Chapter 16: Pychotherapeutic Drugs
A patient who has been taking alprazolam (Xanax) and has been compliant with the therapeutic regimen for 6 weeks is now complaining of adverse effects of the medication. Which substances does the nurse instruct the patient to avoid to help prevent intensification of this medication's adverse effects? (Select all that apply.) A. Alcohol B. Opioids C. Tobacco D. Antihistamines E. Muscle relaxants F. Caffeinated drinks
A. Alcohol B. Opioids D. Antihistamines E. Muscle relaxants Because they are also central nervous system (CNS) depressants, the nurse instructs the patient to avoid alcohol, opioids, antihistamines, and muscle relaxants because when taken together with alprazolam they can cause significant CNS depression, including respiratory depression. Tobacco use is likely to be harmful, but it is unlikely to intensify the adverse effects of a benzodiazepine. Caffeine, a xanthine stimulant, is likely to ameliorate CNS depression associated with benzodiazepines.
The nurse administers amitriptyline hydrochloride to a patient with chronic depression. For which potential effects of the medication should the nurse monitor the patient? (Select all that apply.) A. Constipation B. Hypotension C. Hyperpyrexia D. Hyperglycemia E. Improved sleep F. Urine retention
A. Constipation B. Hypotension E. Improved sleep F. Urine retention Amitriptyline is a tricyclic antidepressant that can induce such anticholinergic effects as constipation and urine retention. It can also cause dopaminergic- and adrenergic-blocker effects such as hypotension. Histamine blockade generally causes sedation and improves sleep. Tricyclic antidepressants should not cause hyperpyrexia or hyperglycemia.
The serum lithium level of a patient who takes lithium carbonate (Lithobid) is 1.8 mEq/L. The nurse assesses the patient for which clinical indicators consistent with this concentration of the drug? (Select all that apply.) A. Frequent diarrhea B. Minor weight loss C. Muscle irritability D. Fine hand tremors E. Adherence to the therapeutic regimen F. Irregular heartbeat
A. Frequent diarrhea C. Muscle irritability E. Adherence to the therapeutic regimen F. Irregular heartbeat The therapeutic drug level for lithium is 1 to1.5 mEq/L. This patient's lithium level is above normal, so the nurse expects to observe clinical indicators of lithium toxicity, including diarrhea, muscle irritability, adherence to the therapeutic regimen, and an irregular heartbeat. The adverse effects of lithium therapy are proportionate to the serum level, so the patient's assessment findings are abnormal but not severe. The nurse concludes that the patient has been compliant with the therapeutic regimen because it is unlikely that a toxic drug level could occur with missed doses. A toxic level of lithium is more likely to increase weight, a result of sodium retention; coarse tremors are associated with toxicity.
Which phenomena does the nurse recognize as positive symptoms of schizophrenia? (Select all that apply.) A. Hallucinations B. Muscle rigidity C. Restless activity D. Chaotic thinking E. Defective insight F. Social withdrawal
A. Hallucinations D. Chaotic thinking E. Defective insight Positive symptoms of schizophrenia include psychotic behaviors such as hallucinations. They also include conceptual disorganization such as chaotic thinking and poor insight. Negative symptoms include social withdrawal and catatonia characterized by agitation and muscle rigidity.
Which benefits are desired effects of instructing a patient with depression to take the daily dose of clomipramine (Anafranil) at bedtime? (Select all that apply.) A. Helps the patient adhere to therapy B. Promotes sleep through significant sedation C. Reduces the rate of drug interactions D. Eases anticholinergic effects E. Diminishes sexual side effects F. Reduces the risk of dysrhythmias
A. Helps the patient adhere to therapy B. Promotes sleep through significant sedation The advantages of taking a tricyclic antidepressant (TCA) at bedtime are twofold: (1) It is easier for the patient to remember to take the medication, facilitating adherence and (2) it promotes sleep by causing maximal sedation at night. Bedtime administration should not improve the adverse effect profile of a TCA and therefore does not reduce the potential for drug interactions, anticholinergic effects, sexual side effects, or dysrhythmias.
