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46. A first-time parent of a 6-week-old infant tells the nurse that she feels anxious and sad, cries a lot, and has difficulty sleeping. What will the nurse do?

a. Ask her to complete the Edinburgh Postnatal Depression Scale.
b. Reassure her that the "baby blues" are normal after childbirth.
c. Suggest that she get more sleep and try to increase her activity.
d. Suggest that she talk to her provider about using an SSRI.

a. Ask her to complete the Edinburgh Postnatal Depression Scale.

Women who experience depressive symptoms after childbirth can be screened using a quick test: the Edinburgh Postnatal Depression Scale, which may be administered 6 to 8 weeks after delivery. Reassuring her that her feelings are normal does not acknowledge her concerns; also, without objective screening, this reassurance may not be warranted. Increased sleep and activity may help, but screening is necessary to determine the severity of the depression. Until the patient is diagnosed as having postpartum depression, an SSRI is not indicated.

47. A patient is brought to the emergency department after taking a handful of TCA pills. The nurse will expect to provide what when caring for this patient? (Select all that apply.)

a. Cardiac monitoring
b. Cholinesterase inhibitors
c. Gastric lavage and activated charcoal
d. Sedative medications
e. Procainamide

a. Cardiac monitoring
b. Cholinesterase inhibitors
c. Gastric lavage and activated charcoal

Patients who overdose with a TCA should have cardiac monitoring, because cardiac side effects can occur. Cholinesterase inhibitors are given to counteract anticholinergic side effects. Gastric lavage followed by activated charcoal can reduce absorption of the TCA. Sedative drugs would only increase the sedative effects of the TCA. Procainamide causes cardiac depression and is not recommended to treat TCA dysrhythmias.

48. Which patients are candidates for MAOIs? (Select all that apply.)

a. Patients who have not responded to SSRIs and TCAs
b. Patients with atypical depression
c. Patients with bulimia nervosa
d. Patients with hypotension
e. Patients with postpartum depression

a. Patients who have not responded to SSRIs and TCAs
b. Patients with atypical depression
c. Patients with bulimia nervosa

Patients who have not responded to SSRIs or TCAs, patients with atypical depression, and patients with bulimia nervosa are candidates for MAOIs. MAOIs contribute to hypotension and therefore are contraindicated in patients with hypotension. MAOIs are not recommended for the treatment of postpartum depression.

49. A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol (Haldol) and finds the patient having facial spasms. The patient's head is thrust back, and the patient is unable to speak. What will the nurse do?

a. Administer the haloperidol as ordered.
b. Discuss increasing the haloperidol dose with the provider.
c. Request an order to give diphenhydramine.
d. Request an order to give levodopa.

c. Request an order to give diphenhydramine.

An early reaction to antipsychotic drugs is acute dystonia. Initial treatment consists of an anticholinergic medication, such as diphenhydramine. Administering more antipsychotic medication would increase the symptoms and could be life threatening. Levodopa is not given for extrapyramidal symptoms, because it could counteract the beneficial effects of antipsychotic treatment.

50. A patient who is taking an antipsychotic drug for schizophrenia comes to the clinic for evaluation. The nurse observes that the patient has a shuffling gait and tremors and is drooling. The nurse will ask the patient's provider about which course of action?

a. Administering a direct dopamine antagonist
b. Giving an anticholinergic medication
c. Increasing the dose of the antipsychotic drug
d. Stopping the antipsychotic drug

b. Giving an anticholinergic medication

The patient is showing signs of parkinsonism, an extrapyramidal effect associated with antipsychotic medications. Anticholinergic medications are indicated. A direct dopamine antagonist would counter the effects of the antipsychotic and remove any beneficial effect it has. Increasing the dose of the antipsychotic medication would only worsen the extrapyramidal symptoms. Stopping the antipsychotic medication would cause the symptoms of schizophrenia to worsen.

51. A patient taking a first-generation antipsychotic (FGA) medication develops severe parkinsonism and is treated with amantadine (Symmetrel). The amantadine is withdrawn 2 months later, and the parkinsonism returns. The nurse will expect the provider to:

a. give anticholinergic medications.
b. make a diagnosis of idiopathic parkinsonism.
c. resume the amantadine indefinitely.
d. try a second-generation antipsychotic (SGA).

d. try a second-generation antipsychotic (SGA).

