Chapter 17: Drugs Used for Psychoses

11. A young male patient taking an antipsychotic is experiencing an oculogyric crisis. The nurse prepares to administer a. diphenhydramine. b. haloperidol. c. aripiprazole. d. risperidone.

ANS: A Acute dystonic reactions may be controlled by intramuscular injections of diphenhydramine. Haloperidol, aripiprazole, and risperidone are not used for dystonic reactions.

4. Which type of adverse effects is present when a patient displays prolonged tonic contractions of the tongue, oculogyric crisis, and torticollis? a. Dystonic reactions b. Pseudoparkinsonism c. Akathisia d. Tardive dyskinesia

ANS: A Dystonic reactions are the first extrapyramidal symptoms to occur when a patient is taking antipsychotic agents. Dystonias are spasmodic movements of muscle groups such as tongue protrusion, rolling back of the eyes (oculogyric crisis), jaw spasms (trismus), or neck torsion (torticollis). Pseudoparkinsonism is characterized by tremor and rigidity. Akathisia is characterized by subjective feelings of anxiety and restlessness, accompanied by pacing and the inability to remain in one place for extended periods. Tardive dyskinesia is characterized by persistent involuntary hyperkinetic movements.

5. The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication? a. Agranulocytosis b. Vitamin deficiencies c. Clotting abnormalities d. Polycythemia

ANS: A The use of clozapine requires a baseline and weekly white blood cell (WBC) counts because of the high incidence of agranulocytosis. Clozapine does not cause vitamin deficiencies. Clozapine does not interfere with clotting abilities. Clozapine does not affect red blood cell volume.

9. Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect? a. Extrapyramidal symptoms b. Allergic reactions c. Idiosyncratic reactions d. Therapeutic responses

ANS: A There are four categories of extrapyramidal symptoms: dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. These are not allergic reactions, idiosyncratic reactions, or therapeutic responses.

3. Which is/are extrapyramidal adverse effect(s) of antipsychotic agents? (Select all that apply.) a. Spasmodic movements of muscle groups b. Masklike expression c. Lip smacking d. Inability to sit in one place for an extended period e. Weight gain

ANS: A, B, C, D Dystonic reactions, pseudoparkinsonism, tardive dyskinesia, and akathisia are extrapyramidal symptoms of antipsychotic agents. Antipsychotic drug therapy often causes substantial weight gain, but this is not classified as an extrapyramidal adverse effect.

4. Which sign(s) and symptom(s) may occur in neuroleptic malignant syndrome? (Select all that apply.) a. Fever b. Hypertension c. Severe extrapyramidal symptoms d. Alterations in consciousness e. Bradycardia

ANS: A, B, C, D Fever, severe extrapyramidal symptoms, hypertension, and alterations in consciousness (such as stupor, mutism, and coma) are characteristic of neuroleptic malignant syndrome. Bradycardia is not a sign of neuroleptic malignant syndrome.

5. Which adverse effect(s) may occur as a result of antipsychotic drug therapy? (Select all that apply.) a. Acute dystonia b. Akathisia c. Weight loss d. Neuroleptic malignant syndrome e. Hypoglycemia f. Tardive dyskinesia

ANS: A, B, D, F Antipsychotic drugs can cause neuroleptic malignant syndrome and motor dysfunctions such as dystonia, akathisia, and tardive dyskinesia. Antipsychotic drugs may cause weight gain and hyperglycemia.

7. Which statement is true regarding the adverse effects associated with antipsychotic medications? a. Tardive dyskinesia is a common, reversible condition. b. Painful dystonic reactions can occur in the first 72 hours of initiation of therapy. c. Neuroleptic malignant syndrome (NMS) is a common adverse effect. d. Pseudoparkinsonian symptoms can cause Parkinson's disease.

ANS: B Approximately 90% of all dystonic reactions occur in the first 72 hours of antipsychotic therapy. These symptoms are often frightening and painful. Tardive dyskinesia is present in 20% to 25% of patients and may become irreversible. NMS is not a common adverse effect. Pseudoparkinsonism is not related to Parkinson's disease.

2. Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient? (Select all that apply.) a. Antipsychotics are not effective for 2 days. b. Benzodiazepines allow for lower dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high-dose therapy. c. It assists in calming the psychotic patient. d. It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations. e. It effectively treats extrapyramidal adverse effects associated with antipsychotic agents.

ANS: B, C The use of benzodiazepines allows lower dosages of antipsychotic agents to be used. Benzodiazepines assist in calming the agitated psychotic patient. Antipsychotic medications can be effective in a matter of minutes when injected. Benzodiazepines do not facilitate the increase of antipsychotic medications or treat extrapyramidal adverse effects associated with antipsychotic agents.

1. A patient admitted to the hospital is exhibiting psychotic behavior. Which sign(s) and/or symptom(s) would support the diagnosis of psychosis? (Select all that apply.) a. Constant eye contact during the admission history b. Deterioration of social functioning c. Reporting that the FBI has solicited important secret information from his phone conversations d. Confirmation of hearing voices in his head e. Changing the topic of conversation inappropriately

ANS: B, C, D, E Social deterioration, disordered thinking (including delusions), disordered perception, (including hallucinations), and flight of ideas are symptoms of psychotic behavior. It is uncommon for a psychotic patient to maintain eye contact.

