PREPU - UNFINISHED Chapter 23: Antipsychotic Drugs

14 of 20 What disease process is haloperidol used to treat? • muscular dystrophy • myasthenia gravis • Tourette's syndrome • early-onset dementia

• Tourette's syndrome Explanation: Haloperidol is used in treating Tourette's syndrome, which is a disorder characterized by involuntary movements and vocalizations. Muscular dystrophy, Alzheimer's disease, and myasthenia gravis are not treated with atypical antipsychotics.

The client is seen today in the clinic for mental evaluation. What existing illness would be a contraindication for a client to take an antipsychotic? Select all that apply. • Bone marrow depression • Osteoporosis • Severe depression • Liver impairment • Kidney disease

Correct response: • Bone marrow depression • Severe depression • Liver impairment Explanation: Contraindications for taking antipsychotics include: bone marrow depression, liver impairment, and severe depression. Kidney disease and osteoporosis are not contraindications for antipsychotics.

19 of 20 Which client statement reflects an understanding of typical length of antipsychotic medication therapy? • "Medications are less effective once my symptoms subside." • "I will need medication if my hallucinations get worse." • "If I take good care of myself, I'll be off medications soon." • "I may always have to take this medication."

• "I may always have to take this medication." Explanation: People with schizophrenia usually need to take antipsychotics for years because there is a high rate of relapse (acute psychotic episodes) when drug therapy is discontinued, most often by clients who become unwilling or unable to continue taking their medication. Symptoms tend to increase when medications are stopped. While ineffective self-care is a factor, it is not the only trigger for an acute psychotic episode.

16 of 20 A client has been achieving an acceptable reduction in the positive and negative signs of schizophrenia after several weeks of treatment with clozapine. The client has asked the nurse if it is acceptable to have "a few drinks from time to time." How should the nurse best respond to the client's inquiry? • "That's okay in most cases, but it's advisable to limit it to beer and wine and to avoid spirits." • "When you're taking clozapine, it's best to avoid drinking alcohol altogether." • "If you notice that your symptoms are worsening when you drink, you should stop doing it." • "That shouldn't present a problem, provided you make sure that you're safe when you do it."

• "When you're taking clozapine, it's best to avoid drinking alcohol altogether." Explanation: Alcohol increases central nervous system depression in clients taking clozapine; clients should ideally abstain from drinking alcohol. This information makes all the remaining responses incorrect.

6 of 20 The nurse is caring for a client newly diagnosed with schizophrenia and whose medical history requires a typical antipsychotic. When explaining possible anticholinergic effects to the client, the nurse should address what potential problems related to these effects? Select all that apply. • Ringing in the ears • Blurred vision • Constipation • Gum ulceration • Urinary retention

• Gum ulceration • Constipation • Urinary retention • Blurred vision Explanation: Anticholinergic effects include decreased salivation (which can cause gum ulceration), constipation, urinary retention and decreased visual accommodation (causing blurred vision). Tinnitus is not an anticholinergic effect.

9 of 20 The nurse on a psychiatric unit contributes to the care of many clients, most of whom have physical as well as psychiatric health problems. For which client would clozapine (Clozaril) most likely be contraindicated? • 45-year-old with bone marrow suppression • 23-year-old with diabetes mellitus • 18-year-old adolescent • 32-year-old with osteoarthritis

• 45-year-old with bone marrow suppression Explanation: Clozapine is associated with bone marrow suppression, a life-threatening decrease in white blood cells. Because of their wide-ranging adverse effects, antipsychotic drugs may cause or aggravate various conditions. They should be used very cautiously in clients with liver damage, coronary artery disease, cerebrovascular disease, Parkinsonism, bone marrow depression, severe hypotension or hypertension, coma, or severely depressed states. Diabetes, osteoarthritis and an age of 18 would not contraindicate its use.

14 of 20 When administering oral chlorpromazine, the nurse should implement which intervention? • Administer the drug on alternating days. • Instruct the client to avoid dairy products for 1 hour before and 2 hours after administration. • Have the client hold the drug under the tongue for at least 30 seconds. • Administer the drug 1 to 2 hours before bedtime.

• Administer the drug 1 to 2 hours before bedtime. Explanation: For oral administration of chlorpromazine, the nurse should give doses 1 to 2 hours before bedtime; peak sedation occurs in about 2 hours. The drug is not given on alternating days, and there is no need to avoid dairy products. It is unnecessary for the client to hold the drug under the tongue.

