PREPU (UNFINISHED) Chapter 22: Antidepressant Drugs

5 A 12 year-old client with depression has been prescribed trazodone 1.5 mg/kg/day in three divided doses. The client weighs 110 lbs. How many 50-mg tablets should the nurse administer for each dose?

• 0.5 Explanation: The client's weight in kg is determined by dividing the weight in pounds by 2.2, giving 50 kg. The daily dose is 1.5 mg/kg and 1.5 mg x 50 kg = 75 mg. Dividing by three gives each individual dose: 25 mg, which is half of a 50-mg tablet.

19 of 20 The nurse is caring for a young female client who is 5 weeks pregnant. What statement made by the nurse about the use of antidepressants during pregnancy is most accurate? • "Most antidepressants are safe during pregnancy but those that are contraindicated should be avoided." • "Antidepressants are used very cautiously during pregnancy and only when benefit outweighs risk." • "Antidepressants are contraindicated and must be discontinued if pregnancy occurs." • "Antidepressants must be chosen carefully because only a few are safe during pregnancy."

• "Antidepressants are used very cautiously during pregnancy and only when benefit outweighs risk." Explanation: Antidepressants should be used very cautiously during pregnancy and lactation because of the potential for adverse effects on the fetus and possible neurological effects on the baby. Use should be reserved for situations in which the benefits to the mother far outweigh the potential risks to the neonate.

18 of 20 The client is taking the medication fluvoxamine (Fluvox) 150 mg PO daily. The nurse is assessing the clients medication regimen. The client denies a history of depression. What assessment question should the nurse subsequently ask? • "Have you ever had a Mini-Mental Status Exam performed?" • "Does anyone else in your family have a history of depression?" • "Have you ever had any thoughts about deliberately harming yourself?" • "Do you have any history of obsessive thoughts of compulsive habits?"

• "Do you have any history of obsessive thoughts of compulsive habits?" Explanation: Fluvoxamine is indicated for the treatment of obsessive-compulsive disorder and is classified as a selective serotonin reuptake inhibitor (SSRI). The MMSE is used to screen for cognitive deficits, which are not likely in this client. Suicide risk is a relevant assessment for all clients, but this client denies a history of depression, so this may not be prioritized over assessing for OCD. The client's family history of depression is not a central concern.

14 of 20 A client comes to the clinic with a possible mood disorder diagnosis of unipolar depression. What question by the nurse will best help in assessing this client's mental status? • "Why are you feeling sad?" • "What have you eaten in the last two days?" • "Have you felt hopeless anytime lately?" • "Can you name six things you would like to change in your life?"

• "Have you felt hopeless anytime lately?" Explanation: A quick depression assessment involves asking the client if he/she has felt helpless or hopeless over the last two weeks. The other questions will not be helpful in assessing the client's current mental status.

16 of 20 The nurse is caring for a client whose current drug regimen includes mirtazapine 15 mg PO daily. What assessment question should the nurse prioritize? • "How are you feeling today?" • "On a scale from zero to ten, how would you rate your anxiety level?" • "Are you feeling happier today than in the past?" • "How would you describe your mood and energy level today?"

• "How would you describe your mood and energy level today?" Explanation: Mirtazapine is an antidepressant and it is prudent for the nurse to assess the client's mood and level of energy. Anxiety is not synonymous with depression and is not treated with this medication. Asking a client how the client feels is often too vague and open-ended to obtain meaningful data. Asking a client if she or she feels "happier" is a closed-ended (yes/no) question and could easily be interpreted by the client as downplaying the severity of depression.

5 of 5 An adult client, diagnosed with depression several weeks ago, has begun taking citalopram 10 days ago. The client has told the nurse of the intent to stop taking the drug, stating, "I don't feel any less depressed than I did before I started taking these pills." How should the nurse bestrespond to the client's statement? • "I'd encourage you to continue with the drug; it can take several weeks before it improves your mood." • "It could be that one of the other medications or supplements you're taking is negating the effects of citalopram." • "I'll pass that information along to your care provider; a different drug might be more appropriate for you." • "People often have unrealistic expectations about how the drug will make them feel."

• "I'd encourage you to continue with the drug; it can take several weeks before it improves your mood." Explanation: Steady-state blood levels of selective serotonin reuptake inhibitors (SSRIs) like citalopram are achieved slowly, over several weeks. The client should expect to sense an eventual improvement in mood, and it would be premature to change medications. This aspect of pharmacokinetics is more likely than a possible drug interaction. The nurse needs to educate the client not demean his or her feelings about the therapy.

10 of 20 A client has been taking Prozac for the past two months for depression. She is seeing her gynecologist for premenopausal symptoms and during the interview with the nurse she says, "I'm interested in trying Sarafem because my friend is taking it and she says it works great." What is the best response by the nurse? • "You cannot safely take both drugs at the same time so it will be important for you and your provider to decide which is best." • "When taking both of these drugs, you'll likely be encouraged to take one in the morning and one at night." • "Before changing drugs it is important to give you enough time to respond to Prozac." • "Sarafem and Prozac are different brand names for the same generic medication."

