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1. A patient receives morphine and shows signs of toxicity. The prescriber orders naloxone (Narcan) to reverse the effects of the morphine. The nurse understands that the naloxone works at the same receptor sites as the morphine to:
a.
block transmitter reuptake.
b.
inhibit transmitter release.
c.
interfere with transmitter storage.
d.
prevent activation of receptors.



ANS: D
Morphine and its antagonist, naloxone, both act directly at the same receptors. Morphine causes activation, and naloxone prevents activation. Neither morphine nor naloxone acts to alter transmitter reuptake, release, or storage.bilify

1. A patient has taken levodopa (Dopar) for Parkinson's disease for 2 weeks but reports no improvement in the symptoms. Which response by the nurse is correct?
a.
"Another agent will be needed to manage your symptoms."
b.
"Double the dose to see whether an effect occurs."
c.
"It may take several months for a response to occur."
d.
"The prescriber may need to change your drug regimen."



ANS: C
A full therapeutic response with levodopa may take several months to develop. Until the true effect of the dose is seen, it is not necessary to change to another drug, increase the dose, or change the drug regimen.
2. A nurse provides teaching for a patient who is newly diagnosed with Parkinson's disease. Which statement by the patient indicates understanding of the drug therapy for this disease?
a.
"A levodopa/carbidopa combination is used to improve motor function."
b.
"There are several drugs available to treat dyskinesias."
c.
"When 'off' times occur, I may need to increase my dose of levodopa."
d.
"With adequate drug therapy, the disease progression may be slowed."



ANS: A
Levodopa combined with carbidopa is the initial drug of choice to treat motor symptoms. Amantadine is the only drug recommended to treat dyskinesias. Entacapone and rasagiline are used to treat abrupt loss of effect, or "off" times. Drug therapy does not slow the progression of the disease.
3. A patient has been diagnosed with Parkinson's disease (PD) and begins treatment with levodopa/carbidopa (Sinemet). After several months of therapy, the patient reports no change in symptoms. The nurse will expect the provider to:
a.
add a dopamine agonist.
b.
discuss the "on-off" phenomenon.
c.
increase the dose of Sinemet.
d.
re-evaluate the diagnosis.




ANS: D
Patients beginning therapy with levodopa/carbidopa should expect therapeutic effects to occur after several months of treatment. Levodopa is so effective that a diagnosis of PD should be questioned if the patient fails to respond in this time frame. Adding a dopamine agonist is not indicated. The "on-off" phenomenon occurs when therapeutic effects are present. Increasing the dose of levodopa/carbidopa is not indicated.
4. A patient with Parkinson's disease is taking levodopa/carbidopa (Sinemet) and reports occasional periods of loss of drug effect lasting from minutes to several hours. The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss:
a.
administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone.
b.
adding the DA-releasing agent amantadine to the regimen.
c.
giving a direct-acting dopamine agonist.
d.
shortening the dosing interval of levodopa/carbidopa.



ANS: A
This patient is describing abrupt loss of effect, or the "off" phenomenon, which is treated with entacapone or another COMT inhibitor. Amantadine is used to treat dyskinesias. A direct-acting dopamine agonist is useful for gradual loss of effect, which occurs at the end of the dosing interval as the dose is wearing off. Shortening the dosing interval does not help with abrupt loss of effect.
5. A patient newly diagnosed with Parkinson's disease has been taking levodopa/carbidopa (Sinemet) for several weeks and complains of nausea and vomiting. The nurse tells the patient to discuss what with the provider?
a.
Taking a lower dose on an empty stomach
b.
Taking an increased dose along with a high-protein snack
c.
Taking a lower dose with a low-protein snack
d.
Taking dopamine in addition to levodopa/carbidopa