Neuroleptic-induced parkinsonism is treated with some of the same drugs used for idiopathic parkinsonism, such as amantadine. If parkinsonism is severe, switching to an SGA may help, because the risk of parkinsonism is much lower with these drugs. An anticholinergic medication may be used initially. A recurrence of parkinsonism when the drug is withdrawn does not indicate idiopathic parkinsonism. These drugs should not be used indefinitely

52. A nurse and a nursing student are discussing the plan of care for a patient with schizophrenia. The patient, who has been taking a high-potency FGA for 2 months, has become restless and constantly needs to be in motion. Which statement by the student indicates a need for further education?

a. "Anticholinergic medications may help control these symptoms."
b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA."
c. "The provider may try a low-potency FGA instead of the high-potency FGA."
d. "This patient may need to take a benzodiazepine or a beta blocker."

b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA."

The patient is showing signs of akathisia, which can resemble an exacerbation of psychosis. If the two are confused and the provider orders more of the FGA, the symptoms may actually increase. Anticholinergic medications may be used, a low-potency FGA may be ordered, or a benzodiazepine or beta blocker may be prescribed.

53. A patient is taking an FGA for schizophrenia. The nurse notes that the patient has trouble speaking and chewing and observes slow, wormlike movements of the patient's tongue. The nurse recognizes which adverse effect in this patient?

a. Acute dystonia
b. Akathisia
c. Parkinsonism
d. Tardive dyskinesia

d. Tardive dyskinesia

Tardive dyskinesia can occur in patients during long-term therapy with FGAs. This patient shows signs of this adverse effect. Acute dystonia is characterized by severe spasm of muscles in the face, tongue, neck, or back and by opisthotonus. Akathisia is characterized by constant motion. Parkinsonism is characterized by bradykinesia, drooling, tremor, rigidity, and a shuffling gait.

54. A nurse provides teaching for a patient about to begin taking a first-generation antipsychotic drug for schizophrenia. Which statement by the patient indicates a need for further teaching about side effects of these drugs?

a. "Anticholinergic effects are uncommon with this medication."
b. "I may experience gynecomastia and galactorrhea."
c. "I may feel lightheaded or dizzy and should sit or lie down if this occurs."
d. "Sedation may occur initially, but will subside in 1 to 2 weeks."

a. "Anticholinergic effects are uncommon with this medication."

Anticholinergic effects are common with FGAs, so this statement indicates a need for further teaching. Neuroendocrine effects, orthostatic hypertension, and sedation can occur with FGAs.

55. A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine (Clozaril). The nurse teaches the family about the medication and its side effects. Which statement by a family member indicates a need for further teaching about this drug?

a. "Blood counts are necessary for several weeks after discontinuation of the drug."
b. "Fever, sore throat, and sores in the mouth should be reported immediately."
c. "If the ANC is less than 3000, the drug will be discontinued permanently."
d. "Use of this drug requires weekly evaluation of blood work."

c. "If the ANC is less than 3000, the drug will be discontinued permanently."

Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal of the drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported immediately.

56. A patient with schizophrenia receives a dose of risperidone (Risperdal Consta) IM. The nurse teaching this patient about this medication will make which statement?

a. "You will experience therapeutic levels of this drug in 1 to 2 weeks."
b. "You will need injections of this drug every 6 weeks."
c. "You will need to take an oral antipsychotic drug for 3 weeks."
d. "You probably will not have extrapyramidal symptoms with this drug."

c. "You will need to take an oral antipsychotic drug for 3 weeks."

Risperidone given intramuscularly is a depot preparation used for long-term therapy. Significant release of the drug does not occur until 2 to 3 weeks after injection; therefore, patients must take an oral antipsychotic medication until drug levels are raised. Therapeutic levels are reached 4 to 6 weeks after injection. Patients need injections every 2 weeks. With IM dosing, the incidence of extrapyramidal symptoms is substantial.

