of apnea during sleep. Insomnia is the inability to sleep. This patient is not exhibiting signs and symptoms of substance abuse.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A patient suffers from narcolepsy. Which of the following aspects of patient teaching should be provided A) Take 250 mg of caffeine daily B) Avoid working shifts C) Take a lengthy nap every afternoon D) Increase the Ritalin dose as needed Ans:B Feedback: The patient who is diagnosed with sleep apnea should avoid shift work. Caffeine use may or may not be indicated. The patient should ideally not take naps. The patient should not increase the Ritalin dose without the input of the primary health provider.

4. A child is prescribed an amphetamine for attention deficit hyperactivity disorder. Which of the following effects provide evidence that the medications are working A) Improved grades B) Increased sleep quality C) Lethargy D) Polyphagia Ans:A Feedback: Amphetamines used with ADHD improve academic performance. Amphetamines often decrease sleep. Amphetamines will not result in lethargy. Amphetamines decrease appetite and do not cause polyphagia 5. A patient is taking dextroamphetamine for ADHD. He has developed constipation since beginning therapy. Which of the following should the patient be taught A) Take an OTC laxative daily B) Increase fiber intake C) Take diphenoxylate hydrochloride (Lomotil) D) Take metronidazole (Flagyl) Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A patient who is experiencing constipation should be instructed to increase fiber in his diet. The patient should not take a laxative. The patient should not be instructed to take diphenoxylate hydrochloride (Lomotil) because it is an antidiarrheal agent. The patient should not be given metronidazole (Flagyl).

6. A neonate is suffering from apnea. Which of the following medications may be administered as a respiratory stimulant A) Caffeine and methylphenidate B) Caffeine and Mefoxitin C) Caffeine and sodium benzoate D) Caffeine and sodium bicarbonate Ans:C Feedback: The combination of caffeine and sodium benzoate is occasionally used as a respiratory stimulant in neonates. Caffeine is not mixed with methylphenidate. Caffeine is not mixed with Mefoxitin. Caffeine is not mixed with sodium bicarbonate for this indication.

7. A patient has been treated with dextroamphetamine for ADHD. At the age of 16 years, she is diagnosed with hyperthyroidism. What intervention should be implemented with this patient A) Discontinue the high-calorie diet B) Assess the patient for pulmonary edema C) Discontinue the amphetamines D) Administer a proton pump inhibitor Ans:C Feedback: Amphetamines are contraindicated upon the development of hyperthyroidism. The patient will require a higher calorie count, not a discontinuation of a high-calorie count. The patient will not require an assessment for pulmonary edema. The patient will only require a proton pump inhibitor if gastric hyperacidity occurs.

8. A teenage boy is on amphetamine therapy for attention deficit hyperactivity disorder. The care provider has suggested a “drug holiday” for July and August. What is the purpose of this drug holiday A) To minimize weight loss B) To prevent hyperthyroidism C) To allow electrolyte imbalances to resolve

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) To slow bone resorption Ans:A Feedback: Dextroamphetamine often causes loss of appetite, and the health care provider may stop the medication during the months when the child is not in school. A drug holiday, as this is called, helps decrease weight loss and growth suppression. It does not address potential electrolyte imbalances, thyroid imbalances, or the process of bone remodeling.

9. A patient is seen in the ambulatory care clinic with a complaint of insomnia. What should the nurse assess in regard to the complaint of insomnia A) Daily intake of caffeine-containing products B) The amount of exercise in which the patient engages C) The family history of insomnia and sleep D) Possible use of amphetamines Ans:A Feedback: The daily intake of caffeine should be assessed to determine if the intake is sufficient to disturb sleep. The amount of exercise the patient engages in is important but not as critical as caffeine consumption. The family history of insomnia and sleep is not critical to assess.

Amphetamines also have the potential to disrupt sleep, but caffeine use is far more prevalent.

10. A female patient asks the nurse how much caffeine is safe to consume per day. What is the recommended amount of caffeine for a nonpregnant woman A) 125 mg of caffeine B) 250 mg of caffeine C) 500 mg of caffeine D) 1 g of caffeine Ans:B Feedback: Some authorities recommend that normal, healthy, nonpregnant adults consume not more than 250 mg of caffeine daily. 125 mg of caffeine is lower than the recommended safe amount of consumption. 500 mg to 1 g is more than the recommended daily consumption of caffeine.

11. A patient who suffers from asthma is given theophylline. Theophylline will have an increased effect if taken with A) Ritalin B) atomoxetine (Stratter A)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) modafinil (Provigil) D) caffeine Ans:D Feedback: Caffeine increases the effects of theophylline. Ritalin, Provigil, and Strattera are noted to have this effect 12. dextroamphetamine for the treatment of ADHD. During health education, the nurse should make the patient aware of the black box warning relating to A) the risks of kidney failure B) the potential for abuse C) the risk of stroke with excessive doses D) the potential for unstable blood glucose levels Ans:B Feedback: A black box warning makes users of dextroamphetamine aware of the drug's high abuse potential. Black box warnings do not address the potential for renal failure, stroke, or unstable blood sugars.

13. A 13-year-old child is started on atomoxetine (Stratter A) for ADHD. The patient and his family should be taught about the peak plasma levels of the medication. He takes his medication at 07:00 AM. When will this medication reach its peak plasma level A) 08:00 to 09:00 AM B) 09:45 to 10:30 AM C) 10:30 to 11:45 AM D) 13:00 to 14:00 PM Ans:A Feedback: Atomoxetine is rapidly absorbed with peak plasma levels in 1 to 2 hours. If he takes the medication at 07:00 AM, it will peak at 08:00 to 09:00 AM. 14. A patient with narcolepsy is placed on a central nervous system stimulant. What is the central nervous system stimulant of choice to treat narcolepsy A) Atomoxetine (Stratter A) B) Guarana

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Caffeine D) Modafinil (Provigil) Ans:D Feedback: Modafinil (Provigil) is used to treat narcolepsy. Atomoxetine is administered for ADHD. Guarana is the main ingredient in caffeine and is not administered for narcolepsy.

Caffeine is not administered for narcolepsy.

15. A boy has been diagnosed with ADHD and has been prescribed Ritalin. The boy's mother tells the nurse that she does not understand why a stimulant would help him, stating, “If anything, he's completely overstimulated, not understimulated!” What should the nurse explain to the mother about the therapeutic use of Ritalin A) Ritalin helps with the symptoms of ADHD, but the reasons for this are not well understood B) Ritalin stimulates the parasympathetic nervous system, resulting in increased control of behavior C) Ritalin stimulates the limbic system, which regulates control over behavior and affect D) Ritalin enhances the function of dopamine, which regulates cognition Ans:A Feedback: The efficacy of Ritalin in ADHD is paradoxical and not well understood. It does not significantly affect dopamine levels or the function of the limbic system and parasympathetic nervous system.

16. After experiencing two workplace accidents in which he fell asleep, a 30-year-old construction worker has been diagnosed with narcolepsy. The patient admits that he is embarrassed to receive this diagnosis and is adamant that no one find out about it. The nurse should respond to the patient by explaining what aspect of the etiology A) “This is the result of neurological factors over which you have no direct control.”

B) “In a lot of cases, making improvements to your sleep habits can resolve narcolepsy.”

C) “This is something that runs in certain families, and it's not your fault that this has happened.”

D) “This usually stems from suppressed emotions, so counseling usually helps greatly.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Narcolepsy is a neurological sleep disorder, not the result of mental illness or psychological problems. It is most likely due to a number of genetic abnormalities, but family history is not noted to be highly significant.

17. A 13-year-old boy has been taking dextroamphetamine for the treatment of ADHD since he was 10, achieving significant improvements in behavior and mood. When assessing the boy during a scheduled follow- up appointment, the nurse should prioritize what physical assessment A) Abdominal girth and assessment for peripheral edema B) Measurement of height and body weight C) Visual acuity and hearing ability D) Assessment of deep tendon reflexes and peripheral pulses Ans:B Feedback: Suppression of weight and height may occur in children taking amphetamines, and the nurse ensures that growth is monitored during drug therapy. Assessments for edema, diminished reflexes, and sensory deficits are not normally warranted

18. A high school boy has been brought to the emergency department (E D) by his friends who state that he has taken a “whole handful of Dex” and is now lapsing in and out of consciousness. The ED nurse should prioritize what assessment related to dextroamphetamine overdose A) Blood glucose monitoring B) Cognitive assessment C) Lung function testing D) Cardiac monitoring Ans:D Feedback: Dextroamphetamine misuse may cause sudden death or serious cardiovascular events. It is essential to obtain a baseline electrocardiogram (ECG) and blood pressure reading.

These assessments are priorities over blood glucose monitoring, respiratory assessment, and cognitive assessment.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A 12-year-old girl has undergone an extensive diagnostic workup that has resulted in a diagnosis of ADHD. The prescriber has reviewed the benefits and risks of dextroamphetamine therapy, and the nurse is now reviewing the correct schedule for taking the drug. The child should most likely take her dextroamphetamine at what times A) 07:00 and 11:30 B) 07:30, 11:30, 16:30, and 20:00 C) 08:00 and 20:00 D) 09:00, 14:00, and 19:00 Ans:A Feedback: People should take the first dose of dextroamphetamine on awakening or early in the day and the last dose at least 6 hours before bedtime. Twice-daily dosing is most common

20. Methylphenidate will be used to treat a 9- year-old boy's ADHD. In light of this drug's most common adverse effects, the nurse who is working with the family should implement what strategy A) A strategy to ensure that the boy maintains normal bladder function B) A plan to address the boy's loss of appetite C) A plan to enhance the boy's self-esteem D) A strategy to regularly monitor the boy's blood glucose levels Ans:B Feedback: Like dextroamphetamine, methylphenidate often causes loss of appetite. Plans to address this should be in place at the beginning of therapy. Frequent blood glucose monitoring and actions to maintain bladder function are not likely necessary. Self-esteem should likely be addressed during treatment, but reduced self-esteem is not an adverse effect of methylphenidate.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 58 Drug Therapy for Substance Abuse Disorders 1. A patient has a long history of heavy alcohol use and has been admitted to the hospital for traumatic injuries after a motor vehicle accident. How should the nurse best assess the patient for physical dependence on alcohol A) Assess the patient's perceptions of his coping strategies B) Assess whether the patient ever feels guilty about his drinking C) Assess the patient for signs and symptoms of alcohol withdrawal D) Assess the patient's typical alcohol intake Ans:C Feedback: Physical dependence involves physiologic adaptation to chronic use of a drug so that withdrawal, or unpleasant symptoms, occurs when the drug is stopped, when its action is antagonized by another drug, or when its dosage is decreased. Assessment of coping strategies, alcohol intake, and the patient's feelings about his drinking are relevant, but none directly addresses the possibility of physical dependence.

2. A patient is admitted to the hospital for treatment of a stasis ulcer of the right leg. The patient's history indicates he has abused alcohol in the past, and he typically consumes at least eight alcoholic beverages daily. What symptoms should the nurse assess the patient for A) Confusion, hallucination, agitation, tremors B) Denial, manipulation, combativeness C) Depression, remorse, withdrawal from reality D) Suspicion, mania, stubbornness, fear Ans:A Feedback: Delirium tremens, the most serious form of alcohol withdrawal, is characterized by confusion, disorientation, delusions, visual hallucinations, and other signs of acute psychosis.

Denial, manipulation, combativeness, depression, remorse, withdrawal from reality, suspicion, mania, stubbornness, and fear are not symptoms of alcohol withdrawal.

3. A patient was admitted to the emergency room with acute alcohol intoxication and has been diagnosed with alcohol abuse after subsequent assessment and treatment. What are the goals of long-term treatment of this patient's substance abuse disorder

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Detoxification, abstinence, and prevention of relapse B) Withdrawal, reeducation, and compliance C) Withdrawal, abstinence, and accountability D) Assessment, planning, and intervention Ans:A Feedback: The major goals of treatment for substance abuse are detoxification, initiation of abstinence, and prevention of relapse Withdrawal may occur, but this is not a goal of treatment. The nursing process may be utilized, but the steps of the process are not the goals of treatment.

4. A patient is admitted to the inpatient alcohol rehabilitation program. What medication will the patient most likely be prescribed to treat alcohol withdrawal syndromes A) Clonidine (Catapres) B) Methyldopa (Aldomet) C) Chlordiazepoxide (Librium) D) Atenolol (Tenormin) Ans:C Feedback: Benzodiazepines antianxiety agents are the drugs of choice for treating alcohol withdrawal syndromes. Chlordiazepoxide is administered to patients for acute withdrawal syndrome. Clonidine is not a benzodiazepine and is not prescribed for acute alcohol syndrome.

Methyldopa is not a benzodiazepine and is not prescribed for acute alcohol syndrome. Atenolol is not a benzodiazepine and is not prescribed for acute alcohol syndrome.

5. A 77-year-old patient is admitted for the treatment of a fracture, and the nurse has identified that the patient has a history of heavy alcohol use. At what point should the care team administer pharmacologic treatments for alcohol withdrawal A) After skeletal muscle relaxants have taken effect B) As soon as the patient shows signs of withdrawal C) After cognitive behavioral therapy has begun D) After treatment for the patient's acute injuries has been completed Ans:B Feedback: Treatment with chlordiazepoxide for alcohol withdrawal should begin as soon as the clinician identifies that the patient needs it. It is unsafe to delay treatment of withdrawal Muscle relaxants are not indicated in the treatment of alcohol withdrawal.

6. A patient is admitted to the emergency room suffering from symptoms of alcohol withdrawal.

The nurse should plan care with the goal of preventing which of the following

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Bradycardia B) Hypotension C) Seizures D) Gastrointestinal bleeding Ans:C Feedback: In acute alcohol withdrawal, a goal of treatment is to prevent seizures. Bradycardia is not the primary symptom of acute alcohol withdrawal. Hypotension is not the primary symptom of acute alcohol withdrawal Gastrointestinal bleeding results from heavy alcohol use but is not the primary symptom of acute alcohol withdrawal.

7. A patient who suffers from alcoholism is prescribed disulfiram (Antabuse). How does this medication assist the patient in refraining from ingestion of alcohol A) Allows the accumulation of acetaldehyde B) Increases the level of serotonin C) Increases the level of acetylcholine D) Decreases stimulation of the CNS Ans:A Feedback: Disulfiram interferes with hepatic metabolism of alcohol and allows accumulation of acetaldehyde. Disulfiram does not increase the level of serotonin. Disulfiram does not increase the level of acetylcholine. Disulfiram does not decrease the stimulation of the central nervous system.

8. A patient who has long abused alcohol is being treated with disulfiram (Antabuse). The patient currently takes phenytoin (Dilantin) for an underlying seizure disorder. Based on the interaction of these two medications, what will need to be adjusted in the medication administration A) The patient will require more frequent administration of disulfiram (Antabuse) B) The patient will require a larger dose of disulfiram (Antabuse) C) The patient will require a reduced dose of phenytoin (Dilantin) D) The patient will require phenytoin (Dilantin) to be administered twice daily Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The patient will require a reduced dose of phenytoin (Dilantin) because disulfiram interferes with the metabolism of phenytoin. The patient will not require more frequent administration of disulfiram. The patient will not require a larger dose of disulfiram. The patient will not require increased administration of phenytoin.

9. A patient is taking disulfiram (Antabuse) and later consumes several shots of vodka. What effect will be produced from the combination of alcohol and disulfiram A) Hypertension B) Vomiting C) Hyperalertness D) Oral bleeding Ans:B Feedback: Disulfiram interferes with hepatic metabolism of alcohol and allows the accumulation of acetaldehyde. If alcohol is ingested during disulfiram therapy, acetaldehyde causes headaches, confusion, seizures, chest pain, flushing, palpitations, hypotension, sweating, blurred vision, nausea, vomiting, and a garlic- like aftertaste. Disulfiram will not cause hypertension, increased alertness, or bleeding.

10. A 22-year-old male is brought to the emergency room due to an overdose of diazepam (Valium). What drug will be administered in the emergency room to treat the overdose A) Disulfiram (Antabuse) B) Flumazenil (Romazicon) C) Methadone (Dolophine) D) Naloxone (Narcan) Ans:B Feedback: Flumazenil (Romazicon) is a specific antidote that can reverse benzodiazepineinduced sedation, coma, and respiratory depression Disulfiram is not administered to reverse benzodiazepine overdose. Methadone is not administered to reverse benzodiazepine overdose. Naloxone is not administered for benzodiazepine overdose.

11. A patient is being treated for opioid abuse after many years of cocaine and heroin use. The nurse should anticipate that this patient will be treated with what drug A) Disulfiram (Antabuse) B) Flumazenil (Romazicon) C) Methadone (Dolophine) D) Naloxone (Narcan)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Opioid withdrawal symptoms are treated with methadone. Naloxone is used to treat acute opioid intoxication or overdose, but it is not used to treat opioid abuse.

12. A nurse is providing health education for the family of a patient who has a substance use disorder. How should the nurse best explain the etiology of this disorder A) “Substance abuse is multifactorial and involves genetics, personality, and culture.”

B) “Substance abuse is considered to be primarily a cultural concept, since definitions vary widely across time and place.”

C) “Many different factors contribute to substance abuse, but the primary ones are lack of willpower and impaired coping.”

D) “Substance abuse is a complex phenomenon, and science has not yet begun to truly understand the phenomenon.”

Ans:A Feedback: Researchers have identified a number of factors in the predisposition to substance abuse and dependence. These factors include genetics, personality, and culture. The disorder is not, however, solely rooted in culture or wholly misunderstood. It is simplistic to understand the disorder as resulting from impaired coping and lack of willpower.

13. A patient with a diagnosis of endocarditis has been admitted, and the care team is aware that IV opioid use is the origin of the patient's infection. The patient is open to the idea of treatment for her substance abuse disorder When planning this aspect of the patient's care, what goal should the nurse first address A) Compliance with treatment B) Safe detoxification C) Taking ownership of the problem D) Adequate stimulation of the CNS Ans:B Feedback: The major goals of treatment for substance abuse are detoxification, initiation of abstinence, and prevention of relapse Ensuring the patient's safety during detoxification is a priority over compliance with treatment.

Taking ownership and providing CNS stimulation are not priority goals.

14. A man has asked the care team to consider the use of benzodiazepines to treat his wife's severe alcoholism. The use of benzodiazepines for this purpose may be contraindicated in what circumstances

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The patient is acutely intoxicated B) The patient denies the severity of her addiction C) The patient has previously been treated with benzodiazepines D) The patient is also addicted to nicotine Ans:A Feedback: If the patient's vital signs are depressed during acute intoxication, the use of benzodiazepines is contraindicated. Denial, previous treatment with benzodiazepines, and nicotine addiction do not contraindicate this treatment.

15. A 33-year-old patient with a diagnosis of alcoholism is to be treated with chlordiazepoxide on an inpatient basis. When a nurse is administering this medication, he or she should do which of the following actions A) Monitor the patient's vital signs closely during IV administration B) Administer the oral form of the medication if the patient is combative C) Assess the patient's cardiac status prior to administering each dose D) Promptly stop administering the medication once status improvements are noted Ans:A Feedback: The nurse should take the patient's vital signs regularly when giving the IV form of this drug, as well as observe and document subjective and objective reports by the patient.

Combative patients usually require a parenteral route of administration, and it is unnecessary to perform a full cardiac assessment before each dose. Usage should be tapered, and not stopped abruptly, in order to prevent rebound CNS stimulation.

16. A patient was admitted with a diagnosis of a gastrointestinal bleed, the latest of several hospital admissions that have been attributed to his alcohol abuse. The addictions medicine specialist has prescribed disulfiram, which will A) prevent the patient from experiencing euphoria if he drinks alcohol B) produce unpleasant reactions if the patient drinks alcohol C) intensify the patient's CNS depression if he drinks alcohol D) result in a depressed mood if he drinks alcohol Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Disulfiram inhibits the enzyme aldehyde dehydrogenase to block the oxidation of alcohol. The resulting accumulation of acetaldehyde produces an unpleasant reaction when disulfiram is consumed with alcohol The effects do not include prevention of euphoria, increased CNS depression, or depressed mood, however.

17. A patient with a well-known history of heroin use has begun addiction treatment. The nurse had administered the patient's daily dose of methadone. The nurses should know that this medication aids in treating opioid addiction because it does which of the following A) Acts as an agonist at opioid receptors and prevents withdrawal symptoms B) Acts as an opioid antagonist and causes unpleasant symptoms if the patient uses opioids C) Acts on the limbic system and the reticular system to suppress brain activity associated with addiction D) Depresses the CNS to a similar degree as opioids, aiding in detoxification Ans:A Feedback: Methadone is an agonist at specific opioid receptors in the CNS. Its action allows it to prevent symptoms of withdrawal. It does not cause unpleasant effects if the patient uses opioids and does not act directly on the limbic system or reticular system.

18. A patient has been brought to the emergency department by paramedics. The patient's known history and highly agitated state are suggestive of cocaine-induced psychosis What assessment should the nurse prioritize prior to administering pharmacologic treatments A) Assessment of blood glucose levels B) Assessment of cranial nerve function C) Lung auscultation D) Cardiovascular assessment Ans:D Feedback: Cocaine intoxication carries a high risk for cardiac dysrhythmias. Consequently, cardiovascular assessment would be a priority over lung auscultation, assessment of cranial nerve function, or assessment of blood glucose levels

19. A 15-year-old boy with a complex psychosocial history is being treated for inhalant abuse.

When providing health education to this boy, the nurse should cite which of the following risks associated with inhalant abuse

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Hyperactivity B) Psychological dependence C) Physiological dependence D) Organ damage Ans:D Feedback: Inhalants can harm the brain, liver, heart, kidneys, and lungs, and abuse of any drug during adolescence may interfere with brain development. Dependence has not been definitively demonstrated, and hyperactivity is not a risk.

20. A patient is being treated for addiction to cocaine and heroin and will begin treatment with naltrexone (ReVi A). If the patient uses an opioid after taking this drug, the nurse should expect what effect A) The patient will experience a decline in neurological function B) The patient will experience visual disturbances and unpleasant hallucinations C) The patient will not experience the usual physiological effects of opioids D) The patient will experience a sudden onset of nausea and vomiting Ans:C Feedback: Naltrexone (ReVi A) is a pure opioid antagonist that blocks opioids from occupying receptor sites, thereby preventing their physiologic effects. It will not cause neurological deficits, GI upset, or hallucinations

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 59 Drug Therapy for Disorders of the Eye 1. A patient is diagnosed with a fungal infection of the eye. What of the following medications is the most likely the cause of the fungal infection of the eye A) Ophthalmic corticosteroid B) Systemic antibiotic agent C) Mydriatic D) Saline ophthalmic drops Ans:A Feedback: Fungal infections commonly occur and may often be attributed to frequent use of ophthalmic antibiotics and corticosteroids. Systemic antibiotic agents are not the cause of fungal infections of the eye. Mydriatics are not the cause of fungal infections of the eye. Saline ophthalmic drops are not the cause of fungal infections of the eye.

2. A patient states that his eyes are “watering” excessively, and he claims that he has a gritty feeling of the eye. What common eye disorder is suspected A) Hordeolum B) Blepharitis C) Conjunctivitis D) Glaucoma Ans:C Feedback: Conjunctivitis is a common eye disorder with redness, tearing, itching, edema, and gritty sensations of the eye. Hordeolum is a sty Blepharitis is a chronic infection of glands and lash follicles on the margins of the eyelids.

Glaucoma is a disease with an increased intraocular pressure.

3. A patient has a foreign body in the right eye. What medication will most likely be administered before removal of the foreign body A) Cortisporin ointment B) Proparacaine eye drops C) Cephalosporin orally D) Atropine eye drops Ans:B Feedback: Proparacaine is a commonly used agent to provide anesthetic. One drop is instilled in the affected eye prior to removing the foreign body. Cortisporin ointment would not routinely be

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

administered before foreign body removal. Cephalosporin is not administered. Atropine eye drops are not administered for this purpose.

4. A patient is scheduled for cataract surgery. What anesthetic agent should the nurse prepare to administer A) Acetazolamide (Diamox) B) Pilocarpine (Pilocar) C) Dipivefrin (Propine) D) Lidocaine Ans:D Feedback: Injectable local anesthetics are administered by ophthalmologists, usually for eye surgery. Lidocaine is commonly used; it has a rapid onset and lasts 1 to 2 hours. Acetazolamide (Diamox) is not used as an anesthetic agent. Pilocarpine (Pilocar) is not used as an anesthetic agent. Dipivefrin (Propine) is not used as an anesthetic agent.

5. A patient is prescribed ophthalmic corticosteroids. What eye disorder may result from longterm use of ophthalmic corticosteroids A) Conjunctivitis B) Hordeolum C) Glaucoma D) Blepharitis Ans:C Feedback: Long-term use of corticosteroid ophthalmic agents may result increased IOP, optic nerve damage, defects in visual acuity, and fields of vision, cataracts, and secondary ocular infections.

6. A patient is predicted to benefit from dexamethasone eye drops. The presence of what eye disorder would contraindicate the use of this drug A) Fungal infection B) Nearsightedness C) Cataracts D) Bacterial conjunctivitis Ans:A Feedback: Contraindications to dexamethasone include corneal or conjunctival viral disease caused by herpes simplex, vaccina, or varicella. Also, other contraindications are mycobacterial and fungal infection of the eye as well as advanced glaucoma and hypersensitivity to corticosteroids.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient is scheduled for an ophthalmic examination. Which of the following medications will be administered A) Pseudoephedrine hydrochloride B) Epoetin alfa (Epogen) C) Phenylephrine D) Pilocarpine (Pilocar) Ans:C Feedback: Phenylephrine is used to dilate the pupil before ophthalmic examinations Pseudoephedrine hydrochloride is used to relieve nasal congestion. Epoetin alfa is used to treat bone marrow depression. Pilocarpine reduces intraocular pressure 8. A patient is being administered phenylephrine in an outpatient clinic. Which of the following conditions requires that phenylephrine be administered cautiously A) Cataracts B) Hypothyroidism C) Diabetes mellitus D) Hypertension Ans:D Feedback: Adrenergic mydriatics should be used cautiously in patients with hypertension, cardiac dysrhythmias, arteriosclerotic heart disease, and hyperthyroidism. Patients with cataracts, hypothyroidism, and diabetes mellitus can safely be administered phenylephrine.

9. A patient's medication administration record include daily timolol maleate eye drops. The nurse should identify what goal of therapy when planning this patient's care A) Decrease intraocular pressure B) Constrict pupils C) Promote lacrimation D) Improve visual acuity Ans:A Feedback: The purpose of the administration of beta- blocking drugs such as timolol is to decrease the IOP. Beta-blockers are not used to promote lacrimation, improve vision, or constrict the pupils.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

10. A nurse is administering eye drops of two different drugs to a patient. How long should the nurse wait between the instillation of the first medication and the second medication A) At least 1 minute B) At least 5 minutes C) At least 15 minutes D) At least 20 minutes Ans:B Feedback: When multiple eye drops are required, there should be an interval of 5 to 10 minutes between drops. The drops should not be as close as 1 minute. The drops will not need to be separated by 15 to 20 minutes.

11. A patient is administering eye drops. What should the patient be taught in order to decrease systemic absorption of eye drops A) Lie supine for 1 minute after instillation B) Apply pressure for 2 minutes over the tear duct C) Apply pressure for 5 minutes over the tear duct D) Remain still for 10 minutes after instillation Ans:C Feedback: Systemic absorption of eye drops can be decreased by closing the eye and applying pressure over the tear duct for 3 to 5 minutes after instillation. Pressure should not be applied to the tear duct for less than 3 minutes or greater than 5 minutes. It is unnecessary to remain still or supine after instillation.

12. A child with glaucoma is being treated with short-acting mydriatics. Which cycloplegic will be administered with the mydriatic agent A) Tropicamide B) Cortisporin C) Phenylephrine D) Acetazolamide (Diamox) Ans:A Feedback: Children with glaucoma are treated with mydriatics and cycloplegics, such as tropicamide. The child with glaucoma is not treated with cortisporin, phenylephrine, or acetazolamide 13. the way the normal intraocular pressure (IOP) is maintained. The nurse should explain that normal IOP results from which of the following

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Consistent production and resorption of tears B) Consistent feedback from baroreceptors located throughout the retina C) A balance between production and drainage of aqueous humor D) Two-way interaction between the medulla oblongata and the eye Ans:C Feedback: Normally, production and drainage of aqueous humor are approximately equal, and the intraocular pressure (IOP) is normal. IOP is not dependent of tear production, baroreceptors in the eye, or stimulation from the medulla.

14. A resident of a long-term care facility was referred to an outpatient ophthalmology clinic for assessment, and the nurse has received the clinical report. The nurse reads that the resident's intraocular pressure was elevated above clinical norms. The nurse should recognize that the resident is at risk of A) cataracts B) glaucoma C) myopia D) conjunctivitis Ans:B Feedback: Glaucoma is characterized by increased IOP, possibly damaging the optic nerve, which transmits images to the brain. If damage to the optic nerve from high IOP continues, glaucoma leads to loss of vision. Cataracts, myopia, and conjunctivitis are not the results of increased IOP

15. A nurse who provides care in an ophthalmology clinic has an order to instill atropine eye drops to a patient prior to the patient's clinical examination. What health education should the nurse provide prior to this intervention A) “These drops might sting a little bit, and they will make you temporarily sensitive to light.”

B) “These eye drops will make it more difficult to close your eyes, but this will pass in a few hours.”

C) “These drops will make your pupil temporarily constrict so that your eye can be examined more closely.”

D) “These drops will make your eyes very bloodshot and sensitive, but this is only temporary.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The nurse instructs patients about the effects of atropine such as photophobia and stinging on administration. Atropine does not make it difficult to close the eyes, and it causes pupil dilation, not constriction.

16. The nurse has administered a scheduled dose of phenylephrine to a patient. The nurse would recognize that a therapeutic effect has been achieved by which of the following assessment findings A) The cornea can be manipulated without causing the patient to blink B) The patient acknowledges an improvement in visual acuity C) The patient's pupils neither dilate nor constrict in response to light D) The inner aspect of the patient's eye can be visualized Ans:D Feedback: Uses of phenylephrine (ophthalmi C) include mydriasis prior to ophthalmic procedures Consequently, the nurse assesses whether the inner aspect of the eye can be visualized 15 minutes after administration. Phenylephrine does not inhibit blinking, improve vision, or eliminate light accommodation.

17. A patient's sudden increase in IOP has necessitated the oral administration of glycerin (Osmoglyn). When assessing the patient for adverse effects related to this intervention, the nurse should prioritize which of the following A) Assessment for signs and symptoms of acid– base imbalances B) Assessment for signs and symptoms of fluid volume deficit C) Monitoring of serum potassium and sodium levels D) Monitoring of aPTT and INR Ans:B Feedback: Adverse effects of glycerin relate to decreased fluid volume. The most serious of these conditions is hyperosmolar nonketotic coma. Consequently, the nurse should prioritize assessments that are focused on the signs and symptoms of fluid volume deficit.

18. A nurse is providing care for a patient who is on the third day of her prescribed course of ciprofloxacin eye drops. The nurse should conclude that this patient most likely has a diagnosis of what health problem

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Astigmatism B) Cataracts C) Conjunctivitis D) Increased IOP Ans:C Feedback: Uses of ciprofloxacin include the treatment of corneal ulcer and bacterial conjunctivitis. This drug is not used to treat cataracts, increased IOP, or astigmatism.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 60 Drug Therapy for Disorders of the Ear 1. A young boy has just returned home from his family's tropical vacation and is now complaining of worsening tenderness in his right ear. He is subsequently diagnosed with otitis externa. What causative factor of this infection should the nurse suspect A) Immunocompromised state resulting from sleep deprivation while on vacation B) The potential for foodborne pathogens ingested while on vacation C) Frequent swimming and water sports while the boy was on vacation D) Ear trauma related to pressurization and depressurization while flying Ans:C Feedback: People whose ears are frequently exposed to moisture are more prone to the development of otitis externa. Swimming is a more likely cause of infection than pressure changes, foodborne pathogens, or impaired immunity.

