Ch. 26 Stuart

Which assessment data would indicate to the nurse that the patient who is prescribed a benzodiazepine is experiencing a medication side effect? a. Dizziness b. Reduced irritability c. Reduced nervousness d. Physiological dependency

ANS: A A common side effect of benzodiazepine therapy is dizziness. Two options indicate that the patient is actually obtaining relief from the benzodiazepine, and physiological dependency is unlikely, whereas psychological dependency can occur if the patient is not taught effective ways to manage anxiety aside from taking a pill

Which statement represents the most appropriate instructions for a patient with a past suicide attempt who is prescribed amitriptyline (Elavil), 150 mg PO at bedtime? a. "You will need to pick up your 7-day supply of medication at the pharmacy each week." b. "Your prescription will provide you with a 6-month supply to save you money and time." c. "I'm going to strongly suggest that your spouse dispense this medication to you each evening." d. "Stop by the clinic each evening for your medication so your emotional state of mind can be assessed."

ANS: A Amitriptyline (Elavil) is a tricyclic antidepressant (TCA) medication (tertiary amine). The TCAs are very toxic when ingested at levels of 1000 to 3000 mg, and overdosage and suicide attempts with this medication are extremely dangerous and often require emergency medical attention. Because an overdose often requires only a 1-week supply of medication, it is the nurse's responsibility to suggest that the prescription be dispensed in weekly doses. In the above situation, the patient has a history of self-directed lethality, and prudence is the best approach. By asking the patient to help the nurse determine the easiest method of dispensing medication, the nurse allows the patient control and offers respect and mutuality

In order to effectively provide appropriate patient teaching regarding the effects of psychotropic medications, the nurse is required to have a thorough understanding of which drug-related topic? a. Clinical indicators b. Pharmacology algorithms c. Monotherapeutic symptoms d. Doses of all atypical psychotropic drugs

ANS: A In 2003, the National Organization of Nurse Practitioner Faculties (NONPF) published a comprehensive set of competencies defining the scope and practice of psychiatric mental health nurse practitioners (PMHNPs). An example of a competency specific to medication prescribing for PMHNPs states that the PMHNP "prescribes psychotropic and related medications based on clinical indicators of a patient's status, including results of diagnostic and lab tests as appropriate, to treat symptoms of psychiatric disorders and improve functional health status." Knowledge of pharmacology algorithms or of monotherapeutic symptoms is not applicable since they are not required needs. A knowledge of the doses of all "atypical" psychotropic drugs is too specific to one class of psychotropic medications. Nurses need to know information about all psychotropic medications

During a home visit with a patient diagnosed with schizophrenia the patient tells the nurse, "I'm going to stop going to the clinic for my fluphenazine decanoate (Prolixin) shots because I think I'm okay now." Which statement represents the best understanding of the effect of the patient's decision on the prognosis? a. "So you think you're better now. Let's discuss why you've decided to stop taking your medication." b. "Your doctor knows what's best for you. Just look at how well you're feeling now so don't stop taking the medication." c. "Our philosophy is to use the least amount of medicine that is needed to treat a problem. Tell me why you think that you are okay now." d. "I'm afraid that you'll be sick again very soon if you aren't taking your medication, but you are an adult and entitled to make your own decisions."

ANS: A Nonadherence or noncompliance with medication is usually lessened with the decanoate preparation of the antipsychotic medication. The most therapeutic communication is usually the one that helps the patient to share thoughts and feelings. By restating and seeking clarification, the nurse can assist the patient in looking at what he or she is saying. If the nurse focuses, the patient will be able to help with the thinking-through process, which is to communicate that the Prolixin injections are received only 12 to 14 times annually and that they will keep the patient's thoughts clear

A patient who is taking lithium shares with the nurse, "I'm planning to breast-feed my baby who is due to be born in 2 months." Which statement shows the best understanding of the effect of lithium on breast-feeding? a. "Your medication would be excreted in your breast milk, so let's discuss a safer option for your baby." b. "Your medication will cause the breast milk to have an unpleasant taste and will likely cause your infant to be gassy." c. "This medication will likely affect your ability to lactate, resulting in a marked decrease in breast milk production." d. "This medication can cause extreme mood fluctuations, which can have a negative effect on your ability to produce breast milk."

ANS: A Lithium crosses the placental barrier and is excreted in the breast milk, so breast-feeding is not an option. Lithium should only be taken by pregnant women when it is an absolute necessity.

