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Chapter 33- Anticholinergic Agents

1. A student asks the pharmacology instructor to explain the action of anticholinergic

agents. What would be the instructor's best response?

A) They block nicotinic receptors.

B) They compete with serotonin for muscarinic acetylcholine receptor sites.

C) They act to block the effects of the parasympathetic nervous system.

D) They increase norepinephrine at the neuromuscular junction.

Ans: C

Feedback:

Drugs that are used to block the effects of acetylcholine are called anticholinergic drugs.

Because this action lyses, or blocks, the effects of the parasympathetic nervous system,

they are also called parasympatholytic agents. The drug works by blocking only the

muscarinic effectors in the parasympathetic nervous system. They compete with

acetylcholine for the muscarinic acetylcholine receptor sites. They do not block the

nicotinic receptors and have little or no effect at the neuromuscular junction.

2. A patient calls the clinic and talks to the nurse. The patient tells the nurse he or she is

going on a cruise and is concerned about motion sickness. The patient says that a

friend has recommended that he or she see his or her primary care physician to get a

prescription for scopolamine. What adverse effect would the nurse inform the patient

that using scopolamine may result in?

A) Pupil constriction

B) Tachycardia

C) Diarrhea

D) Urinary incontinence

Ans: B

Feedback:

Scopolamine blocks the parasympathetic nervous system, which may result in dilated

pupils and increased heart rate (i.e., tachycardia). Blocking the parasympathetic system

also results in decreased GI activity and urinary bladder tone causing constipation and

urinary retention.

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A student asks the pharmacology instructor to explain the action of anticholinergic agents. What would be the instructor's best response? A) They block nicotinic receptors. B) They compete with serotonin for muscarinic acetylcholine receptor sites. C) They act to block the effects of the parasympathetic nervous system. D) They increase norepinephrine at the neuromuscular junction. Ans: C Feedback: Drugs that are used to block the effects of acetylcholine are called anticholinergic drugs. Because this action lyses, or blocks, the effects of the parasympathetic nervous system, they are also called parasympatholytic agents. The drug works by blocking only the muscarinic effectors in the parasympathetic nervous system. They compete with acetylcholine for the muscarinic acetylcholine receptor sites. They do not block the nicotinic receptors and have little or no effect at the neuromuscular junction.
(^) A patient calls the clinic and talks to the nurse. The patient tells the nurse he or she is going on a cruise and is concerned about motion sickness. The patient says that a friend has recommended that he or she see his or her primary care physician to get a prescription for scopolamine. What adverse effect would the nurse inform the patient that using scopolamine may result in? A) Pupil constriction B) Tachycardia C) Diarrhea D) Urinary incontinence Ans: B Feedback: Scopolamine blocks the parasympathetic nervous system, which may result in dilated pupils and increased heart rate (i.e., tachycardia). Blocking the parasympathetic system also results in decreased GI activity and urinary bladder tone causing constipation and urinary retention.

A 29-year-old man is going on a company-sponsored deep-sea fishing trip in 2 weeks. He comes to the clinic requesting a scopolamine patch because he is afraid that he will get seasick. The medication is prescribed for him and the nurse's instructions concerning use of the patch will include what? A) “Shave the area before applying the patch. B) “The patch's effectiveness will last about 72 hours. C) “When replacing the patch, apply the new patch in the same area. D) “Do not clean the application area before applying the patch. Ans: B Feedback: The scopolamine patch is replaced every 3 days (i.e., 72 hours). The scopolamine patch should be applied to a clean, dry, intact, and hairless area of the body. The area should not be shaved because abrasion of the skin could occur and lead to increased absorption. Patches should be placed at new sites each time to avoid skin irritation. The old patch should be removed and the area cleaned.
The nurse is taking a health history on a new patient who has been prescribed propantheline (generic) as adjunctive therapy for peptic ulcers. While collecting the health history, what will the nurse specifically assess for? A) Diabetes mellitus B) Obsessive-compulsive disorder C) Insomnia D) Glaucoma Ans: D Feedback: Propantheline is contraindicated for a patient with glaucoma because the drug could result in increased intraocular pressure due to pupil dilation. Diabetes mellitus, obsessive-compulsive disorder, and insomnia are not recognized as being adversely affected by this drug.

