Pharm Respitory Part 2

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Pharm Respitory Part 2 - Quiz

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Questions and Answers
  • 1. 

    A 78-year-old woman, resident a rehabilitation center, exhibited Cheyne-Stokes breathing from time to time and suffered from urge urinary incontinence and spasticity in her left limb. The woman suffered from an ischemic stroke two months previously. Which of the following drugs was most likely included in the pharmacological therapy of this patient?

    • A.

      Neostigmine

    • B.

      Theophylline

    • C.

      Albuterol

    • D.

      Ipratropium

    • E.

      Metoclopramide

    • F.

      Bromocriptine

    Correct Answer
    B. Theophylline
    Explanation
    Learning objective: describe the main therapeutic uses of theophylline
    Answer: B
    Cheyne-Stokes breathing, which occurs in various disease states including stroke, is a type of .
    periodic breathing in which periods of hyperpnea alternates with periods of apnea. Theophylline
    has been shown to improve Cheyne-Stokes respiration, likely because of its stimulant effect on
    respiratory center.
    A) Neostigmine actually can worse urge incontinence, because it increases urinary bladder
    contractility.
    C, D, E, F) These drugs have no effect on Cheyne-Stokes breathing, urge urinary incontinence
    or limb spasticity.

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  • 2. 

    A 32-year-old female with mild intermittent asthma was successfully maintained on an inhaled antiasthmatic drug “as needed”. Which of the following molecular actions most likely mediated the therapeutic effectiveness of that drug in the patient’s disease?

    • A.

      Blockade of histamine release from bronchial epithelium

    • B.

      Blockade of leukotriene receptors in bronchial muscle

    • C.

      Release of nitric oxide from bronchial epithelium

    • D.

      Activation of beta-2 receptors in bronchial vessels

    • E.

      Increased cAMP in bronchial muscle

    Correct Answer
    E. Increased cAMP in bronchial muscle
    Explanation
    Learning objective: describe the molecular mechanism of action of beta-2 receptor
    agonists.
    Answer: E
    A short acting beta-2 receptor agonist taken “as needed” represents the standard therapy for
    mild intermittent asthma. No daily medication is required in case of non persistent asthma.
    Activation of beta-2 receptors in bronchial muscle increases cAMP which in turn stimulates Ca++
    efflux and decreased phosphorylation of myosin light chains. Both actions leads to smooth
    muscle relaxation.
    A) Beta-2 agonists can block histamine release, but histamine is stored in mast cells and
    basophils, not in bronchial epithelium
    B ,C) Beta-2 agonists do not have these effects.
    D) Beta-2 agonists activate beta-2 receptors in bronchial vessels, but this has nothing to do with
    the bronchodilating action.

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  • 3. 

    A 45-year-old man with a long history of chronic severe asthma was admitted to the emergency room with severe dyspnea and wheezing. He was able to say only 2-3 words without taking a breath. Past history of the patient was significant for duodenal ulcer for two years. Present medications included albuterol, beclomethasone and ipratropium by inhalation on a chronic basis. Vital signs were: heart rate 130 bpm, respiratory rate 30/min, blood pressure 140/90 mm Hg. An ECG showed sinus tachycardia with occasional premature ventricular contractions. Which of the following two events most likely contributed to the patient’s arrhythmia?

    • A.

      Ipratropium dosage and the hypertensive effect of beclomethasone

    • B.

      Duodenal ulcer and the hypertensive effect of beclomethasone

    • C.

      Albuterol dosage and the duodenal ulcer

    • D.

      Ipratropium dosage and the disease-induced hypoxemia

    • E.

      Albuterol dosage and the disease-induced hypoxemia

    Correct Answer
    E. Albuterol dosage and the disease-induced hypoxemia
    Explanation
    Learning objective: explain the likely cause of arrhythmia in an asthmatic patient under
    albuterol therapy.
    Answer: E
    The severe asthma of the patient most likely caused hypoxemia which by itself can predispose to
    arrhythmias. Moreover the patient was likely receiving a high dose of beta-agonists, since the
    increased dyspnea prompted him to increase the number of puffs taken daily. Tachycardia is a
    common adverse effect of beta-2 agonists, likely due to activation of beta-2 receptors in the
    heart, as well as to reflex effects that stem from beta-2 receptor mediated vasodilation.
    A, B, D) Ipratropium and glucocorticoids taken by inhalatory route very seldom cause systemic
    effects.
    C) Duodenal ulcer is not a risk factor for arrhythmias.

