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NURS2002 Pharmacology Case Study #2 Fall 2010

Mr. Morris Trehan is 52-years-old, and is under treatment for migraine headaches. He also has a history of adult-onset diabetes mellitus, as well as peptic ulcer disease. He survived a mild heart attack 2 years ago, and there are no major cardiac concerns at this time. He has been on an established low fat/low cholesterol/low glycemic index diet as well as an exercise plan for his diabetes and his peptic ulcer disease (PUD) is treated prophylactically with a proton-pump inhibitor medication. For his migraine headaches, the nurse practitioner plans to manage this prophylactically as well, using a low dose of the beta-adrenergic blocking drug, propranolol (Inderal). 1. a. b. c. d. Which of the following would represent a contraindication for Inderal therapy? Glaucoma Hyperthyroidism Alcohol withdrawl Peripheral vascular disease (PVD)

2. All of the following behaviors indicate successful patient teaching about propranolol therapy except: a. Reducing or stopping cigarette smoking. b. Using antacids to decrease gastric side effects. c. Taking propranolol on an empty stomach. d. Avoiding alcohol while taking the drug. 3. a. b. c. d. An appropriate nursing diagnosis for Mr. Trehan would be: Noncompliance related to medication regimen for headaches. Anxiety related to the side effects of beta-blocker therapy. Activity intolerance: fatigue related to propranolol therapy. Potential for violence related to administration of ergot derivatives.

4. In planning Mr. Trehans medication regimen, all of the following drugs would be given cautiously except: a. Insulin b. cimetidine c. glyburide (DiaBeta) d. aspirin 5. a. b. c. d. An adverse/side effect of propranolol that should be discussed with Mr. Trehan is: dizziness with activity excessive sleeping increased anxiety in crowds rapid weight loss

6. Before beginning his beta blocker therapy, Mr. Trehan should be instructed to report which of the following to his health care provider? a. a weight gain of more than 2 pounds/week b. excessive energy c. a decreased appetite

2 d. insomnia Ken Anderson, age 40, is an accountant. He has been an insulin-dependent diabetic and asthmatic since age 12 . He has now been diagnosed with secondary open-angle glaucoma. He has recently noticed recurrent blurring of vision with gradual loss of peripheral vision, difficulty adjusting to darkened conditions, and seeing colored rings around lights. He has also experienced an increase in pain and redness of his eyes, particularly at the end of the day. He states that his mother also had glaucoma. Medications prescribed include pilocarpine (Pilocar) 2% solution: 1 drop OU every 6 hours and timolol (Timoptic) 0.5% solution: 1 drop OU at bedtime. Following a thorough history and examination, the physician advises Mr. Anderson to return for IOP (intraocular pressure) check in 1 week. Several months later, Mr. Anderson experienced a flare-up of his seasonal allergy symptoms. A co-worker recommended that Ken try some of his astemizole (Hismanal) because it had worked so well on his own allergy symptoms. 7. Which of the following is the priority in nursing management of Ken prior to administering the first dose of any ophthalmic medication? a. Assessing his understanding of the purpose of medications. b. Assessing Kens eye and vision status. c. Assessing Kens history of hypersensitivity to medications. d. Assessing the clients understanding of the action of the medications. 8. a. b. c. d. Pilocar is in the drug classification: beta adrenergic blockers alpha adrenergic blockers parasympathomimetics parasympatholytics

9. The nurse is aware, when administering pilocarpine eye drops, that the expected therapeutic action would be to: a. Increase outflow of aqueous humor b. relax ciliary muscles c. relax the sphincter muscle of the iris d. achieve complete papillary dilation. 10. A side/adverse effect of pilocarpine for which the nurse will teach Ken to observe for is: a. headache b. tachycardia c. urinary retention d. constipation 11. When assessing Mr. Andersons pupils after installation of pilocarpine, you would expect to observe: a. pupillary dilation b. pupillary constriction c. unequal accommodation d. slow response to light 12. When teaching Ken about the pilocarpine, it would be important to include the following information: a. a burning sensation indicates an allergic reaction b. decreased visual acuity may occur c. blurred vision should be reported immediately d. bright lights may worsen vision

