Exam 4 Flashcards
A nurse is caring for 4 patients- which would she be concerned about developing a substance abuse disorder?
a) A college student who admits experimenting with marijuana in the last year.
b) An older adult patient with terminal cancer who requires twice the normal morphine dosage for pain relief.
c) A patient in moderate to severe pain following total hip replacement who requests pain meds an hour before the next dose is due.
d) A patient whose history indicates prescription narcotic analgesics for back and headache pain.
Answer: D - A patient whose history indicates prescription narcotic analgesics for back and headache pain.
Patient who use narcotics for minor pains are more likely to be drug seekers. Pg 256
A patient has been taking a medication with the side effect of drowsiness stops taking it after several weeks. The patient reports feeling anxious and jittery. The nurse understands this response is due to:
a) addiction
b) psychologic dependence
c) tolerance
d) withdrawal syndrome
Answer: D - withdrawal syndrome
Withdrawal symptoms occur when a patient has developed physical dependence on a drug and then often show signs the opposite of the drug effect when the drug is withdrawn. Addition is characterized by compulsive drug- seeking. Psychologic dependence is intense subjective need for a drug.
A patient is ready for discharge after a lengthy stay following an MVA. The patient suffered multiple fractures and required high doses of morphine for several weeks. The nurse preparing the patient for discharge notices the patient requests the maximum amount of pain medicine at the exact interval prescribed. The nurse suspects what has occurred?
a) Addiction
b) Compulsive drug seeking
c) Cross- tolerance
d) Drug tolerance
Answer: D - Drug tolerance
Patients who use a drug regularly develop a tolerance to the drug when a dose produces a smaller response than it did initially. This patient has been on large doses of opioids for several weeks and has developed tolerance to this class of drugs. Addiction is characterized by compulsive drug seeking which has not occurred. Cross- tolerance occurs when tolerance to one drug confers tolerance to another drug.
A patient falls off a ladder at home hanging Christmas lights on a Friday evening and is experiencing shoulder pain from bruising and cannot sleep. The on-call provider calls in an oral Schedule II analgesic to the pharmacy as the office is closed. How long does the provider have to provide a written prescription to the pharmacy?
a) 24 hours
b) 48 hours
c) 72 hours
d) 1 week
Answer: C - 72 hours
the provider has 72 hours to provide a written prescription for this analgesic. Call in prescriptions for schedule II drugs are only accepted in an emergency. Prescriptions for schedule II drugs cannot be refilled. However, a DEA rule allows a prescriber to write multiple prescriptions on the same day- for the same patient and same drug. Reference: Chapter 32 audio clip
A patient asks a nurse about the effects of chronic alcohol use on the heart. What is the best response?
a) Chronic alcohol use affects the liver more adversely than the heart.
b) Drinking more than two drinks a day protects the heart from atherosclerosis.
c) Long-term alcohol use can damage the heart and cause heart failure.
d) Overtime, alcohol use can lower your blood pressure.
Answer: C; Long-term alcohol use can damage the heart and cause heart failure.
Chronic abuse of alcohol results in direct damage to the myocardium, increasing the risk of heart failure. Drinking fewer than 2 drinks daily can reduce risk of atherosclerosis. Alcohol consumption produces a dose-dependent elevation of blood pressure overtime.
A patient who is an active alcoholic is admitted to the hospital for surgery. Which medication order would the nurse question?
a) Acetaminophen
b) Diazepam
c) Morphine
d) Thiamine
Answer: A; Acetaminophen
Acetaminophen poses a risk of fatal liver damage in alcoholics; evidence indicates even modest consumption combined with acetaminophen has this effect. Diazepam and morphine are safe in history of alcoholism but should not be given with alcohol. Could cause severe CNS depression.
A college student who is unresponsive is brought to the ER by friends who say he drank ½ bottle of whiskey 3 hours ago. Blood alcohol level is 0.32%, b/p 88/32, RR 6, pulse 76 and weak. What would the nurse prepare to do?
a) IV fluids and stimulants
b) Administer activated charcoal
c) Gastric lavage and dialysis
d) Narcan administration
Answer: C; Gastric lavage and dialysis
Alcohol can be removed from the body by gastric lavage and dialysis. Gastric lavage “washes out” most of the alcohol if any is left in the gut. Dialysis is implemented to reduce the chance of renal failure and CV shock.
A pregnant patient in labor tells the nurse she is concerned she may have injured her fetus consuming alcohol. What is an appropriate response by the nurse?
a) Ask the patient how much she consumed and at what stage of her pregnancy.
b) Reassure the patient the risk is likely to be minimal
c) Tell the patient no amount of alcohol is considered safe during pregnancy
d) Tell the patient the full range of outcomes might not be present for years
Answer: A; Ask the patient how much she consumed and at what stage of her pregnancy.
Although heavy use f alcohol during pregnancy is known to cause adverse effects on the fetus, the effects of lower levels are not known. The patient should first be questioned about ho much and when. Many women consume alcohol before knowing they are pregnant without ill effects to fetus. Telling the patient no amount of alcohol is considered safe would be appropriate during pregnancy appointments for teaching but during labor is not appropriate.
