NR-293 Pharmacology Final

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Study Guide for NR 293 Exam 1

Pharmacology

Contents

Principles of Pharmacology ...................................................... 2

Principles of Neuropharmacology .............................................. 13

Cardiovascular Pharmacology .................................................. 25

Endocrine Pharmacology ....................................................... 38

Drugs Affecting Other Systems (Including GI and Pulmonary) .......... 51

Principles of Pharmacology

Select the single best answer.

1. A 28-year-old man with seborrheic dermatitis is prescribed a topical corticosteroid

crème by his dermatologist in hopes of alleviating the chronic rash and erythema on
the cheeks. Which of the following steps is most critical to achieve a therapeutic drug
concentration in plasma?

a) Absorption
b) Distribution
c) Elimination
d) Glycosylation
e) Metabolism

Answer: a) Absorption.
Drug absorption from the site of administration, in this case via the topical route,
allows the medication to enter into the skin and then into the plasma. Following
this step, the medication can distribute into tissues and also be metabolized in
tissues.

2. Drug A and Drug B are of equal magnitude. If Drug A and Drug B are combined
together, this would be an example of which of the following?

a) Additive effects
b) Neutralization
c) Potentiation
d) Synergism

Answer: a) Additive effects

The additive effects of drugs occur when two drugs with the same effect are
added together and produce an effect that is equal in magnitude to the sum of
the effects when the two drugs are given individually.

3. A 28-year-old man is an unrestrained driver in a motor vehicle accident. He suffers a

compound fracture of the right femur and is currently undergoing fixation in the

operating room. The surgery is not completed and anesthesia is not being administered
at this time. Recovery from IV induction agents is caused by
a) Ionization
b) Liver metabolism
c) Plasma clearance
d) Protein binding
e) Redistribution from sites in the CNS

Answer: e) Redistribution from sites in the CNS

Following initial flooding of the CNS with nonionized molecules, the drug
diffuses into other tissues. With secondary tissue uptake, plasma concentration
falls, allowing the drug to diffuse out of the CNS. This initial redistribution of
drug into other tissues leads to the rapid recovery seen after a single dose of an
IV induction drug.

4. A 29-year-old woman cuts her arm when her steak knife slips while cutting a steak at a
barbeque dinner. She sustains a 4-cm laceration of the lateral aspect of her left arm that
will require sutures. A 2% lidocaine is infiltrated prior to suture placement. Which of
the following will have an effect on the onset and duration of action of this
medication?

a) Blood pH
b) Lidocaine pH
c) Lipid solubility of the tissue
d) Nerve diameter
e) pKa of the drug

Answer: e) pKa of the drug.

Onset and duration of action of local anesthetics are influenced by several
factors. These include tissue pH, pKa of the drug, nerve morphology,
concentration, and lipid solubility of the drug. Of these, the most important are
pH of the tissue and pKa of the drug. At physiologic pH, these compounds are
charged. The ionized form interacts with the protein receptor of the sodium
channel to inhibit its function and, thereby, achieve local anesthesia. The pH
may drop in sites of infection, which causes onset to be delayed or even
prevented.

5. A 37-year-old man is in the intensive care unit with sepsis. He is receiving intravenous
(IV) vasopressors to maintain his blood pressure. During morning
rounds, you notice his IV has extravasated and the skin around the IV site is cool and
pale. What should be done?

a) Atropine should be injected

b) Dopamine should be injected

c) Nothing
d) Phentolamine should be injected
e) Topical prednisone should be given

Answer: d) Phentolamine should be injected.

Extravasation of a-adrenergic agonists into surrounding tissue is a serious
problem. The paleness and coolness of the skin around his IV site is caused by
constriction of the vasculature in his skin. The vasoconstriction caused by
vasopressors can lead to tissue necrosis. An a-antagonist should be injected
into the affected tissue as soon as possible to counteract the vasopressor that
has extravasated. Phentolamine can be used to restore blood flow to the
affected area.

6. A 44-year-old man with a sacral spinal cord injury has atonia of the sigmoid colon and
rectum. Despite sacral nerve root stimulation, no normal colorectal function is able to
be achieved. Which of the following is true concerning the postganglionic receptors at
the distal colon and rectum?

a) Exogenous ligand formation is taking place

b) The active and inactive receptor states are in irreversible equilibrium
c) The receptors are likely in a transient state
d) The drugs occupying the receptor are producing conformational change in the
receptor

Answer: d) The drugs occupying the receptor are producing

conformational change in the receptor.
More recent information suggests that receptors exist in at least two states:
inactive (R) and active (R*) states that are in reversible equilibrium with one
another. In the absence of an agonist, R* typically represents a small fraction of
the total receptor population (i.e., the equilibrium favors the inactive state).
Drugs occupying the receptor can stabilize the receptor in a given
conformational state.

