Chapter 22 Psychotherapeutic Agents

14. The nurse is caring for an adolescent patient who began taking an antipsychotic drug last month to treat newly diagnosed schizophrenia. The drug has not been effective and the mother asks the nurse if this means the adolescent's symptoms cannot be controlled by drugs. What is the nurse's best response? A) Patients commonly have to try different drugs until the most effective drug is identified. B) Some patients do not respond to drugs and have to rely solely on behavior therapy. C) Most likely your child was not taking the medication properly as prescribed. D) He may need to take multiple drugs before effects will be seen that control his symptoms.

Ans: A Feedback: A patient who does not respond to one drug may react successfully to another agent. Responses may also vary because of cultural issues. The selection of a specific drug depends on the desired potency and patient tolerance of the associated adverse effects. It is not common to have a patient who does not demonstrate some improvement from medications so it would be incorrect to tell the mother the child won't respond to any drug after trying only one medication. There is no indication the drug was taken improperly and even properly administered drugs will not work on all patients. Multiple drug therapy is not indicated by the question

23. Psychosis is a severe mental illness characterized by what? A) Disordered thought B) Increased social interaction C) Hypoactivity with aggressiveness D) Paranoid hallucinations

Ans: A Feedback: Antipsychotic drugs are used mainly for the treatment of psychosis, a severe mental disorder characterized by disordered thought processes; blunted or inappropriate emotional responses; bizarre behavior ranging from hypoactivity to hyperactivity with agitation, aggressiveness, hostility, and combativeness; social withdrawal in which a person pays less-than-normal attention to the environment and other people; deterioration from previous levels of occupational and social functioning (poor self- care and interpersonal skills); hallucinations; and paranoid delusions.

15. Haloperidol is a typical antipsychotic drug. What adverse effect is associated with this drug? A) Bradycardia B) Bradypnea C) Extrapyramidal effects D) Hypoglycemia

Ans: C Feedback: Haloperidol produces a relatively low incidence of hypotension and sedation and a high incidence of extrapyramidal effects. Haloperidol does not generally produce bradycardia, bradypnea, or hypoglycemia.

20. Parents bring a 15-year-old boy into the clinic. The parents tell the nurse that there is a family history of schizophrenia and they fear their son has developed the disease. What symptoms, if described by the family, would support their conclusion? A) He hears and interacts with voices no one else can hear. B) He is overactive and always so excitable. C) He falls asleep in the middle of a sentence. D) He cannot concentrate and his grades are suffering

Ans: A Feedback: Characteristics of schizophrenia include hallucinations, paranoia, delusions, speech abnormalities, and affective problems. Overactivity and excitement are associated with mania. Falling asleep suddenly describes narcolepsy. Difficulty concentrating and failing grades is associated with attention deficient disorders.

19. The physician has ordered olanzapine (Zyprexa) for a new patient. What laboratory test should be done before administration of olanzapine? A) Blood glucose B) Urine specific gravity C) Cholesterol D) Hemoglobin and hematocrit

Ans: A Feedback: Olanzapine has been associated with weight gain, hyperglycemia, and initiation or aggravation of diabetes mellitus. Other options are not necessary for patients taking olanzapine unless a secondary diagnosis indicates a need.

9. A patient has just been prescribed a phenothiazine. During patient teaching about this drug, what would be important for the nurse to tell the patient? A) The urine can turn pink or reddish. B) The urine output will be decreased. C) Diarrhea can be an adverse effect. D) Hyperexcitability can occur.

Ans: A Feedback: Phenothiazines can cause the urine to turn pink or reddish. The patient should be informed that this is a simple color change and is not caused by blood in his urine. Decreased urine output is not associated with this drug. Constipation is usually an adverse effect of the drug. Drowsiness, not hyperexcitability, can occur.

26. The nurse admits a patient newly diagnosed with schizophrenia to the inpatient mental health unit. What is the priority reason for why the nurse includes the family when collecting the nursing history? A) The patient may not be able to provide a coherent history. B) The patient may not be able to speak due to reduced level of consciousness. C) The family will feel better if they are included in the process. D) The patient will be less anxious if the family listens while he answers questions.

