Chapter 22: Psychotherapeutic Agents
A 14 year-client with symptoms of psychosis has been prescribed pimozide 0.05 mg/kg PO at bedtime. The client weighs 154 lbs. How many mg of pimozide should the client be administered?
3.5 Explanation: The client's weight in kg is 70 kg (154 ÷ 2.2). The prescription is for 0.05 mg/kg, and 0.05 X 70 = 3.5 mg.
A client with schizophrenia has been taking haloperidol for several years. The care team and the client have collaborated and chosen to transition the client to an atypical antipsychotic in an effort to reduce adverse effects and maximize therapeutic effects. In order to reduce the client's risk of extrapyramidal effects during the transition from haloperidol to an atypical antipsychotic, the care team should implement which intervention?
Gradually taper the dose of haloperidol. Explanation: When discontinuing haloperidol, it is essential to taper the dosage to prevent extrapyramidal symptoms. If the medication is abruptly discontinued, the client is at risk for this condition. A drug holiday would exacerbate symptoms, and ECT is not indicated. Concurrent administration of two drugs has the potential to exacerbate adverse effects.
A nurse is providing care for a client diagnosed with attention deficit hyperactivity disorder (ADHD) who has been taking methylphenidate for several months. When monitoring for potential adverse effects, the nurse should include what assessments?
sleep patterns Explanation: Because methylphenidate is a central nervous system (CNS) stimulant, it carries the potential to disturb sleep patterns. The client's pupillary response, orientation, and sexual function are less likely to be affected.
A 10-year-old boy is taking dextroamphetamine (Dexedrine) daily for ADHD. At each clinic visit, the nurse must assess the child. The priority assessment since he is on this medication would be which?
height and weight. Explanation: The nurse should assess blood pressure, body temperature, and vision at each clinic visit as routine nursing measures in caring for a pediatric client. However, the priority assessment would be of height and weight. Monitoring the growth and development of children taking amphetamines is extremely important because these drugs have been associated with growth suppression.
The nurse suspects that a client receiving olanzapine is developing type 2 diabetes. Which finding would help support the nurse's suspicion? Select all that apply.
increased thirst weight gain increased urination Explanation: The nurse would suspect development of type 2 diabetes based on assessment of increased thirst and urination and weight gain. Fever and sore throat would suggest an infection, possibly due to agranulocytosis from clozapine therapy
What is the recommended amount of caffeine for a nonpregnant woman to consume daily?
250 mg of caffeine Explanation: Some authorities recommend that normal, healthy, nonpregnant adults consume not more than 250 mg of caffeine daily. 125 mg of caffeine is lower than the recommended safe amount of consumption. 500 mg to 1 g is more than the recommended daily consumption of caffeine.
A client receiving outpatient therapy with antipsychotic therapy experiences dizziness from time to time. Which suggestion by the nurse would be appropriate?
"Get up slowly from the bed or chair." Explanation: If dizziness occurs when changing positions, the nurse should encourage the client to rise slowly when getting out of the bed or a chair. Frequent sips of water help alleviate dry mouth. Taking the drug with meals would have no effect on the client's dizziness. Limiting salt intake would have no effect on the client's dizziness.
The nurse is providing education to a client who has been prescribed an antipsychotic drug. Which statement suggests that the client understands the typical length of medication therapy?
"I may always have to take this medication." Explanation: People with schizophrenia usually need to take antipsychotics for years because there is a high rate of relapse (acute psychotic episodes) when drug therapy is discontinued, most often by clients who become unwilling or unable to continue taking their medication. Symptoms tend to increase when medications are stopped. While ineffective self-care is a factor, it is not the only trigger for an acute psychotic episode.
A female client 25 years of age has begun taking lithium for treatment of bipolar disorder. Which statement indicates that the client needs further instruction?
"I will need to stop taking my birth control pills while I take lithium." Explanation: Women of childbearing age are often prescribed contraceptives during lithium therapy because lithium is a pregnancy category D and is contraindicated during pregnancy and lactation. The client understands the need to come in regularly for blood tests, and that the lithium level may need to be adjusted depending upon the blood work. Client also understands that diarrhea is one of the early signs of lithium toxicity.
