Topic 4

Which hypnotic agents bind to benzodiazepine receptors (subtype BZ)?

1. zolpidem (Ambien) 2. zaleplon (Sonata) 3. eszopiclone (Lunesta).

Which benzodiazepines are most effective in treating symptoms associated with alcohol withdraw?

1. Ativan (Lorazepam) 2. Phenobarbital **if liver dysfunction is present, lorazepam is the preferred agent because of its different metabolic pathway than other benzodiazepines**

What are the main three medications used as mood stabilizers for bipolar?

1. Lithium 2. Valproic Acid 3. Carbamazepine

Which antipsychotics are used to suppress Tics seem with Tourette's syndrome?

1. Risperidone 2. Haloperidol

What are some ways that a patient may develop serotonin syndrome?

1. SSRIs in combination with St. John's Wort 2. MAOs 3. drugs that inhibit CYP2D6 4. tramadol 5. linezolid (an antibiotic that inhibits MAO) 6. other SSRIs 7. SNRIs 8. TCAs 9. Atypical antidepressants

What are the three indications of use for benizdiapines?

1. anxiety 2. as sedative/hypnotics 3. for anterograde amnesia in procedures (midazolam [Versed]) 4. for epilepsy (clonazepam) 5. muscle relaxants (mostly diazepam).

What examples of selective serotonin reuptake inhibiters?

1. citalopram (Celexa) 2. escitalopram (Lexapro) 3. fluoxetine (Prozac) 4. fluvoxamine (Luvox) 5. paroxetine (Paxil) 6. sertraline (Zoloft) 7. vortioxetine (Trintellix).

What are examples of selective-norepinephrine reuptake inhibiters?

1. desvenlafaxine (Pristiq) 2. duloxetine (Cymbalta) 3. venlafaxine. (Effexor) 4. levomilnacipran (Fetzima)

What are the side effects of SSRIs?

1. nausea 2. agitation 3. insomnia 4. sexual dysfunction (especially anorgasmia) 5. weight gain

Which SSRIs can interact with cough syrup to cause serotonin syndrome?

1. sertraline (Zoloft) 2. escitalopram (Lexapro)

A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement? a. "Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia." b. "Benzodiazepines depress neuronal functions by acting at a single site in the brain." c. "Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous system." d. "Benzodiazepines promote sleep through effects on the limbic system."

ANS: A All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness "clock."

A nurse provides teaching for a patient about to begin taking an FGA drug for schizophrenia. Which statement by the patient indicates a need for further teaching about side effects of these drugs? a. "Dry mouth and constipation are uncommon with this medication." b. "I may experience gynecomastia and galactorrhea." c. "I may feel lightheaded or dizzy and should sit or lie down if this occurs." d. "Sedation may occur initially, but will subside in 1 to 2 weeks."

ANS: A Anticholinergic effects are common with FGAs, so this statement indicates a need for further teaching. Neuroendocrine effects, orthostatic hypertension, and sedation can occur with FGAs

A neonate is born to a patient who reports taking venlafaxine [Effexor XR]. The nurse caring for the infant will observe the infant for: a. irritability, tremor, and respiratory distress. b. poor appetite and disturbed sleeping patterns. c. serotonin syndrome. d. sustained mydriasis.

ANS: A As with the SSRIs, the use of venlafaxine late in pregnancy can result in a neonatal withdrawal syndrome, characterized by irritability, abnormal crying, tremor, respiratory distress, and possibly seizures. Symptoms, which can be managed with supportive care, generally abate within a few days p. 220

A patient recently was diagnosed with bipolar disorder. The patient, who has a history of seasonal allergies, is an athlete who participates i ntrack. The nurse is teaching the patient about lithium [Lithobid], which the prescriber has just ordered. Which statement by the patient indicates the need for further teaching? a. "I can continue to use ibuprofen as needed for muscle pain." b. "I should drink extra fluids before and during exercise." c. "I should not use antihistamines while taking lithium." d. "I should report muscle weakness and tremors to my provider."

ANS: A Because nonsteroidal anti-inflammatory drugs (NSAIDs) can increase lithium levels as much as 60%, they should not be used by patients taking lithium. Aspirin does not have this effect

A nurse is performing an admission assessment on a patient. The patient reports taking alprazolam [Xanax] for "nerves." The nurse knows that this patient is most likely being treated for which condition? a. Generalized anxiety disorder b. Obsessive-compulsive disorder (OCD) c. Panic disorder d. Posttraumatic stress disorder (PTSD)

ANS: A Benzodiazepines are the first-choice drugs for anxiety, and alprazolam and lorazepam are prescribed most often. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs for the treatment of OCD. Panic disorder is treated with any of the three classes of antidepressants: SSRIs, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Research has not shown any drug to be effective in the treatment of PTSD, although two SSRIs have been approved for use for this disorder

An older adult patient who is to begin taking imipramine [Tofranil] asks the nurse when the drug should be taken. The nurse will instruct the patient to: a. divide the daily dose into two equal doses 12 hours apart. b. take the entire dose at bedtime to minimize the sedative effects. c. take the medication once daily in the late afternoon. d. take the medication once daily in the morning.

