Patho Final Review (All)

81. A patient will receive buprenorphine (Butrans) as a transdermal patch for pain. What is important to teach this patient about the use of this drug? a. Avoid prolonged exposure to the sun. b. Cleanse the site with soap or alcohol. c. Remove the patch daily at bedtime. d. Remove hair by shaving before applying the patch.

a. Avoid prolonged exposure to the sun. Patients using the buprenorphine transdermal patch should be cautioned against heat, heating pads, hot baths, saunas, and prolonged sun exposure. The skin should be cleaned with water only. The patch should stay on for 7 days before a new patch is applied. Patients should remove hair by clipping, not shaving.

54. A nurse provides teaching for a patient about to begin taking a first-generation antipsychotic drug for schizophrenia. Which statement by the patient indicates a need for further teaching about side effects of these drugs? a. "Anticholinergic effects are uncommon with this medication." b. "I may experience gynecomastia and galactorrhea." c. "I may feel lightheaded or dizzy and should sit or lie down if this occurs." d. "Sedation may occur initially, but will subside in 1 to 2 weeks."

a. "Anticholinergic effects are uncommon with this medication." Anticholinergic effects are common with FGAs, so this statement indicates a need for further teaching. Neuroendocrine effects, orthostatic hypertension, and sedation can occur with FGAs.

8. A nurse is discussing the use of benzodiazepines as sedative-hypnotic agents with a group of nursing students. A student asks about the actions of these drugs in the central nervous system. The nurse makes which correct statement? a. "Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia." b. "Benzodiazepines depress neuronal functions by acting at a single site in the brain." c. "Benzodiazepines induce muscle relaxation by acting on sites outside the central nervous system." d. "Benzodiazepines promote sleep through effects on the limbic system."

a. "Benzodiazepines affect the hippocampus and the cerebral cortex to cause anterograde amnesia." All beneficial and most adverse effects of benzodiazepines occur from depressant actions in the central nervous system (CNS); the various effects depend on the site of action. Anterograde amnesia is the result of effects in the hippocampus and the cerebral cortex. Benzodiazepines act at multiple sites in the CNS. Muscle relaxant effects are the result of actions on supraspinal motor areas in the CNS. Benzodiazepines promote sleep through effects on cortical areas and on the sleep-wakefulness "clock."

24. The spouse of a patient with bipolar disorder (BPD) tells the nurse that the patient will not stay on the lithium ordered by the provider longer than 1 or 2 months at a time. The nurse understands that adherence to medication regimens in patients with BPD is problematic and will tell the spouse that: a. "During manic episodes, many patients don't see the benefit of prophylactic medications." b. "Increased gastrointestinal side effects occur over time and reduce compliance." c. "Long-term use of lithium causes memory impairment, causing patients to forget to take their medications." d. "Patients who are depressed do not want to take their medications."

a. "During manic episodes, many patients don't see the benefit of prophylactic medications." Patients experiencing manic symptoms often do not see anything wrong with their thinking and behavior and therefore do not believe they need treatment. Moreover, these symptoms are often enjoyable, and they do not want them to stop. Gastrointestinal side effects and central nervous system (CNS) effects of memory impairment subside over time and would diminish with long-term treatment. Patients are usually most uncomfortable during depressive episodes, and it is during these episodes that they often seek treatment.

26. A patient recently was diagnosed with bipolar disorder. The patient, who has a history of seasonal allergies, is an athlete who participates in track. The nurse is teaching the patient about lithium (Lithobid), which the prescriber has just ordered. Which statement by the patient indicates the need for further teaching? a. "I can continue to use ibuprofen as needed for muscle pain." b. "I should drink extra fluids before and during exercise." c. "I should not use antihistamines while taking lithium." d. "I should report muscle weakness and tremors to my provider."

a. "I can continue to use ibuprofen as needed for muscle pain." Because nonsteroidal anti-inflammatory drugs (NSAIDs) can increase lithium levels as much as 60%, they should not be used by patients taking lithium. Aspirin does not have this effect. Lithium induces polyuria in 50% to 70% of patients, so patients should be advised to drink extra fluids, especially during exercise. Antihistamines have anticholinergic effects, which cause urinary hesitancy; this can be uncomfortable when patients experience the polyuria associated with lithium use. Muscle weakness and tremors can occur with lithium; tremors can be treated with beta blockers or by altering the lithium regimen.

