Unit 5: Chapter 33 (Karch 7th Ed) - Anticholinergic Agents

Question 1

1. A student asks the pharmacology instructor to explain the action of anticholinergic agents. What would
   be the instructor’s best response?
   A) They block nicotinic receptors.
   B) They compete with serotonin for muscarinic acetylcholine receptor sites.
   C) They act to block the effects of the parasympathetic nervous system.
   D) They increase norepinephrine at the neuromuscular junction.

Answer 1

Ans: C
Feedback:
Drugs that are used to block the effects of acetylcholine are called anticholinergic drugs. Because this
action lyses, or blocks, the effects of the parasympathetic nervous system, they are also called
parasympatholytic agents. The drug works by blocking only the muscarinic effectors in the
parasympathetic nervous system. They compete with acetylcholine for the muscarinic acetylcholine
receptor sites. They do not block the nicotinic receptors and have little or no effect at the
neuromuscular junction.

Question 2

2. A patient calls the clinic and talks to the nurse. The patient tells the nurse he or she is going on a cruise
   and is concerned about motion sickness. The patient says that a friend has recommended that he or she
   see his or her primary care physician to get a prescription for scopolamine. What adverse effect would
   the nurse inform the patient that using scopolamine may result in?
   A) Pupil constriction
   B) Tachycardia
   C) Diarrhea
   D) Urinary incontine

Answer 2

Ans: B
Feedback:
Scopolamine blocks the parasympathetic nervous system, which may result in dilated pupils and
increased heart rate (i.e., tachycardia). Blocking the parasympathetic system also results in decreased
GI activity and urinary bladder tone causing constipation and urinary retention.

Question 3

3. A 29-year-old man is going on a company-sponsored deep-sea fishing trip in 2 weeks. He comes to the
   clinic requesting a scopolamine patch because he is afraid that he will get seasick. The medication is
   prescribed for him and the nurse’s instructions concerning use of the patch will include what?
   A) Shave the area before applying the patch.
   B) The patch’s effectiveness will last about 72 hours.
   C) When replacing the patch, apply the new patch in the same area.
   D) Do not clean the application area before applying the patch

Answer 3

Ans: B
Feedback:
The scopolamine patch is replaced every 3 days (i.e., 72 hours). The scopolamine patch should be
applied to a clean, dry, intact, and hairless area of the body. The area should not be shaved because
abrasion of the skin could occur and lead to increased absorption. Patches should be placed at new sites
each time to avoid skin irritation. The old patch should be removed and the area cleaned.

Question 4

4. The nurse is taking a health history on a new patient who has been prescribed propantheline(generic) as
   adjunctive therapy for peptic ulcers. While collecting the health history, what will the nurse specifically
   assess for?
   A) Diabetes mellitus
   B) Obsessive-compulsive disorder
   C) Insomnia
   D) Glaucoma

Answer 4

Ans: D
Feedback:
Propantheline is contraindicated for a patient with glaucoma because the drug could result in increased
intraocular pressure due to pupil dilation. Diabetes mellitus, obsessive-compulsive disorder, and
insomnia are not recognized as being adversely affected by this drug.

Question 5

5. A nurse is admitting a patient for outpatient eye surgery. The nurse routinely administers preoperative
   medications for eye surgery and is aware that an increased dosage of a mydriatic is likely when given to
   a member of what ethnic group?
   A) African Americans
   B) German Americans
   C) Irish Americans
   D) Scandinavian Americans

Answer 5

Ans: A
Feedback:
African Americans with dark eyes usually require an increased dosage and may have a prolonged time
to peak effect. The need for an increased dose appears to be related to the amount of pigment in the
person’s eyes because people with darker-pigmented eyes require a higher dose. German, Irish, and
Scandinavian Americans generally have less pigmentation in their eyes and are therefore less likely to
need a greater dose.

