A psychiatric nurse is teaching a patient about an antidepressant medication. The nurse tells the patient that therapeutic effects may not occur for
... [Show More] several weeks. The nurse understands that this is likely the result of: a. changes in the brain as a result of prolonged drug exposure. b. direct actions of the drug on specific synaptic functions in the brain. c. slowed drug absorption across the blood-brain barrier. d. tolerance to exposure to the drug over time. ANS: A It is thought that beneficial responses to central nervous system (CNS) drugs are delayed because they result from adaptive changes as the CNS modifies itself in response to prolonged drug exposure, and that the responses are not the result of the direct effects of the drugs on synaptic functions. The blood-brain barrier prevents protein-bound and highly ionized drugs from crossing into the CNS, but it does not slow the effects of drugs that can cross the barrier. Tolerance is a decreased response to a drug after prolonged use.DIF: Cognitive Level: ApplicationREF: pp. 140TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 50. A 25-year-old patient has been newly diagnosed with Parkinson disease, and the prescriber is considering using pramipexole [Mirapex]. Before beginning therapy with this drug, the nurse will ask the patient about: a. any history of alcohol abuse or compulsive behaviors. b. any previous history of hypertension. c. difficulty falling asleep or staying asleep. d. whether any family members have experienced psychoses. ANS: A Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.DIF: Cognitive Level: ApplicationREF: p. 153TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential 98. A patient with Parkinson disease is taking levodopa/carbidopa [Sinemet] and reports occasional periods of loss of drug effect lasting from minutes to several hours. The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss: a. administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone. b. adding the DA-releasing agent amantadine to the regimen. c. giving a direct-acting dopamine agonist. d. shortening the dosing interval of levodopa/carbidopa. contact: [email protected] Final Exam Question, Answers and Rationale NR 566 2 ANS: A This patient is describing abrupt loss of effect, or the “off” phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.DIF: Cognitive Level: ApplicationREF: p. 154TOP: Nursing Process: Assessment MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 50. A nurse is discussing motor symptoms with a patient with Parkinson disease who has been taking levodopa/carbidopa [Sinemet] for 9 months and who is now having regular tics. Which statement by the patient indicates understanding of this symptom? a. “I may need to try a lower dose of Sinemet to reduce my tics.” b. “My provider may order clozapine to treat these tics.” c. “These tics are an indication that my dose of Sinemet is too low.” d. “This means I will have to have surgery to stop the symptoms.” ANS: A Levodopa can cause movement disorders, generally within the first year of therapy. If they occur, a lower dose of levodopa may be required to alleviate them. Clozapine is an antipsychotic used to treat levodopa-induced psychoses. Movement disorders generally occur as the dose of levodopa increases. Surgery is a last option for treating movement disorders, after amantadine fails.DIF: 51. A patient has been diagnosed with Parkinson disease (PD) and begins treatment with levodopa/carbidopa [Sinemet]. After several months of therapy, the patient reports no change in symptoms. The nurse will expect the provider to: a. add a dopamine agonist. b. discuss the “on-off” phenomenon. c. increase the dose of Sinemet. d. reevaluate the diagnosis. ANS: D Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The “on-off” phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.DIF: Cognitive Level: ApplicationREF: p. 146TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies Final Exam Question, Answers and Rationale NR 566 3 52. A patient has taken levodopa [Dopar] for Parkinson disease for 2 weeks but reports no improvement in the symptoms. Which response by the nurse is correct? a. “Another agent will be needed to manage your symptoms.” b. “Double the dose to see whether an effect occurs.” c. “It may take several months for a response to occur.” d. “The prescriber may need to change your drug regimen.” ANS: C A full therapeutic response with levodopa may take several months to develop. Until the true effect of the dose is seen, it is not necessary to change to another drug, increase the dose, or change the drug regimen.DIF: Cognitive Level: ApplicationREF: p. 148TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 53. A patient with Parkinson disease is taking levodopa/carbidopa [Sinemet]. The prescriber orders bromocriptine [Parlodel] to treat dyskinesias. The nurse notes that the patient is agitated, and the patient reports having frequent nightmares. The nurse will contact the provider to discuss: a. adding an antipsychotic medication. b. changing from bromocriptine to cabergoline [Dostinex]. c. reducing the dose of bromocriptine. d. reducing the dose of levodopa/carbidopa. ANS: C Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychologic side effects. The nurse should suggest reducing the dose of this drug to minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.DIF: Cognitive Level: ApplicationREF: 105.Anurse is teaching a group of nurses about Parkinson medications. The nurse is correct to state that one side effect associated with pramipexole [Mirapex] that is less likely to occur with other dopamine agonists is: a. sleep attacks. b. dizziness. c. hallucinations. d. dyskinesias. ANS: A A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias Final Exam Question, Answers and Rationale NR 566 4 are listed as side effects of pramipexole and other dopamine agonists.DIF: Cognitive Level: ApplicationREF: p.153TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 107.Apatient will begin taking a cholinesterase inhibitor for early Alzheimer disease. The nurse is teaching the patient’s spouse about the medication. Which statement by the spouse indicates a need for further teaching? a. “Gastrointestinal symptoms are common with this medication.” b. “People taking this drug should not take antihistamines.” c. “This drug helps neurons that are not already damaged to function better.” d. “This drug significantly slows the progression of the disease.” ANS: D Cholinesterase inhibitors produce modest improvements in cognition, behavior, and