Question 1

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

Accepted Answer

Allopurinol is a medication frequently used in the prevention of gout. Gout is a buildup of uric acid deposited in the joints that causes pain and inflammation. The medication helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones. Any rash in a client taking allopurinol, even if mild, should be reported immediately to the HCP. The nurse should direct the client to stop taking the medication immediately, schedule an appointment, and notify the HCP. A rash caused by allopurinol may be followed by more severe hypersensitivity reactions that can be fatal, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Option A) Allopurinol can take several months to become effective. Its primary use is to prevent gout attacks; it is not effective in treating acute attacks. The client will need to continue to take anti-inflammatory drugs (eg, nonsteroidal anti-inflammatory drugs or colchicine) for acute attacks. (Option B) Clients are directed to take allopurinol with a full glass of water and to increase daily fluid intake to prevent kidney stones. This will cause an increase in urination and is an expected outcome. (Option D) Nausea can be prevented by instructing the client to take the medication with food or following a meal. Educational objective: The nurse should direct the client taking allopurinol for gout to immediately discontinue the medication and report to the HCP if any rash develops. Allopurinol-induced rashes can develop into severe and sometimes fatal hypersensitivity reactions, such as Stevens-Johnson syndrome. Similar instructions should be given to clients taking anticonvulsants (eg, carbamazepine, phenytoin, lamotrigine) and sulfa antibiotics.

Question 2

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action?

Accepted Answer

Tricyclic antidepressants (eg, amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side effects are especially common in elderly clients. 11ecbb05_cc9b_67a8_b433_f1b3e76161e9_MD0009_00 Due to the increased risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position. (Options A, B, and D) These are important instructions but not priority ones. Educational objective: The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.

Question 3

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client?

Accepted Answer

Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). (Option A) Biosynthesis of uric acid occurs in the liver, and antigout medications are excreted via the kidneys; therefore, liver and renal function should be checked periodically. In addition, blood counts should be monitored as some antigout medications can cause blood dyscrasias. This is important but does not have priority over the daily need for increased fluids. (Option B) This is a common instruction given about the storage of many medications. It helps to ensure potency of the medication and prevent deterioration. (Option C) Taking allopurinol with food or after a meal can help to prevent gastric upset. Educational objective: It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

Question 4

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification?

Accepted Answer

Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option B) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option C) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option D) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue. Educational objective: Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia).

Question 5

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain?

Accepted Answer

11ecbb05_cc9d_3c69_b433_633732f1b0b8_MD0009_00 St. John's wort is an herbal product commonly used by many clients to treat depression. However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs). Taking St. John's wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome. Serotonin is a chemical produced by the body that is needed for the nerve cells and brain to function. Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated. (Option B) The nurse can ask the client if a diagnosis of depression has been made by an HCP, but inquiring about possible medications that can interact with St. John's wort is more important at this time. (Option C) St. John's wort may interfere with the absorption of iron and other minerals. This is a teaching point, but it is not the highest priority question to ask the client. (Option D) St. John's wort can cause photosensitivity which could be exacerbated by use of tanning beds. However, this is not the highest priority question to ask the client. Educational objective: St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome.

Question 6

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones.  Which herbal supplement might help synchronize the body to environmental time?

Accepted Answer

Melatonin supplements are thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most practitioners agree that the lowest possible dose should be used and should be taken only for a short time. There are no long-term studies on the safety of melatonin. Higher doses may cause side effects such as vivid dreams and nightmares. Research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy, and alertness. (Option A) Evening primrose may be used for eczema or skin irritations. (Option B) Ginseng is used to promote mental alertness and enhance the immune system. (Option D) St. John's wort is used for treatment of depression. It has many interactions with other prescription medications. Educational objective: Short-term use of low-dose melatonin may be considered to treat jet lag and fatigue from traveling across time zones.

Question 7

A client with seizure disorder is prescribed a moderately high dose of phenytoin.  Which teaching topic should the nurse discuss with this client?

