Psych Exam 3 - Medications

A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms and lower back pain states that he stopped taking the medication 2 days ago because it was no longer helping him, but now he feels terrible. The nurse should assess the client for which of the following? Select all that apply. 1. Insomnia. 2. Euphoria. 3. Bradycardia. 4. Diaphoresis. 5. Tremor. 6. Vomiting.

1, 4, 5, 6. Diazepam (Valium) is a benzodiazepine that causes symptoms of withdrawal when stopped abruptly. The nurse should assess the client for tremors, agitation, irritability, insomnia, vomiting, sweating, tachycardia, headache, anxiety, and confusion. Euphoria or elevated mood is not a symptom of benzodiazepine withdrawal.

The client is taking 50 mg of lamotrigine (Lamictal) daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do? 1. Report the rash to the primary health care provider. 2. Explain that the rash is a temporary adverse effect. 3. Give the client an ice pack for his arm. 4. Question the client about recent sun exposure.

1. The nurse should immediately report the rash to the primary health care provider because lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun exposure are irresponsible nursing actions because of the possible seriousness of the rash.

104. A client is taking diazepam (Valium) for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. 1. To consult with his health care provider before he stops taking the drug. 2. To avoid eating cheese and other tyramine-rich foods. 3. To take the medication on an empty stomach. 4. Not to use alcohol while taking the drug. 5. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing.

104. 1, 4, 5. The nurse should instruct the client who is taking diazepam to take the medication as prescribed; stopping the medication suddenly can cause withdrawal symptoms. This medication is used for a short term only. The drug dose can be potentiated by alcohol and the client should not drink alcoholic beverages while taking this drug. Swelling of the lips and face and difficulty breathing are signs and symptoms of an allergic reaction. The client should stop taking the drug and seek medical assistance immediately. The client does not need to avoid eating foods containing tyramine; tyramine interacts with monoamine oxidase inhibitors, not Valium. The client can take the medication with food.

110. A client with panic disorder is taking alprazolam (Xanax) 1 mg PO three times daily. The nurse understands that this medication is effective in blocking the symptoms of panic because of its specific action on which of the following neurotransmitters? 1.Gamma-aminobutyrate. 2. Serotonin. 3. Dopamine. 4. Norepinephrine.

110. 1. Alprazolam, a benzodiazepine used on a short-term or temporary basis to treat symptoms of anxiety, increases gamma-aminobutyrate, a major inhibitory neurotransmitter. Because gamma-aminobutyric acid is increased and the reticular activating system is depressed, incoming stimuli are muted and the effects of anxiety are blocked. Alprazolam does not directly target serotonin, dopamine, or norepinephrine.

112. While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid? 1. Chocolate. 2. Cheese. 3. Alcohol. 4. Shellfish

112. 3. Using alcohol or any central nervous system depressant while taking a benzodiazepine, such as alprazolam, is contraindicated because of additive depressant effects. Ingestion of chocolate, cheese, or shellfish is not problematic.

113. Which of the following statements by a client who has been taking buspirone (BuSpar) as prescribed for 2 days indicates the need for further teaching? 1. "This medication will help my tight, aching muscles." 2. "I may not feel better for 7 to 10 days." 3. "The drug does not cause physical dependence." 4. "I can take the medication with food."

113. 1. Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. BuSpar is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects not occurring for 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

114. When preparing the teaching plan for a client about lithium therapy, the nurse should teach the client about: 1. Maintaining an adequate sodium intake. 2. Discontinuing sodium in the diet. 3. Buying foods labeled "low in sodium." 4. Increasing sodium in the diet.

114. 1. The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels. Therefore, the drug may not reach therapeutic effectiveness.

115. A nurse receives a lithium level report of 1.0 mEq/L (1.0 mmol/L) for a client who has been taking lithium for 2 months. The nurse should interpret this level to indicate which of the following? 1. An error in reporting. 2. Too low to be therapeutic. 3. Too high, indicating toxicity. 4. Within the therapeutic range.

115. 4. For the client who has been receiving lithium therapy for the past 2 months, a maintenance serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L) is considered therapeutic. A lithium level greater than 1.2 mEq/L (1.2 mmol/L) suggests toxicity.

