CNS drugs

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.

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 (eg, ondansetron) and dopamine receptor antagonists (eg, prochlorperazine) cannot be used, because they increase the risk of serious postural hypotension. Levodopa only increases nausea and vomiting.

A nurse is discussing motor symptoms with a patient with Parkinson's disease who has been taking levodopa/carbidopa [Sinemet] for 9 months 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, generally within the first year of therapy. 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.

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.

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.

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.

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.

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.

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.

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.

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 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.

A patient who is newly diagnosed with Parkinson's disease is prescribed levodopa [Dopar]. The patient asks the nurse about drugs to prevent disease progression. What will the nurse tell this patient?
a. "Levodopa may prevent disease progression in higher doses and is safe to use for this purpose."
b. "MAO-B inhibitors and dopamine agonists have both shown neuroprotective effects in human studies."
c. "Vitamin E has been shown to delay neuron degeneration and may be used as adjunctive therapy."
d. "While some drugs show promise, there are no studies that have proven a neuroprotective effect."

ANS: D
To date, there is no definitive proof that any drug can protect dopaminergic neurons from progressive degeneration. Levodopa has shown neuroprotective effects, but studies have demonstrated toxic effects in the doses required for this purpose. MAO-B inhibitors have shown benefits, but only in animal studies. Vitamin E was once theorized to offer this protection, but recent studies have provided good evidence that this is not the case.

A patient with Parkinson's disease is taking levodopa/carbidopa [Sinemet] along with amantadine [Symmetrel] 400 mg/day to treat dyskinesias. The patient reports having increased dyskinesias several months after beginning the amantadine. The nurse will contact the provider to discuss which action?
a. Increasing the dose of amantadine [Symmetrel]
b. Interrupting treatment with amantadine for several weeks
c. Ordering renal function tests
d. Ordering another anticholinergic medication

ANS: B
When amantadine is added to therapy to treat dyskinesias associated with levodopa, it often loses effectiveness after several months. If the effects diminish, they can be restored by either increasing the dosage or by interrupting treatment for several weeks. The maximum dosage of amantadine is 400 mg/day, so it is incorrect to increase the dose. Altered renal function would result in drug toxicity, not ineffectiveness of the drug. It is not necessary to order another drug until determining whether the effectiveness can be restored.

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.

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:

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.

The nurse provides teaching for a patient who will begin taking rotigotine [Neupro] to treat Parkinson's disease. What will the nurse include in teaching?
a. "If you develop nausea and vomiting, you should stop taking the medication."
b. "If you need to stop this drug, your provider will order a gradual withdrawal."
c. "You will start this drug regimen with a higher than usual loading dose."
d. "You will take this medication by mouth with food."

ANS: B
Rotigotine is a nonergot dopamine agonist, which is given by starting with a 2-mg dose that is increased by 2 mg each week until the lowest effective dose is reached. It should not be stopped abruptly but should be decreased by 2 mg per week until tapered off. It undergoes extensive first-pass metabolism, so it is not given orally and is currently available as a transdermal patch.

A nurse is caring for an older adult man who has Alzheimer's disease (AD). The patient's daughter wants to know if testing can be done to determine her risk for developing the disease. What will the nurse tell her?
a. Female gender is known to increase the risk.
b. Genetic testing can provide a definitive measure of the risk.
c. Patients with the apolipoprotein E2 gene (apoE2) are more likely to develop the disease.
d. Advancing age and family history are known risk factors.
?

ANS: D
Advancing age and a positive family history are the only two known risk factors. Female gender is not a known risk; the increased incidence among females may be the result of women living longer than men. No definitive genetic tests are available. The presence of apoE2 seems to be protective.

The spouse of a patient who is newly diagnosed with Alzheimer's disease asks the nurse if medications will prevent the need for nursing home care. Which response by the nurse is correct?
a. "Drugs to treat Alzheimer's disease may slow the progression of memory loss."
b. "Drugs may be effective to stop the progression of the disease if they are initiated early in the disease."
c. "Medications to treat Alzheimer's disease are effective for treating core symptoms of the disease."
d. "Medications for Alzheimer's disease are effective in reducing cognitive impairment."