A patient receives a prescription for quetiapine (Seroquel). Which instruction should the nurse include in patient teaching about self-administration of this medication? A. Report abnormal movements. B. Take the medication as needed for agitation. C. Avoid cheese and cured meats. D. Stop taking the medication if dizziness occurs.
A. Report abnormal movements. The nurse instructs the patient to report abnormal movements, which may indicate serious adverse effects of antipsychotic medications, including neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia. Atypical antipsychotic agents are rarely prescribed on an as-needed basis; besides, a patient in a psychotic state is the least likely person to recognize the need for treatment. Patients taking atypical antipsychotic agents such as quetiapine do not need to avoid foods containing tyramine. Dizziness is a common adverse effect of therapy; rather than tell the patient to stop taking the medication, the nurse instructs the patient to report dizziness.
Which medication is used as first-line therapy? A. Sertraline (Zoloft) B. Haloperidol (Haldol) C. Meprobamate (Miltown) D. Chlorpromazine (Thorazine)
A. Sertraline (Zoloft) Sertraline, a selective serotonin reuptake inhibitor, is a first-line therapy for depression. Haloperidol and chlorpromazine are conventional antipsychotic agents but not first-line therapies for psychosis. Meprobamate is an anxiolytic agent but not a first-line therapy for anxiety.
The nurse prepares a patient who is taking sertraline (Zoloft) for discharge. Which instruction should the nurse include in patient teaching? A. Take sertraline at same time each day. B. Expect to feel better in 4 to 6 days. C. Avoid overheating and direct sun. D. Report any increase in mania.
A. Take sertraline at same time each day. Sertraline is a selective serotonin reuptake inhibitor, and the patient is most likely to experience therapeutic effectiveness if the medication is taken at the same time every day. The nurse instructs the patient to adhere to therapy for 4 to 6 weeks to determine the medication's effectiveness. Hyperpyrexia is an adverse effect of antipsychotic agents; lithium is used to treat bipolar disorder, of which mania is a characteristic.
A patient takes sertraline (Zoloft) for depression related to chronic pain. The nurse avoids administering which analgesic agent to help prevent serotonin syndrome? A. Tramadol (Ultram) B. Ibuprofen (Motrin) C. Fentanyl (Duragesic) D. Oxycodone (OxyContin)
A. Tramadol (Ultram) The nurse avoids administering tramadol to a patient who takes a selective serotonin reuptake inhibitor because it increases the risk for serotonin syndrome. This is because tramadol exerts its analgesia by blocking the reuptake of norepinephrine and serotonin. Ibuprofen is unlikely to provide relief to a patient with chronic pain unless the pain has developed an inflammatory aspect. Fentanyl and oxycodone are reasonable choices of analgesics for this patient, but both agents require careful monitoring of the patient.
A patient with a history of abusing opioid analgesics needs an antianxiety agent. Which medication should the nurse expect to administer? A. Diazepam (Valium) B. Buspirone (BuSpar) C. Venlafaxine (Effexor) D. Escitalopram (Lexapro)
B. Buspirone (BuSpar) Because the potential for abuse is low, buspirone is a suitable antianxiety agent for this patient. Diazepam is contraindicated because benzodiazepines are highly addictive. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor and escitalopram is a selective serotonin reuptake inhibitor; both medications have a low potential for abuse and are first-line antidepressant therapies. The nurse does not know whether the patient has depression along with the anxiety, so these drugs are not indicated.
A female patient who has been taking lithium carbonate (Lithobid) for 1 week tells the nurse that she is experiencing dizziness. What is the best nursing intervention to implement in this situation? A. Tell the patient to continue therapy. B. Direct the patient to change positions slowly. C. Check the serum drug level of lithium. D. Ask the patient about her sodium and fluid intake.
