Ch 15

A 75-year-old patient with a long history of depression begins amitriptyline 100 mg/day. The patient also takes a diuretic daily for hypertension. What is the highest priority nursing diagnosis this patient is at risk for? a. Falls related to dizziness and orthostatic hypotension. b. Ineffective thermoregulation related to anhidrosis. c. Infection related to suppressed white blood cell count. d. Constipation related to slowed gastrointestinal peristalsis.

ANS: A Amitriptyline is a tricyclic antidepressants (TCA) that has a high risk of producing orthostatic hypotension. The patient is placed at even greater risk because of older age and diuretic therapy, which reduces fluid volume. The other options are either unassociated or are remote possibilities.

What is the nurse's priority assessment for a patient taking an antidepressant medication? a. Presence of suicidal ideations b. Presence of antiadrenergic side effects c. Presence of anticholinergic side effects d. Presence of symptoms of sexual dysfunction

ANS: A Antidepressant medication tends to energize depressed patients, possibly giving them the impetus to act on suicidal ideation that has been present related to the depression. This complication is particularly applicable to adolescents. Some suggest that suicidal ideation might be the actual result of antidepressant therapy. In either case the implication for nursing is clear—patients should be carefully assessed for the presence of suicidal ideation, suicidal plans, and means for carrying out the plans. This option is related to patient safety and takes priority over the other options.

What is the nurse's highest priority when caring for a patient after a tricyclic antidepressant (TCA) overdose? a. Frequently monitor blood pressure and heart rate/rhythm. b. Monitor for skin rashes, particularly on the torso. c. Measure and record intake and output every 12 hours. d. Institute cooling blankets for hyperthermia.

ANS: A It is necessary to assess cardiovascular function, because cardiovascular reactions can occur suddenly, even several days after the TCA overdose, and can result in acute heart failure. The other options are not as closely aligned with cardiovascular problems.

When teaching about the monoamine oxidase inhibitor (MAOI) tranylcypromine, the nurse should consider it a priority to provide what information? a. A list of tyramine-rich foods b. A warning to avoid direct sunlight c. Instructions to manage fever with acetaminophen d. Directions to report dry mouth and blurred vision

ANS: A MAOIs and ingested tyramine interact to produce hypertensive crisis, a life-threatening medical emergency, so it is necessary to teach the patient foods to avoid. The other options are unrelated to tranylcypromine therapy.

Why do patients taking tricyclic antidepressants (TCAs) exhibit more side effects than patients taking selective serotonin reuptake inhibitors (SSRIs)? a. TCAs inhibit reuptake of norepinephrine and serotonin. b. TCAs selectively inhibit dopamine reuptake. c. TCAs selectively block serotonin uptake. d. TCAs block enzymatic breakdown.

ANS: A TCAs inhibit the reuptake of both norepinephrine and serotonin and because of their nonselectivity produce many side effects. The other options are incorrect statements about the action of TCAs.

Evaluation of a patient's response after 1 week of tricyclic antidepressant (TCA) therapy would be expected to focus on what assessment question? (Select all that apply.) a. "Have you noticed a change in your sleep patterns?" b. "Has your appetite improved?" c. "Are you still having suicidal ideations?" d. "Are you feeling less depressed?" e. "Would you say you are less anxious now?"

ANS: A, B, E Improved appetite is likely due to the antihistaminic effect of the drug. Anxiety reduction is another positive effect of TCAs. Sedation is a therapeutic effect of some of these drugs as well. Neither improvement in mood nor elimination of suicidal ideations are likely to occur for 2 to 4 weeks.

Which assessment finding warrants the nurse's priority attention when caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI)? (Select all that apply.) a. Hyperthermia b. Frontal headache c. Confusion d. Photophobia e. Agitation

ANS: A, C, E The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.

A patient diagnosed with depression has taken a selective serotonin reuptake inhibitor (SSRI) for 1 month. The nurse should use direct questions to evaluate which potential side effect? a. Aggressive impulses b. Sexual dysfunction c. Paranoid delusions d. Weight gain

ANS: B SSRIs often produce sexual dysfunction, such as decreased libido. Patients readily tell nurses about anticholinergic, gastrointestinal, and other side effects, but are not as forthcoming in reporting sexual problems. The nurse might need to ask directly to elicit this information. Patients are more willing to discuss the other options.

A pregnant patient took selective serotonin reuptake inhibitors (SSRIs) during the third trimester of pregnancy. The newborn will be carefully assessed for which neonatal complication? a. Temperature dysregulation b. Serotonin syndrome c. Seizure disorder d. Diabetes

ANS: B The neonate whose mother has received SSRIs might experience respiratory depression, hypoglycemia, tremor, and low birth weight as part of neonatal serotonin syndrome. The disorder normally is resolved within 2 weeks of birth. The other options are not usually seen as a result of in utero exposure to SSRIs.