Ans: A Feedback: Schizophrenia, the most common psychosis, is characterized by delusions, hallucinations, and inappropriate responses to stimuli. As a result, the patient may be unable to provide a coherent history and may be unaware of his behaviors considered dysfunctional. There is no reason to suspect the patient cannot speak and reducing anxiety is not the priority rationale for including family. While family is included in treatment, the goal is to treat the patient and not make the family feel better if actions were not in the patient's best interests

12. A patient on chlorpromazine is feeling better and decides they no longer need their medication. The nurse teaches the patient that abrupt withdrawal of a typical antipsychotic medication can result in what? A) Insomnia B) Tardive dyskinesia C) Somnolence D) Constipation

Ans: A Feedback: Sudden withdrawal can cause cholinergic effects such as diarrhea, gastritis, nausea, vomiting, dizziness, arrhythmias, drooling, and insomnia. Abrupt withdrawal of a typical antipsychotic generally does not cause tardive dyskinesia, somnolence, or constipation.

35. The nurse is caring for a child receiving a central nervous system (CNS) stimulant who was admitted to the pediatric intensive care unit following repeated seizures after a closed head injury. The physician orders phenytoin to control seizures and lorazepam to be administered every time the child has a seizure. What is the nurse's priority action? A) Call the doctor and question the administration of phenytoin. B) Call the doctor and question the administration of lorazepam. C) Wait 24 hours before beginning to administer phenytoin. D) Wait 24 hours before beginning to administer lorazepam

Ans: A Feedback: The combination of CNS stimulants with phenytoin leads to a risk of increased drug levels. Patients who receive such a combination should be monitored for toxicity. There is no contraindication for use of lorazepam.

33. A child was diagnosed with attention-deficit hyperactivity disorder and methylphenidate was prescribed for treatment to be taken once a day in a sustained release form. On future visits what is a priority nursing assessment for this child? A) Weight and height B) Breath sounds and respiratory rate C) Urine output and kidney function D) Electrocardiogram (ECG) and echocardiogram

Ans: A Feedback: The nurse needs to carefully track this child's weight and height because the drug can cause weight loss, anorexia, and nausea that could result in slowed or absent growth. There would be no need to monitor breath sounds, respiratory rate, urine output, and kidney function. Although arrhythmias may occur as an adverse effect necessitating an ECG, there is no need to perform echocardiograms.

31. The mother of a child diagnosed with attention-deficit syndrome receives a prescription for a central nervous system (CNS) stimulant to treat her child. The mother asks the nurse, I don't understand why we're giving a stimulant to calm him down? What is the nurse's best response to this mother? A) It helps the reticular activating system (RAS), a part of the brain, to be more selective in response to incoming stimuli. B) It helps energize the child so they use up all of their available energy and then they can focus on quieter stimuli. C) No one truly understands why it works but it has been demonstrated to be very effective in treating ADHD. D) The drugs work really well and you will see a tremendous change in your child within a few weeks without any other treatment.

Ans: A Feedback: The paradoxical effect of calming hyperexcitability through CNS stimulation seen in attention-deficit syndrome is believed to be related to increased stimulation of an immature RAS, which leads to the ability to be more selective in response to incoming stimuli. CNS stimulants do not cause the child to use all his energy, the effect is thought to be understood, and telling the mother the drug just works without any explanation is not appropriate and may result in noncompliance with pharmacology therapy if the mother does not understand why the drug is given.

5. The nurse is presenting an in-service at a children's unit on hyperactivity. The nurse is told that a 6- year-old on the unit is being treated with methylphenidate (Ritalin). The presenting nurse talks about discharge teaching for this patient and the importance of monitoring what? A) Long bone growth B) Visual acuity C) Weight and complete blood count D) Urea and nitrogen levels

Ans: C Feedback: Methylphenidate is associated with weight loss, bone marrow suppression, and cardiac arrhythmias. Weight, blood count, and cardiac function should be monitored regularly. The drug is not associated with renal dysfunction, visual changes, or growth retardation, so those values would not need to be regularly evaluated as part of drug therapy.

4. The nurse administers chlorpromazine intramuscularly to the preoperative patient who is extremely anxious about surgery in the morning. What priority teaching point will the nurse provide this patient? A) Remain recumbent for at least 30 minutes after the injection. B) Do not eat for 1 hour after the drug is administered. C) Encourage fluids with the goal of 3,000 mL/d. D) Avoid eating avocados and oranges when taking this medication.

