Psychiatric/Mental Health Pharmacology

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary health care provider prescribes the anticholinergic medication benztropine, 2 mg daily. The nurse should inquire about which symptom when assessing the client?

Constipation Rationale: The anticholinergic activity of each medication is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.

Which medication would the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil Rationale: Flumazenil is the medication of choice in the management of overdose when a benzodiazepine is the only agent ingested by a client not at risk for seizure activity. Flumazenil competitively inhibits activity at benzodiazepine recognition sites on gamma-aminobutyric acid-benzodiazepine receptor complexes. Lithium is used in the treatment of mood disorders. Methadone is used for narcotic addiction withdrawal. Chlorpromazine is contraindicated in the presence of central nervous system depressants.

Which medication is contraindicated in a pregnant client?

Paroxetine Rationale: Paroxetine is a selective serotonin reuptake inhibitor that should be avoided in a pregnant client because it may cause birth defects. Sertraline, venlafaxine, and desipramine can be safely prescribed to a pregnant client.

A client on a psychiatric unit who has auditory hallucinations is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. Which statement by the nurse is therapeutic?

"This will help you not to hear the voices. It will only work if you take it." Rationale: Explaining what the medication will do for the client is an appropriate nursing intervention. Telling the client that the provider wants him or her to take the medication and instructing him or her to do so presents reality and simply states the expected behavior. Telling the client that he or she has to take the medication is an authoritarian, not a therapeutic, statement. The client has the right to refuse medication. Telling the client that the medication has been prescribed for him or her does not tell the client what behavior is expected. Noting that there must be a reason that the client doesn't want to take the medication assumes that the client does not want to take medication, even though the client may simply not understand what to do.

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. Which signs and symptoms of this syndrome will the nurse identify? Select all that apply. One, some, or all responses may be correct.

Diaphoresis, Hyperrigidity, Hyperthermia Rationale: Diaphoresis, hyperrigidity, and hyperthermia occur with neuroleptic malignant syndrome as a result of dopamine blockade in the hypothalamus. Jaundice and photosensitivity are not associated with neuroleptic malignant syndrome.

A client who is taking clozapine calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and high fever. Which instruction will the nurse give the client?

Discontinue the medication and, if the primary health care provider is unavailable today, go to the emergency department for evaluation. Rationale: Symptoms of infection are suggestive of agranulocytosis, an adverse effect that can occur with clozapine therapy and may cause death. Remaining in bed, drinking fluids, taking aspirin, and asking the primary health care provider to decrease the dose of clozapine is unsafe, because agranulocytosis may be developing, and this life-threatening side effect requires immediate treatment. Also, prescribing medications is outside the legal role of the nurse. Only a certified nurse practitioner or other licensed health care provider can prescribe them. Although discontinuing the medication is acceptable advice, delaying a primary health care provider's evaluation is unsafe. Continuing the medication, drinking fluids, taking aspirin, and seeing the primary health care provider in a few days if the condition does not improve is unsafe, because agranulocytosis may be developing.

The nurse would identify which medication as a high-potency medication used to treat schizophrenia?

Fluphenazine Rationale: Fluphenazine is a high-potency medication used for schizophrenia. Loxapine and perphenazine are medium-potency medications used to treat schizophrenia. Thioridazine is a low-potency medication used to treat schizophrenia.

A health care provider prescribes disulfiram for a client who abuses alcohol. The nurse teaches the client that disulfiram will have which action?

It causes a severe adverse reaction if alcohol is consumed. Rationale: Disulfiram is used for aversion therapy; a person who consumes alcohol while taking disulfiram will experience a severe reaction consisting of nausea, vomiting, hypotension, headache, tachycardia, tachypnea, and flushing. The medication does not decrease alcohol cravings, and it does not decrease inebriant effects. When taking disulfiram, the client cannot tolerate any alcohol.

Which clinical finding would support the rationale for the addition of valproate and olanzapine to a client's medication regimen?

Mania with psychosis Rationale: Valproate is a mood stabilizing medication, and olanzapine is an antipsychotic. Clients experiencing mania with psychosis are generally prescribed mood stabilizers and antipsychotics. Euphoric mania is treated with a mood stabilizer alone, preferably lithium. Dysphoric and rapid cycling mania is treated with a mood stabilizer alone, preferably valproate.