2. A pediatric nurse practitioner has diagnosed a 4-year-old girl with otitis media. The nurse should understand that infectious microorganisms likely entered the girl's middle ear by what means A) Through an alteration in the eustachian tube B) Through the external ear C) From within the cochlea or vestibule D) From the interstitial spaces in the middle ear Ans:A Feedback: The causative pathogens implicated in otitis media include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. They enter the middle ear as a result of an alteration in the eustachian tube, not from the inner ear, external ear, or interstitial spaces.

3. A patient has responded appreciably to first- line treatments for necrotizing otitis externa, and the care team is concerned about the possible progression of the disease. The nurse should be aware that this infection has the potential to progress to A) meningitis B) osteomyelitis C) necrotizing fasciitis D) epiglottitis

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: The advancement of necrotizing otitis externa results in osteomyelitis of the skull and temporomandibular joint. It does not cause meningitis, necrotizing fasciitis, or epiglottitis.

4. A 12-year-old boy has been diagnosed with acute otitis externa. The patient's mother has asked if oral medications might be more effective than ear drops. The nurse should respond in the knowledge that systemic medications for the treatment of otitis externa are only indicated in what circumstances A) The infection is accompanied by ear discharge B) The patient is allergic to penicillins C) The patient is unable to self-administer ear drops D) A deep tissue infection develops Ans:D Feedback: For acute otitis externa, use of topical agents, as opposed to systemic agents, is more common. Systemic medications are indicated only if a deep tissue infection develops outside the external canal or if immunocompromised status is an issue Allergy status, ability to self-administer, and the presence or discharge are not indications for systemic antibiotics.

5. The nurse is providing health education for the parents of a child whose otitis media has warranted treatment with Cortisporin Otic. The nurse should explain that this medication contains which of the following components Select all that apply A) An analgesic B) A topical anesthetic C) An antibiotic D) A steroid E) An immunomodulator Ans:C, D Feedback: Health care providers use the combination drug Cortisporin Otic (neomycin– polymyxin B–hydrocortisone) for the treatment of acute external otitis media. Neomycin and polymyxin B are antibiotics, which combat bacterial infections. Hydrocortisone is a steroid, which reduces the actions of chemicals in the body that cause inflammation, redness, and swelling. This medication does not contain analgesics, anesthetics, or immunomodulators.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A child's primary health care provider has prescribed Cortisporin Otic for a child who has otitis media in her right ear. What administration instructions should the nurse provide to the parents of the child A) “Put one drop into her right ear each morning.”

B) “Place two drops in her right ear each morning and then again before bedtime.”

C) “Put one to two drops in her right ear whenever you notice discharge or she complains of pain.”

D) “Place three drops into her ear four times a day.”

Ans:D Feedback: For children 6 months and older, 3 drops of Cortisoprin Otic are instilled into the affected ear three to four times daily. Dosage is not matched to acute symptoms.

7. A nurse is demonstrating the correct technique for instilling antibiotic ear drops into a child's ear canal. The nurse should teach the child's caregivers to do which of the following A) Have the child lie supine during instillation of the ear drops B) Have the child lie still for 30 to 45 minutes after instilling the ear drops C) Place a cotton ball in the ear canal after instilling the ear drops D) Rinse the child's ear canal with normal saline prior to instilling the ear drops Ans:C Feedback: The proper administration of ear drops requires tilting the head toward the opposite shoulder, pulling the superior aspect of the auricle upward, and instilling the ear drops into the ear canal. The patient should then lie on the side opposite the side of administration for 20 minutes. To maximize medication absorption, the patient should have a cotton ball placed in the ear canal. Supine positioning is not used, and the ear canal does not need to be rinsed prior to drug administration.

8. The nurse is providing care for a teenager with otitis media. When assessing the patient for potentially adverse effects of Cortisporin Otic, what question should the nurse ask A) “Have you developed a fever since you started to use the ear drops?”

B) “Have you been getting any headaches since you started taking the drops?”

C) “Has there been any blood that you've noticed in your outer ear?”

D) “Have you noticed any loss of hearing since you started taking the drops?”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: It is also necessary to assess the patient taking Cortisporin Otic for signs of hearing loss due to ototoxicity. Fever, bleeding, and headaches are not typical adverse effects.

9. An adult patient has been assessed in the emergency department and diagnosed with necrotizing otitis externa. The primary care provider has prescribed ciprofloxacin. In preparation for administering this medication, what action should the nurse perform A) Establish intravenous access B) Remove as much cerumen as possible from the patient's ear canal C) Flush the affected ear with warmed sterile water D) Establish a sterile field around the perimeter of the ear Ans:A Feedback: Ciprofloxacin (Cipro) is the drug of choice for necrotizing otitis externa. Initially, administration is intravenous, until symptoms decrease; then it is oral. Consequently, IV access is necessary for the initiation of treatment. This is a priority over rinsing the ear or removing cerumen. It is unnecessary to create a sterile field

10. A pediatric nurse is providing inpatient care for a child who was diagnosed with necrotizing otitis externa. The child is currently being treated with ciprofloxacin. What microorganism is the most likely cause of this child's infection A) Aspergillus B) Candida albicans C) Pseudomonas aeruginosa D) Escherichia coli Ans:C Feedback: Health care providers use ciprofloxacin for the treatment of Pseudomonas aeruginosa in patients with necrotizing otitis externa. If the causative agent is Aspergillus, amphotericin B is the drug of choice. E. coli and Candida are not typically implicated in cases of necrotizing otitis externa.

11. A woman was diagnosed with necrotizing otitis externa and will soon begin a course of oral ciprofloxacin. When providing health education to this patient, the nurse should emphasize the need to temporarily avoid A) calcium antacids

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) fatty foods C) grapefruit juice D) foods containing purines Ans:A Feedback: Patients should not take oral ciprofloxacin within 2 hours of eating dairy products, calcium-fortified juices, antacids, zinc, or iron. There is no specific need to avoid fatty foods, grapefruit juice, or high-purine foods

12. A 4-year-old boy was diagnosed with acute otitis media and began a course of oral amoxicillin. The boy's mother has contacted the clinic and states that there has been no significant improvement in her son's ear infection since beginning the antibiotics 3 days ago. The nurse should consider which of the following explanations for this phenomenon A) The boy has not been receiving the medication consistently B) The boy's ear infection has a viral etiology C) The boy's ear infection is caused by an antibiotic-resistant microorganism D) The medication should have been prescribed parenterally Ans:B Feedback: Many people with acute otitis media do not benefit from antibiotics because the cause of their illness is viral, not bacterial. This possibility is more likely than incorrect administration or antibiotic resistance Parenteral administration would be no more effective in this case.

13. A patient has been taking oral amoxicillin to treat otitis media for the past 6 days and has told the nurse that his ear is now “back to normal.” He asks the nurse if he can now stop taking his antibiotics. How should the nurse respond A) “That's excellent that you're feeling better, but it's important to keep taking the antibiotics until they're all finished.”

B) “Try reducing your dose by half. If your ear infection gets worse, resume the dose you've been taking until now.”

C) “You should stop taking the antibiotics because if you don't, it could cause antibiotic resistance.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) “You can likely stop taking the antibiotics, but keep them on hand in case your infection returns.”

Ans:A Feedback: The patient should take the full course of antibiotics and not discontinue them, even if the otitis media seems to be improving Stopping prematurely can cause antibiotic resistance.

14. A child's otitis media has resulted in pain and fever. The child's mother has asked the nurse to recommend OTC remedies to address these problems. Which of the following recommendations is most likely to be safe and effective A) Concurrent use of ASA and ibuprofen for 3 days B) Alternating doses of acetaminophen and ibuprofen C) Monotherapy with ASA until symptoms improve D) Use of an OTC antihistamine and acetaminophen Ans:B Feedback: Alternating acetaminophen and ibuprofen every 4 hours over a 3-day period to control fever in young children (ages 6–36 months) has been shown to be more effective than monotherapy with either agent. ASA is contraindicated in children, and an antihistamine is unnecessary.

15. A young adult has been diagnosed with otitis media. When planning this patient's care, what nursing diagnosis is the most likely priority A) Hyperthermia related to infectious process B) Infection related to presence of microorganisms C) Disturbed auditory sensory perception related to otitis media D) Chronic pain related to otitis media Ans:B Feedback: Infection is the essence of otitis media, and would be a priority over other diagnoses such as hyperthermia or temporary hearing loss The pain associated with this disorder would be acute, not chronic.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 61 Drug Therapy for Disorders of the Skin 1. A teenager is using a tanning bed two times per week. Which cells within the skin change color in response to the tanning bed's lights A) Melanocytes B) Stratum corneum C) Merkel cells D) Dermis Ans:A Feedback: Melanocytes are pigment-producing cells located at the junction of the epidermis and the dermis. The stratum corneum, Merkel cells, and dermis do not perform this role.

2. A teenager is being treated for acne vulgaris Which oral antibiotics may be prescribed to treat acne A) Neomycin and vancomycin B) Gentamicin and Rocephin C) Tetracycline and erythromycin D) Bacitracin and polymyxin B Ans:C Feedback: Commonly used oral antibiotics for acne treatment include tetracycline, doxycycline, minocycline, and erythromycin. Neomycin and vancomycin are not used to treat acne.

Gentamicin and Rocephin are not used to treat acne. Bacitracin and polymyxin B are not used to treat acne

3. A young mother is seen in the clinic with her young children. It is May, and the family is planning to go to the beach for vacation Which of the following aspects of patient teaching is most important A) “Try to stay indoors as much as possible.”

B) “Apply SPF 30 sunscreen to the children before sun exposure.”

C) “Be sure that each child wears a hat at the beach.”

D) “Apply Neosporin to any skin abrasions your children get.”

Ans:B Feedback: Dermatologists recommend sunscreen preparations that block both UVA and UVB and have a sun protective factor of SPF value 30 or higher. It is unnecessary to avoid all outdoor

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

locations. The mother should apply a hat, but this advice is not the most important health promotion intervention; this does not prevent sun damage to most skin surfaces The mother should be cautious with the application of Neosporin.

4. A 17-year-old woman is prescribed isotretinoin (Accutane) for severe acne vulgaris. Which of the following is the most important intervention related to the administration of this medication A) Effective contraception must accompany this medication B) Administer the medication on an empty stomach to decrease discomfort C) The tablets should be crushed if they are too large to swallow D) Administer a vitamin A supplement daily to enhance effectiveness Ans:A Feedback: The administration of retinoids requires adequate contraceptive practices in women.

Retinoids should be given with food, not on an empty stomach. The tablets should not be crushed. The patient should not take vitamin A or a multivitamin because of the retinoid toxicity 5. A college sophomore has sought care because of her worsening acne. Before beginning a medical regime that includes a retinoid, which of the following laboratory tests must be negative A) Throat culture B) Skin culture C) Stool for occult blood D) Pregnancy test Ans:D Feedback: The female patient should have a negative pregnancy test before beginning retinoid therapy. It is not necessary to have a negative throat culture or skin culture. If the patient has a positive stool for occult blood, the cause should be determined but is not affected by retinoid therapy.

6. A teenage male patient is administered isotretinoin (Accutane) for severe acne. When teaching the teen and his parents about the medication, which of the following assessments should be routinely made A) Assess blood pressure B) Assess blood lipid levels C) Assess for euphoria

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Assess for increased weight Ans:B Feedback: The administration of isotretinoin is linked with increased blood lipid levels. The parents and teen should be taught that lipid levels should be periodically assessed. The assessment of blood pressure is not imperative. The patient should be assessed for depression, not euphoria. The patient will not need his weight assessed.

7. The physician orders tretinoin (RetinA) for the treatment of acne. Which of the following instructions should be provided A) “You will see positive results in 1 week” B) “Apply the medication two to three times a day.”

C) “Apply the topical medication one time per day.”

D) “Apply the medication for 1 hour and remove it.”

Ans:C Feedback: Tretinoin is applied one time per day. Positive results from the medication will be noted in 12 weeks, not 1 week. The medication should not be applied two to three times per day.

The medication should not be applied for 1 hour and then removed.

8. A teenager has acne that requires treatment. The physician does not want to use retinoids because of the adverse effects. Which of the following medication regimens will likely be most effective A) Topical azelaic acid B) Topical benzoyl peroxide C) Topical clindamycin D) Topical clindamycin with benzoyl peroxide Ans:D Feedback: Combination products of topical clindamycin or erythromycin and benzoyl peroxide are more effective than antibiotics alone. Azelaic acid and benzoyl peroxide are effective but not as effective as combination medications. Topical clindamycin is effective, but combination medications may be more effective 9. A patient has a severe reaction to poison ivy. Which of the following medications will be most effective A) Topical antihistamines B) Corticosteroids C) Emollients D) Analgesics

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Corticosteroids are used to treat the inflammation present in many dermatologic conditions. They are most often applied topically but also may be given orally or parenterally.

Emollients and analgesics would be ineffective. Antihistamines are not administered topically 10. A patient has psoriasis and has been prescribed coal tar (Balnetar). How will this prescription be administered A) Topically B) Orally in divided daily doses C) Orally in the morning D) Parenterally at bedtime Ans:A Feedback: Coal tar is administered topically 11. A child who has not received the chickenpox vaccine has developed the chickenpox virus.

The child has itching related to the chickenpox pustules. Which of the following herbal preparations would be helpful to decrease itching A) Coal tar (Balnetar) B) Colloidal oatmeal (Aveeno) C) Clindamycin D) Bacitracin (Bacillin) Ans:B Feedback: Oat preparations, such as Aveeno, are used topically to treat minor skin irritation. Coal tar is not used for this child; it is primarily administered for psoriasis and dermatitis Clindamycin is not administered to treat minor skin irritation. Bacitracin is not administered to relieve itching related to chickenpox 12. A patient has rosacea. Which of the following medications is most effective in treating rosacea A) Topical metronidazole (Flagyl) B) Oral nystatin (Mycostatin) C) Oral prednisone D) Topical hydrocortisone Ans:A Feedback: Topical metronidazole is commonly used for rosacea. Oral Mycostatin is not used for rosacea. Oral prednisone is not used for rosacea. Topical hydrocortisone is not used for rosacea 13. A patient has a bacterial skin infection. Which medication can be applied to the lesion A) Bacitracin B) Benzoyl peroxide C) Butenafine (Mentax) D) Clotrimazole (Lotrimin)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Bacitracin is used to treat a bacterial skin infection. Butenafine is an antifungal agent.

Clotrimazole is used to treat tinea infections Benzoyl peroxide is used to treat acne.

14. A patient has developed urticaria following the administration of an oral antibiotic. What substance most commonly mediates the formation of the wheals that characterize urticaria A) Cytokines B) CD4+ lymphocytes C) Histamine D) Interleukin Ans:C Feedback: Histamine is the most common mediator of urticaria; it causes vasodilation, increased vascular permeability, and pruritus Cytokines, including interleukin, and CD4+ lymphocytes do not usually mediate the development of urticaria.

15. An older adult who resides in a long-term care facility has been diagnosed with oral candidiasis (thrush). When considering factors that may have contributed to this health problem, the nurse should prioritize which of the following A) The resident recently completed a course of broad-spectrum antibiotics B) The resident takes metformin for the treatment of type 2 diabetes C) The resident has been using OTC skin emollients several times a day D) The resident was immunized against the influenza virus 1 week ago Ans:A Feedback: Oral candidiasis (thrush) involves mucous membranes of the mouth. It often occurs as a superinfection after the use of broad-spectrum systemic antibiotics. Oral antihyperglycemics, skin emollients, and vaccinations do not contribute to thrush.

16. A topical corticosteroid has been prescribed for short-term use on an infant's skin. When planning the use of a topical medication for an infant, what principle should guide the nurse's actions A) Topical medications on infants' skin must be covered with an impermeable barrier

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Infants' skin is more permeable to medication than older patients' C) Infants have more subcutaneous fat than older patients, so higher concentrations of topical medications are often necessary D) Systemic drugs are preferable to topical medications in the care of infants Ans:B Feedback: With topical medications, cautious use is recommended with infants and young children due to the fact they have more permeable skin and are more likely to absorb the topical drugs. Infants have significant subcutaneous fat, but this does not necessitate higher concentrations of drugs. Topical drugs do not necessarily have to be covered with a barrier following administration.

17. A patient has been diagnosed with severe atopic dermatitis and treatment with tacrolimus (Protopi C) ointment has been deemed necessary. When planning this patient's care, the nurse should ensure that the patient has been informed of what risk A) Risk of chemical burn injury B) Increased risk of developing psoriasis or type IV hypersensitivity C) Risk of opportunistic fungal infection that may become systemic D) Increased risks of skin cancer and lymphoma Ans:D Feedback: Tacrolimus has a black box warning about a possible increased risk of skin cancer and lymphoma. It is not noted to cause fungal infections, psoriasis, or chemical burn injuries.

18. A 15-year-old boy has begun acne treatment using a combination ointment of clindamycin and benzoyl peroxide. The nurse should teach the boy to expect maximum results in how long A) 5 to 7 days B) 1 to 2 weeks C) 3 to 5 weeks D) 8 to 12 weeks Ans:D Feedback: Best results of combination acne treatments require 8 to 12 weeks of therapy, and maintenance therapy is usually required.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A young adult began acne treatment several weeks ago using a combination ointment and has presented for a follow-up appointment at the clinic. When assessing the patient for adverse effects of treatment, what question should the nurse prioritize A) “Have you found that the ointment makes your skin a lighter color?”

B) “Do you find that the ointment makes your pimples bleed more easily?”

C) “Do your eyes burn when you apply the ointment to your face?”

D) “Is the skin on your face uncomfortably dry since you began using the ointment?”

Ans:D Feedback: Adverse effects of topical antibiotics include erythema, peeling, dryness, and burning as well as development of resistant strains of P. acnes. Such ointments are not expected to produce eye irritation, bleeding, or changes in skin tone.

20. A nurse practitioner has discussed the possible risks and benefits of isotretinoin treatment with a patient who has acne vulgaris. The nurse should be aware that this medication achieves a reduction in the signs and symptoms of acne by what method A) Stimulating phagocytosis in the epidermis and dermis B) Suppressing the production of sebum C) Enhancing humoral immunity D) Inhibiting the function of sudoriferous glands Ans:B Feedback: The antiacne effects of isotretinoin include suppression of sebum production, inhibition of comedone formation, and inhibition of inflammation. The drug does not stimulate immune function or reduce the function of sweat glands

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 42 Drug Therapy for Hyperthyroidism and Hypothyroidism 1. A child is born with cretinism. What element was lacking in the mother's diet during pregnancy A) Potassium B) Iodine C) Sodium D) Magnesium Ans:B Feedback: Cretinism is uncommon in the United States but may occur with a lack of iodine in the mother's diet. A lack of potassium, sodium, and magnesium in the mother's diet will not cause cretinism

2. A patient suffers from hyponatremia, hypoglycemia, and lactic acidosis. What condition is most consistent with this clinical presentation A) Myxedema coma B) Psychotic depression C) Cretinism D) Congenital hypothyroidism Ans:A Feedback: Myxedema coma is severe, life-threatening hypothyroidism characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders, such as hyponatremia, hypoglycemia, and lactic acidosis.

3. A woman is started on propylthiouracil (PTU). What is the primary mode of action for propylthiouracil A) Destroys part of the thyroid gland B) Inhibits production of thyroid hormone C) Suppresses the anterior pituitary hormones D) Stimulates the thyroid cells Ans:B Feedback: The thioamide drugs inhibit synthesis of thyroid hormone. Iodine preparations inhibit the release of thyroid hormones and cause them to be stored within the thyroid gland.

Propylthiouracil does not destroy part of the thyroid gland. Propylthiouracil does not suppress the anterior pituitary hormones

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Propylthiouracil does not sedate the central nervous system or suppress the cardiac output.

4. A patient with hypothyroidism is started on levothyroxine (Synthroi D). What should the patient be taught regarding medication administration in the home setting A) Take medication with milk or food B) Do not exercise with the medication C) Take the medication on an empty stomach D) Levothyroxine has a short half-life Ans:C Feedback: Levothyroxine (Synthroi D) should be taken on an empty stomach to increase absorption. The medication should not be taken with food Exercise has no effect on the administration of the medication. Levothyroxine has a long half-life of about 6 to 7 days.

5. A 5-year-old child is diagnosed with hypothyroidism. What will the patient likely develop if the condition is left untreated A) Mental retardation B) Renal dysfunction C) An immune disorder D) Paralytic ileus Ans:A Feedback: If cretinism is untreated until the child is several months old, permanent mental retardation is likely to result. The patient will not suffer from renal dysfunction, an immune disorder, or paralytic ileus.

6. A patient has been diagnosed with myxedema. She currently takes ibuprofen (Motrin) for knee pain. For what is this patient at increased risk A) Nephrotoxicity B) Pulmonary congestion C) Tachycardia D) Apnea Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A patient diagnosed with myxedema cannot metabolize and excrete drugs, so she is at an increased risk of developing nephrotoxicity. Pulmonary congestion, tachycardia, and apnea are not adverse effects related to myxedema or the administration of ibuprofen (Motrin).

7. A patient is scheduled for a thyroidectomy to treat thyroid cancer. What is the medication of choice administered preoperatively A) Sodium iodide 131 (Iodotope) I B) Methimazole (Tapazole) C) Propylthiouracil (PTU) D) Propranolol (Inderal) Ans:C Feedback: Propylthiouracil (PTU) is administered preoperatively for thyroidectomy. Sodium 131 iodide(Iodotope) is a radioactive iodide that is used to destroy thyroid tissue. Methimazole (Tapazole) is similar to PTU but is not the drug of choice preoperatively Propranolol (Inderal) is used to treat cardiovascular conditions, such as hypertension. It is not used in the preoperative phase of thyroidectomy.

8. A patient is to receive a medication that the nurse recognizes as an expectorant that is normally administered for the treatment of hyperthyroidism. Which medication will be administered A) Propylthiouracil (PTU) B) Methimazole (Tapazole) C) Saturated solution of potassium iodide (SSKI) D) Sodium iodide131 (Iodotope) I Ans:C Feedback: Saturated solution of potassium iodide (SSKI) is more often used as an expectorant but may be given as a preparation for thyroidectomy. Propylthiouracil (PTU) is not administered as an expectorant. Methimazole (Tapazole) is not administered as an expectorant. Sodium iodide 131 (Iodotope) is not administered as I an expectorant.

9. A patient has been diagnosed with hyperthyroidism. She is scheduled to receive a medication to destroy the thyroid gland Which medication will be administered A) Propylthiouracil (PTU) B) Methimazole (Tapazole) C) Saturated solution of potassium iodide (SSKI) D) Sodium iodide 131 (Iodotope) I

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Sodium iodide 131 (Iodotope) is a I radioactive isotope of iodine. Therapeutic doses act by emitting beta and gamma rays, which destroy thyroid tissue and thereby decrease the production of thyroid hormones. Propylthiouracil (PTU) is not administered to destroy thyroid tissue. Methimazole (Tapazole) is not administered to destroy thyroid tissue. Saturated solution of potassium iodide (SSKI) is not administered to destroy thyroid tissue.

10. A patient is being administered propranolol (Inderal) to treat hypertension related to hyperthyroidism. Which condition will warrant the tapering and discontinuation of the propranolol (Inderal) A) Hyperthyroidism B) Hypertension C) Angina pectoris D) Euthyroid state Ans:D Feedback: When the patient becomes euthyroid and hyperthyroid symptoms are controlled by definitive treatment measures, propranolol should be tapered and discontinued Hyperthyroidism, hypertension, and angina pectoris all warrant the administration of propranolol (Inderal).

11. A patient is started on levothyroxine (Synthroi D) for treatment of hypothyroidism. During patient teaching, how frequently can the dosage be increased until symptoms are relieved A) Every 3 to 5 days B) Weekly C) Every 2 weeks D) Monthly Ans:C Feedback: Dosage is influenced by the choice of drug. As a general rule, initial dosage is relatively small. Dosage is gradually increased at approximately 2-week intervals until symptoms are relieved. The dosage is not increased in 3 to 5 days. The dosage is not increased in 1 week.

The dosage is not increased monthly.

12. A patient is being treated for hypothyroidism and has developed symptoms of adrenal insufficiency. What medication will be added to the patient's medication regimen A) Anti-infective agent B) Corticosteroid agent C) Nonsteroidal anti-inflammatory agent

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Antiadrenergic agent Ans:B Feedback: When hypothyroidism and adrenal insufficiency coexist, the adrenal insufficiency should be treated with a corticosteroid drug before starting thyroid replacement. Anti- infective agents, nonsteroidal anti- inflammatory agents, or antiadrenergic agents are not administered for adrenal insufficiency.

13. A patient has been diagnosed with hypothyroidism and admits to the nurse that she has heard of her thyroid gland but does not know the function of thyroid hormone. The nurse should explain the fact that thyroid hormone is responsible for A) regulating the levels of most other hormones in the body B) stimulating the brain and sex organs C) controlling the rate of cell metabolism throughout the body D) regulating levels of glucose in the blood and body tissues Ans:C Feedback: Thyroid hormones control the rate of cellular metabolism and thus influence the functioning of virtually every cell in the body. The heart, skeletal muscle, liver, and kidneys are especially responsive to the stimulating effects of thyroid hormones. The brain, spleen, and gonads are less responsive Thyroid hormone does not primarily influence glucose levels or the function of the endocrine system.

14. Following the completion of diagnostic testing, an adult patient has received a diagnosis of hyperthyroidism. What nursing diagnosis should the nurse prioritize in this patient's care A) Risk for hypothermia related to hyperthyroidism B) Constipation related to hyperthyroidism C) Risk for imbalanced nutrition: less than body requirements related to hyperthyroidism D) Anxiety related to hyperthyroidism Ans:D Feedback: Anxiety is characteristic of a hyperthyroid state. Constipation, cold intolerance, and loss of appetite are associated with hypothyroidism.

15. A 55-year-old female patient was successfully treated for thyroid storm earlier in the year. In subsequent health education, the nurse should caution the patient against excessive intake of what foods

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Seafood and kelp B) Leafy green vegetables and beef C) Purine-rich foods D) Red wine and aged cheeses Ans:A Feedback: Iodine is associated with thyroid storm and is present in foods (especially seafood and kelp) and in radiographic contrast dyes. Reports of iodine-induced hyperthyroidism have been reported after ingestion of dietary sources of iodine.

16. Laboratory testing reveals that a patient is in a severely hyperthyroid state and propylthiouracil (PTU) has been prescribed When providing health education related to this drug, what should the nurse teach the patient A) “You'll need to take these pills every 8 hours.”

B) “I'm going to show you how to perform your daily injection.”

C) “At first, you'll come to the outpatient clinic for your IV infusion once per day.”

D) “It's best to inject PTU into your abdomen rather than your arm.”

Ans:A Feedback: PTU is well absorbed with oral administration. Because the half-life in the thyroid is relatively short, PTU must be given every 8 hours.

17. A patient is scheduled to begin a drug regimen for the treatment of hyperthyroidism. Prior to administering propylthiouracil (PTU), the nurse has reviewed the relevant black box warning and should teach the patient about the need for what form of follow-up A) Serial complete blood counts B) Routine liver function testing C) Daily nonfasting blood glucose testing D) Chest radiographs every 3 months Ans:B Feedback: The FDA has issued a black box warning for PTU stating that severe liver injury resulting in death or acute liver failure may occur within 6 months of treatment. All patients should receive instructions about the signs and symptoms of acute liver failure. Routine liver function testing to assess for liver failure is important. There is no specific need for chest radiographs, CBCs, or glucose monitoring.

18. A nurse who provides care at a long-term care facility is preparing to administer a resident's scheduled dose of levothyroxine (Synthroi D). What assessment should the nurse perform prior to administration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Level of consciousness and orientation B) Oxygen saturation level C) Heart rate D) Respiratory rate Ans:C Feedback: Regular monitoring of blood pressure and pulse is essential in older adults receiving Synthroid. As a general rule, levothyroxine should not be given if the resting heart rate is more than 100 beats per minute.

19. A home care nurse observes that a client's supply of Synthroid has run out in less than half the time that it should have. What assessment findings would be most consistent with overuse of Synthroid A) Constipation and abdominal distention B) Hyperactivity and insomnia C) Bradycardia and hypotension D) Joint pain and decreased mobility Ans:B Feedback: Adverse effects of levothyroxine include signs and symptoms of hyperthyroidism.

Other more serious adverse effects are tachycardia, cardiac dysrhythmias, angina pectoris, myocardial infarction, and heart failure. Nervousness, hyperactivity, insomnia, diarrhea, abdominal cramps, nausea, vomiting, weight loss, fever, and an intolerance to heat have also been reported Bradycardia and constipation are associated with hypothyroidism.

20. An older adult patient has been using levothyroxine (Synthroi D) for several years on an outpatient basis. The patient has recently sought care, with complaints that are consistent with hypothyroidism. To which of the patient's following statements may the nurse attribute the decreased effect of Synthroid A) “I've been using a lot of antacids lately because of my indigestion.”

B) “My daughter and I have started the Atkin's diet to try to lose some weight.”

C) “Overall, I'd say that I'm under a lot of stress lately.”

D) “I've stopped taking aspirin for my arthritis and started using Tylenol.”

Ans:A Feedback: Antacids may decrease the effect of levothyroxine. Acetaminophen, stress, and high protein intake do not have this effect.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 43 Drug Therapy for Pituitary and Hypothalamic Dysfunction 1. A patient is scheduled for an exploratory surgery for cancer. What will cause the release of adrenocorticotropic hormone in response to this patient's psychological and physiological stress A) Growth hormone release–inhibiting hormone (Somatostatin) B) Corticotropin-releasing hormone or factor (CRH or CRF) C) Growth hormone–releasing hormone (GHRH) D) Thyrotropin-releasing hormone (TRH) Ans:B Feedback: Corticotropin-releasing hormone or factor (CRH or CRF) causes release of corticotropin (adrenocorticotropic hormone) in response to stress and threatening stimuli.

Growth hormone release–inhibiting hormone (somatostatin) inhibits release of growth hormone.

Growth hormone–releasing hormone causes the release of growth hormone in response to low blood levels of GH. Thyrotropin-releasing hormone causes the release of TSH in response to stress, such as cold.

2. A patient has had surgery. After the surgical procedure, the patient starts to shiver and chill.

What hormone will be released in response to the reaction to cold A) Thyroid-stimulating hormone B) Luteinizing hormone C) Corticotropin D) Somatostatin Ans:A Feedback: Thyroid-stimulating hormone is released in response to stress, such as exposure to cold. Luteinizing hormone is released in response to gonadotropin-releasing hormone Corticotropin stimulates the adrenal cortex to produce corticosteroids. Somatostatin inhibits the release of growth hormone.

3. A patient is suspected of having Cushing's disease. What hormone is used in the diagnosis of this disorder A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Corticotropin-releasing hormone can be used in the diagnosis of Cushing's disease.

Growth hormone is released in response to low blood levels of growth hormone. Corticotropinreleasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

4. A young man has begun weight training. Which hormone will be released in response to the increase in the size and number of muscle cells A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:A Feedback: Growth hormone stimulates the growth of body tissues, including growth of muscle cells. Corticotropin-releasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

5. An adult is diagnosed with an increased low- density lipoprotein cholesterol level. What hormone level may be low based on this diagnosis A) Adrenocorticotropic hormone (ACTH) B) Oxytocin C) Growth hormone D) Somatostatin Ans:C Feedback: In adults, deficient growth hormone can cause increased fat, reduced skeletal and heart muscle mass, reduced strength, reduced ability to exercise, and worsened cholesterol levels (increased low-density lipoprotein cholesterol). Adrenocorticotropic hormone, oxytocin, and somatostatin do not affect low- density lipoprotein.

6. When teaching young women about the hormones of reproduction, the nurse explains how the follicle matures and ruptures in ovulation. Which hormone is needed for this change A) Luteinizing hormone (LH) B) Thyrotropin (TSH) C) Follicle-stimulating hormone (FSH) D) Leydig's cells Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: LH is important in the maturation and rupture of the ovarian follicle. TSH regulates the secretion of thyroid hormones. FSH stimulates the functions of sex glands Leydig's cells are stimulated by LH in men to secrete androgens.