• "Sarafem and Prozac are different brand names for the same generic medication." Explanation: Prozac and Sarafem are different brand names for fluoxetine, so there is no benefit in changing the client's medication regimen and, if taken together, would result in a drug overdose. The other three responses are incorrect or inappropriate because they do not reflect the fact that both drugs are the same.

16 of 20 A new mother asks her nurse about the safety of taking St. John's wort for postpartum depression. What would be the nurse's best response? • "St. John's wort is a natural and safe alternative to prescription antidepressants." • "It's not clear that St. John's wort is effective in treating depression, but it won't cause any harm." • "There is insufficient evidence to support the use of St. John's wort, and drug interactions may be extensive." • "Most experts agree that St. John's wort is effective in treating depression but that it can contribute to hypertension."

• "There is insufficient evidence to support the use of St. John's wort, and drug interactions may be extensive." Explanation: Most experts agree that there is insufficient evidence to establish that St. John's wort is effective in treating depression. The herb has some side effects (such as photosensitivity, dizziness, and nausea), though they are usually infrequent and mild. Drug interactions, however, may be extensive. St. John's wort may decrease the effectiveness of some drugs, and combining it with others, such as cold and flu medications, may result in severe hypertension.

3 of 5 A physician has prescribed an antidepressant medication for a 15-year-old client. Which statement would be appropriate for inclusion in medication teaching? • "There may be an increased risk of suicide while taking this drug." • "Clients may lose all inhibitions while on this drug." • "There may be an increased risk of socialization while taking this drug." • "If you miss a dose of this drug, double the dose the next time you take it."

• "There may be an increased risk of suicide while taking this drug." Explanation: There may be an increased risk of suicidal ideation in children, adolescents, and young adults 18 to 24 years of age when taking antidepressant medications. Antidepressants do not increase the risk of socialization or cause clients to lose their inhibitions. Clients should not increase their dose to make up for a missed dose.

3 of 5 A 28-year-old client asks his nurse how phenelzine therapy will help him. Which would be an appropriate response by the nurse? • "The drug will help increase your attention level." • "This therapy will improve your overall mood and increase your social activity." • "This therapy will help reduce the severity of your bipolar episodes." • "The drug will enable you to gain the appropriate weight."

• "This therapy will improve your overall mood and increase your social activity." Explanation: The effectiveness of phenelzine is demonstrated by improved mood and increased social activity in depressed clients. Reduced severity of bipolar episodes indicates success of valproates. Increased attention levels and weight gain, though desired benefits, are not a direct result of the drug therapy.

5 of 20 What instructions should a nurse include when teaching a client who has depression about the use of amitriptyline? • "Be sure to eat a low fiber diet to prevent diarrhea." • "Limit your fluid intake so you don't have to urinate during the night." • "Take the drug daily in the morning for maximum benefit." • "Use sugarless hard candies and gum to deal with dry mouth."

• "Use sugarless hard candies and gum to deal with dry mouth." Explanation: Sugar-free hard candies and gums would help to alleviate dry mouth that may occur due to anticholinergic effects. The client should take a major portion of the dose at bedtime if drowsiness and anticholinergic effects are severe. Fluid restriction should not be encouraged, and would have no benefit. Similarly, a higher fiber diet would be beneficial for maintaining normal bowel function.

1 of 5 A male client explains to a nurse that he had been taking amitriptyline (Elavil) for depression and that his physician changed his medication to paroxetine (Paxil). The client is confused and doesn't understand why the medication was changed. The nurse's best response to the client would be: • "Did you take the amitriptyline like you should have?" • "Paroxetine is newer and will be much better for you." • "Maybe the old medicine wasn't working anymore." • "Would you like to talk with your physician about this?"

• "Would you like to talk with your physician about this?" Explanation: The nurse should refer the client to the physician and let them address their rationale for the medication change. By asking the client if he took the medication as prescribed, the nurse is insinuating that he may not have and this would not be considered therapeutic communication. The nurse has no basis for commenting that the medication might not be working or that another drug would work better.

8 of 20 For which client would the black box warning that is present on all antidepressants be most relevant? • A 12 year-old boy who has been diagnosed with depression by a pediatric psychiatrist • An 89 year-old female client who is distraught after the recent death of her husband • A 62 year-old client who has depression and ischemic heart disease • A 32 year-old client who uses oral contraceptives and who has depression

• A 12 year-old boy who has been diagnosed with depression by a pediatric psychiatrist Explanation: A black box warning was added to all antidepressants bringing attention to the increase in suicidality, especially in children and adolescents, when these drugs were used. This warning does not address the other listed clients.

4 of 20 A nurse is providing care on a psychiatric unit with many clients that take antidepressants. What client factor would the nurse have to consider when administering these medications? • A client has a history of pulling out her IV cannula • A client has an intense fear of injections • A client actively resists IM injections • A client has dysphagia

• A client has dysphagia Explanation: Antidepressants are almost exclusively administered in oral form not IV or IM. For clients with dysphagia, they have the potential for aspiration.