ANS: A
Alzheimer's disease is a disease in which symptoms progress relentlessly from mild to moderate to severe. Medications have not been clearly effective and do not stop the disease progression, although they may slow loss of memory and cognition and prolong independent function. There is no indication that available drugs stop disease progression if begun early in the course of the disease. There is no clearly effective therapy for core symptoms, but associated symptoms such as incontinence and depression may be treated.

An older adult patient with Alzheimer's disease is admitted to the hospital. The patient's spouse reports that the patient is often confused and gets lost walking to the store, which is three blocks from their home. That evening, the nurse observes the patient pacing the hall and screaming. What will the nurse do?
a. Notify the provider of this patient's worsening symptoms.
b. Prepare the patient's spouse for impending death from Alzheimer's disease.
c. Request an increase in the medication dose to treat the exacerbation in symptoms.
d. Tell the spouse that this is an expected progression of the disease.

ANS: D
This patient is showing signs of the natural progression of AD. Behavior problems such as these occur in 70% to 90% of patients with AD as the disease progresses. There is no need to notify the provider to report these symptoms, because they are expected. The time from onset of symptoms to death usually is 4 to 8 years, but it may be as long as 20 years; this progression does not represent the final stages. Medications are not effective for preventing disease progression, and their effects on memory and cognition are modest, so requesting an increase in the drug dose would not help in this situation.

An older adult patient has confusion, memory loss, and disorientation in familiar surroundings. The patient has been taking donepezil [Aricept] 10 mg once daily for 6 months. The patient's symptoms have begun to worsen, and the patient's spouse asks if the medication dose can be increased. What will the nurse tell the spouse?
a. The dose can be increased, because the patient has been taking the drug for longer than 3 months.
b. The dose can be increased to twice daily dosing instead of once daily dosing.
c. The increase in symptoms is the result of hepatotoxicity from the medication's side effects.
d. The patient must take the drug for longer than 1 year before the dose can be increased.

ANS: A
Donepezil is given for mild, moderate, and severe AD, and dosing may be increased, although it must be titrated up slowly. For patients with moderate to severe AD who have taken 10 mg once daily for at least 3 months, the dose can be increased to 23 mg once daily. Donepezil is not given twice daily. Donepezil does not cause hepatotoxicity; hepatotoxicity occurs with tacrine, the first acetylcholinesterase (AChE) inhibitor, which now is rarely used. Dosing is increased after 3 months, not 1 year.

A patient will begin taking a cholinesterase inhibitor for early Alzheimer's disease. The nurse is teaching the patient's spouse about the medication. Which statement by the spouse indicates a need for further teaching?
a. "Gastrointestinal symptoms are common with this medication."
b. "People taking this drug should not take antihistamines."
c. "This drug helps neurons that aren't already damaged to function better."
d. "This drug significantly slows the progression of the disease."

ANS: D
Cholinesterase inhibitors produce modest improvements in cognition, behavior, and function and may slightly delay disease progression; they do not have a major impact on delaying progression of the disease. Gastrointestinal symptoms are common side effects. Drugs that block cholinergic receptors, including antihistamines, can reduce therapeutic effects and should be avoided. Cholinesterase inhibitors do not affect neurons already damaged, but they do improve function in those not yet affected.

The spouse of a patient with Alzheimer's disease asks a nurse for more information about the rivastigmine [Exelon] transdermal patch that is being used. Which statement by the spouse indicates a need for further explanation?
a. "Doses are lower but more steady with the transdermal patch."
b. "Reduced side effects occur with the transdermal patch."
c. "We only need to change the patch every 2 weeks."
d. "We should remove the old patch before applying the new one."

ANS: C
The rivastigmine transdermal patch needs to be changed daily. Sites used should not be reused for 14 days. Transdermal dosing provides lower, steady levels of the drug. Intensity of side effects is lower with the transdermal patch. The old patch must be removed prior to applying the new patch to prevent toxicity.

A nurse is teaching a group of nursing students about the use of memantine [Namenda] for Alzheimer's disease. Which statement by a student indicates understanding of the teaching?
a. "Memantine is indicated for patients with mild to moderate Alzheimer's disease."
b. "Memantine modulates the effects of glutamate to alter calcium influx into neurons."
c. "Memantine prevents calcium from leaving neurons, which improves their function."
d. "Memantine and donepezil combined may stop progression of Alzheimer's disease."