7. A patient has been involved in a motor vehicle accident. Which hormone will be released in response to his blood loss A) Luteinizing hormone (LH) B) Antidiuretic hormone (ADH) C) Oxytocin D) Melanocyte-stimulating hormone Ans:B Feedback: Antidiuretic hormone is also called vasopressin and is released in response to blood loss. Luteinizing hormone is important in ovulation. Oxytocin functions in childbirth and lactation. Melanocyte-stimulating hormone plays a role in skin pigmentation.

8. A patient has been diagnosed with acromegaly. Which of the following medications may be ordered to treat this endocrine disorder A) Gonadorelin hydrochloride (Factrel) B) Octreotide (Sandostatin) C) Nafarelin (Synarel) D) Gonadorelin acetate (Lutrepulse) Ans:B Feedback: Prescribers order octreotide for patients with acromegaly to reduce levels of GH. Gonadorelin hydrochloride, nafarelin, and gonadorelin acetate are not administered to treat acromegaly.

9. A patient is suspected of having adrenal insufficiency. Which hormone may be administered to diagnose Addison's disease A) Corticotropin (ACTH) B) Somatotropin (Humatrope) C) Octreotide (Sandostatin) D) Leuprolide (Lupron) Ans:A Feedback: Corticotropin (ACTH) is sometimes used as a diagnostic test to differentiate primary adrenal insufficiency (Addison's disease) Somatotropin is therapeutically equivalent to endogenous growth hormone. Octreotide (Sandostatin) is used for acromegaly

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Leuprolide causes a decrease in testosterone and estrogen.

10. A patient is diagnosed with infertility. What medication may the nurse administer for the treatment of infertility A) Thyrotropin alfa (Thyrogen) B) Pegvisomant (Somavert) C) Menotropins (Pergonal) D) Somatotropin (Humatrope) Ans:C Feedback: Menotropins (Pergonal) is administered in combination with HCG to induce ovulation. Thyrotropin alfa (Thyrogen) is a synthetic formulation of TSH used as a diagnostic adjunct for serum thyroglobulin. Pegvisomant (Somavert) is a growth hormone receptor antagonist used in the treatment of acromegaly in adults. Somatotropin (Humatrope) is administered to children for impaired growth.

11. An adolescent is being treated with growth hormone. When assessing for potential adverse effects, what assessment should the nurse prioritize A) Deep tendon reflexes B) Level of anxiety C) Respiratory rate D) Blood glucose Ans:D Feedback: Somatropin decreases insulin sensitivity, resulting in hyperglycemia. Patients most at risk for increased insulin sensitivity are those with obesity, Turner's syndrome, or a family history of diabetes mellitus. Growth hormone can cause anxiety, but is not a priority assessment in this case. The respiratory rate is not the most important objective assessment in this case.

12. An adult patient has been diagnosed with a posterior pituitary lesion that has resulted in diabetes insipidus. The characteristic sign of this health problem is A) blood glucose levels 400 mg/dL B) copious urine production C) hyperglycemia that is unresponsive to exogenous insulin D) hematuria Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Characteristic features of DM include polyuria, with excretion of dilute urine ranging from 4 L to as much as 30 L. Hematuria does not normally occur, and blood glucose levels are not directly affected.

13. A patient with a traumatic head injury and a diagnosis of diabetes insipidus is being treated with intravenous vasopressin (Pitressin). What change in the patient's status would prompt the immediate cessation of the drug infusion A) Infiltration at the IV site B) A sudden decrease in urine output C) The appearance of blood in the patient's urine D) A rapid increase in blood glucose Ans:A Feedback: When administering vasopressin intravenously, it is essential to use extreme caution due to the risk of extravasation of the medication, leading to tissue necrosis Decreased urine output is a goal of treatment Blood in the urine and changes in blood glucose levels are atypical events.

14. Somatropin has been prescribed for a child who has been diagnosed with growth hormone deficiency. When providing health education to the child's parents, what teaching point should then nurse prioritize A) The correct technique for daily injections of the drug B) The importance of regular blood pressure monitoring C) The rationale for not crushing the extended- release tablet D) The need to limit the child's activity level for the duration of treatment Ans:A Feedback: Somatropin is administered by daily injections. Blood pressure monitoring and activity limitations are not necessary.

15. A girl who is 7 1/2 years old has received a diagnosis of precocious puberty from the pediatric endocrinologist. The nurse who collaborates with this physician should anticipate the administration of what drug A) Menotropins (Pergonal) B) Thyrotropin alfa (Thyrogen) C) Cosyntropin (Cortrosyn D) Leuprolide acetate (Lupron) Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Leuprolide is useful for the treatment of central precocious puberty in children.

Menotropins (Pergonal) stimulates ovulation. Cosyntropin (Cortrosyn) stimulates the adrenal cortex to synthesize and secrete adrenocortical hormones. Thyrotropin alfa (Thyrogen) stimulates the secretion of thyroglobulin.

16. A 13-year-old boy who is in the first percentile of height for his age has been referred for care. Which of the following assessment findings would contraindicate the safe and effective use of somatropin to treat his growth deficiency A) The boy has not yet begun puberty B) The boy has low serum albumin levels C) The epiphyses of the boy's long bones have closed D) The sutures of the boy's skull have not yet fully closed Ans:C Feedback: Somatropin is ineffective when impaired growth is present after puberty, when the epiphyses of the long bones have closed. Low albumin is not a contraindication to the use of somatropin. The sutures of the skull close early in life.

17. A patient's current drug regimen includes intranasal administration of desmopressin acetate (DDAVP, Stimate). In this patient's plan of nursing care, what is the most likely desired outcome of treatment A) The patient's urine output will not exceed 80 mL/h B) The patient will gain 2 cm in height over the next 6 months C) The patient will ovulate at least once over the next 8 weeks D) The patient's vertical growth will cease in the next 4 weeks Ans:A Feedback: Desmopressin acetate (DDAVP, Stimate) is the prototype posterior pituitary hormone medication. It is used to treat diabetes insipidus. Consequently, reduced urine output is the primary goal of treatment. The drug does not influence growth or ovulation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse reviews the current medication administration record of a patient who has recently been prescribed octreotide. The nurse performs this important safety action in order to prevent drug interactions that could result in A) increased growth B) anaphylaxis C) cardiac complications D) respiratory arrest Ans:C Feedback: Numerous medications combine with octreotide to result in a prolonged QT interval with an increased risk of ventricular dysrhythmia and cardiac arrest. Increased growth, anaphylaxis, and respiratory arrest are not noted adverse effects or the result of drug interactions with octreotide.

19. A child has been referred to a pediatric endocrinologist and has begun treatment with octreotide acetate. What nursing diagnosis should be noted in the child's plan of nursing care A) Delayed growth and development B) Excess fluid volume C) Risk for deficient fluid volume D) Altered growth and development Ans:D Feedback: Acromegaly is the major clinical indication for the use octreotide. In this condition, growth is excessive, not delayed. Fluid volume is not directly affected

20. A patient who is being cared for in the intensive care unit (ICU) is receiving desmopressin.

In light of the black box warning that accompanies this drug, the ICU nurse should prioritize the assessment of which of the patient's laboratory values A) Hematocrit B) Platelets C) Sodium D) Calcium Ans:C Feedback: The FDA has issued a black box warning stating that patients taking desmopressin can develop hyponatremia, leading to seizures. Consequently, assessment of sodium levels takes precedence over hematocrit, calcium, and platelet levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 44 Drug Therapy to Regulate Calcium and Bone Metabolism 1. An elderly patient has been diagnosed with Paget's disease. Which serum electrolyte is altered in this disease process A) Sodium B) Potassium C) Chloride D) Calcium Ans:D Feedback: Disorders of calcium and bone metabolism include hypocalcemia, hypercalcemia, osteoporosis, Paget's disease, and bone breakdown associated with breast cancer and multiple myeloma. Sodium, potassium, and chloride alterations are not primarily associated with Paget's disease 2. A patient has been diagnosed with hyperplasia of the parathyroid gland. Which of the following alterations in blood values will you expect to observe A) Hypercalcemia B) Hypoparathyroidism C) Hyperthyroidism D) Hypocalcemia Ans:A Feedback: Hyperparathyroidism is most often caused by a tumor or hyperplasia of a parathyroid gland. Hypoparathyroidism, hyperthyroidism, and hypothyroidism are not associated with hyperplasia of the parathyroid gland. Clinical manifestations and treatment of hyperparathyroidism are the same as those of hypercalcemia.

3. When a patient has an increased serum level of ionized calcium, which hormone will be released A) Insulin B) Estrogen C) PTH D) Calcitonin Ans:D Feedback: Calcitonin is a hormone from the thyroid gland whose secretion is controlled by the concentration of ionized calcium in the blood flowing through the thyroid gland. When the serum level of ionized calcium is increased, secretion of calcitonin is increased. The serum level of calcium will not affect the release of insulin or estrogen. PTH is a response to low calcium levels.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

4. A patient has a decreased calcium level. Which of the following will participate in raising the patient's calcium level A) Vitamin D B) Vitamin C C) Ferrous sulfate D) Vitamin B12 Ans:A Feedback: Vitamin D is a fat-soluble vitamin that plays an important role in calcium and bone metabolism. Vitamin C, ferrous sulfate, and vitamin B12 do not play a role in calcium and bone metabolism.

5. A 55-year-old woman is diagnosed with a vitamin D deficit. What disorder results from this deficit A) Chondromalacia B) Chondritis C) Osteomalacia D) Osteopenia Ans:C Feedback: In adults, vitamin D deficiency causes osteomalacia, a condition characterized by decreased bone density and strength Chondromalacia is characterized as a softening of the patella. Chondritis is an inflammation of the cartilage. Osteopenia is a decrease in bone tissue.

6. The nurse is providing health education to an 80-year-old woman who has just been diagnosed with osteoporosis. Which of the following represents an accurate statement when teaching her about this diagnosis A) “Osteoporosis is usually a result of a bone injury.”

B) “Osteoporosis causes a risk for fractures.”

C) “Osteoporosis results from nonmodifiable risk factors.”

D) “Osteoporosis occurs only in women.”

Ans:B Feedback: Osteoporosis results when bone strength is impaired, leading to increased porousness and vulnerability to fracture. Osteoporosis is not a result of fracture. Osteoporosis is partially preventable. Osteoporosis is not limited to the female gender.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient suffers from numbness and tingling around the mouth and has a positive Trousseau's sign after a thyroidectomy. Which of the following medications will be administered A) Parenteral normal saline B) Parenteral potassium chloride C) Parenteral digoxin (Lanoxin) D) Parenteral calcium gluconate Ans:D Feedback: The patient has acute hypocalcemia as evidenced by numbness and tingling around the mouth and a positive Trousseau's sign. An intravenous calcium salt, such as calcium gluconate, is given for acute symptomatic hypocalcemia. Parenteral normal saline may be administered, but it will not increase the calcium level. The administration of potassium chloride parenterally must be diluted and will not affect the calcium level. Parenteral digoxin (Lanoxin) will not be administered.

8. A 75-year-old patient with overall good health is to begin taking vitamin D supplements What is the recommended supplement for her age A) 100 International Units daily B) 200 International Units daily C) 600 International Units daily D) 800 International Units daily Ans:D Feedback: The recommended dietary allowance, or RDA, for vitamin D is 600 International Units for people 1 to 70 years of age and 800 International Units daily for adults 71 years and older to prevent and treat osteoporosis.

9. An older adult patient has been on oral corticosteroids to decrease the symptoms of chronic obstructive pulmonary disease. What is the patient at risk for developing A) Osteoporosis B) Osteoarthritis C) Oat cell carcinoma D) Paget's disease Ans:A Feedback: Drugs used for hypercalcemia, such as corticosteroids, place the patient at risk for developing osteoporosis due to the demineralization of the bone. The patient is not at risk for developing osteoarthritis or oat cell carcinoma. Paget's disease is an inflammatory condition and is not caused by corticosteroid use.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

10. A patient has been prescribed alendronate (Fosamax). Which of the following instructions should the patient be given regarding the administration of this medication A) Take the medication with whole milk B) Take the medication and lie down for 30 minutes C) Take the medication on an empty stomach D) Take the medication to increase bone resorption Ans:C Feedback: Alendronate (Fosamax) must be taken on an empty stomach. Alendronate (Fosamax) should not be taken with milk or food. The patient should be sitting up or ambulatory for 30 minutes after taking the medication. The medication decreases bone resorption, not increases it.

11. A patient has undergone a thyroidectomy in which his parathyroid glands were also inadvertently removed. The patient's morning blood work reveals a serum calcium level of 3.1 mg/dL (normal 8.5 to 10.5 mg/dL). The nurse should consequently assess this patient's A) muscle tone B) level of consciousness C) respiratory rhythm D) respiratory rate Ans:A Feedback: Low calcium levels can result in tetany. Decreased LOC and altered respiratory function are not characteristic of hypocalcemia.

12. A community health nurse is leading a health promotion workshop during a community health fair. A participant has asked the nurse for advice on the necessity of calcium supplements.

The nurse should respond in the knowledge that which of the following demographic groups frequently have low calcium levels? Select all that apply A) Elementary-aged children B) Young women

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Middle-aged men D) Middle-aged women E) Older women Ans:B, E Feedback: Experts believe that the diets of most people of all ages, but especially of young women and older adults, are deficient in calcium

13. An older adult resident of a long-term care facility has been prescribed calcium citrate to address her decreasing bone density. The nurse should review the resident's medication administration record knowing that what medication may decrease the effects of calcium A) Hydrochlorothiazide B) Ibuprofen C) Prednisone D) Diltiazem (Cardizem) Ans:C Feedback: Corticosteroids reduce the effects of calcium by various mechanisms. Thiazide diuretics have the opposite effect. NSAIDs and calcium channel blockers do not appreciably affect the pharmacokinetics of calcium supplements.

14. A patient's low ionized calcium levels have necessitated an infusion of an IV calcium preparation. During the administration of this medication, the nurse should prioritize what assessment A) Oxygen saturation levels B) Cardiac monitoring C) Assessment of cognition D) Assessment for visual changes Ans:B Feedback: Calcium imbalances can result in alterations in heart rate and rhythm; cardiac monitoring is thus necessary. The patient is less likely to experience alterations in respiratory function, cognition, or vision

15. A middle-aged patient is proud of the fact that she is proactive with her health maintenance and tells the nurse that she has been taking 2400 International Units of vitamin D daily, stating,

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

“More is better when it comes to vitamins.” The nurse should provide health teaching to the patient because her current vitamin D intake creates a risk for A) hypercalcemia B) hyperphosphatemia C) hypocalcemia D) tetany Ans:A Feedback: It is important to take vitamin D supplements cautiously and not overuse them; excessive amounts can cause serious problems, including hypercalcemia. Tetany is associated with hypocalcemia. Hypophosphatemia typically accompanies hypercalcemia.

16. A 72-year-old woman has been diagnosed with osteoporosis and has begun taking alendronate (Fosamax). The nurse should be aware that this drug can increase the woman's bone density by which of the following means A) Decreasing renal excretion of calcium B) Increasing the binding of vitamin D to calcium ions C) Suppressing the function of osteoclasts D) Enhancing the function of osteoblasts Ans:C Feedback: Alendronate suppresses osteoclast activity on newly formed resorption surfaces, which reduces bone turnover. This means that bone formation exceeds resorption at remodeling sites, leading to progressive gains in bone mass. Fosamax does not enhance osteoblast function or affect the renal excretion of calcium. It does not influence the chemical interaction between vitamin D and calcium

17. An 80-year-old woman has experienced recent declines in bone density and has consequently been deemed a candidate for treatment with alendronate (Fosamax). During health education, what teaching point should the nurse emphasize A) “Your Fosamax will be most effective if you couple it with an increase in your consumption of dairy products.”

B) “It's important that you not lie down for half an hour after taking your Fosamax.”

C) “Make sure to let your care provider know promptly if you experience bone pain.”

D) “You'll have less stomach upset if you take your Fosamax with some bland food.”

Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The person must remain upright (with head elevated 90 degrees if in bed, sitting upright in a chair, or standing) for at least 30 minutes after administration of Fosamax. It is always necessary to take the drug with a full glass of water, not juice or coffee, at least 30 minutes before breakfast and before taking other drugs. Bone pain is a possible adverse effect, but prevention of esophageal ulceration is a priority. Increased dairy consumption is not vital.

18. A 79-year-old woman has been diagnosed with osteoporosis, and the nurse is reviewing the risks and benefits of Fosamax, which her care provider has prescribed. The patient should be instructed to seek prompt medical attention if she develops which of the following A) Esophageal bleeding B) Fever C) Sudden fatigue D) Musculoskeletal pain Ans:A Feedback: Esophageal erosion and ulcers can result in hemorrhage, which is a medical emergency. Fever, fatigue, and musculoskeletal pain warrant follow-up, but none is an emergency.

19. A patient has been admitted in acute hypercalcemia and has been determined to have a serum calcium level of 12.9 mg/dL. The emergency department nurse's priority intervention is A) administration of IV calcitonin B) administration of IV normal saline C) oxygen supplementation D) subcutaneous administration of exogenous parathyroid hormone (PTH) Ans:B Feedback: Acute hypercalcemia is a medical emergency, and rehydration is a priority; it is essential to administer an IV saline solution. Calcitonin is not administered by the IV route. PTH is not administered exogenously and would exacerbate hypercalcemia.

20. An elderly adult woman has been diagnosed with postmenopausal osteoporosis and has been prescribed calcitonin. The nurse should anticipate administration by what route A) Oral

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Topical C) Intranasal D) Intravenous Ans:C Feedback: Calcitonin can be administered by the intranasal route for the treatment of osteoporosis. It is not given orally, topically, or intravenously.

Chapter 45 Drug Therapy for Addison's Disease and Cushing's Disease 1. days, and she describes herself as feeling “shaky.” Random blood glucose testing reveals a glucose level of 38 mg/dL, but the woman denies any significant change in her diet. The care team should suspect the possibility of what health problem A) Chronic renal failure B) Acute renal failure C) Cushing's disease D) Adrenal insufficiency Ans:D Feedback: Any patient with unexplained severe hypoglycemia requires assessment for adrenal insufficiency. Cushing's disease and kidney disease do not result in hypoglycemia.

2. A patient who has been taking oral prednisone for several months abruptly ceased treatment several days ago on the advice of a family member. The patient has now been admitted to the emergency department with signs and symptoms that are characteristic of addisonian crisis.

When assessing this patient, the nurse should prioritize what assessment A) Assessment of urine for ketones B) Assessment of serum potassium levels C) Assessment for adventitious lung sounds D) Assessment for venous thromboembolism Ans:B Feedback: In addisonian crisis, the loss of sodium leads to retention of potassium, resulting in symptoms of hyperkalemia. As a result, vigilant monitoring of serum potassium levels is more important than respiratory effects, urinalysis, or hypercoagulation

3. A 38-year-old patient has been living with Addison's disease for many years and has achieved adequate symptom control through lifestyle modifications and drug therapy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

However, the patient has now been admitted to the hospital in addisonian crisis. Which of the nurse's following assessment questions is most appropriate A) “Have you been under an unusual amount of stress lately?”

B) “How would you describe your diet over the last few days?”

C) “When was the last time that you drank any alcohol?”

D) “Has your urine output been typical for the past few days?”

Ans:A Feedback: Acute adrenal crisis, or addisonian crisis, is a life-threatening condition that occurs when Addison's disease is the underlying problem and the patient is exposed to minor illness or increased stress. Diet, alcohol use, and impaired urinary function are less likely contributors.

4. A patient's recent symptoms of unexplained fatigue and listlessness have prompted a referral to the endocrinology department. A plasma corticotropin (ACTH) stimulation test for adrenal insufficiency is being performed. Following the administration of ACTH, what finding would confirm the suspected diagnosis A) Low cortisol levels B) Stupor C) Increased levels of CRH D) Signs of Cushing's disease Ans:A Feedback: Confirming the diagnosis of adrenocortical insufficiency requires a short plasma corticotropin (ACTH) stimulation test. The examiner administers corticotropin in the morning, and a subnormal blood cortisol level in the morning and afternoon confirms the diagnosis. CRH is a precursor to ACTH, and would not be directly affected. Cushing's disease is adrenocortical excess, with high cortisol levels.

5. A patient with suspected adrenal insufficiency has been administered 1 mcg of cosyntropin (Cortrosyn) as an IV bolus. Serum testing 30 minutes later reveals a markedly elevated level of cortisol. What conclusion should the nurse infer from this finding A) The patient has normal adrenocortical function B) The patient has primary adrenal insufficiency C) The patient has secondary adrenal insufficiency D) The patient has Addison's disease

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The low-dose test involves the administration of 1 mcg of cosyntropin (Cortrosyn) as an IV bolus. In people with normal adrenocortical function, an increase in cortisol occurs in 20 minutes.

6. A 26-year-old woman's gradual development of a “moon face,” coupled with protracted weight gain, has caused the nurse practitioner to suspect the possibility of Cushing's disease.

When explaining this health problem to the patient, how should the nurse describe it A) “Cushing's disease happens when your pituitary gland doesn't stimulate your other glands enough.”

B) “Cushing's disease is a result of an overproduction of steroid hormones by your kidneys.”

C) “Cushing's disease most often happens when people are taking corticosteroid medications and stop them abruptly.”

D) “Cushing's disease often results from a growth on your kidney that causes inadequate production of steroids.”

Ans:B Feedback: The cause of Cushing's disease is adrenocortical excess. Cessation of exogenous steroids can precipitate addisonian crisis Dysfunction of pituitary gland is an atypical cause. Tumors may cause overproduction, not underproduction, of corticosteroids.

7. A patient with a diagnosis of Cushing's disease has been admitted to the emergency department after taking a fall on the sidewalk outside her apartment building. This patient's underlying disease process creates increased risks of A) hemorrhage and impaired hemostasis B) fractures and impaired wound healing C) neurovascular complications and rhabdomyolysis D) bruising and hematoma Ans:B Feedback: Cushing's disease results in low bone density and impaired wound healing. It does not typically cause impaired hemostasis or neurovascular problems.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

8. The results of a young man's plasma corticotropin (ACTH) stimulation test have confirmed a diagnosis of Addison's disease. The nurse has consequently provided health education around the necessity of hormone replacement therapy. The patient has asked the nurse, “How long am I going to have to take these medications?” How should the nurse best respond A) “You'll need to take these for the rest of your life.”

B) “You'll have to take these until you can pass the corticotropin stimulation test without them.”

C) “You'll have to take these until your kidneys regain their normal level of function.”

D) “You'll need to take these until your symptoms have been stable for at least 6 months.”

Ans:A Feedback: Lifetime hormone replacement is necessary in persons with Addison's disease.

9. A child has received a diagnosis of Addison's disease, and the nurse is providing health education to the child's family around hormone replacement therapy. When planning this child's care, the nurse should know that hormone replacement therapy constitutes a risk for what nursing diagnosis A) Latex allergic response B) Deficient fluid volume C) Delayed growth and development D) Impaired gas exchange Ans:C Feedback: Hydrocortisone may affect growth velocity. It is unlikely to affect allergy response, or respiration. Fluid volume excess, not deficit, is a possibility.

10. Hydrocortisone has been prescribed to a patient for the treatment of Addison's disease, and the patient will soon be discharged. The nurse should encourage the patient to take this medication A) at least 30 minutes before or 2 hours after meals B) at bedtime C) before 9 AM D) with an antacid Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Administration of hydrocortisone should take place every morning before 9 AM. This minimizes HPA suppression. People should take the oral preparation with food to decrease gastric irritation.

11. A patient will soon begin long-term treatment with hydrocortisone after being diagnosed with Addison's disease. In order to mitigate the potentially adverse effect of this treatment regimen, the nurse should encourage the patient to increase her intake of what nutrient A) Water B) Calcium C) Sodium D) Potassium Ans:B Feedback: Due to the potential for reduced bone density, patients should be encouraged to increase calcium intake if hydrocortisone is administered for a prolonged period Increased sodium, potassium, and water intake are not recommended.

12. A patient with a long-standing diagnosis of Addison's disease has been taking hydrocortisone for several years, achieving adequate symptom control. In recent weeks, the patient has experienced profound stress resulting from the collapse of his small business and subsequent conflict with his business partner. How might the presence of these stressors affect the patient's medication regimen A) The patient should take his scheduled hydrocortisone later in the day B) The ratio of mineralocorticoids to glucocorticoids should be adjusted C) The patient's hydrocortisone should be temporarily withheld D) The patient may temporarily require a higher dose of hydrocortisone Ans:D Feedback: During times of increased stress, the dosage of the medication may need to be increased. There would be no need to change the ratio of mineralocorticoids to glucocorticoids or to take the medications later in the day.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

13. A patient with a diagnosis of Addison's disease has had fludrocortisone acetate (Florinef Acetate) added to his medication regimen by his endocrinologist. What is the most plausible rationale for this change in treatment A) The patient's anterior pituitary gland is overstimulated B) The patient requires increased mineralocorticoid supplementation C) The patient's adrenal cortex has become resistant to hydrocortisone D) The patient's GI tract is unable to tolerate hydrocortisone Ans:B Feedback: If a patient with Addison's disease requires additional mineralocorticoid supplementation, then fludrocortisone acetate (Florinef Acetate) may be indicated. Pituitary dysfunction, GI intolerance, and resistance to hydrocortisone are not plausible rationales.

14. A patient with Cushing's disease will soon begin treatment with ketoconazole. When planning the patient's care, the nurse should be cognizant of the black box warning for this drug and consequently monitor what laboratory values A) White blood cell differential B) Blood urea nitrogen and creatinine C) AST, ALT, and GGT D) Hemoglobin, hematocrit, and red blood cell count Ans:C Feedback: The FDA has issued a black box warning stating that ketoconazole can cause hepatotoxicity. As a result, monitoring of liver function may be a priority over assessment of white cells, red cells, and renal function.

15. When assessing for therapeutic effects of mitotane in a patient with adrenocortical carcinoma, the nurse should expect to identify A) a decrease in agitation B) an audible S3 C) a decrease in blood pressure D) a decrease in urine output Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A decrease in blood pressure is an expected therapeutic effect of mitotane. An audible S3 is not expected. Mitotane does not address agitation or high urine output

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 46 Physiology of the Autonomic and Central Nervous Systems and Indications for the Use of Drug Therapy 1. A patient is scheduled for an exploratory surgery for cancer. What will cause the release of adrenocorticotropic hormone in response to this patient's psychological and physiological stress A) Growth hormone release–inhibiting hormone (Somatostatin) B) Corticotropin-releasing hormone or factor (CRH or CRF) C) Growth hormone–releasing hormone (GHRH) D) Thyrotropin-releasing hormone (TRH) Ans:B Feedback: Corticotropin-releasing hormone or factor (CRH or CRF) causes release of corticotropin (adrenocorticotropic hormone) in response to stress and threatening stimuli.

Growth hormone release–inhibiting hormone (somatostatin) inhibits release of growth hormone.

Growth hormone–releasing hormone causes the release of growth hormone in response to low blood levels of GH. Thyrotropin-releasing hormone causes the release of TSH in response to stress, such as cold.

2. A patient has had surgery. After the surgical procedure, the patient starts to shiver and chill.

What hormone will be released in response to the reaction to cold A) Thyroid-stimulating hormone B) Luteinizing hormone C) Corticotropin D) Somatostatin Ans:A Feedback: Thyroid-stimulating hormone is released in response to stress, such as exposure to cold. Luteinizing hormone is released in response to gonadotropin-releasing hormone Corticotropin stimulates the adrenal cortex to produce corticosteroids. Somatostatin inhibits the release of growth hormone.

3. A patient is suspected of having Cushing's disease. What hormone is used in the diagnosis of this disorder A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Corticotropin-releasing hormone can be used in the diagnosis of Cushing's disease.

Growth hormone is released in response to low blood levels of growth hormone. Corticotropinreleasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

4. A young man has begun weight training. Which hormone will be released in response to the increase in the size and number of muscle cells A) Growth hormone B) Adrenocorticotropic hormone C) Thyroid-stimulating hormone D) Corticotropin-releasing hormone Ans:A Feedback: Growth hormone stimulates the growth of body tissues, including growth of muscle cells. Corticotropin-releasing hormone causes the release of corticotropin (adrenocorticotropic hormone) in response to stress. Thyroid-stimulating hormone regulates the secretion of thyroid hormones.

5. An adult is diagnosed with an increased low- density lipoprotein cholesterol level. What hormone level may be low based on this diagnosis A) Adrenocorticotropic hormone (ACTH) B) Oxytocin C) Growth hormone D) Somatostatin Ans:C Feedback: In adults, deficient growth hormone can cause increased fat, reduced skeletal and heart muscle mass, reduced strength, reduced ability to exercise, and worsened cholesterol levels (increased low-density lipoprotein cholesterol). Adrenocorticotropic hormone, oxytocin, and somatostatin do not affect low- density lipoprotein.

6. When teaching young women about the hormones of reproduction, the nurse explains how the follicle matures and ruptures in ovulation. Which hormone is needed for this change A) Luteinizing hormone (LH) B) Thyrotropin (TSH) C) Follicle-stimulating hormone (FSH) D) Leydig's cells Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: LH is important in the maturation and rupture of the ovarian follicle. TSH regulates the secretion of thyroid hormones. FSH stimulates the functions of sex glands Leydig's cells are stimulated by LH in men to secrete androgens.

7. A patient has been involved in a motor vehicle accident. Which hormone will be released in response to his blood loss A) Luteinizing hormone (LH) B) Antidiuretic hormone (ADH) C) Oxytocin D) Melanocyte-stimulating hormone Ans:B Feedback: Antidiuretic hormone is also called vasopressin and is released in response to blood loss. Luteinizing hormone is important in ovulation. Oxytocin functions in childbirth and lactation. Melanocyte-stimulating hormone plays a role in skin pigmentation

8. A patient has been diagnosed with acromegaly. Which of the following medications may be ordered to treat this endocrine disorder A) Gonadorelin hydrochloride (Factrel) B) Octreotide (Sandostatin) C) Nafarelin (Synarel) D) Gonadorelin acetate (Lutrepulse) Ans:B Feedback: Prescribers order octreotide for patients with acromegaly to reduce levels of GH. Gonadorelin hydrochloride, nafarelin, and gonadorelin acetate are not administered to treat acromegaly.

9. A patient is suspected of having adrenal insufficiency. Which hormone may be administered to diagnose Addison's disease A) Corticotropin (ACTH) B) Somatotropin (Humatrope) C) Octreotide (Sandostatin) D) Leuprolide (Lupron) Ans:A Feedback: Corticotropin (ACTH) is sometimes used as a diagnostic test to differentiate primary adrenal insufficiency (Addison's disease)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Somatotropin is therapeutically equivalent to endogenous growth hormone. Octreotide (Sandostatin) is used for acromegaly Leuprolide causes a decrease in testosterone and estrogen.

10. A patient is diagnosed with infertility. What medication may the nurse administer for the treatment of infertility A) Thyrotropin alfa (Thyrogen) B) Pegvisomant (Somavert) C) Menotropins (Pergonal) D) Somatotropin (Humatrope) Ans:C Feedback: Menotropins (Pergonal) is administered in combination with HCG to induce ovulation. Thyrotropin alfa (Thyrogen) is a synthetic formulation of TSH used as a diagnostic adjunct for serum thyroglobulin. Pegvisomant (Somavert) is a growth hormone receptor antagonist used in the treatment of acromegaly in adults. Somatotropin (Humatrope) is administered to children for impaired growth.

11. An adolescent is being treated with growth hormone. When assessing for potential adverse effects, what assessment should the nurse prioritize A) Deep tendon reflexes B) Level of anxiety C) Respiratory rate D) Blood glucose Ans:D Feedback: Somatropin decreases insulin sensitivity, resulting in hyperglycemia. Patients most at risk for increased insulin sensitivity are those with obesity, Turner's syndrome, or a family history of diabetes mellitus. Growth hormone can cause anxiety, but is not a priority assessment in this case. The respiratory rate is not the most important objective assessment in this case.