A health care provider prescribes lithium carbonate for a client with bipolar disorder, depressive episode. Which instructions will the nurse include when teaching the client about lithium? Select all that apply. One, some, or all responses may be correct.

Take the medication with food. It may take several weeks for beneficial results to occur. Restriction of sodium intake is unnecessary. Rationale: Lithium should be taken with food to prevent gastric irritation. It will take 1 to 3 weeks before beneficial results occur. Lithium decreases sodium resorption by the renal tubules. If sodium intake is decreased, sodium depletion may occur. In addition, lithium retention is increased when sodium intake is decreased; restricted sodium intake can lead to lithium toxicity. The dosage should not be adjusted without health care provider supervision. It is not necessary to have a snack with milk when the client goes to bed.

The nurse is preparing to administer methylphenidate to an older adult with apathy and depression. Which would the nurse include in the assessment to monitor for complications? Select all that apply. One, some, or all responses may be correct.

Vision, Weight, Heart Rate Rationale: When methylphenidate is administered to older adults, the nurse will monitor the client's vision for signs of glaucoma, as well as their weight, heart rate, and blood pressure. Skin turgor and bowel sounds are not affected by methylphenidate.

A client is receiving carbamazepine for the treatment of a manic episode of bipolar disorder. Which information would the nurse include when planning client teaching about this medication? Select all that apply. One, some, or all responses may be correct.

"You may want to suck on sugar-free hard candy when you get a dry mouth." "We'll need to test your blood often during the first few weeks of therapy." Rationale: Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. It can cause severe bone marrow depression in the early phase of therapy. Also, the medication level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required, nor is a diuretic. The client may or may not have to take the medication for life.

A client has been receiving phenytoin for epilepsy and is newly prescribed haloperidol. The nurse would include which information when teaching the client about the interaction of these medications?

Potentiation of haloperidol's central nervous system depressant effect Rationale: Antiseizure medications and haloperidol exert a synergistic central nervous system depressant effect. The effect is potentiated, not masked. Anticonvulsants do not affect the absorption or metabolism of haloperidol.

A depressed client is receiving paroxetine. The nurse would monitor this client for which side effects? Select all that apply. One, some, or all responses may be correct.

Sexual dysfunction, Insomnia and restlessness Rationale: Genitourinary side effects of paroxetine include ejaculatory disorders, male genital disorders, and urinary frequency. Central nervous system (CNS) side effects of paroxetine include insomnia, restlessness, dizziness, tremors, nervousness, and headache. Depressed respiration is associated with opioids that affect the CNS. Irregular menses and secondary amenorrhea are not associated with paroxetine.

The nurse understands that which medications are considered typical antipsychotics? Select all that apply. One, some, or all responses may be correct.

Thioridazine, Chlorpromazine Rationale: First-generation antipsychotic medications also are known as typical/conventional antipsychotics. Thioridazine and chlorpromazine are typical antipsychotics. Asenapine, lurasidone, and aripiprazole are atypical antipsychotics, also known as second-generation antipsychotics.

In which situation would the nurse anticipate naltrexone to be administered?

To decrease the recovering alcoholic's desire to drink Rationale: Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. It is an opioid antagonist. It is not used for antianxiety agent withdrawal.

The health care provider instructs a client who has been taking clozapine for 2 months to discontinue the medication for a few weeks. Which laboratory parameter would the nurse recognize as supporting the intervention?

White blood cell count of 2,500/mm3 Rationale: Because clozapine may cause agranulocytosis, the client's white blood cell (WBC) count should be monitored weekly. The medication should be discontinued if the count falls below 3,000/mm3. Thus the medication should be discontinued when the WBC count is 2,500/mm3. A platelet count of 30,000/mm3may indicate thrombocytopenia. Clozapine may not cause thrombocytopenia. A hemoglobin of 12 g/dL is within normal range. A red blood cell count of 4.2 million/mm3 is a normal value.

A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. Which response is the best would the nurse provide?

"The medication will make you feel better." Rationale: Tricyclic antidepressants create a general sense of well-being, increase appetite, and help lift depression. The client might not know the reason for depression, and the medication does not cause amnesia. Symptomatic relief usually begins after 2 to 3 weeks of therapy. Tricyclic antidepressants are not indicated for treatment of social anxiety; social anxiety disorder is treated with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIS), and benzodiazepines.