Ans: A Feedback: When giving a parenteral form of an antipsychotic, the patient should remain recumbent to decrease the risk of injury if orthostatic hypotension occurs. Eating after drug injection should not interfere with the drug's absorption and although adequate hydration should be maintained there is no need to increase fluid intake. Avocados and oranges are not contraindicated in patients receiving this medication

24. The nurse is caring for a patient newly diagnosed with schizophrenia. His parents say they have heard the term before but do not really understand exactly what schizophrenia means. How would the nurse describe the disorder? (Select all that apply.) A) Thought disorder B) Difficulty functioning in society C) Hallucinations can be auditory, visual, or sensory D) Can be cured with the correct medications E) Enter into fugue state in most cases

Ans: A, B, C, D Feedback: Mental disorders are thought process disorders that may be caused by some inherent dysfunction within the brain. A psychosis is a thought disorder, and schizophrenia is the most common psychosis in which delusions and hallucinations are hallmarks. Hallucinations can be auditory, visual, or sensory. Patients diagnosed with schizophrenia have difficulty functioning in society. Schizophrenic patients do not generally go into fugue states and it certainly is not a common disorder.

16. The pharmacology instructor is explaining to their class the difference between the typical and the atypical groups of antipsychotic drugs. What medication would the instructor explain to the students has fewer extrapyramidal effects and greater effectiveness than older antipsychotic drugs in relieving negative symptoms of schizophrenia? A) Chlorpromazine (Thorazine) B) Clozapine (Clozaril) C) Thiothixene (Navane) D) Haloperidol (Haldol)

Ans: B Feedback: Advantages of clozapine include improvement of negative symptoms without causing the extrapyramidal effects associated with older antipsychotic drugs. Chlorpromazine is a typical antipsychotic, one of the older drugs, which does cause the extrapyramidal effects. Navane is part of the thioxanthene group of typical antipsychotics. This group of drugs has low sedative and hypotensive effects but can cause extrapyramidal effects. Haloperidol is a butyrophenone group drug used in psychiatric disorders. Usually, it produces a relatively low incidence of hypotension and sedation and a high incidence of extrapyramidal effects.

17. The nurse, providing teaching about a typical antipsychotic newly prescribed for the patient, cautions against use of alcohol with the drug by explaining it will have what effect? A) Prolonged QT interval B) Increased central nervous system (CNS) depression C) Increased anticholinergic effects D) Increased gastrointestinal (GI) adverse effects

Ans: B Feedback: Antipsychotic alcohol combinations result in an increased risk of CNS depression, and antipsychotic anticholinergic combinations lead to increased anticholinergic effects, so dosage adjustments are necessary. Patients should not take thioridazine or ziprasidone with any other drug associated with prolongation of the QT interval. Increase in GI adverse effects is not associated with concurrent use of alcohol.

10. A patient, in the manic phase of bipolar disorder, is being discharged home on an antimanic drug. What antimanic drug is used for long-term maintenance of bipolar disorders? A) Aripiprazole (Abilify) B) Lamotrigine (Lamictal) C) Quetiapine (Seroquel) D) Ziprasidone (Geodon)

Ans: B Feedback: Lamotrigine is used for long-term maintenance of bipolar disorders. Aripiprazole and ziprasidone are used for acute manic and mixed episodes of bipolar disorders. Quetiapine is used as adjunct or monotherapy for the treatment of manic episodes associated with bipolar disorder.

30. Which drug does not have a recommended pediatric dose? A) Pimozide (Orap) B) Lithium salts (Lithotabs) C) Haloperidol (Haldol) D) Risperidone (Risperdal)

Ans: B Feedback: Lithium does not have a recommended pediatric dose; the drug should not be administered to children younger than 12 years old. Pimozide, haloperidol, and risperidone all have recommended pediatric doses.

32. The nurse is teaching the mother of a child diagnosed with attention-deficit hyperactivity disorder how to administer methylphenidate (Ritalin). When would the nurse instruct the mother to administer this drug? A) Administer at lunch every day. B) Administer at breakfast every day. C) Administer at dinner every day. D) Administer at bedtime.

Ans: B Feedback: Several long-acting formulations of methylphenidate have become available that allow the drug to be given only once a day. It should always be given in the morning because administration at dinnertime or bedtime could result in insomnia.

8. A patient diagnosed with bipolar disorder is to be discharged home in 48 hours. The nurse has completed patient teaching regarding the use of lithium. What statement by the patient indicates an understanding of their responsibility? A) I will increase my salt intake. B) I will increase my fluid intake. C) I will decrease my salt intake. D) I will decrease my fluid intake.

