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Advanced Pharmacology Study Guide (NP Level)
1. Drugs for Muscle Spasm and Spasticity Muscle Spasms Acute, involuntary muscle contractions due to injury or strain. Common Agents:
- Cyclobenzaprine (Flexeril) – TCA-like structure; reduces tonic somatic motor activity
- Methocarbamol (Robaxin) – CNS depressant
- Carisoprodol (Soma) – High abuse potential; metabolized to meprobamate Key Notes:
- Sedating
- Avoid alcohol or CNS depressants
- Caution in elderly Spasticity Chronic hypertonia from CNS injury (e.g., MS, CP, spinal cord injury). Common Agents:
- Baclofen – GABA-B agonist; reduces excitatory neurotransmission
- Tizanidine – Alpha-2 adrenergic agonist; centrally acting
- Diazepam – Benzodiazepine; enhances GABA-A inhibition
- Dantrolene – Direct skeletal muscle relaxant; blocks Ca²⁺ release (used in malignant hyperthermia) Key Notes:
- Baclofen: risk of withdrawal seizures
- Tizanidine: hypotension, dry mouth
- Dantrolene: hepatotoxicity 2. Opioid Analgesics Used for moderate to severe pain. Bind to mu , kappa , and delta opioid receptors.
Common Opioids:
- Morphine – Standard; causes histamine release (itching, hypotension)
- Hydromorphone (Dilaudid) – More potent than morphine
- Fentanyl – Very potent; patch for chronic pain
- Oxycodone, Hydrocodone – Often combined with acetaminophen
- Codeine – Prodrug; metabolized to morphine (watch for CYP2D6 variability)
- Methadone – Long half-life; QT prolongation risk
- Meperidine – Risk of seizures (normeperidine metabolite) Adverse Effects:
- Respiratory depression
- Constipation
- Sedation
- Nausea/vomiting
- Tolerance, dependence, addiction NP Prescribing Tips:
- Start low, go slow
- Use multimodal pain management
- Monitor for misuse (PDMP, contracts)
- Educate on naloxone availability 3. Opioid Antagonists Used to reverse opioid effects or treat opioid use disorder. Common Agents:
- Naloxone (Narcan) – IV/IN; short half-life; emergency reversal
- Naltrexone – PO/IM; long-acting; used for maintenance (OUD, alcohol use disorder)
- Methylnaltrexone – Peripherally acting; treats opioid-induced constipation without reversing analgesia Key Notes:
- Naloxone: may cause withdrawal symptoms
- Naltrexone: avoid in acute opioid dependence (can precipitate withdrawal)
- Monitor liver function with naltrexone
Cluster Headaches:
- Oxygen (first-line)
- Triptans (SQ sumatriptan)
- Verapamil (preventive)
- Lithium (for refractory cases) Clinical Pearls for NP Practice
- Assess pain comprehensively – physical, psychological, and functional impact
- Use stepwise approach – Non-opioids → adjuvants → opioids
- Always consider non-pharmacologic options alongside medication
- Educate patients on risks, especially for opioids and serotonin syndrome
- Know your state laws for prescribing controlled substances
NUR 6011 – Module 4 Exam (Advanced
Pharmacology)
Question 1
Question 4 A patient with a history of asthma experiences three or four migraine headaches each month, uses sumatriptan as an abortive medication but has developed medication-overuse headaches. When asked what can be done to prevent migraines, the provider suggests prescribing which medication? A.Meperidine B.Topiramate C. Botulinum toxin D.Timolol Correct Answer: B Rationale: Topiramate can be used for migraine prophylaxis. β blockers like timolol are not recommended for asthma patients due to bronchoconstriction risk. Question 5 A patient reports stopping baclofen the day before being admitted to the hospital. The provider instructs the hospital staff to monitor the patient for which withdrawal effects? A.Hallucinations B.Dyspnea C. Fatigue D.Dizziness Correct Answer: A Rationale: Abrupt discontinuation of baclofen is associated with visual hallucinations, paranoid ideation, and seizures. Question 6 The provider has prescribed a vasoconstrictor to be given in combination with a local anesthetic. What is the expected goal for this action? (Select all that apply.) A.Enhanced absorption of the anesthetic B.The prevention of bradycardia C. A shortened duration of action D.A reduction of the risk of anesthetic toxicity E.A prolonging of the anesthesic effect Correct Answer: D and E