A client with a history of alcoholism develops Wernicke encephalopathy associated with Korsakoff syndrome. Which medication therapy is indicated for management of this condition?

Intramuscular injections of thiamine Rationale: Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics must be avoided; their use has a higher risk of toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, cannot be used because it is severely toxic to the liver.

A client with a diagnosis of schizophrenia is prescribed an antipsychotic medication. The nurse understands which side effect of antipsychotic medications may be irreversible?

Tardive Dyskinesia Rationale: Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn. Akathisia (motor restlessness), parkinsonian syndrome (a disorder featuring signs and symptoms of Parkinson's disease such as resting tremors, muscle weakness, reduced movement, and festinating gait), and dystonia (impairment of muscle tonus) usually can be treated with antiparkinsonian or anticholinergic medications while the antipsychotic medication is continued.

A client with chronic, undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect would the nurse monitor the client?

Tardive dyskinesia Rationale: Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It most often manifests in abnormal movements of the lips, tongue, and mouth. Torticollis, oculogyric crisis, and pseudoparkinsonism are reversible with administration of an anticholinergic (e.g., benztropine) or an antihistamine (e.g., diphenhydramine) or cessation of the medication.

The laboratory calls to report that a hospitalized client's lithium level is 1.9 mEq/L (1.9 mmol/L) after 10 days of lithium therapy. How will the nurse respond to this information?

The nurse will notify the health care provider of the findings because the level is dangerously high. Rationale: Any result above 1.5 mEq/L (1.5 mmol/L) is approaching or in the toxic range. The therapeutic range for lithium is 0.6 to 1.2 mEq/L (0.6-1.2 mmol/L). Immediate action must be taken. The level is dangerously high, and continued administration of the medication and simply monitoring are unsafe.

Which instructions would the nurse emphasize when teaching a client about starting fluphenazine decanoate therapy? Select all that apply. One, some, or all responses may be correct.

"You should increase your fluid intake to help prevent constipation." "You need to use sunscreen for any outdoor activity, no matter what time of year." Rationale: Constipation is a common side effect of fluphenazine decanoate; increased dietary fluids and fiber help limit constipation. Extreme photosensitivity is a common side effect of fluphenazine decanoate. Once the client's medication has been adjusted and the central nervous system response noted, driving may be permitted; drowsiness usually subsides after the first few weeks. Energy usually is reduced. Although this medication can cause hypotension, it does not consistently lower blood pressure.

A client comes to the mental health clinic for a monthly injection of 37.5 mg of fluphenazine decanoate. It is available as 25 mg/mL. How many milliliters of solution would the nurse administer? Record your answer to one decimal place. ____ mL

1.5

Donepezil is prescribed for a client who has mild dementia of the Alzheimer type. Which information would the nurse include when discussing this medication with the client and family?

Blood tests that reflect liver function will be performed routinely. Rationale: Donepezil may affect the liver because alanine aminotransferase (ALT) is found predominantly in the liver; most ALT increases indicate hepatocellular disease. Clients taking this medication should have regular liver function tests and report light stools and jaundice to the primary health care provider. Fluids should not be limited, because a side effect of donepezil is constipation. A side effect of constipation is expected; therefore, fluids, high-fiber foods, and exercise should be recommended to help keep the stools soft. The client should not increase or decrease the dosage abruptly; donepezil should be taken exactly as prescribed.

An adolescent with a major depressive disorder is prescribed venlafaxine. Which signs or symptoms related to the medication will the nurse communicate immediately to the prescribing provider? Select all that apply. One, some, or all responses may be correct.

Blurred Vision, Suicidal Ideation, Difficult Urination Rationale: Abnormal vision (e.g., blurred or double vision) is a side effect of venlafaxine. Central nervous system effects such as emotional lability, vertigo, anxiety, insomnia, and suicidal ideation in children and adolescents are side effects of venlafaxine. Difficult or painful urination is a serious side effect of venlafaxine; impairment of urine flow can lead to urinary tract infection and renal failure. Extrapyramidal side effects such as tardive dyskinesia do not occur with venlafaxine. Transient hypoglycemia is not a side effect of venlafaxine.