A patient who is prescribed an antidepressant medication says, "I've been getting dizzy in the morning when I wake up ever since I started this drug. Do you think I should stop taking it?" Which communication would reflect the most therapeutic nursing intervention on the basis of the patient's problem? a. "It's important to change positions slowly and dangle your feet at the side of the bed before getting up." b. "You'll have to stop driving your car while you're taking your medicine, and napping during the day should help." c. "This medication does not usually cause dizziness unless it's being taken along with alcohol, wine, or beer." d. "This should not be happening. Stop taking this medicine, and I'll notify your doctor to prescribe something else."

ANS: A Antidepressant medications can cause orthostatic or postural hypotension, and the nurse will teach the patient the following: lie down, rest as able, and change positions slowly. Dangle at the side of the bed for 30 seconds or so. Operate heavy equipment and drive a car only with caution. Check and record your blood pressure, both sitting and standing, twice each day

A patient who has been taking an antidepressant for 2 months shares with the nurse, "Since my depression is over, I've stopped the Prozac and I won't need to see you any longer." Which response by a nurse would be most therapeutic? a. "Do you recall that we discussed the need for you to take the medication for up to 1 year before trying to taper off the drug? Let's discuss why it's not advisable to stop your medication abruptly." b. "It is not recommended that you stop the antidepressants abruptly. I strongly suggest that you continue seeing me regularly to ensure that any change in your condition will be treated immediately." c. "You should not discontinue your medication without consulting your psychiatrist. You will very likely experience withdrawal symptoms and become more depressed than you were before." d. "Although it isn't wise to stop the medication as you have, you seem to be handling things very well. Call me if you have any questions and follow-up with your psychiatrist in a year."

ANS: A Most patients who respond initially to antidepressant therapy require at least 1 year of therapy and may take medication on a lifetime basis. This is similar to patients who take antihypertensives or insulin. The patient's statement alerts the nurse to set clear therapy goals that extend beyond medication assessment. Prozac takes 2 to 4 weeks to reach a steady state and is maintained in the body for several weeks after it is discontinued, but the nurse's suggestion of tapering off the medication is a wise intervention for this patient, who seems impulsive about medication adherence. A patient with a knowledge deficit and nonadherence potential requires communication that recalls prior teaching and that builds on the knowledge he or she already has. Reminding the patient of the time it takes to become depressed provides anticipatory guidance about the possibility of needing medication on a lifetime basis. Sarcastic humor is usually a poor response that demeans the patient and may reflect the nurse's impatience and a judgmental attitude toward the patient, and a laissez-faire response does not reflect a caring attitude. Withdrawal usually is not a problem for medications with a long half-life.

A nurse is assessing a patient who was recently prescribed an antipsychotic medication. Which side effects could the nurse expect to observe? a. Constipation, decreased sweating, and increased sensitivity to heat b. Increased moisture around the eyes, vomiting, and frontal headache c. Slurred speech, hand tremors, and severe occipital headache d. Sleeplessness, irritability, and muscle weakness

ANS: A The most common side effects of antipsychotic medications include the following: dry mouth, blurred vision, nasal stuffiness, weight gain, difficulty urinating, infection, decreased sweating, increased sensitivity to sunlight, yellowing of the eyes (especially the whites of the eyes), breast enlargement/lactation, skin rash, anhedonia, itchy skin, and constipation

What will a health care provider include in medication teaching for a patient who will be starting a monoamine oxidase inhibitor (MAOI) medication after ending treatment with sertraline hydrochloride (Zoloft)? a. "Here is some information concerning the foods you must avoid when you are taking your new medication. In 2 weeks, after your last dose of Zoloft, we will meet and I will give you a prescription for your MAOI and answer any questions you may have." b. "After you have been off Zoloft for 1 week, come see me. I will order the new medication for you. This list includes all the foods you will not be able to eat while taking your new medicine. We'll review your diet and medication when we meet, and we will get a blood sample as well." c. "After 4 weeks off Zoloft, come see me. The prescription for your new medication will be ready along with a list of foods you will need to avoid once you start taking the medication. I'll order some blood work at that time as well." d. "After 2 days off Zoloft, come in to see me before going to work. I'll give you a prescription for the new medication, and we can review the foods you will need to avoid while taking the new medication."

ANS: A The psychiatrist or advanced practice nurse (psychiatric clinical specialist) will wait 2 weeks before changing from a selective serotonin reuptake inhibitor (SSRI) to a monoamine oxidase inhibitor (MAOI). The SSRI should not be administered concomitantly with an MAOI. Foods that contain tyramine (e.g., Chianti, nuts, figs, cheese), a pressor amine, are avoided to prevent hypertensive crisis

A patient being treated for depression reports experiencing nausea, palpitations, and "a terrible headache." When the physical examination determines the patient is diaphoresic and hypertensive, the nurse should ask: a. "When did you last take your phenelzine (Nardil)?" b. "Did you take your amitriptyline (Elavil) on schedule?" c. "What natural foods have you had in the last 24 hours?" d. "Have you had any alcohol to drink within the last 24 hours?"