7. A novel cholinomimetic agent is being designed to improve salivary glandular

secretions in patients with xerostomia. This agent will increase the uptake of choline
into cells. This will combine with acetyl coenzyme A which is found in which of the
following locations?

a) Cytosol
b) Golgi apparatus
c) Mitochondria
d) Rough endoplasmic reticulum

e) Smooth endoplasmic reticulum

Answer: a) Cytosol.
The uptake of choline is the rate-limiting step in ACh synthesis. Choline
acetyltransferase catalyzes the reaction of choline with acetyl coenzyme A
(CoA) to form ACh (an ester) in the cytosol. Acetyl CoA is derived from the
mitochondria and is produced by the pyruvate oxidation and fatty acid
oxidation.

8. A 35-year-old Caucasian man complained to his physician of tingling sensation in his

limbs and noted that his arm s sometimes felt heavy. The man, recently diagnosed with
pulmonary tuberculosis, had been receiving isoniazid and rifampin for 2 months. He
was diagnosed with peripheral neuropathy, a known adverse effect of isoniazid. Which
of the follow ing events most likely caused the patient's symptom s and signs?
a) Rifampin-induced inhibition of isoniazid metabolism
b) Worsening of the disease, despite the therapy
c) Allergic reaction to rifampin
d) Inherited deficiency of N-acetyltransferase
e) Allergic reaction to isoniazid

Answer: d) Inherited deficiency of N-acetyltransferase

Isoniazid is bio-transformed mainly by hepatic acetylation, which is under
genetic control. About one half of people of Caucasian origin are slow
acetylators because they have an inherited deficiency of N-acetyltransferase.
Slow acetylators have a higher risk of adverse effects with isoniazid.

9. Ligand-gated ion channels allow for fast flow of ions across cell membranes via
binding of the ligand to the channel. Based on this information, the most likely
location of these channels in a 35-year-old man with no pertinent medical or surgical
history is in which of the following areas?

a) Cardiac muscle
b) Cerebellum
c) Pancreas
d) Spleen
e) Thyroid gland

Answer: a) Cardiac muscle.

Ligand-gated ion channels are responsible for regulation of the flow of ions
across cell membranes. The activity of these channels is regulated by the
binding of a ligand to the channel. Response to these receptors is very rapid,

enduring for only a few milliseconds. These receptors mediate diverse

functions, including neurotransmission, cardiac conduction, and muscle
contraction.

10. A patient takes an oral sympathomimetic agent for regulation of heart rate. This agent
is taken orally. Which of the following systemic effects is likely a result of this
medication?

a) Bronchoconstriction
b) Hypotension
c) Pupillary constriction
d) Tachycardia
e) Urinary frequency

Answer: d) Tachycardia.
The effect of sympathetic output is to increase heart rate (tachycardia) and
blood pressure, to mobilize energy stores of the body, and to increase blood
flow to skeletal muscles and the heart while diverting flow from the skin and
internal organs. Sympathetic stimulation results in dilation of the pupils and the
bronchioles. It also affects GI motility and the function of the bladder and
sexual organs.

11. A 45-year-old woman recently diagnosed with a urinary tract infection started therapy
with a trimethoprim −sulfamethoxazole combination. Both trimethoprim and
sulfamethoxazole are bacteriostatic drugs when given alone. However, a bactericidal
effect is obtained when the two drugs are given in combination. Which of the follow ing
terms best defines this drug interaction?

a) Additive effect
b) Potentiation
c) Synergism
d) Reverse tolerance
e) Sensitization

Answer: c) Synergism
A drug interaction is defined as synergistic when the response elicited by
combined drugs is greater than the combined responses of the individual drugs. In
other words, the response elicited by the drug combination is more than sim - ply
additive. In the present case, the effects of the individual drugs are bacteriostatic,
whereas the effect of the combined drugs is more than an additive bacteriostatic
effect (by definition, a bactericidal effect is greater than a bacteriostatic effect).
The interaction is therefore defined as synergism.

12. A 39-year-old man takes a 100 mg dose of medication X. This drug is taken orally and
becomes bio-transformed by metabolism in the liver and secondary metabolism in the
kidneys. This defines which of the following processes?

a) Absorption
b) Catabolism
c) Distribution
d) Elimination
e) Metabolism

Answer: e) Metabolism.
This is the definition of metabolism. Metabolism is the third step in the process of
drug delivery and utilization. The drug may be bio-transformed by metabolism by
the liver or other tissues.

