8 
108Medications
ANSWERS
1. B Aspirin 81 mg is the only antiplatelet agent with indication for primary prevention (Meschia et al., 2014).
2. D The mechanism of action of each antiplatelet agent varies, but they all inactivate different aspects of platelet metabolism, thus inhibiting the normal platelet function. When an injury causes a blood vessel wall to break, platelets are activated, that is, they change shape from round to spiny, stick to the broken vessel wall and to each other, and begin to plug the break. They interact with other blood proteins to form fibrin strands that, in turn, form a net that catches more platelets and blood cells, producing a clot that plugs the break. This function is essential with an injury or surgical incision. The problem is when the innermost lining of blood vessels, the intima, gets roughened by uncontrolled hypertension or uncontrolled diabetes, platelets tend to aggregate along the rough patches of the vessel walls and eventually accumulate, which results in atherosclerosis or thrombus formation (Moake, 2016).
3. B Stroke or transient ischemic attack (TIA) patients taking warfarin should not eliminate salads and foods rich in vitamin K, but should be consistent because vitamin K inhibits the action of warfarin. They should 109also not be told to limit physical activity as that is an important part of a healthy lifestyle. There is no specific indication for warfarin to be taken with or without food; either is acceptable.
4. A Rivaroxaban (Xarelto) can be crushed and administered via a feeding tube, as long as the tube is not in the postpyloric position. Dabigatran should not be crushed; apixaban can be given via a feeding tube but the stomach must be empty as food interferes with the crushed version of this drug. Abciximab is not administered enterally.
5. A Alteplase’s action is via the promotion of lysis (breaking down) of fibrin clots, also called fibrinolysis.
6. C Lisinopril is an angiotensin-converting enzyme inhibitor (ACEI), and combination therapy with alteplase has shown an increased incidence of orolingual angioedema (5%).
7. C Lisinopril is an angiotensin-converting enzyme inhibitor (ACEI), and via a complex chemical process, proinflammatory mechanisms occur in the lungs, resulting in a dry cough in up to 20% of patients.
8. A In numerous studies, atorvastatin (Lipitor) was compared to placebo, pravastatin, and simvastatin, and was shown to reduce the risk of death or major cardiovascular events more effectively.
9. D In numerous studies, IV bolus administration of 23.4% saline has been found to reduce intracranial pressure (ICP) and augment cerebral perfusion pressure (CPP) in patients with resistant increased ICP.
10. B Owing to its vasodilation effect, niacin can cause flushing, which can be uncomfortable. Pretreatment with aspirin can be helpful in mitigating this effect.
11. C Insulin glargine (Lantus) is a long-acting insulin.
12. B Historically, metformin (Glucophage) was held after IV contrast to avoid kidney burden while the contrast was being excreted. Guidelines from 2015 have indicated that this is no longer believed to be a fact, and there should be no need to hold metformin, but it will likely be seen in practice for some time.
13. 110A, B, D Stroke patients are at high risk for depression, so you should never just let this type of comment pass without taking action. Reassure Mr. Smith that his feelings are not unusual, and that he will have help to deal with these feelings. Report this conversation to the provider and monitor Mr. Smith’s mood and behavior for further changes.
14. D Any of the above; there is no clear advantage of one over the other selective serotonin reuptake inhibitors (SSRIs).
15. A It has been shown that antidepressants may enhance neurogenesis and thus functional recovery. There have been suggestions that antidepressants may augment pain therapy, but no clinical trial has shown it to make physical therapy less painful. Antidepressants vary in their effect on appetite, with many actually causing weight gain. For patients with concerns about the stigma of psychiatric medications, it is helpful to point out other benefits of the medications to reassure these patients of physical recovery reasons to justify taking the medications, and that they are not taking them because they are crazy.
16. A Fentanyl buccal route is available in oral “lollipop” form.
17. C Acetaminophen has a very weak antiplatelet effect, and only at very high doses. Ibuprofen and aspirin have a stronger antiplatelet effect and should not be given periprocedurely.
18. B Alteplase (Activase) is the only drug that dissolves blood clots. The others inhibit clot formation, but do not dissolve them.
19. C The standard dosing is 0.9 mg/kg over 60 minutes, with 10% of the total dose given as bolus over 1 minute. This patient was 250 lbs, or 113 kgs, but the maximum dose is 90 mg, regardless of weight, so bolus would be 9 mg.
20. B Research has shown that antithrombotics given early facilitate better patient outcomes, so you will get an order for a suppository right away. Antithrombotics are not to be given within 24 hours after IV tissue plasminogen activator (tPA) however.
21. D Warfarin (Coumadin) is the only anticoagulant to be measured by INR; the use of an INR to determine the effectiveness and safety of the others is meaningless because INR is calibrated for use with vitamin K antagonists.
22. 111A The fact that he started taking gingko for memory help is important because it is an herbal supplement that happens to have several drug interactions, as do many of the herbal supplements. Patients often do not consider them drugs, and may fail to mention that they are using them. Education about this is critical.
23. A Dipyridamole/aspirin (Aggrenox) produces headache most frequently in patients with a history of migraine, and can be mitigated with careful dose titration.
24. C Lorazepam (Ativan) is considered the first-line agent for treatment of seizure poststroke.
25. C Patients with an insulin drip should have their blood glucose monitored every 1 to 2 hours to ensure that the target is maintained and to prevent the extremes of hypoglycemia or hyperglycemia.
26. D It was approved by the FDA in 1996 for 3 hours from onset. While many guidelines have recommended that it is safe in select populations up to 4.5 hours from onset, it was not approved by the FDA for that timeframe, so its use in the 3- to 4.5-hour window is considered “off-label.”
27. B Ten percent of the total dose is given as a bolus over 1 minute. There is no indication for a larger gauge needle. It should not be shaken, but twirled, to mix. If anaphylactic reaction is noted, the drug should be stopped immediately and action taken to treat the anaphylaxis.
28. B Oral nimodipine should be administered to all aneurysmal subarachnoid hemorrhage (SAH) patients, a Class I, Level of Evidence A recommendation. It has been shown to improve outcomes, but not necessarily to control vasospasm (Connolly et al., 2012).
29. A The schedule for monitoring was defined in 2003 in the first Guidelines for the Early Management of Patients With Ischemic Stroke, and remains today to be every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours.
30. D Botulinum toxin is not indicated for controlling of shivering; it is used for treatment of poststroke spasticity.
112References
Connolly, E., Rabinstein, A., Carhuapoma, R., Derdeyn, C., Dion, J., Higashida, R. T., . . . Vespa, P. (2012). Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 43, 1711–1737.
Meschia, J. F., Bushnell, C., Boden-Albala, B., Braun, L. T., Bravata, D. M., Chaturvedi, S., . . . Wilson, J. A. (2014). Guidelines for the primary prevention of stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45, 3754–3832.
Moake, J. L. (2016). How blood clots. Merck Manual. Retrieved from https://www.merckmanuals.com/home/blood-disorders/blood-clotting-process/how-blood-clots