Cholinergic Agonists

The patient has had cevimeline (Evoxac) prescribed. What would be an appropriate dosing schedule for the nurse to administer this drug?
A)
Once a day
B)
Twice a day
C)
Three times a day
D)
Every 4 hours
Ans:
C

Feedback:

Cevimeline should be given three times a day with meals. Once or twice a day dosing would cause a decrease in therapeutic effects of the drug and every 4 hours could lead to toxicity.

A student asks the pharmacology instructor to describe the function of a cholinergic agonist. What would the instructor reply?
A)
Cholinergic agonists increase the activity of dopamine receptor sites throughout the brain and spinal cord.
B)
Cholinergic agonists decrease the activity of gamma-aminobutyric acid (GABA) receptor sites throughout the body.
C)
Cholinergic agonists increase the activity of acetylcholine receptor sites throughout the body.
D)
Cholinergic agonists decrease the activity of norepinephrine receptor sites throughout the brain and spinal cord.
Ans:
C

Feedback:

Cholinergic agonists are drugs that increase the activity of acetylcholine receptor sites throughout the body. Dopamine, GABA, and norepinephrine are not associated with cholinergic agonist function.

A 10-year-old child with spina bifida is receiving bethanechol (Urecholine) for treatment of neurogenic bladder. What adverse effect will the nurse assess for?
A)
Constipation
B)
Loss of bowel and bladder control
C)
Decrease salivation
D)
Increased appetite
Ans:
B

Feedback:

Loss of bowel and bladder control is an adverse effect of cholinergic agents that would cause stress in a child. Diarrhea and increased salivation are also adverse effects. Increased appetite is not associated with these drugs. Children are more likely to have gastrointestinal (GI) upset that could result in a decrease in appetite.

A nurse is writing a plan of care for a patient who is taking bethanechol (Urecholine). What would be an appropriate outcome for this patient?
A)
Pupillary dilation
B)
Increased blood pressure
C)
Improved bladder function
D)
Decreased secretions
Ans:
C

Feedback:

Bethanechol is prescribed for nonobstructive urinary retention and neurogenic bladder. The appropriate outcome for this patient would be improved bladder function. This drug causes pupillary constriction and increased secretions. This drug would not increase blood pressure. However, it could cause hypotension in the older patient.

What drug is the nurse likely to administer to diagnose myasthenia gravis in a child?
A)
Atropine (generic)
B)
Bethanechol (Urecholine)
C)
Edrophonium (Enlon, Reversol)
D)
Neostigmine (Prostigmine)
Ans:
C

Feedback:

Edrophonium is the drug of choice for diagnosing myasthenia gravis. Bethanechol is used to treat neurogenic bladder. Neostigmine is used for treatment of myasthenia gravis and could be used for diagnosis if edrophonium could not be used. Atropine is an anticholinergic drug and would not be used to test for myasthenia gravis.

A patient is brought to the emergency department having a cholinergic reaction, which includes a severe drop in blood pressure. What drug will the nurse expect to administer?
A)
Atropine (generic)
B)
Edrophonium (Enlon, Reversol)
C)
Propranolol (Inderal)
D)
Succinylcholine (Anectine)
Ans:
A

Feedback:

The antidote for a cholinergic reaction is atropine. This drug will block the cholinergic sites. Edrophonium would cause an accumulation of acetylcholine and worsen the situation. Propranolol blocks beta-receptors in the sympathetic system. Succinylcholine is a neuromuscular junction drug and would not affect other sites.

Memantine hydrochloride (Namenda) has been prescribed for a 63-year-old patient who has a confirmed diagnosis of Alzheimer’s disease. What would be the target dose for this patient?
A)
5 mg/d
B)
10 mg b.i.d.
C)
15 mg/d
D)
20 mg b.i.d.
Ans:
B

Feedback:

The drug is started at 5 mg/d PO, increasing by 5 mg/d at weekly intervals. The target dose is 20 mg/d given as 10 mg b.i.d.

An Alzheimer’s patient taking donepezil (Aricept) has a complete blood count that indicates he or she is anemic. What drug taken in combination with donepezil could be the cause of the anemia?
A)
Cimetidine (Tagamet)
B)
Ibuprofen (Advil)
C)
Diltiazem (Cardizem)
D)
Furosemide (Lasix)
Ans:
B

Feedback:

There could be an increased risk of gastrointestinal (GI) bleeding if donepezil is taken with a nonsteroidal anti-inflammatory drug (NSAID) because of the combination of increased GI secretions and the GI mucosal erosion associated with the use of NSAIDs. Cimetidine, diltiazem, and furosemide would not affect GI bleeding.