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  • 4. 

    A 52-year-old woman complained to her physician of tremors, muscle cramping, palpitations and anxiety. The woman, recently diagnosed with moderate persistent asthma, had started an inhalatory treatment two weeks previously. Which of the following drugs most likely caused the patient’s symptoms?

    • A.

      Beclomethasone

    • B.

      Salmeterol

    • C.

      Cromolyn sodium

    • D.

      Ipratropium

    • E.

      Theophylline

    • F.

      Zafirlukast

    Correct Answer
    B. Salmeterol
    Explanation
    Learning objective: describe the main adverse effects of beta-2 agonists.
    Answer: B
    Beta-2 agonists by inhalatory route are first line drugs for asthma. The risk of adverse effects is
    increased with long-acting beta-2 agonists like salmeterol. Tremor is the most frequent adverse
    effect (up to 40% of patients receiving high doses). It likely occurs because beta-2 receptor
    activation accelerates the sequestration of cytosolic Ca++ (by opening Ca++ channels in the
    sarcoplasmic reticulum of skeletal muscle) and increases discharge in muscle spindles. Anxiety,
    the second most frequent adverse effects of these drugs can occur in up to 20% of patients.
    Palpitations can occur in up to 10% of patients and is related to the cardiac effects of these
    drugs (beta-2 receptors activation increases heart contractility and rate). Muscle cramping is
    likely a consequence of hypokalemia (beta-2 agonists stimulate Na/K+ ATPase, so facilitating K+
    entry into the cells), since K+ is needed for vasodilation in the skeletal muscle.
    A, C, D, F) These drugs do not cause the pattern of adverse effects reported by the patient.
    E) High doses of theophylline could cause tremors, muscle cramping palpitations and anxiety but
    the drug is not usually given in case of mild allergic asthma and is never administered by
    inhalatory route.

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  • 5. 

    A 50-year-old woman with ventilatory failure due to polymyositis has been on a ventilator for 5 days when the physicians noted increasing endotracheal secretions and decreased oximetry. A bronchoscopy showed abundant mucus plugs filling the bronchial lumen. Suctioning and lavage of the bronchial tree was performed and a drug was given to improve mucociliary clearance. Which of the following drugs was most likely administered?

    • A.

      Epinephrine

    • B.

      Albuterol

    • C.

      Ipratropium

    • D.

      Cromolyn sodium

    • E.

      Dexamethasone

    • F.

      Zafirlukast

    Correct Answer
    B. Albuterol
    Explanation
    Learning objective: describe the main therapeutic actions of albuterol in bronchospastic
    disorders.
    Answer: B
    A patient who is artificially ventilated cannot cleared bronchial secretions, mainly because
    effective cough cannot be performed. Beta-2 agonist drugs improve mucociliary clearance and
    therefore can help to remove secretions from bronchial mucosa.
    A) Epinephrine, by activating beta-2 receptors, can improve mucociliary clearance but can cause
    several adverse effects in this patient, due to its cardiovascular action.
    C) Ipratropium has bronchodilating activity but does not improve mucociliary clearance (even if,
    unlike other anticholinergic drugs, it does not reduce it).
    D, E, F) Chromones, corticosteroids and leukotriene antagonists have no effect on mucociliary
    clearance.

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  • 6. 

    A 44-year old man presented to his physician complaining of an increasing cough productive of yellow sputum and of a moderate some short of breath on exertion. The man had a long history of heavy cigarette smoking, and suffered from an episode of sustained ventricular tachycardia one year ago. Physical examination showed a patient with shallow breathing and a barrel chest. Auscultation demonstrated wheezing and distant heart sounds. An inhalatory therapy was ordered. A drug with which of the following mechanism of action was most likely prescribed?

    • A.

      Activation of adenosine receptors

    • B.