B. Direct the patient to change positions slowly. As a means of maintaining the patient's safety, the most important nursing intervention is instructing the patient to change positions slowly to prevent dizziness. Once action has been taken to maintain patient safety, the nurse gathers additional patient data by investigating possible causes of the dizziness, such as a high lithium level or altered levels of fluids and electrolytes. Unless the nurse has patient data to support the discontinuation of therapy, the nurse instructs the patient to continue taking lithium to prevent disruption of therapy.
What is the main receptor in the central nervous sytem (CNS) to be blocked by conventional antipsychotic drugs? A. Serotonin B. Dopamine C. Acetylcholine D. Norepinephrine
B. Dopamine Conventional antipsychotic agents block dopamine receptors, primarily in the CNS. The blockade of dopamine receptors is responsible for the therapeutic and toxic effects of these medications. Atypical antipsychotic agents block dopamine-2 receptors and serotonin receptors, offering improved therapeutic effectiveness and a more favorable side effect profile.
A patient with schizophrenia does not adhere to the pharmacotherapy regimen. Which potential cause of nonadherence is the nurse's priority because it is the most difficult to improve? A. High incidence of adverse side effects B. Inability to realize the need for therapy C. Need for multiple doses every 24 hours D. Lack of money to pay for medication
B. Inability to realize the need for therapy The nurse's priority is the promotion of continued pharmacotherapy. Because a cure does not exist, a patient with schizophrenia is likely to have altered thought processes that impair his or her ability to recognize the need for therapy. Effective treatment can make the patient believe that the disease has been cured and that there is no further need for the medication. Adverse side effects, multiple doses, and financial issues are problems that often have effective solutions.
What is the most important benefit of taking a parenteral formulation of an antipsychotic medication? A. Fewer doses needed for effective therapy B. Increased likelihood of adherence to therapy C. Better chance of effectiveness D. Can be injected as a long-acting agent
B. Increased likelihood of adherence to therapy The primary benefit of administering an injectable form of an antipsychotic agent is that patient adherence to therapy improves because fewer doses are required to achieve therapeutic effectiveness. Parenteral antipsychotic agents are long-acting medications.
Which patient is a poor candidate for therapy with diazepam (Valium) to treat generalized anxiety disorder? A. One who had convulsions as a child B. One with a history of alcoholism C. One who has had a myocardial infarction D. One with type 2 diabetes mellitus
B. One with a history of alcoholism The patient with a history of alcoholism is a poor candidate for therapy with diazepam because of the potential for substance abuse and the adverse effects of therapy. The patient has an addictive personality, meaning that the patient has resorted to habitual use of a substance to manage anxiety; as a means of preventing additional substance abuse, benzodiazepines will be withheld from this patient. Moreover, benzodiazepines can cause respiratory depression. If the patient takes the benzodiazepine with alcohol, the combination could result in respiratory failure. Diazepam may be indicated for a patient with a history of convulsions because diazepam has antiseizure properties. The use of diazepam in a patient who has had a myocardial infarction or who has diabetes is potentially suitable.
A male patient tells the nurse that he wants to stop taking citalopram (Celexa) because of the sexual side effects. Which instruction should the nurse provide in patient teaching to help relieve the patient's sexual dysfunction? (Select all that apply.) A. Discontinue the medication. B. Take infrequent "drug holidays." C. Decrease the regular dosage. D. Report complaints to the psychiatrist. E. Maintain the current pharmacotherapy. F. Avoid alcoholic beverages.
B. Take infrequent "drug holidays." C. Decrease the regular dosage. D. Report complaints to the psychiatrist. E. Maintain the current pharmacotherapy. F. Avoid alcoholic beverages. Sexual dysfunction is managed in several ways, including reduction in the regular dosage, "drug holidays," addition of a medication for erectile dysfunction, change of antidepressant, and avoidance of alcohol. The nurse encourages the patient to continue taking an SSRI such as citalopram because the adverse effects of therapy often diminish in intensity and frequency over time; this strategy helps prevent disruptions in therapy. After providing this information the nurse encourages the patient to voice complaints to the psychiatrist who prescribes the antidepressant, but the nurse does not depend on the patient to ensure that the psychiatrist is notified of the complaint. The nurse avoids instructing the patient to discontinue therapy or to alter the dosage because these actions are not within the scope of nursing practice.