Which is NOT a benefit of moderate alcohol consumption?
a) Increases bone mineral density
b) Decreases risk of Type 2 DM
c) Increases HDL
d) Improves quality and sleep & promotes regular sleep
Answer: D; Improves quality and sleep & promotes regular sleep
ETOH is commonly used as a sleep aid; however, it disrupts sleep. It alters sleep cycles, decreases total sleep time, and can exacerbate snoring/ OSA. Pg 260
Which drug for alcohol abstinence creates a negative physical reaction to alcohol consumption that can be fatal?
a) Naltrexone
b) Disulfiram
c) Acamprosate
d) Diazepam
Answer: B; Disulfiram
Pts who are prescribed Disulfiram must be very compliant. In its mild form, combination with alcohol creates nausea, copious vomiting, flushing, HA, palpitations, chest pain, weakness, blurred vision, and hypotension and can last minutes to hours from just 7oz of alcohol. Severe reactions can be fatal. Disulfiram is useful in treating a patient where relapse has just occurred but only slightly better than a placebo in maintaining long-term abstinence. In the absence of alcohol, disulfiram rarely causes any effects.
A decrease in intrinsic factor leads to a deficiency in __________ leading to __________.
A. Hydrochloric acid, macrocytic anemia
B. Pepsin, microcytic anemia
C. B12, macrocytic anemia
D. Prostaglandins, microcytic anemia
Answer: C - B12, macrocytic anemia
Reasoning: Info from Acid Controlling Drugs video
What is a treatment option for treating Peptic Ulcer Disease (PUD)cause by H. Pylori
A. A proton pump inhibitor + Clarithromycin + Metronidazole
B. A proton pump inhibitor + Amoxicillin + Metronidazole
C. A proton pump inhibitor + Tetracycline + Azithromycin
D. A proton pump inhibitor + Doxycycline + Amoxicillin
A. A proton pump inhibitor + Clarithromycin + Metronidazole
Reasoning: PUD common etiology is H pylori bacteria. General treatment is PPI plus 2 antibiotics either Amoxicillin + (Clarithromycin or Metronidazole) OR Tetracycline + Metronidazole + bismuth subsalicylate for 1-2 weeks. THEN continue with PPI for 4-8 weeks. Info from Acid Controlling Drugs Video
What is the direction of the ph change to be less acidic? (Higher or lower ph is less acidic)?
A. Lower ph is less acidic
B. Lower ph is neutrally acidic
C. Higher ph is neutrally acidic
D Higher ph is less acidic
Answer: D - Higher ph is less acidic
Reasoning: Info from Acid Controlling Drugs Video
H2 receptor antagonist work by_______________. An example of a H2 receptor antagonist is ______________.
A. Increase stimulation of gastric production; Example Calcium carbonate
B. Divert the stimulation of gastric production; Example Ranitidine
C. Block the stimulation of gastric production from parietal cells: Example Ranitidine
D. Neutralize acid; Example Calcium Carbonate
Answer: C-Block the stimulation of gastric production from parietal cells: Example Ranitidine
Reasoning: Antacids neutralize acid; Example=Calcium carbonate. Indications for antacids are hyperacidity, GERD, gastritis, ulcer prevention. H2 receptor antagonist end in “tidine”block the stimulation of gastric production; Example=Ranitidine. Caution with H2 receptor blockers and patients with liver and kidney disease. Elderly are at greatest risk for adverse CNS effects of H2Ras. Info from Acid Controlling Drugs Video
Match the Drug to the Mechanism of Action (MOA)
A. Omeprazole breaks up gas
B. Sucralfate (Carafate) stops production of acid
C. Simethicone (Mylicon) neutralizes acid
D. Omeprazole stops production of acid
Answer: D - Omeprazole stops production of acid
Reasoning: Omeprazole is a proton pump inhibitor (PPI), they stop the production of acid. PPI end in “prazole” Are first line but not single line for gastric ulcers if H pylori is involved. They are very well tolerated and are more powerful than H2RAs due to the irreversible pump shut down. Sucralfate protects the lining and Simethicone breaks up gas. Disadvantages of Sucralfate: Give QID, can cause GI upset (constipation, nausea, dry mouth). May impair absorption of other drugs (give other drugs 2 hours before Sucralfate). Administer Sucralfate QID 1 H AC meals and HS on empty stomach
What are risk factors for stress ulcers in critically ill patients?
A. Increase prostaglandins
B. Increase in endogenous and exogenous steroid production
C. Decrease in endogenous and exogenous steroid production
D. There are no risk factors for stress ulcers in critically ill patients
Answer: B - Increase in endogenous and exogenous steroid production
Reasoning: After major trauma there is an increase in endogenous and exogenous steroid production (anti-prostaglandins). Prevention drugs that can be used are H2 receptor blockers and PPIs. Info in Acid Controlling Drugs Video
What is rebound acidity and what antacid is at greatest risk for causing it?
A. Stomach increases acid due to higher ph; calcium carbonate
B. Decreased acid production due to higher ph; calcium salts
C. Stomach increases acid due to lower ph; calcium carbonate
D. Decreased acid production due to lower ph; magnesium salts
Answer: A - Stomach increases acid due to higher ph; calcium carbonate
Reasoning: Long duration of calcium carbonate (TUMS) may cause increased acid secretion due to higher ph. Caution all patients that use of antacids over 2 weeks may mean something that needs work up. To avoid drug interactions like chelating (binding) to tetracycline, fluoroquinolones, iron (especially calcium) take 2 hours before other meds. Info from Acid Controlling Drugs Video
Patients with heart failure should avoid _________ antacids. Patients with renal disease should avoid ___________ antacids. Patients with constipation should avoid _________ antacids.
A. Magnesium, Calcium, Sodium
B. Sodium, Calcium, Magnesium
C. Aluminum, Sodium, Calcium
D. Sodium, Magnesium, Calcium
Answer: D - Sodium, Magnesium, Calcium
Reasoning: Caution should be used with Magnesium antacids for patients with diarrhea and renal disease. Calcium antacids cause constipation. Sodium antacids should not be used in patients with heart failure. Info from Acid Controlling Drugs Video
Which particular H2RA has the most drug interactions
A. Nizatidine (Axid)
B. Ranitidine (Zantac)
C. Cimetidine (Tagamet)
D. Famotidine (Pepcid)
Answer: C
Reasoning: Cemetidine (Tagamet) has the most drug interactions due to CP 450 effects. Caution with H2RA and alcohol and CNS depressants for safety reasons (falls). Info from Acid Controlling Drugs Video
What category of ulcers are PPIs used for that Antacids and H2RA are not?