ANS: B
Memantine modulates the effects of glutamate, which is involved in calcium influx into neuronal cells. Memantine is used for patients with moderate to severe AD. Memantine does not prevent calcium from leaving cells; it only affects the influx of calcium. In studies, although the effects of memantine and donepezil appear to be synergistic or may confer independent benefits, they only demonstrate improvement in cognitive function and not a stop in disease progression.

A nurse is caring for an older adult patient who has Alzheimer's disease. The patient is taking a cholinesterase inhibitor drug. Which side effects would concern the nurse?
a. Confusion and memory impairment
b. Dizziness and headache
c. Nausea, vomiting, and diarrhea
d. Slowed heart rate and lightheadedness

ANS: D
Cardiovascular effects of cholinesterase inhibitor drugs are uncommon but cause the most concern. Bradycardia and fainting can occur when cholinergic receptors in the heart are activated. Confusion and memory impairment are signs of the disease and are not side effects of the drug. Dizziness, headache, nausea, vomiting, and diarrhea are all expected adverse effects, and although uncomfortable, they do not present an increased risk to the patient.

A nurse is preparing to administer memantine [Nemanda] to a patient and notes a slight elevation in the patient's creatinine clearance level. What will the nurse expect the provider to order for this patient?
a. Adding sodium bicarbonate to the patient's drug regimen
b. Continuing the memantine as ordered
c. Discontinuing the memantine
d. Reducing the dose of memantine

ANS: D
Patients with severe renal impairment may require a dosage reduction. Adding sodium bicarbonate would alkalinize the urine and increase memantine levels, causing toxicity. It is not necessary to discontinue or decrease the dose of the memantine with mild or moderate renal impairment.

A patient is worried about the risk of developing Alzheimer's disease, because both parents had the disease. The nurse will tell this patient that known risk factors include what? (Select all that apply.)
a. Advanced age
b. Alcoholism
c. Family history
d. Gender
e. Obesity

ANS: A, C
The major known risk factor for AD is advancing age; the only other known risk factor is a family history of AD. Alcoholism, gender, and obesity are not known risk factors.

A patient has been newly diagnosed with multiple sclerosis (MS), and the nurse provides teaching about the medications for the disease. Which statement by the patient indicates a need for further teaching?
a. "I may need to take additional drugs at times of acute relapse."
b. "I will need to take medication indefinitely."
c. "If medication is begun early, permanent remission can be achieved."
d. "Some symptoms may need to be managed with symptom-specific drugs."
?

ANS: C
Drug therapy can reduce the frequency and severity of relapses, maintain quality of life, and prevent permanent damage to axons, but it does not produce permanent remission. Patients may need to take additional drugs during times of relapse and will need to take medications indefinitely. Some symptoms may be managed with symptom-specific drugs.

A patient has been diagnosed with multiple sclerosis (MS) for 10 years and has a history of 3 periods of neurologic dysfunction lasting several weeks separated by long periods of full recovery. In the past 6 months, the patient has had a prolonged period of neurologic dysfunction without remission. The nurse understands that the patient may have which MS subtype?
a. Primary progressive MS
b. Progressive-relapsing MS
c. Relapsing-remitting MS
d. Secondary progressive MS

ANS: D
Secondary progressive MS occurs when a patient with relapsing-remitting MS develops steadily worsening dysfunction with or without plateaus or acute exacerbations, or minor remissions. Within 10 to 20 years of onset, about 50% of patients with MS will develop this type. Primary progressive MS occurs when symptoms grow progressively more intense from the onset. Progressive-relapsing MS is similar to primary progressive MS, but with acute exacerbations imposed on the steadily worsening symptoms. Relapsing-remitting MS is the most common initial presentation, which is characterized by recurrent, clearly defined episodes of symptoms with periods of remission with relapse occurring approximately twice every 3 years.

A patient has been diagnosed with primary progressive multiple sclerosis for 1 year and reports a recent brief period of being symptom free. The nurse will tell the patient that this indicates what?
a. Hope for long-term remission
b. Temporary improvement
c. Development of relapsing-remitting MS
d. Development of secondary progressive MS

ANS: B
Patients with primary progressive MS have symptoms that grow progressively more intense over time; patients may experience occasional plateaus or temporary improvement, but they do not have clear remissions. This episode does not represent hope for long-term remission or the development of a different subtype of MS.

