Pharmacology, 2Nd Semester, Unit 3

Front 1

A nurse teaches a health education class to male adolescents. Which of these topics should be a priority for the nurse to include?
+ Adoption of healthy lifetime hygienic practices
+ Effects of performance-enhancing androgens
+ Pituitary gland regulation of sexual development
+ Self-esteem issues related to delayed onset of puberty

Back 1

Effects of performance-enhancing androgens

Front 2

Which application instruction is the priority for a nurse to provide to a patient starting to use AndroGel testosterone gel?
+ “Apply the gel to clean, dry skin of the shoulders or upper arms.”
+ “Squeeze the entire packet into your palms and then rub the gel into your skin.”
+ “Wait about 5 or 6 hours before showering or swimming.”
+ “Wash your hands after applying the gel to prevent transfer to others.”

Back 2

“Wash your hands after applying the gel to prevent transfer to others.”

Front 3

Which measurements should a nurse obtain to evaluate the effects of androgen therapy on the epiphyses of a patient with hypogonadism?
+ Monthly height and weight
+ Periodic hand and wrist x-rays
+ Body mass/fat ratio indices
+ Blood testosterone levels

Back 3

Periodic hand and wrist x-rays

Front 4

A nurse monitors for which adverse cardiovascular effects in a male patient taking testosterone (Androderm)? (Select all that apply.)
A. Postural hypotension
B. Atrial fibrillation
C. Pedal edema and weight gain
D. Prolonged QT interval
E. Decrease in high-density lipoprotein (HDL) levels

Back 4

C.
E.

Front 5

A nurse identifies therapeutic goals for androgen therapy for which patients? (Select all that apply.)
A. A male patient with prostate cancer
B. A female patient with breast cancer
C. A male patient with hypogonadism
D. A female patient with breast engorgement
E. A female patient with acquired immunodeficiency syndrome (AIDS)

Back 5

C.
D.
E.

Front 6

The principal disadvantage of the testosterone gel is that it can be transferred to others by _____________.

Back 6

skin-to-skin contact

Front 7

Androgens can lower plasma levels of __________ and elevate levels of _______________. This may increase the risk for ___________.

Back 7

HDL cholesterol (“good cholesterol”)
low-density lipoproteins (LDLs, “bad cholesterol”)
atherosclerosis

Front 8

Androgen hormones are produced by the ______________. The major endogenous androgen is _____________.

Back 8

testes, ovaries, and adrenal cortex
testosterone

Front 9

In males, testosterone is made by Leydig cells of the testes. Synthesis is promoted by which hormones?

Back 9

follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

Front 10

In women, preandrogens are secreted by the ______. Conversion into testosterone takes place in _________ tissues. Synthesis of preandrogens by the adrenals is regulated by ________, whereas synthesis of preandrogens by the ovaries is regulated by _______.

Back 10

adrenal cortex and ovaries
peripheral
adrenocorticotropic hormone (ACTH); LH

Front 11

Increased production of testosterone promotes the transformations that signal ______ in males. Androgens are necessary for the production of sperm by the ________ and for maturation of sperm as they pass through the ________ and ________. Androgen deficiency causes ________.

Back 11

puberty
seminiferous tubules
epididymis; vas deferens
sterility

Front 12

Under physiologic conditions, endogenous androgens have __________ effects in females.

Back 12

only moderate

Front 13

___________ promotes the growth of skeletal muscle, an anabolic effect.

Back 13

Testosterone

Front 14

Testosterone promotes the synthesis of ____________ (this explains why men have a higher hematocrit than women).

Back 14

erythropoietin

Front 15

The androgens used clinically can be divided into two basic groups:

Back 15

(1) testosterone and testosterone esters, and
(2) 17-alpha-alkylated compounds

Front 16

The receptor type that mediates the androgenic actions of the androgens is the same receptor type that mediates the _________ actions of these hormones. Therefore, virtually all _________ hormones are also androgenic.

Back 16

anabolic
anabolic

Front 17

What is the principal indication for androgens in males?

Back 17

Hypogonadism

Front 18

When complete hypogonadism occurs in boys, puberty cannot take place unless exogenous _________ are supplied. To induce puberty, a long-acting __________ preparation is chosen, and treatment continues _________ years.

Back 18

androgens
parenteral
3 to 4

Front 19

Androgen replacement therapy is beneficial when ______ failure occurs in adult males. Treatment restores ______, increases _______ volume, and supports expression of ______ sex characteristics.

Back 19

testicular
libido
ejaculate
secondary

Front 20

In some boys, puberty fails to occur at the usual age. Most often, this failure reflects a ______ pattern of delayed puberty and does not indicate a _______ condition.

Back 20

familial
pathologic

Front 21

Testosterone replacement therapy can alleviate some menopausal symptoms, especially....

Back 21

fatigue, reduced libido, and reduced genital sensitivity.

Front 22

________ is the most common complication of androgen therapy. To prevent irreversible ________, androgens must be discontinued when ________ effects first appear.

Back 22

Virilization
masculinization
virilizing

Front 23

When given to children, androgens can accelerate _________, thereby decreasing adult height.

Back 23

epiphyseal closure

Front 24

Androgens can cause ___________ and other disorders of the liver. Androgens may also be carcinogenic: __________ has developed in some patients after prolonged use of these drugs.

Back 24

cholestatic hepatitis
Hepatocellular carcinoma

Front 25

It must be emphasized that not all androgens are hepatotoxic: Liver damage is associated primarily with the ________ androgens.

Back 25

17-alpha-alkylated

Front 26

Androgens can lower plasma levels of _____ cholesterol and elevate plasma levels of ____ cholesterol.

Back 26

high-density lipoprotein (HDL)
low-density lipoprotein (LDL)

Front 27

Because of their ability to induce __________, androgens are contraindicated during pregnancy. Androgens are classified by the U.S. Food and Drug Administration (FDA) as Pregnancy Risk Category ____: the ability to cause fetal harm outweighs any possible therapeutic benefit.

Back 27

masculinization of the female fetus
X

Front 28

Androgens do not cause prostate cancer, but....

Back 28

they can promote the growth of this cancer once it occurs.

Front 29

_______ can result from androgen-induced retention of salt and water.

Back 29

Edema

Front 30

______________ may occur in males receiving androgen replacement therapy.

Back 30

Breast enlargement

Front 31

Androgens frequently are misused to______________. Because of their abuse potential, nearly all androgens are regulated as Schedule III ______________.

Back 31

enhance athletic performance
controlled substances

Front 32

Drugs commonly used by athletes include ________, _________, and __________. All of these drugs are regulated as controlled substances, making their use by athletes ________.

Back 32

nandrolone, stanozolol, and methenolone
illegal

Front 33

Long-term androgen use can lead to an “_______” or “____________” syndrome.

Back 33

abuse
addiction

Front 34

A patient is scheduled to start taking sildenafil (Viagra). A nurse should recognize that the patient is at risk for developing an adverse cardiac event if the patient’s history reveals which of these conditions?
+Angina
+ Hypertension
+ Varicose veins
+ Prosthetic mitral valve

Back 34

Angina

Front 35

A patient in the emergency department reports taking sildenafil (Viagra) and nitroglycerin 1 hour before sexual activity. Which finding should the nurse immediately report to the physician?
+ White blood cell (WBC) count of 3200 units/L
+ Respiratory rate of 26 breaths per minute
+ Body temperature of 100.4°F (38°C)
+ Blood pressure (BP) of 70/50 mm Hg

Back 35

Blood pressure (BP) of 70/50 mm Hg

Front 36

Which statement should a nurse include when providing teaching to a patient who is scheduled to start taking dutasteride (Avodart)?
+ “Protect yourself from sun exposure to avoid any skin sensitivity.”
+ “You may notice immediate relief of your urinary symptoms.”
+ “Dutasteride will increase both ejaculatory volume and libido over time.”
+ “You cannot donate blood while on this medication or for 6 months after stopping it.”

Back 36

“You cannot donate blood while on this medication or for 6 months after stopping it.”

Front 37

When assessing a patient who takes finasteride (Proscar), a nurse should monitor for which adverse effect?
+ Hair loss
+ Increased libido
+ Ejaculatory dysfunction
+ Muscle weakness

Back 37

Ejaculatory dysfunction

Front 38

A patient taking sildenafil (Viagra) asks a nurse what action to take if priapism occurs. Which response should the nurse make?
“Take an additional half-strength dose of sildenafil.”
“The condition usually resolves in 12 hours or less.”
“Wait until the following day and notify the doctor.”
“Seek emergency help, because permanent damage can occur.”

Back 38

“Seek emergency help, because permanent damage can occur.”

Front 39

Which assessment should a nurse monitor more frequently in a patient who takes both an alpha blocker for BPH and metoprolol (Lopressor)?
+ Blood glucose level
+ Hemoglobin level
+ Blood pressure
+ Urine output

Back 39

Blood pressure

Front 40

A nurse is educating a patient about sildenafil (Viagra). The nurse should instruct the patient that which adverse effect would be a priority for the patient to report to his prescriber?
+ Flushing
+ Diarrhea
+ Hearing loss
+ Dyspepsia

Back 40

Hearing loss

Front 41

A nurse should recognize that which therapies would be beneficial to a patient with BPH? (Select all that apply.)
+Saw palmetto
+Botulinum (Botox)
+Tolterodine (Detrol)
+Alfuzosin (Uroxatral)
+Sildenafil (Viagra)

Back 41

Botulinum (Botox)
Tolterodine (Detrol)
Alfuzosin (Uroxatral)

Front 42

Caution must be exercised in combining an alpha blocker (terazosin [Hytrin], doxazosin [Cardura], Tamsulosin [Flomax], alfuzosin [Uroxatral]) with an antihypertensive medication such as metoprolol, because ______________ could result.

Back 42

severe hypotension

Front 43

Sildenafil is used in the treatment of erectile dysfunction. It should be used with caution by men with _________________.

Back 43

coronary heart disease (CHD)

Front 44

When taken in conjunction with nitroglycerin, sildenafil can cause severe ______________ that is unresponsive to treatment. At least ____________ should elapse between the last dose of sildenafil and a nitrate.

Back 44

hypotension
24 hours

Front 45

Dutasteride is harmful to a developing _____________. To avoid transmission to women by way of infusion, men should avoid _______________ while using it and for ___________ after stopping it.

Back 45

male fetus
donating blood
6 months

Front 46

Common adverse effects of finasteride include __________, decreased _________, and decreased volume of ejaculate. The drug also is used to treat __________________.

Back 46

impotence
libido
male pattern baldness

Front 47

Sildenafil is a ____________ that can cause priapism. Patients are advised to seek medical attention for ___________ that lasts longer than 4 hours, because left untreated, priapism can damage ____________, causing permanent loss of _________.

Back 47

phosphodiesterase type 5 (PDE5) inhibitor
an erection
penile tissue
potency

Front 48

In rare cases, sildenafil has caused sudden _____________.

Back 48

hearing loss

Front 49

Erectile dysfunction (ED), also known as ________, is defined as....

Back 49

impotence
a persistent inability to achieve or sustain an erection suitable for satisfactory sexual performance.

Front 50

ED is commonly associated with chronic illnesses, especially _______, ________, and ____________.

Back 50

diabetes
hypertension
depression

Front 51

The cause of ED may be the illness itself or....

Back 51

the drugs used for treatment

Front 52

The risk of ED _______ with advancing age.

Back 52

increases

Front 53

First-line treatments for ED are ______________, changing ______________ that may cause ED, and drug therapy with ___________ or another drug in its class. Other interventions include psychotherapy and surgical implantation of a _________________.

Back 53

lifestyle measures
drug regimens
sildenafil
penile prosthesis

Front 54

The process of erection begins with sexual arousal, which increases __________ to the penis. After a series of steps, relaxation of trabecular smooth muscle—promoted by _____________—causes expansion and engorgement of sinusoidal spaces in the ______________ and sufficient engorgement to produce __________.

Back 54

parasympathetic nerve traffic
cyclic guanosine monophosphate (cGMP)
corpus cavernosum
an erection

Front 55

Drugs for ED are divided into two major groups: ___________ and _______________. The ______________—phosphodiesterase type 5 (PDE5) inhibitors—are by far the most common treatments for ED.

Back 55

oral agents
nonoral agents
oral agents

Front 56

Three PDE5 inhibitors are available—__________, ___________, & _____________. All three are considered first-line therapy for ED.

Back 56

sildenafil, tadalafil, and vardenafil

Front 57

Current guidelines recommend that, in the absence of a specific contraindication, all men with ED be offered one of these drugs:

Back 57

PDE5 inhibitor

Front 58

Benefits of ___________ derive from enhancement of the natural response to sexual stimuli; __________ does not cause erection directly.

Back 58

sildenafil

Front 59

Although sildenafil is generally well tolerated, it can be dangerous for men taking certain vasodilators, specifically _______________, and nitroglycerin and other nitrates used for ____________.

Back 59

alpha-adrenergic blockers
angina pectoris

Front 60

Sildenafil causes selective inhibition of PDE5. By doing so, it increases and preserves ______ levels in the penis, thereby making the erection ___________. The drug only __________ the normal erectile response to sexual stimuli; in the absence of sexual stimuli, _____________.

Back 60

cGMP
harder and longer lasting
enhances
nothing happens

Front 61

Sildenafil helps a wide range of patients, including those with ED resulting from _______, spinal cord injury, and transurethral ___________, as well as ED of no known physical cause.

Back 61

diabetes
prostate resection

Front 62

Sildenafil has little or no effect on the quality or duration of an erection in men who _____________.

Back 62

do not have ED

Front 63

In men taking nitrates or alpha blockers, severe _______________ can develop (when taken in conjunction with silendafil).

Back 63

hypotension

Front 64

With silendafil, a few cases of priapism have been reported. Left untreated, priapism can damage penile tissue, thereby causing permanent ______________.

Back 64

loss of potency

Front 65

In rare cases, men taking sildenafil have developed nonarteritic ischemic optic neuropathy (NAION), resulting in irreversible _______________. The cause is blockage of blood flow to _______________.

Back 65

blurring or loss of vision
the optic nerve

Front 66

Also in rare cases, men taking sildenafil have experienced ________________, usually in one ear, sometimes in association with ____________, vertigo, and ______________. _______________ may be partial or complete.

Back 66

sudden hearing loss
dizziness
tinnitus
Hearing loss

Front 67

The most common adverse effects are __________, ____________, and _________. Sildenafil also may cause nasal congestion, diarrhea, rash, and dizziness. Patients may experience mild transient visual disturbances. In addition, sildenafil may intensify symptoms of obstructive ____________.

Back 67

headache, flushing, and dyspepsia
sleep apnea

Front 68

Sildenafil is absolutely contraindicated for men taking ____________ because of the risk of life-threatening hypotension.

Back 68

nitrates

Front 69

To reduce the risk of adverse events, candidates for sildenafil therapy should undergo a careful evaluation of _________ function.

Back 69

cardiovascular

Front 70

BPH is a ___________ condition that develops in more than 50% of men by age 60 and in 90% by age 85.
The prostate is a heart-shaped gland that surrounds the __________. Its major function is to ________________.

Back 70

common
urethra
produce fluids that contribute to ejaculate volume

Front 71

BPH is a nonmalignant prostate enlargement caused by _________________. Overgrowth of epithelial cells causes __________ obstruction of the urethra, whereas overgrowth of smooth muscle causes ____________ obstruction of the urethra.

Back 71

excessive growth of epithelial and smooth muscle cells
mechanical
dynamic

Front 72

Signs and symptoms of BPH include: (9)

Back 72

urinary hesitancy, urinary urgency, increased frequency of urination, dysuria, nocturia, straining to void, postvoid dribbling, reduced force and caliber of the urinary stream, and a sensation of incomplete bladder emptying

Front 73

BPH can be managed in three ways:

Back 73

invasive treatments, drug therapy, and “watchful waiting"

Front 74

BPH can be treated with two major classes of drugs:

Back 74

5-alpha-reductase inhibitors and alpha1-adrenergic antagonists

Front 75

____________ acts in reproductive tissue to inhibit 5-alpha-reductase, an enzyme that converts testosterone to dihydrotestosterone (DHT). By reducing the availability of DHT, finasteride promotes regression of ____________ tissue, thereby reducing mechanical obstruction of the urethra.

