PrepU Chapter 22

The community health nurse is conducting a class for parents of preschoolers. One of the parents asks if a child with ADHD will always have problems with hyperactivity. What is the nurse's best response?

"ADHD usually starts in childhood and may persist through adulthood."

A client is taking antipsychotic medication and asks the nurse what dopamine is. What is a correct response by the nurse?

"Dopamine is a neurotransmitter that deals with pleasure and reward in the brain." Dopamine is a neurotransmitter in the sympathetic nervous system that deals with pleasure and reward in the brain. Dopamine is not an enzyme or a part of the brain. Dopamine is a medication, but it does not fight infection or help with pain.

A client with dementia has been very agitated lately. What type of medication might the provider prescribe to help with the agitation?

Antipsychotic Antipsychotic medications are used to treat agitation in clients with dementia. Antidepressant, antibiotic, and narcotic medications are not used to treat agitation in clients with dementia.

The classification of central nervous system (CNS) stimulants frequently prescribed for exogenous obesity is:

Amphetamines The CNS stimulant group prescribed for exogenous obesity is amphetamines. The anorexiants are prescribed for general obesity.

The nurse on the unit has several clients taking clozapine. For which client is clozapine, an antipsychotic, contraindicated?

The 45-year-old with bone marrow depression Contraindications to antipsychotic drugs include bone marrow depression, liver damage, coronary artery disease, coma, and severe hypotension or hypertension. The use of clozapine is not contraindicated in clients with upper respiratory infection, diabetes insipidus or osteoarthritis.

A female client asks why it is not legal to have a year's worth of prescription refills for Ritalin, since she has been on it for more than a year. She would also like to have the largest dose possible, so she can use the prescription for 2 months, instead of one. She explains that it is very hard to get off work and come in for appointments. The nurse's best response would be:

"The prescription dose is always started as low as possible and the refills are monitored to prevent abuse." When a CNS stimulant is prescribed, it is started with a low dose that is then increased as necessary, usually at weekly intervals, until an effective dose (i.e., decreased symptoms) or the maximum daily dose is reached. In addition, the number of doses that can be obtained with one prescription should be limited. This action reduces the likelihood of drug dependence or diversion (use by people for whom the drug is not prescribed).

The nursing student is reviewing information learned in anatomy and physiology class about the nervous system. The student recalls that the nervous system has how many divisions?

2 The nervous system has two main divisions: the central nervous system and the peripheral nervous system.

The nurse expects to monitor a client's white blood count weekly when the client is prescribed:

Clozapine

Dexmethylphenidate has been prescribed to Scott, a 7-year-old boy who was diagnosed with ADHD. The mother asks how this medication will help her son. Which would be the most accurate description of the purpose of this medication?

Dexmethylphenidate will improve Scott's attention span so that he will be able to complete a task. Dexmethylphenidate is thought to block the reuptake of norepinephrine and dopamine into the presynaptic neuron and increase the release of these monoamines into the extraneuronal space. This activity results in improved attention spans, decreased distractibility, and increased ability to follow directions or complete tasks, and decreased impulsivity and aggression in patients with ADHD. Although dexmethylphenidate does not produce a physical dependence, it may induce tolerance or psychic dependence.

A parenteral form of an antipsychotic is prescribed for a client who has become aggressive. When administering the drug, which site would be most appropriate for the nurse to use?

Gluteus When giving an antipsychotic parenterally, the drug should be given IM in a large muscle mass such as the gluteus muscle. The deltoid muscle is not a large muscle. The vastuslateralis and the ventrogluteal are not large muscles when a client is aggressive, the larger the muscle the better, thus gluteus is the best choice.

Monitoring of patients taking lithium includes periodically obtaining a serum lithium level; at what level may toxic reactions occur?

Greater than 1.5 mEq/mL Toxic reaction may occur when serum lithium levels are greater than 1.5 mEq/mL

The nurse is aware that CNS stimulants are prescribed for clients with ADHD because these medications have what effect on behavior and attention?

Improving CNS stimulants improve behavior and attention in clients with ADHD.