A patient is being treated with interferon beta-1a [Avonex] for relapsing-remitting MS. The patient calls the clinic to report headache, fever, chills, and muscle aches after administering a dose. What will the nurse recommend?
a. Acetaminophen or ibuprofen
b. Asking the provider to order a complete blood count (CBC)
c. Coming to the clinic for evaluation for leukoencephalopathy
d. Discontinuing the drug immediately
recommend?

ANS: A
Patients treated with interferon beta can experience flulike reactions that diminish over time. Acetaminophen or ibuprofen may be used to treat symptoms. A CBC is not indicated. Leukoencephalopathy is a side effect of natalizumab, not interferon beta. It is not necessary to discontinue the drug.

A patient with multiple sclerosis is to begin treatment with interferon beta. The patient comes to the clinic to have pretreatment laboratory tests. Which statement by the patient indicates a need for further teaching about these tests?
a. "After the first year of treatment, I will need once yearly blood work."
b. "I will need to have lab tests done every 3 months for the first year."
c. "If my liver function tests are abnormal, I will need to stop using this drug."
d. "These lab tests will measure liver and bone marrow function."

ANS: A
Patients treated with interferon beta require evaluation of bone marrow function with CBCs and of liver function with liver function tests (LFTs) at the beginning of therapy for baseline, every 3 months for a year, and then every 6 months thereafter. Abnormal LFTs warrant discontinuation of the drug.

A patient administers interferon beta-1a SQ [Rebif] 22 mcg/0.5 mL three times each week. The patient calls the nurse to report unrelieved itching and erythema at the injection site, despite the use of topical hydrocortisone for several weeks. What will the nurse tell this patient to do?
a. Apply ice to the injection site before and after the injection.
b. Ask the provider to reduce the dose of interferon beta to 8.8 mcg/0.2 mL.
c. Discuss using a prescription-strength hydrocortisone product with the provider.
d. Take oral diphenhydramine [Benadryl].

ANS: D
Oral diphenhydramine can help reduce itching and erythema. Ice is used to control pain and should be used before the injection; warm, moist compresses are used after the injection. Reducing the dose of interferon will not reduce the local reaction. Continuous use of topical steroids is not recommended because of the risk of skin damage.

A patient has received an initial dose of glatiramer acetate [Copaxone] for relapsing-remitting multiple sclerosis. The nurse notes that the patient appears flushed and anxious and has urticaria. The patient reports palpitations, chest pain, and a feeling of laryngeal constriction. What will the nurse do?
a. Obtain an order for epinephrine to treat a hypersensitivity reaction.
b. Prepare to provide cardiorespiratory support.
c. Report a possible cardiotoxic episode to the provider.
d. Stay with the patient until this self-limiting episode passes.

ANS: D
About 10% of patients taking glatiramer acetate experience a self-limited postinjection reaction characterized by flushing, palpitations, severe chest pain, anxiety, laryngeal constriction, and urticaria; the episode usually lasts 15 to 20 minutes. No treatment is required, but the nurse should stay with the patient to help alleviate anxiety associated with this reaction. Epinephrine is not indicated. Cardiorespiratory support is not necessary. This does not represent a cardiotoxic reaction.

A patient who stopped taking teriflunomide [Aubagio] 1 year prior tells the nurse that she has just found out she is pregnant. Which action by the nurse is correct?
a. Contact the provider to obtain an order for serum drug levels.
b. Reassure the patient that her fetus should be safe.
c. Suggest that she consider an abortion.
d. Tell her that she will not be able to nurse her baby when it is born.

ANS: A
Women taking teriflunomide should be tested prior to beginning the drug to rule out pregnancy and should be counseled to use a reliable form of birth control while taking it since the drug is listed as pregnancy category X and can cause serious birth defects. The drug can stay in the system for up to 2 years. Women who become pregnant should be evaluated to determine serum drug levels and bile acid sequestrants or activated charcoal may be given to enhance drug elimination. The nurse cannot assure her that her fetus is safe and should not counsel abortion.