15 of 20 A community health nurse follows many clients, several of whom have depression and who are taking antidepressants. What assessment finding should the nurse prioritize for reporting to the care provider? • A client who takes amitriptyline reports a dry mouth and occasional urinary hesitation • A client taking isocarboxazid with whom the nurse needed to review dietary restrictions • A client who began taking escitalopram two weeks ago says her mood has worsened since starting the drug • A client who takes sertraline 24 mg PO daily says he has noticed some sexual dysfunction since starting the drug

• A client who began taking escitalopram two weeks ago says her mood has worsened since starting the drug Explanation: Worsening mood that accompanies the use of an SSRI could constitute an increased risk for suicidality. The nurse should communicate this to the provider promptly so the client can be reassessed. The client taking amitriptyline is experiencing anticholinergic effects which the nurse can likely manage. A client's sexual dysfunction should be addressed but this is not a safety risk. The fact that the nurse needed to review a client's dietary restrictions is not necessarily problematic and could indicate the client's firm commitment to adhering to the restrictions.

17 of 20 The client presents to the emergency department with a headache in the back of the head, diaphoresis and neck stiffness. The client's blood pressure measures 180/124 mm Hg and heart rate is 168 beats per minute. The spouse says the client is currently prescribed "something for depression" and denies any history of cardiac disease. The nurse should suspect the use of what medication? • A monoamine oxidase inhibitor (MAOI) • An atypical antipsychotic • A tricyclic antidepressant (TCA) • A selective serotonin reuptake inhibitor (SSRI)

• A monoamine oxidase inhibitor (MAOI) Explanation: MAOIs have several serious adverse effects that can be fatal. This client's symptoms indicate fatal hypertensive crisis characterized by occipital headache, palpitations, neck stiffness, nausea, vomiting, sweating, dilated pupils, photophobia, tachycardia, and chest pain. It may progress to intracranial bleeding and fatal stroke. SSRIs and TCAs are not associated with these particular symptoms. Antipsychotics do not have this effect.

6 of 10 The psychiatric-mental health nurse is overseeing care of several clients who are being treated with selective serotonin reuptake inhibitors. Which client should the nurse monitor most closely for adverse effects? • A client whose treatment regimen also includes electroconvulsive therapy (ECT) • A 79-year-old client who has a comorbidity of early stage dementia • A 60-year-old female client who is also taking hormone replacement therapy • A severely depressed 14-year-old client who is receiving inpatient care

• A severely depressed 14-year-old client who is receiving inpatient care Explanation: The use of SSRIs in adolescents requires caution and careful monitoring due to the increased risk for suicidality. Dementia greatly complicates the overall treatment of a client with dementia, but it does not necessarily increase the risk for adverse drug effects. Similarly, ECT and hormone therapy do not increase the likelihood of adverse effects.

3 of 20 The client has been perscribed an MAO inhibitor. As the nurse teaches the client about this medication, what foods will the client be instructed to avoid? • Aged cheeses and meats, concentrated yeast extracts, sauerkraut, and fava beans • Herbal stimulants, pasta, organ meats, and egg products • Coffee, chocolate, organ meats, pasta, and navy beans • Herbal stimulants, caffeine, navy beans, and cheese

• Aged cheeses and meats, concentrated yeast extracts, sauerkraut, and fava beans Explanation: MAO inhibitors are rarely used in clinical practice today, mainly because they may interact with some foods and drugs to produce severe hypertension and possible heart attack or stroke. Foods that interact contain tyramine, a monoamine precursor of norepinephrine. Normally, tyramine is deactivated in the GI tract and liver so that large amounts do not reach the systemic circulation. When deactivation is blocked by MAO inhibitors, tyramine is absorbed systemically and transported to adrenergic nerve terminals, where it causes a sudden release of large amounts of norepinephrine. Foods that should be avoided include aged cheeses and meats, concentrated yeast extracts, sauerkraut, and fava beans.

4 of 10 Assessment of a client reveals muscle rigidity, altered mental status, tachycardia, and sweating. The nurse understands that which antidepressant drug may be the cause? • Bupropion • Fluoxetine • Citalopram • Amoxapine

• Amoxapine Explanation: Amoxapine has been associated with neuroleptic malignant syndrome, which presents with symptoms of tachycardia, sweating, muscle rigidity, and altered mental status. Fluoxetine adverse effects are dry mouth, episodes of orthostatic hypotension, and drowsiness. Bupropion adverse effects are agitation, dizziness, dry mouth, insomnia, sedation, headache, nausea, vomiting, and tremor to name a few. Amitriptyline adverse effects are sedation, anticholinergic effects, and constipation.

2 of 20 A client while experiencing depression is reluctant to start on antidepressant medication. What information should be the basis for the nurse's best response? • If the depression has been present for more than 6 months, medication may be indicated. • Antidepressant therapy may be indicated if depressive symptoms impair social relationships or work performance and occur independently of life events. • Depression is best treated naturally with rest, exercise, and nutritional supplements. • Antidepressant medications should not be used unless the client cannot function without them.