A female patient who takes lorazepam (Ativan) for anxiety tells the nurse that she plans to become pregnant. What is the best instruction for the nurse to give the patient? A. Visit a women's healthcare provider. B. Taper off the drug before conception. C. Form another plan to manage anxiety. D. Eat a well-balanced diet that includes milk.
B. Taper off the drug before conception. The best instruction for the nurse to provide includes health promotion for the patient and the fetus, so the nurse instructs the patient to taper off therapy as a means of avoiding the adverse effects of withdrawal and to prevent fetal harm. Therapy must be stopped before conception because benzodiazepines are lipid soluble and cross the placenta, increasing the risk of fetal harm. To promote fetal development, the nurse instructs the patient to visit a provider for folic acid and prenatal vitamin prescriptions and to eat a well-balanced diet. To help prevent a crisis, the nurse instructs the patient to develop an alternative plan for managing anxiety with the assistance of a health care provider.
A male patient taking lorazepam (Ativan) reports lethargy and confusion. Which action should the nurse implement next? A. Tell the patient that the symptoms will dissipate gradually. B. Plan nursing care to manage a benzodiazepine overdose. C. Ask the patient how many doses he has taken in the past 8 hours. D. Instruct the patient to rest at home until he is thinking clearly again.
C. Ask the patient how many doses he has taken in the past 8 hours. The nurse's next intervention is to investigate the patient's complaint completely before planning or implementing nursing care because nursing care is based on patient assessment data. The nurse assesses the patient's condition by asking how much of the medication he has taken recently. In doing so, the nurse can plan nursing care more accurately. The nurse avoids planning care for an overdose because this has not been determined. Instructing the patient to rest at home is a reasonable nursing response to prevent patient injury and may be indicated once a complete assessment has been performed. Once an overdose has been ruled out, the nurse can help the patient understand that the adverse effects of therapy often disappear over time.
A patient taking risperidone (Risperdal) has a necrotic foot ulcer that started as a minor scratch. Which patient data should the nurse check to help prevent complications of the pharmacotherapy? A. Leukocyte count B. Liver function studies C. Fasting blood glucose D. Kidney function studies
C. Fasting blood glucose Atypical antipsychotics can cause diabetes mellitus because they tend to impair glucose metabolism. Therefore, the nurse checks the fasting blood glucose level in a patient who presents with a deteriorating wound because diabetes impairs wound healing. This patient's glucose is likely to be poorly controlled as a result of the psychosis and the risperidone. Monitoring of liver and kidney function parameters is a reasonable strategy when patients are taking medication; however, the poorly healing ulcer, a common complication of diabetes, and the risperidone therapy indicate the need to check the blood sugar. A WBC count is a reasonable choice of test to determine the presence of infection but would not be needed if the ulcer were not present.
A patient who takes benztropine (Cogentin) needs an antidepressant. Which medication should the nurse avoid administering to prevent anticholinergic syndrome? A. Selegiline (Emsam) B. Duloxetine (Cymbalta) C. Protriptyline (Vivactil) D. Buproprion (Wellbutrin)
C. Protriptyline (Vivactil) Benztropine is an anticholinergic agent used in the treatment of Parkinson's disease. Tricyclic antidepressants like protriptyline (Vivactil) can cause anticholinergic syndrome when combined with benztropine because they block cholinergic receptors. Selegiline is a reasonable choice of antidepressant for a patient with Parkinson's disease because it inhibits monoamine oxidase selectively. Duloxetine and buproprion are not indicated for this patient.