A patient is about to begin therapy with fingolimod [Gilenya] to treat multiple sclerosis. The nurse learns that the patient has not had chickenpox or the varicella zoster virus (VZV) vaccine. What will the nurse do?
a. Advise the patient to avoid individuals with chickenpox.
b. Give the VZV vaccine with the initial dose of fingolimod.
c. Give the VZV vaccine and tell the patient to begin using fingolimod in 1 month.
d. Obtain an order for a VZV antibody test.

ANS: D
Patients who have not had chickenpox or the VZV vaccine should be tested for VZV antibodies before receiving fingolimod. It is not correct to advise patients to avoid people with chickenpox, because this disease is endemic. Patients who do not have VZV antibodies should receive the VZV vaccine 1 month before beginning the fingolimod. The VZV vaccine should be given only to those who do not have VZV antibodies.

A nurse provides teaching for a 25-year-old patient who will receive mitoxantrone [Novantrone] for worsening relapsing-remitting multiple sclerosis. Which statement by the patient indicates a need for further teaching?
a. "I may experience cardiac side effects several years after receiving this drug."
b. "I should report fever, chills, cough, and hoarseness immediately."
c. "I will need an infusion of this medication once weekly."
d. "I will need a liver function test and a pregnancy test before each dose."

ANS: C
Mitoxantrone is given as an infusion once every 3 months. Cardiac side effects may become apparent during treatment or up to years after discontinuation of the drug. Fever, chills, cough, and hoarseness are signs of infection and should be reported immediately. LFTs and a pregnancy test should be done before each infusion.

A patient who has recently begun taking interferon beta reports feeling depressed. Which action by the nurse is correct?
a. Notify the provider of these symptoms.
b. Reassure the patient that these symptoms will subside.
c. Request an order for an antidepressant medication.
d. Suggest counseling to discuss the effects of this chronic disease.

ANS: A
Interferon beta may promote or exacerbate depression and some patients may experience suicidal ideation or may attempt suicide. The provider should be notified so that the patient may be monitored and a reduction of dose may be required. Reassuring the patient is not correct because the symptoms may worsen. Patients experiencing depression should be referred to a psychiatrist for treatment. The depression is caused by the drug and should not be considered a normal effect of the disease.

A patient has begun taking dimethyl fumarate [Tecfidera] to treat relapsing MS and calls the clinic to report flushing of the skin with itching and burning sensations. What will the nurse recommend to this patient?
a. "Take a non-enteric-coated aspirin 30 minutes before each dose."
b. "The provider will order an antihistamine to treat this symptom."
c. "Try taking the medication on an empty stomach."
d. "You should notify the provider immediately."

ANS: A
The most common side effect of dimethyl fumarate is flushing, which decreases over time. Patients should be counseled to take a non-enteric-coated aspirin 30 minutes prior to the dose and to take the medication with food. Antihistamines are not indicated. It is not a serious symptom and the provider does not need to be notified.

Immunomodulator drugs have shown effectiveness for what? (Select all that apply.)
a. Preventing the development of MS
b. Primary progressive MS
c. Progressive-relapsing MS
d. Relapsing-remitting MS
e. Secondary progressive MS

ANS: C, D, E
Immunomodulators can be used in progressive-relapsing MS, relapsing-remitting MS, and secondary progressive MS but not to prevent MS from developing or to treat primary progressive MS.

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.

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.

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.

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 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.

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.

ANS: C
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.

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.

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.

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.

A patient who has a seizure disorder is admitted to the hospital after an increase in seizure frequency, and the prescriber orders carbamazepine [Tegretol] 100 mg twice daily to be added to the patient's medication regimen. The nurse reviewing the patient's medical history notes that the patient is already taking lamotrigine [Lamictal] 375 mg twice daily. The nurse will contact the provider to discuss which action?
a. Reducing the carbamazepine dose to 50 mg twice daily
b. Reducing the lamotrigine dose to 225 mg twice daily
c. Increasing the carbamazepine dose to 200 mg twice daily
d. Increasing the lamotrigine dose to 500 mg twice daily

ANS: D
Carbamazepine induces hepatic drug-metabolizing enzymes and can increase the rate at which lamotrigine and other drugs are metabolized; 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.