The Air Force nurse is treating a patient who was exposed to a particular nerve gas. What drug has been approved to treat this patient?
A)
Neostigmine (Prostigmin)
B)
Pyridostigmine (Mestinon)
C)
Ambenonium (Mytelase)
D)
Edrophonium (Enlon, Reversol)
Ans:
B

Feedback:

Pyridostigmine has been approved for use by military personnel who have been exposed to particular nerve gases. Neostigmine, ambenonium, and edrophonium are not approved for this use.

10.

The nurse administers a direct-acting cholinergic agonist to the patient. When assessing this patient for drug effects, the nurse would expect to see effects arising from stimulation of what receptors?
A)
Nicotinic
B)
Alpha
C)
Beta
D)
Muscarinic
Ans:
D

Feedback:

The direct-acting cholinergic agonists are similar to acetylcholine (ACh) and react directly with receptor sites to cause the same reaction as if Ach had stimulated the receptor sites. These drugs usually stimulate muscarinic receptors within the parasympathetic system. They are used as systemic agents to increase bladder tone, urinary excretion, and gastrointestinal (GI) secretions. One drug is used as an ophthalmic agent to induce miosis to relieve the increased intraocular pressure of glaucoma. They have no effect on alpha and beta receptors in the sympathetic nervous system and little impact on nicotinic receptors.

11.

The nurse is caring for a 49-year-old patient, who has been receiving bethanechol (Duvoid) for 1 week. The patient develops progressive muscle weakness and respiratory difficulty. Edrophonium is ordered and injected and the patient’s symptoms worsen. How would the nurse interpret this response?
A)
Myasthenic crisis
B)
Cholinergic crisis
C)
Anaphylactic reaction
D)
Pulmonary edema
Ans:
B

Feedback:

The patient with a cholinergic crisis presents with progressive muscle weakness and respiratory difficulty because the accumulation of acetylcholine at the cholinergic receptor site leads to reduced impulse transmission and muscle weakness. This is a crisis when the respiratory muscles are involved. Myasthenic crisis and cholinergic crisis display similar clinical pictures. The drug edrophonium can be used as a diagnostic agent to distinguish the two conditions. If the patient improves immediately after the edrophonium injection, the problem is a myasthenic crisis, which is improved by administration of the cholinergic drug. If the patient gets worse, the problem is probably a cholinergic crisis, so withdrawal of the patient’s cholinergic drug along with intense medical support is indicated. The situation does not depict an anaphylactic reaction or pulmonary edema.

12.

A 70-year-old female patient has just been diagnosed with Alzheimer’s disease. What cholinergic drug is used for the treatment of Alzheimer’s disease?
A)
Bethanechol (Duvoid)
B)
Neostigmine (Prostigmin)
C)
Donepezil (Aricept)
D)
Edrophonium (Enlon, Reversol)
Ans:
C

Feedback:

Currently, there are four reversible indirect-acting cholinergic agonists available to slow the progression of this disease. These include tacrine (Cognex), galantamine (Razadyne), rivastigmine (Exelon), and donepezil (Aricept). Edrophonium (Enlon, Reversol) is used to diagnose myasthenia gravis; neostigmine is used for the diagnosis and management of myasthenia gravis; and bethanechol is used to treat neurogenic bladder.

13.

The 38-year-old patient has just been administered edrophonium (Enlon, Reversol). The nurse will know whether this patient has myasthenia gravis if the patient exhibits what within 30 minutes after receiving the medication?
A)
Increased muscle strength
B)
Decreased adventitious breath sounds
C)
Decreased muscle spasms
D)
Increased urinary output
Ans:
A

Feedback:

Edrophonium is administered to diagnose myasthenia gravis because administration of this drug will cause a marked increase in muscle strength within 30 minutes of administration if the patient has this disease. Edrophonium does not produce decreased adventitious breath sounds, decreased muscle spasms, or increased urinary output.

14.

When the nurse administers a cholinergic agonist to the patient, the nurse’s expectation is that what system will be stimulated?
A)
Sympathetic nervous system
B)
Parasympathetic nervous system
C)
Central nervous system
D)
Voluntary nervous system
Ans:
B

Feedback:

Cholinergic agonists act at the same site as the neurotransmitter acetylcholine (ACh) and increase the activity of the ACh receptor sites throughout the body. Because these sites are found extensively throughout the parasympathetic nervous system, their stimulation produces a response similar to what is seen when the parasympathetic system is activated. These drugs do not stimulate the sympathetic, central, or voluntary nervous systems.