A female patient with psychosis is experiencing adverse effects of conventional antipsychotic pharmacotherapy, including dystonia, akathisia, and abnormal limb movements. The nurse collaborates with the psychiatrist to enact a change in therapy. Which medication is best suited to this patient? A. Molindone (Moban) B. Haloperidol (Haldol) C. Risperidone (Risperdal) D. Chlorpromazine (Thorazine)
C. Risperidone (Risperdal) Risperidone is the best medication for this patient; she is experiencing dopamine receptor-related adverse effects of a conventional antipsychotic agent, and risperidone has strong antidopaminergic properties as well as antiadrenergic, antiserotonergic, and antihistaminic activity. Molindone, haloperidol, and chlorpromazine, all conventional antipsychotic agents, could aggravate the adverse effects experienced by the patient.
A patient who is taking an atypical antipsychotic agent for schizophrenia presents with a poorly healing leg ulcer and hyperglycemia. Which atypical antipsychotic agent is the best medication for the nurse to administer? A. Olanzapine (Zyprexa) B. Quetiapine (Seroquel) C. Ziprasidone (Geodon) D. Risperidone (Risperdal)
C. Ziprasidone (Geodon) The best atypical antipsychotic agent for the nurse to administer in this case is ziprasidone, which has the least significant impact on patient weight and therefore on glucose metabolism. Olanzapine carries one of the highest risks for diabetes among the atypical antipsychotic agents. Quetiapine and risperidone affect patient weight more than ziprasidone does but less than olanzapine does.
A patient who is has taken fluoxetine (Prozac) for 2 weeks to treat an anxiety disorder complains that he is not satisfied with the therapy. What is the best information for the nurse to include in patient teaching to promote adherence to the therapeutic regimen? A. The adverse effects can be managed well. B. This medication usually requires titration. C. Relaxation exercises can offer some relief. D. A therapeutic effect is expected 2 to 4 weeks after the start of therapy.
D. A therapeutic effect is expected 2 to 4 weeks after the start of therapy. The full therapeutic effects of selective serotonin reuptake inhibitor (SSRI) therapy may take 4 to 6 weeks to appear, so this patient can anticipate experiencing a therapeutic effect in 2 to 4 more weeks. Knowing the timeframe offers the patient realistic hope and provides a justification for adherence to therapy. Adverse effects can usually be managed, and relaxation exercises may provide some relief from anxiety. The patient must fulfill these tasks to get the full therapeutic effect of the medication, but it can be difficult for a patient with depression to do so. SSRIs can require considerable titration, but, because of the nature of the patient's illness, this information is unlikely to promote adherence to therapy.
Which piece of objective data is contraindication to the use of clozapine (Clozaril)? A. Allergy to phenothiazines B. Self-destructive behaviors C. Failed antipsychotic therapy D. Acute lymphocytic leukemia
D. Acute lymphocytic leukemia Clozapine is contraindicated in patients with a history of myeloproliferative disorders such as leukemia because this medication can cause fatal agranulocytosis. For this reason, weekly monitoring of the white blood cell (WBC) count is mandatory. If the total WBC count falls below 3000/mm3, treatment should be interrupted. Clozapine is indicated for patients with a high risk for suicide and failed antipsychotic therapy involving the use of other medications. Because clozapine is not a phenothiazine, an allergy to those medications poses no obstacle to its use.
A patient is detoxifying from alcohol abuse. Which type of medication is indicated to help the patient through withdrawal? A. Dibenzapine B. Benzisoxazole C. Phenothiazine D. Benzodiazepine
D. Benzodiazepine A benzodiazepine is indicated in the management of the clinical manifestations of alcohol withdrawal because of their wide range of therapeutic effects. Dibenzapines, benzisoxazoles, and phenothiazines are antipsychotic agents and are not indicated for alcohol withdrawal.
A male patient taking a monoamine oxidase inhibitor (MAOI) calls the nurse and reports headaches, tachycardia, nausea, and vomiting. Which patient teaching should the nurse implement? A. Tell the patient to start drinking water. B. Instruct the patient to lie down and rest. C. Ask whether the patient has an antiemetic agent. D. Have the patient call for emergency help.
