Unit 5: Chapter 32 (Karch 7th Ed) - Cholinergic Agonists

Question 1

1. The patient has had cevimeline (Evoxac) prescribed. What would be an appropriate dosing schedule for
the nurse to administer this drug?
A) Once a day
B) Twice a day
C) Three times a day
D) Every 4 hours

Answer 1

Ans: C
Feedback:
Cevimeline should be given three times a day with meals. Once or twice a day dosing would cause a
decrease in therapeutic effects of the drug and every 4 hours could lead to toxicity.

Question 2

2. A student asks the pharmacology instructor to describe the function of a cholinergic agonist. What
   would the instructor reply?
   A) Cholinergic agonists increase the activity of dopamine receptor sites throughout the brain and
   spinal cord.
   B) Cholinergic agonists decrease the activity of gamma-aminobutyric acid (GABA) receptor sites
   throughout the body.
   C) Cholinergic agonists increase the activity of acetylcholine receptor sites throughout the body.
   D) Cholinergic agonists decrease the activity of norepinephrine receptor sites throughout the brain and
   spinal cord.

Answer 2

Ans: C
Feedback:
Cholinergic agonists are drugs that increase the activity of acetylcholine receptor sites throughout the
body. Dopamine, GABA, and norepinephrine are not associated with cholinergic agonist function.

Question 3

3. A 10-year-old child with spina bifida is receiving bethanechol (Urecholine) for treatment of neurogenic
   bladder. What adverse effect will the nurse assess for?
   A) Constipation
   B) Loss of bowel and bladder control
   C) Decrease salivation
   D) Increased appetite

Answer 3

Ans: B
Feedback:
Loss of bowel and bladder control is an adverse effect of cholinergic agents that would cause stress in a
child. Diarrhea and increased salivation are also adverse effects. Increased appetite is not associated
with these drugs. Children are more likely to have gastrointestinal (GI) upset that could result in a
decrease in appetite.

Question 4

4. A nurse is writing a plan of care for a patient who is taking bethanechol (Urecholine). What would be
an appropriate outcome for this patient?
A) Pupillary dilation
B) Increased blood pressure
C) Improved bladder function
D) Decreased secretions

Answer 4

Ans: C
Feedback:
Bethanechol is prescribed for nonobstructive urinary retention and neurogenic bladder. The appropriate
outcome for this patient would be improved bladder function. This drug causes pupillary constriction
and increased secretions. This drug would not increase blood pressure. However, it could cause
hypotension in the older patient.

Question 5

5. What drug is the nurse likely to administer to diagnose myasthenia gravis in a child?
A) Atropine (generic)
B) Bethanechol (Urecholine)
C) Edrophonium (Enlon, Reversol)
D) Neostigmine (Prostigmine)

Answer 5

Ans: C
Feedback:
Edrophonium is the drug of choice for diagnosing myasthenia gravis. Bethanechol is used to treat
neurogenic bladder. Neostigmine is used for treatment of myasthenia gravis and could be used for
diagnosis if edrophonium could not be used. Atropine is an anticholinergic drug and would not be used
to test for myasthenia gravis

Question 6

6. A patient is brought to the emergency department having a cholinergic reaction, which includes a
   severe drop in blood pressure. What drug will the nurse expect to administer?
   A) Atropine (generic)
   B) Edrophonium (Enlon, Reversol)
   C) Propranolol (Inderal)
   D) Succinylcholine (Anectine)

Answer 6

Ans: A
Feedback:
The antidote for a cholinergic reaction is atropine. This drug will block the cholinergic sites.
Edrophonium would cause an accumulation of acetylcholine and worsen the situation. Propranolol
blocks beta-receptors in the sympathetic system. Succinylcholine is a neuromuscular junction drug and
would not affect other sites.

Question 7

7. Memantine hydrochloride (Namenda) has been prescribed for a 63-year-old patient who has a
   confirmed diagnosis of Alzheimer’s disease. What would be the target dose for this patient?
   A) 5 mg/d
   B) 10 mg b.i.d.
   C) 15 mg/d
   D) 20 mg b.i.d.

