Ch 14

A patient who takes a traditional antipsychotic medication says, "I feel shaky and very warm" and is observed to be diaphoretic. The nurse should further assess for what complication? a. Acute dystonia b. Tardive dyskinesia c. Drug-induced parkinsonism d. Neuroleptic malignant syndrome (NMS)

ANS: D NMS is a relatively rare but serious reaction to antipsychotic therapy. It is characterized by muscle rigidity, fever, sweating, autonomic instability, altered levels of consciousness, and possible death. The data given in the scenario are not consistent with other options.

After an unsuccessful trial with fluphenazine, a patient's medication was changed to trifluoperazine. Three months later the patient is still hallucinating and delusional. What is the most likely explanation for the persistent symptoms? a. Trifluoperazine is a low-potency antipsychotic, and the patient might need higher doses. b. The patient has not taken trifluoperazine long enough to decrease symptoms significantly. c. Delusions and hallucinations are negative symptoms of schizophrenia that do not respond to traditional antipsychotic medications. d. Both fluphenazine and trifluoperazine are traditional antipsychotics, and the patient does not respond well to this class of drug.

ANS: D When a trial of a drug produces little change in symptoms and a new drug is to be prescribed, the best plan is to use a drug of another class, because the response to a drug of the first class will usually be poor. The other options are misleading.

Which patient diagnosed with schizophrenia and receiving antipsychotic medication should receive the nurse's priority attention based on presenting characteristics? a. The one assessed with diaphoresis and a temperature of 104°F b. The one reporting feelings of neck and shoulder stiffness c. The one reporting auditory hallucinations of loudly clanging church bells d. The who chanting, "I am the messiah, delivered to earth from the heavens above"

ANS: A Diaporesis and fever are findings indicating neuroleptic malignant syndrome (NMS), a serious adverse reaction to antipsychotic medication. The other findings may be significant but are a lesser priority.

Considering potency, what should the nurse closely monitor a patient receiving a traditional high-potency antipsychotic medication for: a. adrenergic effects. b. extrapyramidal side effects. c. anticholinergic side effects. d. changes in pain perception.

ANS: B High-potency antipsychotics are more likely to cause extrapyramidal side effects (EPSEs) than low-potency antipsychotics. The other effects are not related to potency classification.

A patient who takes haloperidol 10 mg/day orally developed restlessness, agitation, and an inability to sit still. The nurse then administered a PRN dose of haloperidol 5 mg intramuscularly. One hour later the patient's symptoms were worse. What is the most likely explanation for the increase in symptoms? a. The PRN medication has not yet taken effect. b. The patient needs an increase in the dosage of haloperidol to control the rising agitation. c. The patient was experiencing akathisia, which worsened after receiving the haloperidol medication. d. The nurse should consider an adjunctive dose of an antianxiety drug such as lorazepam.

ANS: C Akathisia is characterized by subjective feelings of restlessness accompanied by the inability to sit still and the need to pace. It is an EPSE of antipsychotic medication, made more intense by higher doses of medication and use of PRN doses. It is unnecessary to change to a more sedating drug. The addition of an antianxiety drug is unnecessary.

A patient diagnosed with schizophrenia and well managed with medication therapy tells the clinic nurse, "I stopped taking my antipsychotic medication 2 days ago." What assessment finding would the nurse expect at this visit? a. Mood instability b. Paranoid delusions c. No evidence of symptoms d. Mental clouding and confusion

ANS: C Antipsychotic drugs accumulate in fatty tissue and are released slowly. This explains why symptoms might still be controlled for several days after discontinuing the drug.

Which medication from the patient's pharmacologic profile would most likely led to the development of neuroleptic malignant syndrome? a. Divalproex sodium b. Amitriptyline c. Haloperidol d. Paroxetine

ANS: C Neuroleptic malignant syndrome is more likely to occur in patients taking traditional high-potency antipsychotic drugs. The distracters are not antipsychotic drugs.

During a psychiatric emergency, a patient is given a traditional antipsychotic drug intramuscularly and placed in seclusion. Over the next 2 hours, which aspect of physical assessment is most important? a. Blood pressure, pulse, and respirations b. Urinary output c. Abnormal involuntary movements (AIMS scale) d. Temperature

ANS: A A traditional antipsychotic medication administered intramuscularly might produce the marked antiadrenergic side effect of hypotension, thus making blood pressure an important assessment. It may also precipitate cardiac arrhythmias, so monitoring pulse and respirations is important. Decreased urinary output is related to anticholinergic side effects and would not be a priority assessment during the first 2 hours. The AIMS scale assesses for tardive dyskinesia, a late complication of antipsychotic therapy. Temperature assessment is relevant if assessing for neuroleptic malignant syndrome, a complication that develops after several doses of antipsychotic medication.