7 of 20 When assessing a client with schizophrenia, the nurse observes positive and negative symptoms. Which would the nurse document as a positive symptom? Select all that apply. • Flat affect • Alogia • Delusions • Avolition • Agitation

• Agitation • Delusions Explanation: Positive symptoms of schizophrenia include agitation, delusions, and hallucinations. Flat affect, alogia, and avolition are considered negative symptoms.

4 of 20 What client is being treated with a typical antipsychotic? • An agitated client who was given haloperidol during acute psychosis • A client with schizophrenia who received paliperidone 6 mg PO daily • A client whose thought disorder requires clozapine 25 mg PO b.i.d. • A client who recently began taking ziprasidone

• An agitated client who was given haloperidol during acute psychosis Explanation: Haloperidol is a typical antipsychotic. Ziprasidone, clozapine, and paliperidone are atypical antipsychotics.

17 of 20 When monitoring a client for possible neuroleptic malignant syndrome, the nurse will plan to implement what intervention into client care? Select all that apply. • Assess temperature every 8 hours. • Monitor bradycardia every 4 hours. • Document urinary output into client records every 8 hours. • Perform a daily bedside electrocardiogram (ECG). • Monitor for signs of respiratory distress.

• Assess temperature every 8 hours. • Monitor for signs of respiratory distress. • Document urinary output into client records every 8 hours. Explanation: Neuroleptic malignant syndrome, a rare but potentially fatal adverse effect, is characterized by rigidity, severe hyperthermia, agitation, confusion, delirium, dyspnea, tachycardia, respiratory failure, and acute renal failure. While tachycardia is a characteristic, cardiac arrhythmias are not commonly noted with this condition.

6 of 20 A 17-year-old client has just been diagnosed with schizophrenia. When educating the family about the cause of this disease, the nurse should address what factors? Select all that apply. • Biochemical disruptions • Impaired coping • Genetic factors • Psychosocial trauma • Seizure activity at a young age

• Biochemical disruptions Explanation: This disorder, which seems to have a very strong genetic association, may reflect a fundamental biochemical abnormality. Mental disorders are now thought to be caused by some inherent dysfunction within the brain that leads to abnormal thought processes and responses. Schizophrenia is not caused by poor coping, childhood trauma, or seizure activity.

2 of 20 Which antipsychotics can be administered rectally to a client? • Haloperidol • Aripiprazole • Clozapine • Chlorpromazine

• Chlorpromazine Explanation: Chlorpromazine may be administered rectally to clients with nausea and vomiting. Aripiprazole is given orally. Clozapine is given orally. Haloperidol can be given orally or intramuscularly.

8 of 20 A mother is concerned about recent behaviors by her young-adult son, and asks the nurse about what behaviors characterize schizophrenia. The nurse knows that the characteristics of schizophrenia include what actions? (Select all that apply.) • Impaired socialization • Disordered thinking • Repetitive actions • Abnormal behavior • Sexual promiscuity

• Disordered thinking • Abnormal behavior • Impaired socialization Explanation: Schizophrenia is characterized by disordered thinking, abnormal behavior, and impaired socialization. Sexual promiscuity and repetitive actions are not common characteristics of schizophrenia.

7 of 20 The nursing instructor is discussing psychosis with the nursing students. What behavior would the instructor explain people with psychosis exhibit? • Short manic episodes followed by long depressive episodes • Disorganized and often bizarre thinking • Slowed reaction time and poor coordination • Short- and long-term-memory deficits

• Disorganized and often bizarre thinking Explanation: Behavioral manifestations of psychosis include agitation, behavioral disturbances, delusions, disorganized speech, hallucinations, insomnia, and paranoia. They do not generally exhibit slowed reaction time, short manic episodes followed by long depressive episodes, or short- and long-term memory deficits.

8 of 20 A client's thought disorder has been treated with haloperidol (Haldol). For what adverse effect should the nurse most closely monitor the client? • Hypoglycemia • Bradycardia • Extrapyramidal effects • Shortness of breath

• Extrapyramidal effects Explanation: Haloperidol produces a relatively low incidence of hypotension and sedation and a high incidence of extrapyramidal effects. Haloperidol does not generally produce bradycardia, shortness of breath, or hypoglycemia.