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.

A child is diagnosed with absence seizures, and the prescriber orders ethosuximide [Zarontin]. When teaching the child's parents about dosage adjustments for this drug, the nurse will stress the importance of:
a. frequent serum drug level monitoring.
b. learning as much as possible about the disorder and its treatment.
c. recording the number of seizures the child has each day.
d. reporting dizziness and drowsiness to the provider.

ANS: C
Measurements of plasma drug levels are less important than observation of seizure activity for determining effective dosages for absence seizures, because this type of seizure is characterized by as many as several hundred occurrences a day. Keeping a chart of seizure activity is the best way to monitor drug effectiveness when treating absence seizures. Frequent drug level monitoring is important when side effects occur to ensure that drug toxicity is not occurring. Learning about the disorder is an important part of adherence. Dizziness and drowsiness are common side effects that diminish with continued use.

A patient who has been taking phenobarbital for epilepsy begins taking valproic acid [Depakote] as adjunct therapy. The nurse notes that the patient is very drowsy. What will the nurse do?
a. Explain to the patient that tolerance to sedation eventually will develop.
b. Notify the prescriber, and request an order to reduce the dose of phenobarbital.
c. Notify the prescriber of the need to increase the dose of valproic acid.
d. Request an order for liver function tests to monitor for hepatotoxicity.

ANS: B
Valproic acid competes with phenobarbital for drug-metabolizing enzymes and can increase plasma levels of phenobarbital by approximately 40%. When this combination is used, the dose of phenobarbital should be reduced. Increasing the dose of valproic acid would compound the problem. Patients taking phenobarbital alone experience sedation, which diminishes as tolerance develops. Liver toxicity is a rare adverse effect of valproic acid and is marked by symptoms of nausea, vomiting, and malaise, not drowsiness.

A nurse is providing teaching to a patient newly diagnosed with partial seizures who will begin taking oxcarbazepine [Trileptal]. The patient also takes furosemide [Lasix] and digoxin [Lanoxin]. Which statement by the patient indicates understanding of the teaching?
a. "I may need to increase my dose of Trileptal while taking these medications."
b. "I may develop a rash and itching, but these are not considered serious."
c. "I should report any nausea, drowsiness, and headache to my provider."
d. "I should use salt substitutes instead of real salt while taking these drugs."

ANS: C
Oxcarbazepine can cause clinically significant hyponatremia in 2.5% of patients. If oxcarbazepine is combined with other drugs that reduce sodium, the patient should be monitored. Signs of hyponatremia include nausea, drowsiness, confusion, and headache, and patients should be taught to report these symptoms. Increasing the dose of oxcarbazepine is not indicated. Rashes can indicate a serious drug reaction, and providers should be notified so that the oxcarbazepine can be withdrawn. Salt substitutes would compound the problem of hyponatremia.

A child who receives valproic acid [Depakote] begins taking lamotrigine [Lamictal] because of an increase in the number of seizures. The nurse will observe this child closely for which symptom?
a. Angioedema
b. Hypohidrosis
c. Rash
d. Psychosis

ANS: C
Lamotrigine can cause life-threatening rashes, such as Stevens-Johnson syndrome and toxic epidermal necrolysis, and this risk increases with concurrent use of valproic acid. Angioedema is an adverse effect associated with pregabalin. Hypohidrosis and psychosis are associated with topiramate.

A 20-kg child has been taking valproic acid [Depakote] for 1 week to treat a seizure disorder. The child is receiving 200 mg PO twice daily. The child's parents report no improvement in seizure activity. The nurse will anticipate that the provider will order which change in this child's drug regimen?
a. Adding another seizure medication to supplement the valproic acid
b. Changing to phenytoin [Dilantin] since the valproic acid is not effective
c. Increasing the dose of valproic acid to 300 mg PO twice daily
d. Increasing the dose of valproic acid to 200 mg three times daily

ANS: C
Valproic acid is given initially at a dose of 5 to 15 mg/kg/day, administered in two divided doses. This child is receiving 400 mg/day, which is 10 mg/kg/day. The dosage should be increased by 5 to 10 mg/kg/day each week until optimal levels are achieved up to a maximum dose of 60 mg/kg/day. At this point, adding another AED or changing to another AED is not recommended. Increasing the dose to three times daily is not recommended.