Which medication acts as an antidote to benzodiazepine?

Flumazenil Rationale: Flumazenil is a benzodiazepine receptor antagonist and is used to reverse conscious sedation induced by benzodiazepines. Temazepam, suvorexant, and flumazenil are benzodiazepines.

Which adverse effect would the nurse continually assess for in a client receiving valproic acid?

Yellow sclerae Rationale: Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid. The client must have frequent liver function tests. Motor restlessness (akathisia) is associated with antipsychotic medications. Ringing or buzzing in the ears (tinnitus) is associated with aspirin. Torsion of the neck (torticollis) because of contracted cervical muscles is associated with antipsychotic medications.

The registered nurse is teaching a nursing student about monoamine oxidase inhibitors (MAOIs). Which statement made by the student indicates the need for further teaching? Select all that apply. One, some, or all responses may be correct.

"Isocarboxazid is a selective MAO-B inhibitor." "MAO inhibitors are prescribed as adjunct to diphenhydramine." Rationale: Selegiline is a selective MAO-B inhibitor, whereas isocarboxazid is a non-selective MAO-A and MAO-B inhibitor. MAO inhibitors may be contraindicated in clients on diphenhydramine and cetirizine, as they may aggravate depression of the central nervous system. Hypertensive crisis is an adverse effect of MAO inhibitors. They can be prescribed to clients with Parkinson disease. Hypertensive crisis occurs when the sympathomimetic medications are taken with MAO inhibitors.

A client, who is currently taking digoxin 0.125 mg in the morning and alprazolam 0.5 mg twice a day, is prescribed donepezil 5 mg daily for early dementia of the Alzheimer type. Which instruction would the nurse include when teaching the client's spouse about medication administration?

"Prefill a weekly medication box with the medications for the client to self-administer." Rationale: Clients with early dementia of the Alzheimer type usually have some short-term memory loss. A prefilled box of medications eliminates the need to determine which medications must be taken. Also, it provides the spouse with objective proof whether the medications have been taken. The client may not have the cognitive ability to follow a written medication schedule and may not be able to follow verbal instructions given in the morning due to short-term memory loss. Administering medications to the client is a controlling intervention that may lower self-esteem; safe self-administration of medications should be supported for as long as possible to maintain independence.

While caring for a client on phenelzine, the nurse notes an excess elevation of the person's temperature. Which medication being taken concurrently by the client may be responsible for this condition?

Meperidine Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Meperidine is a strong analgesic that when taken concurrently with MAOIs may result in excessive temperature elevation. Desipramine and amitriptyline are tricyclic antidepressants that may cause hypertensive episodes or hypertensive crisis when taken concurrently with MAOIs. Amphetamine is an indirectly acting sympathomimetic that causes a hypertensive crisis when taken concurrently with MAOIs.

When the client taking haloperidol has a sudden change in health status, the nurse reviews the client's medical record and performs a physical assessment. Which medical emergency would the nurse conclude that the client is experiencing?

Neuroleptic malignant syndrome Rationale: The data presented are indicative of neuroleptic malignant syndrome, a rare and life-threatening complication of antipsychotic medications such as haloperidol. The medication should be discontinued and supportive care provided. An oculogyric crisis is an extrapyramidal side effect of neuroleptic (not antipsychotic) medications in which there is uncontrolled rolling back of the eyes. This should be treated quickly with an antiparkinsonian agent. Although many of the adaptations presented are associated with serotonin syndrome, the client is not taking a selective serotonin reuptake inhibitor antidepressant or other medications that increase the serotonin level. Haloperidol toxicity is manifested as an increase in the intensity of medication side effects; hyperpyrexia and diaphoresis are not associated with toxicity.

An older adult living in a long-term care facility has been receiving 600 mg of lithium twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. Which intervention is appropriate?

Withholding the next dose of lithium and drawing blood for a lithium level Rationale: The client is displaying signs and symptoms of early lithium toxicity; older clients should be monitored carefully and given smaller doses of lithium because its excretion from the kidneys is slower than that in younger adults. There is no antidote to lithium. Coarse hand tremor is an indication of advanced lithium toxicity; the lithium should be withheld. Although antiepileptics are effective in 25% to 50% of clients with treatment-resistant bipolar disorder, this is not the appropriate treatment for lithium toxicity.