ANS: A This question requires analytical decision making to identify hypertensive crises and data for the evaluation process. Knowing when the last dose of the monoamine oxidase inhibitor (MAOI) was taken helps determine immediate treatment. Although the ingestion of alcohol is pertinent to determining what tyramine-containing foods the patient may have had, it is not as crucial as knowing when the last dose of MAOI was consumed. Although natural foods may produce similar bioactivity and other antidepressants should not be taken along with an MAOI, these answers do not reflect medication assessment and evaluation. The patient is experiencing the clinical manifestation of hypertensive crisis. The classic symptoms of this condition are severe occipital headache, dilated pupils, hypertension, and palpitations or arrhythmias. This syndrome can be caused when the patient who is taking an MAOI ingests food containing tyramine, an amino acid released from foods that undergo hydrolysis (e.g., fermentation, aging, pickling, smoking, spoilage). This inhibits the monoamine oxidase and allows tyramine to reach the adrenergic nerve endings and cause the release of excess norepinephrine, which causes hypertensive crisis. To confirm the physical syndrome, first determine whether the patient is taking an MAOI. Knowing when the last dose was ingested provides a window for the duration of hypertension and therapeutic nursing interventions

A nurse is caring for a female diagnosed with a mental disorder who has been prescribed medication. Which fact will most impact the nurse's assessment for possible side effects? a. Women are at higher risk for tardive dyskinesia while taking conventional antipsychotic medications. b. Women experience more severe side effects than men while taking atypical antidepressants. c. Women are more susceptible to developing a dependence on most psychiatric medications than are men. d. Women are less susceptible to developing the common side effects of antipsychotic medications than are men.

ANS: A Women are at higher risk for tardive dyskinesia from conventional antipsychotics and for activating side effects caused by antidepressants. All other answers are incorrect

A patient who is taking psychotropic medication is experiencing constipation. Which intervention would the nurse plan for the patient? a. Drinking six to eight glasses of water daily and eating green vegetables and bran b. Drinking 10 to 12 glasses of water daily and eating a serving of beef liver weekly c. Taking a laxative and stool softener daily in addition to eating prunes and dates d. Using a retention enema weekly and adding bran and vegetables in the daily diet

ANS: A Constipation, an anticholinergic side effect, is alleviated by drinking six to eight glasses of water and eating bran and green vegetables daily. Prunes and raisins are especially helpful. If the side effect continues, the patient should notify the health care provider and use a laxative only when medically advised to do so

Which instructions will the nurse include in the teaching plan of a patient who is prescribed fluphenazine (Prolixin) and has developed a thickly white-coated tongue? (Select all that apply.) a. Avoid foods high in sugar. b. Brush teeth and tongue frequently. c. Continue taking your medication; the coating will subside in about 3 weeks. d. Nasal inhalants should be avoided since they can interact with your medication and cause this problem. e. Smoking cigarettes can make the white coating on your tongue worse and more difficult to treat effectively.

ANS: A, B, E Fluphenazine (Prolixin) may cause the side effect of infection, because this medication can reduce the normal bacteria in the patient's mouth and increase sensitivity to infection. A thick white coating on the tongue indicates infection and must be treated. Brushing the tongue and teeth is a good preventive measure. Smoking and a high sugar diet will exacerbate the problem. The measures the nurse is offering will prevent recurrence if paired with adequate hydration

A patient who has been treated with clozapine (Clozaril) for 9 months calls to cancel a clinic appointment because of flulike symptoms, including a sore throat, fever, and tiredness. The nurse demonstrates the best understanding on the management of these symptoms when responding: a. "I think you need to drink lots of juices and water and go to bed. Call me at the end of the week to reschedule your appointment." b. "I want you to please keep the appointment, and I will arrange for some blood work to be done while you are here." c. "It's flu season all right. Get better soon, and call me to reschedule when you're feeling better." d. "This may be something much more serious than the flu. Go to the hospital at once."

