Chapter 15: Antidepressant Drugs

A patient taking tranylcypromine (Parnate) is being changed to fluoxetine (Prozac). The nurse schedules a time lapse between the last dose of Parnate and the first dose of Prozac of at least: a. 7 days. b. 14 days. c. 21 days. d. 30 days.

ANS: B Because of the long half-life of monoamine oxidase inhibitors (MAOIs), the washout period before beginning SSRI administration is 2 weeks. One week is too short an interval, and the longer times are unnecessary.

A patient taking a tricyclic antidepressant complains of constantly having a dry mouth. The nurse should recommend: a. chewing ice. b. sugarless gum. c. astringent mouthwashes. d. holding a lemon slice against the teeth.

ANS: B Chewing sugarless gum will increase salivation without increasing the possibility of dental caries. Chewing ice poses a risk of cracked teeth. Astringent mouthwashes dry out mucous membranes. Holding a lemon in the mouth is damaging to tooth enamel.

Evaluation of a patient's response after one week of tricyclic antidepressant therapy would be expected to show: a. no change in objective or subjective symptoms. b. increased appetite and weight gain. c. decreased suicidal ideation. d. improved mood and affect.

ANS: B Improved appetite might be caused by the antihistaminic effect of the drug. Improvement in mood might not occur for 2 to 4 weeks. Suicidal ideation might not improve for 2 to 4 weeks.

A patient with depression has taken an SSRI for 1 month. The nurse should use direct questions to evaluate which potential side effect? a. Aggressive impulses b. Sexual dysfunction c. Paranoid delusions d. Weight gain

ANS: B SSRIs often produce sexual dysfunction, such as decreased libido. Patients readily tell nurses about anticholinergic, GI, and other side effects, but are not as forthcoming in reporting sexual problems. The nurse might need to ask directly to elicit this information. Patients are more willing to discuss the other options.

A pregnant patient took SSRI antidepressants during the third trimester of pregnancy. The newborn will be carefully assessed for neonatal: a. temperature dysregulation. b. serotonin syndrome. c. seizure disorder. d. diabetes.

ANS: B The neonate whose mother has received SSRIs might experience respiratory depression, hypoglycemia, tremor, and low birth weight as part of neonatal serotonin syndrome. The disorder normally is resolved within 2 weeks of birth. The other options are not usually seen as a result of in utero exposure to SSRIs.

A depressed patient has taken haloperidol (Haldol) for several weeks. The health care provider prescribes fluoxetine (Prozac). A priority for the nurse would be to: a. instruct the patient regarding a tyramine-free diet. b. assess carefully for extrapyramidal side effects. c. suggest sugarless gum to prevent dry mouth. d. monitor the patient for urinary frequency.

ANS: B The nurse should assess carefully for extrapyramidal side effects, which are more likely with this drug combination. The distracters are not applicable to this interaction.

A patient phones the clinic nurse to report, "I stopped taking my paroxetine (Paxil) antidepressant medication, and now I feel terrible. I'm having nausea, vomiting, and diarrhea." The nurse should assess this as: a. serotonin syndrome. b. antidepressant withdrawal. c. an extrapyramidal reaction. d. neuroleptic malignant syndrome.

ANS: B The symptoms mentioned are more clearly related to antidepressant withdrawal than to any of the other options. Antidepressant withdrawal is common with paroxetine (Paxil). It is known that withdrawal symptoms might occur after abrupt stopping of antidepressant medication.

A patient tells the nurse that he stopped taking sertraline (Zoloft) because the drug made him impotent. The nurse can be most helpful by saying: a. "Your doctor wants you to continue taking your medication." b. "Have you talked with your therapist regarding your feelings about sex?" c. "Let's talk with your doctor. Changing your medication might be a possibility." d. "Our priority is to treat your depression. Impotence can be addressed in a few weeks."

ANS: C SSRIs commonly cause sexual dysfunction. Changing to another type of antidepressant or adding bupropion in small doses can be helpful. The other options are not compassionate or therapeutic.

A 75-year-old patient with a long history of depression begins amitryptiline (Elavil) 100 mg/day. The patient also takes a diuretic daily for hypertension. The highest priority nursing diagnosis is risk for: a. falls related to dizziness and orthostatic hypotension. b. ineffective thermoregulation related to anhidrosis. c. infection related to suppressed WBC count. d. constipation related to slowed peristalsis.

ANS: A Amitryptiline is a TCA that has a high risk of producing orthostatic hypotension. The patient is placed at even greater risk because of older age and diuretic therapy, which reduces fluid volume. The other options are either unassociated or are remote possibilities.