Answer 7

Ans: B
Feedback:
The drug is started at 5 mg/d PO, increasing by 5 mg/d at weekly intervals. The target dose is 20 mg/d
given as 10 mg b.i.d.

Question 8

8. An Alzheimer’s patient taking donepezil (Aricept) has a complete blood count that indicates he or she
   is anemic. What drug taken in combination with donepezil could be the cause of the anemia?
   A) Cimetidine (Tagamet)
   B) Ibuprofen (Advil)
   C) Diltiazem (Cardizem)
   D) Furosemide (Lasix)

Answer 8

Ans: B
Feedback:
There could be an increased risk of gastrointestinal (GI) bleeding if donepezil is taken with a
nonsteroidal anti-inflammatory drug (NSAID) because of the combination of increased GI secretions
and the GI mucosal erosion associated with the use of NSAIDs. Cimetidine, diltiazem, and furosemide
would not affect GI bleeding.

Question 9

9. The Air Force nurse is treating a patient who was exposed to a particular nerve gas. What drug has been
approved to treat this patient?
A) Neostigmine (Prostigmin)
B) Pyridostigmine (Mestinon)
C) Ambenonium (Mytelase)
D) Edrophonium (Enlon, Reversol)

Answer 9

Ans: B
Feedback:
Pyridostigmine has been approved for use by military personnel who have been exposed to particular
nerve gases. Neostigmine, ambenonium, and edrophonium are not approved for this use.

Question 10

10. The nurse administers a direct-acting cholinergic agonist to the patient. When assessing this patient for
    drug effects, the nurse would expect to see effects arising from stimulation of what receptors?
    A) Nicotinic
    B) Alpha
    C) Beta
    D) Muscarinic

Answer 10

Ans: D
Feedback:
The direct-acting cholinergic agonists are similar to acetylcholine (ACh) and react directly with
receptor sites to cause the same reaction as if Ach had stimulated the receptor sites. These drugs usually
stimulate muscarinic receptors within the parasympathetic system. They are used as systemic agents to
increase bladder tone, urinary excretion, and gastrointestinal (GI) secretions. One drug is used as an
ophthalmic agent to induce miosis to relieve the increased intraocular pressure of glaucoma. They have
no effect on alpha and beta receptors in the sympathetic nervous system and little impact on nicotinic

Question 11

11. The nurse is caring for a 49-year-old patient, who has been receiving bethanechol (Duvoid) for 1 week.
    The patient develops progressive muscle weakness and respiratory difficulty. Edrophonium is ordered
    and injected and the patient’s symptoms worsen. How would the nurse interpret this response?
    A) Myasthenic crisis
    B) Cholinergic crisis
    C) Anaphylactic reaction
    D) Pulmonary edema

Answer 11

Ans: B
Feedback:
The patient with a cholinergic crisis presents with progressive muscle weakness and respiratory
difficulty because the accumulation of acetylcholine at the cholinergic receptor site leads to reduced
impulse transmission and muscle weakness. This is a crisis when the respiratory muscles are involved.
Myasthenic crisis and cholinergic crisis display similar clinical pictures. The drug edrophonium can be
used as a diagnostic agent to distinguish the two conditions. If the patient improves immediately after
the edrophonium injection, the problem is a myasthenic crisis, which is improved by administration of
the cholinergic drug. If the patient gets worse, the problem is probably a cholinergic crisis, so
withdrawal of the patient’s cholinergic drug along with intense medical support is indicated. The
situation does not depict an anaphylactic reaction or pulmonary edema.