13. Expected outcomes for Mr. Anderson include: a. reduction in ciliary muscle spasm b. increased visual acuity c. absence of tension headaches d. decreased intraocular pressure 14. An appropriate nursing diagnosis for Mr. Anderson would be: a. Noncompliance related to the proper use of pilocarpine eye drops b. Urinary retention related to the use of cholinergic drugs c. Alteration in sensory perception: visual, related to pilocarpine d. Alteration in bowel elimination: constipation, related to pilocarpine 15. What specific teaching instructions related to Timolol and diabetes should the nurse provide to Ken? a. There are no special considerations for diabetic clients receiving Timolol. b. Beta-blocking agents could mask signs and symptoms of hypoglycemia. c. Do not administer the medication if glucose is greater than 200. d. Beta-blocking agents could increase the risk of hyperglycemia. 16. After the nurse has provided instructions and information about the Timolol, Ken asks, how can eye drops affect my lungs? The nurses explanation includes which of the following? a. The medication does not have any effects on the pulmonary system. b. You are only at risk if the prescribed ophthalmic agent is cardioselective (Beta-1). c. You are only at risk if the prescribed ophthalmic medication is given at the same time as the oral medication taken for your asthma. d. If the ophthalmic medication is systemically absorbed, it can have the same systemic effects as other beta-blocking agents. 17. The nurse determines that Ken understands the pupose for the prescribed ophthalmic betablocker when which of the following statements is made? a. The medication is given to reduce my intraocular pressure. b. I can stop the medication once my intraocular pressure is normal. c. The medication is given to increase my intraocular pressure. d. This medication is one of only two medication treatments available for glaucoma. 18. Ken has scheduled a colonoscopy for later in the week. Ken understands subsequent teaching when which of the following statements are made? a. I will inform my gastroenterologist and the nursing staff of my glaucoma and the medications I am taking. b. I will stop taking my medication 2 days before the colonoscopy. c. I will stop taking my medication 1 day before thecolonoscopy. d. My glaucoma is not a factor when having outpatient procedures done. 19. A nurse working in an outpatient surgical/GI clinic, which of the following preoperative medications should be questioned for a client with a history of glaucoma? a. atropine (generic) b. diphenhydramine (Benadryl) c. hydroxyzine (Vistaril) d. promethazine (Phenergan)

4 20. One month later, Ken returns for a follow-up checkup. He describes symptoms experienced since beginning pilocarine therapy. The nurse concludes that which of the following symptoms indicates a side effect from systemic absorption? a. dry mouth b. hypertension c. exacerbation of his asthma d. constipation You are a nurse working on a SAC (sub-acute) medical/surgical unit. You receive patients who have been transferred from ICU because their condition is stabilized, are of a higher acuity than patients who are on a typical medical/surgical unit, or overflow patients as a result of high hospital patient census. Today your patients include: I. Celia Harrington, age 42, who was admitted with acute cholecystitis last evening. Today she is scheduled for a cholescystectomy. She currently rates her pain at a 10 on the pain scale and is NPO. She has an order for Demerol 25 mg IVP every 4-6 hours as needed for preop pain relief. II. Mr. Van Chin is a 26-year-old man who injured his back in an accident 5 years ago (he fell off a ladder while stringing holiday lights at the insistence of his now ex-wife). He is admitted to the unit as an overflow patient for evaluation of recurrent back pain. He has been taking oxycodone hydrochloride/oxycodone terephthalate/aspirin (Percodan) at home on and off (mostly on, he says) for the past 3 years. III. Chester Monroe is a 57-year-old who is admitted for pain management related to metastatic cancer of the bowel. He has refused Hospice care and his wife is not able to cope with his increasing pain, so she brought him to the emergency room last night. He has been taking Percocet at home with not much success. He has been scheduled to a trial of PCA (patient-controlled analgesia) therapy using morphine sulfate. The PCA pump will be set up so that he will be able to push a button and give himself pain medication. When he pushes the button, he will receive a dose of pain medication into his IV. The button will become inactive for a set period of time as prescribed by his doctor, after which time the pump will again deliver another dose in response to his demand. 21. When Celia requests a dose of pain medication, the nurse looks up meperidine (Demerol) in the units drug handbook. She becomes aware that this medication may not be the best choice for this patient because it can cause: a. biliary cancer b. biliary tract spasm c. biliary tract atrophy d. biliary tract necrosis 22. After the nurse consults with the physician about the Demerol, the order is changed to butorphanol (Stadol) 2 mg IM every 4 hours for pain. The nurse will observe for all of the following adverse reactions with regard to this drug except: a. nausea b. diarrhea c. euphoria d. agitation 23. Postoperatively, Ms. Harrington will receive fentanyl (Sublimaze) via an epidural catheter. For management of pain control using this method, the nurse is aware that epidural fentanyl: a. demonstrates a fast onset of action b . provides a short duration of relief c. has decreased receptor affinity d. is quickly cleared through the cerebrospinal fluid.