      Inhibition of phospholipase A2

    • C.

      Activation of beta-2 receptors

    • D.

      Blockade of Nn and M3 receptors

    • E.

      Blockade of a delayed chloride channel

    Correct Answer
    D. Blockade of Nn and M3 receptors
    Explanation
    Learning objective: describe the mechanism of action of ipratropium.
    Answer: D
    The history and the symptoms of the patient indicate that he was most likely suffering from
    chronic obstructive pulmonary disease (COPD). Ipratropium is a bronchodilator of choice in
    COPD since it action in these patients is equal or superior to that achieved by beta-2 agonists.
    Ipratropium is a quaternary ammonium compound that belongs to the class of antimuscarinic
    drugs. Unlike tertiary amines, quaternary ammonium antimuscarinic drugs block mainly
    muscarinic receptors but also have a significant blocking activity on nicotinic Nn receptors.
    Therefore inhaled ipratropium can block both M3 receptors on bronchial smooth muscle, and Nn
    receptors located in small parasympathetic ganglia within the bronchial tree. Bot actions can
    contribute to the final bronchodilating effect of the drug.
    A) This activation would cause bronchoconstriction, not bronchodilation.
    B) This would be a mechanism of action of glucocorticoids. These drugs are not bronchodilators
    and they are used only in patient with advanced COPD and frequent exacerbations,
    C), This would be the mechanism of action of beta-2 agonists. These drugs are contraindicated
    in this patient because of the history of ventricular tachycardia. Patients who have survived and
    episode of sustained ventricular tachycardia or ventricular fibrillation have a extraordinary high
    risk of experiencing a recurrent arrhythmia.
    E) This would be the mechanism of action of cromolyn. This drug is not a bronchodilator and it is
    not used in COPD

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  • 7. 

    A 46-year-old woman complained to her physician of dry mouth. The woman, recently diagnosed with chronic obstructive pulmonary disease, started an appropriate treatment one week previously. Which of the following drugs most likely caused the patient’s symptom?

    • A.

      Albuterol

    • B.

      Theophylline

    • C.

      Ipratropium

    • D.

      Zileuton

    • E.

      Zafirlukast

    • F.

      Beclomethasone

    Correct Answer
    C. Ipratropium
    Explanation
    Learning objective: describe the main adverse effects of ipratropium.
    Answer: C
    Dry mouth is the most common adverse effects of inhaled ipratropium. It can occur in up to 25%
    of patients and is most likely due to blockade of muscarinic receptors in salivary glands.
    A, B, D, E, F) With all this drugs the occurrence of dry mouth is negligible.

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  • 8. 

    A 43-year old woman complained to her physician of recurrent wheezing and frequent nocturnal awakening. She also noted that wheezing was most frequent when she was anxious and tense. The woman had been suffering from allergic rhinitis for four years and from hyperthyroidism for one year. A diagnosis of mild allergic asthma was made. Which of the following drug treatments would be most appropriate for a relief of her bronchospasm?

    • A.

      Oral glucocorticoids

    • B.

      Oral theophylline

    • C.

      Inhaled ipratropium

    • D.

      Inhaled salmeterol

    • E.

      Oral zileuton

    • F.

      Inhaled cromolyn

    Correct Answer
    C. Inhaled ipratropium
    Explanation
    Learning objective: describe the bronchodilating use of ipratropium in case of a
    contraindication to beta-2 agonists.
    Answer: C
    Accepted guidelines for the treatment of asthma indicate a short acting beta-2 agonist as needed
    in all patients. In the present case, however, the patient’s hyperthyroidism contraindicates the
    use of beta-2 agonists. In general, when drugs are given by inhalatory route, only 10% to 20% of
    the dose can reach the target site of action (lower airways); the rest is swallowed and can be
    absorbed by the intestine so causing systemic effects. Ipratropium is an effective bronchodilator
    agent and the swallowed dose is not absorbed by the intestine (the drug is a quaternary
    ammonium compound). Moreover In this patient:
    a) the bronchospasm was triggered by emotional upset and it has been shown that inhaled
    anticholinergics can block this response.
    b) the nocturnal awakening indicates that the bronchospasm is triggered by a prevalence of the
    parasympathetic system (which is predominant during night)
    A, E, F) These drugs are not bronchodilators and cannot be used for a relief of bronchospasm.
    B) Oral sustained-releases theophylline is an effective bronchodilator, but has the potential to
    cause more adverse effects, may interfere with sleep and is less effective than ipratropium.
    D) (see explanation above)

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  • 9. 