57. A patient with schizophrenia has been taking an oral FGA for 1 week. The patient has been taking the drug daily in two divided doses. The individual complains of daytime drowsiness. The patient's family reports a decrease in the person's hostility and anxiety but states that the patient remains antisocial with disordered thinking. What will the nurse tell the patient and the family?

a. An increased dose of the drug may be needed.
b. Intramuscular dosing may be needed.
c. Some symptoms take months to improve.
d. The entire dose may be taken at bedtime.

c. Some symptoms take months to improve.

When patients begin therapy with antipsychotic medications, some symptoms resolve sooner than others. During the first week, agitation, hostility, anxiety, and tension may resolve, but other symptoms may take several months to improve. It is not necessary to increase the dose in the first week. IM dosing is indicated for patients with severe, acute schizophrenia and for long-term maintenance. Sedation is normal, and once an effective dose has been determined, the entire dose can be taken at bedtime, but not in the initial days of therapy.

58. A patient in whom drug therapy has failed several times in the past is readmitted to a hospital to begin therapy for schizophrenia. What will the nurse do to help improve adherence?

a. Encourage the patient to take responsibility for medication management.
b. Teach the patient about drug side effects and how to manage them.
c. Tell the patient that an abstinence syndrome will occur if the drug is stopped.
d. Tell the patient that the drug may be taken as needed to control symptoms.

b. Teach the patient about drug side effects and how to manage them.

One way to promote adherence to a medication regimen is to teach patients about drug side effects and how to minimize undesired responses. Family members should be encouraged to oversee medication management for outpatients, because patients themselves may fail to appreciate the need for therapy or may be unwilling to take prescribed medications. It is not true that an abstinence syndrome occurs when these drugs are withdrawn. These drugs are not used PRN; they must be given on a regular basis.

59. A nurse in a mental health hospital finds a patient with schizophrenia who takes haloperidol (Haldol) lying rigid in bed with a temperature of 41.3° C. A cardiac monitor shows cardiac dysrhythmias. What will be included in the treatment of this patient? (Select all that apply.)

a. Anticholinergic medications
b. Beta blockers
c. Dantrolene
d. Intravenous fluids
e. Withdrawal of haloperidol

c. Dantrolene
d. Intravenous fluids
e. Withdrawal of haloperidol

Neuroleptic malignant syndrome is characterized by "lead pipe" rigidity, sudden high fever, and autonomic instability. Treatment requires supportive measures, drug therapy, and immediate withdrawal of the antipsychotic medication. Dantrolene is used to relax muscles and reduce heat production. Intravenous fluids are used to maintain hydration. Anticholinergic medications and beta blockers are not helpful.

60. Which side effects are more common in second-generation antipsychotic medications than in first-generation antipsychotic medications? (Select all that apply.)

a. Agranulocytosis
b. Anticholinergic effects
c. Extrapyramidal symptoms
d. Metabolism by CYP3A4
e. Prolactin elevation

a. Agranulocytosis
b. Anticholinergic effects
d. Metabolism by CYP3A4

SGAs are more likely than FGAs to cause agranulocytosis and anticholinergic effects and are metabolized by CYP3A4 enzymes. They are not more likely to cause extrapyramidal effects or prolactin elevation.

61. What are negative symptoms of schizophrenia? (Select all that apply.)

a. Delusions
b. Disordered thinking
c. Poor judgment
d. Poor self-care
e. Poverty of speech

c. Poor judgment
d. Poor self-care
e. Poverty of speech

Poor judgment, poor self-care, and poverty of speech are all negative symptoms of schizophrenia. Delusions and disordered thinking are positive symptoms.

62. A parent reports being afraid that a child may have schizophrenia because of disorganized speech and asocial behaviors. The nurse will tell this parent that which of the following must also be present to make a diagnosis? (Select all that apply.)

a. A decrease in self-care, job, or school function
b. A history of substance abuse
c. A 1-month duration of active phase symptoms
d. Continuous signs of disturbance for longer than 6 months
e. The presence of manic episodes

a. A decrease in self-care, job, or school function
c. A 1-month duration of active phase symptoms
d. Continuous signs of disturbance for longer than 6 months

Patients must have at least two symptoms with 1-month duration of active symptoms. One symptom must be delusions, hallucinations, or disordered speech. Patients must have continuous signs of disturbance for longer than 6 months. A history of substance abuse and manic episodes are not associated with schizophrenia.