A patient has been prescribed lithium. Which intervention should the nurse perform while caring for the client? (Select all that apply.)
Administer lithium with food Continually monitor patient for drowsiness Increase fluid intake to about 3,000 mL/day Explanation: The nurse should administer lithium with food, continually monitor patient for drowsiness, and increase fluid intake to about 3,000 mL/day. Antacids should not be administered because they reduce the potency of the lithium. Blood sample should be obtained immediately before, not after, the dose.
When the nurse is engaging in teaching with clients taking anti-psychotic medications and their families, what would be important to include to decrease adverse effects of the medication?
Alcohol should be avoided. Explanation: Alcohol should be avoided because it may cause excessive drowsiness and decreased awareness of safety hazards in the environment.
What client is being treated with a typical antipsychotic?
An agitated client who was given haloperidol during acute psychosis Explanation: Haloperidol is a typical antipsychotic. Ziprasidone, clozapine, and paliperidone are atypical antipsychotics.
A 21-year-old client refuses to take his oral antipsychotic medication. What would be the appropriate action for the nurse do?
Attempt to reason with the client. If he still refuses, contact the provider for further instructions. Explanation: If a client refuses his medication, attempt to reason with him. If this doesn't work, contact the provider regarding this problem because parenteral administration of this medication may be necessary. Never force a client to take a pill by holding his nose shut. Never give a different medication without a new order from the provider. Arguing with a client and giving up will not solve the issue.
Which antipsychotic medications have antiemetic effects? (Select all that apply.)
Chlorpromazine (Thorazine) Prochlorperazine (Compazine) Explanation: Chlorpromazine (Thorazine) and prochlorperazine (Compazine) are antipsychotic medications that have antiemetic effects.
The nurse expects to monitor a client's white blood count weekly when the client is prescribed:
Clozapine Explanation: Clozapine is associated with significant leukopenia. Subsequently, is it available only through the Clozaril Client Management System, which involves monitoring white blood cell count and compliance issues with only a 1-week supply being given at a time. Aripiprazole, olanzapine, and quetiapine are not associated with leukopenia.
Dexmethylphenidate has been prescribed to Scott, a 7-year-old boy who was diagnosed with ADHD. The mother asks how this medication will help her son. Which would be the most accurate description of the purpose of this medication?
Dexmethylphenidate will improve Scott's attention span so that he will be able to complete a task. Explanation: Dexmethylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. This activity results in improved attention spans, decreased distractibility, and increased ability to follow directions or complete tasks, and decreased impulsivity and aggression in patients with ADHD. Although dexmethylphenidate does not produce a physical dependence, it may induce tolerance or psychic dependence.
The nursing instructor is discussing psychosis with the nursing students. What behavior would the instructor explain people with psychosis exhibit?
Disorganized and often bizarre thinking Explanation: Behavioral manifestations of psychosis include agitation, behavioral disturbances, delusions, disorganized speech, hallucinations, insomnia, and paranoia. They do not generally exhibit slowed reaction time, short manic episodes followed by long depressive episodes, or short- and long-term memory deficits.
A client calls the clinic reporting only being able to get a 1-month supply of pills for the client's son, who takes a CNS stimulant for ADHD. The nurse understands that these medications are given in limited numbers for what reason?
It reduces the likelihood of drug dependence or diversion. Explanation: When a CNS stimulant is prescribed, it is started with a low dose that is then increased as necessary, usually at weekly intervals, until an effective dose (i.e., decreased symptoms) or the maximum daily dose is reached. In addition, the number of doses that can be obtained with one prescription should be limited. This action reduces the likelihood of drug dependence or diversion (use by people for whom the drug is not prescribed).
A client is prescribed doxapram as part of the treatment plan. Which would be important for the nurse to do when caring for this client? Select all that apply.