Question 12

12. A 70-year-old female patient has just been diagnosed with Alzheimer’s disease. What cholinergic drug
    is used for the treatment of Alzheimer’s disease?
    A) Bethanechol (Duvoid)
    B) Neostigmine (Prostigmin)
    C) Donepezil (Aricept)
    D) Edrophonium (Enlon, Reversol)

Answer 12

Ans: C
Feedback:
Currently, there are four reversible indirect-acting cholinergic agonists available to slow the
progression of this disease. These include tacrine (Cognex), galantamine (Razadyne), rivastigmine
(Exelon), and donepezil (Aricept). Edrophonium (Enlon, Reversol) is used to diagnose myasthenia
gravis; neostigmine is used for the diagnosis and management of myasthenia gravis; and bethanechol is
used to treat neurogenic bladder.

Question 13

13. The 38-year-old patient has just been administered edrophonium (Enlon, Reversol). The nurse will
    know whether this patient has myasthenia gravis if the patient exhibits what within 30 minutes after
    receiving the medication?
    A) Increased muscle strength
    B) Decreased adventitious breath sounds
    C) Decreased muscle spasms
    D) Increased urinary output

Answer 13

Ans: A
Feedback:
Edrophonium is administered to diagnose myasthenia gravis because administration of this drug will
cause a marked increase in muscle strength within 30 minutes of administration if the patient has this
disease. Edrophonium does not produce decreased adventitious breath sounds, decreased muscle
spasms, or increased urinary output.

Question 14

14. When the nurse administers a cholinergic agonist to the patient, the nurse’s expectation is that what
system will be stimulated?
A) Sympathetic nervous system
B) Parasympathetic nervous system
C) Central nervous system
D) Voluntary nervous system

Answer 14

Ans: B
Feedback:
Cholinergic agonists act at the same site as the neurotransmitter acetylcholine (ACh) and increase the
activity of the ACh receptor sites throughout the body. Because these sites are found extensively
throughout the parasympathetic nervous system, their stimulation produces a response similar to what
is seen when the parasympathetic system is activated. These drugs do not stimulate the sympathetic,
central, or voluntary nervous systems.

Question 15

15. A 78-year-old patient is admitted to the emergency department and is diagnosed with bradycardia. The
    patient tells the nurse he or she is taking donepezil (Aricept), a cholinergic agent, for Alzheimer’s
    disease. The nurse will anticipate what drug will be ordered to treat the patient’s bradycardia?
    A) Atropine
    B) Pseudoephedrine
    C) Propranolol
    D) Bethanechol

Answer 15

Ans: A
Feedback:
Maintain a cholinergic blocking drug on standby, such as atropine, to use as an antidote for excessive
doses of cholinergic drugs to reverse overdose or counteract severe reactions arising from use of
cholinergic agonists. Atropine will block cholinergic effects that are causing this patient’s heart rate to
decline. Bethanechol will slow the heart rate further whereas propranolol and pseudoephedrine will not
reverse the cholinergic stimulation

Question 16

16. The nurse administers bethanechol (Duvoid, Urecholine) to treat what condition?
A) Hypertension
B) Urinary retention
C) Bradycardia
D) Asthma

Answer 16

Ans: B
Feedback:
Bethanechol is used for the treatment of nonobstructive postoperative and postpartum urinary retention,
neurogenic bladder atony in adults and children older than 8 years; diagnosis and treatment of reflux
esophagitis in adults, and orally in infants and children for treatment of esophageal reflux. It would be
ineffective in treating hypertension, bradycardia, and asthma.

Question 17

17. The nurse is caring for a patient who has indirect-acting cholinergic agonists prescribed to treat
    myasthenia gravis. When administering this classification of drug, the nurse should assess the patient
    for toxic effects of the drugs including what?
    A) Paralytic ileus
    B) Abdominal distension
    C) Hypertension
    D) Muscle weakness

Answer 17

Ans: D
Feedback:
The patient with a cholinergic crisis presents with progressive muscle weakness and respiratory
difficulty because the accumulation of acetylcholine at the cholinergic receptor site leads to reduced
impulse transmission and muscle weakness. This is a crisis when the respiratory muscles are involved.
Toxic effects of the drug would not include paralytic ileus, abdominal distention, or hypertension.