ANS: A For many patients, taking the entire dose of a TCA at bedtime is advantageous for facilitating adherence, minimizing daytime sedation, and promoting sleep. However, older adult patients are at greater risk for cardiotoxicity and may experience intolerable effects on the heart if the entire dose is taken at once; therefore, twice-daily dosing is recommended in the elderly

A patient is admitted to a hospital for treatment for first-time symptoms of mania and is exhibiting euphoric mania. Which medication will the provider order? a. Lithium [Lithobid] b. Olanzapine [Zyprexa] c. Risperidone [Risperdal] d. Divalproex sodium[Valproate]

ANS: A In almost all cases of mania, divalproex sodium is the drug of choice, except for euphoric mania symptoms. Lithium is used to treat euphoric mania. Olanzapine and risperidone are used to treat other symptoms associated with BPD.

A patient who has been taking alprazolam [Xanax] to treat generalized anxiety disorder (GAD) reports recently stopping the medication after symptoms have improved but reports having feelings of panic and paranoia. Which initial action by the nurse is correct? a. Ask the patient if the medication was stopped abruptly. b. Instruct the patient to resume taking the alprazolam. c. Notify the provider that the patient is experiencing a relapse. d. Suggest that the patient discuss taking buspirone [Buspar] with the provider.

ANS: A Long-term use of benzodiazepines can cause physical dependence, with symptoms of panic, paranoia, and delirium occurring with abrupt withdrawal. These symptoms can be confused with symptoms of relapse of anxiety, so the nurse should evaluate this by first asking about how the medication was discontinued. If the symptoms are caused by a relapse, the patient should resume taking the alprazolam. Buspirone is not indicated

The spouse of a patient with bipolar disorder (BPD) tells the nurse that the patient will not stay on the lithium ordered by the provider longer than 1 or 2 months at a time. The nurse understands that adherence to medication regimens in patients with BPD is problematic and will tell the spouse: a. "During manic episodes, many patients don't see the benefit of prophylactic medications." b. "Increased gastrointestinal side effects occur over time and reduce compliance." c. "Long-term use of lithium causes memory impairment, causing patients to forget to take their medications." d. "Patients who are depressed do not want to take their medications."

ANS: A Patients experiencing manic symptoms often do not see anything wrong with their thinking and behavior and therefore do not believe they need treatment. Moreover, these symptoms are often enjoyable, and they do not want them to stop.

A patient with bipolar disorder has been taking lithium[Lithobid] for several years. The patient has developed a goiter, and serum tests reveal hypothyroidism. What will the nurse expect the provider to order for this patient? a. Administration of levothyroxine b. Increasing the lithium dose c. Iodine supplements d. Referral to an endocrinologist

ANS: A Patients taking lithium may experience reduced incorporation of iodine into the thyroid hormone, resulting in goiter and hypothyroidism. Administration of levothyroxine or withdrawing the lithium will reverse both. Increasing the lithium dose will make this worse. Iodine supplements are not indicated. The provider will either order stopping the lithium or administration of levothyroxine, which will reverse this condition, so referral to an endocrinologist is not necessary

During an admission history, a patient reports a frequent need to return to a room multiple times to make sure an iron or other appliance is unplugged. What does the nurse understand about this patient's behavior? a. It helps the patient reduce anxiety about causing a fire. b. It usually is treated with alprazolam [Xanax]. c. It seems perfectly normal to the patient. d. It will best respond to deep brain stimulation.

ANS: A Patients with OCD have compulsive behaviors, such as repeatedly checking to make sure appliances have been unplugged. The compulsion is a ritualized behavior resulting from obsessive anxiety or fear that something bad will happen, such as starting a fire with an overheated appliance. Alprazolam is not a first-line drug for treating OCD. Patients usually understand that compulsive behaviors are excessive and senseless but are unable to stop. Deep brain stimulation is indicated for patients in whom other treatments have failed; its effectiveness at reducing symptoms has been shown to be about 40%.

A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects oft his drug. Which response by the nurse is correct? a. "Phenobarbital doses for seizures are non sedating." b. "This is a short-acting barbiturate, so sedation wears off quickly." c. "Tolerance to the sedative effects will develop in a few weeks." d. "You may actually experience paradoxical effects of euphoria."

ANS: A Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are non sedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur

A patient takes temazepam [Restoril] for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do? a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine. b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration. c. Reassure the patient that this is most likely caused by a paradoxical reaction to the benzodiazepine. d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect of the benzodiazepine.

ANS: A This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.

A patient describes feelings of anxiety and fear when speaking in front of an audience and is having difficulty at work because of an inability to present information at meetings three or four times each year. The patient is reluctant to take long-term medications. The nurse will expect the provider to order which treatment? a. Alprazolam [Xanax] as needed b. Cognitive behavioral therapy c. Paroxetine [Paxil] d. Psychotherapy

ANS: A This patient is describing social anxiety disorder; the symptoms are related to performance only and are not generalized to all social situations. Because this patient must speak in front of an audience only three or four times per year, a PRN medication can be used. Cognitive behavioral therapy is used for OCD. Paroxetine must be used continuously for at least 1 year. Psychotherapy can be used but is more effective when used in combination with drugs.

A nurse is preparing to administer medications to a hospitalized patient who has been taking lithium [Lithobid] for 3 days. The patient is complaining of mild nausea and abdominal bloating. The patient's lithium level is 0.8 mEq/L. What will the nurse do? a. Administer the dose and tell the patient that the side effects are temporary. b. Contact the prescriber to request an order for serum electrolytes. c. Hold the dose and notify the prescriber of the patient's lithium level. d. Request an order for amiloride [Midamor].