    A 10-year-old girl, who has been suffering from seasonal allergic rhinitis for 3 years, presented to the family physician with nasal itching, sneezing and running nose. The physician ordered a nasal spray of a drug that is able to inhibit mast cell degranulation. Which of the following drugs was most likely prescribed?

    • A.

      Zafirlukast

    • B.

      Codeine

    • C.

      Ipratropium

    • D.

      Cromolyn

    • E.

      Zileuton

    Correct Answer
    D. Cromolyn
    Explanation
    Learning objective: explain the mechanism of action of cromolyn.
    Answer: D
    Chromone derivatives like cromolyn sodium are drugs that stabilize mast cells (but not
    basophils) so inhibiting the release of chemical mediators from these cells. Intranasal cromolyn
    is effective for the treatment of allergic rhinitis, even if is generally less effective than intranasal
    corticosteroids.
    A, B, C, E) These drugs do not inhibit mast cell degranulation.

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  • 10. 

    A15-year-old boy complained to his family physician of pain on swallowing. Physical examination revealed white patches in the oropharynx and subsequent histology confirmed the diagnosis of oral candidiasis. The boy, recently diagnosed with mild persistent asthma, had started an inhalatory therapy two weeks previously. Which of the following drugs most likely caused the patient’s candidiasis?

    • A.

      Ipratropium

    • B.

      Albuterol

    • C.

      Cromolyn

    • D.

      Theophylline

    • E.

      Zafirlukast

    • F.

      Beclomethasone

    Correct Answer
    F. Beclomethasone
    Explanation
    Learning objective: describe the main adverse effects of inhaled glucocorticoids.
    Answer: F
    Systemic adverse effects of inhaled corticosteroids are extremely rare. Local adverse effect are
    more common and include cough, dysphonia and oral candidiasis. Candida albicans is a fungal
    organism that is a normal constituent of oral flora, but can cause infection when conditions (like
    compromised cellular immunity due to corticosteroids) favor fungal growth.
    A, B, C, D, E) These drugs do not cause oral candidiasis.

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  • 11. 

    A 9-year-old boy with moderate persistent asthma was in the chest clinic for follow up of his disease. He had been only moderately well controlled on oral sustained-release theophylline and inhaled cromolyn daily, and inhaled albuterol “as needed”. Physical examination showed diffuse expiratory wheezes and pulmonary function testing revealed a peak expiratory flow rate 60% of predicted. Which of the following would be an appropriate therapeutic conduct for this patient?

    • A.

      Substitute albuterol with ipratropium

    • B.

      Add inhaled beclomethasone to the present regimen

    • C.

      Double the dose of theophylline

    • D.

      Substitute albuterol with inhaled isoproterenol

    • E.

      Substitute theophylline with oral ephedrine

    Correct Answer
    B. Add inhaled beclomethasone to the present regimen
    Explanation
    Learning objective: describe the appropriate treatment of a persistent asthma not
    controlled by theophylline and salmeterol.
    Answer: B
    When a moderate persistent asthma is not well controlled with a long-acting bronchodilator (like
    theophylline or salmeterol) plus an antiinflammatory drug like cromolyn, an inhaled steroid
    should be included in the therapeutic regimen.
    A) Ipratropium is usually less effective than a beta-2 agonist in asthma.
    C) Theophylline is a drug with a narrow therapeutic index. To double the dose would certainly
    cause overdose toxicity .
    D) Isoproterenol is non selective beta-agonist and therefore it has no advantage and many
    disadvantages over albuterol.
    E) Ephedrine is a mixed adrenergic agonist with no advantage over a selective beta-2 agonist.

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  • 12. 