Question 18

18. Which indirect-acting anticholinesterase medication will the nurse administer as an antidote to
neuromuscular junction blockers?
A) Pyridostigmine (Mestinon)
B) Donepezil (Aricept)
C) Rivastigmine (Exelon)
D) Ambenonium (Mytelase)

Answer 18

Ans: A
Feedback:
Pyridostigmine is indicated for management of myasthenia gravis; antidote to neuromuscular junction
blockers; increased survival after exposure to nerve gas. Donepezil and rivastigmine are used to treat
Alzheimer’s disease. Ambenonium is used to treat myasthenia gravis.

Question 19

19. A patient is brought to the emergency department after a motor vehicle accident. The patient is
    diagnosed with multiple injuries including a bladder injury. The patient is taken to surgery and develops
    a nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for
    this patient?
    A) Neostigmine
    B) Bethanechol
    C) Ambenonium
    D) Pyridostigmine

Answer 19

Ans: B
Feedback:
The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is
available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum
urinary retention and to treat neurogenic bladder atony. The other options are not indicated for this
purpose.

Question 20

20. A patient is taking memantine for Alzheimer’s disease. This drug does not affect what?
    A) Nicotinic receptor sites
    B) Glucagon receptor sites
    C) Gamma-aminobutyric acid (GABA) receptor sites
    D) Muscarinic receptor sites

Answer 20

Ans: C
Feedback:
The drug, memantine hydrochloride (Namenda) has a low-to-moderate affinity for N-methyl-DTest aspartate (NMDA) receptors with no effects on dopamine, GABA, histamine, glycine, or adrenergic
receptor sites. It is believed that persistent activation of the central nervous system NMDA receptors
contributes to the symptoms of Alzheimer’s disease. By blocking these sites, it is thought that the
symptoms are reduced or delayed. Other options are incorrect.

Question 21

21. A patient is brought to the emergency department and is found to have cholinergic toxicity. What is the
drug of choice to treat this condition?
A) Atropine
B) Epinephrine
C) Lidocaine
D) Edrophonium (injectable)

Answer 21

Ans: A
Feedback:
Maintain atropine sulfate on standby as an antidote in case of overdose or severe cholinergic reaction.
Epinephrine, lidocaine, and edrophonium would not be used for this purpose.

Question 22

22. A 47-year-old man is suspected of having been exposed to nerve gas. Atropine is given to temporarily
    block cholinergic activity and to activate acetylcholine sites in the central nervous system. What drug
    does the nurse give with the atropine to free up the acetylcholinesterase to start breaking down
    acetylcholine?
    A) Pyridostigmine
    B) Pralidoxime
    C) Neostigmine
    D) Rivastigmine

Answer 22

Ans: B
Feedback:
If nerve gas exposure is expected, patients who may have been exposed are given intramuscular
injections of atropine (to temporarily block cholinergic activity and to activate acetylcholine sites in the
central nervous system) and pralidoxime (to free up the acetylcholinesterase to start breaking down
acetylcholine). An auto-injection is provided to military personnel who may be at risk. The injector is
used to give atropine and then pralidoxime. The injections are repeated in 15 minutes. If symptoms of
nerve gas exposure exist after an additional 15 minutes, the injections are repeated. If symptoms still
persist after a third set of injections, medical help should be sought. Pyridostigmine, neostigmine, and rivastigmine are not used in nerve gas exposure.

Question 23

23. A 77-year-old man is brought to the emergency department with a cholinergic overdose. The nurse
    knows that older adults are likely to have a greater number of adverse drug effects for what reason?
    A) They are more likely to take the medications inconsistently.
    B) All older adults have some type of chronic health problem.
    C) Older adults have a number of different physiological changes.
    D) Older adults have a poor memory and are more likely to overdose.