ANS: A This patient is experiencing side effects that are common and that occur at therapeutic levels of the drug. The lithium level is therapeutic and not toxic, so the nurse should give the dose and reassure the patient that the side effects will diminish over time. In the presence of low sodium, lithium can accumulate to toxic doses; therefore, if the lithium level were elevated, evaluating serum electrolytes would be advisable.

Which patients are candidates for MAOIs? Select all that apply. a. Patients who have not responded to SSRIs and TCAs b. Patients with atypical depression c. Patients with bulimia nervosa d. Patients with hypotension e. Patients with postpartum depression

ANS: A, B, C Patients who have not responded to SSRIs or TCAs, patients with atypical depression, and patients with bulimia nervosa are candidates for MAOIs. MAOIs contribute to hypotension and therefore are contraindicated in patients with hypotension. MAOIs are not recommended for the treatment of postpartum depression

A patient is brought to the emergency department after taking a handful of TCA pills. The nurse will expect to provide what when caring for this patient? Select all that apply. a. Cardiac monitoring b. Cholinesterase inhibitors c. Gastric lavage and activated charcoal d. Sedative medications e. Procainamide

ANS: A, B, C Patients who overdose with a TCA should have cardiac monitoring, because cardiac side effects can occur. Cholinesterase inhibitors are given to counteract anticholinergic side effects. Gastric lavage followed by activated charcoal can reduce absorption of the TCA p. 222

Selective serotonin reuptake inhibitors are known to be effective for which disorders? Select all that apply. a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder c. Panic disorder d. Posttraumatic stress disorder e. Social anxiety disorder

ANS: A, B, C, E SSRIs have been shown to be effective in treating GAD, OCD, panic disorder, and social anxiety disorder. They are used to treat PTSD but have not demonstrated effectiveness in clinical research.

Which side effects are more common in second-generation antipsychotic medications than in first-generation antipsychotic medications? Select all that apply. a. Agranulocytosis b. Anticholinergic effects c. Extrapyramidal symptoms d. Metabolism by CYP3A4 e. Prolactin elevation

ANS: A, B, D SGAs are more likely than FGAs to cause agranulocytosis and anticholinergic effects and are metabolized by CYP3A4 enzymes. They are not more likely to cause extrapyramidal effects or prolactin elevation.

A parent reports being afraid that a child may have schizophrenia because of disorganized speech and anti social behaviors. The nurse will tell this parent that which of the following must also be present to make a diagnosis? Select all that apply. a. A decrease in self-care, job, or school function b. A history of substance abuse c. A 1-month duration of active phase symptoms d. Continuous signs of disturbance for longer than 6 months e. The presence of manic episodes

ANS: A, C, D Patients must have at least two symptoms with 1-month duration of active symptoms. One symptom must be delusions, hallucinations, or disordered speech. Patients must have continuous signs of disturbance for longer than 6 months. A history of substance abuse and manic episodes are not associated with schizophrenia.

A patient with bipolar disorder who is taking divalproex sodium [Valproate] has just been admitted to the hospital. During the admission assessment, the patient tells the nurse about recent suicidal ideation. The nurse observes several areas of bruising over soft tissue areas and notes a weight gain of 10 pounds since the last admission 1 year ago. What will the nurse do? a. Ask the patient whether the bruises are self-inflicted. b. Contact the provider to report these findings. c. Give the patient information about weight loss. d. Request an order for an increased dose to help with depressive symptoms.

ANS: B Divalproex sodium is used to control symptoms during manic episodes and can prevent relapse into mania. It is less effective than lithium at reducing the risk of suicide. It can cause thrombocytopenia, which results in bruising and is an indication for immediate drug withdrawal. Weight gain can be serious and chronic. All of these findings are an indication for withdrawing the drug and should be reported to the provider.

A patient who has diabetes mellitus is diagnosed with schizophrenia and the provider orders thioridazine. The patient asks the nurse why the provider has not ordered olanzapine [Zyprexa], which the patient has seen advertised on television. Which response by the nurse is the most important reason that this patient is not receiving olanzapine? a. "Olanzapine is more expensive than thioridazine." b. "Olanzapine causes more metabolic side effects than thioridazine." c. "Thioridazine has fewer side effects than olanzapine." d. "Thioridazine has a faster onset of action than olanzapine."

ANS: B Olanzapine is an SGA and, although it has fewer extrapyramidal side effects than the FGA the provider has ordered, it has an increased risk of metabolic side effects, which is contraindicated in patients with diabetes.

A patient in whom drug therapy has failed several times in the past is readmitted to a hospital to begin therapy for schizophrenia. What will the nurse do to help improve adherence? a. Encourage the patient to take responsibility for medication management. b. Teach the patient about drug side effects and how to manage them. c. Tell the patient that an abstinence syndrome will occur if the drug is stopped. d. Tell the patient that the drug may be taken as needed to control symptoms.