A patient has come to the clinic for a follow-up visit. He or she has been taking glycopyrrolate (Robinul) for adjunctive management of his or her peptic ulcer disease for 1 year. What would the nurse question this patient about? A) Diarrhea B) Oral discomfort C) Headaches D) Dyspnea Ans: B Feedback: Patients taking anticholinergic drugs will have dry mucous membranes. Oral hygiene will be extremely important during glycopyrrolate therapy to avoid gum disease. The nurse should encourage the patient to suck on sugarless lozenges and perform frequent oral care. Diarrhea, headaches, or dyspnea should not be a concern with this drug.
(^) A 73-year-old male with Parkinson's disease comes to the clinic for routine care. The man has a comorbidity of benign prostatic hyperplasia (BPH). An anticholinergic drug is prescribed for the patient. What is the priority teaching point the nurse must give to the patient in regard to his medication? A) “Avoid excessively hot environments.” B) “Avoid driving his car while taking the drug.” C) “Call his doctor if he cannot urinate.” D) “Take the drug with food to avoid gastrointestinal (GI) upset.” Ans: C Feedback: Due to the patient's diagnosis and drug therapy, calling the doctor if he cannot urinate would be the most important instruction. Older men with BPH have difficulty urinating and if an anticholinergic drug is taken, this can lead to urinary retention and bladder sphincter spasm. The patient should be encouraged to empty his bladder before taking the drug. Because this is an anticholinergic drug, avoiding hot environmental temperatures (reduced ability to perspire) and driving or operating machinery (possible central nervous system effects) should also be encouraged as well as taking the medication with food to help with GI upsets. However, the highest priority is addressing urinary retention issues.

A patient has been given atropine to cause mydriasis and cycloplegia. What is the expected outcome for this patient? A) Constricted pupils and blurred vision B) Dilated pupils and improved vision C) Dilated pupils and blurred vision D) Dry eyes and constricted pupils Ans: C Feedback: Atropine can be used to cause dilated pupils, which is mydriasis resulting in cycloplegia, which is the inability of the lens of the eye to accommodate leading to blurred vision.
Because the effects of atropine are dose related, at what dose of atropine would the nurse expect to see a patient having difficulty speaking? A) 0.5 mg B) 1.0 mg C) 2.0 mg D) 5.0 mg Ans: D Feedback: Toxicity of atropine is dose related. With 5.0-mg dosage, the nurse would expect marked speech disturbances, difficulty swallowing, restlessness, fatigue, headache, dry and hot skin, difficulty voiding, and reduced intestinal peristalsis. With 0.5-mg dosage of atropine, slight cardiac slowing, dryness of the mouth, and inhibition of sweating would be noticed. Definite dryness of the mouth and throat, thirst, rapid heart rate, and pupil dilation would be evident with 1.0-mg dosage. With 2.0-mg dosage, the nurse would note rapid heart rate, palpitations, marked mouth dryness, dilated pupils, and some blurring of vision.
(^) A 66-year-old woman presents at the clinic complaining of motion sickness. The physician orders a scopolamine patch. Which statement by the patient leads you to believe she knows how to use the patch? A) “I will place it on my chest each morning after I shower.” B) “I will use it only if I feel sick to my stomach.” C) “I will change the patch every 4 hours. I can use the patches for 1 week.” D) “I will change the patch every 3 days.” Ans: D Feedback: The scopolamine patch should be applied to a clean, dry, intact, and hairless area of the body. The area should not be shaved because abrasion of the skin could occur and lead to increased absorption. Patches should be placed at new sites each time to avoid skin irritation. The old patch should be removed and the area where it had been should be cleaned.