Back 75

Finasteride
prostate epithelial

Front 76

With finasteride, prostate shrinkage occurs....

Back 76

slowly, over 6 to 12 months

Front 77

Finasteride is generally well tolerated. However, in 5% to 10% of patients, it reduces _______________. In addition, _____________ develops in some men. Finasteride reduces serum levels of prostate-specific antigen (PSA) from 30% to 50%. PSA levels should be determined before treatment and 6 months later. If PSA levels do not fall as expected, _________________.

Back 77

ejaculate volume and libido
gynecomastia
the patient should be evaluated for cancer of the prostate

Front 78

Five alpha1 blockers are approved for BPH:

Back 78

alfuzosin, terazosin, doxazosin, silodosin, and tamsulosin

Front 79

With BPH, what does blockade of alpha1 receptors do?

Back 79

relaxes smooth muscle in the bladder neck, prostate capsule, and prostatic urethra, thereby reducing dynamic obstruction of the urethra

Front 80

How soon do Alpha-blockers for BPH produce results?

Back 80

Symptomatic improvement and increased urinary flow develop rapidly.

Front 81

How long must alpha blockers be taken for BPH?

Do Alpha1 blockers reduce the size of the prostate?

Back 81

To maintain benefits, alpha blockers must be taken lifelong.

No

Front 82

Silodosin and tamsulosin are selective for _________; alfuzosin, terazosin, and doxazosin are nonselective __________ and thus block alpha1 receptors in __________ as well as alpha1a receptors in the prostate.

Back 82

alpha1a receptors
alpha1 blockers
blood vessels

Front 83

By blocking alpha1 receptors in blood vessels, these three nonselective agents promote vasodilation and thus can lower blood pressure.
(BPH drugs)

Back 83

alfuzosin, terazosin, and doxazosin

Front 84

Which BPH drugs can cause abnormal ejaculation?

Back 84

Silodosin and tamsulosin

Front 85

Do the alpha blockers reduce PSA levels?

Back 85

No

Front 86

_____________ can result if nonselective alpha blockers are combined with organic nitrates, antihypertensive drugs, and PDE5 inhibitors used for ED.

Back 86

Excessive hypotension

Front 87

______________ and other alpha blockers are used off-label to treat ___________ with urinary hesitancy or urinary retention associated with bladder outlet obstruction or insufficient contraction of the bladder __________ muscle.

Back 87

Tamsulosin
women
detrusor

Front 88

In clinical trials, combining an alpha blocker with a ______________ has been superior to treatment with either agent alone.
(BPH treatment)

Back 88

5-alpha-reductase inhibitor

Front 89

The nurse is assessing a patient who is receiving a sulfonamide for treatment of a urinary tract infection. To monitor the patient for the most severe response to sulfonamide therapy, the nurse will assess for what?

Back 89

Skin rash and lesions

Front 90

A patient is receiving local applications of mafenide (Sulfamylon) to burn areas. Before application, it is most important for the nurse to do what?

Back 90

Administer a pain medication.

Front 91

A nurse should recognize that which sulfonamide, applied topically, has the greatest therapeutic benefit for burns?

Back 91

Silver sulfadiazine (Silvadene)

Front 92

A patient taking a sulfonamide is breast-feeding an infant. Which complication in the infant would the nurse associate with kernicterus?
+ Hemolytic anemia
+ Neurologic deficits
+ Hepatocellular failure
+ Ophthalmic infection

Back 92

Neurologic deficits

Front 93

When providing patient teaching for oral sulfonamide therapy, the nurse should instruct the patient to take the sulfonamide in what way?

Back 93

Between meals with a full cup of water

Front 94

Before administering trimethoprim, it is most important for the nurse to assess the patient for a history of what?

Back 94

Alcoholism

Front 95

A patient who has acquired immunodeficiency syndrome (AIDS) is receiving trimethoprim/sulfamethoxazole (Bactrim). Which response should a nurse expect if the medication is achieving the desired effect?
+ Increase in CD4 T cells
+ Increased appetite and weight gain
+ Resolution of pneumonia
+ Decrease in joint pain

Back 95

Resolution of pneumonia

Front 96

When caring for a patient receiving mafenide (Sulfamylon) for treatment of a severe burn, it is most important for the nurse to monitor which laboratory value?

Back 96

Acid-base status

Front 97

The nurse identifies which statements about Stevens-Johnson syndrome as true? (Select all that apply.)
__ Patients with Stevens-Johnson syndrome have a mortality rate of about 25%.
__ Toxemia is associated with Stevens-Johnson syndrome.
__ Short-acting sulfonamides do not induce Stevens-Johnson syndrome.
__ Patients with Stevens-Johnson syndrome usually are hypothermic.
__ Lesions of the mucous membranes are a characteristic of Stevens-Johnson syndrome.

Back 97

Patients with Stevens-Johnson syndrome have a mortality rate of about 25%.
Toxemia is associated with Stevens-Johnson syndrome.
Lesions of the mucous membranes are a characteristic of Stevens-Johnson syndrome.

Front 98

Which manifestations does the nurse associate with the development of hemolytic anemia? (Select all that apply.)
__ Urticaria
__ Fever
__ Pallor
__ Jaundice
__ Diarrhea

Back 98

Fever
Pallor
Jaundice

Front 99

The sulfonamides and trimethoprim are broad-spectrum ___________ that have closely related mechanisms: They all disrupt the synthesis of ________________.

Back 99

antimicrobials
tetrahydrofolic acid

Front 100

______________ were the first drugs available for systemic treatment of bacterial infections. Their introduction and subsequent widespread use produced a sharp decline in morbidity and mortality from susceptible infections.

Back 100

Sulfonamides

Front 101

Sulfonamides suppress bacterial growth by inhibiting synthesis of ____________, a compound required by all cells to make DNA, RNA, and proteins.

Back 101

folic acid (folate)

Front 102

Sulfonamides are used primarily for ___________.

Back 102

urinary tract infections (UTIs)

Front 103

Sulfonamides can induce a variety of ______________, which are seen in about 3% of patients.

Back 103

hypersensitivity reactions

Front 104

The most severe hypersensitivity response to sulfonamides is ___________________, a rare reaction with a mortality rate of about 25%.

Back 104

Stevens-Johnson syndrome

Front 105

Sulfonamides can cause_______________ in patients whose red blood cells have a genetically determined deficiency in glucose-6-phosphate dehydrogenase (G6PD); additionally, sulfonamides can cause ________, _______________, ______________, and ______________.

Back 105

hemolytic anemia
agranulocytosis, leukopenia, thrombocytopenia, and, very rarely, aplastic anemia

Front 106

Because of the risk of kernicterus, sulfonamides should not be administered to__________________. In addition, sulfonamides should not be given to______________________.

Back 106

infants younger than 2 months
pregnant women near term or to women who are breast-feeding

Front 107

Sulfonamides can intensify the effects of __________, _____________, and ___________.

Back 107

warfarin, phenytoin, and sulfonylurea-type oral hypoglycemics

Front 108

Renal damage is uncommon with today’s sulfonamides, owing to their increased ___________________.

Back 108

water solubility

Front 109

The sulfonamides fall into two major categories: (1) ______________ sulfonamides and (2) _________ sulfonamides. The _______________ are used more often.

Back 109

systemic
topical
systemic agents

Front 110

_____________ is the only intermediate-acting sulfonamide available. Because its effects are moderately prolonged, dosing can be done less often than with the short-acting agents.

Back 110

Sulfamethoxazole

Front 111

The risk of _________ damage from crystalluria can be reduced by maintaining adequate __________.

Back 111

renal
hydration

Front 112

Like the sulfonamides, ________________ suppresses synthesis of tetrahydrofolic acid. _______________ is active against a broad spectrum of microbes.

Back 112

trimethoprim; trimethoprim

Front 113

Trimethoprim is approved only for initial therapy of ________________ caused by susceptible organisms.

Back 113

acute, uncomplicated UTIs

Front 114

Trimethoprim is generally well tolerated. The most frequent adverse effects are _______________. _____________________ reactions occur occasionally.

Back 114

itching and rash
Gastrointestinal

Front 115

Trimethoprim suppresses renal excretion of _______________ and can thereby promote ___________. Patients at greatest risk are those taking high doses, those with renal impairment, and those taking other drugs that can elevate _____________.

Back 115

potassium
hyperkalemia
potassium

Front 116

The combination product ____________ is a powerful antimicrobial preparation whose components act in concert to inhibit sequential steps in tetrahydrofolic acid synthesis.

Back 116

TMP/SMZ

Front 117

What does TMP/SMZ stand for?

Back 117

the combination of trimethoprim and sulfamethoxazole

Front 118

TMP/SMZ is a preferred or alternative medication for a variety of infectious diseases. The combination is especially valuable for __________, ______________, ______________, ___________, and pneumonia caused by _____________.

Back 118

urinary tract infections, otitis media, bronchitis, shigellosis
P. jiroveci

Front 119

The most common adverse effects of TMZ are ____________. However, although infrequent, all of the serious toxicities associated with sulfonamides alone and trimethoprim alone can occur with TMP/SMZ.

Back 119

nausea, vomiting, and rash

Front 120

Hyperkalemia is a potential complication of TMP/SMZ therapy, especially when the dosage is __________. Patients suffering from _________ are unusually susceptible to TMP/SMZ toxicity.

Back 120

high
AIDS

Front 121

Most cases (more than 80%) of uncomplicated, community-acquired urinary tract infection (UTI) are caused by which bacteria?

Back 121

Escherichia coli

Front 122

A patient who has acute cystitis is receiving treatment with trimethoprim/sulfamethoxazole. Which manifestation should indicate to a nurse that the patient’s condition is worsening?
What condition could this indicate?

Back 122

Flank pain
Pyelonephritis

Front 123

A patient is taking nitrofurantoin (Macrodantin). Which finding should a nurse recognize as an indication that the treatment is having an undesired effect?

Back 123

Dyspnea with chills

Front 124

A patient is to begin taking nitrofurantoin (Macrodantin). The nurse should teach the patient that which manifestation should be the priority to report to the healthcare provider?

Back 124

Muscle weakness and tingling (may indicate irreversible damage to sensory and motor nerves caused by demyelinization of nerves)

Front 125

A patient is taking nalidixic acid (NegGram) and experiencing photophobia and diplopia. Which instruction should a nurse provide the patient?

Back 125

Restrict driving temporarily.

Front 126

The nurse is working with a patient who has a UTI. Because patient adherence to a medication regimen is a concern, the nurse anticipates use of which medication?

Back 126

Fosfomycin (requires just one dose)

Front 127

Which outcomes should a nurse establish when planning care for a patient taking methenamine (Mandelamine)? (Select all that apply.)
+ Maintains a urine pH of 5.5 or lower
+ Consumes 3000 mL of liquid daily
+ Uses an enteric-coated formulation
+ Avoids sulfonamide medications
+ No elevation in liver enzymes

Back 127

+ Maintains a urine pH of 5.5 or lower
+ Uses an enteric-coated formulation
+ Avoids sulfonamide medications

Front 128

A nurse assesses the history of a patient who has had multiple complicated UTIs for which risk factors? (Select all that apply.)
Female gender, child-bearing age
Indwelling catheter
Prostate hypertrophy
Fair skin tone
Urinary tract stones

Back 128

Indwelling catheter
Prostate hypertrophy
Urinary tract stones

Front 129

The nurse identifies which statements about frequent urinary tract reinfections as true? (Select all that apply.)
+ Reinfections are considered frequent if the individual has three or more a year.
+ Prophylactic therapy should continue for at least 2 months.
+ If reinfection is associated with sexual intercourse, the risk can be reduced by instructing the patient to void after intercourse.
+ Single-dose nitrofurantoin 50 mg taken 1 hour before intercourse has been found to reduce the rate of reinfection.
+ If a symptomatic episode occurs, the standard therapy for acute cystitis should be used.

Back 129

+ Reinfections are considered frequent if the individual has three or more a year.
+ If reinfection is associated with sexual intercourse, the risk can be reduced by instructing the patient to void after intercourse.
+ If a symptomatic episode occurs, the standard therapy for acute cystitis should be used.

Front 130

Complicated UTIs occur in _____________ and usually are associated with some predisposing factor, such as calculi, prostatic hypertrophy, or catheters. Uncomplicated UTIs occur primarily in ______________ and are not associated with any specific predisposing factor. Fair skin tone is unrelated to UTI occurrence.

Back 130

both males and females
women of child-bearing age

Front 131

_________________ are the most common infections encountered today.

Back 131

Urinary tract infections (UTIs)

Front 132

UTIs may be classified according to their location, in either the lower urinary tract or upper urinary tract. In this classification scheme, _____________ and ___________ are considered lower tract infections, whereas ______________ is considered an upper tract infection.

Back 132

cystitis and urethritis
pyelonephritis

Front 133

The bacteria that cause UTIs differ between ___________-acquired infections and ___________-acquired infections.

Back 133

community
hospital

Front 134

The majority of uncomplicated, community-acquired UTIs are caused by ____________.

Back 134

Escherichia coli

Front 135

Hospital-acquired UTIs frequently are caused by _________, ______________, __________, and ___________ species; ___________cocci; and ________cocci. E. coli is responsible for fewer than 50% of these infections.

Back 135

Klebsiella, Proteus, Enterobacter, and Pseudomonas
staphylo; entero

Front 136

Although most UTIs involve only one organism, infection with multiple organisms may occur, especially in patients with ____________________.

Back 136

an indwelling catheter, renal stones, or chronic renal abscesses

Front 137

Acute cystitis is a lower UTI that occurs most often in women of child-bearing age. Clinical manifestations are _______________________.

Back 137

dysuria, urinary urgency, urinary frequency, suprapubic discomfort, pyuria, and bacteriuria

Front 138

It is important to note that many women (30% or more) with symptoms of acute cystitis also have ___________.

Back 138

asymptomatic upper urinary tract infection (subclinical pyelonephritis)

Front 139

For community-acquired infections, three types of oral therapy can be used:

Back 139

(1) single-dose therapy, (2) short-course therapy (3 days), and (3) conventional therapy (7 days)

Front 140

Acute uncomplicated pyelonephritis is an infection of the kidneys. The disorder is common in ________________. Clinical manifestations include _______________.

Back 140

young children, the elderly, and women of child-bearing age
fever, chills, severe flank pain, dysuria, urinary frequency, urinary urgency, pyuria and, usually, bacteriuria

Front 141

Mild to moderate infection can be treated _______________.
(pyelonephritis)

Back 141

at home with oral antibiotics

Front 142

Severe pyelonephritis requires______________ and _______________.

Back 142

hospitalization
IV antibiotics

Front 143

Complicated UTIs occur in male and female patients who have _______________________.

Back 143

a structural or functional abnormality of the urinary tract that predisposes them to developing infection

Front 144

Symptoms of complicated UTIs can range from mild to severe. Some patients even develop systemic illness, manifesting as ____________________.

Back 144

fever, bacteremia, and septic shock

Front 145

For treatment of complicated UTIs to succeed, we must determine the identity and ____________ of the causative organism. To do so, ____________ for microbiologic testing should be obtained before giving any antibiotics.

Back 145

drug sensitivity
urine

Front 146

______________ result from relapse or from reinfection. Relapse is caused by ______________________. In contrast, reinfection is caused by ___________________.
(UTIs)

Back 146

Recurrent UTIs
recolonization with the same organism responsible for the initial infection
colonization with a new organism

Front 147

More than 80% of recurrent UTIs in female patients are due to __________. These usually involve the _________ urinary tract and may be related to _______________ or use of a contraceptive diaphragm.

Back 147

reinfection
lower
sexual intercourse

Front 148

When reinfections are frequent (______ or more per year), _______ prophylaxis may be indicated. Prophylaxis can be achieved with low daily doses of _______ agents. Prophylaxis should continue for at least _______.

Back 148

three
long-term
several
6 months

Front 149

_________________ accounts for 20% of recurrent UTIs. Symptoms that reappear shortly after completion of a course of therapy suggest a ______________, involvement of the kidneys, or chronic bacterial __________, the most common cause of recurrent UTI in male patients.

Back 149

Recolonization with the original infecting organism
structural abnormality of the urinary tract
prostatitis

Front 150

Acute bacterial prostatitis is defined as inflammation of the prostate caused by local bacterial infection. In most cases (80%), _____________ is the causative organism.