98. A nurse is teaching a patient who has a second-degree burn on one arm about the use of a topical anesthetic for pain. Which statement by the patient indicates understanding of the teaching? a. "I will apply a thin layer of the medication to a small area of skin." b. "I will cover the burn with a dressing after applying the medication." c. "I will make sure to apply the medication to the entire burn area." d. "I will use the medication only on the most painful, blistered areas."

a. "I will apply a thin layer of the medication to a small area of skin." Topical anesthetics can be absorbed in sufficient amounts to cause serious and even life-threatening systemic toxicity, so they should be applied in the smallest amount needed to as small an area as possible. Covering the site increases the skin's temperature, which increases absorption, so this should be avoided. Applying the medication to a large area increases systemic absorption. Applying the medication to broken skin increases systemic absorption.

17. A patient with a new-onset seizure disorder receives a prescription for phenobarbital. The patient reports being concerned about the sedative side effects of this drug. Which response by the nurse is correct? a. "Phenobarbital doses for seizures are nonsedating." b. "This is a short-acting barbiturate, so sedation wears off quickly." c. "Tolerance to the sedative effects will develop in a few weeks." d. "You may actually experience paradoxical effects of euphoria."

a. "Phenobarbital doses for seizures are nonsedating." Phenobarbital and mephobarbital are used for seizure disorders and suppress seizures at doses that are nonsedative. Phenobarbital is a long-acting barbiturate. At therapeutic doses, sedative effects do not occur. Paradoxical drug effects are associated with benzodiazepines and in older adults and debilitated patients with barbiturates.

62. A parent reports being afraid that a child may have schizophrenia because of disorganized speech and asocial behaviors. The nurse will tell this parent that which of the following must also be present to make a diagnosis? (Select all that apply.) a. A decrease in self-care, job, or school function b. A history of substance abuse c. A 1-month duration of active phase symptoms d. Continuous signs of disturbance for longer than 6 months e. The presence of manic episodes

a. A decrease in self-care, job, or school function c. A 1-month duration of active phase symptoms d. Continuous signs of disturbance for longer than 6 months Patients must have at least two symptoms with 1-month duration of active symptoms. One symptom must be delusions, hallucinations, or disordered speech. Patients must have continuous signs of disturbance for longer than 6 months. A history of substance abuse and manic episodes are not associated with schizophrenia.

25. A nurse is preparing to administer medications to a hospitalized patient who has been taking lithium (Lithobid) for 3 days. The patient is complaining of mild nausea and abdominal bloating. The patient's lithium level is 0.8 mEq/L. What will the nurse do? a. Administer the dose and tell the patient that the side effects are temporary. b. Contact the prescriber to request an order for serum electrolytes. c. Hold the dose and notify the prescriber of the patient's lithium level. d. Request an order for amiloride (Midamor).

a. Administer the dose and tell the patient that the side effects are temporary. This patient is experiencing side effects that are common and that occur at therapeutic levels of the drug. The lithium level is therapeutic and not toxic, so the nurse should give the dose and reassure the patient that the side effects will diminish over time. In the presence of low sodium, lithium can accumulate to toxic doses; therefore, if the lithium level were elevated, evaluating serum electrolytes would be advisable. The dose does not need to be withheld, because the patient does not have toxic levels of lithium. Amiloride is used if patients are experiencing lithium-induced polyuria, which this patient does not have.

60. Which side effects are more common in second-generation antipsychotic medications than in first-generation antipsychotic medications? (Select all that apply.) a. Agranulocytosis b. Anticholinergic effects c. Extrapyramidal symptoms d. Metabolism by CYP3A4 e. Prolactin elevation

a. Agranulocytosis b. Anticholinergic effects d. Metabolism by CYP3A4 SGAs are more likely than FGAs to cause agranulocytosis and anticholinergic effects and are metabolized by CYP3A4 enzymes. They are not more likely to cause extrapyramidal effects or prolactin elevation.