ANS: B One way to promote adherence to a medication regimen is to teach patients about drug side effects and how to minimize undesired responses. Family members should be encouraged to oversee medication management for outpatients, because patients themselves may fail to appreciate the need for therapy or may be unwilling to take prescribed medications. p. 213

A patient with bipolar disorder has frequent manic episodes alternating with depressive episodes. The prescriber orders risperidone [Risperdal] in addition to the lithium [Lithobid] that the patient is already taking. The patient asks the nurse why another drug is needed. The nurse will tell the patient that the risperidone is used to: a. elevate mood during depressive episodes. b. help control symptoms during manic episodes. c. manage tremors associated with lithium use. d. prevent recurrence of depressive episodes.

ANS: B Risperidone is an antipsychotic often used in conjunction with lithium to help manage symptoms during manic episodes, regardless of whether psychotic symptoms occur.

A nurse and a nursing student are discussing the plan of care for a patient with schizophrenia. The patient, who has been taking a high-potency FGA for 2 months, has become restless and constantly needs to be in motion. Which statement by the student indicates a need for further education? a. "Anticholinergic medications may help control these symptoms." b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA." c. "The provider may try a low-potency FGA instead of the high-potency FGA." d. "This patient may need to take a benzodiazepine or a beta blocker."

ANS: B The patient is showing signs of akathisia, which can resemble an exacerbation of psychosis. If the two are confused and the provider orders more of the FGA, the symptoms may actually increase. Anticholinergic medications may be used, a low-potency FGA may be ordered, or a benzodiazepine or beta blocker may be prescribed.

A patient who is taking a first-generation antipsychotic (FGA) drug for schizophrenia comes to the clinic for evaluation. The nurse observes that the patient has a shuffling gait and mild tremors. The nurse will ask the patient's provider about which course of action? a. Administering a direct dopamine antagonist b. Giving an anticholinergic medication c. Increasing the dose of the antipsychotic drug d. Switching to a second-generation antipsychotic drug

ANS: B The patient is showing signs of parkinsonism, an extrapyramidal effect associated with antipsychotic medications. Anticholinergic medications are indicated. A direct dopamine antagonist would counter the effects of the antipsychotic and remove any beneficial effect it has. Increasing the dose of the antipsychotic medication would only worsen the extrapyramidal symptoms. A second-generation antipsychotic medication may be used if parkinsonism is severe

Which diuretic is typically chosen to treat Lithium induced polyuria?

Amiloride (Midamor), a potassium-sparing diuretic. Thiazide diuretic can also be helpful but these decrease serum sodium, so amiloride is preferred

A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol [Haldol] and finds the patient having facial spasms. The patient's head is thrust back, and the patient is unable to speak. What will the nurse do? a. Administer the haloperidol as ordered. b. Discuss increasing the haloperidol dose with the provider. c. Request an order to give diphenhydramine. d. Request an order to give levodopa.

ANS: C An early reaction to antipsychotic drugs is acute dystonia. Initial treatment consists of an anticholinergic medication, such as diphenhydramine. Administering more antipsychotic medication would increase the symptoms and could be life threatening. Levodopa is not given for extrapyramidal symptoms, because it could counteract the beneficial effects of antipsychotic treatment.

A patient has been taking an SSRI antidepressant for major depression and reports having headaches and jaw pain. What will the nurse tell the patient? a. This represents an irreversible extrapyramidal side effect. b. Discuss discontinuing the antidepressant with the provider. c. Discuss these symptoms with a dentist. d. Try stress-relieving methods and relaxation techniques.

ANS: C Bruxism is a side effect of SSRIs and can result in headache and jaw pain. Patients who experience these signs should be evaluated for bruxism by a dentist, who can determine whether the patient may benefit from the use of a mouth guard.

A patient who has recently begun taking carbamazepine [Equetro] for bipolar disorder reports having vertigo and headaches. Which action by the nurse is appropriate? a. Ask the provider whether another medication can be used for this patient, because the patient is showing signs of toxicity. b. Contact the provider to request a complete blood count (CBC) to evaluate for other, more serious side effects. c. Reassure the patient that these effects occur early in treatment and will resolve overtime. d. Review the patient's chart for cytochrome P450 enzymes to see whether an increased dose is needed.

ANS: C Carbamazepine can cause several neurologic side effects early in treatment, including vertigo and headaches. These resolve with continued drug use. These side effects are not related to drug toxicity. A CBC should be obtained at baseline and periodically thereafter. Carbamazepine can cause changes in hematologic laboratory values. The side effects reported by this patient are not associated with hematologic side effects. Carbamazepine induces cytochrome P450 enzymes and can accelerate its own metabolism, which would reduce the amount of drug and decrease side effects, so an increased dose is not appropriate.

A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine [Clozaril]. The nurse teaches the family about the medication and its side effects. Which statement by a family member indicates a need for further teaching about this drug? a. "Blood counts are necessary for several weeks after discontinuation of the drug." b. "Fever, sore throat, and sores in the mouth should be reported immediately." c. "If the ANC is less than 3000, the drug will be discontinued permanently." d. "Use of this drug requires weekly evaluation of blood work."

ANS: C Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal ofthe drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported immediately p. 210

A patient with bipolar disorder takes lamotrigine [Lamictal]. Which statement by the patient would prompt the nurse to hold the drug and notify the prescriber for further assessment? a. "I get a little dizzy sometimes." b. "I had a headache last week that lasted for about an hour." c. "I've broken out in a rash on my chest and back." d. "Last night I woke up twice with a bad dream."