Keep a suction machine nearby Avoid giving the client coffee, tea, and carbonated beverages Measure urinary intake and output Palpate the bladder for distention Explanation: Clients receiving modafinil may develop nausea, so the nurse should keep a suction machine nearby in case the client vomits. Coffee, tea, and carbonated beverages should be avoided when the client is taking a CNS stimulant. Urinary retention may occur, so it is important to monitor the client's intake and output and palpate the bladder for distention. Doxapram is given intravenously. The drug should be administered with food or immediately afterward but not on an empty stomach.
Many bipolar patients quit taking their medications. Research has now indicated that what may be effective in the long-term prevention of recurrent psychosis?
Lamictal 25 mg po q day Explanation: Several studies indicate that Lamictal 25 mg po q day is effective in long-term prevention of recurrent psychosis.
What assessment finding should lead the nurse to suspect that a client receiving antipsychotic therapy is developing tardive dyskinesia?
Lip smacking Explanation: Lip smacking is associated with tardive dyskinesia. Abnormal eye movements are associated with dystonia. Tardive dyskinesia is not associated with disorientation or urinary incontinence.
Serotonin abnormalities are thought to be involved in the following disorders:
Mental depression and sleep disorders. Explanation: Normal levels of serotonin in the brain produce mood elevation or euphoria, increasing mental alertness and capacity for work, decrease fatigue and drowsiness, and prolong wakefulness. Abnormalities alter these functions.
Ms. James is started on olanzapine for the treatment of psychotic symptoms associated with schizophrenia. What is part of the routine monitoring for patients on olanzapine?
Monitoring for signs of diabetes, including elevated blood glucose levels Explanation: Precautions should be taken if the patient has diabetes, because all use of atypical antipsychotics is associated with substantially elevated blood glucose levels. Patients who are not diagnosed with diabetes at the start of therapy still remain at risk for developing significant hyperglycemia while taking olanzapine or any other atypical antipsychotic. Patients without a history of diabetes are at risk for developing diabetes from therapy; the more diabetic risk factors present, the more likely hyperglycemia may develop. In addition to elevated glucose levels, patients may gain weight (a significant number of patients gain more than 7% of their baseline weight), have decreased insulin sensitivity, have lipid elevations, and develop metabolic syndrome (increased visceral fat, as measured by waist circumference; hyperglycemia; hypertension; and dyslipidemia), putting them at increased risk for cardiovascular problems.
The nurse observes that a client with a long history of chlorpromazine therapy demonstrates lip smacking and appears to be chewing continually. The nurse should recognize that this client is likely experiencing what adverse effect of the medication?
Tardive dyskinesia Explanation: Tardive dyskinesia occurs as the result of long-term use of chlorpromazine. Clients may experience lip smacking, tongue protrusion, and facial grimaces and may have choreic movements of the trunk and limbs. Akathisia is a form of restlessness, and dystonias are uncoordinated movements. Neuroleptic malignant syndrome is an acute complication.
A young client has been prescribed an antipsychotic agent to relieve psychotic symptoms. Which goal of care is the priority?
The client will remain safe. Explanation: Safety is a priority over other goals. Goals such as participation in ADLs, health maintenance, and participation in relationships are valid, but safety is a priority.
While reviewing a medication history, the nurse sees that a school-age client has been prescribed haloperidol. Based on this information, the nurse suspects that the client may have been diagnosed with what disease process?
Tourette's syndrome Explanation: Haloperidol is used in treating Tourette's syndrome in children. It is not used to treat muscular dystrophy, Alzheimer's disease, or myasthenia gravis.
The nurse knows the medication methylphenidate is used to treat attention deficit hyperactivity disorder(ADHD). What type of medication is methylphenidate?
a central CNS stimulant Explanation: Methylphenidate, a drug used in the treatment of ADHD, is a central CNS stimulant. It is not as SSRI, respiratory stimulant or anorectic agent.
The nurse is preparing to give prescribed haloperidol to an acutely dehydrated client. After administration, the nurse should prioritize what nursing assessment?
blood pressure Explanation: Haloperidol can cause hypotension in clients who are volume depleted or receiving antihypertensive drugs. The client is unlikely to develop hyperthermia, diminished reflexes, or visual dysfunctions.