5. A patient describes feelings of anxiety and fear when speaking in front of an audience and is having difficulty at work because of an inability to present information at meetings three or four times each year. The patient is reluctant to take long-term medications. The nurse will expect the provider to order which treatment? a. Alprazolam (Xanax) as needed b. Cognitive behavioral therapy c. Paroxetine (Paxil) d. Psychotherapy

a. Alprazolam (Xanax) as needed This patient is describing social anxiety disorder; the symptoms are related to performance only and are not generalized to all social situations. Because this patient must speak in front of an audience only three or four times per year, a PRN medication can be used. Cognitive behavioral therapy is used for OCD. Paroxetine must be used continuously for at least 1 year. Psychotherapy can be used but is more effective when used in combination with drugs

46. A first-time parent of a 6-week-old infant tells the nurse that she feels anxious and sad, cries a lot, and has difficulty sleeping. What will the nurse do? a. Ask her to complete the Edinburgh Postnatal Depression Scale. b. Reassure her that the "baby blues" are normal after childbirth. c. Suggest that she get more sleep and try to increase her activity. d. Suggest that she talk to her provider about using an SSRI.

a. Ask her to complete the Edinburgh Postnatal Depression Scale. Women who experience depressive symptoms after childbirth can be screened using a quick test: the Edinburgh Postnatal Depression Scale, which may be administered 6 to 8 weeks after delivery. Reassuring her that her feelings are normal does not acknowledge her concerns; also, without objective screening, this reassurance may not be warranted. Increased sleep and activity may help, but screening is necessary to determine the severity of the depression. Until the patient is diagnosed as having postpartum depression, an SSRI is not indicated.

12. A patient takes temazepam (Restoril) for insomnia. The patient tells the nurse that a recent telephone bill lists several calls to friends that the patient does not remember making. What will the nurse do? a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine. b. Contact the prescriber to request an order for a benzodiazepine with a shorter duration. c. Reassure the patient that this is most likely caused by a paradoxical reaction to the benzodiazepine. d. Tell the patient that this is an example of anterograde amnesia, which is an expected effect of benzodiazepine

a. Ask the patient about any alcohol consumption in conjunction with the benzodiazepine. This patient is describing complex sleep-related behavior, which occurs when patients carry out complex behaviors while taking benzodiazepines but have no memory of their actions. These actions can occur with normal doses but are more likely with excessive doses or when benzodiazepines are combined with alcohol or other CNS depressants, so the nurse is correct in evaluating this possibility. The duration of the benzodiazepine does not contribute to this phenomenon. Paradoxical effects of benzodiazepines include insomnia, excitation, euphoria, anxiety, and rage. Anterograde amnesia occurs when patients have impaired recall of events that occur after dosing.

82. A nurse is preparing a patient for surgery and is teaching the patient about the use of the patient-controlled analgesia pump. The patient voices concern about becoming addicted to morphine. What will the nurse do? a. Ask the patient about any previous drug or alcohol abuse. b. Discuss possible nonopioid options for postoperative pain control. c. Suggest that the patient use the PCA sparingly. d. Tell the patient that the pump can be programmed for PRN dosing only.

a. Ask the patient about any previous drug or alcohol abuse. The nurse should remember that addiction to opioids usually occurs in patients who already have tendencies for addiction, so an assessment of previous experiences with addictive substances would be indicated. Postoperative pain should be treated appropriately with medications that are effective. Nonopioid medications are not sufficient to treat postoperative pain. Patients should be encouraged to use the PCA as needed so that pain can be controlled in a timely fashion. PRN dosing is not as effective as dosing that is continuous, so a basal dose should be given as well as a PRN dose.

95. A postoperative patient complains of abdominal bloating and discomfort. The nurse caring for this patient will contact the provider to request which medication? a. Bethanechol b. Droperidol c. Promethazine d. Ondansetron

a. Bethanechol Bethanechol is a muscarinic agonist that is used to treat abdominal distention and urinary retention. The other three agents are antiemetics and would not be useful in this situation.