ANS: C Evidence of a rash in a patient taking lamotrigine requires further assessment, because this may indicate the development of Stevens-Johnson syndrome. Although dizziness and headaches are side effects of lamotrigine, they are not potentially life threatening. A bad dream is not necessarily related to the lamotrigine

A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient? a. Whether any antihypertensive medications are used b. Whether the patient drinks grapefruit juice c. To list all foods eaten that day d. Whether SSRIs are taken in addition to the MAOI

ANS: C Patients taking an MAOI should be counseled to follow strict dietary restrictions and to avoid all foods containing tyramine. Patients who consume such foods when taking an MAOI experience a hypertensive episode.

A young adult patient has been taking an antidepressant medication for several weeks and reports having increased thoughts of suicide. The nurse questions further and learns that the patient has attempted suicide more than once in the past. The patient identifies a concrete plan for committing suicide. The nurse will contact the provider to discuss: a. changing the medication to another drug class. b. discontinuing the medication immediately. c. hospitalizing the patient for closer monitoring. d. requiring more frequent clinic visits for this patient.

ANS: C Patients with depression often think of suicide, and during treatment with antidepressants, these thoughts often increase for a time. Patients whose risk of suicide is especially high should be hospitalized. All antidepressants carry this risk, so changing medication is not recommended. Discontinuing the medication is not recommended. More frequent clinic visits are recommended for patients with a low to moderate risk of suicide.

A patient with schizophrenia receives a dose of risperidone [Risperdal Consta] IM. The nurse teaching this patient about this medication will make which statement? a. "You will experience therapeutic levels of this drug in 1 to 2 weeks." b. "You will need injections of this drug every 6 weeks." c. "You will need to take an oral antipsychotic drug for 3 weeks." d. "You probably will not have extrapyramidal symptoms with this drug."

ANS: C Risperidone given intramuscularly is a depot preparation used for long-term therapy. Significant release of the drug does not occur until 2 to 3 weeks after injection; therefore, patients must take an oral antipsychotic medication until drug levels are raised. Therapeutic levels are reached 4 to 6 weeks after injection. Patients need injections every 2 weeks. With IM dosing, the incidence of extrapyramidal symptoms is substantial p. 211

A patient taking fluoxetine [Prozac] complains of decreased sexual interest. A prescriber orders a "drug holiday." What teaching by the nurse would best describe a drug holiday? a. "Cut the tablet in half anytime to reduce the dosage." b. "Discontinue the drug for 1 week." c. "Don't take the medication on Friday and Saturday." d. "Take the drug every other day."

ANS: C Sexual dysfunction may be managed by having the patient take a drug holiday, which involves discontinuing medication on Fridays and Saturdays.

A patient is diagnosed with anxiety after describing symptoms of tension, poor concentration, and difficulty sleeping that have persisted for over 6 months. Which medication will the nurse expect the provider to order for this patient? a. Alprazolam [Xanax] b. Amitriptyline [Elavil] c. Buspirone [Buspar] d. Paroxetine [Paxil]

ANS: C This patient has symptoms of generalized anxiety disorder (GAD) that are not acute or severe. Buspirone is as effective as benzodiazepines but without causing CNS depression or having the same abuse potential. Symptoms develop slowly, which is acceptable in this case, since symptoms are not acute or severe. Alprazolam is a benzodiazepine and would be used in the short term to treat acute, severe anxiety. Amitriptyline is a TCA used to treat panic disorder. Paroxetine is an antidepressant used as a second-line drug for GAD

A patient whose spouse has died recently reports feeling down most of every day for the past 2 months. On further questioning, the nurse learns that the patient has quit participating in church and social activities, has difficulty falling asleep, and has lost 5 pounds. The patient reports feeling tired and confused all the time but does not have suicidal thoughts. What does the nurse suspect? a. Grief and sadness b. Hypomania c. Major depression d. Situational depression

ANS: C This patient has symptoms of major depression, which include depressed mood, loss of pleasure in usual activities, insomnia, weight loss, and feelings of fatigue. For a diagnosis of major depression, these symptoms must be present most of the day, nearly every day, for at least 2 weeks.

A patient reports having occasional periods of tremors, palpitations, nausea, and a sense of fear, which usually dissipate within 30 minutes. To treat this condition, the nurse anticipates the provider will prescribe a drug in which drug class? a. Benzodiazepines b. Monoamine oxidase inhibitors c. Selective serotonin reuptake inhibitors d. Tricyclic antidepressants

ANS: C This patient is showing characteristics of panic disorder. All three major classes of antidepressants are effective, but selective serotonin reuptake inhibitors are first-line drugs. Benzodiazepines are second-line drugs and are rarely used because of their abuse potential. MAOIs are effective but are difficult to use because of their side effects and drug and food interactions. Tricyclic antidepressants are second-line drugs, and their use is recommended only after a trial of at least one SSRI has failed.

A patient in the emergency department is given intravenous diazepam [Valium] for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths/minute. The nurse will expect to administer which of the following? a. Flumazenil [Romazicon] b. Gastric lavage c. Respiratory support d. Toxicology testing

ANS: C When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil [Romazicon] is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority

A patient with schizophrenia has been taking an oral FGA for 1 week. The patient has been taking the drug daily in two divided doses. The individual complains of daytime drowsiness. The patient's family reports a decrease in the person's hostility and anxiety but states that the patient remains antisocial with disordered thinking. What will the nurse tell the patient and the family? a. An increased dose of the drug may be needed. b. Intramuscular dosing may be needed. c. Some symptoms take months to improve. d. The entire dose may be taken at bedtime.