Question 6

6. A patient has been newly diagnosed with irritable bowel syndrome (IBS). The nurse knows that the
   most likely choice of anticholinergic drug to be prescribed for this patient is what?
   A) Atropine (generic)
   B) Dicyclomine (generic)
   C) Glycopyrrolate (Robinul)
   D) Methscopolamine (Pamine)

Answer 6

Ans: B
Feedback:
Dicyclomine is the most likely choice of anticholinergic drug for IBS. It relaxes the GI tract and is a
frequent choice in the treatment of hyperactive bowel and IBS. Atropine is used to decrease secretions,
for bradycardia, pylorospasm, ureteral colic, relaxing the bladder, pupil dilation, and as an antidote for
cholinergic drugs. Glycopyrrolate is used to decrease secretions and as an antidote for neuromuscular
blockers. Methscopolamine is used as adjunctive therapy for ulcers.

Question 7

7. A patient has come to the clinic for a follow-up visit. He or she has been taking glycopyrrolate
   (Robinul) for adjunctive management of his or her peptic ulcer disease for 1 year. What would the
   nurse question this patient about?
   A) Diarrhea
   B) Oral discomfort
   C) Headaches
   D) Dyspnea

Answer 7

Ans: B
Feedback:
Patients taking anticholinergic drugs will have dry mucous membranes. Oral hygiene will be extremely
important during glycopyrrolate therapy to avoid gum disease. The nurse should encourage the patient
to suck on sugarless lozenges and perform frequent oral care. Diarrhea, headaches, or dyspnea should
not be a concern with this drug.

Question 8

8. A 73-year-old male with Parkinson’s disease comes to the clinic for routine care. The man has a
   comorbidity of benign prostatic hyperplasia (BPH). An anticholinergic drug is prescribed for the
   patient. What is the priority teaching point the nurse must give to the patient in regard to his
   medication?
   A) Avoid excessively hot environments.
   B) Avoid driving his car while taking the drug.
   C) Call his doctor if he cannot urinate.
   D) Take the drug with food to avoid gastrointestinal (GI) upset.

Answer 8

Ans: C
Feedback:
Due to the patient’s diagnosis and drug therapy, calling the doctor if he cannot urinate would be the
most important instruction. Older men with BPH have difficulty urinating and if an anticholinergic
drug is taken, this can lead to urinary retention and bladder sphincter spasm. The patient should be
encouraged to empty his bladder before taking the drug. Because this is an anticholinergic drug,
avoiding hot environmental temperatures (reduced ability to perspire) and driving or operating
machinery (possible central nervous system effects) should also be encouraged as well as taking the
medication with food to help with GI upsets. However, the highest priority is addressing urinary
retention issues

Question 9

9. A patient has been given atropine to cause mydriasis and cycloplegia. What is the expected outcome for
this patient?
A) Constricted pupils and blurred vision
B) Dilated pupils and improved vision
C) Dilated pupils and blurred vision
D) Dry eyes and constricted pupils

Answer 9

Ans: C
Feedback:
Atropine can be used to cause dilated pupils, which is mydriasis resulting in cycloplegia, which is the
inability of the lens of the eye to accommodate leading to blurred vision.

Question 10

10. Because the effects of atropine are dose related, at what dose of atropine would the nurse expect to see
a patient having difficulty speaking?
A) 0.5 mg
B) 1.0 mg
C) 2.0 mg
D) 5.0 mg

Answer 10

Ans: D
Feedback:
Toxicity of atropine is dose related. With 5.0-mg dosage, the nurse would expect marked speech
disturbances, difficulty swallowing, restlessness, fatigue, headache, dry and hot skin, difficulty voiding,
and reduced intestinal peristalsis. With 0.5-mg dosage of atropine, slight cardiac slowing, dryness of
the mouth, and inhibition of sweating would be noticed. Definite dryness of the mouth and throat,
thirst, rapid heart rate, and pupil dilation would be evident with 1.0-mg dosage. With 2.0-mg dosage,
the nurse would note rapid heart rate, palpitations, marked mouth dryness, dilated pupils, and some
blurring of vision.

Question 11

11. A 66-year-old woman presents at the clinic complaining of motion sickness. The physician orders a
    scopolamine patch. Which statement by the patient leads you to believe she knows how to use the
    patch?
    A) I will place it on my chest each morning after I shower.
    B) I will use it only if I feel sick to my stomach.
    C) I will change the patch every 4 hours. I can use the patches for 1 week.
    D) I will change the patch every 3 days.