12 of 20 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? • Deltoid • Ventrogluteal • Gluteus • Vastuslateralis

• Gluteus Explanation: 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.

3 of 20 What assessment finding should lead the nurse to suspect that a client receiving antipsychotic therapy is developing tardive dyskinesia? • Abnormal eye movements • Disorientation • Urinary incontinence • Lip smacking

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

16 of 20 The nurse monitoring a client prescribed chlorpromazine for adverse reactions should plan on including which interventions into the plan of care? Select all that apply. • Monitor white blood cell (WBC) count. • Monitor for facial edema. • Assess for hallucinations. • Take and record daily weight. • Monitor urinary output.

• Monitor white blood cell (WBC) count. • Take and record daily weight. • Monitor urinary output. Explanation: The nurse assesses the fluid and electrolyte status for a possible fluid volume deficit, making it necessary to measure the client's weight daily and assess for signs of dehydration. In addition, the nurse assesses for increased anticholinergic effects, such as diminished fluid status and urinary retention. The nurse assesses for aspiration related to depressed cough reflex. It is important to monitor renal and hepatic function along with the complete blood count. A depression in white blood cell count requires discontinuation of the medication. Excessive fluid volume is not associated with this medication. The medication is prescribed to eliminate hallucinations.

13 of 20 The nurse has an order to give a client 10 mg PO of Abilify. The client cannot swallow pills. Which choices would be acceptable for the nurse to administer this medication? • Obtain the liquid form of the medication and have the client take 10 mg in liquid form. • Pick another medication used for schizophrenia to substitute for Abilify. • Mark the chart, saying the client refused his medication. • Grind the pill, mix with water, and give IM.

• Obtain the liquid form of the medication and have the client take 10 mg in liquid form. Explanation: Many of the antipsychotic medications come in liquid form and can be given to clients who cannot swallow pills. Never grind up a pill and give IM. Marking the chart saying the client refused this medication is not accurate. Never substitute one medication for another without a new order from the provider.

10 of 20 A client who was diagnosed with schizophrenia in 1962 was prescribed chlorpromazine (Thorazine). The client has been taking the medication for more than 40 years. What adverse effect will the client most likely experience? • Central nervous system agitation • Hypertension • Urinary frequency • Tardive dyskinesia

• Tardive dyskinesia Explanation: A client who has taken chlorpromazine (Thorazine) on a long-term basis will be at risk for late extrapyramidal effects, such as tardive dyskinesia. Hypertension is not an adverse effect of chlorpromazine, but hypotension is an adverse effect. Central nervous system agitation is not an adverse effect of chlorpromazine, but central nervous system depression is an adverse effect. Urinary frequency is not an adverse effect of chlorpromazine, but urinary retention is an adverse effect.

11 of 20 The nurse on the unit has several clients taking clozapine. For which client is clozapine, an antipsychotic, contraindicated? • The 16-year-old with an upper respiratory infection • The 23-year-old with diabetes insipidus • The 32-year-old with osteoarthritis • The 45-year-old with bone marrow depression

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

5 of 20 A client is being treated with clozapine. What should the nurse monitor most closely? • AST, ALT and bilirubin • Cardiac enzymes • White blood cell count • Urine quantity and quality

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

2 of 20 For clients taking clozapine (Clozaril), it is necessary to monitor what lab test for the first 6 months? • White blood cells • Liver enzymes • PT/PTT • Hemoglobin

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

18 of 20 What behavior would cause the nurse to suspect a client is demonstrating an extrapyramidal effect (EPS) of antipsychotic drug therapy? Select all that apply. • repeated, involuntary twisting of the arms • sits with back to the wall to keep others from "hurting me" • near-constant lip smacking • inability to stay seated for any length of time • reporting hearing "voices"

• inability to stay seated for any length of time • repeated, involuntary twisting of the arms • near-constant lip smacking Explanation: Extrapyramidal effects include movement disorders such as tardive dyskinesia (e.g., lip smacking), akathisia (e.g., motor restlessness), and dystonia (e.g., twisting movements of the limbs). Dystocia is an abnormal or difficult birth or labor. Neither paranoia nor auditory hallucinations are associated with EPS.