• Antidepressant therapy may be indicated if depressive symptoms impair social relationships or work performance and occur independently of life events. Explanation: Antidepressant therapy may be indicated if depressive symptoms persist at least 2 weeks, impair social relationships or work performance, and occur independently of life events. Rest, exercise, and nutritional supplements will aid in the effectiveness of a medication regimen but may not necessarily replace it.

14 of 20 The nurse is caring for a 32-year-old client who is taking amitriptyline for depression. What nursing intervention would be appropriate if this client developed orthostatic hypotension? • Asking the client to sit on the side of the bed for 1 minute before getting up • Informing the client this adverse reaction should be gone in a week • Consulting with the physician to change the medication • Instructing the client to double the dosage until the adverse effect goes away

• Asking the client to sit on the side of the bed for 1 minute before getting up Explanation: Cardiovascular effects such as orthostatic hypotension, hypertension, arrhythmias, myocardial infarction, angina, palpitations, and stroke may also pose problems. Miscellaneous reported effects include alopecia, weight gain or loss, flushing, chills, and nasal congestion. It would not be appropriate to tell the client to double their dose or telling the client the adverse effect would go away in a week. Consulting the physician might be an appropriate thing to do, but it would not be the most appropriate response.

2 of 5 A nurse is caring for a client who is taking a monoamine oxidase (MAO) inhibitor for treatment of a depressive disorder. What is a potentially serious side effect of MAO inhibitors? • Hypertension • Decreased urinary output • Respiratory congestion • Anemia

• Hypertension Explanation: MAO inhibitors may interact with some foods and drugs to produce severe hypertension and possible heart attack or stroke. Clients who take MAO inhibitors should avoid foods that contain tyramine, such as aged cheeses and fava beans.

18 of 20 A client on the psychiatry unit with a longstanding history of schizophrenia has been prescribed risperidone (Risperdal). What assessment should the nurse prioritize in the care of this client? • Assessment of the client's behaviors and thought processes • Assessing the client's vital signs • Monitoring the client's hepatic and renal status • Monitoring the client for indications of bone marrow suppression

• Assessment of the client's behaviors and thought processes Explanation: The nurse's priority should be to assess the signs and symptoms of the client's underlying health problem in order to identify therapeutic effects. The client's vital signs are not likely to be volatile, and hepatic and renal status are not commonly affected by Risperdone. Bone marrow suppression is not an expected adverse effect.

8 of 10 A client with a longstanding diagnosis of depression is being treated with phenelzine. The client reports the recent use of some over-the-counter flu and cold remedies and has consequently been admitted for observation and client teaching. What assessment should the nurse prioritize? • Blood pressure monitoring • Pulse oximetry • Monitoring the client for tardive dyskinesia • Pain assessment

• Blood pressure monitoring Explanation: The drug-drug interactions that exist with the use of monoamine oxidase inhibitors create a high risk for hypertensive crisis. Blood pressure monitoring is thus among the priority assessments. Tardive dyskinesia is not among the varied signs and symptoms that can result from drug-drug interactions with MAOIs. The nurse should certainly monitor the client's pain and oxygenation, but blood pressure monitoring is the highest priority due to the likelihood and safety risks associated with hypertensive crisis.

8 of 20 A nurse is preparing to administer selective serotonin reuptake inhibitors (SSRIs) to a group of clients. The nurse would administer the drug cautiously to which clients? • Clients with increased intraocular pressure • Clients with diabetes mellitus • Clients with tendency for urinary retention • Clients with narrow angle glaucoma

• Clients with diabetes mellitus Explanation: The nurse should administer SSRIs cautiously to clients with diabetes mellitus. Sinequan (doxepin) is contraindicated in clients with a tendency for urinary retention. The nurse should use caution with clients with increased intraocular pressure and narrow-angle glaucoma when administering tricyclic antidepressants.

2 of 20 The nurse is providing care for a client who has been prescribed trazodone for the treatment of depression. What assessment should the nurse prioritize? • Cognition and level of consciousness • Urine output and creatinine clearance • Skin integrity and peripheral perfusion • Oxygen saturation and respiratory rate

• Cognition and level of consciousness Explanation: Trazodone (Desyrel) is effective in some forms of depression but has many CNS effects associated with its use. For this reason, the nurse should prioritize the assessment of neurologic status over respiratory, renal or integumentary status.

13 of 20 A client with a severe depression has been hospitalized, and the health care provider has ordered amitriptyline. What common adverse effect might this client have? • Hypertension • Fever • Decreased B/P • Dry mouth

• Dry mouth Explanation: Use of TCAs may lead to GI anticholinergic effects, such as dry mouth, constipation, nausea, vomiting, anorexia, increased salivation, cramps, and diarrhea.

12 of 20 Besides being prescribed as an antidepressant, imipramine helps treat which disorder in children? • Attention deficit hyperactivity disorder • Night terrors • Weight loss • Enuresis

• Enuresis Explanation: Besides being prescribed as an antidepressant, imipramine is used to treat enuresis in children older than age 6.