Back 150

E. coli

Front 151

Clinical manifestations of acute bacterial prostitis include ___________________.

Back 151

high fever, chills, malaise, myalgia, localized pain, and various urinary tract symptoms (dysuria, nocturia, urinary urgency, urinary frequency, urinary retention)

Front 152

Bacterial prostatitis responds well to ______________.

Back 152

antimicrobial therapy

Front 153

After completing a course of ciprofloxacin (Cipro) for a skin infection, the patient says, “I took the whole bottle of pills, but my infection hasn’t gotten any better.” Which additional information should the nurse recognize as most significant?
+ The patient takes antacids on a daily basis.
+ The medication was stored in a cool, dry area.
+ The patient did not use sunscreen while taking the ciprofloxacin (Cipro).
+ The patient took two doses of diphenhydramine (Benadryl) while on ciprofloxacin (Cipro) therapy.

Back 153

The patient takes antacids on a daily basis.

Front 154

Antacids interfere with the absorption of ____________ antibiotics, such as ciprofloxacin (Cipro), and many other drugs.

Back 154

quinolone

Front 155

The nurse identifies which medication as posing a significant risk of causing confusion, somnolence, psychosis, and visual disturbances in elderly patients?
+ Metronidazole (Flagyl)
+ Rifampin (Rifadin)
+ Ciprofloxacin (Cipro)
+ Daptomycin (Cubicin)

Back 155

Ciprofloxacin (Cipro)

Front 156

Which approach should a nurse take when administering an oral dose of levofloxacin (Levaquin)?
+ Give the medication with or without food.
+ Administer the drug with an oral dose of a magnesium-based antacid.
+ Premedicate the patient with diphenhydramine (Benadryl).
+ Administer the drug with milk products.

Back 156

Give the medication with or without food.

Front 157

A patient who takes ciprofloxacin (Cipro) and runs 6 miles daily tells a nurse about heel and calf tenderness. The nurse instructs the patient to take which action?

Back 157

Discontinue the medication, because severe damage can result.

Front 158

Fluoroquinolones may result in ____________ by disrupting the extracellular matrix of cartilage. Because tendon injury is reversible if ____________, fluoroquinolones should be discontinued at the first sign of_____________.

Back 158

tendinitis and rupture
diagnosed early
tendon pain or inflammation

Front 159

A patient is taking daptomycin (Cubicin). The nurse should obtain a creatine phosphokinase (CPK) level when the patient shows what?

Back 159

Muscle pain and weakness
This drug may pose a small risk of myopathy (muscle injury). Patients should be warned about muscle injury and told to report any pain or weakness.

Front 160

A patient who takes multiple antibiotics starts to experience diarrheal stools. The nurse anticipates administration of which antibiotic if a stool sample tests positive for Clostridium difficile?

Back 160

Metronidazole (Flagyl)

Front 161

The nurse identifies rifampin as useful in the treatment of which disorders? (Select all that apply.)

Tuberculosis
Active meningococcal infection
Leprosy
Prophylaxis of meningitis caused by Haemophilus influenzae
C. difficile infection

Back 161

Tuberculosis
Leprosy
Prophylaxis of meningitis caused by Haemophilus influenzae

Front 162

Fluoroquinolones are broad-spectrum antibiotics with a wide variety of clinical applications. Their benefits derive from disruption of ______________.

Back 162

DNA replication and cell division

Front 163

Although side effects are generally mild, all fluoroquinolones can cause ____________.

Back 163

tendonitis and tendon rupture, usually of the Achilles tendon

Front 164

Ciprofloxacin is approved for a wide variety of infections. Among them are infections of the _____________ (7). Also, ciprofloxacin is a preferred drug for preventing __________ in people who have inhaled _____________.

Back 164

respiratory tract, urinary tract, gastrointestinal (GI) tract, bones, joints, skin, and soft tissues
anthrax; anthrax spores

Front 165

Because of concerns about tendon injury, systemic ciprofloxacin is generally avoided in children younger than 18 years. Nonetheless, the drug does have two approved pediatric uses:

Back 165

(1) treatment of complicated urinary tract and kidney infections caused by E. coli, and (2) postexposure treatment of inhalational anthrax.

Front 166

Ciprofloxacin can induce a variety of mild adverse effects, including ____________. _______ infections of the pharynx and vagina may develop as a result of treatment. Very rarely, ________ have occurred. In the elderly, ciprofloxacin poses a significant risk of ______________.

Back 166

GI reactions and central nervous system (CNS) effects
Candida
seizures
confusion, somnolence, psychosis, and visual disturbances

Front 167

Rarely, ciprofloxacin and other fluoroquinolones have caused tendon rupture, usually of the __________. People at highest risk are those age _________, those taking ___________, and those who have undergone a ___________ transplant. Risk in children is ___________.

Back 167

Achilles tendon
60 years and older
glucocorticoids
heart, lung, or kidney
also elevated

Front 168

Ciprofloxacin and other fluoroquinolones pose a risk of phototoxicity (severe sunburn), characterized by ___________. These can occur after exposure to direct sunlight, indirect sunlight, and sunlamps—even if _____________.

Back 168

burning, erythema, exudation, vesicles, blistering, and edema
a sunscreen has been applied

Front 169

Absorption of ciprofloxacin can be reduced by compounds that contain cations. Among these are ______________ (6), all of which contain calcium ions.

Back 169

(1) aluminum- or magnesium-containing antacids, (2) iron salts, (3) zinc salts, (4) sucralfate, (5) calcium supplements, and (6) milk and other dairy products

Front 170

Metronidazole is used to treat________ infections and infections caused by _____________ (e.g., Bacteroides fragilis, Clostridium difficile).
Metronidazole is lethal to __________ organisms only.

Back 170

protozoal
obligate anaerobic bacteria
anaerobic

Front 171

Metronidazole is active against a variety of anaerobic bacterial infections, including infections of the _________________ (5).

Back 171

CNS, abdominal organs, bones and joints, skin and soft tissues, and genitourinary tract

Front 172

______________ is a drug of choice for C. difficile-associated diarrhea (CDAD).

Back 172

Metronidazole

Front 173

Metronidazole is employed for _______ in surgical procedures associated with a high risk of infection by anaerobes (e.g., ______ surgery, ______ surgery, ______ surgery).

Back 173

prophylaxis
colorectal; abdominal; vaginal

Front 174

Metronidazole is used in combination with a tetracycline and bismuth subsalicylate to eradicate ______________ in people with peptic ulcer disease.

Back 174

Helicobacter pylori

Front 175

Daptomycin is the first representative of a new class of antibiotics, the _______________.

Back 175

cyclic lipopeptides

Front 176

________________ has a unique mechanism of action and can rapidly kill virtually all clinically relevant gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA).

Back 176

Daptomycin

Front 177

Does daptomycin have any significant drug interactions?
How is it administered?

Back 177

No, the only notable side effect is possible muscle injury.
The drug is given once a day by IV infusion, and there is no need to monitor its plasma level.

Front 178

A patient with a history of numbness, weakness, and blurred vision recently was diagnosed with multiple sclerosis (MS). What does the nurse understand to be the underlying pathophysiology for these symptoms?

Back 178

Inflammation and myelin destruction in the central nervous system

Front 179

A patient newly diagnosed with MS asks the nurse how a person gets this disease. Which response by the nurse is most accurate and appropriate?
+ “Multiple sclerosis is a congenital condition that typically manifests itself in late adulthood.”
+ “Multiple sclerosis is a disease believed to be caused by exposure to drugs during a mother’s pregnancy.”
+ “This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor.”
+ “This disease is most often caused by an increase of rapidly dividing cells in the central nervous system.”

Back 179

“This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor.”

Front 180

The nurse is caring for a patient with MS who is having worsening recurrent episodes of neurologic dysfunction followed by periods of partial recovery. How would this subtype be classified?
+ Relapsing-remitting
+ Secondary progressive
+ Primary progressive
+ Progressive-relapsing

Back 180

Secondary progressive

Front 181

The nurse is caring for a patient hospitalized with an acute episode (relapse) of MS. Which agent is the preferred treatment during relapse?

Back 181

Methylprednisolone (Solu-Medrol) IV

Front 182

5.
The nurse is caring for a patient receiving glatiramer acetate (Copaxone) for MS. Which finding, if present in this patient, could be considered a potential adverse effect of this drug?
* Flulike symptoms with fever
* Decreased neutrophil count
* Jaundice and elevated bilirubin
* Injection site pain and redness

Back 182

Injection site pain and redness

Front 183

Natalizumab (Tysabri) is a very effective agent for treating MS. Which problem is associated with the administration of this drug, making it a second-line agent?

Back 183

Rare cases of dangerous brain infections

Front 184

The nurse is teaching a patient about a new prescription for mitoxantrone (Novantrone). Which statement made by the patient indicates a need for further teaching?
A. “I volunteer at a local day care center once a week.”
B. “I drink grapefruit juice with breakfast each morning.”
C. “I enjoy walking and outdoor activities in the sun.”
D. “I understand this drug may cause my urine to turn blue.”

Back 184

A.
Mitoxantrone can cause myelosuppression. Patients taking this drug should be advised to avoid contact with people who have infections, such as children in day care centers.

Front 185

Which statement made by a patient indicates a need for further teaching by the nurse about reducing injection site reactions from interferon beta?
* “I need to rotate my injection sites, so I’ll need to keep a record of them.”
* “I will apply hydrocortisone ointment to the injection site if it is itchy.”
* “Applying a warm compress before giving the injection will reduce the risk of pain at the site.”
* “I can take over-the-counter Benadryl if the injection site itches and is red.”

Back 185

* “I can take over-the-counter Benadryl if the injection site itches and is red.”

Front 186

Which medication used for the management of multiple sclerosis cannot be self-administered?

Back 186

Natalizumab (Tysabri) -- administered by intravenous infusion over 1 hour. The patient must be observed during the infusion and also must be monitored for 1 hour after the infusion is complete.

Front 187

Which complaint by a patient taking fingolimod (Gilenya) requires prompt evaluation by the prescriber?

Back 187

Dizziness and fatigue--this drug slows the heart rate and can cause bradycardia

Front 188

The nurse is caring for a patient with MS who is receiving interferon beta-1a (Rebif) by subcutaneous injection. Which laboratory tests should be performed regularly in this patient to monitor for a potential adverse effect? (Select all that apply.)
A. Blood urea nitrogen
B. Complete blood count
C. Hemoglobin A1c
D. Alkaline phosphatase
E. Immunoglobulin G levels

Back 188

B, E

Front 189

Which medication can be used to manage fatigue associated with multiple sclerosis? (Select all that apply.)
* Modafinil (Provigil)
* Clonazepam (Klonopin)
* Amantadine (Symmetrel)
* Carbamazepine (Tegretol)
* Dalfampridine (Ampyra)

Back 189

Modafinil (Provigil)
Amantadine (Symmetrel)

Front 190

Which assessment is essential before a patient receives a second dose of mitoxantrone (Novantrone)? (Select all that apply.)
* Pregnancy test
* Echocardiogram
* Complete blood count
* T3, T4, and TSH levels
* Ophthalmic examination
* Magnetic resonance imaging (MRI)

Back 190

* Pregnancy test
* Echocardiogram
* Complete blood count

Front 191

Multiple sclerosis (MS) is a chronic, inflammatory, autoimmune disorder that damages _________________.

Back 191

the myelin sheath of neurons in the central nervous system (CNS).

Front 192

The pathologic hallmark of ___________ is the presence of multifocal regions of inflammation and myelin destruction in the CNS.

Back 192

MS

Front 193

As a result of demyelination, axonal conduction is ____________, giving rise to a host of ___________ signs and symptoms.

Back 193

slowed or blocked
neurologic

Front 194

When inflammation subsides, damaged tissue is replaced by astrocyte-derived filaments, forming _______ known as ___________.

Back 194

scars
scleroses (from which the disease’s name is derived)

Front 195

It is important to note that, in addition to stripping off myelin, inflammation may injure the underlying __________ and may damage ____________, the cells that produce CNS myelin.

Back 195

axon
oligodendrocytes

Front 196

Axonal injury also can occur in the absence of inflammation and can be seen ___________________.

Back 196

early in the course of the disease

Front 197

The mechanism appears to be ______________: Cells of the immune system mistakenly identify components of ________________ as foreign and mount an attack against them.
(MS)

Back 197

autoimmune
myelin

Front 198

The most likely causes of MS are:

Back 198

genetics, environmental factors, and microbial pathogens.

Front 199

When inflammation subsides, some degree of recovery occurs, at least in the early stages of the disease. Three mechanisms are involved: (1) partial _____________, (2) functional axonal ___________ (axons redistribute their sodium channels from the nodes of Ranvier to the entire region of demyelination), and (3) development of ___________ that bypass the damaged region.

Back 199

remyelination
compensation
alternative neuronal circuits

Front 200

People with MS can experience a wide variety of signs and symptoms. Depending on the site of CNS demyelination, a patient may experience ______(14+)_____. The intensity of these symptoms is determined by the size of the region of demyelination.

Back 200

paresthesias, muscle or motor problems, visual impairment, bladder and bowel symptoms, sexual dysfunction, disabling fatigue, emotional lability, depression, cognitive impairment, slurred speech, dysphagia, dizziness, vertigo, neuropathic pain, and more

Front 201

MS has four subtypes—____________________—which are defined by the clinical course the disease follows.

Back 201

relapsing-remitting, secondary progressive, primary progressive, and progressive-relapsing

Front 202

Relapsing-remitting MS is characterized by ....

Back 202

recurrent, clearly defined episodes of neurologic dysfunction (relapses) separated by periods of partial or full recovery (remissions)

Front 203

Secondary progressive MS occurs when a patient with relapsing-remitting MS develops....

Back 203

steadily worsening dysfunction, with or without occasional plateaus, acute exacerbations, or minor remissions

Front 204

In primary progressive MS, symptoms ____________, although some patients may experience occasional plateaus or even temporary improvement.

Back 204

grow progressively more intense from the outset

Front 205

Progressive-relapsing MS, which is __________, is much like primary progressive MS but with acute exacerbations superimposed on ____________________.

Back 205

rare
the steady intensification of symptoms

Front 206

Diagnosis of MS is based on __________________.

Back 206

the clinical presentation and laboratory data

Front 207

Additional diagnostic tools can help confirm a suspected diagnosis of MS. Important among these are _________________________.

Back 207

magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) tests, and measurement of the visual evoked potential (VEP)

Front 208

In patients with MS, drugs are used to (1) _______________, (2) ____________, and (3) manage __________. __________ drugs can cure MS.

Back 208

modify the disease process
treat acute relapses
symptoms
No

Front 209

In treating the symptoms of MS, ____________ can reduce the frequency and severity of relapses, the development of brain lesions, and future disability, and they may help maintain quality of life. In addition, they may prevent permanent damage to axons.

Back 209

Disease-modifying drugs

Front 210

The two main groups of disease-modifying drugs are _______________________.
(Treatment of MS symptoms)

Back 210

immunomodulators and immunosuppressants

Front 211

The immunomodulators—________________—are much safer than _______________ (the major immunosuppressant in use) and therefore are generally preferred.
(MS drugs)

Back 211

interferon beta, glatiramer acetate, natalizumab, and fingolimod
mitoxantrone

Front 212

All patients with relapsing-remitting MS, regardless of age, frequency of attacks, or level of disability, should be treated with one of the ___________________.

Back 212

immunomodulators

Front 213

Treatment should begin as soon as possible after relapsing-remitting MS has been diagnosed, because early treatment can help prevent _____________ and thereby may prevent permanent _____________. Treatment should continue _________________.

Back 213

axonal injury
neurologic deficits
indefinitely

Front 214

________________ can benefit certain patients with secondary progressive MS, specifically those who still have acute relapses. For these individuals, _____________________ can reduce the severity and frequency of attacks and the development of MRI-detectable brain lesions.

Back 214

Interferon beta
interferon beta

Front 215

_______________________ can reduce the clinical attack rate and the development of new brain lesions and slow the progression of disability in secondary progressive MS.

Back 215

Mitoxantrone

Front 216

Although mitoxantrone is effective, _________________ precludes its long-term use.

Back 216

cardiotoxicity

Front 217

Mitoxantrone is the only disease-modifying drug approved for ___________________ MS. Unfortunately, its benefits generally are modest.