A patient diagnosed with depression is prescribed the tricyclic antidepressant (TCA) bupropion. What is the benefit of this medication for nonhospitalized patients? a. It has antianxiety properties as well as antidepressant effects. b. It lowers the seizure threshold to a lesser extent than TCAs. c. There is reduced potential for lethal overdose. d. It stimulates appetite and weight gain.

ANS: C Bupropion has no lethal-overdose potential, making it well suited for use in outpatient treatment of depression. Bupropion has a narrow therapeutic index but is far less lethal than TCAs or monoamine oxidase inhibitors (MAOIs). However, it might cause agitation, anxiety, seizures, anorexia, and weight loss.

A patient tells the nurse, "I've stopped taking sertraline because the drug made me impotent. Which statement by the nurse will provide the best patient support? a. "Your doctor still wants you to continue taking your medication." b. "Have you talked with your therapist regarding your feelings about sex?" c. "Let's talk with your doctor. Changing your medication might be a possibility." d. "Our priority is to treat your depression. Impotence can be addressed in a few weeks."

ANS: C Selective serotonin reuptake inhibitor (SSRI) commonly causes sexual dysfunction. Changing to another type of antidepressant or adding bupropion in small doses can be helpful. The other options are not compassionate or therapeutic.

A nurse teaches a patient taking a monoamine oxidase inhibitor (MAOI) about important dietary guidelines. Which nutritional choices by the patient indicate that the teaching was effective? (Select all that apply.) a. Sausage b. Avocados c. Pork chops d. Strawberries e. Chocolate chip cookies

ANS: C, D The patient must avoid foods high in tyramine so as to prevent a hypertensive crisis. Sausage, avocados, and chocolate contain significant amounts of tyramine.

A tricyclic antidepressant (TCA) is prescribed for a patient newly diagnosed with depression. What information should be included in patient teaching? a. "Take this medication on an empty stomach." b. "Do not eat aged cheese while using this medication." c. "You might experience sweating, tremors, and excessive urination." d. "It might be 2 weeks or more before you notice the effects of this medicine."

ANS: D Antidepressant effects might take several weeks to be noticeable. Avoidance of tyramine (as is present in aged cheeses) is necessary for monoamine oxidase inhibitors (MAOIs) therapy but not for TCAs. It is not necessary to take TCAs on an empty stomach. Sweating, tremors, and urination problems are not commonly experienced with TCA therapy.

A depressed patient preparing for discharge is prescribed desipramine and will have follow-up outpatient visits. The patient reports, "Why did they gave me only a 1-week supply of my medicine?" Select the nurse's best reply. a. "Federal law limits the amount you may be given at any one time." b. "It will save you money if the drug doesn't work well for your symptoms." c. "This is a way of ensuring that you will come in for your follow-up appointment." d. "Prescribing a small amount of drug addresses our concerns for your continuing safety."

ANS: D Desipramine is an activating antidepressant, and it might provide a patient who has suicidal ideation with the energy to make an attempt. Because the therapeutic dose and lethal dose are not widely separated, tricyclic antidepressants (TCA) overdose is an often-used suicide plan. Because desipramine appears to be the most toxic TCA, prescribing only a 7-day supply limits the possibility of using the drug in a suicide attempt. The other options are either less relevant or incorrect.

A patient prescribed fluoxetine is being changed to tranylcypromine. The nurse provides education on this change that will include a time lapse between the last dose of fluoxetine and the first dose of tranylcypromine of at least how long? a. 7 days. b. 14 days. c. 3 weeks. d. 6 weeks.

ANS: D Drugs that have a high probability for serious interactions (e.g., monoamine oxidase inhibitors {MAOIs} like fluoxetine) will need to be withheld for up to 6 weeks or more as fluoxetine is washing out of the system. The remaining options are too short an interval.

A secondary amine tricyclic antidepressant is prescribed for a patient. The medication will significantly increase the availability of which neurotransmitter? a. GABA b. Glutamate c. Serotonin d. Norepinephrine

ANS: D Secondary amines increase the availability and enhance the action of norepinephrine. They do have a similar effect on any of the other options.

What are the priority history assessments for a patient beginning amitriptyline therapy? (Select all that apply.) a. Agranulocytosis b. Seizures c. Sexual dysfunction d. Orthostatic hypotension e. Blurred vision

ANS: D, E Tricyclic antidepressants (TCAs) like amitriptyline produce anticholinergic (blurred vision) and antiadrenergic (orthostatic hypotension leading to falls and arrhythmias) side effects. Gastrointestinal symptoms, sexual dysfunction, and weight variations are related to selective serotonin reuptake inhibitor (SSRI) therapy. Seizures are seen with bupropion therapy. Agranulocytosis is not considered a major problem with any of the groups of antidepressants.