Chapter 15
1. A client who is on lithium therapy is visited by the home health nurse to have blood drawn for a routine lithium level. The nurse assesses that the client is apathetic, has difficulty responding to questions, walks with an unsteady gait, and has fine hand tremors. Which of the following would the nurse suspect the client is experiencing? 1. An expected reaction to lithium therapy 2. Pseudoparkinson syndrome caused by lithium therapy 3. A medical problem unrelated to lithium therapy 4. Toxic effects of elevated lithium levels View Answer
1. The answer is 4. The symptoms described—apathy, difficulty concentrating, ataxia, and tremors—are those that occur because of elevated lithium levels and their effect on the CNS. These symptoms indicate the client is experiencing mild toxicity. This client's reaction is not an expected response; the goal of monitoring lithium blood levels is to prevent toxicity. Also, these are not the symptoms of pseudoparkinsonism (nor does lithium cause pseudoparkinsonism).
10. The nurse correctly teaches a client who is taking the benzodiazepine oxazepam (Serax) to avoid excessive intake of: 1. cheese. 2. coffee. 3. sugar. 4. shellfish. View Answer
10. The answer is 2. Coffee, which contains caffeine, is psychostimulating and will counteract the intended effect of relaxation that oxazepam produces. There is no reason for the client to avoid cheese, sugar, or shellfish while taking oxazepam. P.285
11. Which principle should the nurse understand before planning the care of a client receiving anxiolytic medication? 1. Enhanced psychomotor coordination is expected. 2. Increased mental alertness is a common effect. 3. Medications that are CNS depressants will potentiate the sedative response. 4. Consumption of foods containing tyramine can cause hypertension. View Answer
11. The answer is 3. The nurse needs to teach the client about the serious effects of potentiation of CNS depression that can occur when taking other medicines that produce the same body reaction as the anxiolytics. Such medications would include any of the sedative-hypnotics, alcohol, and any barbiturates. Enhanced psychomotor coordination and increased mental alertness are the opposite reactions expected of anxiolytic medications; therefore, these statements do not apply. Hypertension when consuming tyramine-containing foods is a side effect of the MAOI antidepressants, not anxiolytics.
12. To prevent the occurrence of lithium toxicity, the nurse should teach the client to maintain adequate intake of: 1. fruits and vegetables. 2. low-fat foods. 3. protein and vitamin C. 4. water and sodium. View Answer
12. The answer is 4. When sodium or water is depleted in a client taking lithium, the potential for lithium toxicity increases; the kidney will reabsorb lithium to replace depleted sodium and counteract water loss. The remaining responses are unrelated to prevention of lithium toxicity.
13. Which of the following best explains why tricyclic antidepressants are used with caution in elderly patients? 1. Central nervous system effects 2. Cardiovascular system effects 3. Gastrointestinal system effects 4. Serotonin syndrome effects View Answer
13. The answer is 2. The TCAs affect norepinephrine as well as other neurotransmitters, and thus have significant cardiovascular side effects. Therefore, they are used with caution in elderly clients who may have increased risk factors for cardiac problems because of their age and other medical conditions. The remaining side effects would apply to any client taking a TCA and are not particular to an elderly person.
14. Which of the following is the most serious side effect of the atypical antipsychotic clozapine (Clozaril)? 1. Agranulocytosis 2. Anticholinergic effects 3. Postural hypotension 4. Pseudoparkinsonism View Answer
14. The answer is 1. The incidence of agranulocytosis associated with clozapine therapy is 1% to 2%. Therefore, clients taking this drug must be screened weekly for the first 6 months of therapy for evidence of decreased white blood count (< 2,000 μl). Anticholinergic effects and postural hypotension can occur; however, they are not considered serious side effects. Pseudoparkinsonism is not usually associated with clozapine, and this lack of extrapyramidal side effects is one of the advantages of the atypical antipsychotics.
15. A client is admitted to the emergency department after a suicide attempt involving an overdose of the tricyclic antidepressant imipramine (Tofranil). In addition to monitoring the client's vital signs and ECG reading, the nurse should prepare to provide which priority intervention? 1. Frequent stimulation 2. Electrolyte replacement 3. Patent airway 4. Quiet environment View Answer
15. The answer is 3. Symptoms of TCA overdose include sedation, ataxia, stupor, and, sometimes, convulsions and respiratory depression. Therefore, maintaining a patent airway is an essential component of nursing care for this client. Although the nurse would assess the client's level of consciousness and provide stimulation in order to do so, this is less essential than maintaining an airway. I.V. therapy and electrolyte replacement may be indicated, especially if the client has been treated with gastric lavage. However, this would not be as important as establishing an airway. A quiet environment may be indicated if the client has any agitation; however, airway patency precedes this measure.
16. The nurse should know that MAOI antidepressants can interact adversely with which drug? 1. Aspirin 2. Acetaminophen 3. Codeine 4. Norepinephrine View Answer
16. The answer is 4. MAOIs act to inhibit the enzyme responsible for breaking down neurotransmitters, including norepinephrine. Therefore, if medicine containing norepinephrine is taken along with the MAOI, the potential for a hypertensive crisis is increased. Norepinephrine acts peripherally to cause vasoconstriction and, therefore, increases blood pressure. The remaining medications are not contraindicated.