Because of the systemic effects of anticholinergic drugs, the nurse understands that older adults using these drugs are susceptible to what? A) Heat stroke B) Diarrhea C) Urinary frequency D) Hypotension Ans: A Feedback: Because older patients are more susceptible to heat intolerance owing to decreased body fluid and decreased sweating, extreme caution should be used when an anticholinergic drug is given that reduces sweating still further and can result in heat stroke. Older adults are not more susceptible to diarrhea, urinary frequency, and hypotension.
A 50-year-old female patient received atropine and meperidine (Demerol) preoperatively. After surgery, the patient complains of mouth dryness. What is the nurse's best response? A) “Preoperative medications decrease saliva production but it is temporary and will improve.” B) “This is the result of all of the blood and fluid you lost during surgery.” C) “You are probably dehydrated. The IV fluids you are receiving will correct the problem.” D) “The preoperative medication causes an electrolyte imbalance making your mouth feel dry.” Ans: A Feedback: Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing, constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of vision, and heat intolerance caused by a decrease in sweating.
Anticholinergics have varied effects on the body. What is one of those effects? A) Preventing vagal stimulation B) Stimulating the release of acetylcholine C) Increasing respiratory tract secretions D) Increasing secretion of sweat glands Ans: A Feedback: Adjunctive therapy to treat peptic ulcer, overactive gastrointestinal (GI) disorders; neurogenic bladder or cystitis; parkinsonism; biliary or renal colic; to decrease secretions pre-operatively; treatment of partial heart block associated with vagal activity; treatment of rhinitis or anticholinesterase poisoning.

Anticholinergic drugs are used in ophthalmology because they produce what effect? A) Sedation B) Pupil dilation C) Pupil constriction D) Decreased lacrimal secretions Ans: B Feedback: Patients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing, constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and blurring of vision, and heat intolerance caused by a decrease in sweating.
A male patient, age 75, is started on flavoxate (Urispas). What adverse effects should the patient be made aware of? A) Rash B) Headache C) Weight gain D) Blurred vision Ans: D Feedback: The patient should be warned of possible blurring of vision when taking this drug, which could put the patient at risk for injury if precautions are not taken. Adverse effects could include central nervous system adverse effects, such as blurred vision, pupil dilation and resultant photophobia, cycloplegia, and increased intraocular pressure, all of which are related to the blocking of the parasympathetic effects in the eye.
The nurse administers atropine preoperatively for what purpose? A) Providing sedation B) Dilating the pupils C) Relaxing bladder muscles D) Decreasing secretions Ans: D Feedback: Atropine is administered preoperatively to reduce secretions, but added indications include gastrointestinal (GI) effects that reduce GI activity. Atropine has no sedating effects, and is not given preoperatively for its pupil dilation effects, or for its bladder muscle relaxation effects.

What drug would the nurse administer to treat a patient diagnosed with bronchospasm associated with chronic obstructive pulmonary disease (COPD)? A) Atropine B) Flavoxate C) Glycopyrrolate D) Ipratropium Ans: D Feedback: Ipratropium is indicated for the treatment of bronchospasm associated with COPD. Atropine is indicated for use to decrease secretions, bradycardia, pylorospasm, ureteral colic, relaxing of bladder, emotional liability with head injuries, antidote for cholinergic drugs, and pupil dilation. Flavoxate is used for the symptomatic relief of dysuria, urgency, nocturia, suprapubic pain, frequency, and incontinence associated with cystitis, prostatitis, urethritis, urethrocystitis, and urethrotrigonitis. Glycopyrrolate is indicated to decrease secretions before anesthesia or intubation, used orally as an adjunct for treatment of ulcers, to protect the patient from the peripheral effects of cholinergic drugs and to reverse neuromuscular blockade
A 72-year-old female patient is being discharged home from the hospital on newly prescribed anticholinergic drugs. A referral to the home health nurse has been made. What priority teaching point will the home health nurse emphasize when discussing the patient's drugs? A) “Do not drive or use machinery. B) “Take lots of hot baths or showers.” C) “Keep the house warm to avoid a chill.” D) “Limit intake of fluids.” Ans: A Feedback: Safety precautions may be needed if blurred vision and dizziness occur. The patient should be urged not to drive or perform tasks that require concentration and coordination. The home care nurse would not teach the patient to take hot baths or showers. The patient would be cautioned about inability to perspire in hot environments and to avoid them. Fluid intake should not be limited.