12. An adult patient has been diagnosed with a posterior pituitary lesion that has resulted in diabetes insipidus. The characteristic sign of this health problem is A) blood glucose levels 400 mg/dL B) copious urine production C) hyperglycemia that is unresponsive to exogenous insulin D) hematuria

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Characteristic features of DM include polyuria, with excretion of dilute urine ranging from 4 L to as much as 30 L. Hematuria does not normally occur, and blood glucose levels are not directly affected.

13. A patient with a traumatic head injury and a diagnosis of diabetes insipidus is being treated with intravenous vasopressin (Pitressin). What change in the patient's status would prompt the immediate cessation of the drug infusion A) Infiltration at the IV site B) A sudden decrease in urine output C) The appearance of blood in the patient's urine D) A rapid increase in blood glucose Ans:A Feedback: When administering vasopressin intravenously, it is essential to use extreme caution due to the risk of extravasation of the medication, leading to tissue necrosis Decreased urine output is a goal of treatment. Blood in the urine and changes in blood glucose levels are atypical events.

14. Somatropin has been prescribed for a child who has been diagnosed with growth hormone deficiency. When providing health education to the child's parents, what teaching point should then nurse prioritize A) The correct technique for daily injections of the drug B) The importance of regular blood pressure monitoring C) The rationale for not crushing the extended- release tablet D) The need to limit the child's activity level for the duration of treatment Ans:A Feedback: Somatropin is administered by daily injections. Blood pressure monitoring and activity limitations are not necessary.

15. A girl who is 7 1/2 years old has received a diagnosis of precocious puberty from the pediatric endocrinologist. The nurse who collaborates with this physician should anticipate the administration of what drug A) Menotropins (Pergonal) B) Thyrotropin alfa (Thyrogen) C) Cosyntropin (Cortrosyn D) Leuprolide acetate (Lupron)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Leuprolide is useful for the treatment of central precocious puberty in children.

Menotropins (Pergonal) stimulates ovulation. Cosyntropin (Cortrosyn) stimulates the adrenal cortex to synthesize and secrete adrenocortical hormones. Thyrotropin alfa (Thyrogen) stimulates the secretion of thyroglobulin.

16. A 13-year-old boy who is in the first percentile of height for his age has been referred for care. Which of the following assessment findings would contraindicate the safe and effective use of somatropin to treat his growth deficiency A) The boy has not yet begun puberty B) The boy has low serum albumin levels C) The epiphyses of the boy's long bones have closed D) The sutures of the boy's skull have not yet fully closed Ans:C Feedback: Somatropin is ineffective when impaired growth is present after puberty, when the epiphyses of the long bones have closed. Low albumin is not a contraindication to the use of somatropin. The sutures of the skull close early in life.

17. A patient's current drug regimen includes intranasal administration of desmopressin acetate (DDAVP, Stimate). In this patient's plan of nursing care, what is the most likely desired outcome of treatment A) The patient's urine output will not exceed 80 mL/h B) The patient will gain 2 cm in height over the next 6 months C) The patient will ovulate at least once over the next 8 weeks D) The patient's vertical growth will cease in the next 4 weeks Ans:A Feedback: Desmopressin acetate (DDAVP, Stimate) is the prototype posterior pituitary hormone medication. It is used to treat diabetes insipidus. Consequently, reduced urine output is the primary goal of treatment. The drug does not influence growth or ovulation.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A nurse reviews the current medication administration record of a patient who has recently been prescribed octreotide. The nurse performs this important safety action in order to prevent drug interactions that could result in A) increased growth B) anaphylaxis C) cardiac complications D) respiratory arrest Ans:C Feedback: Numerous medications combine with octreotide to result in a prolonged QT interval with an increased risk of ventricular dysrhythmia and cardiac arrest. Increased growth, anaphylaxis, and respiratory arrest are not noted adverse effects or the result of drug interactions with octreotide.

19. A child has been referred to a pediatric endocrinologist and has begun treatment with octreotide acetate. What nursing diagnosis should be noted in the child's plan of nursing care A) Delayed growth and development B) Excess fluid volume C) Risk for deficient fluid volume D) Altered growth and development Ans:D Feedback: Acromegaly is the major clinical indication for the use octreotide. In this condition, growth is excessive, not delayed. Fluid volume is not directly affected.

20. A patient who is being cared for in the intensive care unit (ICU) is receiving desmopressin.

In light of the black box warning that accompanies this drug, the ICU nurse should prioritize the assessment of which of the patient's laboratory values A) Hematocrit B) Platelets C) Sodium D) Calcium Ans:C Feedback: The FDA has issued a black box warning stating that patients taking desmopressin can develop hyponatremia, leading to seizures. Consequently, assessment of sodium levels takes precedence over hematocrit, calcium, and platelet levels

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 47 Drug Therapy for Myasthenia Gravis, Alzheimer's Disease, and Urinary Retention 1. A patient has atony of the smooth muscle of the gastrointestinal tract. Which type of medication may be administered to increase smooth muscle strength A) Anticholinergic drugs B) Cholinergic drugs C) Muscle relaxants D) Selective serotonin reuptake inhibitors Ans:B Feedback: Cholinergic drugs are used to treat atony of the smooth muscle of the gastrointestinal tract and urinary systems. Anticholinergic agents will decrease muscle strength. Muscle relaxants will decrease muscle strength Selective serotonin reuptake inhibitors are not used for atony of the smooth muscle of the gastrointestinal tract.

2. A patient is diagnosed with Alzheimer's disease. The nurse should anticipate administering which of the following medications A) Bethanechol (Urecholine) B) Neostigmine (Prostigmin) C) Donepezil (Aricept) D) Physostigmine salicylate (Antilirium) Ans:C Feedback: Donepezil (Aricept) is used to treat mild to moderate Alzheimer's disease.

Bethanechol (Urecholine) produces smooth muscle contractions and is not used to treat Alzheimer's disease. Neostigmine (Prostigmin) is not used to treat Alzheimer's disease; it is used to treat myasthenia gravis. Physostigmine is not used to treat Alzheimer's disease; it is an antidote for overdose of anticholinergic drugs

3. A patient with myasthenia gravis is administered neostigmine (Prostigmin). How does this drug produce its therapeutic effect A) It stimulates the sympathetic nervous system B) It stimulates the parasympathetic nervous system C) It stimulates the cardiac smooth muscle

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) It stimulates the respiratory system Ans:B Feedback: Neostigmine (Prostigmin) stimulates the parasympathetic nervous system. It does not stimulate the sympathetic nervous system, cardiac system, or respiratory system.

4. A patient is administered edrophonium (Tensilon) to confirm the diagnosis of myasthenia gravis. What effect will the edrophonium (Tensilon) have 30 minutes after the medication administration, which will confirm the diagnosis A) Improved breathing B) Decreased fatigue C) Decreased muscle spasms D) Increased urinary output Ans:A Feedback: Edrophonium (Tensilon) is used to diagnose myasthenia gravis. After administration, it will improve breathing in patients who have myasthenia gravis. Edrophonium will not decrease fatigue. Edrophonium will not decrease muscle spasms or increase urinary output.

5. A patient with myasthenia gravis is administered pyridostigmine (Mestinon) for the first time.

She asks the nurse the reason why she has been changed to this medication. Which of the following is the nurse's best response A) “Pyridostigmine (Mestinon) will allow you to awaken with the ability to swallow.”

B) “Pyridostigmine (Mestinon) can be taken every other day.”

C) “Pyridostigmine (Mestinon) is a faster-release form of cholinergic agent.”

D) “Pyridostigmine (Mestinon) is taken one time per day for better control.”

Ans:A Feedback: Pyridostigmine is a slow-release form that is taken at bedtime and allows the patient the ability to swallow in the morning Pyridostigmine is usually taken two times per day, not every other day. Pyridostigmine is a slowrelease form, not a fast-release form Pyridostigmine is taken two times per day, not one time per day.

6. A patient is diagnosed with a paralytic ileus Which of the following medications will be administered to treat a paralytic ileus A) Neostigmine (Prostigmin) B) Donepezil (Aricept)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Bethanechol (Urecholine) D) Ambenonium (Mytelase) Ans:C Feedback: Bethanechol (Urecholine) produces smooth muscle contractions and is used for obstructive conditions of the gastrointestinal tract. Neostigmine is used to treat myasthenia gravis. Donepezil is used to treat Alzheimer's disease. Ambenonium is used to treat myasthenia gravis.

7. When administering anticholinesterase drugs, what assessment finding would indicate the patient is experiencing a toxic effect of the medication A) Loss of consciousness B) Abdominal distention C) Hypertension D) Muscle weakness Ans:D Feedback: The administration of anticholinesterase medications can result in profound muscle weakness. Decreased LOC, abdominal distention, and hypertension are not characteristic adverse effects of the anticholinesterase medications.

8. A patient has been receiving bethanechol (Urecholine) for 1 week. One hour after the dose is administered, he develops sweating, flushing, abdominal cramps, and nausea What is the rationale for the development of these symptoms A) Myasthenic crisis B) Cholinergic overdose C) Anaphylactic reaction D) Pulmonary edema Ans:B Feedback: A patient who suffers cholinergic overdose will experience sweating, flushing, abdominal cramps, and nausea. An accurate diagnosis may be determined from timing in relation to medication. Signs and symptoms having an onset within approximately 1 hour after a dose of anticholinesterase drug are likely to be caused by cholinergic crisis. Signs and symptoms beginning 3 hours or more after a drug dose are more likely to be caused by myasthenic crisis.

These symptoms are not the result of anaphylaxis or pulmonary edema.

9. A patient who is being treated for myasthenia gravis is receiving neostigmine, and her pulse drops to 50 after the administration. Which medication should be administered to treat the bradycardia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Atropine B) Pseudoephedrine C) Propranolol (Inderal) D) Bethanechol (Urecholine) Ans:A Feedback: Atropine will reverse the muscarinic effects of cholinergic crisis. Pseudoephedrine will not affect bradycardia in this patient Propranolol (Inderal) will not affect the bradycardia. Bethanechol will increase the bradycardia.

10. Which of the following medications is administered for ingestion of clitocybe mushrooms A) Pyridostigmine (Mestinon) B) Donepezil (Aricept) C) Rivastigmine (Exelon) D) Atropine sulfate Ans:D Feedback: Atropine sulfate is the specific antidote for mushroom poisoning. Pyridostigmine, donepezil, and rivastigmine are all cholinergic agents that would contribute to the symptoms of toxicity.

11. A 33-year-old female patient with a recent history of visual disturbances and dysphagia has just been diagnosed with myasthenia gravis. The nurse should recognize that this patient's health problem is ultimately attributable to what pathophysiological process A) Idiopathic overproduction of anticholinesterase B) Autoimmune destruction of acetylcholine receptors C) Demyelination of parasympathetic nerve pathways D) Deficient synthesis of dopamine by the substantia nigra Ans:B Feedback: Myasthenia gravis occurs when antibodies produced by the body's own immune system block, alter, or destroy the receptors for acetylcholine at the neuromuscular junction, which prevents muscle contraction from occurring. The disease does not involve dopamine deficits, demyelination, or excess anticholinesterase.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A 40-year-old woman has received a diagnosis of myasthenia gravis (MG) and is scheduled to begin treatment with oral neostigmine in her home. When providing relevant health education, the nurse should emphasize that successful control of MG symptoms will primarily depend on A) matching each dose of neostigmine to the severity of symptoms at that time B) making lifestyle modifications to prioritize a healthy diet and regular activity C) adhering strictly to the prescribed administration schedule D) developing acceptance of the functional deficits that result from MG Ans:C Feedback: Strict adherence to timely medication administration promotes optimal blood levels of neostigmine and optimal symptom control. Doses are not typically matched to short-term symptom severity, except in emergencies Lifestyle modifications and acceptance may be of benefit, but pharmacologic therapy is of paramount importance in the treatment of MG. 13. An accidental overdose of neostigmine has prompted the emergency administration of atropine. When assessing the patient, the emergency department nurse should take into account that this intervention will not relieve the effects of neostigmine on A) skeletal muscle B) smooth muscle C) the heart D) glands Ans:A Feedback: Atropine reverses only the muscarinic effects of cholinergic drugs, primarily in the heart, smooth muscle, and glands. Atropine does not interact with nicotinic receptors and therefore cannot reverse the nicotinic effects of skeletal muscle weakness due to overdose of indirect anticholinergic drugs.

14. A middle-aged female patient has been admitted to the outpatient treatment unit of the hospital for an edrophonium (Tensilon) test. Shortly after the administration of the medication, the patient reports that her muscle strength is significantly weaker than before the test. The nurse who is participating in the test should recognize that this finding is suggestive of what diagnosis

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Alzheimer's disease B) Anticholinergic crisis C) Myasthenia gravis D) Cholinergic crisis Ans:D Feedback: If the edrophonium test makes the patient even weaker, the diagnosis is cholinergic crisis.

15. Following recent changes in memory and personality, a 72-year-old man is undergoing neurological testing to rule out Alzheimer's disease. The nurse is aware that this disease is characterized by what pathophysiological phenomena? Select all that apply A) Meningiomas B) Neuritic plaques C) Neurofibrillary tangles D) Arteriovenous malformations (AVMs) E) Gliomas Ans:C, D Feedback: The neuropathologic hallmarks of Alzheimer's disease are neuritic plaques and neurofibrillary tangles. Gliomas, meningiomas, and AVMs are not associated with Alzheimer's disease.

16. An 80-year-old man has been diagnosed with early-stage Alzheimer's disease and has begun treatment with donepezil (Aricept). When providing health education to the patient and his wife, the nurse should identify what goal of treatment A) Remission of Alzheimer's disease B) Cure of Alzheimer's disease C) Improvement of cognition and function D) Resolution of memory and cognitive deficits Ans:C Feedback: The goal of drug therapy for Alzheimer's disease is to slow the loss of memory and cognition, thus preserving the independence of the individual person for as long as possible.

Remission, cure, and resumption of preillness levels of memory and cognition are unrealistic goals.

17. An older adult patient with a diagnosis of moderate Alzheimer's disease will soon return home with her husband. How can the nurse best facilitate the safe and effective administration of donepezil in the home setting

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Have the patient explain the rationale for drug therapy repeatedly before discharge B) Provide a detailed drug monograph to the patient and her husband and offer to answer any questions C) Assess the patient's need for home care D) Teach the patient's husband to administer the medication in a timely and safe manner Ans:D Feedback: It is important for the home care nurse to work with responsible family members in such cases to ensure accurate drug administration. Assessing the family's need for home care may be warranted, but this action does not necessarily ensure safe drug administration. The presence of moderate Alzheimer's disease may preclude effective patient teaching. Written teaching materials must normally be supplemented by other forms of teaching.

18. A nurse is conducting health education with a man who has Alzheimer's disease and his daughter, who is his primary caregiver. The man has been deemed to be a good candidate for treatment with donepezil (Aricept) and will soon begin taking this medication. What teaching point should the nurse convey A) “Aricept should be taken 1 hour before or 2 hours after any dairy products.”

B) “It's important to take this medication at bedtime.”

C) “Aricept should be taken with food to reduce the chance of stomach upset.”

D) “If you don't notice any cognitive improvement within 2 weeks, the drug should be discontinued.”

Ans:B Feedback: Aricept should normally be taken at bedtime. It does not have to be taken with food.

Dairy does not interfere with pharmacokinetics. The drug should be continued even if improvement is not noticeable.

19. A man with a neurogenic bladder secondary to a spinal tumor has been taking bethanechol.

The patient has illuminated his call light, and the nurse has found him anxious, diaphoretic, and visibly flushed. Following a safety assessment, what action should the nurse take A) Prepare to administer an IV dose of epinephrine to mitigate the effects of acetylcholine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Contact the physician as the patient may be experiencing a cholinergic crisis C) Insert a Foley catheter as the patient may have excessive urine in his bladder D) Assess the volume of the patient's bladder contents using a bladder ultrasound Ans:B Feedback: The presence of sweating and skin flushing in a patient taking bethanechol is suggestive of a cholinergic crisis. This is a medical emergency that warrants prompt intervention by the care team. This problem is not treated with epinephrine. Assessing the patient's bladder or inserting a Foley catheter is not sufficient.

20. A military nurse is part of a team reviewing the appropriate response to chemical weapons attacks, including sarin, tabun, and soman When reviewing the physiology of a response to such drugs, the nurse should identify what goal of treatment A) Restore anticholinesterase function B) Restore GABA function C) Restore dopamine function D) Increase serotonin reuptake Ans:A Feedback: These drugs are irreversible anticholinesterase agents. The goal of treatment, such as atropine administration, is to restore normal function of anticholinesterase and rid synapses of excessive acetylcholine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 48 Drug Therapy for Parkinson's Disease, Urinary Spasticity, and Disorders Requiring Anticholinergic Drug Therapy 1. states he sustained several head injuries playing football. Based on this information, what do you suspect the patient is suffering from A) Seizure disorder B) Degenerative joint disease C) Amyotrophic lateral sclerosis D) Parkinson's disease Ans:D Feedback: Parkinson's disease is a chronic, progressive, degenerative disorder of the central nervous system characterized by resting tremor, bradykinesia, rigidity, and postural instability.

The patient is not experiencing degenerative joint disease. The patient is not showing signs of symptoms of a seizure disorder. The patient has rigidity with tremors, not the signs of muscle weakness that are found in amyotrophic lateral sclerosis.

2. A patient has developed symptoms of rigidity and bradykinesia. Which of the following medications has been linked to secondary parkinsonism A) Haloperidol B) Furosemide (Lasix) C) Psyllium hydrophilic mucilloid (Metamucil) D) Valproic acid (Valproate) Ans:A Feedback: Drugs that deplete dopamine stores or block dopamine receptors, including the older antipsychotic drugs (phenothiazines and haloperidol), reserpine, and metoclopramide, can produce movement disorders such as secondary parkinsonism. Furosemide does not deplete dopamine stores. Psyllium does not deplete dopamine stores. Valproic acid does not deplete dopamine stores

3. A patient is being treated for Parkinson's disease and has been prescribed both levodopa (Ldop A) and carbidopa (Lodosyn). Why is this course of combination treatment most effective A) Levodopa restores dopamine and carbidopa decreases peripheral breakdown of levodopa B) Levodopa decreases the toxic effects of carbidopa to reduce the extrapyramidal reaction

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Carbidopa increases the peripheral breakdown of levodopa to hasten its onset and peak D) Levodopa and carbidopa, when combined, enhance voluntary movement to improve gait Ans:A Feedback: Levodopa restores dopamine levels and, in combination with carbidopa, decreases the peripheral breakdown of levodopa and allows more to reach the brain. Levodopa does not decrease the toxic effects of carbidopa to reduce the extrapyramidal reaction. Carbidopa does not increase the peripheral breakdown of levodopa to increase its effectiveness Levodopa and carbidopa combined do not exacerbate abnormal voluntary movement to increase gait.

4. A patient who suffers from Parkinson's disease is being treated with levodopa/ carbidopa.

Which of the following disorders will result in the discontinuation of this drug based on a disease-related contraindication A) Human immune deficiency virus B) Human papillomavirus C) Transient ischemic attacks D) Narrow-angle glaucoma Ans:D Feedback: Since levodopa can dilate pupils and raise intraocular pressure, it is contraindicated in narrow-angle glaucoma. Levodopa is not contraindicated in patients with human immune deficiency virus. Levodopa is not contraindicated in patients with human papillomavirus.

Levodopa is not listed as a contraindication with TIAs. 5. A patient with long-standing Parkinson's disease has been prescribed entacapone (Comtan).

The patient asks the nurse to describe exactly how this medication works. Which of the following responses is most appropriate A) “Entacapone is best given parenterally to relieve symptoms.”

B) “Entacapone inhibits COMT so that dopamine is active for a longer time.”

C) “It increases the metabolism of levodopa in the bloodstream.”

D) “It increases the amount of dopamine that your brain creates.”

Ans:B Feedback: Entacapone is a COMT inhibitor. COMT plays a role in brain metabolism of dopamine. Entacapone is administered orally, not parenterally. Entacapone does not increase the metabolism of dopamine in the bloodstream. It inhibits the metabolism of levodopa in the blood stream. Entacapone is 90 excreted in the biliary tract and feces and 10 in the urine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient with Parkinson's disease is being treated with rasagiline (Azilect). This medication inhibits the metabolism of dopamine by monoamine oxidase. Which of the following foods should the patient be instructed to avoid A) Cheddar cheese and Polish sausage B) Ham and rye bread C) Roast beef and horseradish D) Dairy products Ans:A Feedback: Cheddar cheese and Polish sausage are high in tyramine, which produces a lifethreatening reaction of hypertension when combined with rasagiline. The other listed foods are not high in tyramine.

7. A patient with Parkinson's disease has been prescribed rasagiline. When educating this patient on this medication, which herbal supplement has the potential to produce hyperpyrexia and death with rasagiline A) Ginger B) Dextromethorphan C) Garlic D) St. John's wort Ans:D Feedback: Rasagiline administered with the herbal supplement St. John's wort will enhance the stimulation of serotonergic receptors to cause hyperpyrexia and death. Dextromethorphan can produce the same reaction but is not an herbal supplement. Ginger and garlic are herbal supplements but will not produce hyperpyrexia and death.

8. An 80-year-old patient has been prescribed an anticholinergic agent for treatment of Parkinson-related symptoms. What patient education should be provided A) “Avoid high environmental temperatures.”

B) “Anticholinergics increase mental alertness.”

C) “It is safe to take Sudafed for a cold.”

D) “You may experience urinary incontinence.”

Ans:A Feedback: Anticholinergic drugs decrease sweating and may cause heat stroke. The patient should be instructed to avoid high environmental temperatures. Anticholinergic agents will decrease mental alertness. Sudafed will produce anticholinergic effects and should not be administered. Anticholinergic agents produce urinary retention, not incontinence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A 77-year-old male patient with Parkinson's disease will soon begin treatment with levodopa, carbidopa, and entacapone (Stalevo). Prior to starting this course of treatment, the nurse must ensure that A) the patient has committed to having weekly blood work drawn for the next 2 months B) the patient has completed an anticholinergic challenge in a clinical setting C) the patient's existing dose of levodopa has been reduced D) the patient has a prognosis for complete recovery from Parkinson's disease Ans:B Feedback: Patients whose medication regime is being changed to Stalevo should be administered levodopa and the adjunctive entacapone. The levodopa dose should be adjusted prior to the conversion to Stalevo therapy. Weekly blood work and the completion of an anticholinergic challenge are not necessary. Complete recovery from Parkinson's disease is not a realistic goal.

10. The nurse is teaching a woman who has Parkinson's disease about the dietary implications of her upcoming treatment with levodopa/carbidopa. What should the nurse teach this patient A) “It's important to take this medication on a full stomach so that it doesn't make you nauseous.”

B) “Most people find that it's best to take this medication at bedtime, provided you haven't snacked in the evening.”

C) “If possible, try to eat extra protein when you're taking this medication.”

D) “Dairy products will make this medication ineffective, so make sure you don't take them at the same time.”

Ans:A Feedback: Levodopa/carbidopa is administered with or just after food or following a meal to reduce nausea and vomiting. Levodopa/carbidopa is not administered with a high-protein diet Dairy products do not interfere with pharmacokinetics.

11. A woman is admitted to the emergency department with a diagnosis of sinus bradycardia.

The patient has been prescribed atropine 0.5 mg IV. How often can atropine be administered A) Every 24 hours B) Every 6 hours C) Every 30 minutes D) Every 3 to 5 minutes

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Atropine 0.5 mg should be administered IV every 3 to 5 minutes and may be repeated up to 3 mg. Atropine can be administered every 24 hours, but this administration is not the recommended therapy for bradycardia Atropine can be administered every 6 hours, but this administration is not the recommended therapy for bradycardia Atropine can be given in 30 minutes, but this administration is not the recommended therapy for bradycardia.

12. A patient is administered atropine to increase the heart rate. What is the action of atropine A) It blocks the parasympathetic vagal stimulation B) It exacerbates the parasympathetic vagal stimulation C) It provides long-acting antihistamine blockage D) It blocks cell wall synthesis of gram-negative bacilli Ans:A Feedback: Moderate to large doses of atropine increase the heart rate by blocking parasympathetic vagal stimulation. The exacerbation of the parasympathetic vagal stimulation is opposite the effect of atropine. The blockage of histamine is seen with the antihistamine medications, not anticholinergic agents Atropine does not block cell wall synthesis.

13. A patient has been administered atropine for sinus bradycardia. Which of the following symptoms is noted with large doses of atropine A) Pallor B) Flushing C) Edema D) Incontinence Ans:B Feedback: Large doses of atropine cause facial flushing because of dilation of blood vessels in the neck. Pallor, edema, and incontinence are not caused by dilation of blood vessels in the neck.

14. A patient is scheduled for a hemithyroidectomy. She has been prescribed an anticholinergic agent prior to surgery. Why is it important to administer the anticholinergic agent in the preoperative phase

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) It will prevent tachycardia B) It will decrease respiratory secretions C) It will decrease gastric motility D) It relaxes the detrusor muscle Ans:B Feedback: In preoperative patients, the nurse assesses for diminished secretions, particularly when an anticholinergic is administered for head and neck surgery. The administration of an anticholinergic agent will not prevent tachycardia. Anticholinergic agents do decrease gastric motility, but this rationale is not a reason for administration in the preoperative phase. The anticholinergic agents cause relaxation of the detrusor muscle, but this rationale is not the reason for administration of the medication in the preoperative phase.

15. The physician orders benztropine mesylate (Cogentin). What disease process would contraindicate the administration of this anticholinergic medication A) Diabetes mellitus B) Myocardial infarction C) Narrow-angle glaucoma D) Hyperparathyroidism Ans:C Feedback: Narrow-angle glaucoma will result in increased intraocular pressure, and the patient should not receive the anticholinergic agent. Patients who suffer from diabetes mellitus, myocardial infarction, or hyperparathyroidism can normally be administered anticholinergic agents.

16. The physician has ordered scopolamine transdermally for motion sickness. Which of the following statements by the patient indicates an understanding of the medication's administration guideline A) “I will place it on my chest each morning.”

B) “I will use it when I am sick to my stomach.”

C) “I will change the patch every 4 hours.”

D) “I will change the patch every 3 days.”

Ans:D Feedback: Scopolamine is used for motion sickness. The disk (Transderm-V) protects against motion sickness for 72 hours. The scopolamine patch is applied behind the ear, not to the chest.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

The patch is used prior to the patient experiencing nausea. The patch is not changed every 4 hours.

17. A patient with myasthenia gravis is experiencing rhinorrhea. Which of the following medications should not be administered to the patient A) Azelastine hydrochloride (Astelin) B) Ipratropium (Atrovent) C) Fexofenadine (Allegr A) D) Nedocromil sodium (Tilade) Ans:B Feedback: Ipratropium (Atrovent) is administered for rhinorrhea, but is contraindicated in patients who have been diagnosed with myasthenia gravis because of its anticholinergic effects.

Azelastine hydrochloride (Astelin), fexofenadine (Allegr A), and nedocromil sodium (Tilade) are not contraindicated for patients with myasthenia gravis.

18. A patient is suffering from urinary urgency and frequency. Which of the following medications will assist in treating the patient's symptoms of urinary frequency A) Belladonna tincture B) Homatropine hydrobromide C) Hyoscyamine (Anaspaz) D) Ipratropium (Atrovent) Ans:C Feedback: Hyoscyamine (Anaspaz) is a belladonna alkaloid used in genitourinary disorders characterized by spasm, increased secretion, and increased motility. Belladonna tincture is used for GI disorders because of its antispasmodic effect. Homatropine hydrobromide is used as an eyedrop to produce mydriasis and cycloplegia Ipratropium (Atrovent) is used to treat rhinorrhea.

19. A patient has been diagnosed with chronic obstructive pulmonary disease. The patient is to be administered tiotropium bromide (Spiriva HandiHaler). The patient's creatinine level is 25.

What is the patient at risk for developing A) Drug toxicity B) Pneumonia C) Hepatotoxicity D) Central nervous system depression Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The patient has an elevated creatinine level. Tiotropium bromide is eliminated by the renal system, and patients with moderate to severe renal dysfunction should be carefully monitored for drug toxicity.

20. A patient has been administered chlorpromazine (Thorazine) for many years to treat his psychotic disorder. He has recently developed extrapyramidal symptoms related to long-term administration of this drug Which of the following medications can be administered to assist in relieving these symptoms A) Diazepam (Valium) B) Darifenacin (Enablex) C) Trihexyphenidyl (Trihexy) D) Trospium chloride (Sanctur A) Ans:C Feedback: Trihexyphenidyl (Trihexy) is used in the treatment of parkinsonism and extrapyramidal reactions caused by antipsychotic drugs Valium is a benzodiazepine and is not used for this purpose. Darifenacin is used for the treatment of overactive bladder. Trospium chloride (Sanctur A) reduces the tone of the smooth muscle in the bladder.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 49 Drug Therapy With Opioids 1. A surgical patient has highly elevated AST and ALT levels. Standard orders specify that she is to receive morphine sulfate 10 mg postoperatively. What action should the nurse take prior to administering the medication A) Draw up half of the medication for administration B) Notify the physician for a reduced dosage C) Assess the patient's respiratory status D) Assess the patient's pain tolerance Ans:B Feedback: Morphine and meperidine form pharmacologically active metabolites. Thus, liver impairment can interfere with metabolism, and kidney impairment can interfere with excretion.

Drug accumulation and increased adverse effects may occur if dosage is not reduced. The nurse cannot administer half of the medication without a physician's order. It is important to assess the patient's respiratory status before administration, but this action is not the primary intervention in this case. Narcotics prior to surgery are administered to increase pain tolerance during the surgical procedure, not during the preoperative phase.

2. An outpatient has been prescribed hydrocodone for back pain related to a compression fracture. Which of the following interventions should the patient be taught regarding the medication administration A) Consume a diet high in fiber B) Decrease activity due to pain C) Elevate the lower extremities D) Take aspirin with the medication Ans:A Feedback: Hydrocodone is an opioid, which, in the gastrointestinal tract, slows motility. To prevent constipation, the patient should consume a diet high in fiber. A decrease in activity due to pain will increase constipation. Elevating the lower extremities will not increase or decrease pain. Hydrocodone should not be routinely combined with aspirin unless prescribed by the physician.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A hospice patient has been ordered morphine (Roxanol) 5 mg sub-Q every 2 hours Roxanol contains 10 mg/mL. How many milliliters will be administered A) 0.25 mL B) 0.5 mL C) 1 mL D) 2 mL Ans:B Feedback: 5 mg/X = 10 mg/mL. The calculation results in 0.5 mL. The administration of 0.25, 1, or 2 mL is incorrect.

4. A patient who suffers from cancer pain is receiving morphine every 2 hours. For which of the following should the family be taught to assess while the patient is on morphine A) Diarrhea B) Respiratory depression C) Lung sounds D) Urinary incontinence Ans:B Feedback: The administration of morphine can result in respiratory depression. The family should be taught to assess the patient for respiratory depression. Morphine sulfate can be administered to treat severe diarrhea. The patient's lung sounds are important to assess, but only after the nurse assesses for respiratory depression. Morphine does not cause urinary incontinence.

5. A patient is admitted to the surgical division after a mastectomy. The patient has a PCA pump and states to you that she is fearful she will overdose on morphine. Which of the following interventions is most appropriate to teach the patient A) “The pump will administer all of the doses, so you don't have to worry.”

B) “If you follow the instructions, that won't happen to you.”

C) “The device is preset, so you cannot receive more than you need.”

D) “The device will give you a placebo when you press it often.”

Ans:C Feedback: PCA pumps deliver a basic amount of analgesic by continuous infusion, with the patient injecting additional doses when needed. The amount of the drug is preset and limited. The pump will administer a basal rate, but the patient can administer the medication at preset intervals. Telling the patient not to worry is not effective teaching or use of therapeutic communication. Telling the patient to follow the instructions is not effective teaching or use of

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

therapeutic communication. Instructing the patient on a placebo is not effective teaching or use of therapeutic communication

6. A patient has been given MS Contin. You enter the room and the patient is unresponsive. His respirations are 6 breaths per minute. What medication will be ordered for the patient A) Naloxone (Narcan) B) Capsaicin (Zostrix) C) Butorphanol (Stadol) D) Nalbuphine (Nubain) Ans:A Feedback: Naloxone (Narcan) has long been the drug of choice to treat respiratory depression caused by an opioid. Capsaicin is made from cayenne pepper and applied topically for pain relief Butorphanol (Stadol) is a synthetic, Schedule IV agonist similar to morphine in analgesic effects and ability to cause respiratory depression. Nalbuphine (Nubain) is a synthetic analgesic used for moderate to severe pain.