45. A patient who has been taking an SSRI tells the nurse that the drug has caused reduced sexual performance, weight gain, and sedation. The nurse will suggest that the patient ask the provider about using which drug? a. Bupropion (Wellbutrin) b. Imipramine (Tofranil) c. Isocarboxazid (Marplan) d. Trazodone (Oleptro)

a. Bupropion (Wellbutrin) Bupropion does not cause weight gain, sexual dysfunction, or sedation, so it may be a useful adjunct to or substitute for an SSRI when those side effects become intolerable. Imipramine causes sedation. Isocarboxazid is an MAOI and is not used unless other drugs are ineffective. Trazodone causes sedation.

47. A patient is brought to the emergency department after taking a handful of TCA pills. The nurse will expect to provide what when caring for this patient? (Select all that apply.) a. Cardiac monitoring b. Cholinesterase inhibitors c. Gastric lavage and activated charcoal d. Sedative medications e. Procainamide

a. Cardiac monitoring b. Cholinesterase inhibitors c. Gastric lavage and activated charcoal Patients who overdose with a TCA should have cardiac monitoring, because cardiac side effects can occur. Cholinesterase inhibitors are given to counteract anticholinergic side effects. Gastric lavage followed by activated charcoal can reduce absorption of the TCA. Sedative drugs would only increase the sedative effects of the TCA. Procainamide causes cardiac depression and is not recommended to treat TCA dysrhythmias.

71. Supplemental oxygen has been shown to help reduce symptoms for which type of headache? a. Cluster b. Menstrual migraine c. Migraine d. Tension-type

a. Cluster Cluster headaches can be treated with 100% oxygen inhalation. Oxygen therapy is not used to treat other types of headaches.

84. A nurse is administering morphine sulfate to a postoperative patient. Which are appropriate routine nursing actions when giving this drug? (Select all that apply.) a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids c. Monitoring the patient's blood pressure closely for hypertension d. Palpating the patient's lower abdomen every 4 to 6 hours e. Requesting an order for methylnaltrexone (Relistor) to prevent constipation

a. Counting respirations before and after giving the medication b. Encouraging physical activity and offering increased fluids d. Palpating the patient's lower abdomen every 4 to 6 hours Respiratory depression, constipation, and urinary retention are common adverse effects of opioid analgesics. It is important to count respirations before giving the drug and periodically thereafter to make sure that respiratory depression has not occurred. Increased physical activity, increased fluid intake, and increased fiber help alleviate constipation. It is important to assess the patient's abdomen and palpate the bladder to make sure that urinary retention has not occurred. Patients taking morphine often experience hypotension, not hypertension. Methylnaltrexone is given as a last resort to treat constipation, because it blocks mu receptors in the intestine.

88. A surgical patient is receiving succinylcholine (Anectine) with an inhalation anesthetic. The patient is intubated, has an indwelling urinary catheter, and has ongoing monitoring of vital signs. Which symptom during the perioperative period is cause for concern? a. Elevated temperature b. Increased urine output c. Muscle paralysis d. No response to painful stimuli

a. Elevated temperature Combining succinylcholine (a skeletal muscle relaxant) with an inhalation anesthetic increases the risk of malignant hyperthermia. The mechanism is not understood. Temperature elevation can be profound, and cooling measures must be initiated or the condition can be fatal. A decrease in urine output would be a sign of hypotension. Muscle paralysis and lack of response to pain are desired effects of anesthesia.

22. Which sedative-hypnotics are useful for both difficulty falling asleep and difficulty maintaining sleep? (Select all that apply.) a. Eszopiclone (Lunesta) b. Flurazepam c. Temazepam (Restoril) d. Triazolam (Halcion) e. Extended-release zolpidem (Ambien CR)

a. Eszopiclone (Lunesta) b. Flurazepam e. Extended-release zolpidem (Ambien CR) Eszopiclone (Lunesta), flurazepam, and extended-release zolpidem (Ambien CR) all help with difficulty falling asleep and difficulty maintaining sleep. Temazepam is useful for maintaining sleep only. Triazolam helps with difficulty falling asleep but does not maintain sleep.