D. Have the patient call for emergency help. Because the patient may be experiencing a hypertensive crisis related to the administration of the MAOI, the nurse instructs the patient to call 911 for emergency medical assistance. The nurse also instructs the patient not to drive himself to the hospital because if a hypertensive crisis is in progress, seizures or circulatory collapse is likely and the patient could be endangering his life and the safety of others by driving. Because the nurse cannot know with certainty that the patient is experiencing a hypertensive crisis, the nurse avoids suggesting that the patient lie down and rest because rest is ineffective therapy for this situation; instead, the nurse instructs the patient to seek emergency help. The nurse also avoids interviewing the patient further or instructing him to drink fluids in response to the vomiting because such actions waste time and endanger the patient, who may require emergency treatment.
A male surgical patient in the postanesthesia care unit who was given a benzodiazepine is not breathing. What is the nurse's priority after administering the antidote for this medication to the patient? A. Monitoring for dysrhythmias B. Taking seizure precautions C. Providing pain management D. Maintaining oxygen saturation
D. Maintaining oxygen saturation The nurse's priority is to support the patient's airway and breathing for adequate oxygenation because reversing the effects of a benzodiazepine does not guarantee the return of breathing. The administration of flumazenil (Romazicon) is indicated to reverse the effects of a benzodiazepine; however, this medication puts the patient at risk for seizures and dysrhythmias. The patient is likely to need analgesic medication because he is in the immediate postoperative period; however, his pain is unrelated to the airway, breathing, or use of the antidote for a benzodiazepine. That said, the apnea could be the result of the intraoperative administration of an opioid, over which flumazenil would have no effect. None of these issues is more important than maintaining the airway and breathing because these are a patient's most basic needs.
A 75-year-old patient is experiencing insomnia. What is the most important reason that the nurse avoids administering a benzodiazepine as a hypnotic agent to this patient? A. This will increase the risk of drug interactions. B. Benzodiazepines can offer short-term sleepiness only. C. Benzodiazepines are addictive when used as a hypnotic agents. D. Older adults are sensitive to sedating effects.
D. Older adults are sensitive to sedating effects. Older adults tend to be more sensitive than younger people to the sedating effects of benzodiazepines, and because older adults tend to take more medications than a younger adult, the likelihood that the sedative properties will be potentiated by the benzodiazepine is much higher, increasing the risk of patient injury unnecessarily. The risk for addiction is higher with the use of a benzodiazepine rather than another agent to induce sleep, another reason that benzodiazepines are a poor choice of hypnotic agent in older adults; however, the addictive properties are present regardless of the indication for the drug's use. Long-acting benzodiazepines that do not interact adversely with most medications are available.
After benzodiazepine treatment fails, the nurse administers buspirone (BuSpar) to a patient with an anxiety disorder. What patient teaching should the nurse provide to help the patient realize the full benefit of buspirone therapy? A. Avoid taking serotonergic agents. B. Stand up slowly to help minimize any dizziness. C. Take the medication with food to help prevent nausea. D. Self-administer buspirone on a consistent basis.
D. Self-administer buspirone on a consistent basis. The nurse instructs the patient to take buspirone daily and to adhere to the dosing schedule to realize the full benefit of therapy because consistent dosing is important in achieving the full therapeutic effect. Although unrelated to achieving the therapeutic effect, instructing the patient to avoid serotonergic agents, as a means of preventing serotonin syndrome, is a reasonable nursing intervention for a patient taking buspirone. The nurse instructs the patient to change positions slowly if dizziness occurs. Nausea is an unusual effect of buspirone.
A male patient asks the nurse how long it will take for escitalopram (Lexapro) to be completely effective for him. Which time frame should the nurse include in patient teaching? A. 1 week B. 2 or 3 days C. 2 or 3 months D. Several weeks
D. Several weeks The nurse instructs the patient to adhere to therapy for several weeks to determine whether escitalopram will be an effective antidepressant for him. Escitalopram is a selective serotonin reuptake inhibitor (SSRIs), and a delay in therapeutic effectiveness is characteristic of SSRIs.