123. A client diagnosed with posttraumatic stress disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which of the following suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. 1. Trying relaxation techniques to help decrease her anxiety before bedtime. 2. Taking the quetiapine (Seroquel) 25 mg as needed as prescribed by the primary health care provider. 3. Staying in the dayroom and trying to sleep in the recliner chair near staff. 4. Listening to calming music as she tries to fall asleep. 5. Processing the content of her flashbacks no less than an hour before bedtime. 6. Leaving her door slightly open to decrease noise during the nightly checks.

123. 1, 2, 4, 6. Relaxation techniques and listening to calming music decrease anxiety and promote sleep. Seroquel is often effective in decreasing nightmare and flashbacks and has a beneficial side effect of drowsiness. Leaving her door slightly open will decrease the noise of making 15-minute checks at night. Staying in the dayroom in a recliner with all the noise and lights is not likely to help. Processing memories an hour or two before bedtime doesn't allow enough time to calm down before sleep.

134. An elderly client hospitalized 4 days for treatment of acute respiratory distress has become confused and disoriented. The client has been picking invisible items off blankets and has been yelling at the daughter who is not in the room. The family tells the nurse that the client has been treated for anxiety with Xanax (alprazolam) for years, but Xanax is not on the current medication list. Which of the following safety measures should be implemented? Select all that apply. 1. The client should be placed on withdrawal precautions and treatment started immediately. 2. The client should be placed in soft restraints. 3. The medications should be available to help with the hallucinations. 4. The daughter should not visit until the client is better. 5. The client's medical and mental status should be evaluated frequently and treated as needed.

134. 1, 3, 5. Especially in the elderly, Xanax withdrawal requires immediate and aggressive treatment. Hallucinations are frightening for the client and family. Changes in medical and mental status can occur quickly in the elderly and the client must be monitored closely. Restraints are not indicated for the client and would likely aggravate the confusion and agitation. There is no need to restrict the daughter from visiting at this point.

15. A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply. 1. Rash. 2. Nausea. 3. Sedation. 4. Hyperthermia. 5. Muscle rigidity.

15. 1, 4, 5. Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. Common adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting, and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of a severe systemic rash known as Stevens-Johnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

15. A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply. 1. Rash. 2. Nausea. 3. Sedation. 4. Hyperthermia. 5. Muscle rigidity.

15. 1, 4, 5. Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. Common adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting, and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of a severe systemic rash known as Stevens-Johnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

178. A client is prescribed buspirone (Buspar) 5 mg two times a day. Which of the following statements indicates that the client has understood the nurse's teaching about this drug? Select all that apply. 1. "This medicine will make me sleepy." 2. "Buspar will relax my muscles." 3. "My anxiety will be completely gone by tomorrow." 4. "Buspar will help me not to worry so much." 5. "I'll be able to focus better."

178. 4, 5. Buspirone is not a benzodiazepine but acts as a serotonin agonist. Serotonin is the neurotransmitter implicated in depression. Buspar reduces symptoms of worry, apprehension, difficulty with concentration, and irritability. It is not sedating, does not cause a high, takes 1 to 6 weeks to be effective, does not cause muscle relaxation, and does not produce dependence, withdrawal, or tolerance. Full therapeutic benefit takes 3 to 6 weeks.

The nurse is reviewing the laboratory report with the client's lithium level taken that morning prior to administering the 5 PM dose of lithium. The lithium level is 1.8 mEq/L (1.8 mmol/L). The nurse should: 1. Administer the 5 PM dose of lithium. 2. Hold the 5 PM dose of lithium. 3. Give the client 8 oz (236 mL) of water with the lithium. 4. Give the lithium after the client's supper.

2. The nurse should hold the 5 PM dose of lithium because a level of 1.8 mEq/L (1.8 mmol/L) can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination, which are early signs of lithium toxicity. The nurse should report the lithium level to the primary health care provider, including any symptoms of toxicity. Administering the 5 PM dose of lithium, giving the client the lithium with 8 oz (236 mL) of water, or giving it after supper would result in an increase of the lithium level, thus increasing the risk of lithium toxicity.

126. Which of the following client statements indicates the need for additional teaching about benzodiazepines? 1. "I can't drink alcohol while taking diazepam (Valium)." 2."I can stop taking the drug anytime I want." 3. "Valium can make me drowsy, so I shouldn't drive for a while." 4. "Valium will help my tight muscles feel better."

2. Valium, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided.Valium can cause drowsiness, and the client should be warned about driving until tolerance develops. Valium has muscle relaxant properties and will help tight, tense muscles feel better.

27. Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next? 1. Withhold the lithium and obtain a lithium level to determine therapeutic effectiveness. 2. Continue the lithium and immediately notify the physician about the assessment findings. 3. Continue the lithium and reassure the client that these temporary side effects will subside.

27. 3. The client is exhibiting temporary side effects associated with lithium therapy. Therefore, the nurse should continue the lithium and explain to the client that the temporary side effects of lithium that will subside. Common side effects of lithium are nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and light- headedness. Immediately notifying the physician about these common side effects is not necessary.

29. The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage? 1. A client who continues work as a computer programmer. 2. A client who attends college classes. 3. A client who can now care for her children. 4. A client who is beginning training for a tennis team.

29. 4. A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.

144. A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of his lorazepam (Ativan) and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. The nurse should do the following in which order of priority from first to last? 1. Monitor the client's safety and place seizure pads on the cart rails. 2. Record the time, duration, and nature of the seizures. 3. Page the ED primary health care provider and prepare to give diazepam (Valium) intravenously. 4. Ask the friend about the client's medical history and current medications.

3. Page the ED primary health care provider and prepare to give diazepam (Valium) intravenously. 1. Monitor the client's safety and place seizure pads on the cart rails. 2. Record the time, duration and nature of the seizures. 4. Ask the friend about the client's medical history and current medications.

81. A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol (Haldol) PO at bedtime. The nurse should: 1. Refuse to give the medications as prescribed. 2. Give the lithium only. 3. Request a decreased dosage of lithium. 4. Give the medications as prescribed.

4. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam (Ativan). Antipsychotic agents, such as Haldol, are prescribed to produce a neuroleptic effect until the lithium, which has a clinical response lag time of 1 to 2 weeks, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

52. A client has just been admitted to the hospital for medication adjustment after outpatient treatment failure of his bipolar disorder and returning mania. He tells his primary nurse about his medications and treatment. Which of his following statements would raise the most urgent need for more medication instruction about his lithium therapy? 1. "My doctor tells me that my lithium level is 1.0 so I don't have to worry about my levels." 2. "I've been getting a lot of good exercise playing on a local soccer team." 3. "I'm trying hard to watch my diet and eat healthy." 4. "I have learned to take my lithium even when I'm not feeling well, like when I had the stomach flu."

52. 4. The therapeutic serum level for lithium is 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Levels due fluctuate with fluid intake and output, however. Therefore, the most urgent matter for teaching is the client's comment about taking his lithium during excessive loss of fluids during an episode of "stomach flu" with diarrhea. Exercising is only concerning if the client becomes dehydrated. A healthy diet is indicated while taking lithium.

55. A young adult client diagnosed with bipolar disorder has been managing the disorder effectively with medication and treatment for several years. The client suddenly becomes manic. The nurse reviews the client's medication record. Which of the following medications may have contributed to the development of his manic state? 1. Amitriptyline. 2. Prednisone. 3. Buspirone. 4. Gabapentin.

55. 2. The use of prednisone or other steroids can initiate a manic state in a bipolar client even if he is well controlled on medication. The other medications would decrease the client's depression, mood swings, and anxiety, making him calmer rather than more agitated.

77. A client diagnosed with bipolar disorder asks the nurse why it is necessary to have a serum lithium level drawn every 3 to 4 months. The nurse's response should be based on which of the following? 1. To monitor compliance with the medication. 2. To prevent toxicity related to the drug's therapeutic range. 3. To monitor the client's white blood cell count. 4. To comply with the drug manufacturer's requirements.

77. 2. The serum lithium level has nothing to do with the client's white blood cell count and the drug manufacturers have no specific requirement for blood testing. While a periodic serum lithium level could monitor whether or not a client was taking the prescribed medication, the most important reason for the blood test is to periodically assess the client's lithium level and prevent even mild toxicity on an ongoing basis.

78. The primary health care provider prescribes determination of the serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At which of the following times should the nurse plan to have the blood specimen obtained? 1. Before bedtime. 2. After lunch. 3. Before breakfast. 4. During the afternoon.

78. 3. Because lithium reaches peak blood levels in 1 to 3 hours, blood specimens for serum lithium concentration determinations are usually drawn before the first dose of lithium in the morning (which is usually 8 to 12 hours after the previous dose) or before breakfast. Stat lithium levels can be drawn at any time, usually when toxicity is suspected.