2 of 5 The nurse is caring for an 8-year-old client who takes imipramine. The nurse should assess this client for a history of which health problem? • Psoriasis • Obsessive compulsive disorder (OCD) • Enuresis (bed-wetting) • Oppositional defiant disorder

• Enuresis (bed-wetting) Explanation: One of the indications for use of the drug imipramine is enuresis in children older than 6 years. Imipramine is not indicated for the treatment of OCD, oppositional defiant disorder, or psoriasis.

9 of 10 What drug should the nurse consider contraindicated for the client taking a monoamine oxidase inhibitor (MAOI)? • Acetaminophen • Docusate (Colace) • Escitalopram (Lexapro) • Insulin

• Escitalopram (Lexapro) Explanation: SSRIs are contraindicated because of a life-threatening serotonin syndrome that could occur. If a client requires insulin the benefit outweighs the risk but careful monitoring of glucose levels is needed because effects of insulin may be additive with an MAOI. There is no known contraindication for acetaminophen or docusate.

4 of 20 Which agent would a nurse identify as a selective serotonin reuptake inhibitor? • Fluvoxamine • Selegiline • Nefazadone • Mirtazapine

• Fluvoxamine Explanation: Fluvoxamine is classified as a selective serotonin reuptake inhibitor. Selegiline is not classified as a selective serotonin reuptake inhibitor; it is a MAO-type B inhibitor. Nefazadone is not classified as a selective serotonin reuptake inhibitor. Mirtazapine is not classified as a selective serotonin reuptake inhibitor.

2 of 5 A client is admitted to the nursing unit with OCD. What drug has been found to be effective for treating OCD? • Amitriptyline • Phenelzine • Fluvoxamine • Desipramine

• Fluvoxamine Explanation: SSRIs are indicated for the treatment of depression, OCDs, panic attacks, bulimia, PMDD, posttraumatic stress disorders, social phobias, and social anxiety disorders. Phenelzine, desipramine, and amitriptyline are not SSRIs.

13 of 20 The nurse has instructed the client on taking a mood disorder medication. The nurse knows that there is a need for further instruction when the client states that the medication can be taken with which breakfast item? • Grapefruit juice • Sausage • Hash brown potatoes • Fried eggs

• Grapefruit juice Explanation: Grapefruit juice should be avoided in clients taking mood disorder medications such as trazodone, sertraline, and vilazodone. Eggs, hash brown potatoes, and sausage are not contraindicated with these drugs.

1 of 5 A client has been prescribed a monoamine oxidase inhibitor (MAOI) by the health care provider. Before administration of the drug, the client wants to know about possible adverse reactions. Which would the nurse expect to describe? • Hypertensive crisis • Photosensitivity • Change in libido • Skin rash

• Hypertensive crisis Explanation: Hypertensive crisis is an adverse reaction of MAOIs. Photosensitivity is an adverse reaction of tricyclic antidepressants. Change in libido and skin rash are adverse reactions of desvenlafaxine and bupropion.

3 of 5 The nurse is admitting a client who has a possible diagnosis of mood disorder. The nurse assesses the client for symptoms of what medical condition that may be mistaken for a mood disorder? • Crohn's disease • Hypothyroidism • Congestive heart failure • Bell's palsy

• Hypothyroidism Explanation: Clients should be assessed for hypothyroidism, which may cause low energy levels and sluggish movements due to low thyroid hormone level. Crohn's disease symptoms may cause fatigue, but the client is also experiencing multiple loose stools. Clients with Bell's palsy have a viral infection that causes paralysis of part of the face. Clients with congestive heart failure will have fatigue, but it is related to reduced functioning of the heart.

11 of 20 A 11-year-old client has been hospitalized with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action? • Assess for weight loss and difficulty sleeping. • Implement suicide precautions. • Monitor the client for migraines. • Monitor food intake and eliminate potential sources of tyramine.

• Implement suicide precautions. Explanation: Recent studies have linked the incidence of suicide attempts to the use of SSRIs in pediatric clients. The priority concern for the nurse would be safety for the client. Severe headaches and reactions to tyramine-containing foods are associated with monoamine oxidase therapy, not SSRIs. Weight loss and difficulty sleeping are of a lower priority concern than the client's safety.

12 of 20 The client has been depressed since her father died 6 months ago. The client's healthcare provider has prescribed amitriptyline. What aspect of this client's health history should prompt the nurse to contact the prescriber? • Concussion 10 months ago • Ischemic heart disease • Gastroesophageal reflux disease (GERD) • Osteoporosis

• Ischemic heart disease Explanation: Caution should be used with tricyclic antidepressants in clients with preexisting cardiovascular (CV) disorders because of the cardiac stimulatory effects of the drug and with any condition that would be exacerbated by the anticholinergic effects (e.g., angle-closure glaucoma, urinary retention, prostate hypertrophy, GI or genitourinary surgery). There is no indication that caution is needed with clients diagnosed with osteoporosis or GERD. A concussion would be significant if it were more recent than 10 months ago.