ANS: C When patients begin therapy with antipsychotic medications, some symptoms resolve sooner than others. During the first week, agitation, hostility, anxiety, and tension may resolve, but other symptoms may take several months to improve

A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient? a. Flurazepam b. Trazodone [Desyrel] c. Zaleplon [Sonata] d. Zolpidem [Ambien]

ANS: C Zaleplon [Sonata] works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem [Ambien] has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess.

A patient with bipolar disorder who wants to minimize the need for drug therapy asks the nurse what else can be done to treat the disorder. The nurse will recommend which measures? Select all that apply. a. Electroconvulsive therapy b. Moderate use of alcohol to reduce stress c. Psychotherapy d. Regular sleep and exercise e. Using a chart to monitor mood changes

ANS: C, D, E BPD should be treated with a combination of drugs and adjunctive psychotherapy, because drug therapy alone is not optimal. Other measures, such as regular sleep and exercise and recognizing early symptoms of mood change, help minimize extreme mood swings. Electroconvulsive therapy is effective, but it is not the first-choice treatment; it is reserved for patients who have not responded to other therapies. Avoidance of alcohol is recommended.

A nurse in a mental health hospital finds a patient with schizophrenia who takes haloperidol [Haldol] lying rigid in bed with a temperature of 41.3°C. A cardiac monitor shows cardiac dysrhythmias. What will be included in the treatment of this patient? Select all that apply. a. Anticholinergic medications b. Beta blockers c. Dantrolene d. Intravenous fluids e. Withdrawal of haloperidol

ANS: C, D, E Neuroleptic malignant syndrome is characterized by "lead pipe" rigidity, sudden high fever, and autonomic instability. Treatment requires supportive measures, drug therapy, and immediate withdrawal of the antipsychotic medication. Dantrolene is used to relax muscles and reduce heat production. Intravenous fluids are used to maintain hydration. Anticholinergic medications and beta blockers are not helpful

What are negative symptoms of schizophrenia? Select all that apply. a. Delusions b. Disordered thinking c. Poor judgment d. Poor self-care e. Poverty of speech

ANS: C, D, E Poor judgment, poor self-care, and poverty of speech are all negative symptoms of schizophrenia. Delusions and disordered thinking are positive symptoms.

A patient with bipolar disorder is admitted to the hospital. The patient has been taking lithium [Lithobid] for several years and has not been evaluated by a provider for over a year. Besides obtaining a lithium level, the nurse caring for this patient will anticipate orders for which laboratory tests? Select all that apply. a. Calcium level b. Complete blood count with differential c. Liver function tests d. Renal function tests e. Serum potassium f. Thyroid function tests

ANS: C, D, F Patients taking lithium can develop a mild, reversible leukocytosis, so annual CBC evaluation with differential is recommended. Chronic lithium use is associated with degenerative changes in the kidneys, so renal function should be assessed annually. Lithium can reduce the incorporation of iodine into thyroid hormone and can inhibit thyroid secretion; therefore, thyroid hormone and thyroid-stimulating hormone (TSH) levels should be measured annually. Lithium is affected by sodium levels but not by calcium or potassium levels. Because lithium is excreted by the kidneys, hepatic function tests are not indicated.

A nurse is preparing a patient who will stop taking lorazepam [Ativan] for anxiety and begin taking buspirone [Buspar]. Which statement by the patient indicates a need for further teaching? a. "I can drink alcohol when taking Buspar, but not grapefruit juice." b. "I may need to use a sedative medication if I experience insomnia." c. "I may not feel the effects of Buspar for a few weeks." d. "I should stop taking the Ativan when I start taking the Buspar."

ANS: D Ativan should not be withdrawn quickly; it must be tapered to prevent withdrawal symptoms. Moreover, Buspar does not have immediate effects. Because no cross-dependence occurs with these two medications, they may be taken together while the benzodiazepine is tapered. Because Buspar does not have sedative effects, patients can consume alcohol without increasing sedation. Levels of Buspar can be increased by grapefruit juice, leading to drowsiness and a feeling of dysphoria. Buspar can cause nervousness and excitement and does not have sedative effects, so patients with insomnia must use a sedative. Buspar does not have immediate effects.

A patient who is experiencing alcohol withdrawal is given a benzodiazepine. The nurse understands that this drug is effective because: a. the alcohol does not interact with the benzodiazepine. b. the benzodiazepine potentiates alcohol withdrawal symptoms. c. the benzodiazepine relieves muscle spasms and spasticity. d. the patient has a cross-dependence to the benzodiazepine.

ANS: D Benzodiazepines are given to ease withdrawal from alcohol because of cross-dependence with these drugs and alcohol, enabling the benzodiazepine to suppress withdrawal symptoms. Alcohol and benzodiazepines can potentiate one another. The benzodiazepine does not potentiate withdrawal symptoms.