Answer 11

Ans: D
Feedback:
The scopolamine patch should be applied to a clean, dry, intact, and hairless area of the body. The area
should not be shaved because abrasion of the skin could occur and lead to increased absorption. Patches
should be placed at new sites each time to avoid skin irritation. The old patch should be removed and
the area where it had been should be cleaned.

Question 12

12. A patient is scheduled for surgery in 2 hours. The physician orders preoperative medications
    glycopyrrolate (Robinul) 1 mg and meperidine (Demerol) 50 mg intramuscularly. The nurse would
    hold the medication and consult the provider if the patient had what disorder?
    A) Tachycardia
    B) Paralytic ileus
    C) Hypertension
    D) Diabetes mellitus

Answer 12

Ans: B
Feedback:
These drugs are also contraindicated with any condition that could be exacerbated by blockade of the
parasympathetic nervous system. These conditions include stenosing peptic ulcer, intestinal atony,
paralytic ileus, gastrointestinal (GI) obstruction, severe ulcerative colitis, and toxic megacolon, all of
which could be exacerbated with a further slowing of GI activity. Tachycardia, hypertension, and
diabetes would not be contraindications to administration of glycopyrrolate.

Question 13

13. The nurse is caring for a patient with atropine poisoning. What drug will the nurse administer to reverse
these effects?
A) Bethanechol
B) Neostigmine
C) Edrophonium
D) Physostigmine

Answer 13

Ans: D
Feedback: Physostigmine can be used as an antidote for atropine poisoning. A slow intravenous injection of 0.5 to
4 mg (depending on the weight of the patient and the severity of the symptoms) usually reverses the
delirium and coma of atropine toxicity. Physostigmine is metabolized rapidly, so the injection may
need to be repeated every 1 to 2 hours until the atropine has been cleared from the system.

Question 14

14. Because of the systemic effects of anticholinergic drugs, the nurse understands that older adults using
these drugs are susceptible to what?
A) Heat stroke
B) Diarrhea
C) Urinary frequency
D) Hypotension

Answer 14

Ans: A
Feedback:
Because older patients are more susceptible to heat intolerance owing to decreased body fluid and
decreased sweating, extreme caution should be used when an anticholinergic drug is given that reduces
sweating still further and can result in heat stroke. Older adults are not more susceptible to diarrhea,
urinary frequency, and hypotension.

Question 15

15. A 50-year-old female patient received atropine and meperidine (Demerol) preoperatively. After
    surgery, the patient complains of mouth dryness. What is the nurse’s best response?
    A) Preoperative medications decrease saliva production but it is temporary and will improve.
    B) This is the result of all of the blood and fluid you lost during surgery.
    C) You are probably dehydrated. The IV fluids you are receiving will correct the problem.
    D) The preoperative medication causes an electrolyte imbalance making your mouth feel dry.

Answer 15

Ans: A
Feedback:
Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing,
constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of
vision, and heat intolerance caused by a decrease in sweating.

Question 16

16. Anticholinergics have varied effects on the body. What is one of those effects?
    A) Preventing vagal stimulation
    B) Stimulating the release of acetylcholine
    C) Increasing respiratory tract secretions
    D) Increasing secretion of sweat glands

Answer 16

Ans: A
Feedback:
Adjunctive therapy to treat peptic ulcer, overactive gastrointestinal (GI) disorders; neurogenic bladder
or cystitis; parkinsonism; biliary or renal colic; to decrease secretions pre-operatively; treatment of
partial heart block associated with vagal activity; treatment of rhinitis or anticholinesterase poisoning.

Question 17

17. Anticholinergic drugs are used in ophthalmology because they produce what effect?
A) Sedation
B) Pupil dilation
C) Pupil constriction
D) Decreased lacrimal secretions

Answer 17

Ans: B
Feedback:
Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing,
constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of
vision, and heat intolerance caused by a decrease in sweating.