A. Gastric ulcer
B. Duodenal ulcers
C. Prevention of stress ulcers
D. Bleeding Ulcers
Answer: D - Bleeding Ulcers
Reasoning: PPI are used for bleeding or NSAID ulcers; Antacids and H2RB are not. PPIs should be taken before meals to prevent acid production. Potential disadvantages of PPI include increased risk of food poisoning, HAI (especially C DIFF) pneumonia. Info from Acid Controlling Drugs Video
An established patient presents to your clinic for their annual physical. The patient recently experienced a death in the family 2 months ago. She has been experiencing loss of concentration, feelings of depressed mood “on and off” and some loss of appetite most days and a 10 pound weight loss. What is this most appropriate intervention for this patient?
A. Empathize with patient and reassure her that her feelings of sadness will go away.
B. Discuss counseling and prescribe Prozac.
C. Discuss counseling and prescribe Wellbutrin.
D. Tell the patient that she needs to go to counseling now and prescribe Imipramine.
Ans: B - Discuss counseling and prescribe Prozac.
SSRIs should be first line treatment with patient depression.
A patient presents to the to your clinic for her annual physical exam. She has a history of hysterectomy secondary to endometriosis, hyperthyroidism, and glaucoma. She recently saw a different provider for depressant feelings and was prescribed an antidepressant. Which antidepressant would be of most concerning and would require intervention?
A. Lexapro
B. Cymbalta
C. Effexor
D. Zoloft
Ans: C - Effexor
Effexor can cause sustained mydriasis, which can increase IOP.
You are discussing patient education on a new prescription of Zoloft for your patient. Which statement is an indication that your patient is in need of further teaching?
a. I can take this while pregnant.
b. I can take this while breastfeeding.
c. I may experience constipation with this medication.
d. I need to contact the office if I want to discontinue this medication.
Ans: C - I may experience constipation with this medication.
Patients taking Zoloft may experience harsher GI effects than other antidepressants. The antidepressant video talked about “Squirt-teraline” (for sertraline) to remember this.
You are prescribing a SNRI to a patient who has failed treatment with an SSRI. This patient has a history of hyperlipidemia, hypertension, and history of CABG. Which medication would be inappropriate for this patient?
a. Wellbutrin
b. Effexor
c. Cymbalta
d. Imipramine
Ans: B - Effexor
Effexor increases HTN 50-100%, and is contraindicated in patients with established HTN.
A 89 year old female patient presents to your clinic with feelings of depression and anxiety. She has been prescribed Zoloft, but after one month of treatment, her feelings have not improved. Her feelings have been heighted due to not seeing friends or family due to the COIVID-19 pandemic. This patient has had a significant weight loss accompanied by her feelings of worthlessness and isolation. You are discussing switching to a SNRI, which would be most appropriate for this patient?
a. Remeron
b. Trazadone
c. Effexor
d. Paxil
Ans: A - Remeron
Remeron is frequently used in elderly patients in nursing homes and also increases appetite and decreases nausea.
A patient comes in to your clinic for a follow up appointment to discuss her antidepressant medication. It has been 6 weeks since initiation of her Lexapro and she has noticed no difference in her depression. She refuses to seek counseling. What would be an appropriate next step in her therapy?
a. Tell her to suck it up and go to counseling and continue her Lexapro.
b. Discuss switching immediately to Wellbutrin.
c. Discuss weaning her Lexapro (having a “wash out” period of 2 weeks) and switching to Effexor.
d. Write a prescription for Amitriptyline.
Ans: C-Discuss weaning her Lexapro (having a “wash out” period of 2 weeks) and switching to Effexor.
Weaning and tapering SSRIs are important to avoid serotonin syndrome from switching from SSRIs to TCAs.
A patient presents to the clinic for her yearly evaluation. Her medication list includes Imipramine for depression and occasional use of aspirin for pain. She states to you, “I think I missed my dose of Imipramine a few days ago, but it’s okay because I took a few extra to stay caught up on my treatment.” Which sign would cause the most alarm and require immediate intervention?
a. Widening QRS on EKG
b. Bruising on her arms and legs
c. Temp 103F
d. BP 130/80
Ans: A - Widening QRS on EKG
TCA’s can cause significant widening of the QRS and is indicative of a TCA overdose. The patient probably wouldn’t be talking if she was overdosed, but this is the best scenario I could think of.
Your patient has just had a diagnosis of Obsessive Compulsive Disorder. Which of the following would the best medication for treatment?
a. Trazadone
b. Imipramine
c. Clomipramine
d. Zoloft
Ans: C
Clomipramine has an FDA approval for OCD.
Your male patient with a history of depression has been taking Prozac for 4 weeks and is complaining of lack of sexual interest. His partner thinks he is cheating on him and is visibly upset in the office. Which medication would be a good alternative?
a. Paxil
b. Effexor
c. Selegiline
d. Trazadone
Ans: D
Trazadone increases sexual drive in patients. In the antidepressant video it states “TrazaBONE” to remember trazadone is for increased sexual drive.
You are prescribing Phenelzine to your patient with depression. Which statement indicates a need for further teaching?
a. I should monitor my BP weekly at home.
b. I should monitor my weight weekly at home.
c. I should keep a journal of feelings of depression and anxiety throughout the beginning of treatment.
d. I should make sure and eat extra cheese and aged meats to make sure I get enough protein in my diet and a glass of wine with dinner each night for cardioprotective uses.