The nurse's priority assessment for an adolescent patient taking an SSRI antidepressant medication is for the presence of: a. suicidal ideation. b. antiadrenergic side effects. c. anticholinergic side effects. d. symptoms of sexual dysfunction.

ANS: A Antidepressant medication tends to energize depressed patients, possibly giving them the impetus to act on suicidal ideation that has been present related to the depression. This complication is particularly applicable to adolescents. Some suggest that suicidal ideation might be the actual result of antidepressant therapy. In either case, the implication for nursing is clear: patients should be carefully assessed for the presence of suicidal ideation, suicidal plans, and means for carrying out the plans. This option is related to patient safety and takes priority over the other options.

What is the nurse's highest priority when caring for a patient after a tricyclic antidepressant overdose? a. Frequently monitor blood pressure and heart rate/rhythm. b. Monitor for skin rashes, particularly on the torso. c. Measure and record intake and output q12h. d. Institute cooling blankets for hyperthermia.

ANS: A It is necessary to assess cardiovascular function because cardiovascular reactions can occur suddenly, even several days after the overdose, and can result in acute heart failure. The other options are not as closely aligned with cardiovascular problems.

When teaching about tranylcypromine (Parnate), the nurse should consider it a priority to: a. provide a list of tyramine-rich foods. b. instruct the patient to avoid direct sunlight. c. advise the patient to manage fever with acetaminophen. d. direct the patient to report dry mouth and blurred vision.

ANS: A MAOIs and ingested tyramine interact to produce hypertensive crisis, a life-threatening medical emergency, so it is necessary to teach the patient foods to avoid. The other options are unrelated to Parnate therapy.

Patients taking tricyclic antidepressants exhibit more side effects than patients taking SSRIs because TCAs: a. inhibit reuptake of norepinephrine and serotonin. b. selectively inhibit dopamine reuptake. c. selectively block serotonin uptake. d. block enzymatic breakdown.

ANS: A TCAs inhibit the reuptake of both norepinephrine and serotonin and because of their nonselectivity produce many side effects. The other options are incorrect statements about the action of TCAs.

A patient diagnosed with recurrent depression says, "A few years ago I took antidepressants, but it was difficult to remember to take them. I often missed doses." The implication for planning is to: a. discuss the possibility of depot medication with the health care provider. b. ensure that the family can remind the patient to take the drugs. c. suggest once-daily dosing to the health care provider. d. teach the patient about the importance of compliance.

ANS: C Many TCAs and SSRIs have long half-lives that permit once-daily dosing. The longer the half-life of the drug, the less frequently it has to be administered. Having family reminders can seem like nagging. Depot medication is available for antipsychotics but not antidepressants. Teaching adherence is appropriate, but the better solution is once-daily dosing.

The nurse cares for four patients receiving SSRIs. Which assessment finding warrants the nurse's priority attention? a. Dry mouth and stuffy nose b. Malaise and frontal headache c. Confusion, agitation, and hyperthermia d. Constipation, photophobia, and anhidrosis

ANS: C The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.

A patient for whom phenelzine (Nardil) is prescribed complains of a sudden headache and palpitations. The nurse observes dilated pupils and diaphoresis. The nurse's first action should be: a. assess for cogwheel rigidity. b. notify the health care provider. c. assess the patient's blood pressure. d. withhold the morning dose of phenelzine.

ANS: C The patient's symptoms are suggestive of hypertensive crisis. It is vital to know whether or not the BP is elevated, so obtaining the BP is the necessary first action. The most probable reason for the reaction would be drug-food interaction. The nurse may notify the health care provider and withhold the morning dose as subsequent actions. Cogwheel rigidity is associated with antipsychotic medications.

A patient with depression and vague suicidal ideation will stay at home, have close family supervision, and make weekly visits to the health care provider. Bupropion (Wellbutrin) is prescribed. What is the benefit of bupropion in this scenario? a. It has antianxiety properties as well as antidepressant effects. b. It lowers the seizure threshold to a lesser extent than TCAs. c. There is reduced potential for lethal overdose. d. It stimulates appetite and weight gain.

ANS: C Wellbutrin has no lethal overdose potential, making it well suited for use in outpatient treatment of depression. However, it might cause agitation, anxiety, seizures, anorexia, and weight loss.