13. A 13-year-old girl with abnormal menses presents to her primary care physician for
treatment. She has a history of inguinal hernia repairs in the past. Her physician begins
therapy with oral micronized estradiol in order to regulate menses. Which of the
following is true regarding this therapy?

a) Limited bioavailability
b) Limited first-pass metabolism
c) Minimally available
d) Nephrotoxicity at low doses
e) Neuromuscular blockade likely

Answer: b) Limited first-pass metabolism

These agents and their esterified or conjugated derivatives are readily absorbed
through the gastrointestinal tract, skin, and mucous membranes. Taken orally,
estradiol is rapidly metabolized (and partially inactivated) by the microsomal
enzymes of the liver. Micronized estradiol is available and has better
bioavailability. Although there is some first-pass metabolism, it is not sufficient to
lessen the effectiveness when taken orally.

14. A 47-year-old man with AIDS is hospitalized for a fever of unknown origin. He is placed
in a combination of antibiotics including a b-lactam and an amino-glycoside. The
rationale behind the use of multiple antibiotics includes which of the following?

a) Hepatotoxicity
b) Nephrotoxicity
c) Synergism
d) Toxicity

Answer: c) Synergism.
Certain combinations of antibiotics, such as b-lactams and aminoglycosides, show
synergism; that is, the combination is more effective than either of the drugs used
separately. Because such synergism among antimicrobial agents is rare, multiple
drugs used in combination are only indicated in special situations—for example,
when an infection is of unknown origin.

15. A potential beneficial effect of a long-acting benzodiazepine, flurazepam, may have a

cost-effective property beneficial to the development of a generic form. This could be
related to which of the following areas?

a) Adverse effects
b) Efficacy
c) Timing of administration
d) Tonicity
e) Toxicity

Answer: b) Efficacy.
This long-acting benzodiazepine significantly reduces both sleep-induction time
and the number of awakenings, and it increases the duration of sleep. Flurazepam
has a long-acting effect and causes little rebound insomnia. With continued use,
the drug has been shown to maintain its effectiveness for up to 4 weeks.

Flurazepam and its active metabolites have a half-life of approximately 85 h,

which may result in daytime sedation and accumulation of the drug.

16. A 72-year-old man is going to undergo a left hemicolectomy. The anesthesiologist is

preparing to anesthetize him and plans to use inhalational anesthetic agents. Which of the
following factors will make the patient require more anesthetic agent to achieve the
desired response?

a) Chronic alcohol abuse

b) Diet
c) Immunodeficiency state
d) Hypothermia
e) Weight

Answer: Chronic alcohol abuse.

The more lipid soluble an anesthetic, the lower the concentration of anesthetic
needed to produce anesthesia and thus the higher the potency of the anesthetic.
Factors that can increase minimum alveolar concentration (MAC) (and make the
patient less sensitive) include hyperthermia (greater than 42°C), drugs that
increase CNS catecholamines, and chronic ethanol abuse.

17. A 59-year-old man with decreased urinary stream and hypertension is prescribed
doxazosin in hopes that both problems will be treated. He begins dose escalation with 1
mg given for one week, 2 mg given for 2 weeks, and 4 mg given for maintenance. He
returns to his primary care physician saying that this medication is not helping. To
determine whether or not the patient is taking the medication, it would be useful to look
at the excreted concentration of medication in which of the following areas?

a) Blood
b) Feces

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c) Liver hepatocyte extract

d) Skin
e) Urine

Answer is B: Feces.
Metabolism leads to inactive products that are excreted in urine except for those
of doxazosin, which appear in feces. Doxazosin is the longest acting of these
drugs used to treat benign prostate hyperplasia. Doxazosin has added benefit in
that it can also treat mild hypertension.