Accepted Answer

11ecbb05_cc9d_b19a_b433_05e056b3cc7a_MD0009_00 The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). (Option A) Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic acid and calcium should be recommended. (Option C) Clients who use anticoagulants (eg, warfarin, rivaroxaban, apixaban) should avoid cuts and preferably use an electric razor for shaving. (Option D) Exposure of the eyes to ultraviolet light and use of corticosteroids are risk factors for cataract development. Educational objective: The nurse should encourage the client taking phenytoin to perform good oral hygiene and visit the dentist regularly to prevent gingival hyperplasia. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis).

Question 8

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO₂ 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug?

Accepted Answer

Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines. (Option A) Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. (Option C) Naloxone (Narcan) is the antidote drug to reverse the effects of opioids. (Option D) Phentolamine (Regitine) is the antidote drug used to treat a norepinephrine (Levophed) extravasation. Educational objective: Flumazenil is a drug used to reverse the sedative effects of benzodiazepines such as midazolam.

Question 9

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours?

Accepted Answer

Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option A) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option B) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option C) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective: Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min.

Question 10

The home health nurse reviews the serum laboratory test results for a client with seizures.  The phenytoin level is 27 mcg/mL.  The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider?

Accepted Answer

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option B) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option C) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option D) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

Question 11

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation.  What complications of this procedure should the nurse be aware of for monitoring and teaching?

Accepted Answer

Botulinum toxin type A (Botox) blocks neuromuscular transmission by inhibiting acetylcholine release from nerve endings. The drug is used for treating wrinkles, blepharospasm, and cervical dystonia. Complications are uncommon when Botox is used for cosmetic purposes but can be life-threatening if they occur. The toxin can also relax the muscles used for swallowing and breathing, resulting in dysphagia (aspiration risk) and respiratory paralysis. (Options A and B) Botulism can be associated with constipation and urinary retention due to relaxation of smooth muscle. Unlike in Clostridium tetani infection (tetanus), painful rigidity and spasms of the neck, back, and abdominal muscles are absent. (Option D) Ataxia and hand tremor usually indicate drug toxicity (eg, phenytoin, lithium). Educational objective: Botulinum toxin type A (Botox) inhibits the release of acetylcholine from nerve endings and causes relaxation of skeletal/smooth muscles. On occasion, surrounding muscle weakness can lead to dysphagia and respiratory paralysis.

Question 12

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA?

Accepted Answer

Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option A). (Option B) A client's history of stroke or head trauma in the last 3 months could exclude tPA use. (Option C) The nurse should determine when the client first developed stroke symptoms. tPA can be administered if symptoms started within the last 3 to 4½ hours or based on facility guidelines. (Option D) Current anticoagulant use may exclude a client from receiving tPA. The duration of action for warfarin is 2-5 days; this client can safely receive tPA as warfarin was discontinued 4 weeks ago. However, if pending coagulation studies drawn prior to tPA administration are elevated, the infusion may be discontinued. Educational objective: Tissue plasminogen activator (tPA) dissolves clots in an ischemic stroke and must be administered within a 3- to 4½-hour window from onset of symptoms. The nurse assesses for contraindications to tPA due to the risk of hemorrhage.

Question 13

A client with a brain tumor is admitted for surgery.  The health care provider prescribes levetiracetam.  The client asks why.   What is the nurse's response?

Accepted Answer

Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option A) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option C) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option D) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors.

Question 14

The nurse reviews the analgesia prescriptions for assigned clients.  The nurse should question the health care provider about which prescription?

Accepted Answer

A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied. (Option A) A lidocaine 5% transdermal patch provides a localized, topical anesthetic to intact skin. It is commonly prescribed for clients with chronic postherpetic neuralgia, a painful, debilitating condition that can develop following a herpes zoster (shingles) infection. (Option B) The client with opioid abuse history would be experiencing the same type and degree of pain as other clients with a fractured femur. However, a higher dose or a stronger opioid analgesic (eg, hydromorphone) is needed for pain relief due to the client's increased opioid tolerance. (Option C) Tramadol is a synthetic opioid analgesic prescribed to treat moderate to severe postoperative pain. It is appropriate to prescribe at discharge as it has fewer complications related to respiratory depression compared with other opioids. Educational objective: A transdermal fentanyl patch is indicated to treat moderate to severe chronic pain. It is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.

Question 15

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription?