The nurse is caring for a new mother who received atropine before undergoing a laparoscopic tubal ligation. The patient tells the nurse that she is breast-feeding her baby and asks whether she can breast-feed when she gets home. What is the nurse's best response? A) “You can breast-feed when you get home because the drugs given before surgery will be out of your system.” B) “You can breast-feed as soon as you get home because atropine will not cross into the breast milk.” C) “Discard all breast milk for the next week and feed the baby formula before returning to breast-feeding.” D) “Discard all breast milk for the next 24 hours and feed formula until tomorrow when you can nurse your baby.” Ans: D Feedback: Lactating mothers should not breast-feed after receiving atropine until the drug has been fully excreted. Because atropine crosses into breast milk and the duration of action is 4 hours, it is safest to have the mother wait 24 hours to breast-feed, continuing to pump and discard the milk while feeding the infant formula. After 24 hours, she can return to breast-feeding because any atropine in breast milk will be eliminated. There is no need to wait a week and although the drug may be out of the bloodstream, the milk in her breast will still contain atropine.
(^) The patient, who takes an anticholinergic medication, tells the nurse how much he or she enjoys experimenting with different herbal teas. What herbs will the nurse caution the patient to avoid? (Select all that apply.) A) Burdock B) Thyme C) Rosemary D) Parsley E) Tumeric Ans: A, C, E Feedback: The risk of anticholinergic effects can be exacerbated if anticholinergic agents are combined with burdock, rosemary, or turmeric and used as herbal therapy. Advise patients who use herbal therapies to avoid these combinations. Nothing indicates that thyme or parsley is contraindicated with anticholinergic medications.

The nurse is caring for a patient who has just been started on hyoscyamine (Symax and others) as adjunctive therapy for his or her peptic ulcers. When developing this patient's plan of care, what nursing diagnosis would the nurse establish related to the purpose of administering this drug? A) Chronic pain related to peptic ulcer disease B) Impaired urinary elimination related to bladder relaxation C) Risk for hyperthermia related to decreased ability to perspire D) Decreased cardiac output related to cardiovascular effects Ans: A Feedback: All these nursing diagnoses could be used for the patient receiving an anticholinergic drug, but only chronic pain is related to the drug this patient is receiving and the purpose for which it is being administered.
What does parasympathetic nervous system blockade cause? (Select all that apply.) A) Decrease in heart rate B) Decrease in urinary bladder tone C) Increase in heart rate D) Pupil constriction E) Decrease in gastrointestinal (GI) activity Ans: B, C, E Feedback: Parasympathetic nervous system blockade causes an increase in heart rate, decrease in GI activity, decrease in urinary bladder tone and function, and pupil dilation and cycloplegia.

The patient was involved in a motor vehicle accident and experienced a severe closed head injury resulting in increased intracranial pressure. While intubating the patient, his or her heart rate dropped and did not return to acceptable levels after the tube was in place so the nurse received an order to administer atropine. The physician is performing an exam to determine whether brain death has occurred. What assessment for brain death will be postponed until all atropine is excreted and no longer exerting an effect. A) Pupil response B) Electroencephalogram C) Brainstem reflexes D) Computed tomographic scan of the brain Ans: A Feedback: One test for neurological function is to shine a light in the patient's eyes to test pupil reaction to light. Because this patient has received atropine, pupils will be dilated and will not react normally to light. This could be mistaken as an indication of brain death if the nurse did not know atropine had been administered. This test will be postponed until the pupils are no longer dilated by the medication. The other tests would not have to be postponed because of atropine.
The nurse is caring for a patient who is unconscious and requires an anticholinergic drug to treat bradycardia. What drug can the nurse administer IV for this purpose? A) Ipratropium (Atrovent) B) Dicyclomine (generic) C) Methscopolamine (Pamine) D) Atropine (generic) Ans: D Feedback: Atropine can be given intramuscularly (IM), subcutaneously, or IV for the treatment of bradycardia. Ipratropium is administered by inhalation to treat bronchospasm. Dicyclomine is used to treat irritable or hyperactive bowel and can be given orally or IM. Methscopolamine is administered orally to treat peptic ulcers.
What is the proper dosage of scopolamine administered by the nurse transdermally to reduce nausea and vomiting associated with motion sickness? A) 0.32 to 0.65 mg B) 1.5 mg C) 3 mg D) 3.5 mg Ans: B Feedback: The scopolamine transdermal patch is 1.5 mg. If administered subcutaneously (SC) or intamuscularly (IM), the dosage would be 0.32 to 0.65 mg. Pediatric dosage is 0. mg/kg subcutaneous, IM, or IV.

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