    A 33-year-old man with severe persistent asthma had been on inhaled albuterol, inhaled beclomethasone, oral zafirlukast and oral sustained-release theophylline for one month. However his asthma was not well controlled and his physician decided to add another drug to the present treatment. Which of the following drugs was most likely prescribed?

    • A.

      Oral triamcinolone

    • B.

      Inhaled ipratropium

    • C.

      Inhaled cromolyn

    • D.

      Inhaled salmeterol

    • E.

      Oral zileuton

    Correct Answer
    A. Oral triamcinolone
    Explanation
    Learning objective: describe the use of oral glucocorticoids in bronchospastic disorders.
    Answer: A
    Oral steroids are usually administered in case of severe asthma that is not controlled by other
    antiasthmatic drugs. Corticosteroids have potent antiinflammatory activity and, even if they are
    not direct bronchodilators, they can relieve bronchial obstruction by improving the
    responsiveness of beta-2 receptors to beta-2 agonists.
    A) Ipratropium is usually less effective than beta-2 agonists in asthma and its action is not
    potentiated by corticosteroids.
    C) The antiinflammatory effect of cromolyn is inferior to that of corticosteroids.
    D) It would be useless to add another beta-2 agonist with pharmacokinetic features very close to
    that of albuterol.
    E) Since a leukotriene antagonist (zafirlukast) was not effective, it is unlikely that an inhibitor of
    leukotriene synthesis (zileuton) would be effective.

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  • 13. 

    A 44-year-old asthmatic man was brought to the emergency room with a severe asthma exacerbation. The patient’s FEV1 did not improve upon administration of inhaled albuterol and the attending physician decided to administered IV corticosteroids and IV theophylline. Which of the following is the most likely potential benefit of IV corticosteroids in this setting?

    • A.

      Direct bronchodilation

    • B.

      Decreased sympathetic tone of airway smooth muscle

    • C.

      Increase mucociliary clearance

    • D.

      Increased bronchial responsiveness to albuterol

    • E.

      Increased theophylline affinity for adenosine receptors.

    Correct Answer
    D. Increased bronchial responsiveness to albuterol
    Explanation
    Learning objective: describe the interaction between beta-2 agonists and glucocorticoids in
    the treatment of asthma.
    Answer: D
    Systemic corticosteroids are given in case of severe asthma exacerbation for two main reasons:
    a) they improve the responsiveness of beta-2 receptors and b) They inhibit many phases of the
    inflammatory responses. The antiinflammatory activity of corticosteroids is delayed for 4-6 hours
    after administration. However the restoration of responsiveness to endogenous catecholamines
    as well as to exogenous beta-2 agonists occurs within one hour of administration in severe
    chronic asthmatics. This restoration is therefore the main potential benefit of IV administration of
    corticosteroids to a patient with severe asthma exacerbation under treatment with beta-2
    agonists.
    A, B, C, E) Corticosteroids do not have these effects.

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  • 14. 

    A 9 year-old girl with a long history of cystic fibrosis presented to the hospital because of worsening of respiratory symptoms. An appropriate therapy was prescribed which included dornase alpha by inhalatory route. Which of the following statement best explains the mechanism of action of the drug in the patient’ disease?

    • A.

      It has bactericidal activity against P. Aeruginosa

    • B.

      It releases nitric oxide from airway epithelium

    • C.

      It depolymerizes the DNA of purulent airways secretions

    • D.

      It stimulates the cystic fibrosis transmembrane regulator

    • E.

      It inhibits the neutrophil migration into the lung tissue

    Correct Answer
    C. It depolymerizes the DNA of purulent airways secretions
    Explanation
    Learning objective: explain the mechanism of action of dornase alpha.
    Answer: C
    The principle source of DNA in the sputum of cystic fibrosis patients is from the nuclei of
    degenerating neutrophils which accumulate in the lung because of the chronic bacterial
    infections. The DNA is the principal factor that increases the viscosity of the sputum in these
    patients. Dornase alpha is a recombinant human deoxyribonuclease that is administered by
    inhalatory route. It degrades the DNA, and this has been shown to significantly decrease the
    viscosity of the sputum so reducing obstruction and the severity of respiratory infections.
    A, B, D, E) (See explanation above).

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    Quiz Edited by
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