17. When the nurse suspects a client is experiencing either neuroleptic malignant syndrome or serotonin syndrome as a result of psychotropic medications, which action takes priority? 1. Providing adequate fluids 2. Maintaining bed rest 3. Monitoring for expected symptoms 4. Withholding further drug doses View Answer
17. The answer is 4. The nurse must withhold any further doses of psychotropic medications if either neuroleptic malignant syndrome or serotonin syndrome is suspected. Withholding the medications will help to avoid increasing the severity of these reactions. The remaining actions are important, but the priority is preventing symptom worsening by stopping the psychotropic drug.
18. The nurse is working with a client who has overdosed on a benzodiazepine. Which medication should the nurse prepare to administer? 1. carbamazepine (Tegretol) 2. diphenhydramine (Benadryl) 3. flumazenil (Mazicon) 4. physostigmine (Antilirium) View Answer
18. The answer is 3. Flumazenil (Mazicon) is the antidote for a benzodiazepine overdose; it acts to reverse the CNS depression caused by overdose. The remaining drugs will not reverse CNS depression.
19. The nurse who is working with the family of a client who is taking tacrine (Cognex) should teach the family to be alert for early signs and symptoms of liver problems, including: 1. constipation and bloating. 2. dizziness and fatigue. 3. frequent belching and heartburn. 4. nausea and abdominal pain. View Answer
19. The answer is 4. Nausea and abdominal pain may occur if the client is developing early liver problems. Jaundice would also be an important symptom; however, it may occur later as liver dysfunction increases. Constipation, bloating, and frequent belching and heartburn may indicate gastrointestinal problems, but not liver dysfunction. Dizziness and fatigue may indicate a problem with the CNS.
2. A client refuses to remain on psychotropic medications after discharge from an inpatient psychiatric unit. Which information should the community mental health nurse assess first during the initial follow-up with this client? 1. Income level and living arrangements 2. Involvement of family and support systems 3. Reason for inpatient admission 4. Reason for refusal to take medications View Answer
2. The answer is 4. The first area for assessment would be the client's reason for refusing medication. The client may not understand the purpose for the medicine, may be experiencing distressing side effects, or may be concerned about the cost of the medicine. In any case, the nurse cannot provide appropriate intervention before assessing the client's problem with the medication. The patient's income level, living arrangements, and involvement of family and support systems are relevant issues following determination of the client's reason for refusing medication. The nurse providing follow-up care would have access to the client's medical record and should already know the reason for inpatient admission.
20. The nurse teaches the family of a child who is taking the psychostimulant methylphenidate (Ritalin) to manage the common side effects of nausea and anorexia. Which of the following would the nurse recommend? 1. Discourage frequent snacking of high-calorie foods. 2. Encourage the client to consume adequate calories to maintain normal weight. 3. Offer six small meals rather than three large meals. 4. Take the prescribed medication at bedtime. View Answer
20. The answer is 3. A client (especially a child) may have increased response of nausea and lack of appetite when presented with large meals. Offering smaller portions more frequently can help stimulate appetite. The remaining responses would not help address this problem.
21. Which nursing intervention would be the priority for a client immediately following ECT treatment? 1. Assessing vital signs and reorienting the client 2. Applying restraints to prevent injury 3. Administering previously withheld medications 4. Encouraging intake of fluids and nutritious food View Answer
21. The answer is 1. The client will be monitored in the same manner as any postoperative client coming out of anesthesia. Applying restraints is not necessary and may cause agitation. Medications, fluids, and food will be given after the client is reoriented and his swallowing and gag reflexes return.
22. The psychiatric nurse is teaching a group of clients about a newly prescribed SSRI antidepressant for the treatment of depression. Which of the following points should the nurse include in her teaching plan? Select all that apply. 1. These drugs act to increase the levels of a mood-elevating chemical in the brain called serotonin. 2. These drugs act quickly, so feelings of depression will decrease in a few days. 3. Clients should avoid drinking alcohol or taking antihistamine medications with these drugs. 4. Clients who have trouble falling asleep while on this medication can try taking it in the morning instead of at night. 5. Clients must remain on a special diet when taking these drugs. 6. Clients must return for weekly blood level tests to ensure the safety of these drugs. View Answer
22. The answer is 1, 3, 4. SSRIs will increase serotonin levels; they should not be taken with alcohol or antihistamines because this will increase the chance of CNS depression. Insomnia is a possible side effect of SSRIs, and taking the medication in the morning will help decrease the problem. Option 2 is incorrect because these drugs take 2 to 4 weeks before they are effective. No special diet is required for SSRIs (option 5); however, a tyramine-reduced diet is important for MAOIs. Weekly blood level checks (option 6) are not indicated for SSRIs.