Ans: D - I should make sure and eat extra cheese and aged meats to make sure I get enough protein in my diet and a glass of wine with dinner each night for cardioprotective uses.
MAOIs are associated with HTN crisis with patients that ingest foods with high levels of tyramine including aged cheeses/meats and wines. The video talks about having a fine dinner with Tyra Banks (Tyramine) having cheese and wine in Maui (MAOIs). Or think about wine night would not be good for people taking MAOIs LOL!
A patient with cerebral palsy was prescribed Dantrolene (Dantrium) 2 months ago. At this visit, the patient’s caregiver explains to the NP that the patient is still experiencing significant muscle spasms and she has not seen any improvement in patient’s dexterity. What should the NP do?
a. Increase dose of dantrolene
b. Increase frequency of doses
c. Advise patient to continue taking dantrolene as ordered and schedule a follow up visit in 2 weeks to check patient’s status
d. Discontinue Dantrolene (Dantrium)
Answer: D. Discontinue Dantrolene (Dantrium)
P. 174: If beneficial effects do not develop within 45 days, dantrolene should be discontinued.
Tolerance is:
a. a state in which abrupt discontinuation of drug use will precipitate a withdrawal syndrome
b. when a patient is finally able to tolerate a certain medications side effects
c. a decreased response to a drug that occurs with prolonged drug use.
d. Is seen only with CNS medications
Answer C: a decreased response to a drug that occurs with prolonged drug use.
p. 125. Tolerance is a decreased response that occurs with prolonged drug use. Physical dependence is a state in which abrupt discontinuation of drug use will precipitate a withdrawal syndrome.
All of the following are true about CNS drugs EXCEPT:
a. When CNS drugs are taken long term, the intensity of side effects may decrease
b. Most of the compounds believed to be CNS neurotransmitters have been proven to serve this function
c. If certain CNS drugs are stopped abruptly, the drug-adapted brain can no longer function properly, and a withdrawal syndrome ensues.
d. Certain CNS drugs must be taken for several weeks and up to 2 months before full therapeutic effects develop
Answer B. - Most of the compounds believed to be CNS neurotransmitters have been proven to serve this function
p. None of the compounds believed to be CNS neurotransmitters has actually been proved to serve this function.
A 45 year old female has been taking Dantrolene (Dantrium) 100 mg TID for 3 months. Her caregiver calls the NP and states that the has been acting extremely tired and has new onset of epigastric pain. What should the NP do?
a. Discontinue the Dantrolene (Dantrium) and advise the caregiver to bring the patient in as soon as possible to be evaluated.
b. Advise the caregiver to half the dose of Dantrolene (Dantrium) to 50 mg and only give it BID.
c. Instruct the caregiver to continue the medication as ordered, but to bring the patient in to have her blood drawn in order to check her liver function
d. Prescribe a proton pump inhibitor to help with the epigastric pain
Answer A. - Discontinue the Dantrolene (Dantrium) and advise the caregiver to bring the patient in as soon as possible to be evaluated.
p. 174: Dose-related liver damage is the most serious adverse effect. The incidence is 1 in 1000. Deaths have occurred. Hepatotoxicity is most common in women older than 35 years. Inform patients about signs of liver dysfunction (e.g., jaundice, abdominal pain, malaise), and instruct them to seek medical attention if these develop.
A patient is currently taking methocarbamol (Robaxin) for back spasms. Upon review of systems, the patient tells the NP that is urine has turned dark brown. What should the NP do?
a. Advise the patient to drink more water as this can be an indication of dehydration
b. Reassure the patient that this is an expected, harmless side effect of methocarbamol (Robaxin)
c. Discontinue the methocarbamol (Robaxin) immediately due to the possibility of acute kidney injury
d. Order a UA to assess for blood in the urine.
Answer B. - Reassure the patient that this is an expected, harmless side effect of methocarbamol (Robaxin)
p. 176 Methocarbamol may turn urine brown, black, or dark green. Chlorzoxazone may color urine orange to purple-red. This appears to be dose related. The effect is harmless.
All of the following statements about baclofen (Lioresal) are true EXCEPT:
a. It is approved for relief of spasms related to multiple sclerosis and some spinal cord injuries
b. Patients on it should avoid alcohol.
c. It decreases muscles strength due to its direct effects on skeletal muscles
d. It can cause drowsiness and fatigue
Answer C. - It decreases muscles strength due to its direct effects on skeletal muscles
p. 173. Baclofen has no direct effects on skeletal muscle. Because baclofen has no direct muscle relaxant action, it does not decrease muscle strength.
A 50 year old patient presents to the NP with complaint of back spasms and back pain associated to the back spasms. The patient has a medical history of depression. Before prescribing cyclobenzaprine (Amrix) for the back spasms, what should the NP most importantly verify?
a. If the patient is allergic to sulfas
b. If the patient is currently taking any medications for depression
c. If the patient is taking ibuprofen for the pain
d. If the patient has a history of back surgery
Answer B.- If the patient is currently taking any medications for depression
p. 175: Cyclobenzaprine use is contraindicated for patients taking monoamine oxidase (MAO) inhibitors. For patients previously undergoing therapy with MAO inhibitors, at least 2 weeks must have passed after discontinuing the drug before starting cyclobenzaprine. Failure to do so has led to potentially fatal serotonin syndrome manifested by high fever, seizures, and rhabdomyolysis.