A client, prescribed dextroamphetamine for attention deficit hyperactivity disorder (ADHD), has developed a common adverse effect of the medication since beginning therapy. Which initial intervention should the client be encouraged to implement?

Increase fiber intake A client who is experiencing constipation should be instructed to increase fiber in the diet. The client should not take a laxative before attempting to manage the problem with dietary modifications. The client should not be instructed to take diphenoxylate hydrochloride because it is an antidiarrheal agent. The client should not be given metronidazole since it is an anti-infective agent.

A child with attention deficit hyperactivity disorder has been receiving methylphenidate for several years. The prescriber has explained a plan to temporarily discontinue the drug. What rationale for this action should the nurse explain?

It needs to be determined if the child still has symptoms that require treatment. Periodically the drug therapy needs to be interrupted to determine if the child experiences a recurrence of symptoms, which if they do occur, indicates the need for continued treatment. This is not done because the plan is to switch drugs if the current drug is effective or because of an increased risk. The absence of medicine will determine if he no longer needs the medication.

A client calls the clinic reporting only being able to get a 1-month supply of pills for the client's son, who takes a CNS stimulant for ADHD. The nurse understands that these medications are given in limited numbers for what reason?

It reduces the likelihood of drug dependence or diversion. When a CNS stimulant is prescribed, it is started with a low dose that is then increased as necessary, usually at weekly intervals, until an effective dose (i.e., decreased symptoms) or the maximum daily dose is reached. In addition, the number of doses that can be obtained with one prescription should be limited. This action reduces the likelihood of drug dependence or diversion (use by people for whom the drug is not prescribed).

What assessment finding should lead the nurse to suspect that a client receiving antipsychotic therapy is developing tardive dyskinesia?

Lip smacking Lip smacking is associated with tardive dyskinesia. Abnormal eye movements are associated with dystonia. Tardive dyskinesia is not associated with disorientation or urinary incontinence.

Serotonin abnormalities are thought to be involved in the following disorders:

Mental depression and sleep disorders. Normal levels of serotonin in the brain produce mood elevation or euphoria, increasing mental alertness and capacity for work, decrease fatigue and drowsiness, and prolong wakefulness. Abnormalities alter these functions.

A female client relates that she is taking diazepam for a muscle relaxant and modafinil for treatment of narcolepsy. Additionally, she informs you that she takes a contraceptive. As part of client education, the nurse would include:

Modafinil may decrease the effects of her contraceptive, and she may need to use other protection. Modafinil may increase the effects of citalopram, clomipramine, diazepam, phenytoin, propranolol, sertraline, tricyclic antidepressants, and warfarin. It may decrease the effects of cyclosporine and oral contraceptives.

A nurse observes rhythmic, involuntary facial movements in a patient who has been administered antipsychotic drugs. The patient also makes chewing movements and, at times, his tongue protrudes. What is the most likely reason for the patient's behavior?

Tardive dyskinesia Tardive dyskinesia is characterized by rhythmic, involuntary movements of the tongue, face, mouth, or jaw, and sometimes the extremities. The tongue may protrude, and there may be chewing movements, puckering of the mouth, and facial grimacing. Extrapyramidal syndrome (EPS), neuroleptic malignant syndrome (NMS), and Stevens-Johnson syndrome do not cause rhythmic, involuntary, facial movements.

A 24-year-old client is being seen in the emergency department because of a high fever and cannot move the right arm. During the history-taking process, The nurse discovers the client is being treated with an antipsychotic medication for schizophrenia. The nurse knows that what may be happening with this client?

The client may be having a neuroleptic malignant syndrome reaction to his antipsychotic medication and needs treatment immediately. Neuroleptic malignant syndrome (NMS) is a rare reaction characterized by extrapyramidal effects, hyperthermia, and autonomic disturbance. NMS is potentially fatal and requires immediate treatment. NMS does not self-resolve. Influenza A is not characterized by having an immobile arm. Usually a schizophrenic client would be able to tell you how he had broken his arm.

A female client is diagnosed with renal insufficiency. The nurse develops a teaching plan based on the diagnosis and antipsychotic drug usage. The client asks the nurse why it is so important to have renal function tests routinely. The nurse replies that if renal function test results become abnormal, what may be a consequence?