Question 18

18. A male patient, age 75, is started on flavoxate (Urispas). What adverse effects should the patient be
made aware of?
A) Rash
B) Headache
C) Weight gain
D) Blurred vision

Answer 18

Ans: D
Feedback:
The patient should be warned of possible blurring of vision when taking this drug, which could put the
patient at risk for injury if precautions are not taken. Adverse effects could include central nervous
system adverse effects, such as blurred vision, pupil dilation and resultant photophobia, cycloplegia,
and increased intraocular pressure, all of which are related to the blocking of the parasympathetic
effects in the eye.

Question 19

19. The nurse administers atropine preoperatively for what purpose?
A) Providing sedation
B) Dilating the pupils
C) Relaxing bladder muscles
D) Decreasing secretions

Answer 19

Ans: D
Feedback:
Atropine is administered preoperatively to reduce secretions, but added indications include
gastrointestinal (GI) effects that reduce GI activity. Atropine has no sedating effects, and is not given
preoperatively for its pupil dilation effects, or for its bladder muscle relaxation effects.

Question 20

20. What is the recommended dosage for atropine for a patient with a bradycardia?
A) 0.2 to 0.4 mg
B) 0.3 to 0.5 mg
C) 0.4 to 0.6 mg
D) 0.5 to 0.7 mg

Answer 20

Ans: C
Feedback:
The usual dosage for atropine is 0.4 to 0.6 mg intramuscularly, subcutaneously, or IV; use caution with
older patients. The other options are incorrect dosages and therefore wrong

Question 21

21. When the nurse administers an anticholinergic drug to a child, the nurse would carefully assess for
    what effect that is more likely to occur in children than in adults?
    A) Rashes
    B) Pupil dilation
    C) Heat intolerance
    D) Tachycardia

Answer 21

Ans: C
Feedback:
Children are often more sensitive to the adverse effects of the drugs, including constipation, urinary
retention, heat intolerance, and confusion. Similar effects are seen in children related to pupil dilation.
Tachycardia and rashes would not be associated with these drugs in children.

Question 22

22. The nurse is writing a plan of care for an older adult patient taking flavoxate. What is an appropriate
    goal for this patient’s plan of care?
    A) The patient will have adequate pupil dilation within 24 hours.
    B) The patient will experience fewer bronchospasms within 8 hours.
    C) The patient will experience fewer symptoms of prostatitis within 24 hours.
    D) The patient will show resolution of peptic ulcer within 2 weeks

Answer 22

Ans: C
Feedback:
Flavoxate is used to relieve symptoms of dysuria, urgency, nocturia, suprapubic pain, frequency, and
incontinence associated with cystitis, prostatitis, urethritis, urethrocystitis, and urethrotrigonitis. As a
result, the nurse would know the drug was working when the patient experienced fewer symptoms
related to any one of these conditions. Because the drug is not indicated for pupil dilation,
bronchospasm, or treatment of a peptic ulcer, the nurse’s outcomes would not be related to these
conditions.

Question 23

23. What drug would the nurse administer to treat a patient diagnosed with bronchospasm associated with
    chronic obstructive pulmonary disease (COPD)?
    A) Atropine
    B) Flavoxate
    C) Glycopyrrolate
    D) Ipratropium

Answer 23

Ans: D
Feedback:
Ipratropium is indicated for the treatment of bronchospasm associated with COPD. Atropine is
indicated for use to decrease secretions, bradycardia, pylorospasm, ureteral colic, relaxing of bladder,
emotional liability with head injuries, antidote for cholinergic drugs, and pupil dilation. Flavoxate is
used for the symptomatic relief of dysuria, urgency, nocturia, suprapubic pain, frequency, and
incontinence associated with cystitis, prostatitis, urethritis, urethrocystitis, and urethrotrigonitis.
Glycopyrrolate is indicated to decrease secretions before anesthesia or intubation, used orally as an
adjunct for treatment of ulcers, to protect the patient from the peripheral effects of cholinergic drugs
and to reverse neuromuscular blockade

Question 24

24. A 72-year-old female patient is being discharged home from the hospital on newly prescribed
    anticholinergic drugs. A referral to the home health nurse has been made. What priority teaching point
    will the home health nurse emphasize when discussing the patient’s drugs?
    A) Do not drive or use machinery.
    B) Take lots of hot baths or showers.
    C) Keep the house warm to avoid a chill.
    D) Limit intake of fluids.