All of the following statements about the blood brain barrier are true EXCEPT:
a. The blood brain barrier is fully developed at birth
b. Protein-bound drugs and highly ionized drugs cannot cross the blood brain barrier.
c. The blood–brain barrier presents an advantage and a disadvantage; it can protects the brain from injury, but it can also be a significant obstacle to entry of therapeutic agents
d. The blood–brain barrier impedes the entry of drugs into the brain
Answer A. The blood brain barrier is fully developed at birth
p. 125: The blood–brain barrier is not fully developed at birth. Accordingly, infants are much more sensitive to CNS drugs than are older children and adults.
An NP is prescribing metaxalone (Skelaxin) to a 48 year old truck driver for back spasms and back pain. that What should the NP make sure to include in a patient’s education?
a. Alcoholic beverages should be limited to one a day when taking metaxalone (Skelaxin).
b. The patient should refrain from truck driving for the first few days or longer due to the CNS depression that this medication causes.
c. No baseline labs need to be drawn with Metaxalone (Skelaxin)
d. This medication cannot cause physical dependence
Answer B. - The patient should refrain from truck driving for the first few days or longer due to the CNS depression that this medication causes.
p. 176 Depressant effects (of centrally acting muscle relaxants) may include drowsiness, lightheadedness, and fatigue. These may be dangerous if the patient must engage in hazardous activities (e.g., truck-driving or construction)
Which one of these medications could possibly cause rebound hypertension if discontinued abruptly?
a. Methocarbamol (Robaxin)
b. Tizanidine (Zanaflex)
c. Cyclobenzaprine (Amrix, Fexmid)
d. Diazepam (Diastat, Valium)
Answer B. Tizanidine (Zanaflex)
p. 176: Tizanidine is similar to clonidine and can cause hypotension. When discontinuing this drug, it may be necessary to taper dosage to avoid rebound hypertension.
Which of following medication are controlled substances? Select all that apply.
a. Diazepam (Diastat, Valium)
b. Methocarbamol (Robaxin
c. Carisoprodol (Soma)
d. Cyclobenzaprine (Amrix, Fexmid)
Answer A&C
A. Diazepam (Diastat, Valium)
C. Carisoprodol (Soma)
p. 173: Table 22.2
What should the NP include to a patient with multiple sclerosis that was just prescribed baclofen?
a. This medication will slow down the progression of your multiple sclerosis
b. It is ok to drink alcohol with this medication
c. This medication should not be discontinued suddenly
d. This medication will decrease muscle strength
Answer: C - This medication should not be discontinued suddenly
p. 173: Abrupt discontinuation (of baclofen) has been associated with adverse reactions. Abrupt withdrawal of oral baclofen can cause visual hallucinations, paranoid ideation, and seizures. Accordingly, withdrawal should be done slowly (over 1 to 2 weeks)
When starting a patient on an SSRI, you should educate the patient that:
a. You should start to feel better in 48 hours
b. You should take this medication as needed
c. Initial responses can take 1-3 weeks to develop
d. Treatment will typically last 1-3 months
Answer: C - Initial responses can take 1-3 weeks to develop
pg. 215
A patient presents with depression and insominia, which medication would be the most appropriate choice?
a. Buproprion
b. Isocarboxazid
c. Mirtazapine
d. Fluoxetine
Answer: C Mirtazapine
pg. 216. Mirtazapine has the side effect of substantial sedation which would help with insomnia.
Important patient education regarding the SSRI Fluoxetine includes:
a. This drug may cause you to be drowsy
b. This drug may suppress your appetite.
c. This drug commonly causes sexual disfunction.
d. This drug can be given with an MAOI.
Answer: C-This drug commonly causes sexual disfunction.
pg. 218
A patient who is taking citalopram presents to their PCP with symptoms of altered mental status, incoordination, excessive sweating and fever. The provider suspects that the patient is experiencing:
a. An anaphylactic reaction
b. Serotonin Syndrome
c. Steven Johnson’s syndrome
d. Normal side effects of citalopram
Answer: B- Serotonin Syndrome
pg. 218
Which drug may cause hypotension and requires blood pressure monitoring?
a. Escitalopram
b. Venlaflaxine
c. Sertraline
d. Amitriptyline
Answer: D - Amitriptyline
pg. 221
True/False: SNRI’s can cause withdrawal and should be discontinued slowly?
Answer: True. Pg 220
Which is true of treatment for patients with mild to moderate depression?
a. Drug therapy is superior to psychotherapy
b. Psychotherapy is superior to drug therapy
c. Combination therapy is superior
d. Drug therapy and psychotherapy are equal
Answer: D - Drug therapy and psychotherapy are equal
Pg. 214
Which lab value should be monitored in an older adult taking an SSRI?
a. Sodium
b. Potassium
c. BUN
d. PT/INR
Answer: A - Sodium
pg. 220
Which symptoms would you monitor for in a newborn whose mother was taking Fluoxetine in the third trimester?
a. Poor feeding
b. Irritability and abnormal crying
c. Excessive sedation
d. Poor tone
Answer: B. Irritability and abnormal crying
Pg. 218
Which antidepressant is the preferred drug for a breastfeeding mother?
a. Amitriptyline
b. Sertraline
c. Bupropion
d. MAOI
Answer: B-Sertraline
pg. 219
Which class of antidepressants does not exhibit anticholinergic side effects?
a. SSRI
b. SNRI
c. TCA
d. MAOI
Answer: B -SNRI
pg. 221
Question: What uses is ondansetron approved for (select all that apply)
A) pregnancy
B) chemotherapy induced nausea and vomiting
C) radiotherapy
D) viral gastritis
Answer: B and C A and D are off label
Reasoning: Ondansetron is approved for CINV, radiotherapy, and anesthesia. A and D are off label
Question: Out of all of the Nonspecific Drugs for Irritable Bowel Syndrome, which one has good evidence that it relieves symptoms?