63. A patient who has occasional migraine headaches tells a nurse that the abortive medication works well, but she would like to do more to prevent the occurrence of these headaches. The nurse will suggest that the patient:

a. ask the provider about an adjunct medication, such as prochlorperazine.
b. discuss the use of prophylactic medications with the provider.
c. keep a headache diary to help determine possible triggers.
d. take the abortive medication regularly instead of PRN.

c. keep a headache diary to help determine possible triggers.

Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications are used when headaches are more frequent. To prevent medication overuse headache, abortive medications should not be used more than 1 to 2 days at a time.

64. A woman with moderate migraine headaches asks a nurse why the provider has ordered metoclopramide (Reglan) as an adjunct to aspirin therapy, because she does not usually experience nausea and vomiting with her migraines. The nurse will tell her that the metoclopramide is used to:

a. help induce sleep.
b. improve absorption of the aspirin.
c. prevent gastric irritation caused by the aspirin.
d. prolong the effects of the aspirin.

b. improve absorption of the aspirin.

Besides reducing nausea and vomiting, metoclopramide also reverses gastric stasis and improves absorption of oral antimigraine drugs. It is not used to induce sleep. It does not prevent gastric irritation or prolong the effects of the aspirin.

65. A patient who uses ergotamine (Ergomar) to abort migraine headaches reports nausea and vomiting with the headaches. What will the nurse tell the patient?

a. "Ask your provider about using another antimigraine medication."
b. "Nausea and vomiting are signs of ergotamine toxicity."
c. "These symptoms occur with migraine headaches and will diminish over time."
d. "You should talk to your provider about an adjunct antiemetic medication."

d. "You should talk to your provider about an adjunct antiemetic medication."

Nausea and vomiting, which occur with migraines, can increase with ergotamine use, because the drug can stimulate the chemoreceptor trigger zone. Patients should be treated with metoclopramide or a phenothiazine antiemetic. It is not necessary to change antimigraine medications at this time. Nausea and vomiting do not indicate ergotamine toxicity. These symptoms will not diminish over time.

66. A prescriber orders sumatriptan (Imitrex) for a patient for a migraine headache. Before administration of this drug, it would be important for the nurse to assess whether the patient:

a. has a family history of migraines.
b. has taken acetaminophen in the past 3 hours.
c. has taken ergotamine in the past 24 hours.
d. is allergic to sulfa compounds.

c. has taken ergotamine in the past 24 hours.

Sumatriptan, other triptans, and ergot alkaloids all cause vasoconstriction and should not be combined, or excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative and another triptan. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-to-drug interaction with sumatriptan. Sulfa is not a component of sumatriptan and therefore is not relevant.

67. A patient arrives in the emergency department complaining of numbness in the extremities. The nurse notes that the patient's hands and feet are cool and pale. When conducting a health history, the nurse learns that the patient has a history of migraine headaches. The nurse recognizes this patient's symptoms as:

a. ergotamine withdrawal.
b. ergotism.
c. severe migraine symptoms.
d. sumatriptan side effects.

b. ergotism.

Ergotism is a serious toxicity caused by acute or chronic overdose of ergotamine. The toxicity results in ischemia, causing the extremities to become cold, pale, and numb. Symptoms associated with ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.

68. A patient is being treated for an infection with erythromycin. The nurse obtains a health history and learns that the patient has migraine headaches. The nurse will tell the patient to avoid which medication while taking the erythromycin?

a. Acetaminophen
b. Ergotamine (Ergomar)
c. Sumatriptan (Imitrex)
d. Topiramate

b. Ergotamine (Ergomar)

Macrolide antibiotics, such as erythromycin, are potent inhibitors of CYP3A4; these drugs can raise ergotamine to dangerous levels, so this combination should be avoided. It is safe to take acetaminophen, sumatriptan, and topiramate with erythromycin.