5 of 20 A client has been taking citalopram for 2 weeks and has expressed a desire to discontinue it, stating, "I don't feel any better than I did before I started these pills." What should the nurse teach the client? • Improvements are likely evident to others even if not to the client • It may take up to two more weeks before the client feels better • The client's pessimism is likely a symptom of the underlying depression • The drug requires six to eight weeks before it reaches peak levels

• It may take up to two more weeks before the client feels better Explanation: It may take up to 4 weeks before the full effect of a SSRI such as escitalopram is noted. This phenomenon is the most likely cause of the client's appraisal, not a lack of perspective or worsening symptoms.

7 of 10 A tricyclic antidepressant has been prescribed to a 77-year-old client whose current medication regimen includes omeprazole, captopril, calcium carbonate, alendronate, and warfarin. What assessment should the nurse prioritize when monitoring the client for drug-drug interactions? • Monitor the client for tetany and review serum calcium levels when available. • Ask the client at each meal about any episodes of gastroesophageal reflux. • Assess the client's blood pressure every six hours for the first week of therapy. • Monitor the client closely for bleeding and review coagulation indices when available.

• Monitor the client closely for bleeding and review coagulation indices when available. Explanation: Combining TCAs with warfarin creates a risk for bleeding, which should be addressed in the nursing care plan. There is no known interaction between TCAs and calcium supplements or bisphosphonates that would create a risk for hypocalcemia. TCAs do not heighten the risk of gastroesophageal reflux. TCAs can affect blood pressure, but this is unrelated to any known drug-drug interactions.

9 of 20 The nurse refers a client to a psychiatrist for medication to treat a severe anxiety disorder. What medication does the nurse expect the client to be given? • Paroxetine (Paxil) 10 mg po qd • Benztropine (Cogentin) 2 mg PO bid • Chlorpromazine (Thorazine) 25 mg PO tid • Clozapine (Clozaril) 200 mg PO bid

• Paroxetine (Paxil) 10 mg po qd Explanation: SSRIs are indicated for the treatment of depression, OCDs, panic attacks, bulimia, PMDD, posttraumatic stress disorders, social phobias, and social anxiety disorders.

5 of 10 The nurse is aware that which medication taken by a client for treatment of mood disorder requires a diet that restricts the amount of tyramine eaten? • Diazepam (Valium) • Triazolam (Halcion) • Paroxetine (Paxil) • Phenelzine (Nardil)

• Phenelzine (Nardil) Explanation: MAOIs are drugs used in the treatment of mood disorders. They require that the client follow a strict diet that restricts tyramine to prevent a hypertensive crisis. Nardil is an MAOI. Diazepam and triazolam are benzodiazepines and paroxetine is an SSRI.

9 of 20 A client comes to the mental health clinic for a regular appointment. The client tells the nurse he has been taking oral fluoxetine (Prozac) 20 mg daily for the past 3 weeks and that he has lost 3 pounds during that time due to a loss of appetite. What action should the nurse take? • Reassuring the client that the weight loss is due to diuresis and will resolve once fluid balance is restored • Recommending the use of over-the-counter multivitamin supplements • Encouraging the client to increase fat intake to avoid further weight loss • Reassuring the client that this is a common adverse effect with this medication

• Reassuring the client that this is a common adverse effect with this medication Explanation: Adverse effects of fluoxetine include anorexia and weight loss. This client's weight loss is modest and would not likely necessitate a change in drug therapy. Although teaching about healthy eating is a good idea, it is more important to teach the client how to take the medication in a way that will reduce adverse effects as well as how to optimize healthy calories to maintain weight. The client should increase caloric intake, not just fluid intake. It would not be healthy to recommend exclusively increasing fat intake. The client should continue the medication to see whether therapeutic effects are obtained and adjust nutritional intake if necessary.

10 of 20 A middle-aged client was diagnosed with major depression after a suicide attempt several months ago and has failed to respond appreciably to treatment with SSRIs. As a result, the client was prescribed phenelzine. When planning this client's subsequent care, what nursing diagnosis should the nurse prioritize? • Risk for Injury related to drug-drug interactions or drug-nutrient interactions • Risk for Ineffective Peripheral Tissue Perfusion related to cardiovascular effects of phenelzine • Risk for Constipation related to decreased gastrointestinal peristalsis • Risk for Infection related to immunosuppressive effects of phenelzine

• Risk for Injury related to drug-drug interactions or drug-nutrient interactions Explanation: MAOIs such as phenelzine carry a significant risk of injury that results from the multiple interactions associated with these drugs. Infection, impaired tissue perfusion, and constipation are less common, and less serious, adverse effects.

10 of 10 A client has been taking a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression. Which represents the action of the medication? • SSRIs block GABA function. • SSRIs increase serotonin synthesis. • SSRIs increase serotonin synthesis. • SSRIs prevent serotonin from being reabsorbed.

• SSRIs prevent serotonin from being reabsorbed. Explanation: Fluoxetine and the other SSRIs block the reabsorption of the neurotransmitter serotonin in the brain. This helps elevate mood. SSRIs do not increase serotonin synthesis or the number of binding sites. They do not influence the role of GABA.