Back 217

progressive-relapsing

Front 218

No disease-modifying therapy has been shown effective against __________________ MS.

Back 218

primary progressive

Front 219

A short course of a high-dose IV _________________ is the preferred treatment of an acute relapse. ________________ suppress inflammation and can thereby reduce the severity and duration of a clinical attack.
(MS)

Back 219

glucocorticoid
Glucocorticoids

Front 220

Acute relapse may also be treated with IV _________________. This option can be especially helpful in patients intolerant of or unresponsive to glucocorticoids.
(MS)

Back 220

gamma globulin

Front 221

Seven immunomodulators are available: ______________________.
(MS)

Back 221

glatiramer acetate, natalizumab, fingolimod, and four preparations of interferon beta

Front 222

________________ is reserved for patients with relapsing-remitting MS who have not responded to at least one of the other four immunomodulators.

Back 222

Natalizumab

Front 223

All of the first-line ____________ used to treat MS have nearly equal efficacy, reducing the relapse rate by about 30%. Natalizumab is more effective than the first-line drugs, reducing the relapse rate by 68%, but it also is ________________.

Back 223

immunomodulators
more dangerous

Front 224

Interferon beta is a naturally occurring glycoprotein with __________, _______________, and _____________ actions.

Back 224

antiviral
antiproliferative
immunomodulatory

Front 225

In patients with MS, interferon beta is believed to help in two ways:

Back 225

(1) It inhibits the migration of proinflammatory leukocytes across the blood-brain barrier, thereby preventing these cells from reaching neurons of the CNS, and (2) it suppresses T-helper cell activity.

Front 226

Interferon beta products are approved for relapsing forms of MS. These drugs can reduce the frequency and severity of _________ and the number and size of ____________ and delay __________________.

Back 226

attacks
MRI-detectable lesions
the progression of disability

Front 227

Interferon beta generally is well tolerated, although side effects are common: ____________ reactions occur often; the drug can injure ________ and suppress ___________; and subcutaneous injection can cause ___________. Also, interferon beta has been loosely associated with _____________. (MS)

Back 227

flulike
the liver
bone marrow function
pain, erythema, bumps, and itching
depression

Front 228

Like all other foreign proteins, interferon beta is immunogenic and thus can ____________. If present in sufficiently high titers, these neutralizing antibodies can _______________. (MS)

Back 228

stimulate the production of antibodies against itself
reduce the clinical benefits

Front 229

Glatiramer acetate, also known as copolymer-1, is used for long-term therapy of ____________ MS. Glatiramer can reduce____________________ and the development of MRI-detectable __________ and delay the _____________ of disability.

Back 229

relapsing-remitting
the frequency and severity of relapses
lesions
progression

Front 230

In patients with MS, glatiramer promotes a “_______shift”; that is, it reduces the production of proinflammatory ____ cells and increases production of anti-inflammatory ____ cells. The anti-inflammatory cells migrate across the __________ at sites of inflammation and then suppress the inflammatory attack on _______.

Back 230

T-cell
TH1
TH2
blood-brain barrier
myelin

Front 231

Glatiramer is generally well tolerated. _________________—pain, erythema, pruritus (itching), and induration (pitting)—are most common. (MS)

Back 231

injection-site reactions

Front 232

When taking glatiramer for therapy of MS, about 10% of patients have a self-limited postinjection reaction—characterized by__________________________—that typically lasts 15 to 20 minutes.

Back 232

flushing, palpitations, severe chest pain, anxiety, laryngeal constriction, and urticaria

Front 233

Natalizumab is a recombinant monoclonal antibody. Protective restrictions have been placed on who can prescribe, dispense, administer, and receive the drug, because it poses a risk of ____________________.

Back 233

progressive multifocal leukoencephalopathy (PML), a severe infection of the brain

Front 234

Natalizumab is approved only for monotherapy of _________ forms of MS. In studies, natalizumab reduced the annualized rate of relapse by 68% and the number of new or enlarging brain lesions by 83%. However, owing to the risk of PML, natalizumab should be reserved for patients who have not responded to at least one of the first-line agents, and it should _________________.

Back 234

relapsing
not be combined with other disease-modifying drugs

Front 235

Natalizumab prevents circulating leukocytes (T cells and monocytes) from ______________, thereby preventing these cells from migrating to sites where they can do harm.

Back 235

leaving the vasculature

Front 236

Natalizumab--the most common reactions are ________________. Other common reactions include abdominal discomfort, arthralgia, depression, diarrhea, gastroenteritis, urinary tract infections, and lower respiratory tract infections. The most serious effects are ________________________ (3).

Back 236

headache and fatigue
PML, liver injury, and hypersensitivity reactions

Front 237

_________________ is a first-in-class sphingosine 1-phosphate receptor modulator and the first oral disease-modifying agent for MS.

Back 237

Fingolimod

Front 238

Fingolimod is approved for reducing ______________ and delaying _____________________ with relapsing forms of the disease.

Back 238

the frequency of MS exacerbations
disability in patients

Front 239

Fingolimod can cause significant _____________. Accordingly, it should be reserved for patients who cannot tolerate _________________ or have not responded well to other ____________________.

Back 239

adverse effects
injections
immunomodulators

Front 240

Fingolimod binds with high affinity to a class of molecules known as sphingosine 1-phosphate (S1P) receptors on ___________, causing their sequestration in lymph nodes. This leaves fewer _____________ in the peripheral blood, reducing the inflammation that underlies neuronal injury.

Back 240

lymphocytes
lymphocytes

Front 241

Fingolimod can cause multiple adverse effects. The most common are ____________. The most serious are _________________.

Back 241

headache, diarrhea, cough, back pain, influenza, and elevation of liver enzymes
bradycardia, macular edema, infection, fetal harm, and liver injury

Front 242

_______________ causes a 20% to 30% decrease in circulating lymphocytes and thus increases the risk of infection.

Back 242

Fingolimod

Front 243

Fingolimod is _________________ in animals at doses equivalent to those used clinically. Women of child-bearing age should be informed of the risk of fetal harm and advised to use _________________ both during treatment and _________________.

Back 243

teratogenic and embryolethal
two effective forms of contraception
for 2 months after the cessation of therapy

Front 244

Fingolimod can cause a dose-dependent decrease in ______________.

Back 244

lung function

Front 245

_________________ is the only immunosuppressant approved for the treatment of MS.

Back 245

Mitoxantrone

Front 246

Mitoxantrone poses a significant risk of ___________ and therefore generally is reserved for patients who cannot be treated with safer agents.

Back 246

toxicity

Front 247

Mitoxantrone is approved for reducing neurologic disability and clinical relapses in patients with worsening ________________ MS, _______________ MS, and ________________ MS.

Back 247

relapsing-remitting
secondary progressive
progressive-relapsing

Front 248

Mitoxantrone may delay the time to ___________ and the time to _____________ progression. In addition, it may reduce the number of new ___________________.

Back 248

relapse
disability
MRI-detectable lesions

Front 249

Mitoxantrone is a ___________ drug that binds with __________ and inhibits topoisomerase II. These actions inhibit DNA and RNA synthesis and promote cross-linking and ___________ of DNA strands.

Back 249

cytotoxic
DNA
breakage

Front 250

In patients with MS, mitoxantrone suppresses production of immune system cells (B lymphocytes, T lymphocytes, and macrophages), thereby reducing _________________.

Back 250

autoimmune destruction of myelin

Front 251

Mitoxantrone can cause a variety of adverse effects:

Back 251

myelosuppression, cardiotoxicity, and fetal injury are the greatest concerns.

Front 252

Because mitoxantrone is especially toxic to tissues with a high percentage of dividing cells, it can cause ________________.

Back 252

reversible hair loss and injury to the gastrointestinal (GI) mucosa

Front 253

Mitoxantrone can impart ____________ to the skin, sclera, and urine; patients should be ____________.

Back 253

a harmless, blue-green tint
forewarned

Front 254

A patient with multiple sclerosis (MS) is participating in a rehabilitation program. The patient has just been started on baclofen (Lioresal) 5 mg three times/day to help manage spasticity. How will the baclofen interfere with rehabilitation activities?
+ By producing drowsiness, lethargy, and blurred vision
+ By causing gastrointestinal distress
+ By reducing sensation in the extremities
+ By impairing coordinated movements

Back 254

By producing drowsiness, lethargy, and blurred vision

Front 255

Which skeletal muscle relaxant is also the drug of choice for treating malignant hyperthermia?
+ Baclofen (Lioresal)
+ Dantrolene (Dantrium)
+ Diazepam (Valium)
+ Tizanidine (Zanaflex)

Back 255

Dantrolene (Dantrium)

Front 256

The nurse is caring for a patient receiving dantrolene (Dantrium) for spasticity associated with MS. Which laboratory test will be important in monitoring for a potential adverse effect of this drug?
+ Blood urea nitrogen (BUN)
+ Albumin level
+ Correct Gamma-glutamyltransferase (GGTP)
+ Complete blood count (CBC)

Back 256

Gamma-glutamyltransferase (GGTP)

In large doses dantrolene has been associated with fatal liver failure.

Front 257

The nurse is caring for a patient after total hip replacement on postoperative day 1. The patient is restricted to nothing by mouth. Which skeletal muscle relaxant may be given by the intramuscular route?
+ Methocarbamol (Robaxin)
+ Carisoprodol (Soma)
+ Baclofen (Lioresal)
+ Cyclobenzaprine (Flexeril)

Back 257

Methocarbamol (Robaxin)

Front 258

Which statement made by a patient indicates a need for further discharge instruction about baclofen (Lioresal)?
+ “If I develop any difficulty urinating, I will call my physician.”
+ “I’m glad I can still have a glass or two of wine at dinner.”
+ “I’ll contact my healthcare provider when I feel I no longer need the medication.”
+ “I’ll need to check with my healthcare provider before taking my allergy medications.”

Back 258

“I’m glad I can still have a glass or two of wine at dinner.”

Alcohol can intensify the CNS depressant effects of baclofen.

Front 259

Administration of dantrolene (Dantrium) for the treatment of muscle spasticity is contraindicated in which patient?
+ A patient with a C-6 spinal cord injury
+ A patient with cerebral palsy
+ A patient with multiple sclerosis and underlying cirrhosis
+ A patient experiencing malignant hyperthermia

Back 259

A patient with multiple sclerosis and underlying cirrhosis

Although dantrolene is effective for treating spasticity in multiple sclerosis, it is contraindicated in this patient because of the underlying liver disease.

Front 260

The nurse on an orthopedic unit routinely cares for patients receiving carisoprodol (Soma). For which adverse effects should the nurse monitor these patients? (Select all that apply.)
+ Drowsiness and sedation
+ Decreased renal function
+ Risk of dependence
+ Decreased neutrophil count
+ Unusual hair growth

Back 260

Drowsiness and sedation
Risk of dependence

Front 261

Drugs for muscle spasm and spasticity produce their effects through actions in the _____________.

Back 261

central nervous system (CNS)

Front 262

An exception to centrally acting agents is the drug dantrolene, which acts directly on ______________.

Back 262

skeletal muscle

Front 263

As a rule, the drugs used to treat ____________ do not relieve acute muscle spasm and vice versa. The two groups are not interchangeable.

Back 263

spasticity

Front 264

Muscle spasm

Back 264

involuntary contraction of a muscle or muscle group

Front 265

Muscle spasm often is _________ and reduces the patient’s level of _____________.

Back 265

painful
functioning

Front 266

Localized muscle spasm is treated with _____________ and ______________.

Back 266

centrally acting muscle relaxants
aspirin-like drugs

Front 267

Two drugs—______________—are thought to relieve spasm by enhancing presynaptic inhibition of motor neurons in the CNS.

Back 267

diazepam and tizanidine

Front 268

Diazepam promotes presynaptic inhibition by enhancing the effects of ___________________, an inhibitory neurotransmitter.
(muscle spasm)

Back 268

gamma-aminobutyric acid (GABA)

Front 269

___________________ promotes inhibition by acting as an agonist at presynaptic alpha2 receptors.
(muscle spasm)

Back 269

Tizanidine

Front 270

Spasticity is treated with three drugs:

Back 270

baclofen, diazepam, and dantrolene

Front 271

Baclofen can reduce spasticity associated with _________________________, but not that associated with ______________.

Back 271

multiple sclerosis, spinal cord injury, and cerebral palsy

stroke

Front 272

All centrally acting muscle relaxants produce generalized ___________.

Back 272

CNS depression

Front 273

Chlorzoxazone, a central muscle relaxant, is ____________effective and can cause ___________. Accordingly, the drug should be avoided.

Back 273

marginally
fatal hepatic necrosis

Front 274

Like the centrally acting muscle relaxants, _______ and ______ cause generalized CNS depression.

Back 274

baclofen and diazepam

Front 275

Tizanidine (Zanaflex) and metaxalone (Skelaxin) can cause ____________. _______________ should be assessed before starting treatment and periodically thereafter. If _______ injury develops, these drugs should be discontinued. If the patient has pre-existing ____________, these drugs should be avoided. (muscle spasm)

Back 275

liver damage
liver function
liver
liver disease

Front 276

_________________ (Paraflex, others) can cause hepatitis and potentially fatal hepatic necrosis. Because of this potential for harm and because the benefits of _______________ are questionable, the drug should not be used.
(muscle spasm)

Back 276

chlorzoxazone

Front 277

Abrupt discontinuation of ______________ can lead to rhabdomyolysis, multiple organ system failure, and death.
(muscle spasm)

Back 277

intrathecal baclofen

Front 278

In contrast to all other drugs discussed in this chapter, dantrolene acts ________________ to promote relaxation.
(muscle spasm)

Back 278

directly on muscle

Front 279

Dantrolene relieves spasm by suppressing release of ________________; this leaves the muscle less able to contract.

Back 279

calcium from the sarcoplasmic reticulum (SR)

Front 280

Fortunately, therapeutic doses of dantrolene have only minimal effects on ________________________.

Back 280

contraction of smooth muscle and cardiac muscle

Front 281

With prolonged use, dantrolene can cause ___________________. Therefore,_______________ must be monitored; the smallest effective dosage must be used; and treatment _____________ must be the shortest possible.

Back 281

potentially fatal liver damage
liver function
duration

Front 282

In addition to relieving spasticity, dantrolene is used to treat ____________, a potentially fatal condition caused by succinylcholine and general anesthetics.

Back 282

malignant hyperthermia

Front 283

The heat of malignant hyperthermia is generated by _____________ that occurs secondary to a massive release of ____________ from the sarcoplasmic reticulum (SR). Dantrolene relieves symptoms by acting on the SR to block the release of ___________.

Back 283

muscle contraction
calcium
calcium

Front 284

The nurse is preparing to give ergotamine (Ergomar). This agent is effective against headaches of which origin?
+ Hypertension
+ Hyperthyroidism
+ Sinus pressure
+ No identifiable cause

Back 284

No identifiable cause

Front 285

The nurse is teaching a patient with a new prescription for ergotamine (Ergomar). Which statement is most appropriate to include in the teaching plan?
+ “You should not use this drug more than 1 or 2 days per week.”
+ “You should rise slowly from a sitting to a standing position.”
+ “Be sure to include bananas and melons in your diet to increase potassium.”
+ “You will need to return to the clinic for blood work monthly.”

Back 285

“You should not use this drug more than 1 or 2 days per week.”

Front 286

The nurse is assessing a patient receiving dihydroergotamine (Migranal) for potential side effects. Which symptom, if found, would indicate a side effect of this drug?
+ Nausea and vomiting
+ Diarrhea
+ Physical dependence
+ Constipation

Back 286

Diarrhea
(a common problem with dihydroergotamine)

Front 287

The nurse is caring for a female patient receiving sumatriptan (Imitrex). Which concept guides the nursing care of this patient?
+ Coronary vasospasm is a common problem with this drug.
+ Many patients experience symptoms of chest pressure or heavy arms.
+ Sumatriptan increases the risk of nausea and vomiting with migraines.
+ Sumatriptan is considered safe to use during pregnancy.

Back 287

Many patients experience symptoms of chest pressure or heavy arms. (about 50% of those who take the drug)

Front 288

The nurse is reviewing the patient’s current medication list and recognizes that which medication is considered first-line for migraine prevention?
+ Topiramate (Topamax)
+ Metoclopramide (Reglan)
+ Propranolol (Inderal)
+ Ergotamine (Ergomar)

Back 288

Propranolol--beta blockers are preferred drugs to prevent migraines.