When assessing for a positive outcome to drug therapy with fluphenazine, the nurse would look primarily for improvement in which focus area? a. Hallucinations b. Range of affect c. Personal hygiene d. Social interactions

ANS: A Fluphenazine, a typical antipsychotic, will produce improvement in the positive symptoms associated with schizophrenia, such as hallucinations. Less improvement is expected in negative symptoms such as affect, activity, and grooming.

When a patient is taking a traditional antipsychotic medication, the nurse should assess carefully for which common extrapyramidal (EPSE) side effect? a. Akathisia b. Mydriasis c. Hypotension d. Constipation

ANS: A It is estimated that more than 25% of all patients receiving antipsychotic medication experience akathisia, a subjective feeling of restlessness and jitteriness and a desire to stand or walk. Akathisia typically manifests itself early in treatment. The other options are not considered EPSEs.

A patient has taken a traditional antipsychotic medication for several years is now demonstrating involuntary tongue movements and lip smacking. What should be the nurse's initial action? a. Notifying the health care provider b. Administering PRN doses of an anticholinergic drug c. Implementing behavioral modification techniques to help the patient manage these motions. d. Counseling the patient about the social ramifications of these movements by others.

ANS: A These symptoms suggest the presence of tardive dyskinesia and should be reported to the health care provider, who will probably discontinue the drug or change to an atypical drug. The movements are involuntary so behavioral modification would not be effective and counseling would not be directed to this aspect of the problem. Tardive dyskinesia does not respond to anticholinergics.

A nurse reviews laboratory reports for a patient who has taken clozapine for 1 year. Which WBC and granulocyte values would prompt the nurse to notify the health care provider of the need to suspend treatment? a. 2900 cells/mm3 and 1450 cells/mm3. b. 3500 cells/mm3 and 1850 cells/mm3. c. 4000 cells/mm3 and 2000 cells/mm3. d. 4500 cells/mm3 and 2500 cells/mm3.

ANS: A These values indicate that leukopenia is present. Agranulocytosis is a sometimes fatal side effect of clozapine. The other values are above baseline.

A 60-year-old female patient who has taken traditional antipsychotic medication for 20 years should be screened for which potential side effect? a. Osteoporosis b. Metabolic syndrome c. Polycystic ovary disease d. Neuroleptic malignant syndrome (NMS)

ANS: A Traditional antipsychotic medications increase prolactin levels, placing patients at risk for development of osteoporosis. Atypical antipsychotics increase the risk for metabolic syndrome. Screening for NMS and polycystic ovary disease are not indicated.

Which information should the nurse include in the teaching plan for a patient receiving clozapine? a. "Abstain from using tobacco products." b. "Increase your daily carbohydrate intake." c. "Notify your health care provider if you start drooling." d. "You will need monthly electrocardiographic tracings done."

ANS: A Use of tobacco products speeds metabolism of clozapine in the liver, reducing the clozapine level and diminishing its effectiveness in reducing symptoms. Increasing carbohydrate intake is contraindicated because of the possibility of developing metabolic syndrome. Drooling is a common side effect. Monthly electrocardiographic tracings are unnecessary, but annual or semiannual tracings might be suggested, because arrhythmia development is possible.

A patient diagnosed with schizophrenia has experienced good symptom control through medication therapy. Today, the patient is admitted with paranoia and auditory hallucinations. The nurse should initially determine if the patient's symptoms are related to which possible trigger? a. Not taking the drug as prescribed b. Activation of serotonin receptors c. Development of tolerance to the drug d. An expected illness-exacerbation cycle

ANS: A When a patient does not respond to a drug, or when symptoms reappear after a good response to the drug, the nurse should assess for compliance. Is the patient taking the drug? Is the patient taking less of the drug than ordered? The other options are less relevant or of no value to the development of the stated symptoms.

A patient who takes a traditional antipsychotic medication says, "I feel shaky and very warm." The patient is diaphoretic. What is the nurse's best first action when suspecting that a patient is experiencing neuroleptic malignant syndrome (NMS)? a. Take the patient's vital signs. b. Position the patient in the semi-Fowler position. c. Begin oxygen by nasal cannula at 2 L/min. d. Place the patient on one-to-one supervision.

ANS: A When signs and symptoms suggest that the patient might be experiencing NMS, the first action would be to check vital signs. NMS produces elevated temperature, blood pressure fluctuations, and irregular heart rate in addition to muscle rigidity and altered levels of consciousness. None of the other options address the assessment needs of such a patient

When comparing major differences between traditional and atypical antipsychotic drugs, which statements are correct? (Select all that apply.) a. Traditional antipsychotic drugs produce more EPSEs. b. Traditional antipsychotic drugs are more likely to produce weight gain. c. Traditional antipsychotic drugs alter dopamine and serotonin transmission. d. Atypical medications have a greater therapeutic effect on both positive and negative symptoms. e. Atypical medications are more likely to cause tardive dyskinesia.