ANS: B Although agranulocytosis occurs in only about 1% to 2% of patients, this is a risk 10 to 20 times greater than the risk with standard antipsychotic agents. In addition, even though the risk for this adverse effect decreases substantially after 5 months of taking these drugs, the risk always remains and requires vigilant monitoring. After the first 6 months, blood counts are drawn biweekly, so the nurse in the above situation would want to obtain one today to determine whether the patient is experiencing agranulocytosis or flu. Although this is a serious adverse effect, the nurse will provide specific instructions but endeavor not to alarm the patient. In addition, the fact that this patient is female and of an older age places her at increased risk for agranulocytosis

A patient taking medication for depression states, "I need to stop taking my medication because it blurs my vision, and I'm making mistakes when I paint jewelry by hand." Which response by a nurse would be most therapeutic? a. "If you cannot take medication, would you consider a course of 6 to 10 electroconvulsive therapy (ECT) treatments offered on an outpatient basis? ECT treatments usually work immediately." b. "Do you recall the two of us discussing that blurred vision may occur but that it will resolve shortly? In the meantime, let's discuss how to best avoid getting injured until your vision clears up." c. "I understand your concern considering that you need to work to receive health insurance. Would you like me to ask the psychiatrist to change your medication?" d. "You may need to apply for a sick leave for 6 months until your depression improves enough to lessen the medication dosage."

ANS: B Blurred vision, an anticholinergic side effect of antidepressant and antipsychotic medications, will usually resolve within 1 to 2 weeks. The most therapeutic intervention is the one that assesses the patient's recall of medication teaching. Moreover, it offers a strategy to assist the patient to cope during work time. The nurse must apply knowledge of the anticholinergic side effects of antidepressants and antipsychotics to select the appropriate nursing intervention for the patient's problem. Although ECT may be offered when patients are unable to take medication, it is premature to suggest ECT or other medications, and these suggestions reflect a knowledge deficit. It is considered best to encourage patients to maintain activities of daily living and work, if possible.

When assessing a patient who has been prescribed an antipsychotic medication, which statement would indicate a need for further patient education? a. "I'm already too thin; I'm concerned that I'm going to get even thinner on this new type of medication." b. "I'm a warm weather person, I follow the sun—I live in Florida in the winter and Maine in the summer." c. "I just got married, and my wife and I are so excited about starting a family as soon as we can." d. "My parents said that as soon as I am off the medication, they'll give me the money for a car."

ANS: B Increased sensitivity to sunlight is one of the most common side effects of antipsychotic agents. The patient will need to be instructed about the importance of using a sunscreen at all times when in the sun

A nurse who administers an antipsychotic medication explains to the client patient how the medication helps manage the symptoms by affecting: a. dopamine and GABA. b. serotonin and dopamine. c. synaptic neurovesicles and neurodendrites. d. monoamine oxidase inhibitors and serotonin.

ANS: B Many psychiatric disorders are thought to be caused by a dysregulation (imbalance) in the complex process of brain structures communicating with each other through neurotransmission. It is currently thought that excessive dopamine and serotonin contribute to dysregulation

Which set of instructions is most appropriate when preparing the patient for collection of a 24-hour creatinine clearance for a prelithium workup? a. "Collect all urine when you wake up and for 12 hours thereafter, and then discard all collected urine, noting the time. Begin again to collect all urine, and refrigerate it for the next 12 hours after your blood is drawn." b. "Discard your first morning urine on awakening, and then begin to time and collect your urine. Keep it refrigerated in a clean 3-L plastic container. Your blood may be drawn at any time during the collection." c. "Sign this consent form; then collect your urine for the next 24 hours after discarding the first urine of the morning and then refrigerate the clean 3-L container between voidings." d. "Sign this consent form, and then begin to collect your urine in a clean 3-L plastic container for 24 hours. You may refrigerate the urine collection if you wish."

ANS: B No consent form is required for this 24-hour urine and serum collection. Blood may be drawn at any time during the collection. In the morning the first voiding is discarded, and then the collection is timed and urine is collected for 24 hours. All urine is stored in a clean, 3-L plastic container that is refrigerated when not in use and then delivered to the lab. Teaching the patient the procedure for a 24-hour creatinine clearance as part of a prelithium workup (urinalysis, BUN, TSH, T3 and T4, FBS, and a complete physical examination with history and workup for family history of renal disease, diabetes mellitus, hypertension, diuretic use, and analgesic abuse) is required

A patient taking a benzodiazepine says to the nurse, "I really like this pill because if I just take an extra one when I get very anxious, I always feel a lot better." What is the nurse's best response? a. "That isn't the way the medication is to be taken. I think you need to talk to your doctor so something more effective can be prescribed for you." b. "Let's review the way you use this medication. Remember to try the coping measures that we discussed to help manage your nervousness." c. "You are not taking the medication as the doctor ordered. I think the doctor will be very concerned that you are abusing your medication." d. "You really shouldn't be adjusting your medication dosage like that. You need to take the medication only as it was originally prescribed by your physician."