7. A patient has been administered an opioid For which of the following effects should the patient be assessed A) Oliguria B) Decreased level of consciousness C) Edema D) Tachycardia Ans:B Feedback: Opioids will produce decreased LOC. Oliguria is not a result of the administration of an opioid. Edema is not a result of the administration of an opioid. Tachycardia is not a result of the administration of an opioid.

8. A nurse is teaching a patient about her prescription for Tylenol #3 that she will take at home.

This medication consists of acetaminophen and what other drug A) Codeine B) Acetylsalicylic acid (aspirin) C) Methadone (Dolophine) D) Tramadol (Ultram) Ans:A Feedback: Tylenol #3 is acetaminophen (Tylenol) and codeine. Acetylsalicylic acid (aspirin) is not combined with acetaminophen (Tylenol)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Methadone (Dolophine) is not combined with Tylenol. Tramadol (Ultram) is not combined with Tylenol.

9. A patient is near the end of life and has developed increased respiratory secretions and labored breathing. The physician is likely to order which of the following medications to decrease these symptoms A) Meclizine (Antivert) B) Ampicillin C) Naloxone (Narcan) D) Morphine sulfate Ans:D Feedback: Morphine is used for the treatment of acute pulmonary edema. Meclizine (Antivert) is given for dizziness. Ampicillin is used to treat infection. Naloxone (Narcan) is the opioid antidote.

10. A patient has been receiving morphine sulfate 5 mg IV every 4 hours for the past several days. She states that the pain is not being relieved as well as it was in the past. What is the reason for this development A) She has developed a dependency on the morphine B) She has metastatic cancer and is dying C) She has greater pain with inactivity D) She has developed tolerance to morphine Ans:D Feedback: Larger-than-usual doses of morphine are required to treat pain in opiate-tolerant people. The patient has not developed a dependence on morphine. A patient with metastatic cancer will require increasing pain management, but this feature is not the rationale for the patient's statement. The increased pain is not related to inactivity.

11. In which of the following patients should the nurse question the physician's order for IV morphine A) An 88-year-old female with failure to thrive B) A 45-year-old female, 1-day postoperative mastectomy C) An 8-year-old male with a fractured femur D) A 17-year-old female, 1-day postoperative appendectomy

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Opioid analgesics should be used cautiously in older adults, especially if they are debilitated. Treatment with morphine 1 day after mastectomy is appropriate for pain management. The treatment of pain with morphine is appropriate for a patient with a fractured femur. The treatment of pain with morphine is appropriate for a patient who is 1-day postoperative for an appendectomy.

12. A 30-year-old male patient has been ordered Demerol 75 mg IM every 4 hours after a fractured femur. What action should the nurse take A) Give the medication as ordered B) Administer half the dose C) Call the physician for a smaller dose D) Give the dose by mouth Ans:A Feedback: The patient should be administered the full dose of medication, which is within dosing recommendations. A male patient with a fractured femur who has adequate hepatic and renal function should not receive a lower dose of Demerol and should not receive the medication by mouth.

13. A nurse is instructing a patient on the administration of an opioid medication. What medication effect will most likely develop A) Lower extremity paresthesia B) Drowsiness C) Occipital headache D) Polyuria Ans:B Feedback: Drowsiness and sedation are results of central nervous system depression. The patient will not develop lower extremity paresthesia, occipital headache, or polyuria. If these effects develop, they are not related to the opioid medication.

14. A patient has been ordered a fentanyl patch known as Duragesic for chronic pain. What patient teaching should be provided to the patient and family A) Remove the patch every 3 days

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Apply it to the chest only C) Apply it for breakthrough pain D) Remove it daily and clean skin Ans:A Feedback: Duragesic has a slow onset of action, but lasts about 72 hours. Duragesic can be applied to other areas of the skin, not solely on the chest. Duragesic is not applied for breakthrough pain. Duragesic is not removed daily 15. What is the most effective way to evaluate the patient's pain response after administering an opioid analgesic A) Observe the patient when he/she is not aware you are assessing him/her B) Ask another nurse to assess the patient's response to the medication C) Using a pain scale, ask the patient to describe the pain D) Ask the family to determine the patient's response to the pain Ans:C Feedback: Asking the patient to describe the pain using a pain scale is the most effective assessment of pain response. Observing the patient when he/ she is unaware is an objective assessment and does not represent a true pain experience Asking another nurse to assess the patient's response will not provide accurate data Asking the family to determine the patient's response will not provide accurate data.

16. Nonopioid analgesics may sometimes be added to a narcotic analgesic. What action will result A) Antagonism B) Additive effect C) Interference D) Increased excretion Ans:B Feedback: Aspirin and Tylenol are added to narcotic analgesics for additive effects of pain relief without the addition of narcotic adverse effects. Aspirin and Tylenol do not provide an antagonistic effect. Aspirin and Tylenol do not cause an interference of action. Aspirin and Tylenol will not increase excretion

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

17. A 16-year-old has been brought to the emergency department by his football coach after twisting his ankle during a practice drill. Diagnostic testing reveals a fracture. This patient is experiencing what type of pain A) Acute somatic pain B) Acute cutaneous pain C) Visceral pain D) Neuropathic pain Ans:A Feedback: Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in skin, bone, muscle, and soft tissue. Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues. Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system.

Cutaneous pain is not a recognized category.

18. A patient with traumatic injuries describes his current pain as being “unbearable.” The pathophysiology of pain begins with a signal from A) myelin sheaths B) nociceptors C) baroceptors D) synapses Ans:B Feedback: For a person to feel pain, the signal from nociceptors in peripheral tissues must be transmitted to the spinal cord, then to the hypothalamus and cerebral cortex in the brain. Myelin sheaths, synapses, and baroceptors are not directly involved in pain transmission

19. A 54-year-old woman is being admitted to the postsurgical unit following a transverse rectus abdominis myocutaneous (TRAM) flap. The patient's care plan specifies the use of preemptive analgesia. This approach to pain control will involve A) frequent administration of high-dose opioids B) simultaneous use of analgesics from different drug classes C) alternating administration of opioid antagonists with opioid agonists

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) patient-controlled analgesia Ans:B Feedback: Preemptive analgesia is used to reduce postsurgical pain by simultaneously administering medications from different drug classes to suppress pain by blocking multiple pain pathways. It is not synonymous with PCA and does not require alternation between opioid agonists and antagonists.

20. Following the administration of pentazocine (Talwin) to a patient with moderate pain, the nurse should assess for what change in the patient's vital signs A) Increased blood pressure B) Decreased oxygen saturation C) Increased temperature D) Increased respiratory rate Ans:A Feedback: Talwin may cause increased blood pressure. It does not typically cause deoxygenation, fever, or tachypnea.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 50 Drug Therapy With Local Anesthetics 1. A patient has suffered a severe laceration to his thumb and index finger during a workplace accident, and local anesthetic is to be utilized to facilitate suturing. Which of the patient's following statements should prompt the nurse to provide further health education A) “I have to admit I'm relieved that they'll be freezing my hand before they stitch it up.”

B) “I'm feeling pretty queasy about getting stitches, so I'm glad they'll be knocking me out.”

C) “They told me that it will take a few hours before I can feel my hand again.”

D) “If I understand correctly, I won't be able to move my hand normally for a while after getting the anesthesia.”

Ans:B Feedback: Local anesthesia is differentiated from general anesthesia in that there is no loss of consciousness. “Freezing” is an accurate description. Normal motor control and sensation return after a period of time.

2. Spinal anesthesia will be used to perform a patient's scheduled bunionectomy. What should the nurse teach the patient about the administration of this form of anesthesia A) It will cause a significant, but temporary, decrease in level of consciousness B) It will be injected at the level of C7 to T2 C) It will be injected between T8 and T9 D) It will be injected into the cerebrospinal fluid Ans:D Feedback: Spinal anesthesia involves injecting the anesthetic agent into the cerebrospinal fluid, usually in the lumbar spine. It does not cause a significant decrease in level of consciousness

3. Resetting of a patient's fracture will take place under local anesthetic. These anesthetics reduce movement and sensation by decreasing the permeability of the nerve cell membrane to ions.

What is the most important ion that participates in this process A) Calcium B) Magnesium C) Sodium D) Potassium

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Local anesthetics decrease the permeability of the nerve cell membrane to ions, especially sodium.

4. A patient who suffered a laceration while doing woodwork in his garage will have his wound treated under local anesthesia achieved using lidocaine and epinephrine. The nurse who will assist with the procedure should recognize that epinephrine performs what function in this situation A) Promoting vasodilation B) Prolonging the effects of lidocaine C) Preventing adverse effects of lidocaine D) Blocking the afferent nerve pathways Ans:B Feedback: Lidocaine has a rapid effect, and, when combined with epinephrine, this effect is prolonged. Epinephrine can promote vasoconstriction, not vasodilation, and it neither prevents adverse effects nor blocks afferent nerve pathways.

5. A patient's chronic venous ulcer on the lower lateral surface of his leg requires incision and debridement (I & D). The nurse should anticipate that lidocaine will be administered by which of the following routes A) Intravenous B) Topical C) Injection D) Nebulized Ans:C Feedback: Injectable lidocaine is used for infiltration of the skin or subcutaneous administration prior to minor surgical procedures, such as I & D. Nebulized administration of lidocaine is reserved for lung procedures. Topical administration would be insufficient, and IV administration is not warranted.

6. A patient with hand trauma following a gunshot wound currently has bier block anesthesia with lidocaine. What assessment finding should signal the nurse to the possibility that the patient has local anesthetic systemic toxicity (LAST)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The patient has become intensely anxious and agitated B) The patient has complained of nausea and had an episode of blood-tinged emesis C) The patient's heart rate has become bradycardic and irregular D) The patient states that he still has sensation in his hand Ans:A Feedback: Initial symptoms of LAST may include analgesia, circumoral numbness, metallic taste, tinnitus or auditory changes, and agitation. Nausea, dysrhythmias, and continued sensory nerve function do not suggest LAST. 7. An older adult patient has sought care for the treatment of hemorrhoids, and the care provider has prescribed topical lidocaine. The nurse should teach the patient that full pain relief will normally be achieved how long after application of lidocaine A) 5 to 10 minutes B) 15 to 30 minutes C) 20 to 60 minutes D) 90 minutes to 2 hours Ans:C Feedback: Following topical administration of lidocaine, the area becomes numb in 20 to 60 minutes.

8. A patient undergoing chemotherapy for the treatment of lung cancer has developed stomatitis.

Oral lidocaine viscous has consequently prescribed by the primary caregiver. To minimize the patient's chance of aspiration, the nurse should encourage the patient to A) take small bites of food and small sips of fluid after administration B) adopt a minced and pureed diet for the duration of treatment C) remain in a high Fowler's position for 90 minutes following the use of lidocaine viscous D) avoid eating or drinking for 1 hour following the use of lidocaine viscous Ans:D

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Patients should not drink fluids or eat after gargling with viscous lidocaine for at least 60 minutes due to risk of aspiration. Upright positioning will not mitigate this risk. A textured diet is unnecessary.

9. A patient has been administered lidocaine in anticipation of a bronchoscopy and lung biopsy.

What change in status would the nurse recognize as a potential hypersensitivity to lidocaine A) Audible wheeze B) Pleural pain C) Audible S3 D) Hemoptysis Ans:A Feedback: It is necessary to assess the respiratory status and lung sounds for signs of bronchospasm related to hypersensitivity after lidocaine administration. An audible wheeze is suggestive of bronchospasm. Pleural pain, audible S3, and hemoptysis are less likely to be a direct result of hypersensitivity.

10. A woman who is in her second trimester of pregnancy has suffered burns to her forearm from a steaming kettle. What amide local anesthetic can the nurse safely administer by the topical route during pregnancy A) Lidocaine B) Mepivacaine (Carbocaine, Polocaine) C) Bupivacaine (Marcaine, Sensorcaine) D) Dibucaine (Nupercainal) Ans:D Feedback: Dibucaine (Nupercainal) is local anesthetic administered topically to the affected area to induce pain relief. It is not absorbed systemically; therefore, it is considered safe during pregnancy. The other amides are not approved for use during pregnancy.

11. A hospital patient's medication administration record specifies the parenteral administration of lidocaine before a tissue biopsy to be performed later in the day. What action should the nurse take in response to this order A) Obtain an order for epinephrine in order to potentiate the action of lidocaine B) Contact the prescriber because administration should be performed by a physician or nurse anesthetist C) Administer a 500 mL bolus of normal saline to ensure adequate vascular volume

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Assess the patient's need for an antihistamine to be on hold during administration of the lidocaine Ans:B Feedback: A physician or nurse anesthetist administers the injectable form of lidocaine. A fluid bolus, an antihistamine, and epinephrine are not necessarily indicated.

12. Spinal anesthesia using procaine has been ordered for a patient prior to revision of the patient's ankle hardware. This drug achieves anesthesia by A) preventing the influx of sodium into nerve cells B) increasing the action of anticholinesterase in nerve synapses C) antagonizing nociceptors D) agonizing opioid receptors in the CNS Ans:A Feedback: Procaine decreases the influx of sodium into the nerve cell and depresses depolarization to prevent conduction of the nerve impulse. It does not alter the function of nociceptors, opioid receptors, or anticholinesterase.

13. The nurse is assessing a patient who was recently administered procaine for local anesthesia. Which of the following assessment findings would suggest the possibility of adverse effects A) Increased temperature B) Increased heart rate C) Decreased blood pressure D) Lethargy Ans:B Feedback: Following administration of procaine, the nurse assesses the CNS for excitability and the cardiovascular status for tachycardia and hypertension, leading to cardiovascular collapse.

Lethargy, hypotension, and fever are not typical adverse effects 14. anesthesia. The nurse recognizes that there is a risk to the patient who has local anesthesia due to what nursing diagnosis A) Disturbed sensory perception B) Autonomic dysreflexia C) Self-care deficit D) Latex allergy response

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The absence of sensory perception means that patients are at risk for injuring the anesthetized body part without their knowledge. Autonomic dysreflexia and latex allergy response are not plausible risks. The brief action of local anesthetics means that self-care deficit is rarely an issue.

15. A woman's prolonged epistaxis (noseblee D) following a basketball injury has created a need for anesthesia and vasoconstriction of the nasal mucous membranes. These therapeutic effects can best be achieved with what drug A) Prilocaine B) Procaine hydrochloride C) Bupivacaine D) Cocaine hydrochloride Ans:D Feedback: Topical cocaine is an anesthetic administered to the ear, nose, or throat to produce adequate anesthesia and vasoconstriction of the mucous membranes. The other listed anesthetics are not typically used for this purpose.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 51 Drug Therapy with General Anesthetics 1. Prior to her elective hip replacement surgery, the nurse is explaining the basic characteristics of general anesthesia to the patient. The nurse should perform this education in the understanding that general anesthesia is best understood as A) a nonreversible, temporary state of unresponsiveness B) a state of reversible unconsciousness C) stage N2 non–rapid eye movement sleep D) stage N3 non–rapid eye movement sleep Ans:B Feedback: General anesthesia is defined as a medication- induced reversible unconsciousness with loss of protective reflexes. There is the misconception that general anesthesia is a deep sleep.

2. A perioperative nurse is explaining the process of general anesthesia in anticipation of the adult patient's imminent bowel resection. When describing the phase of induction, the nurse should explain that this is usually achieved by what means A) Intramuscular injection of anesthetics and benzodiazepines B) Intravenous administration of opioid analgesics C) Subcutaneous injection of a rapid-acting anesthetic D) Intravenous administration of anesthetics Ans:D Feedback: The administration of a general anesthetic can be divided into three phases. The first phase is induction, which is rendering the patient unconscious by using inhalation anesthetics, intravenous anesthetics, or both. Adult patients usually receive a rapid-acting intravenous anesthetic medication. IM medications, sub-Q medications, and opioids are not used.

3. An adult patient who is currently undergoing rhinoplasty has developed the characteristic signs and symptoms of malignant hyperthermia. The operating room nurse should anticipate what intervention A) Hemodialysis B) Tracheal intubation C) IV administration of naloxone (Narcan) D) IV administration of dantrolene sodium (Dantrium)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: The treatment for malignant hyperthermia consists of intravenous dantrolene sodium (Dantrium), oxygenation and hyperventilation, hydration, and body cooling. The patient will already be intubated. Narcan and dialysis are not indicated.

4. The operating room nurse is reading the anesthesiologist's consult of a 30-year-old female patient who will undergo surgical repair of a meniscus tear later that day. The nurse reads that total intravenous anesthesia (TIV A) is indicated. What is the most likely rationale for this intervention A) The patient has a diagnosis of chronic obstructive pulmonary disease (COP D) B) The patient's insurer does not reimburse for inhaled anesthesia C) The patient has previously experienced severe postoperative nausea and vomiting D) The patient is in the first trimester of pregnancy Ans:C Feedback: In patients who have history of severe postoperative nausea and vomiting, the anesthetist may substitute the inhalation anesthetic with a technique called total intravenous anesthesia (TIV A). TIVA is not necessarily indicated in patients who are pregnant or who have COPD. Insurance considerations would not normally be an absolute indication for the use of TIVA

5. A certified registered nurse anesthetist is describing the minimum alveolar concentration (MA C) of isoflurane. How will the addition of nitrous oxide or IV anesthetics affect the MAC of isoflurane A) The MAC will remain the same B) The MAC will decrease C) The MAC of isoflurane will not be relevant D) The MAC will be more difficult to calculate

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: With the addition of other medications such as opioids, intravenous anesthetics, or nitrous oxide, the MAC values decrease.

6. A patient is scheduled to undergo craniofacial surgery, a procedure that will necessitate the use of propofol. The operating use nurse should be aware that alternative medications will be absolutely necessary in order to produce what effect in the patient A) Amnesia B) Euphoria C) Analgesia D) Hypnosis Ans:C Feedback: Propofol produces amnesia, euphoria, and hypnosis. It therefore blocks the perception of pain. It does not, however, provide analgesia.

7. The anesthesiologist has specified that ketamine will be included in a surgical patient's balanced anesthesia. When in postanesthetic recovery, the nurse should assess for what adverse effect of this medication A) Labile blood pressure B) Increased intracranial pressure C) Hyperventilation and respiratory alkalosis D) Delirium and agitation Ans:D Feedback: Ketamine can produce emergence delirium, hallucinations, and unpleasant dreams Symptoms of this effect may include confusion, agitation, and nystagmus. The drug preserves blood pressure and does not cause hyperventilation or increased ICP. 8. Vecuronium will be administered to a surgical patient to facilitate intubation and achieve balanced anesthesia. This medication induces paralysis by A) antagonizing acetylcholine receptors at neuromuscular junctions B) potentiating the effects of acetylcholinesterase in synapses C) crossing the blood–brain barrier and agonizing cerebellar function D) binding with serotonin and inhibiting its neuromuscular effects

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Because vecuronium is structurally similar to ACh, it binds to the receptors on the muscle and prevents normal function of ACh, producing skeletal muscle paralysis. The drug does not influence the physiology of serotonin, the cerebellum, or acetylcholinesterase.

9. A 39-year-old patient has been diagnosed with thyroid cancer and will have a thyroidectomy performed. During surgery in this nerve-rich and highly vascular region of the body, the patient may require vecuronium. What will be the primary purpose of this medication A) To ensure that the patient does not move during surgery B) To prevent intraoperative vomiting C) To protect the patient's airway during surgery D) To induce hypnosis and amnesia Ans:A Feedback: Delicate repairs, such as neck surgery and neurosurgery, may require the use of neuromuscular agents to prevent movement and subsequent damage. Vecuronium is not used to prevent nausea and vomiting, to protect the patient's airway, or to induce hypnosis and amnesia.

10. A surgical patient's balanced anesthesia includes the use of vecuronium. What nursing action should the operating room nurses prioritize A) Monitoring the patient for signs of increased level of consciousness B) Assessing and protecting the patient's airway C) Protecting the patient's skin integrity D) Monitoring the patient's deep tendon reflexes Ans:B Feedback: The maintenance of the patient's airway and respiratory function following the administration of neuromuscular blocking agents such as vecuronium is the most important nursing implication. The importance of airway protection supersedes that of DTR assessment, assessing LOC, and maintaining skin integrity, though each of these is a valid consideration.

11. A patient will undergo an endoscopy with conscious sedation using midazolam (Verse D). The nurse who is participating in this procedure should monitor the patient closely for signs of A) increased intracranial pressure B) respiratory depression

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) hemorrhage D) rhabdomyolysis Ans:B Feedback: Following administration of midazolam, continuous monitoring for respiratory depression is required, and if necessary, age- specific resuscitative measures should be implemented. Increased ICP, rhabdomyolysis, and hemorrhage are less likely than respiratory depression.

12. A 55-year-old woman will have a partial mastectomy performed as treatment for breast cancer. The anesthesiologist has informed the operating room nurse that opioids will be used to supplement anesthesia. What opioid is most likely to be utilized A) Codeine B) Oxycodone C) Fentanyl D) Meperidine Ans:C Feedback: A synthetic opioid that is about 100 times more potent than morphine sulfate, fentanyl can be used to supplement sedation, regional techniques, and general anesthesia. Codeine, meperidine, and oxycodone do not have intraoperative applications.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 52 Drug Therapy for Migraines and Other Headaches 1. A patient has been diagnosed with migraines after experiencing headaches of increasing severity. When providing health education to this patient about her new diagnosis, what should the nurse convey A) The etiology of migraines is thought to have a genetic component B) Migraines are typically the result of prolonged psychosocial stress C) Migraines can be a precursor to transient ischemic attacks (TIAs) or stroke D) The pathophysiology of migraine headaches involves a disruption in the limbic system Ans:A Feedback: Migraines demonstrate a familial pattern, and authorities believe that they are inherited as autosomal dominant traits with incomplete penetrance. Stress may precipitate a migraine, but this is not an aspect of the etiology. They are not a precursor to TIAs or stroke, and they do not involve disruption of the limbic system.

2. A middle-aged patient describes her headaches as “utterly debilitating” and tells the nurse, “It's hard to explain, but I just know when one is coming, and I'm never wrong.” This patient's statement suggests that she has what diagnosis A) Migraines B) Cluster headaches C) Tension headaches D) Ischemic headaches Ans:A Feedback: The severity of her headaches coupled with the fact that she experiences a prodrome suggests that she experiences migraines. This clinical presentation is not typical of cluster headaches or tension headaches. Ischemic headache is not a recognized subtype.

3. A young man has been diagnosed with migraines, and the nurse is teaching him about abortive therapy. The primary goal of this form of therapy will be to A) permanently correct the patient's brain physiology B) ensure that the patient experiences fewer migraine headaches C) relieve the symptoms of the patient's migraines

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) foster coping skills that will allow the patient to live with his migraines Ans:C Feedback: Abortive therapy is the administration of medications to treat the symptoms of migraine headache. These medications do not provide a permanent correction of pathophysiological neurological function, and they are not preventative. Coping skills are not provided through medications.

4. A patient who lives with migraines has been prescribed naproxen. The nurse should recognize that this drug achieves a therapeutic effect through which of the following means A) Demyelinizing pain fibers in the CNS B) Selectively antagonizing opioid receptors in the CNS C) Inhibiting the synthesis of COX-1 and COX-2 D) Slowing the reuptake of serotonin and acetylcholine in brain synapses Ans:C Feedback: Naproxen is a nonselective inhibitor of cyclooxygenase resulting in the inhibition of prostaglandin synthesis of COX-1 and COX-2. It does not involve serotonin, acetylcholine, or opioid receptors.

5. A nurse has administered a scheduled dose of naproxen to a hospital patient who has been taking the drug for several weeks. What assessment finding should cause the nurse to suspect that the patient is experiencing adverse effects of this drug treatment A) There is an increase in the patient's neutrophils but no increase in temperature B) The patient's stool tests positive for occult blood C) The patient complains of itchy, dry skin D) The patient has peripheral edema and there is a steady increase in the patient's weight Ans:B Feedback: GI bleeding is a significant adverse effect of naproxen. This drug does not typically cause leukocytosis, dry skin, or fluid imbalances.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. The nurse at a long-term care facility is assessing a new resident's current medication regimen, and the resident states that she often takes an OTC remedy when she experiences a migraine. She has brought the bottle with her, and the nurse notes it to be Anacin Advanced Headache Formula. The nurse should document that the patient takes which drugs Select all that apply A) Codeine B) Acetaminophen C) Aspirin D) Caffeine E) Naproxen Ans:B, C, D Feedback: Anacin Advanced Headache Formula and other similar OTC formulations include acetaminophen, aspirin, and caffeine.

7. A patient who is well-known to the clinic asked if it would safe for him to take Excedrin Extra Strength for the treatment of a severe headache. The nurse is well aware of this patient's medical history and should advise against using this medication based on what aspect of his current health status A) The patient has not adhered to previous treatment regimens B) The patient has a chronic venous ulcer on his lower leg C) The patient has a diagnosis of liver cirrhosis D) The patient is a smoker Ans:C Feedback: People with hepatic impairment should not receive this combination agent on an ongoing basis. They may not metabolize acetaminophen in this combined medication effectively, leading to hepatotoxicity. Lack of previous adherence, cigarette smoking, and the presence of skin ulcers do not necessarily contraindicate the use of this drug.

8. A young woman who is 14 weeks pregnant has sought care because she has been experiencing migraine headaches with increasing severity and frequency in recent months. She states, “My headaches used to be something I could live with, but now they're affecting every

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

other part of my life.” The patient has conducted online research and requested a prescription for ergotamine. How will this patient's current health status affect the clinician's response to this request A) The patient can safely use ergotamine but must be monitored for blood dyscrasias B) The patient must use a reduced dose of ergotamine until she has given birth C) The patient must wait until she has given birth before taking ergotamine D) The patient cannot safely take ergotamine until she has weaned her infant Ans:D Feedback: Pregnancy and lactation are contraindications to the use of ergotamine.

9. A patient has been treated for migraines on an ongoing basis and the care provider has just prescribed sumatriptan. Which of the following is the priority intervention for patient education A) “You might get dizzy and lightheaded after you take sumatriptan, but this is normal.”

B) “It's important that you never take Tylenol within 12 hours of sumatriptan.”

C) “Make sure that you stop taking ergotamine before you get this prescription filled.”

D) “You will likely experience a brief worsening of your migraine before this drug relieves the pain.”

Ans:C Feedback: It is important to ask the patient about recent administration ergot alkaloids. The ergot alkaloids should not be given within 24 hours of the administration of triptans. Signs of low blood pressure should be reported promptly, and there is no particular reason to avoid acetaminophen. Triptans do not make symptoms worse before they provide relief.

10. A nurse is teaching a patient how to take Imitrex in the home setting in order to maximize therapeutic benefit while reducing the risk of adverse effects. The nurse should teach the patient to take Imitrex A) before breakfast each day B) on days when migraines may be anticipated C) as soon as the earliest symptoms of migraine are sensed D) when the pain of a migraine becomes too much to bear Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: It is important to administer sumatriptan at the onset of migraine symptoms. The drug is not taken on a daily, scheduled basis and is not used as a preventative treatment.

11. A middle-aged patient has not achieved adequate symptom relief of migraines with first-line therapies, and the clinician is considering the use of frovatriptan (Frov A). The patient's concurrent use of what medication would contraindicate the safe use of frovatriptan A) Albuterol (Ventolin) B) Metformin C) Atorvastatin (Lipitor) D) Fluoxetine (Proza C) Ans:D Feedback: Frovatriptan (Frov A) interacts unfavorably with selective serotonin reuptake inhibitors and may lead to serotonin syndrome Ventolin, metformin, and Lipitor do not present a risk for interactions.

12. A woman in her 40s has been living with migraines for many years, and these have only just been identified as being linked to her menstrual cycles. Estradiol has been prescribed, which the nurse will administer A) intravenously B) transcutaneously C) intramuscularly D) sublingually Ans:B Feedback: Estradiol for the treatment of migraines is administered by the transcutaneous route.

13. A nurse in surgical daycare is completing a preoperative assessment of a woman who will undergo hip arthroplasty. The nurse has questioned the woman about her daily use of gabapentin

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

(Neurontin), and the woman has stated that she takes this drug to treat her migraines. What role does this drug play in migraine treatment A) It reduces the intensity of menstrual migraines B) It prevents migraines from occurring C) It relieves acute migraine pain D) It lengthens the aura that precedes a migraine Ans:B Feedback: Studies have shown that gabapentin is effective in reducing the frequency of migraines. Gabapentin is not an abortive treatment

14. on a frequent basis and has had oral prochlorperazine (Compazine) added as an adjuvant medication to abortive therapy When teaching the patient to take this drug safely in the home setting, the nurse should emphasize what teaching point A) The importance of taking the pill whole and not crushing or splitting it B) The importance of having a bimonthly complete blood count (CB C) drawn C) The need to avoid taking the drug after eating fatty food D) The need to be aware of the potential for hypotension Ans:A Feedback: When taking prochlorperazine orally, it is important to swallow it whole and not chew or crush the tablets. Blood work is not warranted, and there is no need to avoid fatty food prior to taking the drug. Compazine is not noted to cause hypotension.

15. Mrs. Gonzaga is a 60-year-old woman who first began having headaches during the onset of menopause and who has subsequently been diagnosed with migraines. She tearfully explains to the nurse how her husband downplays her health condition and tells her that she needs to “just push through a headache.” She describes how her migraines have limited her ability to provide

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning Mrs. Gonzaga's care A) Ineffective health maintenance related to migraine headaches B) Ineffective role performance related to migraine headaches C) Situational low self-esteem related to migraine headaches D) Spiritual distress related to migraine headaches Ans:B Feedback: Many nursing diagnoses likely apply to this patient's situation, but there is evidence that she grieves her inability to perform a caregiving role for her grandchildren. There is no evidence that the patient's health maintenance is inadequate or that she has low self-esteem.

Spiritual distress is also not in evidence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 53 Drug Therapy for Seizure Disorders and Spasticity 1. A patient has a left temporal brain tumor. He smells an odor of ammonia prior to experiencing rapid rhythmic jerking movements. What is the odor of ammonia classified as A) Chemical agent evoked by the tumor B) An aura prior to the seizure activity C) The metastatic process of tumor growth D) The inhibition of serotonin and acetylcholine Ans:B Feedback: The smell of ammonia is an aura, which is a warning prior to seizure activity. The tumor will not evoke a chemical agent prior to the seizure. The metastatic process will not evoke a chemical smell. The chemical smell is not related to the inhibition of serotonin and acetylcholine.

2. A patient has been taking phenytoin (Dilantin) for a seizure disorder. He has recently run out of his medication and has not obtained a refill What is the patient at risk for developing A) Hypotension B) Migraine headaches C) Status epilepticus D) Depression Ans:C Feedback: In a person taking medications for a diagnosed seizure disorder, the most common cause of status epilepticus is abruptly stopping AEDs. Abruptly stopping phenytoin will not cause hypotension. Abruptly stopping phenytoin will not cause migraine headaches. Abruptly stopping phenytoin will not cause depression.

3. A patient is admitted to the emergency room in status epilepticus. What medication may be administered intravenously to assist in reducing seizure activity A) Diazepam (Valium) B) Hydromorphone (Dilaudi D) C) Insulin D) Meperidine (Demerol) Ans:A

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: IV diazepam is an adjunctive skeletal muscle relaxant administered for the treatment of severe recurrent convulsive seizures and status epilepticus. Ethosuximide (Zarontin) is not administered for status epilepticus Meperidine (Demerol) and insulin are not administered for status epilepticus.