Answer 24

Ans: A
Feedback:
Safety precautions may be needed if blurred vision and dizziness occur. The patient should be urged
not to drive or perform tasks that require concentration and coordination. The home care nurse would
not teach the patient to take hot baths or showers. The patient would be cautioned about inability to
perspire in hot environments and to avoid them. Fluid intake should not be limited

Question 25

25. The nurse is caring for a new mother who received atropine before undergoing a laparoscopic tubal
    ligation. The patient tells the nurse that she is breast-feeding her baby and asks whether she can breastfeed
    when she gets home. What is the nurse’s best response?
    A) You can breast-feed when you get home because the drugs given before surgery will be out of your
    system.
    B) You can breast-feed as soon as you get home because atropine will not cross into the breast milk.
    C) Discard all breast milk for the next week and feed the baby formula before returning to breastfeeding.
    D) Discard all breast milk for the next 24 hours and feed formula until tomorrow when you can nurse
    your baby.

Answer 25

Ans: D
Feedback:
Lactating mothers should not breast-feed after receiving atropine until the drug has been fully excreted.
Because atropine crosses into breast milk and the duration of action is 4 hours, it is safest to have the
mother wait 24 hours to breast-feed, continuing to pump and discard the milk while feeding the infant
formula. After 24 hours, she can return to breast-feeding because any atropine in breast milk will be
eliminated. There is no need to wait a week and although the drug may be out of the bloodstream, the
milk in her breast will still contain atropine.

Question 26

26. The patient, who takes an anticholinergic medication, tells the nurse how much he or she enjoys
experimenting with different herbal teas. What herbs will the nurse caution the patient to avoid? (Select
all that apply.)
A) Burdock
B) Thyme
C) Rosemary
D) Parsley
E) Tumeric

Answer 26

Ans: A, C, E
Feedback:
The risk of anticholinergic effects can be exacerbated if anticholinergic agents are combined with
burdock, rosemary, or turmeric and used as herbal therapy. Advise patients who use herbal therapies to
avoid these combinations. Nothing indicates that thyme or parsley is contraindicated with
anticholinergic medications.

Question 27

27. A 27-year-old male patient is taking an anticholinergic drug as adjunctive therapy to treat his peptic
    ulcer disease. The patient comes to the clinic and tells the nurse that he feels his heart beating. What
    adverse effect is the patient experiencing from the anticholinergic medication?
    A) Tachypnea
    B) Tachycardia
    C) Hypotension
    D) Urinary frequency

Answer 27

Ans: B
Feedback:
Tachycardia and palpitations are possible adverse effects related to blocking of the parasympathetic
effects on the heart; this would give the sensation of a heart beating. Tachypnea, hypotension, and
urinary frequency are not generally adverse effects of anticholinergic medications and they would not
be evident the way the patient described

Question 28

28. The 10-year-old child is brought to the respiratory clinic and is prescribed ipratropium (Atrovent). Prior
    to administering the medication, what would the nurse assess for?
    A) Cardiac disorders
    B) Hypertension
    C) Recent injuries
    D) Breath sounds

Answer 28

Ans: D
Feedback:
The nurse would assess breath sounds because ipratropium is indicated for treatment of bronchospasm
so it is important to get a baseline assessment to determine whether the drug improves the patient’s
condition after administration. Cardiac disorders, hypertension, and recent injuries are all valid
assessments but are likely to have been assessed during admission history taking and are not related to
the purpose of administering the drug.

Question 29

29. The nurse is caring for a patient who has just been started on hyoscyamine (Symax and others) as
    adjunctive therapy for his or her peptic ulcers. When developing this patient’s plan of care, what
    nursing diagnosis would the nurse establish related to the purpose of administering this drug?
    A) Chronic pain related to peptic ulcer disease
    B) Impaired urinary elimination related to bladder relaxation
    C) Risk for hyperthermia related to decreased ability to perspire
    D) Decreased cardiac output related to cardiovascular effects

Answer 29

Ans: A
Feedback:
All these nursing diagnoses could be used for the patient receiving an anticholinergic drug, but only
chronic pain is related to the drug this patient is receiving and the purpose for which it is being
administered.