24. Which of the following are priority assessments by the nurse when caring for a patient receiving opioid analgesics? a. pain intensity, respiratory rate, and level of consciousness b. pain intensity, liver function studies, urine output c. respiratory status, mental status, and seizure activity d. pain intensity, blood glucose, electrolytes 25. Celia recovers from surgery without complications. For discharge, Tylenol with codeine 30 mg by mouth has been ordered for pain. The nurse will teach Celia to: a. take the drug every 3 to 4 hours with meals b. initiate measures to prevent constipation, such as drinking fluids c. observe for signs of analgesic neuropathy, which may occur early in treatment d. continue the medication, if needed, for symptoms of arthritis. 26. During the assessment phase with Mr. Van Chin, the nurse continues questioning him about his current medications. He goes on to state that the Percodan used to work very well for his back pain, but now the effect lasts only for an hour. The nurse is aware that this probably indicates: a. psychologic addiction b. hepatic insufficiency c. opiate inactivation d. tolerance 27. During the assessment, Mr. Chin describes his pain as nagging and burning. He states that it has become the focus of [his] life. These symptoms are characteristic of which type of pain? a. chronic b. psychologic c. phantom d. acute 28. Spinal evaluation reveals two herniated disks, and Mr. Chin undergoes a lumbar laminectomy. Postoperative orders include hydromorphone (Dilaudid) 2 mg IM 4 times per day as need for pain. The nurse is aware of the following with regard to this drug: a. hydromorphone is less potent than morphine when given intramuscularly b. as a partial opiate antagonist, hydromorphone has less potential for abuse and addiction c. hydromorphone has fewer central nervous system effects than morphine d. it may have an addictive effect if given with general anesthetics 29. Mr. Chin is 48-hours postop and is progressing well. He requests medication for back pain. When administering an opiate pain reliever to this patient, all of the following actions are appropriate except: a. maintain a positive outlook in anticipation of pain relief b. encourage the patient to relax and allow the drug to work c. wait until Mr. Chin shows signs of pain before administering the drug d. take advantage of the placebo effect of the drug 30. In evaluating Mr. Chin to determine effectiveness of the pain medication regimen, the nurse is aware of the following factor: a. sedation is always linked with signs of an overdose