Rationale: Vasoconstrictors reduce the risk of toxicity and prolong anesthetic effects by slowing absorption. Question 7 A patient with cerebral palsy who has been receiving baclofen for 3 months is admitted to the hospital for evaluation of new-onset seizures. What assessment question will the provider ask to help identify the most likely cause of these seizures? A.Have you taken any extra doses of baclofen? B.Are you aware of the most common adverse effect of baclofen? C. Have you missed any doses of baclofen? D.Did you know that seizures are an idiopathic response to baclofen? Correct Answer: C Rationale: Abrupt withdrawal of baclofen can cause seizures. Asking about missed doses helps identify this risk. Question 8 A provider counsels a patient who is prescribed phenytoin for epilepsy. Which statement by the patient indicates understanding of the teaching? A.I can consume alcohol in moderation while taking this drug. B.Rashes are a common side effect but are not serious. C. Once therapeutic blood levels are reached, they are easy to maintain. D.I should brush and floss my teeth regularly. Correct Answer: D Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent it. Question 9 A client is suspected of having salicylate poisoning, what clinical manifestation should the provider assess the client for? A.Tinnitus B.Diarrhea C. Constipation D.Photosensitivity
A. Has the patient taken ergotamine in the past 24 hours? B. Has acetaminophen been taken in the past 3 hours? C. Is the patient allergic to sulfa compounds? D. Is there a family history of migraines? Correct Answer: A Rationale: Sumatriptan and ergot alkaloids both cause vasoconstriction. Using them close together can lead to excessive vasospasm. They should not be taken within 24 hours of each other.
Question 13
Within a few minutes of administration of a local anesthetic, the patient has a pulse of 54 beats/minute, respirations of 18 breaths/minute, and a blood pressure of 90/42 mm Hg. The provider should monitor the patient for further signs of what condition? A. Central nervous system excitation B. Respiratory depression C. Anaphylaxis D. Heart block Correct Answer: D Rationale: Local anesthetics in systemic circulation can suppress cardiac conduction, leading to bradycardia, hypotension, and heart block. These signs require close monitoring.
Question 14
A patient who has infrequent migraine headaches wants to prevent them from occurring. What intervention will the provider take? A. Prescribe amitriptyline. B. Prescribe prochlorperazine. C. Schedule the abortive medication to be taken regularly instead of PRN. D. Ask the patient to keep a headache diary to help determine possible triggers. Correct Answer: D Rationale: A headache diary helps identify and avoid triggers. Prophylactic medications like amitriptyline are reserved for frequent migraines. Regular use of abortive medications may lead to medication-overuse headaches.
Question 15
A client is taking acetaminophen daily for the relief of generalized discomfort. The provider recognizes which laboratory value would indicate toxicity associated with the medication?
A. Sodium level of 140 mEq/L B. Platelet count of 150,000 mm³ C. Prothrombin time of 12 seconds D. AST 268 U/L, ALT 150 U/L Correct Answer: D Rationale: Elevated liver enzymes (AST and ALT) suggest hepatotoxicity, which is a known risk of chronic or excessive acetaminophen use.
Question 16
An infant is prescribed a central nervous system (CNS) drug. The parents are concerned that the child exhibits unusual drowsiness and sedation. The provider explains these effects based on an understanding of which difference in the physiology of infants and adults? A. Renal filtration B. Blood-brain barrier C. First-pass effect D. Gastrointestinal absorption Correct ANS: B - the blood-brain barrier is not fully developed at birth, making infants much more sensitive to CNS drugs than older children and adults. CNS symptoms may include sedation and drowsiness. The first-pass effect and GI absorption affect metabolism and absorption of drugs, and renal filtration affects elimination of drugs, all of which may alter drug levels.