ANS: C
Because levodopa activates the chemoreceptive trigger zone (CTZ) of the medulla, causing nausea and vomiting (N/V), the patient may need to take a lower dose temporarily until tolerance develops. A meal helps slow absorption to minimize this side effect. A high protein intake contributes to abrupt loss of effect, so meals should be low in protein. Taking a dose on an empty stomach increases absorption and also N/V. An increased dose with a high-protein snack increases N/V and also abrupt loss of effect. Dopamine increases N/V, because it activates the CTZ of the medulla.
6. A nurse is discussing motor symptoms with a patient with Parkinson's disease who has been taking levodopa/carbidopa (Sinemet) and who is now having regular tics. Which statement by the patient indicates understanding of this symptom?
a.
"I may need to try a lower dose of Sinemet to reduce my tics."
b.
"My provider may order clozapine to treat these tics."
c.
"These tics are an indication that my dose of Sinemet is too low."
d.
"This means I will have to have surgery to stop the symptoms."



ANS: A
Levodopa can cause movement disorders. If they occur, a lower dose of levodopa may be required to alleviate them. Clozapine is an antipsychotic used to treat levodopa-induced psychoses. Movement disorders generally occur as the dose of levodopa increases. Surgery is a last option for treating movement disorders, after amantadine fails.
7. A patient who has begun taking levodopa/carbidopa (Sinemet) reports feeling lightheaded and dizzy, especially when standing up from a sitting position. What will the nurse recommend?
a.
An alpha-adrenergic antagonist medication
b.
Discussing amantadine with the prescriber
c.
Increasing the salt and water intake
d.
Taking a drug holiday



ANS: C
Postural hypotension is common early in treatment and can be reduced by increasing the intake of salt and water. An alpha-adrenergic agonist, not an antagonist, can help. Amantadine is used to treat levodopa-induced dyskinesias. Drug holidays are used when adverse effects increase with long-term use of levodopa; the drug holiday allows beneficial effects to be achieved with lower doses, which reduces the incidence of side effects.
8. A nursing student wants to know why a patient who has been taking levodopa (Dopar) for years will now receive levodopa/carbidopa (Sinemet). The nurse explains the reasons that levodopa as a single agent is no longer available. Which statement by the student indicates a need for further education?
a.
"Carbidopa increases the availability of levodopa in the central nervous system."
b.
"Carbidopa reduces the incidence of nausea and vomiting."
c.
"Combination products reduce peripheral cardiovascular side effects."
d.
"Combination products cause fewer dyskinesias and decreased psychosis."



ANS: D
Adding carbidopa to levodopa does not reduce the incidence of dyskinesias or psychosis. In fact, carbidopa can increase the intensity and the speed of onset of these effects. Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Peripheral side effects are reduced, including nausea, vomiting, and cardiovascular effects.
9. A nurse is teaching a group of nurses about Parkinson's medications. The nurse is correct to state that one side effect associated with pramipexole (Mirapex) that is less likely to occur with other dopamine agonists is:
a.
sleep attacks.
b.
dizziness.
c.
hallucinations.
d.
dyskinesias.



ANS: A
A few patients taking pramipexole have experienced sleep attacks, or an overwhelming and irresistible sleepiness that comes on without warning. Dizziness, hallucinations, and dyskinesias are listed as side effects of pramipexole and other dopamine agonists.
10. A nursing student wants to know how carbidopa can be effective for treating Parkinson's disease if it prevents the conversion of levodopa to dopamine. The nurse explains that carbidopa:
a.
can be taken with high-protein meals.
b.
does not cross the blood-brain barrier.
c.
has dopamine-like effects of its own.
d.
reduces abrupt loss of effect.



ANS: B
Carbidopa inhibits decarboxylation of levodopa in the intestine and peripheral tissues, leading to more levodopa in the CNS. Carbidopa cannot cross the blood-brain barrier, so it does not have this action in the CNS. Carbidopa is not given with high-protein meals. Carbidopa does not have dopamine-like effects. Carbidopa does not affect abrupt loss of effect.
11. A 25-year-old patient has been newly diagnosed with Parkinson's disease, and the prescriber is considering using pramipexole (Mirapex). Before beginning therapy with this drug, the nurse will ask the patient about:
a.
any history of alcohol abuse or compulsive behaviors.
b.
any previous history of hypertension.
c.
difficulty falling asleep or staying asleep.
d.
whether any family members have experienced psychoses.