Ans: B Feedback: To maintain a therapeutic lithium level, the patient must increase fluids. A decrease in consumption of fluids can lead to toxicity. An increase in salt intake can lead to lithium excretion and a decrease in effectiveness. A decrease in salt intake can cause retention, also leading to toxicity. Adequate salt intake is necessary to keep serum levels in therapeutic range but need not be increased or decreased.

29. A patient, who is 77 years old, is admitted with a diagnosis of dementia. Haloperidol (Haldol) has been ordered for this patient. What nursing considerations would govern the nurse's actions? (Select all that apply.) A) It is classed as an atypical antipsychotic. B) A lowered dosage is indicated for older adult. C) It often has a hyperactive effect on patients. D) It should not be used to control behavior with dementia. E) It should only be given every other day

Ans: B, D Feedback: Haloperidol is classified as a typical antipsychotic with a high risk of extrapyramidal effects and lower risk for hypotension and sedation. Older patients may be more susceptible to the adverse effects of antipsychotic drugs. All dosages need to be reduced and patients monitored very closely for toxic effects and to provide safety measures if central nervous system effects do occur. They should not be used to control behavior with dementia. Haloperidol does not have a hyperactive effect on patients; it should not be given on an every-other-day schedule.

28. What antiepileptic medication might the nurse administer to treat bipolar disorder? A) Apriprazole (Abilify) B) Cyclobenzaprine (Flexeril) C) Lamotrigine (Lamictal) D) Temazepam (Restoril)

Ans: C Feedback: Lamotrigine is an antiepileptic agent used for long-term maintenance of patients with bipolar disorders because it decreases occurrence of acute mood episodes. Apriprazole is an atypical antipsychotic and is not an antiepileptic medication. Flexeril is a muscle relaxant and Temazepam is a hypnotic agent. None of these medications are indicated for the treatment of bipolar disorder.

13. A patient's medication has been changed to clozapine (Clozaril). The nurse evaluates this patient for which life-threatening adverse effect? A) Renal insufficiency B) Emphysema C) Neuroleptic malignant syndrome D) Cerebrovascular accident (CVA)

Ans: C Feedback: Neuroleptic malignant syndrome can be a life-threatening adverse effect of atypical non- phenothiazines. Renal insufficiency, emphysema, and CVA are not commonly seen adverse effects of atypical non-phenothiazines

25. A 7-year-old boy is admitted to the pediatric behavioral health unit with a diagnosis of an acute psychotic episode. Aripiprazole has been ordered. Before administering the medication, what is the nurse's first priority? A) Weigh the patient. B) Obtain baseline vital signs. C) Call the physician. D) Administer the medication between meals.

Ans: C Feedback: Of the antipsychotics, chlorpromazine, haloperidol, pimozide, prochlorperazine, risperidone, thioridazine, and trifluoperazine are the only ones with established pediatric regimens. Aripiprazole has dosages for children 13 to 17 years of age but would not be appropriate for a 7-year-old child. Weighing the patient and obtaining baseline vital signs is necessary assessment data but is not the first priority. There is nothing to indicate medications should be administered between meals.

2. What nursing intervention is appropriate for a 70-year-old female patient receiving lithium? A) Instruct the patient to use barrier contraceptives. B) Monitor blood glucose levels. C) Monitor fluid and sodium intake. D) Encourage the patient to check daily for weight loss

Ans: C Feedback: Older patients, and especially those with renal impairment, should be encouraged to maintain adequate hydration and salt intake. Decreased dosages may also be necessary with the elderly. A 70-year-old patient would not be concerned about the use of contraceptives. These drugs alone do not affect glucose levels. Weight loss is usually not associated with lithium use.

3. A nurse is caring for a patient who is taking lithium for mania. The nurse's assessment includes a notation of a lithium serum level of 2.4 mEq/L. The nurse anticipates seeing what? A) Fine tremors of both hands B) Slurred speech C) Clonic movements D) Nausea and vomiting

Ans: C Feedback: Serum levels of 2 to 2.5 mEq/L may produce ataxia, clonic movements, possible seizures, and hypotension. Fine hand tremors, slurred speech, and nausea and vomiting are indicative of lithium levels less than 1.5 mEq/L.