73. A patient asks the nurse what can be given to alleviate severe, chronic pain of several months' duration. The patient has been taking oxycodone (OxyContin) and states that it is no longer effective. The nurse will suggest discussing which medication with the provider? a. Fentanyl (Duragesic) transdermal patch b. Hydrocodone (Vicodin) PO c. Meperidine (Demerol) PO d. Pentazocine (Talwin) PO

a. Fentanyl (Duragesic) transdermal patch Transdermal fentanyl is indicated only for persistent, severe pain in patients already opioid tolerant. Hydrocodone, a combination product, has actions similar to codeine and is not used for severe, chronic pain. Meperidine is not recommended for continued use because of the risk of harm caused by the accumulation of a toxic metabolite. Pentazocine is an agonist-antagonist opioid and is less effective for pain; moreover, when given to a patient who is already opioid tolerant, it can precipitate an acute withdrawal syndrome.

2. A nurse is admitting a patient to a hospital unit and is taking a history. The patient reports taking alprazolam (Xanax) for "nerves." The nurse knows that this patient is most likely being treated for which condition? a. Generalized anxiety disorder b. Obsessive-compulsive disorder (OCD) c. Panic disorder d. Post-traumatic stress disorder (PTSD)

a. Generalized anxiety disorder Benzodiazepines are first-choice drugs for anxiety, and alprazolam and lorazepam are prescribed most often. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs for the treatment of OCD. Panic disorder is treated with any of the three classes of antidepressants: SSRIs, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs). Research has not shown any drug to be effective in the treatment of PTSD, although two SSRIs have been approved for use for this disorder.

7. Selective serotonin reuptake inhibitors are known to be effective for which disorders? (Select all that apply.) a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder c. Panic disorder d. Post-traumatic stress disorder e. Social anxiety disorder

a. Generalized anxiety disorder (GAD) b. Obsessive-compulsive disorder c. Panic disorder e. Social anxiety disorder SSRIs have been shown to be effective in treating GAD, OCD, panic disorder, and social anxiety disorder. They are used to treat PTSD but have not demonstrated effectiveness in clinical research.

6. During an admission history, a patient reports a frequent need to return to a room multiple times to make sure an iron or other appliance is unplugged. What does the nurse understand about this patient's behavior? a. It helps the patient reduce anxiety about causing a fire. b. It usually is treated with clomipramine (Anafranil). c. It seems perfectly normal to the patient. d. It will best respond to deep brain stimulation.

a. It helps the patient reduce anxiety about causing a fire. Patients with OCD have compulsive behaviors, such as repeatedly checking to make sure appliances have been unplugged. The compulsion is a ritualized behavior resulting from obsessive anxiety or fear that something bad will happen, such as starting a fire with an overheated appliance. Clomipramine is not a first-line drug for treating OCD. Patients usually understand that compulsive behaviors are excessive and senseless but are unable to stop. Deep brain stimulation is indicated for patients in whom other treatments have failed; its effectiveness at reducing symptoms has been shown to be about 40%.

97. A patient is given nitrous oxide, along with another inhalation anesthetic. The nurse knows that the benefits of nitrous oxide include what? (Select all that apply.) a. It is a potent analgesic. b. It has high anesthetic potency. c. It is less likely to cause nausea and vomiting. d. It is less likely to precipitate malignant hyperthermia. e. It can significantly reduce the dose of inhalation anesthetic.

a. It is a potent analgesic. d. It is less likely to precipitate malignant hyperthermia. e. It can significantly reduce the dose of inhalation anesthetic. Nitrous oxide is an inhalation agent with high analgesic potency. It is not likely to precipitate malignant hyperthermia. It can significantly reduce the dose of the primary anesthetic by as much as 50% or more. It does not have high anesthetic potency, so it cannot be used alone to induce anesthesia. It is more likely to cause postoperative nausea and vomiting.