ANS: A
Pramipexole has been associated with impulse control disorders, and this risk increases in patients with a history of alcohol abuse or compulsive behaviors. Pramipexole increases the risk of hypotension and sleep attacks, so a history of hypertension or insomnia would not be cautionary. Unlike with levodopa, the risk of psychoses is not increased.
12. A hospitalized patient with Parkinson's disease who is receiving apomorphine to treat "off" episodes develops nausea and vomiting. The nurse will discuss the use of which medication with the patient's provider?
a.
Levodopa (Dopar)
b.
Ondansetron (Zofran)
c.
Prochlorperazine (Compazine)
d.
Trimethobenzamide (Tigan)



ANS: D
Trimethobenzamide can be used as an antiemetic in patients treated with apomorphine. Serotonin receptor agonists (e.g., ondansetron) and dopamine receptor antagonists (e.g., prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.
13. A patient with Parkinson's disease is taking levodopa/carbidopa (Sinemet). The prescriber orders bromocriptine (Parlodel) to treat dyskinesias. The nurse notes that the patient is agitated, and the patient reports having frequent nightmares. The nurse will contact the provider to discuss:
a.
adding an antipsychotic medication.
b.
changing from bromocriptine to cabergoline (Dostinex).
c.
reducing the dose of bromocriptine.
d.
reducing the dose of levodopa/carbidopa.



ANS: C
Bromocriptine is used to treat levodopa-induced dyskinesias and has dose-dependent psychologic side effects. The nurse should suggest reducing the dose of this drug to minimize these side effects. Adding an antipsychotic medication is not indicated. Cabergoline is not approved for this use. Reducing the dose of levodopa/carbidopa is not indicated.
1. A patient shows loss of consciousness, jaw clenching, contraction and relaxation of muscle groups, and periods of cyanosis. The nurse correctly identifies this as which type of seizure?
a.
Tonic-clonic
b.
Petit mal
c.
Myoclonic
d.
Atonic



ANS: A
Tonic-clonic seizures (or grand mal seizures) are considered generalized seizures and are manifested by a loss of consciousness, jaw clenching, muscle relaxation alternating with muscle contractions, and periods of cyanosis. Absence seizures (or petit mal seizures) are characterized by loss of consciousness for a brief period and usually involve eye blinking and staring into space. Myoclonic seizures consist of sudden contractions that may be limited to one limb or may involve the entire body. Atonic seizures are characterized by sudden loss of muscle tone.
2. A nurse is assessing a patient who becomes motionless and seems to stare at the wall and then experiences about 60 seconds of lip smacking and hand wringing. What should the nurse do?
a.
Ask the patient about a history of absence seizures.
b.
Contact the provider to report symptoms of a complex partial seizure.
c.
Notify the provider that the patient has had a grand mal seizure.
d.
Request an order for intravenous diazepam (Valium) to treat status epilepticus.



ANS: B
This patient showed signs of a complex partial seizure, characterized by impaired consciousness beginning with a period of motionlessness with a fixed gaze, followed by a period of automatism. The entire episode generally lasts 45 to 90 seconds. Absence seizures are characterized by loss of consciousness for a brief period (about 10 to 30 seconds) and may involve mild, symmetric motor activity or no motor signs. A grand mal seizure is characterized by jaw clenching and rigidity followed by alternating muscle relaxation and contraction and then periods of cyanosis, all with a loss of consciousness. Status epilepticus is a seizure that persists for 30 minutes or longer.
3. A nurse is discussing partial versus generalized seizures with a group of nursing students. Which statement by a student indicates understanding of the teaching?

a.
"Febrile seizures are a type of generalized tonic-clonic seizure."
b.
"Generalized seizures are characterized by convulsive activity."
c.
"Partial seizures do not last as long as generalized seizures."
d.
"Patients having partial seizures do not lose consciousness."