The drug may need to be lowered in dosage or discontinued. Because most antipsychotic drugs are extensively metabolized in the liver and the metabolites are excreted through the kidneys, the drugs should be used cautiously in clients with impaired renal function. Renal function should be monitored periodically during long-term therapy. If renal function test results (e.g., blood urea nitrogen) become abnormal, the drug may need to be lowered in dosage or discontinued.

The nurse is caring for a patient who is receiving drug therapy for a psychotic disorder. Which goals should the nurse include in a care plan for the patient following discharge from the hospital?

The patient will take medications as prescribed. Goals that relate to care following discharge may include ensuring that the patient takes medications as prescribed and returns for all scheduled follow-up appointments with health care providers. Normalizing sleep and eating patterns and decreasing symptoms are short-term (e.g., within the first week of treatment) goals of patients who experience acute psychotic episodes.

Which test should be scheduled every week for a patient taking clozapine?

WBC count Use of the drug clozapine has been associated with severe agranulocytosis, (i.e., decreased white blood cells), so weekly WBC count tests are scheduled. Serum lithium tests are taken for patients who have been administered lithium, not clozapine. There is no need to take blood glucose or pH level tests.

For clients taking clozapine, it is necessary to monitor what lab test for the first 6 months?

White blood cells Advantages of clozapine include improvement of negative symptoms without causing the extrapyramidal effects associated with older antipsychotic drugs. However, despite these advantages, it is a second-line drug, recommended only for clients who have not responded to treatment with at least two other antipsychotic drugs or who exhibit recurrent suicidal behavior. The reason for the second-line status of clozapine is its association with agranulocytosis, a life-threatening decrease in white blood cells (WBCs), which usually occurs during the first 3 months of therapy. A BLACK BOX WARNING alerts health practitioners to this dangerous side effect. Weekly WBC counts are required during the first 6 months of therapy; if acceptable WBC counts are maintained, then WBC counts can be monitored every 2 weeks.

During an intake assessment, the nurse notes that the client cannot sit still and continually stands up and walks around the room. The nurse knows that the term for this behavior is:

akathisia Akathisia is defined as extreme restlessness and increased motor activity. Anhedonia is lack of joy or pleasurable feelings. Avolution is the inability to determine and initiate goals and activities. Dystonia is prolonged muscle contractions.

A client, who has been diagnosed with schizophrenia and is taking an antipsychotic medication, reports constant thirst, frequent urination, and feeling nauseous. The nurse knows that the client may:

have undiagnosed diabetes. Schizophrenic clients have a higher than normal incidence of diabetes. The flu usually has a fever along with respiratory symptoms. A urinary tract infection may cause burning and frequent urination, but thirst is not normally a symptom. Also, UTIs are not more common in schizophrenics. A client could be making up symptoms, but the nurse should first consider other options that could be causing the symptoms.

A 10-year-old boy is taking dextroamphetamine (Dexedrine) daily for ADHD. At each clinic visit, the nurse must assess the child. The priority assessment since he is on this medication would be which?

height and weight The nurse should assess blood pressure, body temperature, and vision at each clinic visit as routine nursing measures in caring for a pediatric client. However, the priority assessment would be of height and weight. Monitoring the growth and development of children taking amphetamines is extremely important because these drugs have been associated with growth suppression.

The nurse would monitor a patient closely for lithium toxicity if the patient is also receiving:

indomethacin Indomethacin and lithium, when combined, increase the risk of lithium toxicity. Psyllium interferes with the absorption of lithium leading to nontherapeutic levels. Antacids, when combined with lithium, leads to a decrease in lithium effectiveness. Tromethamine, when combined with lithium, leads to a decrease in lithium effectiveness.