7. A psychotic patient is admitted through the emergency department. The physician has ordered chlorpromazine (Thorazine) 25 mg intramuscularly. After administration of the medication, what is the nurse's priority to evaluate? A) The patient's ability to ambulate B) Return of the patient's appetite C) A decrease in psychotic symptoms D) Blood pressure and pulse

Ans: C Feedback: The nurse will evaluate the effectiveness of the drug in diminishing psychotic symptoms because this is the purpose of administering the drug. Monitoring blood pressure, pulse, and appetite is part of all patient care but is not the priority evaluation criterion for this patient. The ability to ambulate and maintain adequate nutrition would be assessed but is not the priority evaluation for this patient.

11. A 16-year-old youth has just been diagnosed with schizophrenia. The parents ask the nurse what causes schizophrenia. What would be the nurse's best response? A) Schizophrenia is caused by pain that the brain perceives. B) Schizophrenia is thought to occur due to trauma experienced in childhood. C) Schizophrenia is thought to reflect a fundamental biochemical abnormality. D) Schizophrenia is caused by seizure activity in the brain

Ans: C Feedback: 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 pain, childhood trauma, or seizure activity.

27. The nurse is teaching the soon-to-be-discharged patient, diagnosed with schizophrenia, about his medications. What is a priority teaching point for this patient? A) The patient must eat three nutritious meals daily. B) Over-the-counter medications may be taken with antipsychotic drugs. C) Cough medicines potentiate the actions of antipsychotic drugs. D) Alcohol consumption should be avoided

Ans: D Feedback: Alcohol consumption should be avoided because it increases the central nervous system (CNS) effects of the drug and may cause excessive drowsiness and decreased awareness of safety hazards in the environment. Some patients may find it easier and more effective to eat five small meals rather than three nutritious meals. While promoting good nutrition is good practice, it is not the priority. Drugdrug interactions with antipsychotic drugs are common so the nurse would teach the patient not to take any medication without consulting with the doctor or a pharmacist to make sure it is safe.

18. The nurse is caring for four patients. Which patient would the nurse know that clozapine (Clozaril) is contraindicated for? A) 17-year-old adolescent B) 23-year-old with diabetes insipidus C) 32-year-old with osteoarthritis D) 45-year-old with bone marrow depression

Ans: D Feedback: 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 patients with liver damage, coronary artery disease, cerebrovascular disease, Parkinsonism, bone marrow depression, severe hypotension or hypertension, coma, or severely depressed states. Options A, B, and C are incorrect.

34. The nurse is preparing to administer methylphenidate to the child admitted to the pediatric unit after breaking a leg when jumping off the garage roof at home. Where will the nurse find the medication? A) In the patient's drawer B) In the refrigerator C) At the patient's bedside D) In the controlled substance cabinet

Ans: D Feedback: Methylphenidate is a controlled medication due to risk for physical and psychological dependence. As a result, the drug would be found in the controlled substance cabinet.

22. The nurse works on an inpatient mental health unit. When administering antipsychotic medications, what patient would the nurse expect to require a standard dosage? A) African American adolescent diagnosed with schizophrenia B) Malaysian middle adult diagnosed with bipolar disorder C) Iranian older adult diagnosed with schizophrenia D) Caucasian young adult diagnosed with bipolar disorder

Ans: D Feedback: Only the Caucasian young adult has no indications for administering a smaller than usual dosage. African Americans respond more rapidly to antipsychotic medications and have a greater risk for development of disfiguring adverse effects, such as tardive dyskinesia. Consequently, these patients should be started off at the lowest possible dose and monitored closely. Patients in Asian countries (e.g., India, Turkey, Malaysia, China, Japan, Indonesia) receive lower doses of neuroleptics and lithium to achieve the same therapeutic response as seen in patients in the United States. Arab American patients metabolize antipsychotic medications more slowly than Asian Americans do and may require lower doses to achieve the same therapeutic effects as in Caucasians

21. The patient taking an antipsychotic drug asks the nurse how long he will continue to feel the effects of the drug after stopping the medication. What is the nurse's best response? A) 2 to 4 hours B) 2 to 4 weeks C) 2 to 4 months D) 6 months

Ans: D Feedback: The antipsychotics are widely distributed in the tissues and are often stored there, being released for up to 6 months after the drug therapy has been stopped.

6. The nurse is caring for a patient taking an oral neuroleptic medication. What is the nurse's priority assessment to monitor for? A) Urge incontinence B) Orthostatic hypotension C) Bradycardia D) Tardive dyskinesia

Ans: D Feedback: The nurse would monitor for and teach the patient and family about tardive dyskinesia because it is such a common adverse effect with continued use of the drug. Oral neuroleptic agents do not cause urge incontinence, orthostatic hypotension, or bradycardia.