1 of 20 Antipsychotic drugs are contraindicated in clients with: • peptic ulcer disease, mild hypertension, chronic joint pain, and kidney failure. • kidney damage, chronic obstructive lung disease, mild hypotension, and chronic bone pain. • nausea, severe hypotension, or intractable hiccups. • liver damage, coronary artery disease, severe hypertension, bone marrow depression, or cerebrovascular disease.

• liver damage, coronary artery disease, severe hypertension, bone marrow depression, or cerebrovascular disease. Explanation: 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.

17 of 20 In light of current treatment modalities, the nurse should anticipate that the client newly diagnosed with schizophrenia will most likely be prescribed what drug? • haloperidol • olanzapine • prochlorperazine • chlorpromazine

• olanzapine Explanation: The "atypical" antipsychotics, such as olanzapine, are the drugs of choice, especially for clients who are newly diagnosed with schizophrenia.

18 of 20 Phenothiazines such as chlorpromazine are occasionally used for clinical indications not associated with psychiatric illness. What indications would be included? Select all that apply. • nausea and vomiting • postoperative headaches • preoperative restlessness • Parkinson's disease • peptic ulcer disease

• preoperative restlessness • nausea and vomiting Explanation: Chlorpromazine is administered rectally or intramuscularly for the control of nausea and vomiting. It is also used preoperatively for the control of restlessness and apprehension. It is not used to treat headaches. It should be avoided in clients diagnosed with Parkinson's disease and used with caution for those clients with peptic ulcer disease.

15 of 20 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? • lower cost • absence of black box warnings • the possibility of oral administration • reduced adverse effects

• reduced adverse effects Explanation: 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.

20 of 20 Chlorpromazine is contraindicated for a client with what medical diagnosis? Select all that apply. • major depression • atrial fibrillation • stroke • cirrhosis • hyperthyroidism

• stroke • cirrhosis • major depression Explanation: Contraindications to chlorpromazine include liver damage, coronary artery disease, cerebrovascular disease, parkinsonism, bone marrow depression, severe hypotension or hypertension, coma, and severely depressed states. Neither of the other options are contraindications for chlorpromazine use.

20 of 20 During health education with the nurse, what subject should be the primary focus for a client newly diagnosed with schizophrenia? • the need for weekly blood coagulation testing • the importance of adherence to prescribed treatment • potential therapeutic effects of medication • maintenance of adequate nutrition

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

16 of 20 The nurse should focus on what aspects of care when preparing a caregiver to address the needs of a client who demonstrates psychotic behaviors? Select all that apply. • encouraging the client to avoid people outside of family and friends • encouraging the client to be as independent as is possible • being familiar with the available social services in the community • keeping all follow-up mental health appointments • understanding the nature of the client's mental health illness

• understanding the nature of the client's mental health illness • encouraging the client to be as independent as is possible • being familiar with the available social services in the community • keeping all follow-up mental health appointments Explanation: Major recurring challenges face clients with psychosis and their caregivers in the home. Supporting efforts to stabilize positive and negative symptoms and cognitive function, take medications as prescribed, manage adverse effects, and follow-up psychiatric care may require the coordinated efforts of several health and social service agencies or providers. Socialization is needed when it is appropriate and safe.

13 of 20 A prescriber has written for olanzapine for a client diagnosed with schizophrenia. What additional tests should the nurse anticipate the prescriber to order? Select all that apply. • weight • cholesterol profile • blood type • Fasting blood sugar • blood pressure

• weight • cholesterol profile • Fasting blood sugar Explanation: The administration of an atypical antipsychotic (SGA) medication such as olanzapine can put the client at a higher risk of acquiring type 2 diabetes. The client should be weighed and a family history documented to indicate type 2 diabetes risk. Laboratory work for fasting blood sugar, total and low-density lipoprotein (LDL) cholesterol, and triglycerides should be taken and compared at periodic intervals. Blood pressure would be part of the routine assessment by the nurse and not the prescriber. Blood type is not indicated for the client.

18 of 20 For clients taking clozapine, it is necessary to regularly monitor what lab test during the initial months of therapy and periodically thereafter? • red blood cell (RBC) count • white blood cell (WBC) count • blood urea nitrogen (BUN) • partial thromboplastin time (PTT)

• white blood cell (WBC) count Explanation: It is essential to monitor the WBC counts of the client taking clozapine due to the risk of fatal agranulocytosis. Coagulation tests, RBC counts, and measurement of BUN are not indicated.