.
ANS: A
Febrile seizures typically manifest as a tonic-clonic seizure of short duration and are a type of generalized seizure. Generalized seizures may be convulsive or nonconvulsive. Partial seizures may last longer than some types of generalized seizures. Patients with complex partial seizures and secondarily generalized seizures, which are types of partial seizures, may lose consciousness
4. A nurse provides teaching for a patient with a newly diagnosed partial complex seizure disorder who is about to begin therapy with antiepileptic drugs (AEDs). Which statement by the patient indicates understanding of the teaching?
a.
"Even with an accurate diagnosis of my seizures, it may be difficult to find an effective drug."
b.
"I will soon know that the drugs are effective by being seizure free for several months."
c.
"Serious side effects may occur, and if they do, I should stop taking the medication."
d.
"When drug levels are maintained at therapeutic levels, I can expect to be seizure free."



ANS: A
Even with an accurate diagnosis of seizures, many patients have to try more than one AED to find a drug that is both effective and well tolerated. Unless patients are being treated for absence seizures, which occur frequently, monitoring of the clinical outcome is not sufficient for determining effectiveness, because patients with convulsive seizures often have long seizure-free periods. Serious side effects may occur, but withdrawing a drug precipitously can induce seizures. Not all patients have seizure control with therapeutic drug levels, because not all medications work for all patients.
5. A nurse is caring for a patient who has been taking an antiepileptic drug for several weeks. The nurse asks the patient if the therapy is effective. The patient reports little change in seizure frequency. What will the nurse do?

a.
Ask the patient to complete a seizure frequency chart for the past few weeks.
b.
Contact the provider to request an order for serum drug levels.
c.
Reinforce the need to take the medications as prescribed.
d.
Request an order to increase the dose of the antiepileptic drug.



ANS: B
If medication therapy is not effective, it is important to measure serum drug levels of the medication to determine whether therapeutic levels have been reached and to help monitor patient compliance. Patients should be asked at the beginning of therapy to keep a seizure frequency chart to help deepen their involvement in therapy; asking for historical information is not helpful. Until it is determined that the patient is not complying, the nurse should not reinforce the need to take the medication. Until the drug level is known, increasing the dose is not indicated.
A patient with a form of epilepsy that may have spontaneous remission has been taking an AED for a year. The patient reports being seizure free for 6 months and asks the nurse when the drug can be discontinued. What will the nurse tell the patient?
A.AEDs must be taken for life to maintain remission.
B.Another AED will be substituted for the current AED.
C.The provider will withdraw the drug over a 6- to 12-week period.
D.The patient should stop taking the AED now and restart the drug if seizures recur.
C.The provider will withdraw the drug over a 6- to 12-week period.

The most important rule about withdrawing AEDs is that they should be withdrawn slowly over 6 weeks to several months to reduce the risk of status epilepticus (SE). AEDs need not be taken for life if seizures no longer occur. Substituting one AED for another to withdraw AED therapy is not recommended. Stopping an AED abruptly increases the risk of SE.
7. A patient with a seizure disorder is admitted to the hospital and has a partial convulsive episode shortly after arriving on the unit. The patient has been taking phenytoin (Dilantin) 100 mg three times daily and oxcarbazepine (Trileptal) 300 mg twice daily for several years. The patient's phenytoin level is 8.6 mcg/mL, and the oxcarbazepine level is 22 mcg/mL. The nurse contacts the provider to report these levels and the seizure. What will the nurse expect the provider to order?
a.
A decreased dose of oxcarbazepine
b.
Extended-release phenytoin
c.
An increased dose of phenytoin
d.
Once-daily dosing of oxcarbazepine