18. A 44-year-old black male is brought to the emergency department with 6 h of worsening
lethargy and confusion. Past medical history is significant for easy bruising, 3 months of
bone pain, and frequent pneumococcal infections. Labs were ordered, revealing serum
calcium of 17 mg/dL (normal: 9.0 to 10.5 mg/dL). To rapidly lower his serum calcium,
you administer calcitonin. However, calcitonin alone is insufficient because it is known to
rapidly and suddenly lose its effectiveness within 2 to 3 days of repeated dosing. For this
reason, a bisphosphonate, which take 2 to 3 days to become effective, is added
simultaneously. What is the term for the rapid decrease in response to calcitonin?

a) Anaphylaxis
b) Prophylaxis
c) Tachyphylaxis
d) Tolerance

Answer: c) Tachyphylaxis
Tachyphylaxis describes a scenario in which the response to a drug rapidly
decreases. Tachyphylaxis resembles tolerance in that the response to the drug
cannot be restored by increasing the dose. There are some important differences
between tolerance and tachyphylaxis, however. Tolerance is a slow decrease in
response to a drug, whereas tachyphylaxis is rapid. Tolerance comes from the

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target cells or tissue modifying its physiology to compensate for the effect of a
drug. Tachyphylaxis occurs when something disrupts the drug itself from
functioning, such as internalization of receptors or uncoupling of signal
transduction

19. A 24-year-old primigravid female's water breaks at 39 weeks gestation. Twenty-four

hours later, she is having regular contractions 3 min apart. Her labor lasts 8 h. At the
hospital, she gives birth to a baby boy, who initially appeared healthy. Within the next 12
h, the baby boy begins to have temperature fluctuations, difficulty breathing, and reduced
movements. You suspect neonatal sepsis, so IV gentamicin plus ampicillin is started.
Gentamicin and ampicillin are commonly used together because the combined effect is
greater than the additive effects of both alone. This increased effectiveness is an example
of what principle?

a) Agonism
b) Anergy
c) Symbiosis
d) Synergy

Answer: d) Synergy
Synergy is a term used to describe a situation when the combined effect of two or
more drugs simultaneously is greater than can be explained by arithmetically
adding the individual effects. A fine example is the synergistic effect when
penicillin such as ampicillin is combined with an aminoglycoside such as
gentamicin.

20. A 17-year-old pregnant female asks her doctor what she can do about her acne. The
doctor prescribes a topical benzoyl peroxide preparation, but the patient is unsatisfied
with the results. She has a close friend taking a vitamin A-based acne control product,
and her friend often tells her how well it works. She begins taking her friend's pills and is

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pleased with the reduction in her acne. During which prenatal period is her unborn child
at greatest risk for developing a birth defect?

a) Before conception, because the drug described is known to cause mutations in the
maternal germ cell line
b) Days 1 to 17 after conception
c) Days 18 to 55 after conception
d) Days 56 to birth
e) Vitamin A is a natural substance and therefore poses no risk of ill effects

Answer: c) Days 18 to 55 after conception.

Development can be divided into three periods based on reaction to teratogens.
The first period, which includes implantation, starts at fertilization (day 1) and
goes to about day 17. Insults during this period have an "all-or-nothing" effect.
This is because at this stage, cells are still totipotent, so either so many cells are
lost that a spontaneous abortion results or enough cells are spared that can replace
destroyed cells completely so no defect is seen in the newborn. The next stage is
the embryonic period, days 18 to 55. Organogenesis takes place during this stage,
so any insults to the rapidly dividing, differentiated cells during this period easily
lead to malformations. This is the period of development in which an unborn child
is at greatest risk for a birth defect. Days 56 to parturition comprise the fetal
period. Insults during this period generally cause only a reduction in cell number
in the growing organs (not structural defects to the organs themselves).

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Principles of Neuropharmacology

21. A 38-year-old woman presents to the ophthalmologist for a routine eye examination. She
is given intraocular pilocarpine. She was supposed to be administered two drops in each
to dilate the eyes for the examination. Unfortunately, the eyedrops were administered by
a new technician who inadvertently administered 10 drops of pilocarpine in each eye.
Which of the following agents should be immediately given to the patient?

a) Atropine
b) Carbachol
c) Donepezil
d) Galantamine
e) Rivastigmine

Answer: a) Atropine.
Pilocarpine is applied topically to the eyes and produces rapid miosis and
contraction of the ciliary muscle. This patient received too much medication.
Atropine, an ocular muscarinic blocker, should be administered immediately.

22. Commonalities of the sympathetic, parasympathetic, and somatic nervous systems

involve which of the following neuroeffector transmitters?

a) Acetylcholine
b) Dopamine

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c) Epinephrine
d) Norepinephrine
e) Serotonin

Answer: a) Acetylcholine.
In the somatic and autonomic nervous system, the common neuroeffector
transmitter is acetylcholine. However, in sympathetic stimulation of the adrenal
medulla, epinephrine is released into the blood. In the sympathetic nervous
system, norepinephrine is released by the postganglionic neurons.