6 of 20 After teaching a group of nursing students about antidepressants, the instructor determines that the teaching was successful when the students identify which as inhibiting the reuptake of serotonin? • Selective serotonin reuptake inhibitors • Monoamine oxidase inhibitors • Tricyclic antidepressants • Atypical antidepressants

• Selective serotonin reuptake inhibitors Explanation: Selective serotonin reuptake inhibitors exert their effects by inhibiting reuptake of serotonin. Tricyclic antidepressants exert their effects by inhibiting reuptake of norepinephrine and serotonin. Monoamine oxidase inhibitors, classified as MAOIs inhibit the activity of monoamine oxidase, a complex enzyme system responsible for inactivating certain neurotransmitters. Lithium is not a true antidepressant drug, it is grouped with the antidepressants because of its use in regulating the severe fluctuations of the manic phase of bipolar disorder.

17 of 20 After seeking care for persistent exhaustion and sadness, a client has been diagnosed with depression. The nurse should be aware of what potential contributing factors? Select all that apply. • High levels of thyroid-stimulating hormone and thyroxine • Low levels of norepinephrine • Serotonin deficiency • Dopamine deficiency • Excessive cortisol levels

• Serotonin deficiency • Low levels of norepinephrine • Dopamine deficiency Explanation: A current hypothesis regarding the cause of depression is a deficiency of norepinephrine, dopamine, or serotonin, which are all biogenic amines, in key areas of the brain. Thyroid hormone and cortisol levels have not been implicated in the etiology of depression.

7 of 20 A nurse is caring for a client with suicidal tendencies and severe depression. Which would the nurse be alert for when monitoring the client's condition? • Signs of insomnia • Urinary retention • Photosensitivity • Visual disturbances

• Signs of insomnia Explanation: The nurse should look for signs of insomnia when checking for suicidal tendencies in the client. and report any expressions of guilt, hopelessness, or helplessness; insomnia; weight loss; and direct or indirect threats of suicide. Urinary retention, visual disturbances, and photosensitivity are adverse reactions of tricyclic antidepressants and are not indicative of suicidal tendencies.

7 of 20 When assessing a client's medication history, the use of which herb would alert the nurse to the potential for adverse reactions when taken with antidepressants? • Ginseng • Eucalyptus • St. John's wort • Feverfew

• St. John's wort Explanation: Clients should be assessed for use of the herbal preparation containing St. John's wort because of the potential for adverse reactions when taken with antidepressants. Ginseng is believed to be helpful with memory loss. Feverfew is known to have properties to aid in the relief of migraine headaches. Eucalyptus has many benefits, from aiding in cough relief, stuffy noses but the concomitant use of eucalyptus with sedative and hypnotic drugs, not antidepressants, has been reported to cause increased sedation.

4 of 5 The nurse would contact the health care provider prior to administering lithium if is discovered that the client is allergic to what? • Milk • Eggs • Tartrazine (yellow dye) • Penicillin

• Tartrazine (yellow dye) Explanation: Lithium is contraindicated in clients with the following: hypersensitivity to tartrazine; renal or cardiovascular disease; sodium depletion; and dehydration. It is also contraindicated in clients receiving diuretics. An allergy to penicillin, milk, or eggs would not cause a problem with lithium.

11 of 20 Ms. Keller has been prescribed sertraline for depression and anxiety. She has been taking the medication for 3 months now. After completing her health history, the nurse notes that she is having difficulty sleeping since starting this medication. What would be the best goal for Ms. Keller based on the assessment of her sleep dysfunction? • The client will have no difficulty falling asleep at night. • The client will sleep 8 hours each night. • The client will take a nap each day to prevent fatigue. • The client will drink two glasses of wine before bedtime each night.

• The client will sleep 8 hours each night. Explanation: The only goal that promotes a positive sleep schedule is for the client to get 8 hours of sleep each night. Alcohol use is not recommended while taking sertraline because of adverse effects that can occur. It is unrealistic to expect no difficulty falling asleep.

19 of 20 To best assure client safety, what information should the nurse provide to a client whose fluoxetine therapy has been discontinued? • A monoamine oxidase (MAO) inhibitor will be prescribed concurrently with the fluoxetine for 2 to 3 weeks. • The dosage of the medication will be gradually reduced over a period of 6 to 8 weeks. • It will be important that the client avoid stressful situations until another selective serotonin reuptake inhibitor (SSRI) can be prescribed. • Electroconvulsive therapy (ECT) will be prescribed 2 to 3 weeks before stopping the fluoxetine.

• The dosage of the medication will be gradually reduced over a period of 6 to 8 weeks. Explanation: To avoid antidepressant discontinuation syndrome, it is essential to taper the dosage of the antidepressant and discontinue it gradually, over 6 to 8 weeks, unless severe drug toxicity, anaphylactic reaction, or another life-threatening condition is present. ECT will not avoid this syndrome. Concurrent use of an MAO inhibitor is dangerous. Avoiding stress is advisable but will not minimize the risk of injury in this situation.