A patient has begun taking phenobarbital after experiencing several seizures and is currently receiving 60 mg PO twice daily. After two weeks of therapy, the patient has a serum drug level of 30 mcg/mL and reports feeling drowsy much of the day. What will the nurse tell this patient?
a. "I will contact your provider to discuss changing your dosing to once daily to minimize the drowsiness."
b. "The drug level is low and you may need a higher dose, but taking it three times daily will reduce the drowsiness."
c. "This side effect is expected and should decrease over time. You should avoid driving in the meantime."
d. "Your lab work shows a higher than normal level of the drug and your provider will probably lower your dose."

ANS: A
Phenobarbital has a long half-life and may be given once daily at bedtime to help manage its sedative effects. The serum drug level is within the normal range of 15 to 40 mcg/mL, so the dose does not need to be adjusted. Increasing the dose and the frequency is not necessary since the drug levels are therapeutic and scheduling the drug to three times daily will compound the sedative effects. The sedative side effects do not increase over time.

A nurse is admitting a patient to the hospital. The patient reports taking oral baclofen [Lioresal] but stopped taking the drug the day before admission. The nurse would be correct to anticipate which adverse effects?
a.Weakness and dizziness
b.Fatigue and drowsiness
c.Seizures and hallucinations
d.Respiratory depression and coma

ANS: C
Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid
ideation, and seizures. Central nervous system effects of baclofen include weakness,
dizziness, fatigue, and drowsiness. Respiratory depression is a result of overdose of
baclofen.

A patient who has a lower back injury exhibits muscle spasms. The provider orders cyclobenzaprine [Flexeril] 10 mg three times a day. What will the nurse
include when teaching this patient about this drug?
a."This drug carries some risk of developing hallucinations and psychotic symptoms."
b."This medication may cause your urine to turn brown, black, or dark green."
c."You may experience blurred vision, dry mouth, or constipation."
d."You will need to have liver function tests performed while taking this medication."

ANS: C
Cyclobenzaprine has significant anticholinergic effects and patients should be warned
about dry mouth, blurred vision, and constipation. Tizanidine can cause hallucinations
and psychotic symptoms. Methocarbamol may turn urine brown, black, or green, which is
a harmless side effect. Tizanidine and metaxalone can cause liver toxicity and require
monitoring.

A nurse is caring for a patient receiving intrathecal baclofen [Lioresal]. The patient is unresponsive. After asking a coworker to contact the provider, the nurse
anticipates performing which intervention?
a.Preparing to support respirations
b.Administering an antidote to baclofen
c.Administering diazepam to prevent seizures
d.Obtaining an electrocardiogram

ANS: A
An overdose of baclofen can produce coma and respiratory depression, so the nurse
would be correct to suspect overdose in this patient. Respiratory support is essential to
prevent a fatal outcome. There is no antidote for baclofen overdose. Diazepam would not
be indicated, because seizures are not a result of baclofen overdose and may further
depress respirations. An electrocardiogram is not indicated for this patient.

A patient has localized muscle spasms after an injury. The prescriber has ordered tizanidine [Zanaflex] to alleviate the spasms. When obtaining the patient's health history, the nurse should be concerned about which possible reason for considering
another drug?
a.Concomitant use of aspirin
b.A history of hepatitis
c.A history of malignant hyperthermia
d.Occasional use of alcohol

ANS: B
Hepatotoxicity is a serious potential problem in a patient receiving tizanidine, because the
drug can cause liver damage. Baseline liver enzymes should be obtained before dosing
and periodically thereafter. Analgesic anti-inflammatory drugs commonly are used in
conjunction with centrally acting muscle relaxants, so using aspirin is not a concern. This
drug does not contribute to malignant hyperthermia. Patients should be advised to avoid
alcohol when taking this drug, but a history of occasional alcohol use is not a
contraindication.