Front 289

An adult patient presents to the emergency department and is diagnosed with a severe migraine headache. Which class or classes of medications would the nurse expect to be ordered for this patient? (Select all that apply.)
+Beta blocker
+Opioid analgesic
+Migraine-specific agent
+Antiemetic
+Aspirin-like agent

Back 289

Opioid analgesic
Migraine-specific agent
Antiemetic

Front 290

Regular daily use of ergotamine is likely to cause _____________.

Back 290

physical dependence

Front 291

Headache is a common symptom that can be triggered by a variety of stimuli, including....

Back 291

stress, fatigue, acute illness, and sensitivity to alcohol

Front 292

Many people experience mild, episodic headaches that can be relieved with ______________; and medical intervention is _______________ in these cases.

Back 292

over-the-counter medications
unnecessary

Front 293

Some people experience severe, recurrent, debilitating headaches that are frequently unresponsive to _________ drugs. These individuals require ___________.

Back 293

aspirin-like
medical attention

Front 294

In attempting to treat headache, healthcare professionals must differentiate between headaches with an __________ underlying cause and headaches with no ____________ cause.

Back 294

identifiable (x2)

Front 295

When considering drugs for headache, three basic principles must be kept in mind:

Back 295

(1) antiheadache drugs may be used in two ways: to abort an ongoing attack or to prevent an attack;
(2) not all patients with a particular type of headache respond to the same drugs; therefore, therapy must be individualized; and
(3) several of the drugs used to treat severe headaches (e.g., ergotamine, opioids) can cause physical dependence. Accordingly, every effort should be made to keep dependence from developing.

Front 296

Migraine headache is characterized by....

Back 296

throbbing head pain of moderate to severe intensity that may be unilateral or bilateral

Front 297

Most patients also have nausea and vomiting, along with along with ______ pain and sensitivity to _________. Physical activity __________ the pain.
(migraine)

Back 297

neck
light and sound
intensifies

Front 298

Migraines usually develop in the ___________. The pain increases _____________ and lasts _______________.

Back 298

morning after arising
gradually
4 to 72 hours

Front 299

Precipitating factors for migraine include:

Back 299

anxiety, fatigue, stress, menstruation, alcohol, weather changes, and foods containing tyramine

Front 300

Migraine has two primary forms:

Back 300

migraine with aura and migraine without aura

Front 301

In migraine with aura, the headache is preceded by visual symptoms (______________________). Of the two forms, migraine ____________ aura is more common.

Back 301

flashes of light, a blank area in the field of vision, zigzag patterns
without

Front 302

Migraine is a ____________ disorder involving dilation and inflammation of _________________.

Back 302

neurovascular
intracranial arteries

Front 303

Generation of the headache begins with ______________.
(migraine)

Back 303

neural events that trigger vasodilation

Front 304

Vasodilation then leads to ________, which leads to further neural activation, thereby amplifying _____________.
(migraine)

Back 304

pain
pain-generating signals

Front 305

Although the cause of migraines is not clearly understood, two compounds—calcitonin gene–related peptide (CGRP) and serotonin (5-hydroxy-tryptamine [5-HT])—play important roles. The role of CGRP is to _____________, and the role of 5-HT is to _________________.

Back 305

promote migraine
suppress migraine

Front 306

Drugs used for migraine prophylaxis include....

Back 306

beta blockers, tricyclic antidepressants, and antiepileptic drugs

Front 307

Drugs for migraine are used either to ______________ or to _____________. Drugs used to abort an attack are divided into two groups: ____________________

Back 307

abort an ongoing attack; prevent attacks
nonspecific analgesics and migraine-specific drugs

Front 308

Nondrug measures can help with migraines. Patients should try to control or eliminate __________ and should maintain a regular pattern of ....

Back 308

triggers
eating, sleeping, and exercise

Front 309

The objective of abortive therapy is to eliminate _____________ and suppress associated _______________.
Treatment should commence at ________________.

Back 309

headache pain
nausea and vomiting
the earliest sign of an attack

Front 310

Drug selection depends on the intensity of the attack.
For mild to moderate symptoms, ______________ may be sufficient.
For moderate to severe symptoms, patients should take ___________________—either an ergot alkaloid or a serotonin1B/1D agonist.
If these agents fail to relieve pain, ________________ may be needed.

Back 310

an aspirin-like drug
a migraine-specific drug
an opioid analgesic

Front 311

Use of abortive medications should be limited to ___________, because more frequent use can lead to __________________, also known as ______________________.
(migraines)

Back 311

1 or 2 days a week
medication overuse headache (MOH)
drug-induced headache or drug-rebound headache

Front 312

Antiemetics are important adjuncts to migraine therapy. By reducing nausea and vomiting, these drugs can...

Back 312

(1) make the patient more comfortable and
(2) permit therapy with oral antimigraine drugs

Front 313

For migraine, which two antiemetics are used most often?

Back 313

metoclopramide and prochlorperazine

Front 314

Aspirin, acetaminophen, naproxen, diclofenac, and other aspirin-like analgesics can provide ____________.
When combined with ______________ (to enhance absorption), aspirin may work as well as __________.
_______________ should be used only in combination with other drugs, not alone.

Back 314

adequate relief of mild to moderate migraine attacks
metoclopramide; sumatriptan
Acetaminophen

Front 315

Opioid analgesics are reserved for ________________. The agents used most often are ________________ and ________________ nasal spray.

Back 315

severe migraine that has not responded to first-line medications
meperidine; butorphanol

Front 316

____________ has complex actions, and the precise mechanism by which it aborts migraine is unknown. Current evidence suggests that antimigraine effects are related to agonist activity at subtypes of serotonin receptors, specifically 5-HT1B and 5-HT1D receptors.

Back 316

Ergotamine

Front 317

Ergotamine is a drug of choice for....

Back 317

stopping an ongoing migraine attack

Front 318

Ergotamine is well tolerated at the usual therapeutic doses. The drug can stimulate the _____________ trigger zone, causing _______________.

Back 318

chemoreceptor; nausea and vomiting

Front 319

Besides N/V, other common side effects of ergotamine include ___________________.

Back 319

weakness in the legs, myalgia, numbness and tingling in fingers and toes, angina-like pain, and tachycardia or bradycardia

Front 320

Acute or chronic overdose can cause serious toxicity, referred to as ergotism; overdose can cause ____________ secondary to constriction of peripheral arteries and arterioles: the extremities become ___________; muscle pain develops; and ___________ eventually may result.

Back 320

ischemia
cold, pale, and numb
gangrene

Front 321

Ergotamine should not be combined with ______________, because a prolonged vasospastic reaction could occur.

Back 321

triptans (e.g., sumatriptan, zolmitriptan)

Front 322

Regular daily use of ergotamine, even in moderate doses, can cause __________________. The ______________ is characterized by headache, nausea, vomiting, and restlessness.

Back 322

physical dependence
withdrawal syndrome

Front 323

Ergotamine can promote ___________ and therefore may cause fetal harm or abortion; ergotamine is classified by the U.S. Food and Drug Administration (FDA) as Pregnancy Risk Category ___.

Back 323

uterine contractions
X

Front 324

Parenteral _________________ is a drug of choice for terminating a migraine attack.

Back 324

dihydroergotamine

Front 325

Dihydroergotamine causes little nausea and vomiting, no physical dependence, and minimal peripheral vasoconstriction; _____________, however, is prominent.

Back 325

diarrhea

Front 326

Dihydroergotamine should not be combined with potent inhibitors of ___________, and should not be administered within 24 hours of a _______________ agonist.

Back 326

CYP3A4
serotonin

Front 327

Dihydroergotamine is contraindicated in patients with ____________________________ and for patients taking triptans or potent inhibitors of CYP3A4.

Back 327

coronary artery disease (CAD), peripheral vascular disease, sepsis, pregnancy, or hepatic or renal impairment

Front 328

The serotonin1B/1D receptor agonists, also known as ______________, are first-line drugs for terminating a migraine attack.

Back 328

triptans

Front 329

_____________ is taken to abort an ongoing migraine attack. The drug relieves headache and associated symptoms (nausea, neck pain, photophobia, phonophobia).

Back 329

Sumatriptan

Front 330

Complete relief occurs in 50% to 80% of patients (depending on the route of administration); unfortunately, headache returns in about 40% of patients within 24 hours.
What migraine drug is this?

Back 330

Sumatriptan

Front 331

Sumatriptan is generally well tolerated. Most side effects are transient and mild. _________________ is the most significant concern.
(migraines)

Back 331

Coronary vasospasm

Front 332

With sumatriptan, about 50% of patients experience _____________ symptoms.

Back 332

unpleasant chest symptoms, usually described as “heavy arms” or “chest pressure” rather than pain

Front 333

Triptans should not be combined with one another or with ergot derivatives, because _____________ could occur.
(migraines)

Back 333

excessive vasoconstriction

Front 334

Sumatriptan should be avoided during ______________.
(migraines)

Back 334

pregnancy

Front 335

_________ can suppress hepatic degradation of sumatriptan, causing sumatriptan’s plasma level to rise; toxicity can result.
(migraines)

Back 335

Monoamine oxidase inhibitors (MAOIs)

Front 336

Combining triptans with selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) can lead to ____________. Accordingly, these combinations should not be used.
(migraines)

Back 336

excessive serotonin receptor activation and serotonin syndrome

Front 337

Prophylactic therapy for migraines can ....

Back 337

reduce the frequency, intensity, and duration of migraine attacks, and can improve responses to abortive drugs

Front 338

Preventive treatment for migraines is indicated for patients who ....

Back 338

have frequent attacks (three or more a month), attacks that are especially severe, or attacks that do not respond adequately to abortive agents.

Front 339

__________________ are first-line drugs for migraine prevention. _______________ is the one used most often.

Back 339

Beta blockers
Propranolol

Front 340

Beta blocker use for migraine prevention can reduce the ______________ of attacks in 70% of patients. Benefits take a few weeks to develop.
The most common side effects are _______________, which occur in about 10% of patients. In addition, the drug can exacerbate symptoms of asthma and may promote ______________.

Back 340

number and intensity
extreme tiredness and fatigue
depression

Front 341

Several drugs developed for the treatment of epilepsy can reduce migraine attacks. Proof of efficacy is strongest for ___________________.

Back 341

divalproex and topiramate

Front 342

Divalproex reduces the incidence of attacks by 50% or more in 30% to 50% of patients.
The most common side effect of divalproex is _________. Other side effects include fatigue, weight gain, tremor, bone loss, and reversible hair loss. Potentially fatal ____________ and __________ occur in rare cases. Divalproex is contraindicated ____________.

Back 342

nausea
pancreatitis; hepatitis
during pregnancy

Front 343

Topiramate reduced ___________ frequency by at least 50% in 83% of adolescents and about 50% of adults. It also reduced the need for ________ medication.
Side effects of topiramate are common, especially _________, __________, and cognitive dysfunction. Other side effects include metabolic acidosis and moderate weight loss.

Back 343

migraine
rescue
paresthesias; fatigue

Front 344

_____________ antidepressants can prevent migraine and tension-type headaches in some patients.

Back 344

Tricyclic

Front 345

The tricyclic agent used most often (for migraine prevention) is _________. Benefits equal those of propranolol.
Amitriptyline can cause __________ and ___________ effects. Excessive doses can cause____________.

Back 345

amitriptyline
hypotension; anticholinergic
dysrhythmias

Front 346

_____________ is defined as migraine that routinely occurs within 2 days of the onset of menses. An important trigger is the decline in ___________ levels that precedes menstruation. For many women, menstrual migraine can be prevented by taking __________ supplements.

Back 346

Menstrual migraine
estrogen
estrogen

Front 347

The nurse is preparing to give neostigmine (Prostigmin). What best describes the action of this drug?
+ It inhibits acetylcholine at all cholinergic synapses.
+ It prevents inactivation of acetylcholine.
+ It prevents activation of muscarinic receptors.
+ It stimulates activation of adrenergic receptors.

Back 347

It prevents inactivation of acetylcholine.

Front 348

What best describes the rationale for using neostigmine (Prostigmin) in the treatment of myasthenia gravis?
+ It promotes neuromuscular blockade in the periphery.
+ It promotes emptying of the bladder and sphincter relaxation.
+ It reduces intraocular pressure and protects the optic nerve.
+ It increases the force of skeletal muscle contraction.

Back 348

It increases the force of skeletal muscle contraction.

Front 349

The nurse is caring for a patient with a suspected overdose of pancuronium, which was used during surgery. Which drug does the nurse anticipate will be used as a reversal agent?
+ Neostigmine (Prostigmin)
+ Atropine (Sal-Tropine)
+ Pralidoxime (DuoDote)
+ Dobutamine (Dobutrex)

Back 349

Neostigmine (Prostigmin)

Front 350

A patient goes to the emergency department after using organophosphate insecticides improperly. What assessment finding would the nurse expect?
+ Urinary retention
+ Stool incontinence
+ Mydriasis
+ Flushed, dry skin

Back 350

Stool incontinence

Front 351

The nurse is caring for a patient with myasthenia gravis who is beginning a new prescription of neostigmine (Prostigmin), 75 mg PO twice daily. What is the most important initial nursing action?
+ Obtain a measurement of the plasma level of neostigmine
+ Teach the patient to wear a Medic Alert bracelet
+ Assess the patient’s ability to swallow
+ Check the patient’s deep tendon reflexes (DTRs)

Back 351

Assess the patient’s ability to swallow

Front 352

Cholinesterase inhibitors are drugs that prevent the degradation of acetylcholine (ACh) by acetylcholinesterase. By preventing the inactivation of ACh, cholinesterase inhibitors enhance the actions of ACh released from cholinergic neurons.
The cholinesterase inhibitors can be viewed as indirect-acting cholinergic __________.

Back 352

agonists

Front 353

Neostigmine typifies the reversible cholinesterase inhibitors and is the prototype for the group. The drug’s principal indication (use) is __________________.

Back 353

myasthenia gravis

Front 354

By preventing inactivation of ACh, neostigmine and the other cholinesterase inhibitors can intensify transmission at virtually all junctions where ACh is the transmitter. Cholinesterase inhibitors, therefore, can cause....

Back 354

bradycardia, bronchial constriction, urinary urgency, increased glandular secretions, increased tone and motility of GI smooth muscle, miosis, and focusing of the lens for near vision.

Front 355

At therapeutic doses, cholinesterase inhibitors ________ the force of the heart’s contraction. In contrast, toxic doses __________ the force of contraction.
(myasthenia gravis)

Back 355

increase
reduce

Front 356

At therapeutic levels, cholinesterase inhibitors can produce mild ________; at toxic levels, they ___________ the central nervous system, including the areas that regulate respiration.

Back 356

stimulation
depress

Front 357

Overdose with cholinesterase inhibitors causes excessive ____________ stimulation and ________ depression; intravenous ___________ can alleviate the muscarinic effects of cholinesterase inhibition.

Back 357

muscarinic; respiratory
atropine

Front 358

______________ is the drug of choice for treating poisoning by atropine and other drugs that cause muscarinic blockade.

Back 358

Physostigmine

Front 359

Irreversible cholinesterase inhibitors. also known as organophosphate cholinesterase inhibitors, are used primarily as insecticides. The only indication for these potentially toxic drugs is ____________.

Back 359

glaucoma

Front 360

Toxic doses of irreversible cholinesterase inhibitors produce cholinergic crisis, a condition characterized by excessive ___________ stimulation and depolarizing ___________ blockade.

Back 360

muscarinic
neuromuscular

Front 361

Myasthenia gravis (MG) is a neuromuscular disorder characterized by:

Back 361

fluctuating muscle weakness and a predisposition to rapid fatigue

Front 362

Common symptoms of myasthenia gravis include _______________. Patients with severe MG may have difficulty____________ owing to weakness of the muscles of respiration. Symptoms of MG result from an _________ process.

Back 362

ptosis (drooping eyelids), difficulty swallowing, and weakness of skeletal muscles
breathing
autoimmune

Front 363

By preventing ACh inactivation, anticholinesterase agents can __________ the effects of ACh released from motor neurons, thereby increasing _________.
(myasthenia gravis)

Back 363

intensify
muscle strength

Front 364

Cholinesterase inhibitors do not cure MG; rather, they only produce symptomatic relief. Therefore, patients usually need _________.