A client, who has been diagnosed with schizophrenia and is taking an antipsychotic medication, reports constant thirst, frequent urination, and feeling nauseous. The nurse knows that the client may:
have undiagnosed diabetes. Explanation: Schizophrenic clients have a higher than normal incidence of diabetes. The flu usually has a fever along with respiratory symptoms. A urinary tract infection may cause burning and frequent urination, but thirst is not normally a symptom. Also, UTIs are not more common in schizophrenics. A client could be making up symptoms, but the nurse should first consider other options that could be causing the symptoms.
The community health nurse is conducting a class for parents of preschoolers. One of the parents asks if a child with ADHD will always have problems with hyperactivity. What is the nurse's best response?
"ADHD usually starts in childhood and may persist through adulthood." Explanation: ADHD usually starts in childhood and may persist through adulthood.
The pediatric client has been prescribed methylphenidate. Which statement should be included in the teaching plan for a client receiving methylphenidate?
"Adverse effects include hypertension and nervousness." Explanation: Adverse effects of methylphenidate include hypertension, tachycardia, nervousness, and appetite suppression with resulting weight loss. The drug has a high potential for abuse and dependence. The last dose of any CNS stimulant is usually taken at least 6 hours before bedtime to prevent interference with sleep.
The nursing student is reviewing information learned in anatomy and physiology class about the nervous system. The student recalls that the nervous system has how many divisions?
2 Explanation: The nervous system has two main divisions: the central nervous system and the peripheral nervous system.
A female client's physician orders a low-dose antipsychotic to manage her acute agitation. Her daughter states that her mother is improved but her cognitive functions are the same, if not worse, than last month. What is the best explanation for this development?
Antipsychotics do not improve memory loss and may further impair cognitive functioning. Explanation: If antipsychotic drugs are used to control acute agitation in older adults, they should be used in the lowest effective dose for the shortest effective duration. If the drugs are used to treat dementia, they may relieve some symptoms (e.g., agitation, hallucinations, hostility, suspiciousness, uncooperativeness), but they do not improve memory loss and may further impair cognitive functioning.
A nurse should be able to differentiate between the typical and atypical antipsychotic. Which are classified as atypical antipsychotics? (Select all that apply.)
Aripiprazole (Abilify) Clozapine (Clozaril) Explanation: Aripiprazole (Abilify) and clozapine (Clozaril) are classified as atypical antipsychotics.
A high-school-age client, brought to the emergency department (ED) by friends after taking a "whole handful of dextroamphetamine," is now lapsing in and out of consciousness. The ED nurse should prioritize what assessment related to dextroamphetamine overdose?
Cardiac monitoring Explanation: Dextroamphetamine misuse may cause sudden death or serious cardiovascular events. It is essential to obtain a baseline electrocardiogram (ECG) and blood pressure reading. These assessments are priorities over blood glucose monitoring, respiratory assessment, and cognitive assessment.
A nurse is reviewing a bipolar client's serum lithium level, which is 1.8 mEq/L. What is the nurse's best action?
Inform the prescriber and monitor for GI and CNS effects Explanation: Therapeutic serum lithium levels range from 0.6 to 1.2 mEq/L. A level of 1.8 mEq/L would be considered toxic, but would be unlikely to warrant admission to intensive care. The nurse should report the finding and assess for common adverse effects of toxicity, which include GI and CNS effects more often than respiratory effects.
The nurse is preparing to provide education to a client who has been prescribed clozapine for schizophrenia. What is the most important aspect of client teaching?
Maintaining medication regimen Explanation: The client should be instructed to maintain the medication regimen to control symptoms of schizophrenia. Reporting signs of neuralgia is not taught because the medication does not have this effect. The medications will cause weight gain and should not be stopped in the event that weight gain develops. The use of alcohol is strictly prohibited with antipsychotic agents.
A client who was diagnosed with schizophrenia in 1962 was prescribed chlorpromazine. The client has been taking the medication for more than 40 years. What adverse effect will the client most likely experience?