Which patient should receive dantrolene [Dantrium] with caution?
a.A 20-year-old woman with a spinal cord injury
b.A 45-year-old man with a history of malignant hyperthermia
c.A 55-year-old woman with multiple sclerosis
d.An 8-year-old child with cerebral palsy

ANS: C
Dose-related liver damage is the most serious adverse effect of dantrolene and is most
common in women older than 35 years. Dantrolene is used to treat spasticity associated
with multiple sclerosis, cerebral palsy, and spinal cord injury, so all of these patients
would be candidates for this agent. Dantrolene also is used to treat malignant
hyperthermia.

A nurse is teaching the parent of a child with spastic quadriplegia about intrathecal baclofen [Lioresal]. Which statement by the parent indicates a need for further teaching?
a."I can expect my child to be more drowsy when receiving this medication."
b."I should not notice any change in my child's muscle strength."
c."I will contact the provider if my child is constipated or cannot urinate."
d."If my child has a seizure, I should stop giving the medication immediately."

ANS: D
Seizures may occur if oral baclofen is withdrawn abruptly; seizures are not an adverse
effect of baclofen. If intrathecal baclofen is stopped abruptly, patients can experience lifethreatening
effects, so parents should be advised not to stop the drug abruptly. The central
nervous system effects of baclofen include drowsiness and lethargy, so these effects are
expected. Baclofen does not reduce muscle strength. It can cause constipation and urinary
retention, and patients should be advised to contact their provider so that these conditions
can be treated.

A patient with cerebral palsy has severe muscle spasticity and muscle weakness. The patient is unable to take anything by mouth. The nurse is correct to
anticipate that which medication will be ordered for home therapy?
a.Baclofen [Lioresal]
b.Dantrolene [Dantrium]
c.Diazepam [Valium]
d.Metaxalone [Skelaxin]

ANS: A
Baclofen is used to treat muscle spasticity associated with multiple sclerosis, spinal cord
injury, and cerebral palsy. It does not reduce muscle strength, so it will not exacerbate this
patient's muscle weakness. It can be given intrathecally, via an implantable pump, and
therefore is a good choice for patients who cannot take medications by mouth. Dantrolene
must be given by mouth or intravenously and so would not be a good option for this
patient. It also causes muscle weakness. Diazepam is not the first-line drug of choice.
Alternative routes to PO administration are IM, IV, or by rectum. Metaxalone is used to
treat localized muscle spasms caused by injury and is not used for cerebral palsy.

A patient with multiple sclerosis needs pharmacologic treatment for
spasticity to begin strengthening exercises to improve walking ability. The nurse
anticipates that which medication will be ordered for spasticity?
a.Baclofen [Lioresal]
b.Dantrolene [Dantrium]
c.Diazepam [Valium]
d.Metaxalone [Skelaxin]

ANS: A
Baclofen is used to treat spasms associated with multiple sclerosis. It has no direct
muscle relaxant effects, so it does not reduce muscle strength. Dantrolene works well to
reduce spasms, but it also has significant effects on muscle strength. Diazepam is not the
first-line drug of choice, but it could be used because it does not reduce muscle strength.
Metaxalone is not indicated to treat spasms caused by multiple sclerosis.

A patient with cerebral palsy who has been receiving baclofen [Lioresal] via gastrostomy tube for 3 months is admitted to the hospital for evaluation of new-onset
seizures. What may the nurse suspect to be the cause of these seizures?
a.Baclofen toxicity
b.Common adverse effect of baclofen
c.Idiopathic causes related to disease process
d.Missed doses of baclofen

ANS: D
Baclofen does not appear to cause physical dependence, but abrupt discontinuation has
been associated with adverse reactions. Abrupt withdrawal of oral baclofen can cause
visual hallucinations, paranoid ideation, and seizures and should be considered when a
patient develops these symptoms. Seizures are not a symptom of baclofen toxicity.

Which drugs are used to treat spasticity? (Select all that apply.)
a.Baclofen [Lioresal]
b.Dantrolene [Dantrium]
c.Diazepam [Valium]
d.Metaxalone [Skelaxin]
e.Tizanidine [Flexeril]

ANS: A, B, C
Three drugs—baclofen, dantrolene, and diazepam—are used to treat spasticity. Baclofen
and diazepam act in the CNS, whereas dantrolene acts directly on skeletal muscles. With
the exception of diazepam, drugs used for muscle spasm, such as metaxalone and
tizanidine, are not effective for treating spasticity.