A patient who has been using secobarbital for several months to treat insomnia tells the nurse that the prescriber has said the prescription will be changed to temazepam [Restoril] because it is safer. The patient asks why this agent is safer. The nurse is correct in telling the patient that temazepam: a. does not depress the central nervous system. b. shows no respiratory depression, even in toxic doses. c. mimics the actions of a central nervous system inhibitory neurotransmitter. d. potentiates endogenous gamma-aminobutyric acid (GABA) producing a finite CNS depression

ANS: D Benzodiazepines potentiate the actions of GABA, and because the amount of GABA in the CNS is finite, these drugs' depressive effect on the CNS is limited. Benzodiazepines depress the CNS but not to the extent that barbiturates do. Benzodiazepines are weak respiratory depressants at therapeutic doses and moderate respiratory depressants at toxic doses. Barbiturates mimic GABA; therefore, because they produce CNS depression, this effect is limited only by the amount of barbiturate administered

A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug's half-life is only 2 to 3 hours. Which response by the nurse is correct? a. "Benzodiazepines commonly cause residual effects lasting into the day after the dose is given." b. "The patient is having a paradoxical reaction to this medication." c. "This patient must have developed a previous tolerance to benzodiazepines." d. "When this drug is metabolized, the resulting compound has longer-lasting effects."

ANS: D Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication.

A patient who has been taking a monoamine oxidase inhibitor (MAOI) for depression for several months tells the provider that the medication has not helped with symptoms. The provider plans to switch the patient to an SSRI. The nurse will teach this patient to: a. start taking the SSRI and stop the MAOI when symptoms improve. b. start taking the SSRI and then gradually withdraw the MAOI. c. stop taking the MAOI and wait 5 weeks before starting the SSRI. d. stop taking the MAOI 2 weeks before starting the SSRI.

ANS: D MAOIs increase 5-HT availability, thus greatly increasing the risk of serotonin syndrome. MAOIs should be withdrawn at least 14 days before an SSRI is started. An SSRI should never be given at the same time as an MAOI. It is not necessary to wait 5 weeks before starting an SSRI.

A patient taking an FGA medication develops severe parkinsonism and is treated with amantadine [Symmetrel]. The amantadine is withdrawn 2 months later, and the parkinsonism returns. The nurse will expect the provider to: a. give anticholinergic medications. b. make a diagnosis of idiopathic parkinsonism. c. resume the amantadine indefinitely. d. try a second-generation antipsychotic (SGA).

ANS: D Neuroleptic-induced parkinsonism is treated with some of the same drugs used for idiopathic parkinsonism, such as amantadine. If parkinsonism is severe, switching to an SGA may help, because the risk of parkinsonism is much lower with these drugs.

A patient who has obsessive-compulsive disorder (OCD) has been undergoing behavioral therapy but continues to exhibit symptoms that interfere with daily life. Which intervention will the nurse expect the provider to order for this patient? a. Alprazolam [Xanax] b. Buspirone [Buspar] c. Deep brain stimulation d. Fluoxetine [Paxil]

ANS: D Patients with OCD usually respond optimally to a combination of an SSRI, such as fluoxetine, and behavioral therapy. Alprazolam and buspirone are used to treat GAD. Deep brain stimulation is used when other therapies fail to treat OCD.

A patient is diagnosed with major depression with severe symptoms and begins taking an antidepressant medication. Three weeks after beginning therapy, the patient tells the nurse that the drug is not working. The nurse will counsel this patient to ask the provider about: a. adding a second medication to complement this drug. b. changing the medication to one in a different drug class. c. increasing the dose of this medication. d. using nondrug therapies to augment the medication.

ANS: D Patients with severe depression benefit more from a combination of drug therapy and psychotherapy than from either component alone, so this patient should ask the provider about nondrug therapies. Once a drug has been selected for treatment, it must be used for 4 to 8 weeks before its efficacy can be assessed. Until a drug has been used at least 1 month without success, it should not be considered a failure.

A patient is taking an FGA for schizophrenia. The nurse notes that the patient has trouble speaking and chewing and observes slow, wormlike-movements of the patient's tongue. The nurse recognizes which adverse effect in this patient? a. Acute dystonia b. Akathisia c. Parkinsonism d. Tardive dyskinesia

ANS: D Tardive dyskinesia can occur in patients during long-term therapy with FGAs. This patient shows signs oft his adverse effect. Acute dystonia is characterized by severe spasm of muscles in the face, tongue, neck, or back, and by opisthotonus. Akathisia is characterized by constant motion. Parkinsonism is characterized by bradykinesia, drooling, tremor, rigidity, and a shuffling gait.

An agitated, extremely anxious patient is brought to the emergency department. The prescriber orders a benzodiazepine. The nurse understands that benzodiazepines are used in this clinical situation based on which principle? a. Benzodiazepines have a very short half-life. b. Physical dependence is not a risk when taking benzodiazepines. c. Benzodiazepines are known to cure generalized anxiety. d. Benzodiazepines have a rapid onset of action.

ANS: D The patient is clearly in a state of extreme, uncontrolled anxiety. Benzodiazepines are the drugs of choice for acute episodes of anxiety because of their rapid onset of action. Benzodiazepines do not have a very short half-life. Benzodiazepines are associated with physical dependence. Benzodiazepines do not cure generalized anxiety, nor do any other drugs.

What should be used to evaluate EPS symptoms in a patient treated for acute psychosis using Haloparidol?