Tardive dyskinesia Explanation: A client who has taken chlorpromazine on a long-term basis will be at risk for late extrapyramidal effects, such as tardive dyskinesia. Hypertension is not an adverse effect of chlorpromazine, but hypotension is an adverse effect. Central nervous system agitation is not an adverse effect of chlorpromazine, but central nervous system depression is an adverse effect. Urinary frequency is not an adverse effect of chlorpromazine, but urinary retention is an adverse effect.
A nurse observes rhythmic, involuntary facial movements in a patient who has been administered antipsychotic drugs. The patient also makes chewing movements and, at times, his tongue protrudes. What is the most likely reason for the patient's behavior?
Tardive dyskinesia Explanation: Tardive dyskinesia is characterized by rhythmic, involuntary movements of the tongue, face, mouth, or jaw, and sometimes the extremities. The tongue may protrude, and there may be chewing movements, puckering of the mouth, and facial grimacing. Extrapyramidal syndrome (EPS), neuroleptic malignant syndrome (NMS), and Stevens-Johnson syndrome do not cause rhythmic, involuntary, facial movements.
The nurse is providing education to a client who has been prescribed clozapine. During teaching, the nurse should inform the client of the need for regular monitoring of what laboratory test during the initial months of therapy and periodically thereafter?
Complete blood count (CBC) Explanation: It is essential to monitor white blood cell counts via CBC in clients taking clozapine due to the risk of fatal agranulocytosis. Coagulation tests and measurement of BUN are not indicated.
Parents bring a 15-year-old male into the clinic. The parents tell the nurse that there is a family history of schizophrenia and they fear their son has developed the disease. What is an appropriate question to ask the parents?
How long has your son been exhibiting symptoms? Explanation: Characteristics of schizophrenia include hallucinations, paranoia, delusions, speech abnormalities, and affective problems. This disorder, which seems to have a very strong genetic association, may reflect a fundamental biochemical abnormality.
The school nurse is conducting a screening of kindergarten students. The nurse will assess the children for what characteristics of ADHD? (Select all that apply.)
Hyperactivity Impulsivity Short attention span Explanation: ADHD is characterized by hyperactivity, impulsivity, and a short attention span. Most often, they do not get along well with other children because of their impulsivity and difficulty maintaining control.
A nurse who is providing care on a pediatric client has conducted a medication reconciliation. In light of the fact that the client takes methylphenidate, the nurse is justified in considering a history of what health problem?
Hyperactivity Explanation: Methylphenidate is clinically used to treat ADHD and narcolepsy. The drug is not indicated in the treatment of obesity, respiratory depression, or anxiety.
A client visits the occupational health office of the factory in which he works. He has fallen asleep on the line and has a history of muscle weakness. This instance is not the first time he has fallen asleep on the line. These behaviors support which medical diagnosis?
Narcolepsy Explanation: Narcolepsy is characterized by daytime sleep attacks in which the person goes to sleep at any place or at any time. Sleep apnea is episodes of apnea, temporary cessation of breathing, during sleep. Insomnia is the inability to sleep. This client is not exhibiting signs and symptoms consistent with substance abuse.
The nurse on the unit has several clients taking clozapine. For which client is clozapine, an antipsychotic, contraindicated?
The 45-year-old with bone marrow depression Explanation: Contraindications to antipsychotic drugs include bone marrow depression, liver damage, coronary artery disease, coma, and severe hypotension or hypertension. The use of clozapine is not contraindicated in clients with upper respiratory infection, diabetes insipidus or osteoarthritis.
A 24-year-old client is being seen in the emergency department because of a high fever and cannot move the right arm. During the history-taking process, The nurse discovers the client is being treated with an antipsychotic medication for schizophrenia. The nurse knows that what may be happening with this client?
The client may be having a neuroleptic malignant syndrome reaction to his antipsychotic medication and needs treatment immediately. Explanation: Neuroleptic malignant syndrome (NMS) is a rare reaction characterized by extrapyramidal effects, hyperthermia, and autonomic disturbance. NMS is potentially fatal and requires immediate treatment. NMS does not self-resolve. Influenza A is not characterized by having an immobile arm. Usually a schizophrenic client would be able to tell you how he had broken his arm.