1 of 10 Anticholinergic effects such as dry mouth, sedation, and urinary retention are common adverse events occurring with the use of which classes of antidepressants? • Tricyclic antidepressants • Monoamine oxidase inhibitors • Selective serotonin reuptake inhibitors • Atypical antidepressants

• Tricyclic antidepressants Explanation: Anticholinergic side effects commonly occur with the use of the tricyclic class of antidepressants. Common adverse effects for selective serotonin reuptake inhibitors are somnolence, dizziness, headache, insomnia, tremor, and weakness. Monoamine oxidase inhibitors' most common side effects include orthostatic hypotension, dizziness, vertigo, headache, and blurred vision. Adverse effects of lithium include tremors, nausea, vomiting, thirst, and polyuria. Toxic reactions may occur when serum lithium levels are greater than 1.5 mEq/L.

6 of 20 Which medications exert their effects by inhibiting reuptake of norepinephrine and serotonin? • Monoamine oxidase inhibitors • Tricyclic antidepressants • Selective serotonin reuptake inhibitors • Atypical antidepressants

• Tricyclic antidepressants Explanation: Tricyclic antidepressants exert their effects by inhibiting reuptake of norepinephrine and serotonin. Selective serotonin reuptake inhibitors exert their effects by inhibiting reuptake of serotonin. Monoamine oxidase inhibitors, classified as MAOIs inhibit the activity of monoamine oxidase, a complex enzyme system responsible for inactivating certain neurotransmitters. Lithium is not a true antidepressant drug, it is grouped with the antidepressants because of its use in regulating the severe fluctuations of the manic phase of bipolar disorder (a mood disorder characterized by severe swings from extreme hyperactivity to depression).

1 of 20 What statement should a nurse use to plan a client assessment for the characterizations associated with major depression? • negative thoughts that are unresponsive to reason • an impaired ability to function in activities and relationships • a diagnosable lack of self-efficacy and self-advocacy • a quantifiable deficiency of epinephrine

• an impaired ability to function in activities and relationships Explanation: Major depression is associated with impaired ability to function in usual activities and relationships. It is not characterized by a lack of response to reason or a deficiency of epinephrine. A lack of self-efficacy and self-advocacy may exist, but this is not a central characteristic of the illness.

4 of 5 A client prescribed a selective serotonin reuptake inhibitor (SSRI) has begun taking St. John's wort daily. The nurse should teach the client that this combination may result in what adverse reaction? • worsened symptoms of depression • development of blood dyscrasias • hemostatic instability • dangerous drug interactions

• dangerous drug interactions Explanation: Combining St. John's wort with antidepressants can cause serious drug-to-drug interactions. These effects do not typically include worsened depression, alterations in coagulation, or dyscrasias.

3 of 10 What medication is effective in treating enuresis in children older than 6 years of age? • duloxetine • imipramine • venlafaxine • amitriptyline

• imipramine Explanation: Imipramine is approved for treating childhood enuresis in children older than 6 years. Amitriptyline is a tricyclic antidepressant but is not used for childhood enuresis. Duloxetine is a serotonin-norepinephrine reuptake inhibitor that is used for depression. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that is used for depression.

20 of 20 The psychiatric nurse would recognize that venlafaxine's therapeutic effect is achieved by what means? • slowing the reuptake of endorphins in the central nervous system (CNS) • slowing the reuptake of acetylcholine in brain synapses • increasing levels of both serotonin and norepinephrine • stimulating synthesis and potentiating the action of dopamine

• increasing levels of both serotonin and norepinephrine Explanation: Venlafaxine increases the levels of serotonin and norepinephrine in the brain by preventing the reuptake of these neurotransmitters known to play an important part in mood. It does not directly affect endorphins or acetylcholine. The drug weakly inhibits dopamine reuptake.

20 of 20 A client, prescribed fluoxetine 1 week ago, presents for a scheduled follow-up appointment. What should be the focus of the client's nursing assessment? • presence of suicidal ideation • cardiac rate and rhythm • improvement in the ability to concentrate • indications of a type IV hypersensitivity reaction

• presence of suicidal ideation Explanation: It is essential to assess for suicidal thoughts or plans, especially at the beginning of selective serotonin reuptake inhibitor (SSRI) therapy or when dosages are increased or decreased. This supersedes the need to assess for concentration, cardiac function, or hypersensitivity.

15 of 20 The normal function of which neurotransmitter is most likely impaired when a client expresses feelings of gloom and the inability to perform activities of daily living? • acetylcholine • serotonin • epinephrine • insulin

• serotonin Explanation: Serotonin helps regulate several behaviors that are disturbed in depression. Acetylcholine is a neurotransmitter with action in the cardiac and skeletal muscle. Acetylcholine has a limited impact in depression. Epinephrine is not associated with depression, though norepinephrine is implicated. Insulin is released by the pancreas to regulate blood sugar.

3 of 20 After teaching a client who is prescribed isocarboxazid, the nurse determines that additional teaching is needed when the client states a need to avoid what food? • whole milk. • Parmesan cheese • red wine. • sausage.

• whole milk. Explanation: Whole milk is not high in tyramine and thus does not need to be avoided during treatment with an MAOI. Red wine, sausage, and aged cheeses are high in tyramine and should be avoided.