79. A client will be discharged on lithium carbonate 600 mg three times daily. When teaching the client and his family about lithium therapy, the nurse determines that teaching has been effective if the client and family state that they will notify the prescribing health care provider immediately if which of the following occur? Select all that apply. 1. Nausea. 2. Muscle weakness. 3. Vertigo. 4. Fine hand tremor. 5. Vomiting. 6. Anorexia.

79. 2, 3, 5. Serious side effects that may indicate lithium toxicity include muscle weakness, vertigo, vomiting, extreme hand tremor, and sedation. The prescribing health care provider should be notified immediately when these symptoms occur. When lithium is initiated, mild or transient side effects can occur, such as nausea, fine hand tremor, anorexia, increased thirst and urination, and diarrhea or constipation.

80. After the nurse teaches a client with bipolar disorder about lithium therapy, which of the following client statements indicates the need for additional teaching? 1. "It's important to keep using a regular amount of salt in my diet." "It's okay to double my next dose of lithium if I forget a dose." 3. "I should drink about 8 to 10 eight-ounce glasses (240 to 300 mL) of water each day." 4. "I need to take my medicine at the same time each day."

80. 2. The therapeutic and toxic range of lithium is very narrow. If the client forgets to take a scheduled dose of lithium, the client needs to wait until the next scheduled time to take it, because taking twice the amount of lithium can cause lithium toxicity. The client needs to maintain a regular diet and regular salt intake. Lithium and sodium are eliminated from the body through the kidneys. An increase in salt intake leads to decreased plasma lithium levels because lithium is excreted more rapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8 to 10 eight-ounce glasses (240 to 300 mL) of water daily to maintain fluid balance and decrease thirst. Decreased water intake can lead to an increase in the lithium level and consequently a risk of toxicity. Lithium must be taken on a regular basis at the same time each day to ensure maximum therapeutic effect.

84. The primary health care provider prescribes valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which of the following should the nurse include in the client's medication teaching plan? 1. Follow-up blood tests are unnecessary. 2. The tablet can be crushed if necessary. 3. Drowsiness and upset stomach are common side effects. 4. Consumption of a moderate amount of alcohol is safe.

84. 3. Valproic acid, an anticonvulsant agent, is used as a mood stabilizer in the client with bipolar disorder. Common side effects include drowsiness and gastrointestinal upset. The client needs to be cautioned not to drive or perform tasks requiring alertness and to take the medication with food or milk or eat frequent, small meals. Blood tests are required to evaluate the serum level and to check for possible hematologic effects. Valproic acid can cause changes in liver function and blood dyscrasias. The tablet must be swallowed whole and not chewed or crushed to prevent irritation of the mouth and throat. Alcohol as well as over-the-counter drugs and sleep-inducing agents must be avoided to prevent oversedation.

92. A client has been taking increased amounts of alprazolam (Xanax) for about 6 months for anxiety. She asks the nurse how she can "get off the Xanax." The most accurate answer by the nurse is which of the following? 1. "There will be an immediate discontinuation of the Xanax and haloperidol (Haldol) will be available if needed." 2. "Instead of Xanax, you will take lorazepam (Ativan) in decreasing doses and frequency over a period of 3 to 4 days." 3. "The Xanax will be tapered down over a period of 48 hours." 4. "Xanax will be available on an as-needed basis for 4 to 5 days."

92. 2. Ativan, as opposed to Xanax, is available in dosage ranges that allow more gradual tapering down of doses over the 3 to 4 days. Haldol is not effective for benzodiazepine withdrawal. Tapering Xanax in 48 hours is too rapid. Offering Xanax as a PRN does not deal with the need to gradually reduce the dose and frequency over time.

98. The nurse is teaching the client about the appropriate use of lorazepam (Ativan) to manage anxiety. Which of the following statements indicates that the client understands the nurse's teaching? 1. "I can take my medicine whenever I feel anxious." 2. "It's okay to double my dose if I need to." 3. "My medicine isn't for the everyday stress of life." 4. "It's safe to have a glass of wine while taking this medicine."

98. 3. The statement, "My medicine is not for the everyday stress of life," indicates an accurate understanding of the nurse's teaching about the use of lorazepam. Antianxiety agents like the benzodiazepines are used to treat anxiety that is unmanageable by other means and beyond the client's ability to cope. For the drug to be effective, it must be taken as prescribed. Lorazepam can cause physical and psychological dependence. Tolerance can occur, and doubling the dose of lorazepam may increase the risk of tolerance. Lorazepam is a central nervous system depressant. When it is taken in combination with alcohol, the depressant effect increases, posing a danger to the client.