Question 30

30. What does parasympathetic nervous system blockade cause? (Select all that apply.)
    A) Decrease in heart rate
    B) Decrease in urinary bladder tone
    C) Increase in heart rate
    D) Pupil constriction
    E) Decrease in gastrointestinal (GI) activity

Answer 30

Ans: B, C, E
Feedback:
Parasympathetic nervous system blockade causes an increase in heart rate, decrease in GI activity,
decrease in urinary bladder tone and function, and pupil dilation and cycloplegia.

Question 31

31. The patient was involved in a motor vehicle accident and experienced a severe closed head injury
    resulting in increased intracranial pressure. While intubating the patient, his or her heart rate dropped
    and did not return to acceptable levels after the tube was in place so the nurse received an order to
    administer atropine. The physician is performing an exam to determine whether brain death has
    occurred. What assessment for brain death will be postponed until all atropine is excreted and no longer
    exerting an effect.
    A) Pupil response
    B) Electroencephalogram
    C) Brainstem reflexes
    D) Computed tomographic scan of the brain

Answer 31

Ans: A
Feedback:
One test for neurological function is to shine a light in the patient’s eyes to test pupil reaction to light.
Because this patient has received atropine, pupils will be dilated and will not react normally to light.
This could be mistaken as an indication of brain death if the nurse did not know atropine had been
administered. This test will be postponed until the pupils are no longer dilated by the medication. The
other tests would not have to be postponed because of atropine.

Question 32

32. The nurse is caring for a patient who is unconscious and requires an anticholinergic drug to treat
    bradycardia. What drug can the nurse administer IV for this purpose?
    A) Ipratropium (Atrovent)
    B) Dicyclomine (generic)
    C) Methscopolamine (Pamine)
    D) Atropine (generic)

Answer 32

Ans: D
Feedback:
Atropine can be given intramuscularly (IM), subcutaneously, or IV for the treatment of bradycardia.
Ipratropium is administered by inhalation to treat bronchospasm. Dicyclomine is used to treat irritable
or hyperactive bowel and can be given orally or IM. Methscopolamine is administered orally to treat
peptic ulcers.

Question 33

33. What is the proper dosage of scopolamine administered by the nurse transdermally to reduce nausea
    and vomiting associated with motion sickness?
    A) 0.32 to 0.65 mg
    B) 1.5 mg
    C) 3 mg
    D) 3.5 mg

Answer 33

Ans: B
Feedback: The scopolamine transdermal patch is 1.5 mg. If administered subcutaneously (SC) or intamuscularly
(IM), the dosage would be 0.32 to 0.65 mg. Pediatric dosage is 0.006 mg/kg subcutaneous, IM, or IV.

Question 34

34. The nurse receives an order to administer glycopyrrolate 0.002 mg/kg to the pediatric patient
    preoperatively. The patient weighs 14 lbs. If 1 pound = 2.2 kg, how many kilograms would the nurse
    administer to this patient?
    A) 0.013 mg
    B) 0.13 mg
    C) 0.028 mg
    D) 0.28 mg

Answer 34

Ans: A
Feedback:
Begin by calculating the child’s weight in kilogram 14 lbs/2.2 kg = 6.36 kg. Multiply child’s weight in
kg by dosage in kg 6.36 × 0.002 = 0.01272 rounded to 0.013 mg.

Question 35

35. A mother calls the pediatric clinic and tells the nurse the family is planning a cross-country trip to visit
    some attractions the children will enjoy. Her 2-year-old child gets motion sickness soon after starting
    the car and she would like some scopolamine patches to use. What is the nurse’s best response?
    A) One patch lasts for 3 days. How long will you be driving?
    B) Children cannot receive scopolamine orally or by patch.
    C) It might be better to use the oral form of the drug only on days it is needed.
    D) Scopolamine loses effectiveness if it is used for several days.

Answer 35

Ans: B
Feedback:
Scopolamine does not come in a pediatric oral or patch formulation. Scopolamine can only be given
subcutaneously, or IV. Because children cannot use the patch, asking how many days they will be
traveling or suggesting oral prescription when that form is not available is incorrect. Scopolamine does
not lose effectiveness.