15.

A 78-year-old patient is admitted to the emergency department and is diagnosed with bradycardia. The patient tells the nurse he or she is taking donepezil (Aricept), a cholinergic agent, for Alzheimer’s disease. The nurse will anticipate what drug will be ordered to treat the patient’s bradycardia?
A)
Atropine
B)
Pseudoephedrine
C)
Propranolol
D)
Bethanechol
Ans:
A

Feedback:

Maintain a cholinergic blocking drug on standby, such as atropine, to use as an antidote for excessive doses of cholinergic drugs to reverse overdose or counteract severe reactions arising from use of cholinergic agonists. Atropine will block cholinergic effects that are causing this patient’s heart rate to decline. Bethanechol will slow the heart rate further whereas propranolol and pseudoephedrine will not reverse the cholinergic stimulation.

16.

The nurse administers bethanechol (Duvoid, Urecholine) to treat what condition?
A)
Hypertension
B)
Urinary retention
C)
Bradycardia
D)
Asthma
Ans:
B

Feedback:

Bethanechol is used for the treatment of nonobstructive postoperative and postpartum urinary retention, neurogenic bladder atony in adults and children older than 8 years; diagnosis and treatment of reflux esophagitis in adults, and orally in infants and children for treatment of esophageal reflux. It would be ineffective in treating hypertension, bradycardia, and asthma.

17.

The nurse is caring for a patient who has indirect-acting cholinergic agonists prescribed to treat myasthenia gravis. When administering this classification of drug, the nurse should assess the patient for toxic effects of the drugs including what?
A)
Paralytic ileus
B)
Abdominal distension
C)
Hypertension
D)
Muscle weakness
Ans:
D

Feedback:

18.

Which indirect-acting anticholinesterase medication will the nurse administer as an antidote to neuromuscular junction blockers?
A)
Pyridostigmine (Mestinon)
B)
Donepezil (Aricept)
C)
Rivastigmine (Exelon)
D)
Ambenonium (Mytelase)
Ans:
A

Feedback:

Pyridostigmine is indicated for management of myasthenia gravis; antidote to neuromuscular junction blockers; increased survival after exposure to nerve gas. Donepezil and rivastigmine are used to treat Alzheimer’s disease. Ambenonium is used to treat myasthenia gravis.

19.

A patient is brought to the emergency department after a motor vehicle accident. The patient is diagnosed with multiple injuries including a bladder injury. The patient is taken to surgery and develops a nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for this patient?
A)
Neostigmine
B)
Bethanechol
C)
Ambenonium
D)
Pyridostigmine
Ans:
B

Feedback:

The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum urinary retention and to treat neurogenic bladder atony. The other options are not indicated for this purpose.

20.

A patient is taking memantine for Alzheimer’s disease. This drug does not affect what?
A)
Nicotinic receptor sites
B)
Glucagon receptor sites
C)
Gamma-aminobutyric acid (GABA) receptor sites
D)
Muscarinic receptor sites
Ans:
C

Feedback:

The drug, memantine hydrochloride (Namenda) has a low-to-moderate affinity for N-methyl-D-aspartate (NMDA) receptors with no effects on dopamine, GABA, histamine, glycine, or adrenergic receptor sites. It is believed that persistent activation of the central nervous system NMDA receptors contributes to the symptoms of Alzheimer’s disease. By blocking these sites, it is thought that the symptoms are reduced or delayed. Other options are incorrect.

21.

A patient is brought to the emergency department and is found to have cholinergic toxicity. What is the drug of choice to treat this condition?
A)
Atropine
B)
Epinephrine
C)
Lidocaine
D)
Edrophonium (injectable)
Ans:
A

Feedback:

Maintain atropine sulfate on standby as an antidote in case of overdose or severe cholinergic reaction. Epinephrine, lidocaine, and edrophonium would not be used for this purpose.

22.