69. A young woman with migraine headaches who has recently begun taking sumatriptan (Imitrex) calls the nurse to report a sensation of chest and arm heaviness. The nurse questions the patient and determines that she feels pressure and not pain. What will the nurse do?

a. Ask the patient about any history of hypertension or coronary artery disease.
b. Determine whether the patient might be pregnant.
c. Reassure the patient that this is a transient, reversible side effect of sumatriptan.
d. Tell the patient to stop taking the medication immediately.

c. Reassure the patient that this is a transient, reversible side effect of sumatriptan.

Some patients taking sumatriptan experience unpleasant chest symptoms, usually described as "heavy arms" or "chest pressure." These symptoms are transient and are not related to heart disease. Patients experiencing angina-like pain when taking sumatriptan, as a result of coronary vasospasm, should be asked about hypertension or coronary artery disease (CAD); they should not take sumatriptan if they have a history of either of these. The symptoms this patient describes are not characteristic of pregnancy. There is no need to stop taking the medication.

70. A patient who has a history of asthma experiences three or four migraine headaches each month. The patient uses sumatriptan (Imitrex) as an abortive medication and has developed medication overuse headaches. The patient asks the nurse what can be done to prevent migraines. The nurse will suggest that the patient discuss which preventive medication with the provider?

a. Botulinum toxin
b. Meperidine (Demerol)
c. Timolol
d. Topiramate (Topamax)

d. Topiramate (Topamax)

Topiramate can be used for migraine prophylaxis, and its benefits appear equal to those of the first line beta blockers. Botulinum toxin can be used for migraine prophylaxis in patients who have 15 or more headaches a month. Meperidine may be used as abortive therapy but has addictive potential. Timolol is a beta blocker; this patient has asthma, and because beta blockers cause bronchoconstriction, these agents are not recommended.

71. Supplemental oxygen has been shown to help reduce symptoms for which type of headache?

a. Cluster
b. Menstrual migraine
c. Migraine
d. Tension-type

a. Cluster

Cluster headaches can be treated with 100% oxygen inhalation. Oxygen therapy is not used to treat other types of headaches.

72. A patient on the unit complains of cluster headaches. A new graduate nurse is asked to differentiate between a migraine headache and cluster headaches. The graduate nurse is correct to state that manifestations and/or risk factors for a patient with cluster headaches include what? (Select all that apply.)

a. Female gender
b. Male gender
c. Complaints of nausea and vomiting
d. Short duration (15 minutes to 2 hours)
e. Auras before the onset of headache pain
f. Throbbing, sometimes piercing pain

b. Male gender
d. Short duration (15 minutes to 2 hours)
f. Throbbing, sometimes piercing pain

Cluster headaches are more common in males, are short in duration, and present as throbbing and piercing pain. Migraine headaches are more common in females and are manifested by nausea and vomiting and the presence of an aura before the onset of headache pain.

73. A patient asks the nurse what can be given to alleviate severe, chronic pain of several months' duration. The patient has been taking oxycodone (OxyContin) and states that it is no longer effective. The nurse will suggest discussing which medication with the provider?

a. Fentanyl (Duragesic) transdermal patch
b. Hydrocodone (Vicodin) PO
c. Meperidine (Demerol) PO
d. Pentazocine (Talwin) PO

a. Fentanyl (Duragesic) transdermal patch

Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

74. A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are dilated and that the patient is drowsy and lethargic. The patient's heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do?

a. Discuss possible opiate dependence with the patient's provider.
b. Encourage the patient to turn over and cough and take deep breaths.
c. Note the effectiveness of the analgesia in the patient's chart.
d. Prepare to administer naloxone and possibly ventilatory support.

d. Prepare to administer naloxone and possibly ventilatory support.

Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

75. A patient with moderate to severe chronic pain has been taking oxycodone (OxyContin) 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss:

a. administering a combination opioid analgesic/acetaminophen preparation.
b. changing the medication to a continued-release preparation.
c. confronting the patient about drug-seeking behaviors.
d. withdrawing the medication, because physical dependence has occurred.

b. changing the medication to a continued-release preparation.

Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

76. A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient?

a. PRN dosing of the drug may be more effective.
b. The risk of respiratory depression increases over time.
c. The patient should discuss increasing the dose with the provider.
d. The patient should request the addition of a benzodiazepine to augment pain relief.

c. The patient should discuss increasing the dose with the provider.

This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, as they increase the risk of oversedation.

77. A woman in labor receives meperidine (Demerol) for pain. The nurse caring for the infant will observe the infant closely for:

a. congenital anomalies.
b. excessive crying and sneezing.
c. respiratory depression.
d. tremors and hyperreflexia.

c. respiratory depression.

Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are all signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

78. A postoperative patient has received an epidural infusion of morphine sulfate. The patient's respiratory rate decreases to 8 breaths per minute, and he has a decreased level of consciousness and miosis. Which medication would the nurse anticipate administering?

a. Naloxone (Narcan)
b. Acetylcysteine (Mucomyst)
c. Methylprednisolone (Medrol)
d. Physostigmine (Antilirium)

a. Naloxone (Narcan)

Narcan is an opioid antagonist and would counteract the apparent toxicity. Acetylcysteine is the antidote for acetaminophen poisoning. Methylprednisolone is an anti-inflammatory agent and would not have an effect on toxicity related to opiate overdose. Physostigmine is indicated for organophosphate poisoning.

79. A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient's arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient's pupils are dilated. The nurse recognizes these symptoms as signs of:

a. a mild opioid overdose.
b. decreased opioid drug levels.
c. improved ventilation.
d. worsening hypoxia.

d. worsening hypoxia.

The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

80. A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine (Talwin). The nurse will monitor the patient for:

a. euphoria.
b. hypotension.
c. respiratory depression.
d. yawning and sweating

d. yawning and sweating


Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.

81. A patient will receive buprenorphine (Butrans) as a transdermal patch for pain. What is important to teach this patient about the use of this drug?

a. Avoid prolonged exposure to the sun.
b. Cleanse the site with soap or alcohol.
c. Remove the patch daily at bedtime.
d. Remove hair by shaving before applying the patch.

a. Avoid prolonged exposure to the sun.

Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

82. A nurse is preparing a patient for surgery and is teaching the patient about the use of the patient-controlled analgesia pump. The patient voices concern about becoming addicted to morphine. What will the nurse do?

a. Ask the patient about any previous drug or alcohol abuse.
b. Discuss possible nonopioid options for postoperative pain control.
c. Suggest that the patient use the PCA sparingly.
d. Tell the patient that the pump can be programmed for PRN dosing only.

a. Ask the patient about any previous drug or alcohol abuse.

The nurse should remember that addiction to opioids usually occurs in patients who already have tendencies for addiction, so an assessment of previous experiences with addictive substances would be indicated. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

83. A patient has been taking methadone (Dolophine) for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes?

a. Prolonged QT interval
b. Prolonged P-R interval
c. AV block
d. An elevated QRS complex

a. Prolonged QT interval

Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

84. A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.)

a. Counting respirations before and after giving the medication
b. Encouraging physical activity and offering increased fluids
c. Monitoring the patient's blood pressure closely for hypertension
d. Palpating the patient's lower abdomen every 4 to 6 hours
e. Requesting an order for methylnaltrexone (Relistor) to prevent constipation

a. Counting respirations before and after giving the medication
b. Encouraging physical activity and offering increased fluids
d. Palpating the patient's lower abdomen every 4 to 6 hours

Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient's abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

85. Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.)

a. Biliary colic
b. Cough suppression
c. Suppression of bowel motility
d. Urinary retention
e. Vasodilation

b. Cough suppression
c. Suppression of bowel motility
e. Vasodilation

Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

A postoperative patient is reporting pain as a 7 on a scale from 1 to 10, with 10 being the worst pain. The nurse caring for the patient assesses vital signs of HR, 76; RR, 16; and BP, 110/70. The patient has vomited twice. Which postoperative medications will the nurse expect to administer?

a. Atropine and morphine
b. Bethanechol and ibuprofen
c. Morphine and ondansetron (Zofran)
d. Promethazine and clonidine (Catapres)

c. Morphine and ondansetron (Zofran)