ANS: A, D Traditional antipsychotics have a higher incidence of EPSEs and tardive dyskinesia. Atypical antipsychotics are more likely to produce weight gain and alter dopamine and serotonin transmission.

An adult diagnosed with schizophrenia was started on clozapine 4 days ago. At 2100 today, the patient's vital signs are temperature 101°F; pulse 143 beats/min; respirations 20 breaths/min; blood pressure 100/60 mm Hg. What is the nurse's best action regarding the 2100 dose of clozapine? a. Recognize the alterations in vital signs as typical for early therapy, and administer the medication. b. Hold the medication, and notify the health care provider. c. Give the drug and continue to monitor vital signs every 4 hours. d. Postpone the dose until vital signs are normal.

ANS: B Clozapine might cause agranulocytosis, a potentially fatal illness. Any symptoms or signs of infection raise suspicion and call for investigation of white cell differential counts. Clozapine should be withheld until the white blood cell (WBC) count and absolute neutrophil count (ANC) are known. Administering the drug has the potential for further lowering the WBC count and ANC.

A patient receiving a traditional low-potency antipsychotic medication should assess closely for what possible peripheral nervous system related side effect? a. Urinary frequency b. Urinary retention c. Hypertension d. Diarrhea

ANS: B Low-potency antipsychotics tend to cause anticholinergic side effects. Urinary retention and other anticholinergic effects are important findings for which the nurse should be alert. The other effects would not be expected.

An antipsychotic medication is prescribed for a 72-year-old patient with a psychiatric disorder. It is most critical for the nurse to obtain information about which preexisting condition by asking what assessment question? a. "Are you being treated for cataracts?" b. "Have you ever been diagnosed with heart disease?" c. "Do you have diabetes mellitus? d. "Are you being treated for chronic bronchitis?"

ANS: B The anticholinergic and antiadrenergic effects of this drug might produce reflex tachycardia and/or arrhythmias. Individuals with known heart disease must be carefully evaluated before and during therapy. The remaining options are not influenced as directly by this medication.

A patient is to be discharged on a maintenance dose of a high-potency antipsychotic medication. Which remark indicates that discharge teaching about the medication was effective? a. "I will be able to have a few glasses of wine." b. "I have to use sun block when I go to the beach." c. "It is important for me to dress warmly in all seasons." d. "If I miss a dose, I will take an extra one the next day."

ANS: B The patient understands that antipsychotics cause photosensitivity and sunburn with minimal exposure to the sun. The other remarks suggest that the patient does not understand the additive effects of the antipsychotics and other central nervous system depressants, and does not understand what to do in the event of a missed dose.

A patient is being switched to clozapine from therapy using a traditional antipsychotic. The patient asks, "What's the advantage of the new drug?" What is the nurse's best response? a. "It is much less expensive." b. "It has a lower risk for seizure activity." c. "It is sometimes effective when other drugs fail." d. "It has a lower risk for causing blood abnormalities."

ANS: C Clozapine is often effective against refractory schizophrenia. The distracters are incorrect statements.

Which patient receiving antipsychotic medication has the greatest risk for the development of neuroleptic malignant syndrome (NMS) and should be most carefully monitored for this serious adverse reaction? a. One who has a history of hypothermia. b. One with an elevated serum prolactin level. c. One who began treatment with a high-potency drug. d. One whose antipsychotic medication therapy began more than 6 months.

ANS: C Neuroleptic malignant syndrome (NMS) is more common among patients receiving high-potency drugs. NMS is associated with hyperthermia and occurs within the first 3 to 9 days of administration. Prolactin levels and NMS are not causally related.

During a psychiatric emergency, a patient is given a traditional antipsychotic drug intramuscularly and placed in seclusion. Over the next 2 hours, concerns for safety and physiologic stability require that the patient be carefully monitored for what antiadrenergic effect? (Select all that apply.) a. Tardive dyskinesia b. Dystonia c. Drug-induced parkinsonian movements d. Orthostatic hypotension e. Reflex tachycardia.

ANS: D, E Hypotension is the major antiadrenergic effect of antipsychotic drugs. It is related to the blocking of alpha1-receptors on peripheral blood vessels, preventing the vessels from constricting automatically to positional changes. Hypotension is frequently noted following intramuscular administration and is of concern because it relates to patient safety and injury from falls. Hypotension also causes a reflex tachycardia that can cause general cardiovascular inefficiency, and jeopardize the patient's physiologic stability. Drug-induced parkinsonian movements, dystonia, and tardive dyskinesia develop over time are not antiadrenergic in mature.