Question 17
A patient with multiple sclerosis has severe muscle spasticity and muscle weakness which makes it difficult to take anything by mouth. The provider will prescribe and educate the patient on which medication for home therapy? A. Baclofen B. Diazepam C. Metaxolone D. Dantrolene ANS: A - Baclofen is used to treat muscle spasticity associated with multiple sclerosis and spinal cord injuries. 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 causes muscle weakness and must be given by mouth or intravenously, so it would not be a good option for this patient. Diazepam is not the first-line drug of choice. Metaxalone is used to treat localized muscle spasms caused by injury and is not used for cerebral palsy.
ANS : D - 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. 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.
Question 21
A provider has prescribed dantrolene for the following patients. Which patient will the provider monitor most closely for risk of injury? 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 and hepatitis 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.
Question 22
Which medications would a provider prescribe to treat menstrually associated migraine? (Select all that apply.) A. Estrogen B. Frovatriptan C. Ergotamine D. Amitriptyline E. Naproxen ANS: A, B, E - Menstrual migraines may be treated with estrogen, some perimenstrual triptans, such as frovatriptan, and Naproxyn. Neither amitriptyline nor ergotamine are used for that purpose.
Question 23
A provider has prescribed the topical anesthetic lidocaine for a patient who has a second- degree burn on one arm. Which statement by the patient indicates understanding of the teaching regarding this treatment? A. “I will cover the burn with a dressing after applying the medication.” B. "I need to limit use of the medication to areas where the blisters have ruptured.” C. “Applying an occlusive dressing is needed to increase absorption to relieve pain.” D. “I will apply a thin layer of the medication to only the burned area.” ANS: D - Topical anesthetics can be absorbed in sufficient amounts to cause serious and even life- threatening systemic toxicity, so they should be applied in the smallest amount needed to as small an area as possible. Covering the site increases the skin’s temperature, which increases absorption, so this should be avoided. Applying the medication to broken skin increases systemic absorption and should be avoided.
Question 24
A patient who has recurrent migraine headaches is prescribed sumatriptan. Which condition in this patient’s history is of concern to the prescriber? A. Renal disease B. Coronary Artery Disease C. Diabetes D. Asthma ANS: B - Serotonin receptor agonists can cause vasoconstriction and coronary vasospasm and should not be given to patients with coronary artery disease, current symptoms of angina, or uncontrolled hypertension. There is no contraindication for asthma, diabetes, or renal disease.
Question 25
Before administering the mixed opioid agonist-antagonist pentazocine, the provider asks the patient if he has used opioids. Administering a mixed opioid agonist-antagonist to a patient dependent on opioid agonists may cause which reaction? A. Hypersensitivity reaction B. Constipation
Symptoms associated with
ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.
Question 28
A provider provides teaching for a patient with a newly diagnosed partial complex seizure disorder who will begin therapy with an antiepileptic drug (AED). Which statement by the patient indicates to the provider an understanding of the teaching? A. “When the drug level is maintained at therapeutic levels, I can expect to be seizure free.” B. “I may need to try several drugs before finding one is effective.” C. “Serious side effects may occur, and if they do, I should stop taking the medication.” D. “I will know that the drug is effective if I am seizure-free for two months.” ANS: B - 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.
Question 29
A patient who has migraine headaches has been using sumatriptan with good initial results but now reports frequent migraine recurrence 24 hours later. Which medication will the provider order for this patient? A. Aspirin B. Naratriptan C. Ergotamine D. Zolmitriptan ANS: B - Naratriptan has effects that persist longer than other triptans, and the 24-hour recurrence rate may be reduced when taking this formulation. Aspirin has a shorter half-life than the triptans
Question 30
The provider used lidocaine with epinephrine as a local anesthetic when suturing a laceration on a patient’s hand. Following the procedure, which patient symptom causes the
A. Inability to feel pressure at the suture site B. Difficulty moving the fingers of the affected hand C. Nervousness and tachycardia D. Sensation of pain returning to the wound ANS: C - Absorption of the vasoconstrictor can cause systemic effects, including nervousness and tachycardia. Local anesthetics are nonselective modifiers of neuronal function and also can block motor neurons, so it is expected that patients may have difficulty with movement. The sensation of pressure also is affected and is an expected effect. As the local anesthetic wears off, the sensation of the pain will return.