23. A 47-year-old man is given atropine to decrease dental secretions during a root canal
procedure. This agent is most likely to have an effect on which of the following target
organs/glands?

a) Adrenal medulla
b) Kidney
c) Pilomotor muscles
d) Salivary glands
e) Sweat glands

Answer: d) Salivary glands.

Although most tissues receive dual innervation, some effector organs, such as the
adrenal medulla, kidney, pilomotor muscles, and sweat glands, receive
innervation only from the sympathetic system. The salivary glands receive
cholinergic innervation and would be affected by administration of atropine.

24. A 58-year-old woman with a history of myasthenia gravis presents to the emergency
department complaining of generalized abdominal pain. Her current medications include
nifedipine and neostigmine. Her caretaker reports that her bottle of neostigmine is empty
but was full earlier in the day. Which of the following findings is likely in this patient?

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a) Bronchodilation
b) Constipation
c) Dizziness
d) Hypotension
e) Xerostomia

Answer: d) Hypotension.
This patient is currently taking neostigmine for treatment of myasthenia gravis.
She has apparently overdosed on this medication. Adverse effects can include
salivation, flushing, hypotension, nausea, abdominal pain, diarrhea, and
bronchospasm.

25. A 62-year-old retired small business owner has had slowly increasing intraocular pressure
bilaterally. You start him on drug used to treat his open-angle glaucoma, which also
happens to cross the blood-brain barrier better than other drugs in its class. Which of the
following drugs is this?
a) Echothiophate
b) Edrophonium
c) Neostigmine
d) Physostigmine
e) Pyridostigmine

Answer: d) Physostigmine.
All of the drugs listed inhibit acetylcholinesterase, but physostigmine best crosses
the blood-brain barrier. These drugs increase the effects of endogenous
acetylcholine by inhibiting acetylcholinesterase, which increase the half-life of
acetylcholine in the synaptic cleft. Physostigmine decreases intraocular pressure
by stimulating contraction of the ciliary muscle, which opens the trabecular
meshwork, increasing outflow of the aqueous humor.

16

26. A group of teenage boys comes to the emergency department after ingesting a plant they
heard would make them high. One member of the group still had some plant parts in his
pocket, which you use to identify deadly nightshade that contains compounds
metabolized to atropine. Which of the following is an effect of atropine?

a) Bronchospasm
b) Lacrimation
c) Mydriasis
d) Salivation
e) Urination

Answer: c) Mydriasis.
The sympathetic and parasympathetic nervous systems often work simultaneously
on the same organ. The net effect on an organ is determined by which branch of
the autonomic nervous system is most active at any given time. The sympathetic
nervous system's effector neurotransmitter is generally norepinephrine, whereas
the parasympathetic nervous system's is acetylcholine. Atropine is a cholinergic
antagonist. Exposure to atropine would result in a clinical picture in which the
parasympathetic nervous system (PNS) appeared to be missing, leaving control to
the sympathetic nervous system (SNS). The PNS would normally push
equilibrium toward bronchospasm, lacrimation, meiosis, salivation, and urination.
Leaving the SNS in control then would lead to bronchodilation; mydriasis; and
decreased lacrimation, salivation, and urination.

27. A medical student is involved in a summer research project evaluating the potencies of
the a-adrenergic agonists at different receptor sites. Which of the following a-adrenergic
agonists would be expected to have the strongest potency at the a-receptor?

a) Acetylcholine

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b) Epinephrine
c) Isoproterenol
d) Metanephrine
e) Norepinephrine

Answer: b) Epinephrine.
The a-adrenoceptors show a weak response to the synthetic agonist isoproterenol,
but they are responsive to the naturally occurring catecholamines: epinephrine and
norepinephrine. For receptors, the rank order of potency is epinephrine,
norepinephrine, isoproterenol.

28. A 79-year-old man undergoes a hip replacement procedure under general anesthesia and
is unable to be weaned from the ventilator postoperatively. Review of the anesthesia
records indicated that he received the following agents: succinylcholine, diazepam,
rocuronium, and fentanyl. He spends the next 5 days on a ventilator in the intensive care
unit. Which of the following is the most likely explanation for this situation?

a) Diaphragm paralysis
b) Hypokalemia
c) Hyponatremia
d) Hypocalcemia
e) Underlying digitalis toxicity

Answer: a) Diaphragm paralysis.

Administration of succinylcholine to a patient who is genetically deficient in
plasma cholinesterase or who has an atypical form of the enzyme can lead to
prolonged apnea caused by paralysis of the diaphragm. The rapid release of
potassium may also contribute to prolonging apnea in patients with electrolyte
imbalances who receive this drug.

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