Accepted Answer

Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider (Option C). (Option A) A blood urea nitrogen level of 12 mg/dL (4.28 mmol/L) is a normal value (normal range 6-20 mg/dL [2.1-7.1 mmol/L]). (Option B) Sumatriptan is not contraindicated for underweight or overweight clients. (Option D) Sumatriptan is not contraindicated with alprazolam therapy. However, because of its serotonergic effects, clients already taking selective serotonin reuptake inhibitors (eg, sertraline, paroxetine) or selective norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) should be monitored for signs of serotonin syndrome. Educational objective: Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.

Question 16

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider.  Which intervention does the nurse add to this client's care plan?

Accepted Answer

11ecbb05_cc9a_cb67_b433_05039919bc3e_MD0009_00 Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: Oral care - use a small, soft-bristled toothbrush or a warm mouth wash Use lukewarm water; avoid beverages or food that are too hot or cold (Option A) Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option B) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option C) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain. Educational objective: The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine.Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat.

Question 17

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication?

Accepted Answer

Phenytoin (Dilantin) is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. The nurse's priority action is to stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing calcium (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can decrease the absorption and the serum level of this drug. (Option A) Unless clients have renal insufficiency, renal function tests are not routinely monitored during prescribed phenytoin therapy. Phenytoin is metabolized in the liver and can cause liver damage. Monitoring of liver function test during therapy is recommended. (Option B) Flushing the tube with 30-50 mL of water before and after administering phenytoin is recommended to minimize drug loss and drug-drug incompatibility. Flushing with normal saline before and after drug administration is recommended in clients receiving intravenous (IV) phenytoin. (Option D) BP is not usually affected in clients prescribed oral phenytoin therapy for seizure disorders. However, IV phenytoin can cause hypotension and arrhythmias. Educational objective: Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

Question 18

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago.  Today, the client has a serum phenytoin level of 32 mcg/mL (127 mcmol/L).  The nurse notifies the health care provider and expects which prescription?

Accepted Answer

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin range is 10-20 mcg/mL (40-79 mcmol/L). In the presence of an elevated phenytoin level (32 mcg/mL [127 mcmol/L]), the nurse anticipates that the health care provider will prescribe a decreased daily dose (Option B). The nurse should continue to monitor for signs of toxicity, typically presenting as neurological manifestations (eg, ataxia, nystagmus, slurred speech, decreased mentation). (Options A and C) The serum phenytoin level is above the therapeutic level, so administering the prescribed dose or increasing the dose can further increase the risk for drug-induced toxicity. (Option D) Repeating the serum phenytoin level in 2 hours will not result in a significant change because the average half-life of the drug is 22 hours. Educational objective: Phenytoin (Dilantin) is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when serum phenytoin levels exceed the therapeutic range (10-20 mcg/mL [40-79 mcmol/L]).

Question 19

A client is receiving scheduled doses of carbidopa-levodopa.  The nurse evaluates the medication as having the intended effect if which finding is noted?

Accepted Answer

Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably. (Option A) Carbidopa-levodopa does not improve memory. Medications for the treatment of Alzheimer disease, such as donepezil and rivastigmine, are used to improve cognition and memory. (Options C and D) Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions, agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care providers usually start the medications at low doses and gradually increase them to prevent these effects. Educational objective: The combination medication carbidopa-levodopa is most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as doing so can lead to akinetic crisis (complete loss of movement).

Question 20

The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history?

Accepted Answer

Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk (Option A). (Option B) Cervical spine problems should be assessed before the intubation. Low back pain history is not a priority for general anesthesia. (Option C) It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. (Option D) History of prior opioid intake may be helpful, but the most important question is to ask about side effects and allergies. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives had ever experienced an adverse reaction to general anesthesia, including unexplained death.

Exam 8: Pharmacology

A client with gout who was started on allopurinol a week ago calls the health care provider's (HCP's) office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action?

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client?

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification?

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain?

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time?

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client?

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours?

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider?

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. What complications of this procedure should the nurse be aware of for monitoring and teaching?

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA) . Which client statement would be most important to clarify before administering tPA?

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response?

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription?

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription?

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan?

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication?

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago. Today, the client has a serum phenytoin level of 32 mcg/mL (127 mcmol/L) . The nurse notifies the health care provider and expects which prescription?

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?

The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history?