Answer 23

Ans: C
Feedback:
Older patients are more likely to experience the adverse effects associated with these drugs (e.g.,
central nervous system, cardiovascular, gastrointestinal, respiratory, and urinary) because of normal
physiological changes associated with aging. Those patients with known renal or hepatic impairment
would receive a lower dosage to avoid overdose. Older people are not more likely to take medications
inconsistently or to take too much medication. Not all older adults have chronic health problems.

Question 24

24. The nurse is caring for a 45-year-old female patient who is in chronic renal failure. What cholinergic
    drug is contraindicated for this patient?
    A) Neostigmine
    B) Pyridostigmine
    C) Edrophonium
    D) Galantamine

Answer 24

Ans: D
Feedback:
Drugs used to treat Alzheimer’s disease are metabolized in the liver and excreted in the urine, so
caution should be used in the presence of hepatic or renal dysfunction, which could interfere with the
metabolism and excretion of the drugs. Dosage adjustments may be needed for neostigmine,
edrophonium, and pyridostigmine if the patient has renal disease but they are not contraindicated

Question 25

25. A 72-year-old man is newly diagnosed with Alzheimer’s disease. The patient’s daughter asks the nurse
    how her father’s medication is going to help him. What will the nurse explain in layman’s terms?
    A) The drugs work by increasing acetylcholine (ACh) levels in the brain and slowing the progression
    of the disease.
    B) The drugs work by crossing the blood brain barrier and cure the disease in the brain.
    C) The drugs work by increasing ACh levels in the brain and reverse the progression of the disease.
    D) The drugs work by crossing the blood brain barrier and decreasing ACh levels in the neuromuscular junctions.

Answer 25

Ans: A
Feedback:
Acetylcholinesterase inhibitors that cross the blood brain barrier are used to manage Alzheimer’s
disease by increasing ACh levels in the brain and slowing the progression of the disease. Decreasing
ACh levels in the brain does not slow the progression, reverse the progression, or cure the disease.
Decreasing ACh levels at the neuromuscular junctions has no effect on Alzheimer’s disease.

Question 26

26. A patient has been newly diagnosed with myasthenia gravis. What important teaching will the nurse
    provide the family?
    A) If one dose of medication is missed double the next dose
    B) The warning signs of drug overdose
    C) How to encourage activity when the patient is tired
    D) Importance of monitoring level of consciousness

Answer 26

Ans: B
Feedback:
The patient who is being treated for myasthenia gravis and his or her significant other should both
receive instruction in drug administration, warning signs of drug overdose, and signs and symptoms to
report immediately to enhance patient knowledge about drug therapy and to promote compliance.
Missed doses should not be doubled with next dose because this will lead to overdosage. Patients with
myasthenia gravis will experience muscle weakness and should not be pushed to do more than they can
tolerate. Level of consciousness is not a concern in patients with myasthenia gravis.

Question 27

27. A new patient has come to the clinic. The patient tells the nurse he or she takes donepezil (Aricept).
    What is the priority nursing assessment related to the medication? (Select all that apply.)
    A) Nutritional status
    B) Blood pressure
    C) History of incontinence
    D) Breath sounds
    E) Muscle strength

Answer 27

Ans: A, B, C
Feedback:
Gastrointestinal (GI) adverse effects can include nausea, vomiting, cramps, diarrhea, increased
salivation, and involuntary defecation, so it is important for the nurse to assess nutritional status. This is
made all the more important by the condition the drug is treating that often results in patients forgetting
to eat healthfully. Blood pressure should be monitored because adverse effects of donepezil include
hypotension, bradycardia, and heart block. Involuntary defecation and relaxation of bladder sphincter
can result in incontinence so the nurse should assess for both incontinence and, if it occurred, skin
integrity. Respiratory adverse effects are not associated with donepezil and muscle strength should not
be impacted either.

Question 28

28. What family of drugs is used in the treatment of myasthenia gravis?
A) Direct-acting cholinergic agonists
B) Muscarinic inhibitors
C) Indirect-acting cholinergic agonists
D) Nicotinic agonists

Answer 28

Ans: C
Feedback:
The drugs used to treat patients with myasthenia gravis include several indirect-acting cholinergic
agonists that do not cross the blood brain barrier and do not effect acetylcholine transmission in the
brain. These drugs include ambenonium (Mytelase), edrophonium (Enlon, Reversol), neostigmine
(Prostigmin), and pyridostigmine (Mestinon). Other options are incorrect.