A 47-year-old man is suspected of having been exposed to nerve gas. Atropine is given to temporarily block cholinergic activity and to activate acetylcholine sites in the central nervous system. What drug does the nurse give with the atropine to free up the acetylcholinesterase to start breaking down acetylcholine?
A)
Pyridostigmine
B)
Pralidoxime
C)
Neostigmine
D)
Rivastigmine
Ans:
B

Feedback:

If nerve gas exposure is expected, patients who may have been exposed are given intramuscular injections of atropine (to temporarily block cholinergic activity and to activate acetylcholine sites in the central nervous system) and pralidoxime (to free up the acetylcholinesterase to start breaking down acetylcholine). An auto-injection is provided to military personnel who may be at risk. The injector is used to give atropine and then pralidoxime. The injections are repeated in 15 minutes. If symptoms of nerve gas exposure exist after an additional 15 minutes, the injections are repeated. If symptoms still persist after a third set of injections, medical help should be sought. Pyridostigmine, neostigmine, and rivastigmine are not used in nerve gas exposure.

23.

A 77-year-old man is brought to the emergency department with a cholinergic overdose. The nurse knows that older adults are likely to have a greater number of adverse drug effects for what reason?
A)
They are more likely to take the medications inconsistently.
B)
All older adults have some type of chronic health problem.
C)
Older adults have a number of different physiological changes.
D)
Older adults have a poor memory and are more likely to overdose.
Ans:
C

Feedback:

Older patients are more likely to experience the adverse effects associated with these drugs (e.g., central nervous system, cardiovascular, gastrointestinal, respiratory, and urinary) because of normal physiological changes associated with aging. Those patients with known renal or hepatic impairment would receive a lower dosage to avoid overdose. Older people are not more likely to take medications inconsistently or to take too much medication. Not all older adults have chronic health problems.

24.

The nurse is caring for a 45-year-old female patient who is in chronic renal failure. What cholinergic drug is contraindicated for this patient?
A)
Neostigmine
B)
Pyridostigmine
C)
Edrophonium
D)
Galantamine
Ans:
D

Feedback:

Drugs used to treat Alzheimer’s disease are metabolized in the liver and excreted in the urine, so caution should be used in the presence of hepatic or renal dysfunction, which could interfere with the metabolism and excretion of the drugs. Dosage adjustments may be needed for neostigmine, edrophonium, and pyridostigmine if the patient has renal disease but they are not contraindicated.

25.

A 72-year-old man is newly diagnosed with Alzheimer’s disease. The patient’s daughter asks the nurse how her father’s medication is going to help him. What will the nurse explain in layman’s terms?
A)
The drugs work by increasing acetylcholine (ACh) levels in the brain and slowing the progression of the disease.
B)
The drugs work by crossing the bloodbrain barrier and cure the disease in the brain.
C)
The drugs work by increasing ACh levels in the brain and reverse the progression of the disease.
D)
The drugs work by crossing the bloodbrain barrier and decreasing ACh levels in the neuromuscular junctions.
Ans:
A

Feedback:

Acetylcholinesterase inhibitors that cross the bloodbrain barrier are used to manage Alzheimer’s disease by increasing ACh levels in the brain and slowing the progression of the disease. Decreasing ACh levels in the brain does not slow the progression, reverse the progression, or cure the disease. Decreasing ACh levels at the neuromuscular junctions has no effect on Alzheimer’s disease.

26.

A patient has been newly diagnosed with myasthenia gravis. What important teaching will the nurse provide the family?
A)
If one dose of medication is missed double the next dose
B)
The warning signs of drug overdose
C)
How to encourage activity when the patient is tired
D)
Importance of monitoring level of consciousness
Ans:
B

Feedback:

The patient who is being treated for myasthenia gravis and his or her significant other should both receive instruction in drug administration, warning signs of drug overdose, and signs and symptoms to report immediately to enhance patient knowledge about drug therapy and to promote compliance. Missed doses should not be doubled with next dose because this will lead to overdosage. Patients with myasthenia gravis will experience muscle weakness and should not be pushed to do more than they can tolerate. Level of consciousness is not a concern in patients with myasthenia gravis.

27.

A new patient has come to the clinic. The patient tells the nurse he or she takes donepezil (Aricept). What is the priority nursing assessment related to the medication? (Select all that apply.)
A)
Nutritional status
B)
Blood pressure
C)
History of incontinence
D)
Breath sounds
E)
Muscle strength
Ans:
A, B, C

Feedback:

Gastrointestinal (GI) adverse effects can include nausea, vomiting, cramps, diarrhea, increased salivation, and involuntary defecation, so it is important for the nurse to assess nutritional status. This is made all the more important by the condition the drug is treating that often results in patients forgetting to eat healthfully. Blood pressure should be monitored because adverse effects of donepezil include hypotension, bradycardia, and heart block. Involuntary defecation and relaxation of bladder sphincter can result in incontinence so the nurse should assess for both incontinence and, if it occurred, skin integrity. Respiratory adverse effects are not associated with donepezil and muscle strength should not be impacted either.