A nurse is teaching the client about CNS medications and how they are addictive. What is primary reason CNS medications are addictive?
The medication stimulates the brain's pleasure centers with enhanced neurotransmission of dopamine. Explanation: CNS medications have a high degree of addiction potential because they stimulate the brain's pleasure centers with enhanced neurotransmission of dopamine. CNS stimulants do not promote sleep. CNS stimulants do not change visual acuity. Decreased dopamine does not produce feelings of euphoria.
For clients taking clozapine, it is necessary to monitor what lab test for the first 6 months?
White blood cells Explanation: Advantages of clozapine include improvement of negative symptoms without causing the extrapyramidal effects associated with older antipsychotic drugs. However, despite these advantages, it is a second-line drug, recommended only for clients who have not responded to treatment with at least two other antipsychotic drugs or who exhibit recurrent suicidal behavior. The reason for the second-line status of clozapine is its association with agranulocytosis, a life-threatening decrease in white blood cells (WBCs), which usually occurs during the first 3 months of therapy. A BLACK BOX WARNING alerts health practitioners to this dangerous side effect. Weekly WBC counts are required during the first 6 months of therapy; if acceptable WBC counts are maintained, then WBC counts can be monitored every 2 weeks.
A nurse is caring for a patient who is taking haloperidol. The patient has orders for a new drug, and the nurse notes that it is highly protein bound. The nurse will plan care based on a(n):
increased risk for toxic effects of haloperidol therapy. Explanation: Haloperidol is highly protein bound. Therefore, if it is administered along with another drug that is highly protein bound, it is likely to cause higher blood levels, leading to an increased risk for toxic effects. It does not decrease the risk for muscular contractions and spasms or increase drug efficacy.
The nurse is providing health education to a client who has been newly diagnosed with schizophrenia. What subject should be the primary focus?
the importance of adherence to prescribed treatment Explanation: The success or failure of treatment is largely dependent on the client's adherence to treatment. For most clients, this supersedes the immediate significance of nutrition or teaching about therapeutic effects. There is no need for weekly coagulation tests.
A female client asks why it is not legal to have a year's worth of prescription refills for Ritalin, since she has been on it for more than a year. She would also like to have the largest dose possible, so she can use the prescription for 2 months, instead of one. She explains that it is very hard to get off work and come in for appointments. The nurse's best response would be:
"The prescription dose is always started as low as possible and the refills are monitored to prevent abuse." Explanation: When a CNS stimulant is prescribed, it is started with a low dose that is then increased as necessary, usually at weekly intervals, until an effective dose (i.e., decreased symptoms) or the maximum daily dose is reached. In addition, the number of doses that can be obtained with one prescription should be limited. This action reduces the likelihood of drug dependence or diversion (use by people for whom the drug is not prescribed).
The nurse is providing education on the safe use of caffeine. The nurse would strongly discourage use in clients with a history of what disorders? Select all that apply.
cardiac dysrhythmias bipolar disorder history of stroke Explanation: CNS stimulants stimulate the cardiovascular system and thus are contraindicated in clients with cardiovascular disorders (e.g., angina, dysrhythmias, and hypertension) that are likely to be aggravated by the drugs. They also are contraindicated in clients with anxiety or agitation, glaucoma, or hyperthyroidism. They are usually contraindicated in clients with a history of drug abuse. Caffeine is not recommended for people with a history of stroke, peptic ulcer disease, bipolar mood disorder, and schizophrenia. Reasonable consumption of caffeine is not contraindicated for clients diagnosed with hypothyroidism or cataracts.
A client is being treated with clozapine. What should the nurse monitor most closely?
White blood cell count Explanation: Clozapine is associated with significant leukopenia. Subsequently, it is available only through the Clozaril Client Management System, which involves monitoring white blood cell count and compliance issues with only a 1-week supply being given at a time. The drug is not associated with changes in sliver function, cardiac enzymes, or urine output.