ANS: B The patient seems to be using the medication first rather than trying more holistic ways of controlling the anxiety. It is the nurse's responsibility to teach complementary and alternative ways to cope with anxiety and stress as a lifetime measure rather than simply using a pill every time the patient identifies anxiety. Mild anxiety may help the individual adapt.

A patient will be starting on fluoxetine hydrochloride (Prozac) therapy and taking 20 mg PO every morning. Which information should the nurse provide to the patient? a. "Make sure that you take your pulse before getting out of bed in the morning." b. "Try taking your medication with breakfast if you begin experiencing nausea." c. "You may need to reduce your fluids at night because of nocturnal urination." d. "Remember to avoid red wine, nuts, and any cheese except cottage and cream."

ANS: B This question requires the application of knowledge about selective serotonin reuptake inhibitors (SSRIs) to a specific plan for medication education. To reduce nausea, the patient should be advised to take the medicine with meals. When teaching patients who are taking tricyclic antidepressants (TCAs), one must emphasize that patients should dangle their legs over the bed and change positions slowly to prevent postural hypotension. It is also advisable for patients to increase fluids, exercise, and roughage intake to prevent the anticholinergic effects of antidepressants. Foods that contain tyramine (e.g., Chianti, nuts, cheese) are prohibited when patients are taking monoamine oxidase inhibitors (MAOIs). The primary synaptic activity for SSRIs is to inhibit the reuptake of 5-HT. The possible clinical effects of 5-HT include the following: gastrointestinal (GI) disturbances and sexual dysfunction. Fluoxetine hydrochloride (Prozac), an SSRI that is usually administered in the morning to reduce the potential of a side-effect profile that is 2+ for insomnia/agitation, also demonstrates a 3+ for GI disturbances.

A nurse observes a patient diagnosed with schizophrenia tapping both feet, smacking both lips, and making contorted faces while speaking to another patient. These behaviors prompt the nurse to suspect the patient is experiencing: a. neuroleptic malignant syndrome. b. Parkinson syndrome. c. tardive dyskinesia. d. torticollis.

ANS: C Tardive dyskinesia usually occurs with long-term conventional antipsychotic agent treatment and is evidenced by stereotypical involuntary movements (e.g., tongue protrusion, lip smacking, chewing, blinking, grimacing, choreiform movements of the limbs and trunk, foot tapping).

Which medication would the nurse expect to administer when observing that a patient being treated for schizophrenia is fidgety, demonstrates motor restlessness, and jiggles both legs when asked to sit down? a. Olanzapine (Zyprexa) b. Molindone (Moban) c. Biperiden (Akineton) d. Thioridazine (Mellaril)

ANS: C By blocking dopamine, antipsychotic medications produce extrapyramidal side effects. Akathisia is internal or external restless fidgeting or pacing. Patients with akathisia demonstrate motoric restlessness and complain of feeling their muscles quiver. When this condition has advanced, the patient will say that he or she is not able to sit still or lie down quietly. The nurse will want to observe whether the patient's legs are shaking. If the patient's feet are not shaking, the nurse will observe that his or her arms will start to shake. The therapeutic treatment is the administration of anticholinergic agents, such as benztropine (Cogentin), trihexyphenidyl (Artane), or procyclidine (Kemadrin). Diphenhydramine (Benadryl), an antihistamine, also may be administered. The other three medication selections are antipsychotic agents: Zyprexa, an atypical antipsychotic; Moban, an antipsychotic (dihydroindolone); and Mellaril (phenothiazine), a typical antipsychotic.

In order to accurately predict how the body absorbs, distributes, metabolizes, and eliminates psychotropic medications the nurse must be familiar with a medication's: a. half-life. b. side effects. c. pharmacokinetics. d. therapeutic dosage range.

ANS: C Pharmacokinetics is the study of how the body affects a drug. It answers the question: how does the body get drugs to and from their intended target? Body functions such as absorption, distribution, metabolism, and elimination all are pharmacokinetics.

When a patient requires an ever-increasing dose of a medication to achieve the same therapeutic effect, the nurse must assess the patient for: a. withdrawal. b. patency. c. side effects. d. tolerance.

ANS: D Some patients become less responsive to the same dose of a particular drug over time, which is called tolerance, requiring that higher doses of the drug be given over time to obtain the same therapeutic effect