A) Antispasmodics (hyoscyamine and dicyclomine)
B) Bulk Forming Agents (psyllium and polycarbophil)
C) Antidiarrheal (loperamide)
D) Tricyclic Antidepressants
Answer: D- Tricyclic Antidepressants
Reasoning: Antispasmotics - not enough evidence
Bulk Forming Agents and Antidiarrheal – no better that placebo at relieving IBS symptoms
Tricyclic Antidepressants – good evidence that they are effective (p. 611)
Question: There is a Black Box Warning that which of the following are contraindications to taking Alosetron (select all that apply)
A) Crohn’s or ulcerative colitis
B) diverticulitis
C) chronic constipation
D) women
Answer: A, B, C
Reasoning: D – Alostetron is approved ONLY for women with severe IBS- D that has lasted more than 6 months and has not responded to conventional treatment. The other answers are in the black box warning ( p 612)
When giving a child promethazine for post-op nausea and vomiting, what adverse effects would you pay special attention to? (select all that apply)
A) seizure activity
B) diarrhea
C) respiratory depression
D) local tissue injury at site of infusion
Answer: C and D
Reasoning: BLACK BOX WARNING: respiratory depression can be severe and is contraindicated in children under 2 and should be used with caution in children above that age. Local tissue injury is also an adverse effect
A patient is about to go on a road trip and has a history of motion sickness. Would medication would you recommend?
A) Scopolamine
B) Diphenhydramine
C) Loperamide
D) Lorazepam
Answer: A-Scopolamine
Reasoning: scopolamine is the most effective drug for motion sickness. Diphenhydramine can be taken but is less effective and causes drowsiness. Loperamide is an antidiarrheal. Lorazepam is an antiemetic used for CINV
What is the first line drug used for nausea and vomiting in pregnancy?
A) ondansetron
B) methylprednisone
C) Diclectin (combination of doxylamine and B2)
D) metoclopramide
Answer: C
Reasoning: diclectin is first line, ondansetron or metoclopramide are second line, methylprednisone can be used after 10 weeks as a last resort (p 609)
What is Aprepitant’s relationship with CYP enzymes? (select all that apply)
A) a substrate for
B) inhibitor of
C) does not interact
D) an inducer of
Answer: A, B, D
Reasoning: p606
A patient that you are caring for is taking ondansetron for CINV. What type of monitoring would you do on this patient?
A) QT level
B) electrolytes
C) CBC
D) none
Answer: A
Reasoning: Patients taking ondansetron for an extended amount of time should have QT checked regularly. Baseline data would include QT and electrolytes. (p. 606)
Question: Which of the following drugs should be avoided while breastfeeding? (select all that apply) A) Metoclopramide B) Dronabinol C) Droperidol D) promethazine
Answer: A, B, C
Reasoning: A, B, and C should be avoided. Promethazine appears to be safe, but the infant should be monitored for sedation.
Question: What group of drugs would you most likely prescribe for a patient with mild to moderate symptoms of Crohn’s disease? A) Glucocorticoids B) Thiopurines C) Immunomodulators D) 5-aminosalicylates
Answer: D
Reasoning:
A) Glucocorticoids: used for the induction of remission of crohn’s
B) Thiopurines: reserved for those Crohn’s patient that have no responded to traditional therapy
C) Immunomodulators: generally considered second-line, but some now think that should be used earlier on
D) 5-aminosalicylates: correct answer
A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects of this drug. Which response by the nurse is correct?
a. “Phenobarbital doses for seizures are non-sedating.”
b. “This is a short-acting barbiturate, so sedation wears off quickly.”
c. “Tolerance to the sedative effects will develop in a few weeks.”
d. “You may actually experience paradoxical effects of euphoria.”
Answer: A - “Phenobarbital doses for seizures are non-sedating.”
Rationale:
Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are non-sedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur. Paradoxical drug effects are associated with benzodiazepines and in older adults and debilitated patients with barbiturates. (Ch 29)
A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient?
a. Flurazepam
b. Trazodone [Desyrel]
c. Zaleplon [Sonata]
d. Zolpidem [Ambien]
Answer: C - Zaleplon [Sonata]
Rationale: Zaleplon [Sonata] works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem [Ambien] has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess (Ch. 29)
A patient who is experiencing alcohol withdrawal is given a benzodiazepine. The nurse understands that this drug is effective because:
a. the alcohol does not interact with the benzodiazepine.
b. the benzodiazepine potentiates alcohol withdrawal symptoms.
c. the benzodiazepine relieves muscle spasms and spasticity.
d. the patient has a cross-dependence to the benzodiazepine.
Answer: D- the patient has a cross-dependence to the benzodiazepine.
Rationale: Benzodiazepines are given to ease withdrawal from alcohol because of cross-dependence with these drugs and alcohol, enabling the benzodiazepine to suppress withdrawal symptoms. Alcohol and benzodiazepines can potentiate one another. The benzodiazepine does not potentiate withdrawal symptoms (Ch. 29)
A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement?
a. “Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia.”
b. “Benzodiazepines depress neuronal functions by acting at a single site in the brain.”
c. “Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous
system. ”
d. “Benzodiazepines promote sleep through effects on the limbic system.”
Answer: A - “Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia.”
Rationale: All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness “clock.” (Ch. 29)
A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug’s half-life is only 2 to 3 hours. Which response by the nurse is correct?
a. “Benzodiazepines commonly cause residual effects lasting into the day after the dose is given.”
b. “The patient is having a paradoxical reaction to this medication.”
c. “This patient must have developed a previous tolerance to benzodiazepines.”
d. “When this drug is metabolized, the resulting compound has longer-lasting effects.”