Back 364

lifelong therapy

Front 365

In the treatment of MG, establishing the optimum ______ for cholinesterase inhibitors can be a challenge. Dosage determination is accomplished by administering a _____ initial dose, which is followed by additional small doses until the optimum level of muscle function has been achieved.
Important signs of improvement include:

Back 365

dosage
small
increased ease of swallowing and increased ability to raise the eyelids.

Front 366

Because myasthenic crisis and cholinergic crisis have similar symptoms (muscle weakness or paralysis) but are treated very differently, it is essential to distinguish between them. A differential diagnosis can be made by administering a challenge dose of ________, an ultra-short-acting cholinesterase inhibitor. If symptoms improve, the crisis is _____. If symptoms worsen, the crisis is _________.

Back 366

edrophonium
myasthenic
cholinergic

Front 367

What is the goal of pharmacologic therapy in the treatment of Parkinson’s disease?
+ To increase the amount of acetylcholine at the presynaptic neurons
+ To reduce the amount of dopamine available in the substantia nigra
+ To balance cholinergic and dopaminergic activity in the brain
+ To block dopamine receptors in both presynaptic and postsynaptic neurons

Back 367

To balance cholinergic and dopaminergic activity in the brain

Front 368

A patient with Parkinson’s disease who takes levodopa/carbidopa (Sinemet) comes to the clinic for a semiannual physical examination. Which question is the most important for the nurse to ask?
+ “Have you noticed any swelling in your feet?”
+ “Are you having vivid dreams or visual hallucinations?”
+ “Have you noticed any changes in your stool?”
+ “Have you had your flu vaccine?”

Back 368

“Are you having vivid dreams or visual hallucinations?”

Front 369

3.
A patient with Parkinson’s disease who has been positively responding to drug treatment with levodopa/carbidopa (Sinemet) suddenly develops a relapse of symptoms. Which explanation by the nurse is appropriate?
+ “You have apparently developed resistance to your current medication and will have to change to another drug.”
+ “This is an atypical response. Unfortunately, there are no other options of drug therapy to treat your disease.”
+ “This is called the ‘on-off’ phenomenon. Your healthcare provider can change your medication regimen to help diminish this effect.”
+ “You should try to keep taking your medication at the current dose. These effects will go away with time.”

Back 369

“This is called the ‘on-off’ phenomenon. Your healthcare provider can change your medication regimen to help diminish this effect.”

Front 370

4.
A patient with Parkinson’s disease is prescribed pramipexole (Mirapex) along with his levodopa/carbidopa (Sinemet). Which symptom is most likely a manifestation of an adverse effect of these drugs when given together?
+ Diarrhea
+ Dyskinesia
+ Wheezing
+ Headache

Back 370

Dyskinesia

Front 371

Which statement should the nurse include in the teaching plan for a patient being started on levodopa/carbidopa (Sinemet) for newly diagnosed Parkinson’s disease?
+ Take the medication on a full stomach.
+ Change positions slowly.
+ The drug may cause the urine to be very dilute.
+ Carbidopa has many adverse effects.

Back 371

Change positions slowly.

Front 372

A patient with a history of Parkinson’s disease treated with selegiline (Eldepryl) has returned from the operating room after an open reduction of the femur. Which physician order should the nurse question?
+ Decaffeinated tea, gelatin cubes, and ginger ale when alert
+ Docusate 100 mg orally daily
+ Meperidine 50 mg IM every 4 hours as needed for pain
+ Acetaminophen 650 mg every 6 hours as needed for temperature

Back 372

Meperidine 50 mg IM every 4 hours as needed for pain

Front 373

Parkinson’s disease (PD) is a slowly progressive ______________ disorder. Cardinal symptoms are....

Back 373

neurodegenerative
tremor, rigidity, postural instability, and slowed movement

Front 374

Motor symptoms result from damage to the ____________ system. When it is disrupted, __________ (disorders of movement) result.

Back 374

extrapyramidal
dyskinesias

Front 375

In severe PD, bradykinesia may progress to ________, or complete absence of movement.

Back 375

akinesia

Front 376

The primary pathology in PD is degeneration of the neurons in the ____________ that supply dopamine to the striatum. The result is an ____________ between dopamine and acetylcholine (ACh).

Back 376

substantia nigra
imbalance

Front 377

The goal of treatment with current drugs is simply to improve the patient’s ability to carry out ______________.
Drug selection and dosage are determined by the extent to which PD interferes with work, walking, dressing, eating, bathing, and other activities. It is important to note that drugs provide only symptomatic relief; they do not ____ PD.

Back 377

activities of daily life
cure

Front 378

Given the neurochemical basis of parkinsonism—too little striatal dopamine and too much ACh—the approach to treatment is obvious:

Back 378

give drugs that can restore the functional balance between dopamine and ACh

Front 379

Two types of drugs are used: (1)_______________ agents (i.e., drugs that directly or indirectly cause activation of dopamine receptors); and (2) ____________ agents (i.e., drugs that block receptors for ACh).
(Parkinson's)

Back 379

dopaminergic
anticholinergic
(Of the two groups, dopaminergic agents are by far the more widely used.)

Front 380

Levodopa promotes _______________.

Back 380

dopamine synthesis

Front 381

Amantadine promotes _________________.

Back 381

dopamine release (and may also block dopamine reuptake)

Front 382

All of the anticholinergic agents share the same mechanism: blockade of ______________ receptors in the __________.

Back 382

muscarinic; striatum

Front 383

For patients with mild Parkinson's symptoms, treatment can be begin with __________, an MAO-B inhibitor that confers mild symptomatic benefit.

Back 383

selegiline

Front 384

For patients with more severe symptoms, treatment should begin with either_____________ (combined with carbidopa) or a ________________.

Back 384

levodopa; dopamine antagonist

Front 385

Levodopa is more effective than the dopamine agonists, but long-term use poses a higher risk of ___________. Therefore, the choice must be tailored to the patient.
(Parkinson's)

Back 385

disabling dyskinesias

Front 386

“Off” times can be reduced with three types of drugs:
(Parkinson's)

Back 386

dopamine agonists, COMT inhibitors, and MAO-B inhibitors.

Front 387

The only drug recommended for dyskinesias is _______________.
(Parkinson's)

Back 387

amantadine

Front 388

Unfortunately, although Levedopa is highly effective in treating PD, beneficial effects diminish _________.

Back 388

over time

Front 389

______________ is so effective that a diagnosis of PD should be questioned if the patient fails to respond to the drug.

Back 389

Levodopa

Front 390

The principal adverse effects of levodopa are...; additionally, levodopa may _____ sweat and urine and activate malignant melanoma. With ______ use of levodopa, adverse effects tend to increase and therapeutic effects tend to diminish.

Back 390

nausea and vomiting, dyskinesias, cardiovascular effects (postural hypotension and dysrhythmias), and psychosis
darken
long-term

Front 391

Levodopa currently is available only in combination preparations: levodopa/carbidopa or levodopa/carbidopa/entacapone. Carbidopa is used to:

Back 391

enhance the effects of levodopa (Carbidopa has no therapeutic effects of its own)

Front 392

_______________, an oral nonergot dopamine agonist, is used alone in early-stage PD; it is combined with levodopa to treat advanced-stage PD.

Back 392

Pramipexole

Front 393

When used as monotherapy, pramipexole can produce significant improvement in ______________. When combined with levodopa in advanced PD, the drug can reduce fluctuations in motor control and may permit a reduction in the dosage of _________. The major adverse effects of pramipexole— ______________________ —result from excessive activation of dopamine receptors.

Back 393

motor performance
levodopa
nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, and hallucinations

Front 394

A few Parkinson's patients have reported sleep attacks (overwhelming and irresistible sleepiness that comes on without warning). What drug causes this?

Back 394

pramipexole

Front 395

Two COMT inhibitors are available—entacapone and tolcapone.
With both drugs, benefits derive from inhibition of metabolism of ___________ in the periphery; these drugs have no direct therapeutic effects of their own.
Entacapone, a selective, reversible inhibitor of COMT, is indicated only for use with ___________. The drug inhibits metabolism of _____________ in the intestine and peripheral tissues, thereby prolonging the time ____________ is available to the brain..
In clinical trials, entacapone increased the half-life of levodopa by 50% to 75%, producing smoother, more sustained drug levels of ___________. As a result, “wearing off” was delayed and “on” times were extended.

Back 395

levodopa

Front 396

The nurse is caring for a group of patients diagnosed with Alzheimer’s disease (AD). Which neurotransmitter level is decreased by as much as 90% in patients with severe AD?
+ Norepinephrine
+ Serotonin
+ Acetylcholine
+ Dopamine

Back 396

Acetylcholine

Front 397

The nurse is caring for a patient receiving tacrine (Cognex). Which laboratory test (or tests) will be most important for assessing the patient for adverse effects of this drug?
+ Blood urea nitrogen (BUN) and creatinine
+ Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
+ White blood cell (WBC) count with differential
+ Hemoglobin

Back 397

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Front 398

Which cholinesterase inhibitor has the highest incidence of adverse gastrointestinal (GI) effects?
+ Donepezil (Aricept)
+ Rivastigmine (Exelon)
+ Galantamine (Reminyl)
+ Tacrine (Cognex)

Back 398

Rivastigmine (Exelon)

Front 399

The nurse is reviewing the care of patients with AD. Which factors are associated with the pathophysiology of this disease? (Select all that apply.)
*Dilation and inflammation of cranial blood vessels
*Beta-amyloid and neuritic plaques
*Neurofibrillary tangles and tau
*Autoimmune changes in the myelin sheath
*Firing of hyperexcitable neurons throughout the brain
*Neuronal degeneration and decreased acetylcholine

Back 399

Dilation and inflammation of cranial blood vessels
Neurofibrillary tangles and tau
Firing of hyperexcitable neurons throughout the brain

Front 400

According to the 2008 guidelines published by the American College of Physicians and the American Academy of Family Physicians, which statement is/are true about the drugs used to treat AD? (Select all that apply.)
*Cholinesterase inhibitors are the first-line agents for the treatment of AD.
*None of the five drugs approved is more effective than any of the others.
*Memantine (Namenda) is a promising new drug that now is a first-line agent.
*All drugs show statistically significant improvement with little clinical significance.
*Donepezil (Aricept) has fewer side effects and should be the first-line drug.

Back 400

None of the five drugs approved is more effective than any of the others.
All drugs show statistically significant improvement with little clinical significance.

Front 401

Alzheimer’s disease is a relentless illness characterized by:

Back 401

progressive memory loss, impaired thinking, neuropsychiatric symptoms, and inability to perform routine tasks of daily living.

Front 402

Major pathologic findings of Alzheimer's are:

Back 402

cerebral atrophy, degeneration of cholinergic neurons, and the presence of neuritic plaques and neurofibrillary tangles, all of which begin to develop years before clinical symptoms appear.

Front 403

The neuronal damage in AD is ___________; drugs in current use do little to relieve symptoms or prevent neuronal loss.

Back 403

irreversible

Front 404

______________, which form outside of neurons, are a hallmark of AD.

Back 404

Neuritic plaques

Front 405

Apolipoprotein E (apoE), long known for its role in cholesterol transport, may also contribute to AD. It may promote the formation of ______________.

Back 405

neurofibrillary tangles

Front 406

The major known risk factor for AD is ____________.
Female gender may be a risk factor; however, the incidence of AD in women may be higher simply because ____________________.

Back 406

advancing age
women live longer than men

Front 407

Alzheimer's symptoms progress relentlessly from mild to moderate to severe. In early stages, patients begin to experience ___________; judgment then becomes impaired, and _________________ changes may develop. As the disease progresses, patients have increasing difficulty with ______________.

Back 407

memory loss and confusion
personality
self-care

Front 408

The ______________________ were the first drugs approved by the U.S. Food and Drug Administration (FDA) to treat AD. In clinical trials these drugs produced modest improvements in cognition, behavior, and function and slightly delayed progression of the disease.

Back 408

cholinesterase inhibitors

Front 409

___________ is a first-in-class NMDA receptor antagonist. It is indicated only for moderate to severe AD. Whether it is more effective than the cholinesterase inhibitors is not yet known. However, it has proved to be ______________.

Back 409

Memantine
better tolerated

Front 410

_____________ symptoms (e.g., agitation, aggression, delusions, hallucinations) occur in more than 80% of people with AD. Although multiple drug classes—antipsychotics, cholinesterase inhibitors, mood stabilizers, antidepressants, anxiolytics, and NMDA receptor antagonists—have been tried as treatment, very few are _________, and even then benefits are _______.

Back 410

Neuropsychiatric
effective; limited

Front 411

A patient who has gastroesophageal reflux disease (GERD) is taking magnesium hydroxide (milk of magnesia). Which outcome should a nurse expect if the medication is achieving the desired therapeutic effect?
+ Neutralized gastric acid
+ Reduced stomach motility
+ Increased barrier to pepsin
+ Reduced duodenal pH

Back 411

Neutralized gastric acid

Front 412

Antacids work by neutralizing, absorbing, or buffering _________, which raises the gastric pH above ___. For patients with GERD, antacids can produce symptomatic relief.

Back 412

gastric acid; 5

Front 413

A nurse should give which nonmedication instruction to a patient who has peptic ulcers?
+ “Reduce your intake of caffeine-containing beverages, such as coffee and colas.”
+ “Take a nonsteroidal anti-inflammatory drug once a day to help with pain.”
+ “It would be better to eat five or six small meals a day instead of three larger ones.”
+ “An ulcer diet of bland foods with milk and cream products will speed healing.”

Back 413

“It would be better to eat five or six small meals a day instead of three larger ones.”

Front 414

Some optimal nondrug measures, in addition to drug management, to aid patients with peptic ulcers include changing the eating pattern to ____________ to avoid fluctuations in intragastric pH.

Back 414

more frequent, smaller meals

Front 415

A nurse monitors a patient who has peptic ulcer disease and is taking antibacterial medications. If the treatment has been effective, the patient’s breath test result should reveal the absence of what?
+ Bicarbonate
+ H. pylori
+ Histamine2
+ Prostaglandins

Back 415

H. pylori

Front 416

A nurse is planning care for a patient who has peptic ulcer disease and is taking amoxicillin (Amoxil). Which of these should the nurse establish as a therapeutic outcome?
+ Inhibition of an enzyme to block acid secretion
+ Coating of the ulcer crater as a barrier to acid
+ Selective blockade of parietal cell histamine2 receptors
+ Disruption of the bacterial cell wall, causing lysis and death

Back 416

Disruption of the bacterial cell wall, causing lysis and death

Front 417

Amoxicillin disrupts the cell wall of H. pylori, which causes lysis and death. Inhibition of an enzyme to block acid secretion is a function of the _____________. Coating of the ulcer crater as a barrier to acid is an action of ______________. Selective blockade of parietal cell histamine2 receptors is an action of the histamine2 receptor antagonists -- ___________.

Back 417

proton pump inhibitors (PPIs)
sucralfate (Carafate)
cimetidine, ranitidine, famotidine, and nizatidine

Front 418

A nurse should take which action when administering an intravenous piggyback (IVPB) of pantoprazole (Protonix) 40 mg?
+ Administer the infusion at least 1 hour before a meal
+ Avoid giving the infusion within 30 minutes of an antibacterial agent
+ Prevent precipitates by using an in-line filter
+ After reconstitution of the drug, administer the infusion over 5 minutes

Back 418

Prevent precipitates by using an in-line filter

Front 419

Pantoprazole is a ______ given to treat peptic ulcer disease. For IV therapy, an in-line filter must be used to remove any ______. The infusion may be given without regard to ______. IVPB infusions are done over ____ minutes. Giving an antibacterial agent is unrelated to IV administration.

Back 419

PPI
precipitate
food
15

Front 420

A nurse instructs a female patient with peptic ulcer disease who is to start a treatment regimen that includes ranitidine (Zantac) and bismuth subsalicylate (Pepto-Bismol). Which statement by the patient indicates that the teaching has been effective?
+ “While I’m taking these medications, my bowel movements could look black.”
+ “I have a medicine at home to take when I start having some loose diarrhea stools.”
+ “I’m so glad that my allergies will be helped while I’m taking these medications.”
+ “I’ll include more calcium and vitamin D in my diet to prevent osteoporosis.”