Abnormal Involuntary Movement Scale (AIMS)

Which medication is the most effective in treating pseudoparkinson syndrome and acute dystonias?

Benztropine (Anticholinergic)

What is the mechanism of action for SNRIs?

Blocks the re-uptake of serotonin and norepinephrine

Which direct dopamine agonist is most effective in treating Parkinson-like symptoms?

Bromocriptine

Which anxiolytic drug is considered first-line in the treatment of Generalized Anxiety Disorder (GAD)?

Buspirone (BuSpar) **Buspirone is useful for the chronic treatment of generalized anxiety disorder (GAD), but has a slow onset of action, should not be used in acute anxiety states (e.g., panic disorder), and must be dosed twice daily (has a short T1/2).**

What medication should be reserved for the treatment of neuroleptic malignant syndrome (NMS)?

Dantrolene a direct-acting muscle relaxant (see Chapter 22). In patients with NMS, this drug reduces rigidity and hyperthermia.

This SNRI is FDA-approved to treat diabetic neuropathy

Duloxetine (Cymbalta)

Which SNRI is indicated to treat depression associated with pain?

Duloxetine (Cymbalta)

Which SSRI is used to treat depression coupled with anxiety?

Escitalopram (Lexapro)

What is an example of a benzodiazepine antagonist?

Flumazenil (Romazicon), GABA receptor antagonist

What medication is commonly used to treat neuropathies and seizures?

Gabapentin **make increase thoughts of suicide**

Why is it important that patients taking lithium for bipolar consume about the same amount of sodium each day?

Hyponatremia can lead to lithium toxicity

What endocrine disorder can develop with Lithium use?

Hypothyroidism

Why shouldn't antipsychotics be used to treat dementia-related psychosis in older adults?

Increases the risk of mortality

Which atypical antidepressant agent can cause drowsiness and increased appetite?

Mirtazepine

What side effect isn't seen as often when using Haloparidol in comparison to other antipsychotics?

Orthostatic Hypotension Compared with the low-potency FGAs, the high-potency FGAs cause more early EPSs but cause less sedation, orthostatic hypotension, and anticholinergic effects.

What beta-blocker is the drug of choice used to treat Haloperidol-induced akathisia (restlessness)

Propranolol

D2 blockade by haloperidol can result in which syndrome?

Pseudoparkinson syndrome

Which hypnotic agent acts on the MT1 and MT2 type of melatonin receptor?

Ramelteon (Rozerem)

What antipsychotic medications are typically used to control manic symptoms in a bipolar patient?

Second generation antipsychotics, risperidone and olanzapine These are preferred over first generation antipsychotics such as haloperidol

What are the signs and symptoms of serotonin syndrome?

Signs and symptoms include altered mental status (agitation, confusion, disorientation, anxiety, hallucinations, poor concentration) as well as incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever

Haloperidol is a first generation antipsychotic (FGA), what is believed to be the mechanism of action for these medications?

The current dominant theory suggests that FGA drugs suppress symptoms of psychosis by blocking dopamine2 (D2) receptors in the mesolimbic area of the brain. In support of this theory is the observation that all of the FGAs produce a D2 receptor blockade. Furthermore, there is a close correlation between the clinical potency of these drugs and their potency as D2 receptor antagonists

How do benzodiazepines work?

They bind to the GABA receptor-chloride channel complex and inhibit cell excitability.

What is the Black Box Warning associated with Clozapine?

Very rarely, clozapine has been associated with myocarditis (inflammation of the heart muscle), which can be fatal. If a patient develops signs and symptoms (e.g., unexplained fatigue, dyspnea, tachypnea, chest pain, palpitations), clozapine should be withheld until myocarditis has been ruled out. If myocarditis is diagnosed, clozapine should not be used again.

What advantage does Olanzapine, an SGA have over other medications in its class?

being available as a long-acting injection for acute psychotic reactions.

What is the function of tapentadol

centrally-acting mu-opioid agonist **is also an inhibitor of NE reuptake, and used for diabetic peripheral neuropathy; use cautiously in patients with seizure activity or those using other opioid drugs**

What are the cognitive symptoms of schizophrenia?

disordered thinking, reduced ability to focus attention, and prominent learning and memory difficulties.

Haloperidol (Haldol), fluphenazine, and metoclopramide (Reglan) are first generation antipsychotics, what adverse affect is seen with the use of these medications compared to second generation antipsychotics?

extrapyramidal reactions—especially tardive dyskinesia (TD)

What enzyme should be avoided by patients taking MAOs?

food that is rich in tyramine can promote hypertensive crisis in these patients

What are the positive symptoms of schizophrenia?

hallucinations, delusions, agitation, tension, and paranoia

What are the negative symptoms of schizophrenia?

lack of motivation, poverty of speech, blunted affect, poor self-care, and social withdrawal.

What undesirable side effects are seen with second generation antipsychotics such a Clozapine, but not FGAs?

metabolic effects—obesity, diabetes, and dyslipidemia—all of which increase the risk for cardiovascular events. As indicated in Table 26.2, risk is highest with clozapine and olanzapine and lowest with aripiprazole, lurasidone, and ziprasidone.

What are first generation antipsychotics (FGA) also known as?

neuroleptics

Why are TCAs nor recommended in the treatment of bipolar?

promote incidents of mania