6 b. ambulation is encouraged for patients with nausea c. symptoms such as vomiting may indicate poorly controlled pain d. addiction is usually a problem, even with real pain 31. If Mr. Chin has problems with urinary retention postoperatively, the following drug may be given: a. droperidol b. neostigmine c. levallorphan d. naloxone 32. When assessing Mr. Monroe with regard to his pain, the nurse will: a. consider that valid pain has an identifiable cause b. rely on the patient as the authority on his pain experience c. base the assessment on stereotypical pain related to culture d. depend on his family for assessment of pain experience 33. In planning intervention for Mr. Monroe and PCA using morphine, the nurse will include all of the following except: a. initiating patient teaching the day before hospital discharge b. observing the pump device for malfunction or dosage error c. checking for side effects related to morphine administration d. assessing dose-effect relationship at 1 to 3 hour intervals 34. The nurse will observe for all of the following side effects of morphine except: a. constipation b. urinary retention c. nausea d. mydriasis 35. The nurse is aware of the potential for drug interaction with morphine and will be cautious when administering: a. anti-inflammatory agents b. aluminum-containing antacids c. skeletal muscle relaxants d. stool softeners 36. Mr. Monroe says to the nurse, Im afraid I will give myself too much medication! The best nursing diagnosis for Mr. Monroe would be: a. Impaired adjustment related to need to control chronic pain b. Alteration in thought process related to misunderstanding of PCA c. Knowledge deficit related to pain management using PCA d. Powelessness related to need to rely on the nurse for pain control As a unit coordinator in a postanesthesia recovery room, Jill Henderson frequently applies knowledge of anesthetic agents.. 37. Bob Wills, a 40-year-old, received halothane (Fluothane) as an induction agent. Jill will observe for all of the following with regard to halothane except: a. hepatotoxicity b. skeletal muscle relaxation c. respiratory depression d. bradycardia and cardiac dysrhythmias

38. Amy Pallet is recovering from abdominal surgery in which isoflurane (Forane) was used as the anesthetic agent. In planning postanesthesia care, Jill will most likely expect: a. nausea and vomiting b. postoperative excitation c. cardiac dysrhythmias d. depressed mental altertness 39. Jill prepares to administer naloxone (Narcan) 0.1 mg IV to Mr. Steiner to reverse the effects of narcotics that were administered preoperatively. It will be important for Jill to assess for the following with regard to naloxone administration: a. respiratory difficulty b. dry mouth c. intense pain d. urine output 40. Justine Smith, a 6-year-old, received a pediatric dose of propranolol (Inderal) preoperatively. During recovery from general anesthesia, Jill will observe Ms. Smith for the following reaction: a. anxiety b. hypotension c. barbiturate potentiation d. hypertensive crisis 41. Mrs. Hayes is scheduled for removal of a ganglionic cyst, using lidocaine (Xylocaine) with epinephrine for a nerve block. It is vital that Jill review medications that Mrs. Hayes takes, because severe hypertension may result if lidocaine with epinephrine is given to patients who are taking: a. beta-blockers b. anticholinergic agents c. monoamine oxidase inhibitors d. H2 antagonists 42. Before giving glycopyrrolate (Robinul) 0.1 mg IM as a preoperative medication to Mr. Shores, Jill will assess for the following patient condition: a. asthma b. anxiety c. narrow-angle glaucoma d. rheumatoid arthritis 43. Mrs. Carlson is in the early recovery phase from a cholecystectomy. Which of the following responses indicates successful preoperative and postoperative teaching? a. It hurts too much to move, so Im just going to stay in one position. b. Even though it hurts, I need to turn, cough and deep breathe. I can use a pillow to splint my abdomen. c. The nurse will bring my pain medication every four hours on the hour whether I ask for it or not. d. Im afraid my incision will open if I sit up. 44. Maureen Rhodes returns from surgery, during which an inhalation anesthetic was used. Jill is aware that Mrs. Rhodes may experience the following with regard to inhalation anesthetics: a. rapid onset of pain b. reduced mobility c. confusion and disorientation

8 d. respiratory complications 45. During the postoperative planning phase, Jill takes into consideration all of the following except: a. type of anesthetic used b. surgical procedure performed c. associated anesthetic side effects d. dependence on anesthetic agents ~The End~