4. An 80-year-old patient has severe pain after a case of shingles. The pain is noted along the shoulder and back. He states the pain is so severe he cannot sleep. What is the primary medication that will relieve this pain A) Meperidine (Demerol) B) Morphine sulfate (MS Contin) C) Naproxen sodium (Naprosyn) D) Gabapentin (Neurontin) Ans:D Feedback: Gabapentin is the first oral medication approved by the FDA for the management of postherpetic neuralgia. Meperidine will provide pain relief but is not effective in postherpetic neuralgia. Morphine sulfate will provide pain relief but is not effective in postherpetic neuralgia.

Naproxen sodium will decrease inflammation but is not effective for postherpetic neuralgia.

5. A patient who has been taking valproic acid (sodium valproate) for a seizure disorder is asking the nurse about getting pregnant. Why is pregnancy discouraged in women who are being treated for seizure disorders A) Seizure disorders are genetic B) Seizure disorders are familial C) Antiepilepsy drugs decrease fertility D) Antiepilepsy drugs are teratogenic Ans:D Feedback: Antiepileptic drugs such as valproic acid must be used cautiously during pregnancy because they are teratogenic. Seizure disorders are not normally genetic or familial. Antiepilepsy medications do not decrease fertility.

6. A patient is being treated for a seizure disorder with phenytoin (Dilantin). He is admitted to the emergency room with sinus bradycardia. What action will occur regarding his antiepileptic agent A) Phenytoin (Dilantin) dose will be reduced

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Phenytoin (Dilantin) will be discontinued C) Phenytoin (Dilantin) will be given every other day D) Phenytoin (Dilantin) dose will be increased Ans:B Feedback: Phenytoin should be discontinued immediately because it is contraindicated in patients with sinus bradycardia. Reducing the frequency of administration would likely be insufficient.

7. A patient is admitted to the hospital with severe dehydration and also has decreased albumin levels. What effect will the patient's current status have if a prescribed dose of phenytoin (Dilantin) is administered A) Potentially toxic serum level B) Reduced serum level C) Increased seizure activity D) Thromboembolism Ans:A Feedback: Phenytoin is highly bound to plasma proteins and only a fraction is not bound to albumin; hypoalbuminemia will result in toxic serum levels of phenytoin. A reduced serum level of phenytoin will not be seen with hypoalbuminemia. The patient will not suffer from increased seizure activity. The patient will not suffer from thromboembolism.

8. The nurse has been educating the patient on the self-administration of phenytoin (Dilantin).

Which of the following statements by the patient demonstrates an understanding of the medication A) “I'll only take the drug when I feel an impending seizure.”

B) “I'll reduce my dose if I remain seizure free.”

C) “I'll make sure to take the drug with food.”

D) “I'll stop taking the drug if I don't have a seizure for 8 weeks.”

Ans:C Feedback: Phenytoin should be taken with food to reduce the chance of stomach upset. It should be taken on a regular basis, and not only when a seizure occurs. The patient should not arbitrarily reduce his or her dose of phenytoin. Abrupt cessation can cause seizures.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A patient suffers from trigeminal neuralgia. What antiepileptic agent may be used to treat this disorder A) Phenytoin (Dilantin) B) Carbamazepine (Tegretol) C) Fosphenytoin (Cerebyx) D) Ethosuximide (Zarontin) Ans:B Feedback: Carbamazepine (Tegretol) is prescribed to treat trigeminal neuralgia. Phenytoin is not administered for trigeminal neuralgia Fosphenytoin is not administered for trigeminal neuralgia. Ethosuximide is not administered for trigeminal neuralgia.

10. A child suffers from absence seizures and has been prescribed acetazolamide (Diamox). The nurse should know that this medication is an adjuvant medication useful in the treatment of seizures. What is the therapeutic action of Diamox A) It slows the action potential of neurons B) It slows the reuptake of acetylcholine C) It suppresses the limbic and reticular systems D) It controls fluid secretion in the CNS Ans:D Feedback: The sulfonamide diuretic acetazolamide (Diamox) controls fluid secretion in the CNS; it is thought to inhibit CNS carbonic anhydrase to decrease neuronal excitability 11. activity. The patient is being treated with gabapentin (Neurontin). After administering the medication, the nurse should assess the patient because of the potential for what adverse effect A) Tetany B) Hypersensitivity C) Paradoxical seizures D) CNS depression Ans:D Feedback: The most common adverse effects of gabapentin are associated with CNS depression and include dizziness, somnolence, insomnia, and ataxia. The drug has not been noted to cause tetany, hypersensitivity reactions, or paradoxical seizures.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

12. A patient with impaired liver function is suffering from a seizure disorder that most often results in partial seizures. Which of the following AEDs may be administered to a patient with impaired liver function A) Oxcarbazepine (Trileptal) B) Fosphenytoin (Cerebyx) C) Carbamazepine (Tegretol) D) Levetiracetam (Keppr A) Ans:D Feedback: Levetiracetam (Keppr A) is not primarily metabolized in the liver. Oxcarbazepine (Trileptal) is metabolized in the liver Fosphenytoin (Cerebyx) is metabolized in the liver. Carbamazepine (Tegretol) is metabolized in the liver.

13. A patient is admitted to the hospital for severe back spasms and pain. Which of the following skeletal muscle relaxants will act peripherally on the muscle itself A) Cyclobenzaprine (Flexeril) B) Carisoprodol (Som A) C) Methocarbamol (Robaxin) D) Dantrolene sodium (Dantrium) Ans:D Feedback: Dantrolene is the only skeletal muscle relaxant that acts peripherally on the muscle itself; it inhibits the release of calcium in skeletal muscle cells, thereby decreasing the strength of muscle contraction. The other listed drugs act centrally.

14. A patient is recovering from a stroke and has developed severe muscle contractions. Which of the following medications will inhibit the release of calcium in skeletal muscle cells A) Dantrolene sodium (Dantrium) B) Baclofen (Lioresal) C) Carisoprodol (Som A) D) Cyclobenzaprine (Flexeril) Ans:A Feedback: Dantrium relieves spasticity by inhibiting the release of calcium in skeletal muscle cells Lioresal, Soma, and Flexeril act centrally.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

15. A patient with multiple sclerosis is admitted to the medical division for treatment of severe spasticity. What medication is used to treat spasticity and is administered intrathecally A) Baclofen (Lioresal) B) Carisoprodol (Som A) C) Diazepam (Valium) D) Dantrolene (Dantrium) Ans:A Feedback: Baclofen is used to treat spasticity in MS and spinal cord injuries. It can be administered intrathecally. Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. Diazepam is used to relieve muscle spasms but not used intrathecally.

Dantrolene is used to treat malignant hyperthermia but not multiple sclerosis.

16. A patient is admitted with acute, painful muscle spasms and suffers from intermittent porphyria, an inherited enzyme deficiency. Which of the following muscle relaxants is contraindicated due to the patient's history of porphyria A) Baclofen (Lioresal) B) Carisoprodol (Som A) C) Diazepam (Valium) D) Dantrolene (Dantrium) Ans:B Feedback: Carisoprodol is used to relieve discomfort from acute, painful musculoskeletal disorders. It is contraindicated in patients with intermittent porphyria. Baclofen is not known to be contraindicated with porphyria Diazepam is not known to be contraindicated with porphyria. Dantrolene is not known to be contraindicated with porphyria.

17. A patient with muscle spasms is administered cyclobenzaprine (Flexeril). Which adverse effect should the nurse assess for with this medication A) Muscle spasms B) Insomnia C) Drowsiness D) Urinary incontinence Ans:C Feedback: A common adverse effect with cyclobenzaprine (Flexeril) is drowsiness. The patient will not experience muscle spasms, insomnia, or urinary incontinence.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A patient has been started on dantrolene (Dantrium). What is the most serious adverse effect about which the patient should be instructed A) Metabolic acidosis B) Hypercarbia C) Renal calculi D) Hepatitis Ans:D Feedback: The most serious adverse effect of oral dantrolene is fatal hepatitis. Metabolic acidosis, hypercarbia, and renal calculi are not adverse effects of oral dantrolene.

19. A patient has been started on cyclobenzaprine (Flexeril). For the duration of treatment, the nurse should teach the patient to avoid A) OTC vitamin supplements B) alcohol C) stool softeners D) fatty foods Ans:B Feedback: Increased CNS depression occurs when cyclobenzaprine is combined with alcohol or other CNS depressants. There is no particular need for the patient to avoid fatty foods, stool softeners, or vitamin supplements.

20. A patient is taking tizanidine (Zanaflex) to treat spasticity from multiple sclerosis. Which of the following adverse effects of muscle relaxants is most pronounced with this medication A) Hypotension B) Dark black urine C) Excessive salivation D) Eczema Ans:A Feedback: Hypotension is the most significant adverse effect of tizanidine. Dark black urine, excessive salivation, and eczema are not adverse effects of tizanidine.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 54 Drug Therapy for Anxiety and Insomnia 1. A patient is having seizure activity, and the physician has ordered diazepam (Valium) to be given parenterally. If this medication is administered intravenously, when will its onset of action be observed A) 1 to 5 minutes B) 7 to 10 minutes C) More than 10 minutes D) Less than 1 minute Ans:A Feedback: Intravenous diazepam (Valium) is administered intravenously to decrease seizure activity and has a 1- to 5-minute onset of action. Diazepam (Valium) decreases seizure activity in less than 7 to 10 minutes Diazepam (Valium) should decrease seizure activity in less than 10 minutes. Diazepam (Valium) will take more than 1 minute to begin working.

2. A patient suffers from insomnia and is prescribed flurazepam. This medication has a longer half-life than 24 hours. Which of the following contributes to the long half-life of this medication and other benzodiazepines A) Metabolism by cytochrome P450 B) Presence of active metabolites C) Excretion by the renal system D) Movement of calcium in the cell Ans:B Feedback: Benzodiazepines differ mainly in their plasma half-lives, production of active metabolites, and clinical uses. Drugs with half-lives longer than 24 hours form active metabolites that also have long half-lives and tend to accumulate, especially in older adults and people with impaired liver function Flurazepam is not metabolized by cytochrome P450. Flurazepam is excreted in the renal system but does not contribute to the effect on the half-life. Flurazepam does not contribute to movement of calcium in the cell.

3. A patient is given midazolam (Verse D) in combination with an opioid in the preoperative phase before a laparoscopic cholecystectomy. What does the administration of midazolam (Verse D) assist in minimizing A) Oral secretions

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Anxiety C) Hypotension D) Muscle tone Ans:B Feedback: Midazolam (Verse D) provides preoperative sedation and mechanical ventilation. It does not reduce secretions, increase blood pressure, or reduce muscle tone.

4. A patient's medication regimen for treatment of anxiety has been changed from a benzodiazepine. The patient asks the nurse what likely prompted his care provider to change his medication. What is the nurse's best response A) “Your doctor may have been concerned about causing depression.”

B) “Your doctor may have been worried about the possibility of convulsions.”

C) “Long-term use of benzodiazepines can result in dependency.”

D) “Long-term use of benzodiazepines can cause insomnia.”

Ans:C Feedback: Although benzodiazepines are effective anxiolytics, long-term use is associated with concerns over tolerance, dependency, withdrawal, lack of efficacy for treating the depression that often accompanies anxiety disorders, and the need for multiple daily dosing with some agents.

They do not cause insomnia, convulsions, or depression.

5. A patient has developed excessive sedation and respiratory depression. The patient has been taking a benzodiazepine and has diminished liver function. Which of the following medications will reduce the effects of sedation and respiratory depression in this patient A) Olmesartan medoxomil (Benicar) B) Pancrelipase (Pancrease) C) Pamidronate disodium (Aredi A) D) Flumazenil (Romazicon) Ans:D Feedback: Toxic effects of benzodiazepines include excessive sedation, respiratory depression, and coma. Flumazenil (Romazicon) is a specific antidote that competes with benzodiazepines for benzodiazepine receptors and reverses toxicity. Olmesartan medoxomil (Benicar) is an angiotensin II receptor antagonist that is used to treat hypertension. Pancrelipase (Pancrease) is used for enzyme replacement therapy. Pamidronate disodium is used as a bone metabolism regulator.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A patient is being observed for acute benzodiazepine withdrawal symptoms. Which of the following symptoms is characteristic of this problem A) Bradycardia B) Agitation C) Lethargy D) Diaphoresis Ans:B Feedback: Common signs and symptoms of withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Bradycardia, lethargy, and diaphoresis are uncharacteristic.

7. A patient is administered a benzodiazepine for anxiety. Which of the following will place the patient at risk for benzodiazepine toxicity A) Decreased albumin B) Increased calcium C) Decreased potassium D) Low bicarbonate Ans:A Feedback: Patients with liver disease are at risk for adverse effects with drugs that are highly bound to plasma proteins. Increased calcium will not contribute to benzodiazepine toxicity.

Decreased potassium will not have a direct impact on benzodiazepine toxicity. The normal bicarbonate will not contribute to benzodiazepine toxicity.

8. An older adult patient suffers from generalized anxiety disorder. The use of benzodiazepines in this patient population creates a risk for what adverse effect A) Seizures B) Falls C) Dysrhythmias D) Sexual dysfunction Ans:B Feedback: Adverse effects of benzodiazepines may contribute to falls and other injuries unless patients are carefully monitored and safeguarded. Seizures, dysrhythmias, and sexual dysfunction are not characteristic adverse effects

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

9. A 77-year-old patient is suffering from insomnia. Which of the following medications can be most safely administered to this patient to induce sleep A) Alprazolam (Xanax) B) Clonazepam (Klonopin) C) Diazepam (Valium) D) Temazepam (Restoril) Ans:D Feedback: Temazepam (Restoril) is eliminated by conjugation with glucuronide. Thus, temazepam (Restoril) is the drug of choice for patients who are elderly, have liver disease, or are taking drugs that interfere with hepatic drug–metabolizing enzymes. Alprazolam (Xanax) is not administered for insomnia Clonazepam (Klonopin) is not administered for insomnia. Diazepam (Valium) is not administered for insomnia.

10. A child with night terrors is administered a benzodiazepine agent. Why must the nurse follow the child's health status closely A) The child is more likely to develop insomnia B) The child is more likely to develop dependence C) The child is more vulnerable to adverse effects D) The child is more vulnerable to hepatotoxicity Ans:C Feedback: Children may be more sensitive to its effects of this drug, namely mood and/or mental changes. Hepatotoxicity, insomnia, and dependence are not among the most common adverse effect.

11. When administering benzodiazepines, which of the following medications should be considered the drug of first choice A) Lorazepam (Ativan) B) Estazolam (Prosom) C) Temazepam (Restoril) D) Triazolam (Halcion) Ans:A Feedback: Lorazepam (Ativan) is probably the benzodiazepine of first choice. The drug provides rapid tranquilization of patients experiencing agitation. Administered intravenously, it

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

reduces nausea and vomiting as well as anxiety and induces procedural amnesia. Lorazepam has a slow onset of action (5 to 20 minutes) because of delayed brain penetration but an intermediate to prolonged duration.

12. A patient is admitted to the intensive care unit with a diagnosis of septicemia. In addition to relieving agitation and anxiety, what is a rationale for using benzodiazepines in the treatment of a critically ill patient A) Increased diffusion and perfusion B) Decreased cardiac workload C) Increased level of consciousness D) Decreased blood pH Ans:B Feedback: Antianxiety and sedative–hypnotic drugs are often useful in critically ill patients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. They do not decrease blood pH, increase diffusion and perfusion, or increase LOC. 13. A patient is scheduled to undergo a bronchoscopy for the investigation of a bronchial mass.

What benzodiazepine should the clinic nurse anticipate administering for conscious sedation A) Triazolam (Halcion) B) Midazolam (Verse D) C) Oxazepam (Serax) D) Chlordiazepoxide (Librium) Ans:B Feedback: Midazolam (Verse D) is frequently used for conscious sedation during invasive procedures. Halcion, Serax, and Librium are not typically used for this purpose.

14. A middle-aged woman has become increasingly debilitated by anxiety, to the extent that she has sought medical help. After a thorough assessment, her care provider has diagnosed her with an anxiety disorder. The etiology of anxiety involves which of the following physiological processes A) Stimulation of the parasympathetic nervous system

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Stimulating effects of somatotropin C) Increased activation of the autonomic nervous system D) Adrenocortical suppression Ans:C Feedback: Clinical manifestations of anxiety include overactivity of the autonomic nervous system, such as dyspnea, palpitations, tachycardia, sweating, dry mouth, dizziness, nausea, and diarrhea. Somatotropin is not directly involved, and the adrenal cortex is not suppressed during times of anxiety. The parasympathetic nervous system is not stimulated during times of anxiety.

15. A patient's current medical status includes multiple comorbidities. In recent months, the patient has been complaining of insomnia that has begun to have a significant impact on his quality of life. What aspect of this patient's health is most likely to cause insomnia A) The patient has hypothyroidism B) The patient is morbidly obese C) The patient has chronic pain D) The patient has type 2 diabetes Ans:C Feedback: Chronic pain is commonly associated with insomnia. Diabetes, obesity, and hypothyroidism are not normally associated with insomnia.

16. In the 18 months following the death of his wife, a middle-aged man has been taking benzodiazepines on a daily basis. He has expressed to the nurse his desire to stop taking these medications. In order to minimize the chances of withdrawal symptoms, the nurse knows that the patient will likely be advised to A) taper down his dose of benzodiazepines over a prolonged period of time B) replace the benzodiazepine with a herbal supplement in anticipation of stopping the medication C) replace the immediate-acting form of the drug with a long-acting form D) replace the benzodiazepine with an anticonvulsant

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: To avoid withdrawal symptoms, it is necessary to taper benzodiazepines gradually before discontinuing them completely. Long- acting benzodiazepines, anticonvulsants, and herbal remedies are not recommended in the effort to prevent withdrawal

17. A patient with a history of alcoholism is being treated in the intensive care unit for multiple trauma following a motor vehicle accident The patient is currently being treated with lorazepam (Ativan) to treat signs of alcohol withdrawal as well as hydromorphone (Dilaudi D) for the pain of injuries. The intensive care nurse should prioritize what assessments A) Arterial blood gases B) Respiratory rate and oxygen saturation C) Deep tendon reflexes and pupillary response D) Cardiac rate and rhythm Ans:B Feedback: The combination of opioids and benzodiazepines creates a significant risk for CNS depression; respiratory function is consequently an important focus of assessment. It would likely supersede other assessments, even though each may be warranted.

18. A 77-year-old woman who experiences significant anxiety has been taking diazepam for several months. She was brought to the clinical earlier this week by her daughter, who stated that her mother had been behaving in an uncharacteristically confused manner. The clinician discontinued the patient's diazepam. Three days later, the daughter states that her mother has still been having problems with impaired memory and confusion. The nurse should consider what possible explanation for the patient's current status A) Benzodiazepines can occasionally cause permanent alterations in personality and level of consciousness B) The patient may have decreased liver function C) The patient may have been experiencing a hypersensitivity to the drug, rather than an adverse effect D) The adverse effects of benzodiazepines can persist for several days after stopping the drug

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued Hypersensitivity and decreased liver function are unlikely. Benzodiazepines do not cause permanent changes in cognition.

19. A patient's severe family tragedy 1 year ago resulted in depression and insomnia. Which of the following hypnotics may be safely taken for longer-term treatment of insomnia A) Lorazepam (Ativan) B) Eszopiclone (Lunest A) C) Chloral hydrate D) Oxazepam (Serax) Ans:B Feedback: Eszopiclone (Lunest A) is the first oral nonbenzodiazepine hypnotic to receive FDA approval for long-term use ( 12 months).

20. A nurse has noted that a newly admitted patient has been taking ramelteon (Rozerem) for the past several weeks. The nurse is justified in suspecting that this patient was experiencing what problem prior to starting this drug A) Somnambulism (sleepwalking) B) Difficulty falling asleep at night C) Early morning waking D) Frequent nighttime awakenings Ans:B Feedback: Ramelteon (Rozerem), the newest oral nonbenzodiazepine hypnotic, has received FDA approval for the long-term treatment of insomnia characterized by difficulty with sleep onset.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 55 Drug Therapy for Depression and Mood Stabilization 1. A woman has a history of long periods of depression interspersed with hypomanic episodes.

What mood disorder is the patient most likely suffering from A) Bipolar disorder type I B) Bipolar disorder type II C) Situational depression D) Coping disorder Ans:B Feedback: Bipolar disorder type II is characterized by episodes of major depression plus hypomanic episodes and occurs more frequently in women. Bipolar disorder type I is characterized by episodes of major depression plus mania and occurs equally in men and women.

Situation depression lasts a shorter amount of time and is related to life events. A coping disorder is not related to hypomania.

2. A patient is admitted for assessment because of his history of inappropriately flamboyant and extroverted behavior coupled with risk- taking behaviors. The wife states he has also had periods of major depression but refuses to seek help. From what mood disorder is the patient most likely suffering A) Schizophrenia B) Depression C) Bipolar disorder type I D) Bipolar disorder type II Ans:C Feedback: Bipolar disorder type I is characterized by episodes of major depression plus mania and occurs equally in men and women Schizophrenia results from abnormal brain synapses and includes a wide variety of diseases.

Depression is a mood disorder, but does not exhibit periods of mania. Bipolar disorder type II is characterized by episodes of major depression plus hypomanic episodes and occurs more frequently in women.

3. A patient suffers from depression and states feelings of gloom and inability to perform the activities of daily living. The normal function of which neurotransmitter is most likely impaired A) Acetylcholine

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Epinephrine C) Insulin D) Serotonin Ans:D Feedback: Serotonin helps regulate several behaviors that are disturbed in depression.

Acetylcholine is a neurotransmitter with action in the cardiac and skeletal muscle. Acetylcholine has a limited impact in depression. Epinephrine is not associated with depression, though norepinephrine is implicated. Insulin is released by the pancreas to regulate blood sugar.

4. A patient has been taking a selective serotonin reuptake inhibitor for the treatment of depression. Which of the following represents the action of the medication A) Selective serotonin reuptake inhibitors block GABA B) Selective serotonin reuptake inhibitors prevent serotonin from being reabsorbed C) Selective serotonin reuptake inhibitors increase serotonin synthesis D) Selective serotonin reuptake inhibitors increase the number of serotonin binding sites Ans:B Feedback: Fluoxetine and the other SSRIs block the reabsorption of the neurotransmitter serotonin in the brain. This helps elevate mood. SSRIs do not increase serotonin synthesis or the number of binding sites. They do not influence the role of GABA. 5. An 8-year-old child is being seen in the clinic. The mother states he suffers from bed-wetting at least four times per week. What medication is effective in treating enuresis in children A) Amitriptyline (Elavil) B) Duloxetine (Cymbalt A) C) Imipramine (Tofranil) D) Venlafaxine (Effexor) Ans:C Feedback: Imipramine (Tofranil) is approved for treating childhood enuresis in children older than 6 years. Amitriptyline (Elavil) is a tricyclic antidepressant but is not used for childhood enuresis. Duloxetine (Cymbalt A) is a serotonin–norepinephrine reuptake inhibitor that is used for depression. Venlafaxine (Effexor) is a serotonin–norepinephrine reuptake inhibitor that is used for depression.

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6. An elderly patient is admitted to the medical unit after a fall. At home he is taking amitriptyline (Elavil) 20 mg three times per day. What adverse effect could be related to the patient's fall A) Urinary frequency B) Urinary retention C) Visual disturbances D) Orthostatic hypotension Ans:D Feedback: Orthostatic hypotension is an adverse effect related to amitriptyline (Elavil). Urinary retention (not frequency) is an adverse effect of amitriptyline but is not related to the falls. Visual disturbances are not a common adverse effect.

7. A 40-year-old man has been prescribed fluoxetine (Proza C). The patient states he has not continued the prescribed therapy even though his depression improved. What assessment is most important for the nurse to make A) Assess for sexual dysfunction B) Assess for hypotension C) Assess for pain and discomfort D) Assess for cardiac dysrhythmia Ans:A Feedback: Fluoxetine (Proza C) produces adverse effects, such as sexual dysfunction. It is imperative that the nurse assess for sexual dysfunction, which is a major reason for noncompliance in men. The assessment of hypotension is not accurate without symptoms of hypotension. The assessment of pain or discomfort is not accurate in this patient. The assessment of cardiac dysrhythmia is not accurate in this patient.

8. A patient is to be switched from fluoxetine (Proza C) to isocarboxazid (Marplan). What patient education is most important when changing from fluoxetine (Proza C) A) Wait 5 days before starting isocarboxazid (Marplan) B) Wait 1 week before starting isocarboxazid (Marplan)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Wait 2 weeks before starting isocarboxazid (Marplan) D) Wait 5 weeks before starting isocarboxazid (Marplan) Ans:D Feedback: If a patient is taking fluoxetine (Proza C) and is being switched to isocarboxazid (Marplan), the fluoxetine should be discontinued at least 5 weeks before starting the MAO inhibitor Waiting less time than this before starting the isocarboxazid (Marplan) will place the patient at risk for serotonin syndrome.

9. Duloxetine (Cymbalt A) is being considered in the treatment of a patient's depression. Which of the following laboratory values would prevent the patient from being treated with this medication A) Decreased hemoglobin level B) Decreased potassium level C) Increased ALT D) Increased erythrocyte sedimentation rate Ans:C Feedback: Duloxetine (Cymbalt A) is highly protein bound, extensively metabolized by CYP2D6 and CYP1A2 enzymes in the liver, and excreted by the kidneys. It is not recommended for use in patients with severe renal or any degree of liver impairment. Low hemoglobin, elevated potassium, and increased ESR do not necessarily preclude the use of Cymbalta.

10. A patient has been prescribed phenelzine sulfate (Nardil), which is an MAO inhibitor. Which of the following foods should the patient avoid eating A) Mashed potatoes and roast beef B) Aged Swiss cheese and bratwurst C) Tortellini in cream sauce D) Anise cookies and milk Ans:B Feedback: When taking an MAO inhibitor, the following foods should be avoided: aged cheeses and meats, concentrated yeast extracts, sauerkraut, and fava beans. None of the other listed foods is problematic.

11. A patient has been prescribed mirtazapine (Remeron). How will it decrease migraine headaches and depression

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) It increases concentration of endogenous epinephrine B) It blocks the presynaptic alpha2-adrenergic receptors C) It acts on the dopamine only receptors in the brain D) It inhibits norepinephrine and serotonin reuptake Ans:B Feedback: Mirtazapine blocks presynaptic alpha2- adrenergic receptors (which increase the release of norepinephrine), serotonin receptors, and histamine H1 receptors. Consequently, the drug decreases anxiety, agitation, insomnia, and migraine headaches as well as depression.

12. A patient suffers from insomnia secondary to temporomandibular joint pain. Which of the following selective serotonin reuptake inhibitors is most effective for treating insomnia A) Fluoxetine (Proza C) B) Olanzapine (Zyprex A) C) Citalopram hydrobromide (Celex A) D) Trazodone (Desyrel) Ans:D Feedback: Trazodone (Desyrel) is administered more often for sedation and sleep than depression. Fluoxetine (Proza C) is not administered for sleep. Olanzapine (Zyprex A) is not administered for sleep. Citalopram hydrobromide is not administered for sleep.

13. A patient is being treated for bipolar disorder with lithium carbonate (Eskalith). He also suffers from congestive heart failure and hypertension. The patient has an increased fluid volume and has recently had difficulty breathing. What laboratory value will most affect the action of the patient's lithium carbonate A) Increased hematocrit B) Increased sodium level C) Increased potassium level D) Increased white blood cell count

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: A sodium excess causes more lithium to be excreted and may lower lithium levels to nontherapeutic ranges. An increased lithium level would not be noted with a patient who has fluid volume excess and hypertension. An increased potassium level is unlikely with fluid volume excess. An increased white blood cell count is indicative of infection, from which the patient does not suffer.

14. A patient with a diagnosis of depression states to the nurse that she has started taking St John's wort to help her feel better and tolerate the demands of parenting. The patient has been taking an SSRI for the past several months. The nurse should teach that patient that this combination may result in A) worsened symptoms of depression B) blood dyscrasias C) dangerous drug interactions D) hemostatic instability Ans:C Feedback: Combining St. John's wort with antidepressants can cause serious adverse effects.

These effects do not typically include worsened depression, alterations in coagulation, or dyscrasias.

15. A patient has been taking lithium carbonate (Eskalith) for many years to treat bipolar disorder. Which of the following diets will require the dose of lithium carbonate (Eskalith) be reduced A) Low calorie B) Low carbohydrate C) Low sodium D) Low residue Ans:C Feedback: A low-salt (sodium) diet will impair lithium secretion, so the dose of lithium should be reduced. The administration of a low-calorie diet will not affect the dose of lithium. The administration of a low-carbohydrate diet will not affect the dose of lithium. The administration of a low-residue diet will not affect the dose of lithium.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

16. A patient treated for bipolar disorder with lithium carbonate (Eskalith) is scheduled for a lithium blood level. What is the therapeutic serum lithium level A) 0.5 to 1.2 mEq/L B) 1.5 to 2.0 mEq/L C) 2.7 to 2.9 mEq/L D) 2.75 to 3.25 mEq/L Ans:A Feedback: The therapeutic serum lithium level is 0.5 to 1.2 mEq/L. A serum lithium level of 2.7 to 2.9 mEq/L is toxic. A serum lithium level of 1.5 to 2.0 mEq/L is toxic. A serum lithium level of 2.75 to 3.25 mEq/L is toxic

17. depression several weeks ago and began taking citalopram (Celex A) 10 days ago. He has now scheduled an appointment at the clinic and has told the nurse that he intends to stop taking the drug, stating, “I don't feel any less depressed than I did before I started taking these pills.” How should the nurse best respond to the patient's statement A) “I'll pass that information along to your care provider; a different drug might be more appropriate for you.”

B) “I'd encourage you to continue with the drug; it can take several weeks before it improves your mood.”

C) “People who take this drug often think they don't feel better because the changes in mood are incremental and subtle.”

D) “It could be that one of the other medications or supplements you're taking is negating the effects of Celexa.”

Ans:B Feedback: Steady-state blood levels of SSRIs are achieved slowly, over several weeks. This aspect of pharmacokinetics is more likely than a possible drug interaction. The patient should expect to sense an eventual improvement in mood, and it would be premature to change medications.

18. A high school–aged girl has been suffering from major depression for several months, and she has begun treatment with an SSRI. In light of the black box warning accompanying SSRIs, the nurse should prioritize which of the following assessments A) Assessment for venous thromboembolism (VTE) B) Assessment of cardiac rate and rhythm C) Assessment for hypomanic state D) Assessment for suicidal ideation

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: The FDA has issued a black box warning alerting health care providers to the increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications. VTE, arrhythmias, and hypomania are not likely adverse effects.

19. A patient with a diagnosis of major depression has failed to respond to treatment with SSRIs, and the use of venlafaxine is being considered. The psychiatric nurse would recognize that this drug may have a therapeutic effect by which of the following means A) Slowing the reuptake of endorphins in the CNS B) Increasing levels of serotonin and norepinephrine C) Stimulating synthesis and potentiating the action of dopamine D) Slowing the reuptake of acetylcholine in brain synapses Ans:B Feedback: Venlafaxine increases the levels of serotonin and norepinephrine in the brain by preventing the reuptake of these neurotransmitters known to play an important part in mood. It does not directly affect endorphins or acetylcholine The drug weakly inhibits dopamine reuptake.

20. An elderly woman tells the nurse that she was successfully treated with phenelzine (Nardil) during a bout of severe depression in the 1970s. Her mood has been worsening in recent years as she has dealt with the death of her husband and functional declines. As a result, she has asked the nurse if her care provider is likely to prescribe this same drug. What fact should underlie the nurse's response to the patient A) Cognitive behavioral therapy has been found to be more effective than MAO inhibitors, so they are rarely prescribed B) In most situations, MAO inhibitors have been largely superseded by tricyclic antidepressants C) The risks of serious drug interactions and food interactions mean that MAO inhibitors are rarely used D) MAO inhibitors are rarely used because serum levels must be monitored with blood work every 2 weeks

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: MAO inhibitors are rarely used in clinical practice today, mainly because they may interact with some foods and drugs to produce severe hypertension and possible heart attack or stroke. Serum levels do not need to be monitored. The potential benefits of cognitive behavioral therapy do not affect prescribers' decisions to use MAO inhibitors. SSRIs have become the first line of treatment for depression, replacing tricyclic antidepressants.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 56 Drug Therapy for Psychotic Disorders 1. A person is seen wandering the streets and talking in an animated way to people who are not there. From what disorder do you suspect the person is suffering A) Confusion B) Delusions C) Psychosis D) Depression Ans:C Feedback: The patient is suffering from psychosis, which is a severe mental disorder characterized by disordered thought processes. Delusions are false beliefs that persist in the absence of reason or evidence and are also a symptom of a psychosis. Depression is a disorder and symptom that is not as severe as a psychotic disorder. Confusion is a more generic term that denotes a lack of clear thinking.