This patient is experiencing postoperative symptoms of moderate to severe pain and nausea and vomiting. Morphine is used postoperatively for this degree of pain, and ondansetron is one of the most effective antiemetics. Atropine is an anticholinergic drug and usually is given preoperatively or perioperatively to prevent bradycardia. Bethanechol is a muscarinic agonist that is used to counter postoperative abdominal distention and urinary retention. Ibuprofen can be used, but it is effective only for mild postoperative pain. Promethazine is less effective as an antiemetic and can be used, but clonidine, marketed as Catapres, is used for postoperative hypertension.

87. A nurse is teaching nursing students about inhalation anesthesia and asks, "What is balanced anesthesia?" Which response by a student is correct?

a. "An anesthesia that has a brief induction period with a rapid emergence from its effects."
b. "An inhalation anesthesia that produces both muscle relaxation and unconsciousness."
c. "An anesthesia that provides maximum analgesia with minimal respiratory side effects."
d. "An anesthesia that combines other drugs with inhalation anesthesia to produce the desired effects."

d. "An anesthesia that combines other drugs with inhalation anesthesia to produce the desired effects."


Balanced anesthesia is the use of a combination of drugs, along with an inhaled anesthetic, to produce effects that cannot safely be accomplished with inhalation anesthesia alone. These adjunct drugs are used to help induce anesthesia, provide muscle relaxation, and increase analgesia so that a lower and safer dose of the inhalation anesthetic can be used. The other three options describe characteristics of an ideal anesthetic, which does not exist; to get these effects, a combination of other drugs must be used.

88. A surgical patient is receiving succinylcholine (Anectine) with an inhalation anesthetic. The patient is intubated, has an indwelling urinary catheter, and has ongoing monitoring of vital signs. Which symptom during the perioperative period is cause for concern?

a. Elevated temperature
b. Increased urine output
c. Muscle paralysis
d. No response to painful stimuli

a. Elevated temperature

Combining succinylcholine (a skeletal muscle relaxant) with an inhalation anesthetic increases the risk of malignant hyperthermia. The mechanism is not understood. Temperature elevation can be profound, and cooling measures must be initiated or the condition can be fatal. A decrease in urine output would be a sign of hypotension. Muscle paralysis and lack of response to pain are desired effects of anesthesia.

89. A nurse administers atropine to a patient before induction of anesthesia for a surgical procedure. When evaluating the effects of this medication, the nurse will:

a. assess for excessive bronchial secretions.
b. expect a reduction in the patient's anxiety.
c. monitor the patient's heart rate.
d. observe for muscle paralysis.

c. monitor the patient's heart rate.

Anticholinergic drugs, such as atropine (Sal-Tropine), may be given to reduce the risk of bradycardia during surgery. Atropine can alter bronchial secretions, but the effect would be to reduce them, not increase them. It is not used to reduce anxiety. It does not cause muscle paralysis.

90. An anesthesiologist completes preoperative teaching for a patient the night before surgery. The patient asks the nurse to clarify the reason thiopental sodium will be given as an adjunct to the anesthetic. Which statement by the patient indicates understanding?

a. "Pentothal allows a larger amount of inhaled anesthetic to be used without increased side effects."
b. "Pentothal is given to enhance the analgesic and muscle relaxation effects of the inhaled anesthetic."
c. "Pentothal is used to produce rapid unconsciousness before administration of the inhaled anesthetic."
d. "Pentothal is used to reduce cardiovascular and respiratory depression caused by the inhaled anesthetic.

c. "Pentothal is used to produce rapid unconsciousness before administration of the inhaled anesthetic."

Thiopental sodium, a short-acting barbiturate, is given intravenously for induction of anesthesia. It has a rapid onset and short duration and must be followed immediately by an inhalation anesthetic. It does not alter the side effects of inhalation anesthetics. Most adjuncts to inhalation anesthetics are given so that lower doses of the anesthetic may be used. Thiopental sodium has very weak analgesic and muscle relaxation effects. Thiopental sodium causes cardiovascular and respiratory depression.

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