A nurse teaches a patient taking an MAOI antidepressant about important dietary guidelines. Which nutritional choices by the patient indicate that the teaching was effective? Select all that apply. a. Sausage b. Avocados c. Pork chops d. Strawberries e. Chocolate chip cookies

ANS: C, D The patient must avoid foods high in tyramine in order to prevent a hypertensive crisis. Sausage, avocadoes, and chocolate contain significant amounts of tyramine.

A tricyclic antidepressant is prescribed for a patient newly diagnosed with depression. What information should be included in patient teaching? a. "Take this medication on an empty stomach." b. "Do not eat aged cheese while using this medication." c. "You might experience sweating, tremors, and excessive urination." d. "It might be 2 weeks or more before you notice the effects of this medicine."

ANS: D Antidepressant effects might take several weeks to be noticeable. Tyramine avoidance is necessary for MAOI therapy. It is not necessary to take TCAs on an empty stomach. Sweating, tremors, and urination problems are not commonly experienced with TCA therapy.

A depressed patient prepares for discharge. The patient will take desipramine (Norpramin) and have outpatient visits. The patient complains, "They gave me only a one-week supply of my medicine." Select the nurse's best reply. a. "Federal law limits the amount you may be given at any one time." b. "It will save you money if the drug doesn't work well for your symptoms." c. "This is a way of ensuring that you will come in for your follow-up appointment." d. "Prescribing a small amount of drug addresses our concerns for your continuing safety."

ANS: D Desipramine is an activating antidepressant, and it might provide a patient who has suicidal ideation with the energy to make an attempt. Because the therapeutic dose and lethal dose are not widely separated, TCA overdose is an often used suicide plan. Prescribing only a 7-day supply limits the possibility of using the drug in a suicide attempt. The other options are either less relevant or incorrect.

To help a patient cope with orthostatic hypotension caused by antidepressant medication, the nurse should advise the patient to: a. take hot showers and baths. b. restrict fluids to 1000 mL/day. c. avoid drinks containing caffeine. d. rise slowly and to sit before standing.

ANS: D Rising slowly and sitting before standing allow time for the patient's vascular system to adjust to positional change. The other options are incorrect.

A patient who takes an SSRI reports, "I started taking St. John's wort to boost the effects of my anti-depressant." The nurse should advise the patient, "The herb: a. will counteract the antidpressant action." b. is of no particular benefit, but will do no harm." c. and the SSRI will quickly relieve your depression." d. may interact with the SSRI to cause a life-threatening reaction."

ANS: D SSRIs and St. John's wort taken together might produce serotonin syndrome, a life-threatening condition. The other options are incorrect.

Priority assessments for a patient beginning amitriptyline (Elavil) include: a. nausea, diarrhea, and irritability. b. seizures, agranulocytosis, and insomnia. c. headache, sexual dysfunction, and weight loss. d. orthostatic hypotension, arrhythmias, and eye pain.

ANS: D Tricyclic antidepressants (TCAs) produce anticholinergic (eye pain) and antiadrenergic (orthostatic hypotension and arrhythmias) side effects. GI symptoms, sexual dysfunction, and weight variations are related to selective serotonin reuptake inhibitor (SSRI) therapy. Seizures are seen with Wellbutrin therapy. Agranulocytosis is not considered a major problem with any of the groups of antidepressants.

Which individual has the highest risk for urinary retention associated with taking a tricyclic antidepressant? a. A middle-aged woman taking amoxapine (Ascendin) b. A young woman taking nortriptyline (Pamelor) c. A young man taking amitriptyline (Elavil) d. An older adult male patient taking imipramine (Tofranil)

ANS: D Urinary retention might occur when a drug has strong anticholinergic properties. Imipramine has strong anticholinergic effects. Older adult men are at higher risk related to benign prostatic hypertrophy.

A patient recently diagnosed with major depression will begin treatment with antidepressant medication. The nurse expects the health care provider to first prescribe a medication from the ____1___ classification. If this medication is ineffective, the nurse anticipates the health care provider to next prescribe a medication from the ____2___ classification. Lastly, if this medication is ineffective, the nurse anticipates the health care provider to prescribe a medication from the ____3___ classification. a. tricyclic (TCA) b. benzodiazepine c. monoamine oxidase inhibitor (MAOI) d. selective serotonin reuptake inhibitor (SSRI)

ANS: D, A, C SSRIs are effective for treatment of major depression and have the least troubling side effects. These drugs are considered first-line treatment for depression. If these drugs are ineffective, TCAs are likely to be prescribed. MAOIs are seldom used because of the potential drug and food interactions. Benzodiazepines are not antidepressants.