Answer: D -“When this drug is metabolized, the resulting compound has longer-lasting effects.”
Rationale: Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication. (Ch. 29)
Which of the following is NOT one of the three therapeutic uses of benzodiazepines?
a. Anxiety
b. Muscle spasms
c. Insomnia
d. Seizures
Answer: B - Muscle Spasms
Rationale: The three main therapeutic uses of benzodiazepines are anxiety, insomnia, and seizures. Only one benzodiazepine is approved for muscle spasms (diazepam).
You are treating a patient with complaints of insomnia and anxiety. You know that a benzodiazepines or benzodiazepine-like drug would be contraindicated if they also take:
a. PO morphine BID
b. Diphenhydramine once daily
c. Acetaminophen BID
d. Captopril TID
Answer: A - PO Morphine BID
Rationale: Benzodiazepines and benzodiazepine-like drugs can cause death if used with other CNS depressants, such as opioids and alcohol. Diphenhydramine would cause the provider to proceed with caution, but the most concern would be related to the PO morphine. (Ch 29 video study guide)
A 55-year-old patient presents to your clinic. She states “I don’t have trouble falling asleep, but I can never stay asleep and its really affecting me during the day”. You prescribe her a sedative-hypnotic after attempting to assess the root cause. You prescribe:
a. Triazolam (Halcion)
b. Zaleplon (Sonata)
c. Ramelteon (Rozerem)
d. Suvorexant (Belsomra)
Answer: D - Suvorexant (Belsomra)
Rationale: Triazolam has a short duration with rapid onset. Zaleplon has a very rapid onset and short duration of action, so it is great at helping people fall asleep but not good at helping them maintain sleep. Ramelteon is approved for treating chronic insomnia characterized by difficulty with sleep onset (has a rapid onset), but not maintaining sleep. Suvorexant approved for treating chronic insomnia characterized by difficulty with sleep onset AND/OR sleep maintenance. (Ch 29 video study guide and Table 29.2 and Table 29.3)
A patient takes temazepam [Restoril] for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do?
a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine.
b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration.
c. Reassure the patient that this is most likely caused by a paradoxical reaction to the
benzodiazepine.
d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect
of the benzodiazepine.
Answer: A - Ask the patient about any alcohol consumption in conjunction with the benzodiazepine.
Rationale: This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.
A patient in the emergency department is given intravenous diazepam [Valium] for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths/minute. The nurse will expect to administer which of the following?
A. Flumazenil [Romazicon]
B. Gastric lavage
C. Respiratory support
D. Toxicology testing
Answer: C - Resp support
Rationale: When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil [Romazicon] is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.
Newer seizure medications require more frequent monitoring
A) True
B) False
Answer: False, older antiseizure meds had a very narrow therapeutic index so frequent monitoring was required to prevent toxicity or under dosing
Which medication is the best choice for a 33 year old woman with epilepsy interested in having a baby one day but not in the next year?
A) Keppra
B) Phenytoin
C) Valproic Acid
D) Carbamazepine
Answer: A - Keppra
Valproic Acid, Carbamazepine, Phenytoin are all teratogenic and contraindicated in pregnancy
Which medication is known to be effective for all seizure types?
A) Keppra
B) Valproic Acid
C) Trileptal
D) Rifaxamin
Answer: B - Valproic Acid
Reasoning: pg 160
Valproic Acid is contraindicated in pregnancy due to high risk for:
A) Autism, decreased IQ, neural tube defects
B) Gestational Diabetes, premature rupture of membranes
C) Hyponatremia, hyperkalemia, oliguria
D) Bone density loss and osteopenia
Answer: A - Autism, decreased IQ, neural tube defects
Reasoning: pg 160
These epilepsy medications carry an FDA warning of increased suicidal thoughts and behaviors. Select all that apply
A) Topiramate
B) Vigabatrin
C) Pregabalin
D) Lamotrigine
Answer: A, D
Reasoning: pg 154
A post-stroke patient has developed epilepsy and been prescribed Phenytoin. What education should be given to their caregiver in regards of Phenytoin dose timing?
A) Phenytoin should be administered with his PEG tube feeds to prevent nausea
B) Phenytoin should be administered 1-2 hours separate from tube feeds
C) Phenytoin absorption is not effected by feed timing
D) Patient can drink alcohol safely on Phenytoin
Answer: B - Phenytoin should be administered 1-2 hours separate from tube feeds
Reasoning: pg 158, administering phenytoin with tube feeds can decrease phenytoin levels and lead to subtherapeutic serum levels
Carbamazepine carries a black box warning of Stevens-Johnson Syndrome and toxic epidermal necrolysis. Which ethnicity is most at risk of this adverse skin reaction?
A) Ashkenazi Jewish
B) Asian
C) African
D) Hispanic
Answer: B - Asian
Reasoning: pg 159, high risk for SJS or TEN reaction is associated with an HLA-B gene variant found predominately in the Asian population. All Asian patients should be screened for the HLA-B 1502 gene variant if prescribed carbamazepine
What education should be provided to a patient with a new prescription for Oxcarbazepine? Select all that apply
A) Birth Control pills are ineffective when taken concurrently with oxcarbazepine, alternative contraceptive methods must be utilized
B) Rash, fever, jaundice, and joint pain should be immediately reported to your provider because these could be signs of a life-threatening reaction
C) Severe thirst is a common side effect and should be watched for
D) Diuretics can decrease risk of hypernatremia and should be given at the same time as oxcarbazepine
Answer: A & B
A) Birth Control pills are ineffective when taken concurrently with oxcarbazepine, alternative contraceptive methods must be utilized
B) Rash, fever, jaundice, and joint pain should be immediately reported to your provider because these could be signs of a life-threatening reaction
Reasoning: pg 163
Oral contraceptives are not effective with oxcarbazepine because oxcarbazepine induces enzymes to metabolize estrogen and progestin
Rash, fever, jaundice, join pain are all signs of a multiorgan hypersensitivity reaction and should be reported, oxcarbazepine should be discontinued if they occur
Severe thirst is a sign of hypernatremia, oxcarbazepine puts patients at risk for hyponatremia so diuretics should be used with great caution
Which antiepileptic is not a good fit for a patient with history of multidrug dependence?