Back 420

“While I’m taking these medications, my bowel movements could look black.”

Front 421

Regimens for eradicating H. pylori include using two or three antibacterials with an antisecretory agent or __________ receptor antagonist. Bismuth acts topically to ________ of H. pylori. It can cause a harmless black stool discoloration. Loose stools are an adverse effect of systemic _________ such as amoxicillin (Amoxil). Ranitidine (Zantac) produces selective blockade of H2 receptors, which inhibits __________. Osteoporosis is an adverse effect of omeprazole, a __________.

Back 421

histamine2
disrupt the cell wall
antibacterials
gastric acid secretion
PPI

Front 422

A nurse administers which medication to inhibit an enzyme that makes gastric acid in a patient who has a duodenal ulcer?
+ Omeprazole (Prilosec)
+ Famotidine (Pepcid)
+ Misoprostol (Cytotec)
+ Ranitidine (Zantac)

Back 422

Omeprazole (Prilosec)

Front 423

Omeprazole causes irreversible inhibition of __________, the enzyme that generates gastric acid. It is a powerful suppressant of acid secretion. Famotidine and ranitidine block ________ on parietal cells. Misoprostol protects against ulcers caused by ________ by stimulating the secretion of mucus and bicarbonate to maintain submucosal blood flow.

Back 423

the proton pump
histamine2 receptors
nonsteroidal anti-inflammatory drugs (NSAIDs)

Front 424

Which approach should a nurse take to administer sucralfate (Carafate) to a patient with a duodenal ulcer?
+ Crush the tablet into a fine powder before mixing it with water.
+ Administer the tablet with sips of water 1 hour before meals.
+ Allow the tablet to dissolve in water before administering it.
+ Administer the tablet with an antacid for maximum benefit.

Back 424

Administer the tablet with sips of water 1 hour before meals.

Front 425

Sucralfate acts through a compound that is a ______, which adheres to an ulcer crater, creating a barrier to back-diffusion. The drug is best taken _________. The tablet form does not dissolve in water when crushed, and crushing it could reduce the effectiveness of the drug. Sucralfate acts under mildly acidic conditions; antacids raise the gastric pH above 4 and may interfere with the effects of sucralfate.

Back 425

sticky gel
on an empty stomach

Front 426

A nurse assesses a male patient who has developed gynecomastia while receiving treatment for peptic ulcers. Which medication from the patient’s history should the nurse recognize as a contributing factor?
+ Amoxicillin (Amoxil)
+ Cimetidine (Tagamet)
+ Metronidazole (Flagyl)
+ Omeprazole (Prilosec)

Back 426

Cimetidine (Tagamet)

Front 427

Cimetidine binds to _______ receptors, producing receptor blockade, which can cause enlarged breast tissue (gynecomastia), reduced libido, and impotence. All these effects reverse _______.

Back 427

androgen
when dosing stops

Front 428

A patient who has peptic ulcer disease and is receiving magnesium hydroxide (milk of magnesia) is experiencing an increased number of bowel movements. Which is the nurse’s priority action?
+ Ask the healthcare provider for a reduction in dose.
+ Encourage the patient to increase dietary fiber.
+ Administer the drug with an aluminum hydroxide antacid.
+ Instruct the patient to keep an accurate stool count.

Back 428

Administer the drug with an aluminum hydroxide antacid.

Front 429

Magnesium hydroxide is a rapid-acting antacid with a prominent adverse effect of _______. To compensate, it usually is administered in combination with aluminum hydroxide, which promotes _______.

Back 429

diarrhea
constipation

Front 430

Which instruction should the nurse give a patient who is to take bismuth subsalicylate for eradication of H. pylori?
+ “Nausea and diarrhea are common side effects.”
+ “Do not drink alcohol while taking this medication.”
+ “The drug can cause your bowel movements to be black.”
+ “Take the medication through a straw to prevent staining of your teeth.”

Back 430

“The drug can cause your bowel movements to be black.”

Front 431

Bismuth may impart a harmless black coloration to the tongue and the stool, and patients should be forewarned of this effect. Nausea and diarrhea are the most common side effects of __________, which also is used to treat H. pylori. Alcohol must be avoided when the patient is treated with __________ for H. pylori infection, because it may cause a disulfiram-like reaction. Tetracycline, which is also highly active against H. pylori, can cause staining of __________.

Back 431

clarithromycin (Biaxin)
metronidazole (Flagyl)
developing teeth

Front 432

Instruction by the nurse regarding alcohol abstinence is essential when a patient will be discharged taking which medication?
+ Tetracycline
+ Metronidazole
+ Bismuth subsalicylate
+ Clarithromycin

Back 432

Metronidazole

Front 433

A disulfiram-like reaction can occur if ________________ is used with alcohol; therefore, alcohol must be avoided during treatment with this drug.

Back 433

metronidazole

Front 434

The nurse is reviewing the prescriber’s orders and notes that omeprazole (Prilosec) has been ordered for a patient admitted with acute coronary syndrome (ACS). The nurse should be concerned if this medication is combined with which medication noted on the patient’s record?
+ Aspirin 81 mg daily
+ Clopidogrel (Plavix) 75 mg daily
+ Heparin 5000 units subQ every 12 hours
+ Metoprolol 50 mg every 8 hours

Back 434

Clopidogrel (Plavix) 75 mg daily

Front 435

The nurse reviews the patient’s medication record and notes the following: Sucralfate (Carafate) 1 gram orally four times daily before meals (7:30 AM, 11:30 AM, and 4:30 PM) and at bedtime (10:00 PM); phenytoin (Dilantin) 200 mg orally daily at 8 AM. Which modifications, if any, should be made to the medication regimen?
+ The medications can be administered as ordered.
+ The nurse should obtain a prescriber order to administer the phenytoin at 9:30 AM daily.
+ The nurse should obtain a prescriber order for intravenous phenytoin to avoid a drug interaction.
+ The nurse should administer the phenytoin with the 7:30 AM dose of sucralfate (Carafate), because this is more time efficient.

Back 435

The nurse should obtain a prescriber order to administer the phenytoin at 9:30 AM daily.

Front 436

Sucralfate can impede the absorption of ______________; therefore, a period of 2 hours should separate these drugs.
(PUD)

Back 436

phenytoin

Front 437

An 80-year-old patient with a history of renal insufficiency recently was started on cimetidine. Which assessment finding indicates that the patient may be experiencing an adverse effect of the medication?
+ +3 pitting edema
+ Pain with urination
+ New onset of disorientation to time and place
+ Heart rate changes from a baseline of 70 to 80 beats per minute (bpm) to 110 to 120 bpm

Back 437

New onset of disorientation to time and place

Front 438

Using cimetidine, effects on the central nervous system are most likely to occur in _______________. Patients may experience confusion, hallucinations, lethargy, restlessness, and seizures.

Back 438

elderly patients who have renal or hepatic impairment

Front 439

A nurse should associate which factors with the pathophysiology of peptic ulcer disease? (Select all that apply.)
*Poor submucosal gastric blood flow
*Presence of Zollinger-Ellison syndrome
*Reduced stomach production of bicarbonate
*Increased synthesis of prostaglandins
*Gastrointestinal (GI) tract colonized with Haemophilus influenzae

Back 439

Poor submucosal gastric blood flow
Presence of Zollinger-Ellison syndrome
Reduced stomach production of bicarbonate

Front 440

Peptic ulcers develop when an imbalance exists between ________________ and aggressive factors. Sufficient _____________ to cells of the GI mucosa is needed to maintain integrity. In Zollinger-Ellison syndrome, hypersecretion of acid alone causes ________ by overcoming mucosal defenses. ____________ is needed to neutralize hydrogen ions. _________________ are needed to stimulate mucus and bicarbonate to maintain mucosal blood flow. _________________ is a bacillus that can disrupt the protective mucosal layer when colonized in the GI tract.

Back 440

mucosal defensive factors
blood flow
ulcers
Bicarbonate
Prostaglandins
Helicobacter pylori

Front 441

The term peptic ulcer disease (PUD) refers to a group of upper gastrointestinal (GI) disorders characterized by _________________.

Back 441

varying degrees of erosion of the gut wall

Front 442

It is thought that H. pylori promotes ulcers through enzymatic degradation of the ______________, elaboration of a _________________ that injures mucosal cells, and infiltration of __________________ and other inflammatory cells in response to the bacterium’s presence.

Back 442

protective mucus layer
cytotoxin
neutrophils

Front 443

Aspirin and other NSAIDs inhibit the biosynthesis of ______________. By doing so, they can reduce submucosal blood flow, suppress secretion of mucus and bicarbonate, and promote secretion of ______________. Furthermore, NSAIDs can irritate the _____________ directly.

Back 443

prostaglandins
gastric acid
mucosa

Front 444

_________________ is the primary disorder in which hypersecretion of acid alone causes ulcers.

Back 444

Zollinger-Ellison syndrome

Front 445

The goals of drug therapy for PUD are to:

Back 445

(1) alleviate symptoms, (2) promote healing, (3) prevent complications, and (4) prevent recurrence

Front 446

The major drugs used to treat PUD are:

Back 446

antibiotics, antisecretory agents, mucosal protectants, antisecretory agents that enhance mucosal defenses, and antacids

Front 447

Drugs act in three basic ways to promote ulcer healing; they can

Back 447

(1) eradicate H. pylori, (2) reduce gastric acidity, and (3) enhance mucosal defenses.

Front 448

All patients with gastric or duodenal ulcers and confirmed infection with H. pylori should be treated with _________ in combination with an antisecretory agent.

Back 448

antibiotics

Front 449

Ulcer healing is evaluated by monitoring for relief of pain and by _____________________ examination of the ulcer site.

Back 449

radiologic or endoscopic

Front 450

To minimize the emergence of resistance, current guidelines recommend the use of ______________________. An antisecretory agent––proton pump inhibitor (PPI) or histamine2 receptor antagonist (H2RA)––should be included as well.
(PUD)

Back 450

at least two antibiotics and preferably three

Front 451

The histamine2 receptor antagonists (H2RAs) promote ulcer healing by ___________________. Four H2RAs are available: ______________.

Back 451

suppressing the secretion of gastric acid
cimetidine, ranitidine, famotidine, and nizatidine

Front 452

Cimetidine is a drug of choice for relieving the symptoms of ___________________.

Back 452

gastroesophageal reflux disease (GERD)

Front 453

Activation of H2 receptors, which are located on parietal cells of the stomach, promotes the secretion of gastric acid. By blocking H2 receptors, cimetidine reduces both________________ of gastric juice and its _______________. Cimetidine promotes healing of gastric and _______________ ulcers.

Back 453

the volume
hydrogen ion concentration
duodenal

Front 454

____________________ is available over the counter to treat heartburn, acid indigestion, and sour stomach.

Back 454

Cimetidine

Front 455

Elevation of gastric pH with an antisecretory agent increases the risk of pneumonia, because when gastric acidity is reduced, ______________________, resulting in a secondary increase in colonization of the respiratory tract.

Back 455

bacterial colonization of the stomach increases

Front 456

Antacids can reduce _______________ of cimetidine.

Back 456

absorption

Front 457

Ranitidine shares many of the properties of cimetidine. However, although similar to cimetidine, ranitidine differs in three important respects:

Back 457

it is more potent; it produces fewer adverse effects; and it causes fewer drug interactions.

Front 458

The PPIs are the most effective drugs available for ________________.
Indications for use include ___________________.

Back 458

suppressing gastric acid secretion
gastric and duodenal ulcers and GERD

Front 459

Although PPIs are generally well tolerated, they can increase the risk serious adverse events, including fractures, pneumonia, acid rebound and, possibly, intestinal infection with _____________.

Back 459

Clostridium difficile

Front 460

Except for therapy of hypersecretory states, treatment with omazeprole should be limited to ___________.

Back 460

4 to 8 weeks

Front 461

Long-term therapy with omazeprole, especially in high doses, increases the risk of _________________________.

Back 461

osteoporosis and fractures

Front 462

When patients stop taking PPIs, they often experience dyspepsia brought on by....

Back 462

rebound hypersecretion of gastric acid

Front 463

Sucralfate is an effective antiulcer medication notable for minimal side effects and lack of significant drug interactions. The drug promotes ulcer healing by ___________________. Sucralfate has no acid-neutralizing capacity and does not reduce acid secretion.

Back 463

creating a protective barrier against acid and pepsin

Front 464

Sucralfate is approved for ________________.

Back 464

acute and maintenance therapy of duodenal ulcers

Front 465

Sucralfate has _____________ serious adverse effects. The most significant side effect is ________________.

Back 465

no known
constipation

Front 466

Misoprostol is an analog of prostaglandin E1. In the United States, the drug’s only approved GI indication is _____________________.

Back 466

the prevention of gastric ulcers caused by long-term therapy with NSAIDs

Front 467

In normal individuals, ________________ help protect the stomach by suppressing the secretion of gastric acid, promoting the secretion of bicarbonate and cytoprotective mucus and maintaining submucosal blood flow.
Aspirin and other NSAIDs cause gastric ulcers in part by inhibiting prostaglandin biosynthesis. _________ prevents NSAID-induced ulcers by serving as a replacement for endogenous prostaglandins.

Back 467

prostaglandins
Misoprostol

Front 468

Antacids are alkaline compounds that neutralize stomach acid. Their principal indications are _______________.

Back 468

PUD and GERD

Front 469

Antacids react with gastric acid to produce _______________. By neutralizing acid, these drugs reduce________________.

Back 469

neutral salts or salts of low acidity
destruction of the gut wall

Front 470

A nurse is planning care for a patient undergoing chemotherapy. The care plan includes medications to reduce chemotherapy-induced nausea and vomiting (CINV). Which regimen should the nurse recognize as effective?
+ Scopolamine (Transderm Scôp) and lorazepam (Ativan)
+ Prochlorperazine (Compazine) and diphenhydramine (Benadryl)
+ Ondansetron (Zofran) and dimenhydrinate (Dramamine)
+ Aprepitant (Emend) and ondansetron (Zofran)

Back 470

Aprepitant (Emend) and ondansetron (Zofran)

Front 471

Regimens for preventing CINV may include medications such as a serotonin receptor antagonist (______________); the substance P/neurokinin1 antagonist aprepitant; and a benzodiazepine (______________). Scopolamine and dimenhydrinate are indicated for ___________; diphenhydramine is an antihistamine indicated for ___________________.

Back 471

ondansetron; lorazepam
motion sickness
allergic reactions

Front 472

A patient going on a vacation cruise is prescribed a scopolamine transdermal patch (Transderm Scôp) for motion sickness. The nurse teaches the patient to recognize which side effect?
+ Increased heart rate
+ Dry mouth
+ Irritability
+ Urinary frequency

Back 472

Dry mouth

Front 473

Scopolamine blocks the binding of acetylcholine with cholinergic receptors in ___________, an imbalance that is a common cause of motion sickness. The most common side effects are dry mouth, _____________, and drowsiness.

Back 473

the inner ear
blurred vision

Front 474

A patient is having high-volume output from a new ileostomy. A nurse develops a plan that includes teaching the patient to take which antidiarrheal agent?
+ Loperamide (Imodium)
+ Alosetron (Lotronex)
+ Bismuth subsalicylate (Pepto-Bismol)
+ Paregoric (camphorated opium tincture)

Back 474

Loperamide (Imodium)

Front 475

Opioids are the most effective antidiarrheal agents that activate opioid receptors in the gastrointestinal tract, thus slowing intestinal transit. This action allows more time for ___________ in the colon. Loperamide, a structural analog of ___________, is used to reduce the volume of discharge from ileostomies. Alosetron is a dangerous medication that is approved only for ___________________. Bismuth subsalicylate is effective only for ________ diarrhea.

Back 475

fluid and electrolyte absorption
meperidine
irritable bowel syndrome–diarrhea (IBS-D)
mild

Front 476

A nurse should offer which fluid choice to a patient with acute diarrhea?
+ Low-fat milk
+ Apple juice
+ Coffee with cream
+ Prune juice

Back 476

Apple juice

Front 477

Managing fluids and electrolytes is a high priority for patients with acute diarrhea because _________. Clear liquids, such as apple juice, do not irritate the gastrointestinal (GI) tract.