6. A patient admitted to a psychiatric facility is hallucinating, pacing, and acting highly suspicious. Based on this information, the nurse will take which action(s)? (Select all that apply.) a. Use the most restrictive restraints available to subdue the patient. b. Be open and direct when handling the patient. c. Encourage a variety of interactions with others. d. Provide high-protein, high-calorie foods. e. Reinforce hallucinations.

ANS: B, D Nursing interventions for patients with psychosis must be individualized and based on patient assessment data. The nurse should be open and direct when handling patients who are highly suspicious. High-protein, high-calorie foods are appropriate for the individual to eat while pacing or highly active. If physical restraints are necessary, they should be the least restrictive possible for the circumstances. Interactions should be minimized when perceptions are altered. Hallucinations should not be reinforced.

7. The psychiatric nurse is educating an elderly patient and family about antipsychotic drug therapy. When providing this education, the nurse will include which statement(s)? (Select all that apply.) a. Hallucinations may be reduced within 1 week of starting. b. Rapid increase in dosages will increase frequency of adverse effects. c. Older patients should be observed for hypertension. d. Tardive dyskinesia may be reversible in early stages. e. Full therapeutic response may require 6 to 8 weeks to be achieved.

ANS: B, D, E Rapid increases in dosages of antipsychotic medication will not reduce the antipsychotic response time but will increase the frequency of adverse effects. Tardive dyskinesia may be reversible in early stages, but it becomes irreversible with continued use of the antipsychotic medication. Reduction in hallucinations, delusions, and thought disorders often requires 6 to 8 weeks for a full therapeutic response to be achieved. Older patients should be observed for hypotension.

2. A patient with schizophrenia has been nonadherent with his home medication regimen. He requires frequent admissions to the intensive psychiatric unit for treatment of acute psychotic episodes. Which medication regimen would be appropriate for this patient? a. Daily home nursing visits to administer the prescribed oral medication b. Continuous inpatient hospitalization for medication therapy c. Administration of depot antipsychotic medication d. Subcutaneous medication administration

ANS: C Depot antipsychotic medications are long-acting injections that may be used with noncompliant patients and may assist in avoiding repeated hospital admissions. Daily home nursing visits are not an efficient way to ensure medication compliance. Continuous inpatient hospitalization is not an efficient way to ensure medication compliance. Subcutaneous medication administration is not an option for this patient.

6. A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take? a. Support the patient's decision to refuse the medication. b. Discreetly ask an assistant to put the medication in the patient's food. c. Firmly redirect the patient to take the medication. d. Speak privately with the patient and reinforce medication action.

ANS: C During episodes of acute psychosis, the patient is out of touch with reality and often does not understand the need for medication in stabilizing his or her condition. Target symptoms such as agitation, suspicion, and paranoia are common. Health care providers must be supportive yet firm in their expectations. An open and direct manner in handling patients who are highly suspicious is critical. Delusions should not be supported. The patient is not competent to determine his need for medication. It is dishonest to hide medication in a patient's food and destroys a trusting relationship. Reasoning with the patient is unlikely to change his mind; he needs external structure for making decisions when he is aggressive and paranoid.

3. What is the most common cause of nonadherence to antipsychotic pharmacologic treatment? a. Expense b. Increased symptoms of chemical dependency c. Extrapyramidal effects d. Inability of the patient to understand the need to take medications

ANS: C Extrapyramidal effects are the most common reason for nonadherence to antipsychotic therapy. The four categories of extrapyramidal effects are dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia. Although expense may be a concern, it is not the most common reason for noncompliance. Chemical dependency is not a feature of therapy with antipsychotic drugs. Although knowledge deficit is a concern, it is not the most common reason for noncompliance.

8. To what does potency of an antipsychotic medication refer? a. Severity of adverse effects associated with the drug b. Length of time that it takes to reach a therapeutic blood level of the drug c. Milligram doses used for the medication d. Effectiveness of the drug in alleviating psychotic behavior

ANS: C Low and high potency refers only to the milligram doses used for the medications and does not suggest any difference in effectiveness. Potency is not related to severity of adverse effects or onset of action. Potency does not refer to effectiveness.

10. Which is an appropriate nursing intervention for a patient who has recently been prescribed clozapine (Clozaril)? a. Assess for signs and symptoms of hypoglycemia. b. Encourage a low-fiber diet. c. Measure the patient's waist circumference. d. Monitor for insomnia.

ANS: C Waist circumference baseline measurement is appropriate because of the weight gain and onset of diabetes with use of these medications. Hypoglycemia and insomnia do not occur with this medication. A low-fiber diet is not appropriate.

1. The nurse is assessing a patient who is complaining of hearing voices. What is this patient experiencing? a. Delusions b. Flight of ideas c. Disorganized thinking d. Hallucinations

ANS: D Hallucinations are false sensory perceptions that are experienced without an external stimulus but seem real to the patient. Auditory hallucinations are prominent in a schizophrenic patient. Additional sensory hallucinations include those of touch, sight, smell, and body sensation. Delusions are false beliefs that persist despite evidence to the contrary. Flight of ideas is characterized by rapid changes in thought from one topic to another. Disorganized thinking is commonly associated with psychoses and consists of a flight of ideas during which the individual jumps from one idea or topic to another one.