A) Keppra
B) Valproic Acid
C) Phenobarbital
D) Ethosuximide
Answer: C- Phenobarbital
Reasoning: pg 161, phenobarbital has a risk of misuse, patients with history of addiction are not good candidates for phenobarbital
The other medications carry no risk of abuse
Which antiepileptic should not be given to patients with a sulfa allergy?
A) Rufinamide
B) Vigabatrin
C) Tiagabine
D) Zonisamide
Answer: D - Zonisamide
Reasoning: pg 166, Zonisamide belongs is the same chemical family as sulfa antibiotics but does not have antimicrobial activity
What actions occur when taking Benzodiazepines?
a. Reduced anxiety
b. Sleep promotion and muscle relaxation
c. Reduced anxiety and sleep promotion
d. Reduced anxiety, sleep promotion, muscle relaxation
Answer: D. - Reduced anxiety, sleep promotion, muscle relaxation
pg: 234
Benzodiazepine metabolism may be reduced in patients with hepatic impairment. Some Benzodiazepines, however, undergo minimal metabolic alteration. What Benzodiazepines are they?
a. Oxazepam, temazepam, lorazepam
b. Oxazepam, temazepam
c. Lorazepam, Oxazepam
d. None of the above
Answer: A - Oxazepam, temazepam, lorazepam
pg: 235
What are the therapeutic uses of benzodiazepines?
a. Anxiety, seizure disorders
b. Anxiety, seizure disorders, insomnia
c. Anxiety, insomnia
d. Insomnia, seizure disorders
Answer: C. Anxiety, insomnia
pg: 235
Benzodiazepine-like drugs are the preferred agents for insomnia and NOT anxiety. These drugs share the same mechanism of action as benzodiazepines by acting as agonists at the benzodiazepine receptor site on the GABA receptor chloride-channel complex. What drugs are these?
a. Romelteon, suvorexant
b. Zolpidem, zaleplon, eszopiclone
c. Temazepam, Quazepam, triazolam
d. Trazodone, doxepin
Answer: B. - Zolpidem, zaleplon, eszopiclone
pg: 237
Barbiturates have important applications in which of the following?
a. Anesthesia, seizure control
b. Anxiety, seizure control
c. Anesthesia, seizure control, insomnia
d. anesthesia, anxiety, seizure control, insomnia
Answer: A - Anesthesia, seizure control
pg: 239
Which drug can directly mimic GABA?
a. Benzodiazepine-like drugs
b. Barbiturates
c. Hypnotics
d. Benzodiazepines
Answer: B. - Barbiturates
pg: 239
When a patient being treated for insomnia with hypnotic drugs experiences less effects than before, suggesting tolerance to the drug, the provider should…
a. Increase the dose and monitor for adverse effects
b. Interrupt the therapy allowing tolerance to decline, thereby restoring responsiveness to treatment
c. Switch the patient to a barbiturate therapy and monitor the patient closely for adverse effects
d. Start the patient on Melatonin
Answer: B. Interrupt the therapy allowing tolerance to decline, thereby restoring responsiveness to treatment
pg: 241
Doxepin, a strong, tricyclic antidepressant, is approved in low dose formulations for treating patients who have trouble staying asleep. What are the most common adverse effects of this medication when used in low doses for treating insomnia?
a. Sedation, nausea, upper respiratory infections
b. Headache, visual disturbance, nausea, vomiting, diarrhea
c. Sedation, upper respiratory infections
d. Hypotension, sedation, nausea
Answer: A. - Sedation, nausea, upper respiratory infections
pg: 241
Doxepin, a strong, tricyclic antidepressant, is approved in high dose formulations for treating patients with depression. What are the most common adverse effects of this medication when used in high doses for treating depression?
a. Tachycardia, hypotension, visual disturbance
b. Dysrhythmias, hypertension
c. Sedation, headache, nausea
d. Hypotension, dysrhythmias, anticholinergic effects
Answer: D. Hypotension, dysrhythmias, anticholinergic effects
pg: 241
Typically, benzodiazepines cause low physical dependency. However, one type of benzodiazepine, Alprazolam (Xanax, Xanax XR, Niravam), may create a greater dependency and benzodiazepine withdrawal syndrome may resemble an anxiety disorder. Because of this, doses should be tapered, and patients should be monitored for ______weeks for indication of withdrawal or recurrence of original symptoms.
a. 2
b. 3
c. 4
d. 6
Answer: B. - 3 weeks
pg: 237
What are the uses for Valproic Acid? Select all that apply
A. Simple partial B. Complex partial C. Tonic clonic D. Absence E. Myoclonic
A, B,C,D,E The answer all of the above Valproic acid can be used to treat all types of seizures. P.160
True or false
Valproic has a black box warning for …
• Fetal hepatic failure in young patient and patients with mitochondrial disease are at increased risk
• Fatal and rapidly progressing pancreatitis has occurred common symptoms include nausea, vomiting, anorexia, and abdominal pain
• Valproate is highly teratogenic. Neonates who survive may have major congenital malformations and decrease mental capacity
True there is a black box warning for Valproic acid pg. 160