Back 477

risk for dehydration

Front 478

A nurse administers metoclopramide (Reglan) to a patient who is having nausea and vomiting postoperatively. The nurse should expect which therapeutic action if the medication is having the desired result?
+ Blocking of serotonin and dopamine receptors
+ Inactivation of histaminergic (H1) receptors
+ Activation of chloride channels in the intestine
+ Reduced motility in the small intestine

Back 478

Blocking of serotonin and dopamine receptors

Front 479

Metoclopramide works by blocking ___________________ receptors in the chemoreceptor trigger zone (CTZ) and by ___________________ in the small intestine. This action minimizes gastric distention and the accompanying stimulation of the vomiting center.

Back 479

serotonin and dopamine; increasing motility

Front 480

A nurse teaches a patient who has ulcerative colitis about the side effects of the treatment medication, sulfasalazine (Azulfidine). Which statement by the patient would indicate understanding of the information?
+ “My tongue may become discolored and my taste altered.”
+ “I may have constipation, so I’ll increase my fluid intake.”
+ “I’ll report any fatigue or sore throat and fever to my doctor.”
+ “I’ll immediately report any chest pain or shortness of breath.”

Back 480

“I’ll report any fatigue or sore throat and fever to my doctor.”

Front 481

Sulfasalazine is used to treat ulcerative colitis by suppressing ____________. It has the adverse hematologic effects of: ______________ Patients should report any signs of infection and/or ________________.

Back 481

inflammation
agranulocytosis, hemolytic anemia, and macrocytic anemia
fatigue

Front 482

A nurse administers palifermin to reduce oral mucositis from chemotherapy in a patient with which type of malignancy?
+ Brain
+ Breast
+ Leukemia
+ Lung

Back 482

Leukemia

Front 483

In the treatment of oral mucositis, palifermin acts through keratinocyte growth factor (KGF) receptors to stimulate the proliferation and migration of _________________. Because these receptors are not found on cells of hematopoietic origin, palifermin is used only in hematologic malignancies.

Back 483

epithelial cells

Front 484

A patient who has had a pancreatectomy is taking pancrelipase (Viokase). Which finding would the nurse use to evaluate the effectiveness of this drug?
+ Increase in flatulence
+ Reduction in fatty stools
+ Resolution of jaundice
+ Decrease in abdominal distention

Back 484

Reduction in fatty stools

Front 485

A deficiency of pancreatic enzymes through pancreatectomy or pancreatitis may compromise digestion, especially the digestion of _____. Fatty stools are characteristic of the deficiency. Replacement of pancreatic enzymes with ________ results in a reduction of fat excretion through the stools.

Back 485

fats
pancrelipase

Front 486

A nurse should teach a patient who takes alosetron (Lotronex) for diarrhea-prominent irritable bowel syndrome (IBS-D) to stop the medication immediately if the patient develops which condition?
+ Blurred vision
+ Heart palpitations
+ Bruising
+ Constipation

Back 486

Constipation

Front 487

Alosetron selectively blocks ________ receptors on neurons that innervate the viscera, thereby reducing the symptoms associated with IBS-D. Serious complications of _________ and ischemic colitis can be life-threatening.

Back 487

serotonin
constipation

Front 488

Why is intramuscular (IM) administration of promethazine (Phenergan) preferred over intravenous (IV) administration?
+ The risk of respiratory depression is eliminated with IM injection.
+ Extravasation of IV promethazine can lead to abscess formation or tissue necrosis.
+ Extrapyramidal reactions do not occur when the drug is administered IM.
+ IM injection has a more rapid onset of action.

Back 488

Extravasation of IV promethazine can lead to abscess formation or tissue necrosis

Front 489

Extravasation of IV promethazine can lead to ________ formation, tissue ____________, and gangrene, leading to __________; therefore, IV administration should be avoided. Respiratory depression and extrapyramidal side effects can occur regardless of the route of administration.

Back 489

abscess; necrosis; amputation

Front 490

An adult patient in a physician’s office reports severe diarrhea after returning from a trip to Mexico. Which medication might be prescribed for this patient?
+ Ciprofloxacin (Cipro) 500 mg twice daily
+ Sulfasalazine (Azulfidine) 500 mg daily
+ Metoclopramide (Reglan) 10 mg three times daily 30 minutes before meals and at bedtime
+ Ondansetron (Zofran) 8 mg three times daily

Back 490

Ciprofloxacin (Cipro) 500 mg twice daily

Front 491

Traveler’s diarrhea, when severe, can be treated with _______________. Sulfasalazine is indicated for the treatment of _______________; it is not used for the treatment of infection. Oral metoclopramide, a prokinetic agent, is administered for the treatment of __________. Ondansetron is used for the treatment of ____________.

Back 491

ciprofloxacin, levofloxacin, or norfloxacin
mild to moderate ulcerative colitis
diabetic gastroparesis and suppression of gastroesophageal reflux
emesis related to chemotherapy, radiation, and anesthetic agents.

Front 492

Which medication is useful for stimulating the appetite in patients with acquired immunodeficiency syndrome (AIDS)?
+ Aprepitant (Amend)
+ Ondansetron (Zofran)
+ Dronabinol (Marinol)
+ Metoclopramide (Reglan)

Back 492

Dronabinol (Marinol)

Front 493

Dronabinol is used to stimulate the appetite in patients with ______. It is administered before lunch and dinner. Aprepitant, ondansetron, and metoclopramide are used to prevent and treat ______.

Back 493

AIDS
emesis

Front 494

Which medications are used in the treatment plan for chemotherapy-induced nausea and vomiting? (Select all that apply.)
*Lorazepam (Ativan)
*Meclizine (Antivert)
*Dolasetron (Anzemet)
*Loperamide (Imodium)
*Dexamethasone (Decadron)

Back 494

Lorazepam (Ativan)
Dolasetron (Anzemet)
Dexamethasone (Decadron)

Front 495

Lorazepam, a benzodiazepine, is used in combination regimens to suppress ______. Dolasetron and dexamethasone also are used in the treatment of ______. Meclizine is most often used to treat _________, and loperamide is used to treat ______________.

Back 495

Chemotherapy Induced Nauea and Vomiting (CINV)
CINV
motion sickness
diarrhea

Front 496

What must be in place before alosetron (Lotronex) can be prescribed for a patient with IBS-D? (Select all that apply.)
*Intestinal obstruction has been ruled out.
*The patient is aware of the signs and symptoms of ischemic colitis.
*The physician is enrolled in a prescriber program for alosetron.
*The patient has signed a Patient-Physician Agreement.
*The patient’s IBS-D has lasted at least 2 months and has not responded to conventional treatment.

Back 496

Intestinal obstruction has been ruled out.
The patient is aware of the signs and symptoms of ischemic colitis.
The physician is enrolled in a prescriber program for alosetron.
The patient has signed a Patient-Physician Agreement.

Front 497

__________ is contraindicated in patients with intestinal obstruction. The drug is approved for use in female patients only with severe IBS-D that has lasted for 6 months or longer and has not responded to conventional treatment.

Back 497

Alosetron

Front 498

Emesis is a complex reflex brought about by activation of the ________, a nucleus of neurons in the medulla oblongata.

Back 498

vomiting center

Front 499

Serotonin receptor antagonists are the most effective drugs available for suppressing nausea and vomiting caused by cisplatin and other highly emetogenic ________ drugs, radiation therapy, anesthesia, viral gastritis, and pregnancy. Four serotonin antagonists are available for treating emesis: _________

Back 499

anticancer
ondansetron, granisetron, dolasetron, and palonosetron

Front 500

______________ was the first serotonin receptor antagonist approved for chemotherapy-induced nausea and vomiting (CINV). The drug is also used to prevent nausea and vomiting associated with radiotherapy and anesthesia. In addition, the drug is used off-label to treat nausea and vomiting from other causes, including childhood viral gastritis and morning sickness of pregnancy.

Back 500

Ondansetron

Front 501

Ondansetron is very effective by itself and even more effective when combined with _________________.
Its most common side effects are _____________.

Back 501

dexamethasone
headache, diarrhea, and dizziness

Front 502

Two glucocorticoids—__________—are commonly used to suppress CINV.

Back 502

methylprednisolone and dexamethasone

Front 503

____________ is used in combination regimens to suppress CINV.
The drug has three principal benefits: sedation, suppression of anticipatory emesis, and production of anterograde amnesia.

Back 503

Lorazepam

Front 504

The phenothiazines suppress emesis by _______________.
These drugs can reduce emesis associated with surgery, cancer chemotherapy, and toxins.

Back 504

blocking dopamine2 receptors in the CTZ

Front 505

__________________ is the most widely used antiemetic in young children, despite its dangers (respiratory depression and local tissue injury) and despite the availability of safer alternatives (e.g., ondansetron). Respiratory depression from can be severe. Deaths have occurred.

Back 505

promethazine

Front 506

Two butyrophenones are used as antiemetics. What are they? How doe they suppress emesis?

Back 506

haloperidol and droperidol;
The butyrophenones suppress emesis by blocking dopamine2 receptors in the CTZ.

Front 507

Metoclopramide suppresses emesis through ________.

Back 507

blockade of dopamine receptors in the CTZ (chemoreceptor trigger zone)

Front 508

Many anticancer drugs cause severe nausea and vomiting, leading to ______. Worse yet, these reactions can be so intense that patients may ____________________ rather than endure further discomfort.

Back 508

dehydration, electrolyte imbalances, nutrient depletion, and esophageal tears
discontinue chemotherapy

Front 509

Chemotherapy is associated with three types of emesis:

Back 509

(1) anticipatory, (2) acute, and (3) delayed.

Front 510

Antiemetics are more effective at _______ CINV than at _______ CINV that has already begun. Accordingly, antiemetics should be administered ____________ chemotherapy.

Back 510

preventing
suppressing
before

Front 511

Nausea and vomiting of pregnancy (NVP) is extremely common, especially during the _____ trimester.
NVP can be managed with drugs and with nondrug measures. First-line drug therapy consists of a two-drug combination:

Back 511

first
doxylamine plus vitamin B6

Front 512

Motion sickness can be caused by sea, air, automobile, and space travel. Symptoms are ___________. Drug therapy is most effective when given ________________ rather than after symptom onset. _______________, a muscarinic antagonist, is the most effective drug for preventing and treating motion sickness.

Back 512

nausea, vomiting, pallor, and cold sweats
prophylactically
Scopolamine

Front 513

The benefits of scopolamine (for motion sickness) derive from suppression of nerve traffic in the neuronal pathway that connects _________. The most common side effects are ___________.

Back 513

the vestibular apparatus of the inner ear to the vomiting center
dry mouth, blurred vision, and drowsiness

Front 514

The antihistamines used most often for motion sickness are:

Back 514

dimenhydrinate, meclizine, and cyclizine

Front 515

Suppression of motion sickness appears to result from blocking of _________ in the neuronal pathway that connects the inner ear to the vomiting center.

Back 515

histaminergic (H1) and muscarinic cholinergic receptors

Front 516

The most prominent side effect of the antihitamines used for motion sickness—sedation—results from blocking of ________ receptors. Other side effects—dry mouth, blurred vision, urinary retention, and constipation—result from blocking of ________ receptors.

Back 516

H1
muscarinic

Front 517

Diarrhea is characterized by stools of excessive _________ and by increased frequency of defecation. Management is directed at:

Back 517

volume and fluidity
(1) diagnosis and treatment of the underlying disease, (2) replacement of lost water and salts, (3) relief of cramping, and (4) reducing passage of unformed stools.

Front 518

________ are the most effective antidiarrheal agents available.

Back 518

Opioids

Front 519

Several opioid preparations—diphenoxylate, difenoxin, loperamide, paregoric, and opium tincture—are approved for diarrhea. Of these, ________ are the most frequently used.

Back 519

diphenoxylate and loperamide

Front 520

Diphenoxylate is an opioid used only for _________. It is formulated in combination with atropine. The atropine is present to ________; doses of the combination that are sufficiently high to produce euphoria from the diphenoxylate would ____________.

Back 520

diarrhea
discourage diphenoxylate abuse
produce unpleasant side effects from the correspondingly high dose of atropine

Front 521

Loperamide is a structural analog of meperidine. The drug is used to treat diarrhea and to reduce the volume of discharge from _____________.

Back 521

ileostomies

Front 522

For infectious diarrhea, antibiotics should be administered only when clearly indicated. Indiscriminate use of antibiotics is undesirable in that...

Back 522

(1) it can promote the emergence of antibiotic resistance; and (2) it can produce an asymptomatic carrier state by killing most, but not all, of the infectious agents.

Front 523

Several measures can reduce the acquisition of traveler’s diarrhea. Two measures are highly effective.

Back 523

avoiding local drinking water and carefully washing foods

Front 524

Clostridium difficile is a gram-positive, anaerobic bacillus that infects the bowel. Injury results from ________. Symptoms range from relatively mild to very severe, even death.

Back 524

the release of bacterial toxins

Front 525

______________________________ is the most common disorder of the GI tract.

Back 525

Irritable bowel syndrome (IBS)

Front 526

Only three drugs are approved for IBS:

Back 526

alosetron (approved for diarrhea-predominant IBS, IBS-D) and lubiprostone and tegaserod (both approved for constipation-predominant IBS, IBS-C)

Front 527

Owing to a risk of serious cardiovascular events, ________ is used rarely and then only in emergency situations. Alosetron is a potentially dangerous drug approved for severe IBS-D________.

Back 527

tegaserod
in women

Front 528

IBS-D is considered severe if the patient experiences one or more of the following:

Back 528

(1) frequent and severe abdominal pain or discomfort,
(2) frequent bowel urgency or fecal incontinence, and
(3) disability or restriction of daily activities because of IBS

Front 529

______________ causes selective blockade of type 3 serotonin receptors (5-HT3 receptors), which are found primarily on neurons that innervate the viscera. In patients with IBS-D, _____________ can reduce abdominal pain, increase colonic transit time, reduce intestinal secretions, and increase absorption of water and sodium.

Back 529

Alosetron; alosetron

Front 530

Although alosetron is generally well tolerated, it can cause severe adverse effects. Deaths have occurred. The most common problem is __________, which can be complicated by impaction, bowel obstruction, and perforation. In addition, alosetron can cause ischemic colitis.

Back 530

constipation

Front 531

Inflammatory bowel disease (IBD) has two forms:

Back 531

Crohn’s disease and ulcerative colitis.

Front 532

Crohn’s disease is characterized by transmural inflammation and usually affects __________, but it also can affect all other parts of the GI tract. Ulcerative colitis is characterized by inflammation of the mucosa and submucosa of __________.

Back 532

the terminal ileum
the colon and rectum

Front 533

Five types of drugs are used in IBD therapy:___________________________________. None of these drugs is curative; at best, drugs may control the disease process.

Back 533

5-aminosalicylates, glucocorticoids, immunosuppressants, immunomodulators, and antibiotics

Front 534

The _____________________ are used to treat mild or moderate ulcerative colitis and Crohn’s disease and to maintain remission after symptoms have subsided.

Back 534

5-aminosalicylates (5-ASA)

Front 535

Sulfasalazine is not used to treat infections. Its only approved indications are _________________________.

Back 535

IBD and rheumatoid arthritis

Front 536

Glucocorticoids can relieve symptoms of ulcerative colitis and Crohn’s disease. Their benefits derive from __________.

Back 536

anti-inflammatory actions

Front 537

Glucocorticoids are indicated primarily for induction of remission, not for ____________________.
______________________ are used for long-term therapy of selected patients with ulcerative colitis and Crohn’s disease.

Back 537

long-term maintenance
Immunosuppressants

Front 538

Prokinetic drugs (e.g., metoclopramide) increase the tone and motility of the GI tract. Indications include __________________________ (3).

Back 538

gastroesophageal reflux disease (GERD), CINV, and diabetic gastroparesis

Front 539

Metoclopramide has two beneficial actions—it increases ___________________ and suppresses _____________________.

Back 539

upper GI motility
emesis

Front 540

Palifermin is the first drug to be approved for reducing ____________, a serious and painful complication of cancer chemoradiotherapy.

Back 540

oral mucositis (OM)

Front 541

Palifermin acts through keratinocyte growth factor (KGF) receptors (which are not found on cells of hematopoietic origin) and stimulates proliferation, differentiation, and migration of _____________ cells.

Back 541

epithelial