2. A patient is admitted to the hospital for cardiac surgery and has just come up to the postsurgical unit from the recovery room. He develops unprecedented confusion and states, “I see bugs up and down the walls. They are going to get me.” The nurse suspects the patient is suffering from what symptom A) Depression B) Delusions C) Delirium D) Schizophrenia Ans:C Feedback: The patient is suffering from delirium as a postoperative complication. Delusions are false beliefs that persist in the absence of reason or evidence. Schizophrenia is a variety of disorders and not a single symptom.

3. A teenage boy has begun to exhibit the characteristic signs and symptoms of schizophrenia.

During his mother's pregnancy, during what time in development could she have experienced an intrauterine insult A) Conception B) First trimester C) Second trimester

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Third trimester Ans:C Feedback: The neurodevelopmental model proposes that schizophrenia results when abnormal brain synapses are formed in response to an intrauterine insult during the second trimester of pregnancy, when neuronal migration is normally taking place. At conception, no implantation in the uterus has occurred. The first trimester is prior to neuronal migration. The third trimester is after neuronal migration.

4. A patient is experiencing an episode of psychosis. He is belligerent, loud, and abusive when you enter the room. What is the best response by the nurse during future interactions A) Respond to him in an assertive tone B) Use a calm, soft voice C) Delegate care to the technician D) Place him in the quiet room Ans:B Feedback: The most therapeutic communication technique for this patient is to use a calm, soft voice. To respond to the patient in a loud tone will increase his agitation. Delegating care to the patient care technician can increase the patient's agitation based on the fact that the unlicensed caretaker may not possess strong therapeutic communication skills. Placing the patient in a quiet room will not affect any changes in his behavior and may increase his hallucinations.

5. A patient who has a diagnosis of schizophrenia is likely to have which of the following pathophysiologic effects A) Increased dopamine B) Increased serum potassium C) Decreased numbers of glutamate receptors D) Decreased interaction with GABA Ans:A Feedback: The patient suffering from schizophrenia has increased dopamine activity in the brain. The amount of potassium would cause other physiological symptoms, but not affect schizophrenic symptoms. The patient with schizophrenia will have widespread glutamate receptors, not decreased glutamate receptors. In addition, the glutamatergic system interacts with the dopaminergic and gamma- aminobutyric acid systems and possibly other neurotransmission systems.

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6. A patient has been prescribed an antipsychotic agent to relieve psychotic symptoms. Which of the following goals of care is the priority A) The patient will demonstrate independent health maintenance B) The patient will interact therapeutically with peers C) The patient will participate in activities of daily living D) The patient will remain safe Ans:D Feedback: Safety is a priority over other goals. Goals such as participation in ADLs, health maintenance, and participation in relationships are valid, but safety is a priority.

7. A patient in her 60s has been living with schizophrenia since she was a young woman and was treated with chlorpromazine for many years. The nurse who is meeting the patient for the first time observes that the patient continually smacks her lips and appears to be chewing. The nurse should recognize that this patient is likely experiencing what problem A) Tardive dyskinesia B) Akathisia C) Dystonias D) Neuroleptic malignant syndrome Ans:A Feedback: Tardive dyskinesia occurs as the result of long-term use of chlorpromazine. Patients may experience lip smacking, tongue protrusion, and facial grimaces and may have choreic movements of trunk and limbs Akathisia is a form of restlessness, and dystonias are uncoordinated movements. Neuroleptic malignant syndrome is an acute complication.

8. An elderly patient with a long-standing history of schizophrenia has been admitted to the hospital for treatment of hyponatremia The nurse reviews the patient's medical chart and reads that the patient was previously treated with phenothiazine antipsychotics

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

What medication may this patient have been treated with A) Aminophylline (Theophylline) B) Acetylsalicylic acid (aspirin) C) Chlorpromazine (Thorazine) D) Dantrolene sodium (Dantrium) Ans:C Feedback: Chlorpromazine (Thorazine) is the prototype phenothiazine. Aminophylline (Theophylline) is a xanthine agent administered to increase bronchioles. Acetylsalicylic acid (aspirin) and dantrolene sodium (Dantrium) are not phenothiazines.

9. A patient who was diagnosed with schizophrenia in 1962 was prescribed chlorpromazine (Thorazine). The patient has been taking the medication for more than 40 years. What adverse effect will the patient most likely experience A) Hypertension B) Extrapyramidal effects C) Central nervous system agitation D) Urinary frequency Ans:B Feedback: A patient who has taken chlorpromazine (Thorazine) on a long-term basis will be at risk for late extrapyramidal effects Hypertension is not an adverse effect of chlorpromazine, but hypotension is an adverse effect.

Central nervous system agitation is not an adverse effect of chlorpromazine, but central nervous system depression is an adverse effect. Urinary frequency is not an adverse effect of chlorpromazine, but urinary retention is an adverse effect.

10. A child suffers from tics and verbal outbursts in the classroom and while he is awake. The patient is prescribed haloperidol (Haldol) What disease process is haloperidol (Haldol) used to treat A) Muscular dystrophy B) Early-onset dementia C) Tourette's syndrome D) Myasthenia gravis Ans:C Feedback: Haloperidol (Haldol) is used in treating Tourette's syndrome, which is a disorder characterized by involuntary movements and vocalizations. Muscular dystrophy is not treated with atypical antipsychotics Alzheimer's disease is not normally treated with atypical antipsychotics. Myasthenia gravis is not treated with atypical antipsychotics.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

11. A patient is prescribed clozapine (Clozaril). The patient and family should be instructed on the adverse effects of this medication What laboratory test is most important in the first months of the medication regime A) Weekly liver enzymes B) Daily INR C) Monthly creatinine levels D) Regular complete blood counts Ans:D Feedback: Clozapine (Clozaril) is associated with life- threatening decrease in white blood cells (agranulocytosis). It is essential to monitor the complete blood count due to this risk. Weekly liver enzymes are not recommended when administering clozapine. Monthly creatinine levels and INR monitoring are not recommended with clozapine therapy.

12. A patient is prescribed olanzapine (Zyprex A) for the treatment of schizophrenia. The patient tells the nurse he is voiding three times each night and is always thirsty. Based on the adverse effects of this medication, what should the nurse suspect the patient has developed A) Urinary tract infection B) Diabetes mellitus C) Renal calculi D) Hyperthyroidism Ans:B Feedback: The development of polyuria and polydipsia is indicative of diabetes mellitus.

Olanzapine has been associated with weight gain, hyperglycemia, and initiation or aggravation of diabetes mellitus. Urinary tract infection is not considered an adverse effect with olanzapine.

Renal calculus is not an adverse effect of olanzapine. Hyperthyroidism is not an adverse effect of olanzapine.

13. A patient diagnosed with schizophrenia is being seen by the home care nurse. What is the most important aspect of patient teaching with this patient A) Maintain the medication regimen B) Report signs of neuralgia

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Stop medications if weight gain occurs D) Limit alcohol intake to two drinks per day Ans:A Feedback: The patient should be instructed to maintain the medication regime to control symptoms of schizophrenia. Reporting signs of neuralgia is not taught because the medication does not have this effect. The medications will cause weight gain and should not be stopped in the event that weight gain develops. The use of alcohol is strictly prohibited with antipsychotic agents.

14. A patient with schizophrenia has been taking haloperidol for several years. The care team and the patient have collaborated and chosen to transition the patient to an atypical antipsychotic in an effort to reduce adverse effects and maximize therapeutic effects. In order to reduce the patient's risk of extrapyramidal effects during this transition, the care team should do which of the following A) Gradually taper the dose of haloperidol B) Have a 2- to 3-week “drug holiday” between stopping the haloperidol and starting the atypical antipsychotic C) Administer haloperidol and the atypical antipsychotic drug concurrently for 6 to 8 weeks D) Arrange for weekly electroconvulsive therapy during the time of transition Ans:A Feedback: When discontinuing haloperidol, it is essential to taper the dosage to prevent extrapyramidal symptoms. If the medication is abruptly discontinued, the patient is at risk for this condition. A drug holiday would exacerbate symptoms, and ECT is not indicated Concurrent administration of two drugs has the potential to exacerbate adverse effects

15. A psychiatric nurse is discussing the advantages of atypical antipsychotics with the parents of a teenage girl who has been diagnosed with schizophrenia. When comparing these drugs with the older, typical antipsychotics, what advantage should the nurse cite A) Lower cost B) The possibility of oral administration

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Reduced adverse effects D) Absence of black box warnings Ans:C Feedback: Atypical antipsychotics may be more effective in relieving some symptoms than typical antipsychotics, and they usually produce milder adverse effects. A major drawback is the high cost of these drugs. All antipsychotics are available for the oral route. There are several black box warnings relating to atypical antipsychotics.

16. A 22-year-old man's increasingly bizarre behavior has culminated in a diagnosis of schizophrenia. In light of current treatment modalities for schizophrenia, the nurse should anticipate that the patient is most likely to be prescribed what drug A) Chlorpromazine (Thorazine) B) Olanzapine (Zyprex A) C) Haloperidol (Haldol) D) Prochlorperazine (Compazine) Ans:B Feedback: The "atypical" antipsychotics, such as olanzapine, are the drugs of choice, especially for patients who are newly diagnosed with schizophrenia

17. A psychiatric nurse is providing care for a female patient with schizophrenia whose medication regimen includes oral chlorpromazine. When administering this medication, the nurse should do which of the following A) Have the patient hold the drug under her tongue for at least 30 seconds B) Administer the drug 1 to 2 hours before bedtime C) Administer the drug on alternating days D) Instruct the patient to avoid dairy products for 1 hour before and 2 hours after administration Ans:B Feedback: For oral administration of chlorpromazine, the nurse should give doses 1 to 2 hours before bedtime; peak sedation occurs in about 2 hours. The drug is not given on alternating days, and there is no need to avoid dairy products. It is unnecessary for the patient to hold the drug under her tongue.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

18. A patient has been achieving an acceptable reduction in his positive and negative signs of schizophrenia after several weeks of treatment with clozapine. The patient has asked the nurse if it is acceptable for him to have “a few drinks from time to time.” How should the nurse best respond to the patient's inquiry A) “If you notice that your symptoms are worsening when you drink, you should stop doing it.”

B) “That shouldn't present a problem, provided you make sure that you're safe when you do it.”

C) “That's okay in most cases, but it's advisable to limit it to beer and wine and to avoid spirits.”

D) “When you're taking clozapine, it's best to avoid drinking alcohol altogether.”

Ans:D Feedback: Alcohol increases central nervous system depression in patients taking clozapine; patients should ideally abstain from drinking alcohol.

19. A patient's medication administration record orders the IM administration of chlorpromazine. When administering this drug, the nurse should A) observe the patient while he or she self- administers the drug B) administer the drug into the deltoid muscle with a 1 1/2-inch needle C) have the patient massage the injection site for 1 to 2 minutes after the injection D) have the patient lie down for 30 to 60 minutes after the injection Ans:D Feedback: For IM administration of chlorpromazine, the nurse should have the patient lie down for 30 to 60 minutes after the injection to prevent orthostatic hypotension. Massage is unnecessary, and the ventrogluteal site is used. Self-administration is not the norm.

20. Parenteral haloperidol has been ordered for a patient who is experiencing an acute psychotic episode. The nurse should recognize what primary goal of treatment A) Increased insight into delusional thinking B) Increased sophistication of thinking C) Decreased agitation and combativeness D) Decreased CNS stimulation Ans:C Feedback: When haloperidol is given for acute psychotic episodes, the nurse observes for sedation, decreased agitation, combativeness, and psychomotor activity. Insight, clarity of

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

thinking, and decreased CNS stimulation are not short-term priorities during an acute psychotic episode

Chapter 57 Drug Therapy for Attention Deficit Hyperactivity Disorder and Narcolepsy

1. A 4-year-old child is brought to the pediatric clinic by his mother. She states, “I don't know what to do with him. He is in constant motion. He won't sit for more than a few seconds and he is doing something else. He often throws his toys and yells loudly, even compared with other kids his age.” The child is diagnosed with attention deficit hyperactivity disorder Which of the following medications will most likely be administered in conjunction with treatment A) ACE inhibitors B) SSRIs C) Central nervous system stimulants D) MAO inhibitors Ans:C Feedback: ADHD is characterized by persistent hyperactivity, short attention span, difficulty completing tasks, restlessness, and impulsivity. The diagnosis has increased in recent years, with a concomitant increase in the use of prescribed CNS stimulants for its treatment. SSRIs, ACE inhibitors, and MAOIs are not typically used.

2. A patient visits the occupational health office of the factory in which he works. He has fallen asleep on the line and has a history of muscle weakness. This instance is not the first time he has fallen asleep on the line. From what disease process does the occupational health nurse suspect the patient is suffering A) Sleep apnea B) Insomnia C) Narcolepsy D) Substance abuse Ans:C Feedback: Narcolepsy is characterized by daytime sleep attacks in which the person goes to sleep at any place or at any time. Sleep apnea is episodes of apnea during sleep. Insomnia is the inability to sleep. This patient is not exhibiting signs and symptoms of substance abuse.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

3. A patient suffers from narcolepsy. Which of the following aspects of patient teaching should be provided A) Take 250 mg of caffeine daily B) Avoid working shifts C) Take a lengthy nap every afternoon D) Increase the Ritalin dose as needed Ans:B Feedback: The patient who is diagnosed with sleep apnea should avoid shift work. Caffeine use may or may not be indicated. The patient should ideally not take naps. The patient should not increase the Ritalin dose without the input of the primary health provider.

4. A child is prescribed an amphetamine for attention deficit hyperactivity disorder. Which of the following effects provide evidence that the medications are working A) Improved grades B) Increased sleep quality C) Lethargy D) Polyphagia Ans:A Feedback: Amphetamines used with ADHD improve academic performance. Amphetamines often decrease sleep. Amphetamines will not result in lethargy. Amphetamines decrease appetite and do not cause polyphagia 5. A patient is taking dextroamphetamine for ADHD. He has developed constipation since beginning therapy. Which of the following should the patient be taught A) Take an OTC laxative daily B) Increase fiber intake C) Take diphenoxylate hydrochloride (Lomotil) D) Take metronidazole (Flagyl) Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: A patient who is experiencing constipation should be instructed to increase fiber in his diet. The patient should not take a laxative. The patient should not be instructed to take diphenoxylate hydrochloride (Lomotil) because it is an antidiarrheal agent. The patient should not be given metronidazole (Flagyl).

6. A neonate is suffering from apnea. Which of the following medications may be administered as a respiratory stimulant A) Caffeine and methylphenidate B) Caffeine and Mefoxitin C) Caffeine and sodium benzoate D) Caffeine and sodium bicarbonate Ans:C Feedback: The combination of caffeine and sodium benzoate is occasionally used as a respiratory stimulant in neonates. Caffeine is not mixed with methylphenidate. Caffeine is not mixed with Mefoxitin. Caffeine is not mixed with sodium bicarbonate for this indication.

7. A patient has been treated with dextroamphetamine for ADHD. At the age of 16 years, she is diagnosed with hyperthyroidism. What intervention should be implemented with this patient A) Discontinue the high-calorie diet B) Assess the patient for pulmonary edema C) Discontinue the amphetamines D) Administer a proton pump inhibitor Ans:C Feedback: Amphetamines are contraindicated upon the development of hyperthyroidism. The patient will require a higher calorie count, not a discontinuation of a high-calorie count. The patient will not require an assessment for pulmonary edema. The patient will only require a proton pump inhibitor if gastric hyperacidity occurs.

8. A teenage boy is on amphetamine therapy for attention deficit hyperactivity disorder. The care provider has suggested a “drug holiday” for July and August. What is the purpose of this drug holiday A) To minimize weight loss B) To prevent hyperthyroidism C) To allow electrolyte imbalances to resolve

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D) To slow bone resorption Ans:A Feedback: Dextroamphetamine often causes loss of appetite, and the health care provider may stop the medication during the months when the child is not in school. A drug holiday, as this is called, helps decrease weight loss and growth suppression. It does not address potential electrolyte imbalances, thyroid imbalances, or the process of bone remodeling.

9. A patient is seen in the ambulatory care clinic with a complaint of insomnia. What should the nurse assess in regard to the complaint of insomnia A) Daily intake of caffeine-containing products B) The amount of exercise in which the patient engages C) The family history of insomnia and sleep D) Possible use of amphetamines Ans:A Feedback: The daily intake of caffeine should be assessed to determine if the intake is sufficient to disturb sleep. The amount of exercise the patient engages in is important but not as critical as caffeine consumption. The family history of insomnia and sleep is not critical to assess.

Amphetamines also have the potential to disrupt sleep, but caffeine use is far more prevalent.

10. A female patient asks the nurse how much caffeine is safe to consume per day. What is the recommended amount of caffeine for a nonpregnant woman A) 125 mg of caffeine B) 250 mg of caffeine C) 500 mg of caffeine D) 1 g of caffeine Ans:B Feedback: Some authorities recommend that normal, healthy, nonpregnant adults consume not more than 250 mg of caffeine daily. 125 mg of caffeine is lower than the recommended safe amount of consumption. 500 mg to 1 g is more than the recommended daily consumption of caffeine.

11. A patient who suffers from asthma is given theophylline. Theophylline will have an increased effect if taken with A) Ritalin B) atomoxetine (Stratter A)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) modafinil (Provigil) D) caffeine Ans:D Feedback: Caffeine increases the effects of theophylline. Ritalin, Provigil, and Strattera are noted to have this effect 12. dextroamphetamine for the treatment of ADHD. During health education, the nurse should make the patient aware of the black box warning relating to A) the risks of kidney failure B) the potential for abuse C) the risk of stroke with excessive doses D) the potential for unstable blood glucose levels Ans:B Feedback: A black box warning makes users of dextroamphetamine aware of the drug's high abuse potential. Black box warnings do not address the potential for renal failure, stroke, or unstable blood sugars.

13. A 13-year-old child is started on atomoxetine (Stratter A) for ADHD. The patient and his family should be taught about the peak plasma levels of the medication. He takes his medication at 07:00 AM. When will this medication reach its peak plasma level A) 08:00 to 09:00 AM B) 09:45 to 10:30 AM C) 10:30 to 11:45 AM D) 13:00 to 14:00 PM Ans:A Feedback: Atomoxetine is rapidly absorbed with peak plasma levels in 1 to 2 hours. If he takes the medication at 07:00 AM, it will peak at 08:00 to 09:00 AM. 14. A patient with narcolepsy is placed on a central nervous system stimulant. What is the central nervous system stimulant of choice to treat narcolepsy A) Atomoxetine (Stratter A) B) Guarana

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

C) Caffeine D) Modafinil (Provigil) Ans:D Feedback: Modafinil (Provigil) is used to treat narcolepsy. Atomoxetine is administered for ADHD. Guarana is the main ingredient in caffeine and is not administered for narcolepsy.

Caffeine is not administered for narcolepsy.

15. A boy has been diagnosed with ADHD and has been prescribed Ritalin. The boy's mother tells the nurse that she does not understand why a stimulant would help him, stating, “If anything, he's completely overstimulated, not understimulated!” What should the nurse explain to the mother about the therapeutic use of Ritalin A) Ritalin helps with the symptoms of ADHD, but the reasons for this are not well understood B) Ritalin stimulates the parasympathetic nervous system, resulting in increased control of behavior C) Ritalin stimulates the limbic system, which regulates control over behavior and affect D) Ritalin enhances the function of dopamine, which regulates cognition Ans:A Feedback: The efficacy of Ritalin in ADHD is paradoxical and not well understood. It does not significantly affect dopamine levels or the function of the limbic system and parasympathetic nervous system.

16. After experiencing two workplace accidents in which he fell asleep, a 30-year-old construction worker has been diagnosed with narcolepsy. The patient admits that he is embarrassed to receive this diagnosis and is adamant that no one find out about it. The nurse should respond to the patient by explaining what aspect of the etiology A) “This is the result of neurological factors over which you have no direct control.”

B) “In a lot of cases, making improvements to your sleep habits can resolve narcolepsy.”

C) “This is something that runs in certain families, and it's not your fault that this has happened.”

D) “This usually stems from suppressed emotions, so counseling usually helps greatly.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Narcolepsy is a neurological sleep disorder, not the result of mental illness or psychological problems. It is most likely due to a number of genetic abnormalities, but family history is not noted to be highly significant.

17. A 13-year-old boy has been taking dextroamphetamine for the treatment of ADHD since he was 10, achieving significant improvements in behavior and mood. When assessing the boy during a scheduled follow- up appointment, the nurse should prioritize what physical assessment A) Abdominal girth and assessment for peripheral edema B) Measurement of height and body weight C) Visual acuity and hearing ability D) Assessment of deep tendon reflexes and peripheral pulses Ans:B Feedback: Suppression of weight and height may occur in children taking amphetamines, and the nurse ensures that growth is monitored during drug therapy. Assessments for edema, diminished reflexes, and sensory deficits are not normally warranted

18. A high school boy has been brought to the emergency department (E D) by his friends who state that he has taken a “whole handful of Dex” and is now lapsing in and out of consciousness. The ED nurse should prioritize what assessment related to dextroamphetamine overdose A) Blood glucose monitoring B) Cognitive assessment C) Lung function testing D) Cardiac monitoring Ans:D Feedback: Dextroamphetamine misuse may cause sudden death or serious cardiovascular events. It is essential to obtain a baseline electrocardiogram (ECG) and blood pressure reading.

These assessments are priorities over blood glucose monitoring, respiratory assessment, and cognitive assessment.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A 12-year-old girl has undergone an extensive diagnostic workup that has resulted in a diagnosis of ADHD. The prescriber has reviewed the benefits and risks of dextroamphetamine therapy, and the nurse is now reviewing the correct schedule for taking the drug. The child should most likely take her dextroamphetamine at what times A) 07:00 and 11:30 B) 07:30, 11:30, 16:30, and 20:00 C) 08:00 and 20:00 D) 09:00, 14:00, and 19:00 Ans:A Feedback: People should take the first dose of dextroamphetamine on awakening or early in the day and the last dose at least 6 hours before bedtime. Twice-daily dosing is most common

20. Methylphenidate will be used to treat a 9- year-old boy's ADHD. In light of this drug's most common adverse effects, the nurse who is working with the family should implement what strategy A) A strategy to ensure that the boy maintains normal bladder function B) A plan to address the boy's loss of appetite C) A plan to enhance the boy's self-esteem D) A strategy to regularly monitor the boy's blood glucose levels Ans:B Feedback: Like dextroamphetamine, methylphenidate often causes loss of appetite. Plans to address this should be in place at the beginning of therapy. Frequent blood glucose monitoring and actions to maintain bladder function are not likely necessary. Self-esteem should likely be addressed during treatment, but reduced self-esteem is not an adverse effect of methylphenidate.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 58 Drug Therapy for Substance Abuse Disorders 1. A patient has a long history of heavy alcohol use and has been admitted to the hospital for traumatic injuries after a motor vehicle accident. How should the nurse best assess the patient for physical dependence on alcohol A) Assess the patient's perceptions of his coping strategies B) Assess whether the patient ever feels guilty about his drinking C) Assess the patient for signs and symptoms of alcohol withdrawal D) Assess the patient's typical alcohol intake Ans:C Feedback: Physical dependence involves physiologic adaptation to chronic use of a drug so that withdrawal, or unpleasant symptoms, occurs when the drug is stopped, when its action is antagonized by another drug, or when its dosage is decreased. Assessment of coping strategies, alcohol intake, and the patient's feelings about his drinking are relevant, but none directly addresses the possibility of physical dependence.

2. A patient is admitted to the hospital for treatment of a stasis ulcer of the right leg. The patient's history indicates he has abused alcohol in the past, and he typically consumes at least eight alcoholic beverages daily. What symptoms should the nurse assess the patient for A) Confusion, hallucination, agitation, tremors B) Denial, manipulation, combativeness C) Depression, remorse, withdrawal from reality D) Suspicion, mania, stubbornness, fear Ans:A Feedback: Delirium tremens, the most serious form of alcohol withdrawal, is characterized by confusion, disorientation, delusions, visual hallucinations, and other signs of acute psychosis.

Denial, manipulation, combativeness, depression, remorse, withdrawal from reality, suspicion, mania, stubbornness, and fear are not symptoms of alcohol withdrawal.

3. A patient was admitted to the emergency room with acute alcohol intoxication and has been diagnosed with alcohol abuse after subsequent assessment and treatment. What are the goals of long-term treatment of this patient's substance abuse disorder

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Detoxification, abstinence, and prevention of relapse B) Withdrawal, reeducation, and compliance C) Withdrawal, abstinence, and accountability D) Assessment, planning, and intervention Ans:A Feedback: The major goals of treatment for substance abuse are detoxification, initiation of abstinence, and prevention of relapse Withdrawal may occur, but this is not a goal of treatment. The nursing process may be utilized, but the steps of the process are not the goals of treatment.

4. A patient is admitted to the inpatient alcohol rehabilitation program. What medication will the patient most likely be prescribed to treat alcohol withdrawal syndromes A) Clonidine (Catapres) B) Methyldopa (Aldomet) C) Chlordiazepoxide (Librium) D) Atenolol (Tenormin) Ans:C Feedback: Benzodiazepines antianxiety agents are the drugs of choice for treating alcohol withdrawal syndromes. Chlordiazepoxide is administered to patients for acute withdrawal syndrome. Clonidine is not a benzodiazepine and is not prescribed for acute alcohol syndrome.

Methyldopa is not a benzodiazepine and is not prescribed for acute alcohol syndrome. Atenolol is not a benzodiazepine and is not prescribed for acute alcohol syndrome.

5. A 77-year-old patient is admitted for the treatment of a fracture, and the nurse has identified that the patient has a history of heavy alcohol use. At what point should the care team administer pharmacologic treatments for alcohol withdrawal A) After skeletal muscle relaxants have taken effect B) As soon as the patient shows signs of withdrawal C) After cognitive behavioral therapy has begun D) After treatment for the patient's acute injuries has been completed Ans:B Feedback: Treatment with chlordiazepoxide for alcohol withdrawal should begin as soon as the clinician identifies that the patient needs it. It is unsafe to delay treatment of withdrawal Muscle relaxants are not indicated in the treatment of alcohol withdrawal.

6. A patient is admitted to the emergency room suffering from symptoms of alcohol withdrawal.

The nurse should plan care with the goal of preventing which of the following

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Bradycardia B) Hypotension C) Seizures D) Gastrointestinal bleeding Ans:C Feedback: In acute alcohol withdrawal, a goal of treatment is to prevent seizures. Bradycardia is not the primary symptom of acute alcohol withdrawal. Hypotension is not the primary symptom of acute alcohol withdrawal Gastrointestinal bleeding results from heavy alcohol use but is not the primary symptom of acute alcohol withdrawal.

7. A patient who suffers from alcoholism is prescribed disulfiram (Antabuse). How does this medication assist the patient in refraining from ingestion of alcohol A) Allows the accumulation of acetaldehyde B) Increases the level of serotonin C) Increases the level of acetylcholine D) Decreases stimulation of the CNS Ans:A Feedback: Disulfiram interferes with hepatic metabolism of alcohol and allows accumulation of acetaldehyde. Disulfiram does not increase the level of serotonin. Disulfiram does not increase the level of acetylcholine. Disulfiram does not decrease the stimulation of the central nervous system.

8. A patient who has long abused alcohol is being treated with disulfiram (Antabuse). The patient currently takes phenytoin (Dilantin) for an underlying seizure disorder. Based on the interaction of these two medications, what will need to be adjusted in the medication administration A) The patient will require more frequent administration of disulfiram (Antabuse) B) The patient will require a larger dose of disulfiram (Antabuse) C) The patient will require a reduced dose of phenytoin (Dilantin) D) The patient will require phenytoin (Dilantin) to be administered twice daily Ans:C

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: The patient will require a reduced dose of phenytoin (Dilantin) because disulfiram interferes with the metabolism of phenytoin. The patient will not require more frequent administration of disulfiram. The patient will not require a larger dose of disulfiram. The patient will not require increased administration of phenytoin.

9. A patient is taking disulfiram (Antabuse) and later consumes several shots of vodka. What effect will be produced from the combination of alcohol and disulfiram A) Hypertension B) Vomiting C) Hyperalertness D) Oral bleeding Ans:B Feedback: Disulfiram interferes with hepatic metabolism of alcohol and allows the accumulation of acetaldehyde. If alcohol is ingested during disulfiram therapy, acetaldehyde causes headaches, confusion, seizures, chest pain, flushing, palpitations, hypotension, sweating, blurred vision, nausea, vomiting, and a garlic- like aftertaste. Disulfiram will not cause hypertension, increased alertness, or bleeding.

10. A 22-year-old male is brought to the emergency room due to an overdose of diazepam (Valium). What drug will be administered in the emergency room to treat the overdose A) Disulfiram (Antabuse) B) Flumazenil (Romazicon) C) Methadone (Dolophine) D) Naloxone (Narcan) Ans:B Feedback: Flumazenil (Romazicon) is a specific antidote that can reverse benzodiazepineinduced sedation, coma, and respiratory depression Disulfiram is not administered to reverse benzodiazepine overdose. Methadone is not administered to reverse benzodiazepine overdose. Naloxone is not administered for benzodiazepine overdose.

11. A patient is being treated for opioid abuse after many years of cocaine and heroin use. The nurse should anticipate that this patient will be treated with what drug A) Disulfiram (Antabuse) B) Flumazenil (Romazicon) C) Methadone (Dolophine) D) Naloxone (Narcan)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:C Feedback: Opioid withdrawal symptoms are treated with methadone. Naloxone is used to treat acute opioid intoxication or overdose, but it is not used to treat opioid abuse.

12. A nurse is providing health education for the family of a patient who has a substance use disorder. How should the nurse best explain the etiology of this disorder A) “Substance abuse is multifactorial and involves genetics, personality, and culture.”

B) “Substance abuse is considered to be primarily a cultural concept, since definitions vary widely across time and place.”

C) “Many different factors contribute to substance abuse, but the primary ones are lack of willpower and impaired coping.”

D) “Substance abuse is a complex phenomenon, and science has not yet begun to truly understand the phenomenon.”

Ans:A Feedback: Researchers have identified a number of factors in the predisposition to substance abuse and dependence. These factors include genetics, personality, and culture. The disorder is not, however, solely rooted in culture or wholly misunderstood. It is simplistic to understand the disorder as resulting from impaired coping and lack of willpower.

13. A patient with a diagnosis of endocarditis has been admitted, and the care team is aware that IV opioid use is the origin of the patient's infection. The patient is open to the idea of treatment for her substance abuse disorder When planning this aspect of the patient's care, what goal should the nurse first address A) Compliance with treatment B) Safe detoxification C) Taking ownership of the problem D) Adequate stimulation of the CNS Ans:B Feedback: The major goals of treatment for substance abuse are detoxification, initiation of abstinence, and prevention of relapse Ensuring the patient's safety during detoxification is a priority over compliance with treatment.

Taking ownership and providing CNS stimulation are not priority goals.

14. A man has asked the care team to consider the use of benzodiazepines to treat his wife's severe alcoholism. The use of benzodiazepines for this purpose may be contraindicated in what circumstances

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) The patient is acutely intoxicated B) The patient denies the severity of her addiction C) The patient has previously been treated with benzodiazepines D) The patient is also addicted to nicotine Ans:A Feedback: If the patient's vital signs are depressed during acute intoxication, the use of benzodiazepines is contraindicated. Denial, previous treatment with benzodiazepines, and nicotine addiction do not contraindicate this treatment.