Question 29

29. For what purpose would the nurse in the critical care unit administer pyridostigmine?
    A) To reverse neuromuscular junction blockers
    B) To reverse smooth muscle blockade
    C) To reverse cholinergic crisis
    D) To prevent myasthenic crisis

Answer 29

Ans: A
Feedback:
Pyridostigmine is approved for management of myasthenia gravis, as an antidote to neuromuscular
junction blockers, and to increase survival after exposure to nerve gas. Other options are not indications
for use of this drug.

Question 30

30. A patient diagnosed with myasthenia gravis is having trouble swallowing. What anticholinesterase
    inhibitor would be the drug of choice for this patient?
    A) Galantamine
    B) Pyridostigmine
    C) Donepezil
    D) Bethanechol

Answer 30

Ans: B
Feedback:
Pyridostigmine is preferred in some cases for the management of myasthenia gravis because it does not
need to be taken as frequently and can be given parenterally for patients who are having difficulty
swallowing. Galantamine and bethanechol cannot be given parenterally to the patient having difficulty
swallowing. Donepezil is not indicated for the treatment of myasthenia gravis but is used to manage
Alzheimer dementia, including severe dementia.

Question 31

31. The nurse is treating a patient who has been exposed to nerve gas. The provider ordered pyridostigmine
    (Mestinon) 0.25 mg/kg. The patient weighs 96 kg. What dosage will the nurse administer to this
    patient?
    A) 24 mg
    B) 384 mg
    C) 11 mg
    D) 31.7 mg

Answer 31

Ans: A
Feedback:
Multiply the patient’s weight times the ordered dose per kilogram: 0.25 × 96 = 24 mg. Other options
are incorrect.

Question 32

32. The nurse is caring for a patient diagnosed with Sjögren’s syndrome. What medication will the nurse
    anticipate administering to treat this condition?
    A) Bethanechol
    B) Carbachol
    C) Ambenonium
    D) Pilocarpine

Answer 32

Ans: D
Feedback:
Only pilocarpine is indicated for treatment of Sjögren’s syndrome. None of the other medications are
indicated for this purpose.

Question 33

33. The nurse administers bethanechol to the patient on an empty stomach for what purpose?
    A) To promote rapid absorption
    B) To prevent destruction of the drug
    C) To reduce irritation of stomach lining
    D) To decrease nausea and vomiting

Answer 33

Ans: D
Feedback:
Administer bethanechol and all oral forms of direct-acting cholinergic agonists on an empty stomach to
decrease nausea and vomiting. The other options do not correctly explain the rationale for
administering bethanechol on an empty stomach.

Question 34

34. The nurse in the pediatric intensive care unit is caring for an infant with severe gastroesophageal reflux. What medication, if ordered, would the nurse administer to treat this condition?
A) Bethanechol
B) Carbachol
C) Cevimeline
D) Pilocarpine

Answer 34

Ans: A
Feedback:
Only bethanechol is indicated for the treatment of esophageal reflux in infants and children. The other
drugs treat intraocular pressure, dry mouth, or to allow surgeons to perform certain surgical procedures.

Question 35

35. The nurse is caring for a patient receiving carbachol to treat glaucoma. The patient says he or she has
    stopped driving at night because he or she just does not see well in the dark. What is the best nursing
    diagnosis for this patient?
    A) Anxiety related to poor vision
    B) Grief related to loss of driving privileges
    C) Risk for injury related to visual changes
    D) Pain related to altered vision

Answer 35

Ans: C
Feedback:
This patient is at risk for injury related to visual changes and requires safety teaching to make the home
as safe as possible. Nothing indicates the patient is experiencing anxiety, grief, or pain.