ANS: C
This patient's phenytoin level is low; the therapeutic range is 10 to 20 mcg/mL. An increase in the phenytoin dose is necessary. The oxcarbazepine level is within the normal range of 3 to 40 mcg/mL, so changing the dose is not necessary. Extended-release phenytoin is absorbed more slowly and would not increase this patient's serum phenytoin level. The dosing of oxcarbazepine does not need to be changed.
8. A nurse counsels a patient who is to begin taking phenytoin (Dilantin) for epilepsy. Which statement by the patient indicates understanding of the teaching?
a.
"I should brush and floss my teeth regularly."
b.
"Once therapeutic blood levels are reached, they are easy to maintain."
c.
"I can consume alcohol in moderation while taking this drug."
d.
"Rashes are a common side effect but are not serious."



ANS: A
Gingival hyperplasia occurs in about 20% of patients who take phenytoin. It can be minimized with good oral hygiene, so patients should be encouraged to brush and floss regularly. Because small fluctuations in phenytoin levels can affect response, maintaining therapeutic levels is not easy. Patients should be cautioned against consuming alcohol while taking phenytoin. Rashes can be serious and should be reported immediately.
9. A patient is to begin taking phenytoin (Dilantin) for seizures. The patient tells the nurse that she is taking oral contraceptives. What will the nurse tell the patient?
a.
She may need to increase her dose of phenytoin while taking oral contraceptives.
b.
She should consider a different form of birth control while taking phenytoin.
c.
She should remain on oral contraceptives, because phenytoin causes birth defects.
d.
She should stop taking oral contraceptives, because they reduce the effectiveness of phenytoin.



ANS: B
Because phenytoin can reduce the effects of oral contraceptive pills (OCPs) and because avoiding pregnancy is desirable when taking phenytoin, patients should be advised to increase the dose of oral contraceptives or use an alternative method of birth control. Increasing the patient's dose of phenytoin is not necessary; OCPs do not affect phenytoin levels. Phenytoin is linked to birth defects; OCPs have decreased effectiveness in patients treated with phenytoin, and the patient should be advised to increase the OCP dose or to use an alternative form of birth control. OCPs do not alter the effects of phenytoin.
10. A patient is admitted to the hospital for a new onset seizure disorder, and the prescriber orders carbamazepine (Tegretol). The nurse reviewing the patient's medical history notes that the patient is taking warfarin. The nurse will contact the provider to discuss _____ dose.
a.
reducing the carbamazepine
b.
reducing the warfarin
c.
increasing the carbamazepine
d.
increasing the warfarin



ANS: D
Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which it and other drugs are metabolized, including oral contraceptives and warfarin; therefore, patients taking any of these drugs would need an increased dose. Reducing the dose of either drug is not indicated. Increasing the dose of carbamazepine may be necessary but only after serum drug levels have been checked.
11. A patient who is taking oral contraceptives begins taking valproic acid (Depakote) for seizures. After a week of therapy with valproic acid, the patient tells the nurse that she is experiencing nausea. What will the nurse do?

a.
Ask the patient if she is taking the valproic acid with food, because taking the drug on an empty stomach can cause gastrointestinal side effects.
b.
Contact the provider to request an order for a blood ammonia level, because hyperammonemia can occur with valproic acid therapy.
c.
Suggest that the patient perform a home pregnancy test, because valproic acid can reduce the efficacy of oral contraceptives.
d.
Suspect that hepatotoxicity has occurred, because this is a common adverse effect of valproic acid.



ANS: A
Gastrointestinal effects, including nausea, vomiting, and indigestion, are common with valproic acid and can be minimized by taking the drug with food or using an enteric-coated product. Hyperammonemia can occur when valproic acid is combined with topiramate. Signs of pregnancy usually do not occur within a week, so this is less likely. Hepatotoxicity is a rare adverse effect.