28.

What family of drugs is used in the treatment of myasthenia gravis?
A)
Direct-acting cholinergic agonists
B)
Muscarinic inhibitors
C)
Indirect-acting cholinergic agonists
D)
Nicotinic agonists
Ans:
C

Feedback:

The drugs used to treat patients with myasthenia gravis include several indirect-acting cholinergic agonists that do not cross the bloodbrain barrier and do not effect acetylcholine transmission in the brain. These drugs include ambenonium (Mytelase), edrophonium (Enlon, Reversol), neostigmine (Prostigmin), and pyridostigmine (Mestinon). Other options are incorrect.

29.

For what purpose would the nurse in the critical care unit administer pyridostigmine?
A)
To reverse neuromuscular junction blockers
B)
To reverse smooth muscle blockade
C)
To reverse cholinergic crisis
D)
To prevent myasthenic crisis
Ans:
A

Feedback:

Pyridostigmine is approved for management of myasthenia gravis, as an antidote to neuromuscular junction blockers, and to increase survival after exposure to nerve gas. Other options are not indications for use of this drug.

30.

A patient diagnosed with myasthenia gravis is having trouble swallowing. What anticholinesterase inhibitor would be the drug of choice for this patient?
A)
Galantamine
B)
Pyridostigmine
C)
Donepezil
D)
Bethanechol
Ans:
B

Feedback:

Pyridostigmine is preferred in some cases for the management of myasthenia gravis because it does not need to be taken as frequently and can be given parenterally for patients who are having difficulty swallowing. Galantamine and bethanechol cannot be given parenterally to the patient having difficulty swallowing. Donepezil is not indicated for the treatment of myasthenia gravis but is used to manage Alzheimer dementia, including severe dementia.

31.

The nurse is treating a patient who has been exposed to nerve gas. The provider ordered pyridostigmine (Mestinon) 0.25 mg/kg. The patient weighs 96 kg. What dosage will the nurse administer to this patient?
A)
24 mg
B)
384 mg
C)
11 mg
D)
31.7 mg
Ans:
A

Feedback:

Multiply the patient’s weight times the ordered dose per kilogram: 0.25 × 96 = 24 mg. Other options are incorrect.

32.

The nurse is caring for a patient diagnosed with Sjögren’s syndrome. What medication will the nurse anticipate administering to treat this condition?
A)
Bethanechol
B)
Carbachol
C)
Ambenonium
D)
Pilocarpine
Ans:
D

Feedback:

Only pilocarpine is indicated for treatment of Sjögren’s syndrome. None of the other medications are indicated for this purpose.

33.

The nurse administers bethanechol to the patient on an empty stomach for what purpose?
A)
To promote rapid absorption
B)
To prevent destruction of the drug
C)
To reduce irritation of stomach lining
D)
To decrease nausea and vomiting
Ans:
D

Feedback:

Administer bethanechol and all oral forms of direct-acting cholinergic agonists on an empty stomach to decrease nausea and vomiting. The other options do not correctly explain the rationale for administering bethanechol on an empty stomach.

34.

The nurse in the pediatric intensive care unit is caring for an infant with severe gastroesophageal reflux. What medication, if ordered, would the nurse administer to treat this condition?
A)
Bethanechol
B)
Carbachol
C)
Cevimeline
D)
Pilocarpine
Ans:
B

Feedback:

Only bethanechol is indicated for the treatment of esophageal reflux in infants and children. The other drugs treat intraocular pressure, dry mouth, or to allow surgeons to perform certain surgical procedures.

35.

The nurse is caring for a patient receiving carbachol to treat glaucoma. The patient says he or she has stopped driving at night because he or she just does not see well in the dark. What is the best nursing diagnosis for this patient?
A)
Anxiety related to poor vision
B)
Grief related to loss of driving privileges
C)
Risk for injury related to visual changes
D)
Pain related to altered vision
Ans:
C

Feedback:

This patient is at risk for injury related to visual changes and requires safety teaching to make the home as safe as possible. Nothing indicates the patient is experiencing anxiety, grief, or pain.