3. A nurse is assessing postural blood pressures for a client taking risperidone (Risperdal) for chronic schizophrenia. Which of the following results would cause the nurse to withhold the next dose of this drug? 1. Sitting blood pressure (BP) of 124/84 mm Hg; standing BP of 104/60 mm Hg 2. Sitting BP of 112/60 mm Hg; standing BP of 104/60 mm Hg 3. Sitting BP of 130/80 mm Hg; standing BP of 128/78 mm Hg 4. Sitting BP of 150/90 mm Hg; standing BP of 146/88 mm Hg View Answer
3. The answer is 1. The significant blood pressure decrease with position change is an indication of the side effect of postural hypotension. The prudent nurse would withhold the next dose and notify the doctor. The other blood pressure readings do not indicate postural hypotension.
4. The nurse understands that the therapeutic effects of typical antipsychotic medications are associated with which neurotransmitter change? 1. Decreased dopamine level 2. Increased acetylcholine level 3. Stabilization of serotonin 4. Stimulation of GABA View Answer
4. The answer is 1. Excess dopamine is thought to be the chemical cause for psychotic thinking. The typical antipsychotics act to block dopamine receptors and therefore decrease the amount of this neurotransmitter at the synapses. The typical antipsychotics do not increase acetylcholine, stabilize serotonin, or stimulate GABA.
5. Sertraline (Zoloft), an SSRI, is prescribed for a client with major depression. After 1 week, the client complains of no improvement and refuses to take the medication from the nurse. Which of the following would be the nurse's first response? 1. Charting the client's refusal to take this dose 2. Informing the client's doctor about noncompliance 3. Informing the client that 2 to 4 weeks is needed for a positive response 4. Reviewing the client's presenting symptoms and current complaints View Answer
5. The answer is 3. The client may not understand that at least 2 to 4 weeks are needed before therapeutic effects of antidepressants are noticed. If the client continues to refuse medication even after the appropriate teaching, the nurse should then chart refusal and inform the doctor. The response in option 4 is irrelevant to the situation described.
6. Which information would be most important for the nurse to teach a client taking phenelzine (Nardil), an MAOI drug? 1. The need to avoid foods and beverages containing tyramine 2. The importance of maintaining regular follow-up visits 3. The drug's possible adverse effects, such as hypertension 4. The rationale for the therapeutic effect of mood elevation View Answer
6. The answer is 1. The most important thing the client taking an MAOI needs to understand is that foods and beverages containing tyramine must be avoided to prevent a severe hypertensive reaction. Medications containing psychostimulating drugs must also be avoided. Follow-up care is important; however, the priority teaching issue is dietary restrictions because the client could have a hypertensive reaction before any follow-up appointment if he is unaware of which foods to avoid. Option 3 is too vague. Although hypertension is possible, the client is not being informed how to avoid this. The client may or may not want details regarding how mood elevation is achieved with an MAOI. For many clients, knowledge that their mood will elevate is sufficient; details about how this occurs are not a priority.
7. A client who is taking the antipsychotic medication chlorpromazine (Thorazine) complains of dry mouth and constipation. Which nursing intervention would be appropriate? 1. Advise the client to chew sugarless gum and eliminate gas-forming foods. 2. Encourage the client to rinse his mouth with water and to add fiber to his diet. 3. Consult the client's doctor about changing the antipsychotic medication. 4. Question the client about his usual amount and type of daily exercise. View Answer
7. The answer is 2. Rinsing the mouth with water (rather than mouthwash, which is drying) will help eliminate the problem of dry mouth. Adding fiber to the diet will facilitate the passage of a normal stool and help avoid constipation. Chewing sugarless gum will help with dry mouth; however, eliminating gas-forming foods is not the treatment for constipation. Changing medications because of experiencing these common side effects is not indicated. The client should be instructed in measures to counteract the side effects. Exercise is important and it can help stimulate peristalsis; however, the problem of dry mouth is not addressed in this response.
8. A client taking fluphenazine (Prolixin) experiences an acute dystonic reaction. Which of the following p.r.n. medications would the nurse administer to this client? 1. Acetaminophen (Tylenol), 325 mg orally 2. Diphenhydramine (Benadryl), 25 mg intramuscularly 3. Milk of magnesia, 30 ml orally 4. Thiothixene (Navane), 6 mg intramuscularly View Answer
8. The answer is 2. Diphenhydramine (Benadryl) is the antidote for acute dystonia. The dose needs to be given intramuscularly because a client in acute dystonia often has difficulty swallowing. The remaining medications would not treat an acute dystonic reaction and are prescribed as needed for other reasons; for example, acetaminophen would be prescribed for headache, milk of magnesia for constipation, and thiothixene for agitation.
9. While assessing a client who is taking haloperidol (Haldol), the nurse notes a temperature of 102° F (38.9° C), BP of 180/92 mm Hg, and profuse diaphoresis. Which side effect should the nurse suspect? 1. Agranulocytosis 2. Extrapyramidal reaction 3. Hepatotoxicity 4. Neuroleptic malignant syndrome View Answer
9. The answer is 4. High temperatures, elevated blood pressure, diaphoresis, tachycardia, and extrapyramidal symptoms characterize neuroleptic malignant syndrome. The other reactions are all serious adverse effects of the typical antipsychotics (such as haloperidol).