Antipsychotic drugs are contraindicated in clients with:

liver damage, coronary artery disease, severe hypertension, bone marrow depression, or cerebrovascular disease. Because of their wide-ranging adverse effects, antipsychotic drugs may cause or aggravate a number of conditions. They are contraindicated in clients with liver damage, coronary artery disease, cerebrovascular disease, parkinsonism, bone marrow depression, severe hypotension or hypertension, coma, or severely depressed states. They should be used cautiously in people with seizure disorders, diabetes mellitus, glaucoma, prostatic hypertrophy, peptic ulcer disease, and chronic respiratory disorders.

A 13-year-old has been prescribed dextroamphetamine for the treatment of attention deficit hyperactivity disorder (ADHD) since age 10, achieving significant improvements in behavior and mood. When assessing the child during a scheduled follow-up appointment, the nurse should prioritize what physical assessment to monitor for a potential adverse reaction to the therapy?

measurement of height and body weight Suppression of weight and height may occur in children taking amphetamines, and the nurse ensures that growth is monitored during drug therapy. Assessments for edema, diminished reflexes, and sensory deficits are not normally warranted.

A client is being prescribed dextroamphetamine for the treatment of attention deficit hyperactivity disorder (ADHD). During health education, the nurse should make the client aware of the black box warning relating to what potential risk issue?

potential for abuse A black box warning makes users of dextroamphetamine aware of the drug's high abuse potential. Black box warnings do not address the potential for renal failure, stroke, or unstable blood sugars.

A psychiatric nurse is discussing the advantages of atypical antipsychotics with the parents of a teenager who has been diagnosed with schizophrenia. When comparing these drugs with the older, typical antipsychotics, what advantage should the nurse cite?

reduced adverse effects Atypical antipsychotics may be more effective in relieving some symptoms than typical antipsychotics, and they usually produce milder adverse effects. A major drawback is the high cost of these drugs. All antipsychotics are available for the oral route. There are several black box warnings relating to atypical antipsychotics.

While caring for a client who is receiving antipsychotic therapy, the nurse observes lip smacking, a darting tongue, and slow and aimless arm movements. The nurse interprets this as:

tardive dyskinesia. Tardive dyskinesia involves abnormal muscle movements such as lip smacking and tongue darting, slow and aimless arm and leg movements, and chewing movements. Akathisia is manifested by continued restlessness and an inability to sit still. Pseudoparkinsonism is manifested by muscle tremors, cogwheel rigidity, drooling, shuffling gait, and slow movements. Dystonia is manifested by spasms of the tongues, neck, back, and legs.

During health education with the nurse, what subject should be the primary focus for a client newly diagnosed with schizophrenia?

the importance of adherence to prescribed treatment The success or failure of treatment is largely dependent on the client's adherence to treatment. For most clients, this supersedes the immediate significance of nutrition or teaching about therapeutic effects. There is no need for weekly coagulation tests.

A client is being treated with clozapine. What should the nurse monitor most closely?

white blood cell count Clozapine is associated with significant leukopenia. Subsequently, it is available only through the Clozaril Client Management System, which involves monitoring white blood cell count and compliance issues with only a 1-week supply being given at a time. The drug is not associated with changes in sliver function, cardiac enzymes, or urine output.

A black, male client routinely takes haloperidol to manage his psychosis. Recently, he presented to the health care provider's (HCP's) office with signs of tardive dyskinesia, and his HCP modified the drug regimen over time. The client will now take the drug olanzapine and discontinue the haloperidol. What will the nurse tell the client to help decrease his anxiety about the new drug regimen?

"When compared with haloperidol, olanzapine has been associated with fewer extrapyramidal reactions in black clients." Black clients tend to respond more rapidly; experience a higher incidence of adverse effects, including tardive dyskinesia; and metabolize antipsychotic drugs more slowly than white clients. When compared with haloperidol, olanzapine has been associated with fewer extrapyramidal reactions in black clients.

The nurse just administered chlorpromazine to a client by intramuscular injection. The nurse should instruct the client to:

stay in bed for the next half hour. After administering parenteral forms of antipsychotic agents, the nurse should keep the client recumbent in bed for approximately 30 minutes to reduce the risk of orthostatic hypotension. Urinary urgency and chest pain are not anticipated adverse effects, so would not need to be addressed. There is no obvious need for the client to perform deep breathing and coughing exercises.