function and may slightly delay disease progression; they do not have a major impact on delaying progression of the disease. Gastrointestinal symptoms are common side effects. Drugs that block cholinergic receptors, including antihistamines, can reduce therapeutic effects and should be avoided. Cholinesterase inhibitors do not affect neurons already damaged, but they do improve function in those not yet affected.DIF: Cognitive Level: ApplicationREF: pp. 164TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 108. The spouse of a patient who is newly diagnosed with Alzheimer disease asks the nurse if medications will prevent the need for nursing home care. Which response by the nurse is correct? a. “Drugs to treat Alzheimer disease may slow the progression of memory loss.” b. “Drugs may be effective to stop the progression of the disease if they are initiated early in the disease.” c. “Medications to treat Alzheimer disease are effective for treating core symptoms of the disease.” d. “Medications for Alzheimer disease are effective in reducing cognitive impairment.” ANS: A Alzheimer disease is a disease in which symptoms progress relentlessly from mild to moderate to severe. Medications have not been clearly effective and do not stop the disease progression, although they may slow loss of memoryand cognition and prolong independent function. There is no indication that available drugs stop disease progression if begun early in the course of the Final Exam Question, Answers and Rationale NR 566 5 disease. There is no clearly effective therapy for core symptoms, but associated symptoms such as incontinence and depression may be treated.DIF: Cognitive Level: ApplicationREF: pp. 162TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Physiologic Adaptation 108. A nurse is caring for an older adult patient who has Alzheimer disease. The patient is taking a cholinesterase inhibitor drug. Which side effects would concern the nurse? a. Confusion and memory impairment b. Dizziness and headache c. Nausea, vomiting, and diarrhea d. Slowed heart rate and lightheadedness ANS: D Cardiovascular effects of cholinesterase inhibitor drugs are uncommon but cause the most concern. Bradycardia and fainting can occur when cholinergic receptors in the heart are activated. Confusion and memory impairment are signs of the disease and are not side effects of the drug. Dizziness, headache, nausea, vomiting, and diarrhea are all expected adverse effects, and although uncomfortable, they do not present an increased risk to the patient.DIF: Cognitive Level: ApplicationREF: pp. 164TOP: Nursing Process: Evaluation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential 108. A nurse is preparing to administer memantine [Nemanda] to a patient and notes a slight elevation in the patient’s creatinine clearance level. What will the nurse expect the provider to order for this patient? a. Adding sodium bicarbonate to the patient’s drug regimen b. Continuing the memantine as ordered c. Discontinuing the memantine d. Reducing the dose of memantine ANS: D Patients with severe renal impairment may require a dosage reduction. Adding sodium bicarbonate would alkalinize the urine and increase memantine levels, causing toxicity. It is not necessary to discontinue or decrease the dose of the memantine with mild or moderate renal impairment.DIF: Cognitive Level: ApplicationREF: pp. 167TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Reduction of Risk Potential 108. The spouse of a patient with Alzheimer disease asks a nurse for more information about the rivastigmine [Exelon] transdermal patch that is being used. Which statement by the spouse indicates a need for further explanation? Final Exam Question, Answers and Rationale NR 566 6 a. “Doses are lower but more steady with the transdermal patch.” b. “Reduced side effects occur with the transdermal patch.” c. “We only need to change the patch every 2 weeks.” d. “We should remove the old patch before applying the new one.” ANS: C The rivastigmine transdermal patch needs to be changed daily. Sites used should not be reused for 14 days. Transdermal dosing provides lower, steady levels of the drug. Intensity of side effects is lower with the transdermal patch. The old patch must be removed prior to applying the newpatch to prevent toxicity.DIF: Cognitive Level: ApplicationREF: pp. 164TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 108. A nurse is teaching a group of nursing students about the use of memantine [Namenda] for Alzheimer disease. Which statement by a student indicates understanding of the teaching? a. “Memantine is indicated for patients with mild to moderate Alzheimer disease.” b. “Memantine modulates the effects of glutamate to alter calcium influx into neurons.” c. “Memantine prevents calcium from leaving neurons, which improves their function.” d. “Memantine and donepezil combined may stop progression of Alzheimer disease.” ANS: B Memantine modulates the effects of glutamate, which is involved in calcium influx into neuronal cells. Memantine is used for patients with moderate to severe AD. Memantine does not prevent calcium from leaving cells; it only affects the influx of calcium. In studies, although the effects of memantine and donepezil appear to be synergistic or may confer independent benefits, they only demonstrate improvement in cognitive function and not a stop in disease progression.DIF: Cognitive Level: AnalysisREF: pp. 165TOP: Nursing Process: Implementation MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies 108. An older adult patient has confusion, memory loss, and disorientation in familiar surroundings. The patient has been taking donepezil [Aricept] 10 mg once daily for 6 months. The patient’s symptoms have begun to worsen, and the patient’s spouse asks if the medication dose can be increased. What will the nurse tell the spouse? a. The dose can be increased, because the patient has been taking the drug for longer than 3 months. Final Exam Question, Answers and Rationale NR 566 7 b. The dose can be increased to twice daily dosing instead of once daily dosing. c. The increase in symptoms is the result of hepatotoxicity from the medication’s side effects. d. The patient must take the drug for longer than 1 year before the dose can be increased. ANS: A Donepezil is given for mild, moderate, and severe AD, and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.DIF: Cognitive Level: ApplicationREF: pp. 164TOP: Nursing Process: Planning MSC: NCLEX Client Needs Category: Physiologic Integrity: Pharmacologic and Parenteral Therapies [Show Less]