15. A 33-year-old patient with a diagnosis of alcoholism is to be treated with chlordiazepoxide on an inpatient basis. When a nurse is administering this medication, he or she should do which of the following actions A) Monitor the patient's vital signs closely during IV administration B) Administer the oral form of the medication if the patient is combative C) Assess the patient's cardiac status prior to administering each dose D) Promptly stop administering the medication once status improvements are noted Ans:A Feedback: The nurse should take the patient's vital signs regularly when giving the IV form of this drug, as well as observe and document subjective and objective reports by the patient.

Combative patients usually require a parenteral route of administration, and it is unnecessary to perform a full cardiac assessment before each dose. Usage should be tapered, and not stopped abruptly, in order to prevent rebound CNS stimulation.

16. A patient was admitted with a diagnosis of a gastrointestinal bleed, the latest of several hospital admissions that have been attributed to his alcohol abuse. The addictions medicine specialist has prescribed disulfiram, which will A) prevent the patient from experiencing euphoria if he drinks alcohol B) produce unpleasant reactions if the patient drinks alcohol C) intensify the patient's CNS depression if he drinks alcohol D) result in a depressed mood if he drinks alcohol Ans:B

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Feedback: Disulfiram inhibits the enzyme aldehyde dehydrogenase to block the oxidation of alcohol. The resulting accumulation of acetaldehyde produces an unpleasant reaction when disulfiram is consumed with alcohol The effects do not include prevention of euphoria, increased CNS depression, or depressed mood, however.

17. A patient with a well-known history of heroin use has begun addiction treatment. The nurse had administered the patient's daily dose of methadone. The nurses should know that this medication aids in treating opioid addiction because it does which of the following A) Acts as an agonist at opioid receptors and prevents withdrawal symptoms B) Acts as an opioid antagonist and causes unpleasant symptoms if the patient uses opioids C) Acts on the limbic system and the reticular system to suppress brain activity associated with addiction D) Depresses the CNS to a similar degree as opioids, aiding in detoxification Ans:A Feedback: Methadone is an agonist at specific opioid receptors in the CNS. Its action allows it to prevent symptoms of withdrawal. It does not cause unpleasant effects if the patient uses opioids and does not act directly on the limbic system or reticular system.

18. A patient has been brought to the emergency department by paramedics. The patient's known history and highly agitated state are suggestive of cocaine-induced psychosis What assessment should the nurse prioritize prior to administering pharmacologic treatments A) Assessment of blood glucose levels B) Assessment of cranial nerve function C) Lung auscultation D) Cardiovascular assessment Ans:D Feedback: Cocaine intoxication carries a high risk for cardiac dysrhythmias. Consequently, cardiovascular assessment would be a priority over lung auscultation, assessment of cranial nerve function, or assessment of blood glucose levels

19. A 15-year-old boy with a complex psychosocial history is being treated for inhalant abuse.

When providing health education to this boy, the nurse should cite which of the following risks associated with inhalant abuse

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Hyperactivity B) Psychological dependence C) Physiological dependence D) Organ damage Ans:D Feedback: Inhalants can harm the brain, liver, heart, kidneys, and lungs, and abuse of any drug during adolescence may interfere with brain development. Dependence has not been definitively demonstrated, and hyperactivity is not a risk.

20. A patient is being treated for addiction to cocaine and heroin and will begin treatment with naltrexone (ReVi A). If the patient uses an opioid after taking this drug, the nurse should expect what effect A) The patient will experience a decline in neurological function B) The patient will experience visual disturbances and unpleasant hallucinations C) The patient will not experience the usual physiological effects of opioids D) The patient will experience a sudden onset of nausea and vomiting Ans:C Feedback: Naltrexone (ReVi A) is a pure opioid antagonist that blocks opioids from occupying receptor sites, thereby preventing their physiologic effects. It will not cause neurological deficits, GI upset, or hallucinations

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 59 Drug Therapy for Disorders of the Eye 1. A patient is diagnosed with a fungal infection of the eye. What of the following medications is the most likely the cause of the fungal infection of the eye A) Ophthalmic corticosteroid B) Systemic antibiotic agent C) Mydriatic D) Saline ophthalmic drops Ans:A Feedback: Fungal infections commonly occur and may often be attributed to frequent use of ophthalmic antibiotics and corticosteroids. Systemic antibiotic agents are not the cause of fungal infections of the eye. Mydriatics are not the cause of fungal infections of the eye. Saline ophthalmic drops are not the cause of fungal infections of the eye.

2. A patient states that his eyes are “watering” excessively, and he claims that he has a gritty feeling of the eye. What common eye disorder is suspected A) Hordeolum B) Blepharitis C) Conjunctivitis D) Glaucoma Ans:C Feedback: Conjunctivitis is a common eye disorder with redness, tearing, itching, edema, and gritty sensations of the eye. Hordeolum is a sty Blepharitis is a chronic infection of glands and lash follicles on the margins of the eyelids.

Glaucoma is a disease with an increased intraocular pressure.

3. A patient has a foreign body in the right eye. What medication will most likely be administered before removal of the foreign body A) Cortisporin ointment B) Proparacaine eye drops C) Cephalosporin orally D) Atropine eye drops Ans:B Feedback: Proparacaine is a commonly used agent to provide anesthetic. One drop is instilled in the affected eye prior to removing the foreign body. Cortisporin ointment would not routinely be

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

administered before foreign body removal. Cephalosporin is not administered. Atropine eye drops are not administered for this purpose.

4. A patient is scheduled for cataract surgery. What anesthetic agent should the nurse prepare to administer A) Acetazolamide (Diamox) B) Pilocarpine (Pilocar) C) Dipivefrin (Propine) D) Lidocaine Ans:D Feedback: Injectable local anesthetics are administered by ophthalmologists, usually for eye surgery. Lidocaine is commonly used; it has a rapid onset and lasts 1 to 2 hours. Acetazolamide (Diamox) is not used as an anesthetic agent. Pilocarpine (Pilocar) is not used as an anesthetic agent. Dipivefrin (Propine) is not used as an anesthetic agent.

5. A patient is prescribed ophthalmic corticosteroids. What eye disorder may result from longterm use of ophthalmic corticosteroids A) Conjunctivitis B) Hordeolum C) Glaucoma D) Blepharitis Ans:C Feedback: Long-term use of corticosteroid ophthalmic agents may result increased IOP, optic nerve damage, defects in visual acuity, and fields of vision, cataracts, and secondary ocular infections.

6. A patient is predicted to benefit from dexamethasone eye drops. The presence of what eye disorder would contraindicate the use of this drug A) Fungal infection B) Nearsightedness C) Cataracts D) Bacterial conjunctivitis Ans:A Feedback: Contraindications to dexamethasone include corneal or conjunctival viral disease caused by herpes simplex, vaccina, or varicella. Also, other contraindications are mycobacterial and fungal infection of the eye as well as advanced glaucoma and hypersensitivity to corticosteroids.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

7. A patient is scheduled for an ophthalmic examination. Which of the following medications will be administered A) Pseudoephedrine hydrochloride B) Epoetin alfa (Epogen) C) Phenylephrine D) Pilocarpine (Pilocar) Ans:C Feedback: Phenylephrine is used to dilate the pupil before ophthalmic examinations Pseudoephedrine hydrochloride is used to relieve nasal congestion. Epoetin alfa is used to treat bone marrow depression. Pilocarpine reduces intraocular pressure 8. A patient is being administered phenylephrine in an outpatient clinic. Which of the following conditions requires that phenylephrine be administered cautiously A) Cataracts B) Hypothyroidism C) Diabetes mellitus D) Hypertension Ans:D Feedback: Adrenergic mydriatics should be used cautiously in patients with hypertension, cardiac dysrhythmias, arteriosclerotic heart disease, and hyperthyroidism. Patients with cataracts, hypothyroidism, and diabetes mellitus can safely be administered phenylephrine.

9. A patient's medication administration record include daily timolol maleate eye drops. The nurse should identify what goal of therapy when planning this patient's care A) Decrease intraocular pressure B) Constrict pupils C) Promote lacrimation D) Improve visual acuity Ans:A Feedback: The purpose of the administration of beta- blocking drugs such as timolol is to decrease the IOP. Beta-blockers are not used to promote lacrimation, improve vision, or constrict the pupils.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

10. A nurse is administering eye drops of two different drugs to a patient. How long should the nurse wait between the instillation of the first medication and the second medication A) At least 1 minute B) At least 5 minutes C) At least 15 minutes D) At least 20 minutes Ans:B Feedback: When multiple eye drops are required, there should be an interval of 5 to 10 minutes between drops. The drops should not be as close as 1 minute. The drops will not need to be separated by 15 to 20 minutes.

11. A patient is administering eye drops. What should the patient be taught in order to decrease systemic absorption of eye drops A) Lie supine for 1 minute after instillation B) Apply pressure for 2 minutes over the tear duct C) Apply pressure for 5 minutes over the tear duct D) Remain still for 10 minutes after instillation Ans:C Feedback: Systemic absorption of eye drops can be decreased by closing the eye and applying pressure over the tear duct for 3 to 5 minutes after instillation. Pressure should not be applied to the tear duct for less than 3 minutes or greater than 5 minutes. It is unnecessary to remain still or supine after instillation.

12. A child with glaucoma is being treated with short-acting mydriatics. Which cycloplegic will be administered with the mydriatic agent A) Tropicamide B) Cortisporin C) Phenylephrine D) Acetazolamide (Diamox) Ans:A Feedback: Children with glaucoma are treated with mydriatics and cycloplegics, such as tropicamide. The child with glaucoma is not treated with cortisporin, phenylephrine, or acetazolamide 13. the way the normal intraocular pressure (IOP) is maintained. The nurse should explain that normal IOP results from which of the following

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Consistent production and resorption of tears B) Consistent feedback from baroreceptors located throughout the retina C) A balance between production and drainage of aqueous humor D) Two-way interaction between the medulla oblongata and the eye Ans:C Feedback: Normally, production and drainage of aqueous humor are approximately equal, and the intraocular pressure (IOP) is normal. IOP is not dependent of tear production, baroreceptors in the eye, or stimulation from the medulla.

14. A resident of a long-term care facility was referred to an outpatient ophthalmology clinic for assessment, and the nurse has received the clinical report. The nurse reads that the resident's intraocular pressure was elevated above clinical norms. The nurse should recognize that the resident is at risk of A) cataracts B) glaucoma C) myopia D) conjunctivitis Ans:B Feedback: Glaucoma is characterized by increased IOP, possibly damaging the optic nerve, which transmits images to the brain. If damage to the optic nerve from high IOP continues, glaucoma leads to loss of vision. Cataracts, myopia, and conjunctivitis are not the results of increased IOP

15. A nurse who provides care in an ophthalmology clinic has an order to instill atropine eye drops to a patient prior to the patient's clinical examination. What health education should the nurse provide prior to this intervention A) “These drops might sting a little bit, and they will make you temporarily sensitive to light.”

B) “These eye drops will make it more difficult to close your eyes, but this will pass in a few hours.”

C) “These drops will make your pupil temporarily constrict so that your eye can be examined more closely.”

D) “These drops will make your eyes very bloodshot and sensitive, but this is only temporary.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: The nurse instructs patients about the effects of atropine such as photophobia and stinging on administration. Atropine does not make it difficult to close the eyes, and it causes pupil dilation, not constriction.

16. The nurse has administered a scheduled dose of phenylephrine to a patient. The nurse would recognize that a therapeutic effect has been achieved by which of the following assessment findings A) The cornea can be manipulated without causing the patient to blink B) The patient acknowledges an improvement in visual acuity C) The patient's pupils neither dilate nor constrict in response to light D) The inner aspect of the patient's eye can be visualized Ans:D Feedback: Uses of phenylephrine (ophthalmi C) include mydriasis prior to ophthalmic procedures Consequently, the nurse assesses whether the inner aspect of the eye can be visualized 15 minutes after administration. Phenylephrine does not inhibit blinking, improve vision, or eliminate light accommodation.

17. A patient's sudden increase in IOP has necessitated the oral administration of glycerin (Osmoglyn). When assessing the patient for adverse effects related to this intervention, the nurse should prioritize which of the following A) Assessment for signs and symptoms of acid– base imbalances B) Assessment for signs and symptoms of fluid volume deficit C) Monitoring of serum potassium and sodium levels D) Monitoring of aPTT and INR Ans:B Feedback: Adverse effects of glycerin relate to decreased fluid volume. The most serious of these conditions is hyperosmolar nonketotic coma. Consequently, the nurse should prioritize assessments that are focused on the signs and symptoms of fluid volume deficit.

18. A nurse is providing care for a patient who is on the third day of her prescribed course of ciprofloxacin eye drops. The nurse should conclude that this patient most likely has a diagnosis of what health problem

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

A) Astigmatism B) Cataracts C) Conjunctivitis D) Increased IOP Ans:C Feedback: Uses of ciprofloxacin include the treatment of corneal ulcer and bacterial conjunctivitis. This drug is not used to treat cataracts, increased IOP, or astigmatism.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 60 Drug Therapy for Disorders of the Ear 1. A young boy has just returned home from his family's tropical vacation and is now complaining of worsening tenderness in his right ear. He is subsequently diagnosed with otitis externa. What causative factor of this infection should the nurse suspect A) Immunocompromised state resulting from sleep deprivation while on vacation B) The potential for foodborne pathogens ingested while on vacation C) Frequent swimming and water sports while the boy was on vacation D) Ear trauma related to pressurization and depressurization while flying Ans:C Feedback: People whose ears are frequently exposed to moisture are more prone to the development of otitis externa. Swimming is a more likely cause of infection than pressure changes, foodborne pathogens, or impaired immunity.

2. A pediatric nurse practitioner has diagnosed a 4-year-old girl with otitis media. The nurse should understand that infectious microorganisms likely entered the girl's middle ear by what means A) Through an alteration in the eustachian tube B) Through the external ear C) From within the cochlea or vestibule D) From the interstitial spaces in the middle ear Ans:A Feedback: The causative pathogens implicated in otitis media include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. They enter the middle ear as a result of an alteration in the eustachian tube, not from the inner ear, external ear, or interstitial spaces.

3. A patient has responded appreciably to first- line treatments for necrotizing otitis externa, and the care team is concerned about the possible progression of the disease. The nurse should be aware that this infection has the potential to progress to A) meningitis B) osteomyelitis C) necrotizing fasciitis D) epiglottitis

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: The advancement of necrotizing otitis externa results in osteomyelitis of the skull and temporomandibular joint. It does not cause meningitis, necrotizing fasciitis, or epiglottitis.

4. A 12-year-old boy has been diagnosed with acute otitis externa. The patient's mother has asked if oral medications might be more effective than ear drops. The nurse should respond in the knowledge that systemic medications for the treatment of otitis externa are only indicated in what circumstances A) The infection is accompanied by ear discharge B) The patient is allergic to penicillins C) The patient is unable to self-administer ear drops D) A deep tissue infection develops Ans:D Feedback: For acute otitis externa, use of topical agents, as opposed to systemic agents, is more common. Systemic medications are indicated only if a deep tissue infection develops outside the external canal or if immunocompromised status is an issue Allergy status, ability to self-administer, and the presence or discharge are not indications for systemic antibiotics.

5. The nurse is providing health education for the parents of a child whose otitis media has warranted treatment with Cortisporin Otic. The nurse should explain that this medication contains which of the following components Select all that apply A) An analgesic B) A topical anesthetic C) An antibiotic D) A steroid E) An immunomodulator Ans:C, D Feedback: Health care providers use the combination drug Cortisporin Otic (neomycin– polymyxin B–hydrocortisone) for the treatment of acute external otitis media. Neomycin and polymyxin B are antibiotics, which combat bacterial infections. Hydrocortisone is a steroid, which reduces the actions of chemicals in the body that cause inflammation, redness, and swelling. This medication does not contain analgesics, anesthetics, or immunomodulators.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

6. A child's primary health care provider has prescribed Cortisporin Otic for a child who has otitis media in her right ear. What administration instructions should the nurse provide to the parents of the child A) “Put one drop into her right ear each morning.”

B) “Place two drops in her right ear each morning and then again before bedtime.”

C) “Put one to two drops in her right ear whenever you notice discharge or she complains of pain.”

D) “Place three drops into her ear four times a day.”

Ans:D Feedback: For children 6 months and older, 3 drops of Cortisoprin Otic are instilled into the affected ear three to four times daily. Dosage is not matched to acute symptoms.

7. A nurse is demonstrating the correct technique for instilling antibiotic ear drops into a child's ear canal. The nurse should teach the child's caregivers to do which of the following A) Have the child lie supine during instillation of the ear drops B) Have the child lie still for 30 to 45 minutes after instilling the ear drops C) Place a cotton ball in the ear canal after instilling the ear drops D) Rinse the child's ear canal with normal saline prior to instilling the ear drops Ans:C Feedback: The proper administration of ear drops requires tilting the head toward the opposite shoulder, pulling the superior aspect of the auricle upward, and instilling the ear drops into the ear canal. The patient should then lie on the side opposite the side of administration for 20 minutes. To maximize medication absorption, the patient should have a cotton ball placed in the ear canal. Supine positioning is not used, and the ear canal does not need to be rinsed prior to drug administration.

8. The nurse is providing care for a teenager with otitis media. When assessing the patient for potentially adverse effects of Cortisporin Otic, what question should the nurse ask A) “Have you developed a fever since you started to use the ear drops?”

B) “Have you been getting any headaches since you started taking the drops?”

C) “Has there been any blood that you've noticed in your outer ear?”

D) “Have you noticed any loss of hearing since you started taking the drops?”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:D Feedback: It is also necessary to assess the patient taking Cortisporin Otic for signs of hearing loss due to ototoxicity. Fever, bleeding, and headaches are not typical adverse effects.

9. An adult patient has been assessed in the emergency department and diagnosed with necrotizing otitis externa. The primary care provider has prescribed ciprofloxacin. In preparation for administering this medication, what action should the nurse perform A) Establish intravenous access B) Remove as much cerumen as possible from the patient's ear canal C) Flush the affected ear with warmed sterile water D) Establish a sterile field around the perimeter of the ear Ans:A Feedback: Ciprofloxacin (Cipro) is the drug of choice for necrotizing otitis externa. Initially, administration is intravenous, until symptoms decrease; then it is oral. Consequently, IV access is necessary for the initiation of treatment. This is a priority over rinsing the ear or removing cerumen. It is unnecessary to create a sterile field

10. A pediatric nurse is providing inpatient care for a child who was diagnosed with necrotizing otitis externa. The child is currently being treated with ciprofloxacin. What microorganism is the most likely cause of this child's infection A) Aspergillus B) Candida albicans C) Pseudomonas aeruginosa D) Escherichia coli Ans:C Feedback: Health care providers use ciprofloxacin for the treatment of Pseudomonas aeruginosa in patients with necrotizing otitis externa. If the causative agent is Aspergillus, amphotericin B is the drug of choice. E. coli and Candida are not typically implicated in cases of necrotizing otitis externa.

11. A woman was diagnosed with necrotizing otitis externa and will soon begin a course of oral ciprofloxacin. When providing health education to this patient, the nurse should emphasize the need to temporarily avoid A) calcium antacids

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) fatty foods C) grapefruit juice D) foods containing purines Ans:A Feedback: Patients should not take oral ciprofloxacin within 2 hours of eating dairy products, calcium-fortified juices, antacids, zinc, or iron. There is no specific need to avoid fatty foods, grapefruit juice, or high-purine foods

12. A 4-year-old boy was diagnosed with acute otitis media and began a course of oral amoxicillin. The boy's mother has contacted the clinic and states that there has been no significant improvement in her son's ear infection since beginning the antibiotics 3 days ago. The nurse should consider which of the following explanations for this phenomenon A) The boy has not been receiving the medication consistently B) The boy's ear infection has a viral etiology C) The boy's ear infection is caused by an antibiotic-resistant microorganism D) The medication should have been prescribed parenterally Ans:B Feedback: Many people with acute otitis media do not benefit from antibiotics because the cause of their illness is viral, not bacterial. This possibility is more likely than incorrect administration or antibiotic resistance Parenteral administration would be no more effective in this case.

13. A patient has been taking oral amoxicillin to treat otitis media for the past 6 days and has told the nurse that his ear is now “back to normal.” He asks the nurse if he can now stop taking his antibiotics. How should the nurse respond A) “That's excellent that you're feeling better, but it's important to keep taking the antibiotics until they're all finished.”

B) “Try reducing your dose by half. If your ear infection gets worse, resume the dose you've been taking until now.”

C) “You should stop taking the antibiotics because if you don't, it could cause antibiotic resistance.”

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) “You can likely stop taking the antibiotics, but keep them on hand in case your infection returns.”

Ans:A Feedback: The patient should take the full course of antibiotics and not discontinue them, even if the otitis media seems to be improving Stopping prematurely can cause antibiotic resistance.

14. A child's otitis media has resulted in pain and fever. The child's mother has asked the nurse to recommend OTC remedies to address these problems. Which of the following recommendations is most likely to be safe and effective A) Concurrent use of ASA and ibuprofen for 3 days B) Alternating doses of acetaminophen and ibuprofen C) Monotherapy with ASA until symptoms improve D) Use of an OTC antihistamine and acetaminophen Ans:B Feedback: Alternating acetaminophen and ibuprofen every 4 hours over a 3-day period to control fever in young children (ages 6–36 months) has been shown to be more effective than monotherapy with either agent. ASA is contraindicated in children, and an antihistamine is unnecessary.

15. A young adult has been diagnosed with otitis media. When planning this patient's care, what nursing diagnosis is the most likely priority A) Hyperthermia related to infectious process B) Infection related to presence of microorganisms C) Disturbed auditory sensory perception related to otitis media D) Chronic pain related to otitis media Ans:B Feedback: Infection is the essence of otitis media, and would be a priority over other diagnoses such as hyperthermia or temporary hearing loss The pain associated with this disorder would be acute, not chronic.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Chapter 61 Drug Therapy for Disorders of the Skin 1. A teenager is using a tanning bed two times per week. Which cells within the skin change color in response to the tanning bed's lights A) Melanocytes B) Stratum corneum C) Merkel cells D) Dermis Ans:A Feedback: Melanocytes are pigment-producing cells located at the junction of the epidermis and the dermis. The stratum corneum, Merkel cells, and dermis do not perform this role.

2. A teenager is being treated for acne vulgaris Which oral antibiotics may be prescribed to treat acne A) Neomycin and vancomycin B) Gentamicin and Rocephin C) Tetracycline and erythromycin D) Bacitracin and polymyxin B Ans:C Feedback: Commonly used oral antibiotics for acne treatment include tetracycline, doxycycline, minocycline, and erythromycin. Neomycin and vancomycin are not used to treat acne.

Gentamicin and Rocephin are not used to treat acne. Bacitracin and polymyxin B are not used to treat acne

3. A young mother is seen in the clinic with her young children. It is May, and the family is planning to go to the beach for vacation Which of the following aspects of patient teaching is most important A) “Try to stay indoors as much as possible.”

B) “Apply SPF 30 sunscreen to the children before sun exposure.”

C) “Be sure that each child wears a hat at the beach.”

D) “Apply Neosporin to any skin abrasions your children get.”

Ans:B Feedback: Dermatologists recommend sunscreen preparations that block both UVA and UVB and have a sun protective factor of SPF value 30 or higher. It is unnecessary to avoid all outdoor

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

locations. The mother should apply a hat, but this advice is not the most important health promotion intervention; this does not prevent sun damage to most skin surfaces The mother should be cautious with the application of Neosporin.

4. A 17-year-old woman is prescribed isotretinoin (Accutane) for severe acne vulgaris. Which of the following is the most important intervention related to the administration of this medication A) Effective contraception must accompany this medication B) Administer the medication on an empty stomach to decrease discomfort C) The tablets should be crushed if they are too large to swallow D) Administer a vitamin A supplement daily to enhance effectiveness Ans:A Feedback: The administration of retinoids requires adequate contraceptive practices in women.

Retinoids should be given with food, not on an empty stomach. The tablets should not be crushed. The patient should not take vitamin A or a multivitamin because of the retinoid toxicity 5. A college sophomore has sought care because of her worsening acne. Before beginning a medical regime that includes a retinoid, which of the following laboratory tests must be negative A) Throat culture B) Skin culture C) Stool for occult blood D) Pregnancy test Ans:D Feedback: The female patient should have a negative pregnancy test before beginning retinoid therapy. It is not necessary to have a negative throat culture or skin culture. If the patient has a positive stool for occult blood, the cause should be determined but is not affected by retinoid therapy.

6. A teenage male patient is administered isotretinoin (Accutane) for severe acne. When teaching the teen and his parents about the medication, which of the following assessments should be routinely made A) Assess blood pressure B) Assess blood lipid levels C) Assess for euphoria

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

D) Assess for increased weight Ans:B Feedback: The administration of isotretinoin is linked with increased blood lipid levels. The parents and teen should be taught that lipid levels should be periodically assessed. The assessment of blood pressure is not imperative. The patient should be assessed for depression, not euphoria. The patient will not need his weight assessed.

7. The physician orders tretinoin (RetinA) for the treatment of acne. Which of the following instructions should be provided A) “You will see positive results in 1 week” B) “Apply the medication two to three times a day.”

C) “Apply the topical medication one time per day.”

D) “Apply the medication for 1 hour and remove it.”

Ans:C Feedback: Tretinoin is applied one time per day. Positive results from the medication will be noted in 12 weeks, not 1 week. The medication should not be applied two to three times per day.

The medication should not be applied for 1 hour and then removed.

8. A teenager has acne that requires treatment. The physician does not want to use retinoids because of the adverse effects. Which of the following medication regimens will likely be most effective A) Topical azelaic acid B) Topical benzoyl peroxide C) Topical clindamycin D) Topical clindamycin with benzoyl peroxide Ans:D Feedback: Combination products of topical clindamycin or erythromycin and benzoyl peroxide are more effective than antibiotics alone. Azelaic acid and benzoyl peroxide are effective but not as effective as combination medications. Topical clindamycin is effective, but combination medications may be more effective 9. A patient has a severe reaction to poison ivy. Which of the following medications will be most effective A) Topical antihistamines B) Corticosteroids C) Emollients D) Analgesics

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:B Feedback: Corticosteroids are used to treat the inflammation present in many dermatologic conditions. They are most often applied topically but also may be given orally or parenterally.

Emollients and analgesics would be ineffective. Antihistamines are not administered topically 10. A patient has psoriasis and has been prescribed coal tar (Balnetar). How will this prescription be administered A) Topically B) Orally in divided daily doses C) Orally in the morning D) Parenterally at bedtime Ans:A Feedback: Coal tar is administered topically 11. A child who has not received the chickenpox vaccine has developed the chickenpox virus.

The child has itching related to the chickenpox pustules. Which of the following herbal preparations would be helpful to decrease itching A) Coal tar (Balnetar) B) Colloidal oatmeal (Aveeno) C) Clindamycin D) Bacitracin (Bacillin) Ans:B Feedback: Oat preparations, such as Aveeno, are used topically to treat minor skin irritation. Coal tar is not used for this child; it is primarily administered for psoriasis and dermatitis Clindamycin is not administered to treat minor skin irritation. Bacitracin is not administered to relieve itching related to chickenpox 12. A patient has rosacea. Which of the following medications is most effective in treating rosacea A) Topical metronidazole (Flagyl) B) Oral nystatin (Mycostatin) C) Oral prednisone D) Topical hydrocortisone Ans:A Feedback: Topical metronidazole is commonly used for rosacea. Oral Mycostatin is not used for rosacea. Oral prednisone is not used for rosacea. Topical hydrocortisone is not used for rosacea 13. A patient has a bacterial skin infection. Which medication can be applied to the lesion A) Bacitracin B) Benzoyl peroxide C) Butenafine (Mentax) D) Clotrimazole (Lotrimin)

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

Ans:A Feedback: Bacitracin is used to treat a bacterial skin infection. Butenafine is an antifungal agent.

Clotrimazole is used to treat tinea infections Benzoyl peroxide is used to treat acne.

14. A patient has developed urticaria following the administration of an oral antibiotic. What substance most commonly mediates the formation of the wheals that characterize urticaria A) Cytokines B) CD4+ lymphocytes C) Histamine D) Interleukin Ans:C Feedback: Histamine is the most common mediator of urticaria; it causes vasodilation, increased vascular permeability, and pruritus Cytokines, including interleukin, and CD4+ lymphocytes do not usually mediate the development of urticaria.

15. An older adult who resides in a long-term care facility has been diagnosed with oral candidiasis (thrush). When considering factors that may have contributed to this health problem, the nurse should prioritize which of the following A) The resident recently completed a course of broad-spectrum antibiotics B) The resident takes metformin for the treatment of type 2 diabetes C) The resident has been using OTC skin emollients several times a day D) The resident was immunized against the influenza virus 1 week ago Ans:A Feedback: Oral candidiasis (thrush) involves mucous membranes of the mouth. It often occurs as a superinfection after the use of broad-spectrum systemic antibiotics. Oral antihyperglycemics, skin emollients, and vaccinations do not contribute to thrush.

16. A topical corticosteroid has been prescribed for short-term use on an infant's skin. When planning the use of a topical medication for an infant, what principle should guide the nurse's actions A) Topical medications on infants' skin must be covered with an impermeable barrier

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

B) Infants' skin is more permeable to medication than older patients' C) Infants have more subcutaneous fat than older patients, so higher concentrations of topical medications are often necessary D) Systemic drugs are preferable to topical medications in the care of infants Ans:B Feedback: With topical medications, cautious use is recommended with infants and young children due to the fact they have more permeable skin and are more likely to absorb the topical drugs. Infants have significant subcutaneous fat, but this does not necessitate higher concentrations of drugs. Topical drugs do not necessarily have to be covered with a barrier following administration.

17. A patient has been diagnosed with severe atopic dermatitis and treatment with tacrolimus (Protopi C) ointment has been deemed necessary. When planning this patient's care, the nurse should ensure that the patient has been informed of what risk A) Risk of chemical burn injury B) Increased risk of developing psoriasis or type IV hypersensitivity C) Risk of opportunistic fungal infection that may become systemic D) Increased risks of skin cancer and lymphoma Ans:D Feedback: Tacrolimus has a black box warning about a possible increased risk of skin cancer and lymphoma. It is not noted to cause fungal infections, psoriasis, or chemical burn injuries.

18. A 15-year-old boy has begun acne treatment using a combination ointment of clindamycin and benzoyl peroxide. The nurse should teach the boy to expect maximum results in how long A) 5 to 7 days B) 1 to 2 weeks C) 3 to 5 weeks D) 8 to 12 weeks Ans:D Feedback: Best results of combination acne treatments require 8 to 12 weeks of therapy, and maintenance therapy is usually required.

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TB-Abrams Clinical Drug Therapy;Rationales[13E,Frandsen]

19. A young adult began acne treatment several weeks ago using a combination ointment and has presented for a follow-up appointment at the clinic. When assessing the patient for adverse effects of treatment, what question should the nurse prioritize A) “Have you found that the ointment makes your skin a lighter color?”

B) “Do you find that the ointment makes your pimples bleed more easily?”

C) “Do your eyes burn when you apply the ointment to your face?”

D) “Is the skin on your face uncomfortably dry since you began using the ointment?”

Ans:D Feedback: Adverse effects of topical antibiotics include erythema, peeling, dryness, and burning as well as development of resistant strains of P. acnes. Such ointments are not expected to produce eye irritation, bleeding, or changes in skin tone.

20. A nurse practitioner has discussed the possible risks and benefits of isotretinoin treatment with a patient who has acne vulgaris. The nurse should be aware that this medication achieves a reduction in the signs and symptoms of acne by what method A) Stimulating phagocytosis in the epidermis and dermis B) Suppressing the production of sebum C) Enhancing humoral immunity D) Inhibiting the function of sudoriferous glands Ans:B Feedback: The antiacne effects of isotretinoin include suppression of sebum production, inhibition of comedone formation, and inhibition of inflammation. The drug does not stimulate immune function or reduce the function of sweat glands

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