78. A postoperative patient has received an epidural infusion of morphine sulfate. The patient's respiratory rate decreases to 8 breaths per minute, and he has a decreased level of consciousness and miosis. Which medication would the nurse anticipate administering? a. Naloxone (Narcan) b. Acetylcysteine (Mucomyst) c. Methylprednisolone (Medrol) d. Physostigmine (Antilirium)

a. Naloxone (Narcan) Narcan is an opioid antagonist and would counteract the apparent toxicity. Acetylcysteine is the antidote for acetaminophen poisoning. Methylprednisolone is an anti-inflammatory agent and would not have an effect on toxicity related to opiate overdose. Physostigmine is indicated for organophosphate poisoning.

48. Which patients are candidates for MAOIs? (Select all that apply.) a. Patients who have not responded to SSRIs and TCAs b. Patients with atypical depression c. Patients with bulimia nervosa d. Patients with hypotension e. Patients with postpartum depression

a. Patients who have not responded to SSRIs and TCAs b. Patients with atypical depression c. Patients with bulimia nervosa Patients who have not responded to SSRIs or TCAs, patients with atypical depression, and patients with bulimia nervosa are candidates for MAOIs. MAOIs contribute to hypotension and therefore are contraindicated in patients with hypotension. MAOIs are not recommended for the treatment of postpartum depression.

83. A patient has been taking methadone (Dolophine) for 5 months to overcome an opioid addiction. The nurse should monitor the patient for which of the following electrocardiographic changes? a. Prolonged QT interval b. Prolonged P-R interval c. AV block d. An elevated QRS complex

a. Prolonged QT interval Methadone prolongs the QT interval. It does not prolong the P-R interval, cause AV block, or produce an elevated QRS complex.

42. An older adult patient who is to begin taking imipramine (Tofranil) asks the nurse when the drug should be taken. The nurse will instruct the patient to: a. divide the daily dose into two equal doses 12 hours apart. b. take the entire dose at bedtime to minimize sedative effects. c. take the medication once daily in the late afternoon. d. take the medication once daily in the morning.

a. divide the daily dose into two equal doses 12 hours apart. For many patients, taking the entire dose of a TCA at bedtime is advantageous for facilitating adherence, minimizing daytime sedation, and promoting sleep. However, older adult patients are at greater risk for cardiotoxicity and may experience intolerable effects on the heart if the entire dose is taken at once; therefore, twice-daily dosing is recommended in the elderly.

39. A neonate is born to a patient who reports taking venlafaxine (Effexor XR). The nurse caring for the infant will observe the infant for: a. irritability, tremor, and respiratory distress. b. poor appetite and disturbed sleeping patterns. c. serotonin syndrome. d. sustained mydriasis.

a. irritability, tremor, and respiratory distress. Use of venlafaxine late in pregnancy can result in a neonatal withdrawal syndrome characterized by irritability, abnormal crying, tremor, respiratory distress, and possibly seizures. Poor appetite and disturbed sleep are not part of this withdrawal syndrome. Serotonin syndrome is not likely. Sustained mydriasis occurs as an adverse effect in patients taking the drug.

96. A patient will receive isoflurane (Forane) as an anesthetic for a surgical procedure. The nurse caring for this patient during the perioperative period knows that, unlike halothane, this agent will not cause: a. myocardial depression. b. muscle relaxation. c. rapid induction. d. respiratory depression.

a. myocardial depression. Isoflurane does not cause myocardial depression and does not reduce cardiac output. Isoflurane actually produces more muscle relaxation than halothane. Induction with isoflurane is rapid. Isoflurane causes respiratory depression, as do all inhalation anesthetics.

52. A nurse and a nursing student are discussing the plan of care for a patient with schizophrenia. The patient, who has been taking a high-potency FGA for 2 months, has become restless and constantly needs to be in motion. Which statement by the student indicates a need for further education? a. "Anticholinergic medications may help control these symptoms." b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA." c. "The provider may try a low-potency FGA instead of the high-potency FGA." d. "This patient may need to take a benzodiazepine or a beta blocker."

b. "Because this may be an exacerbation of psychosis, the provider may increase the dose of the FGA." The patient is showing signs of akathisia, which can resemble an exacerbation of psychosis. If the two are confused and the provider orders more of the FGA, the symptoms may actually increase. Anticholinergic medications may be used, a low-potency FGA may be ordered, or a benzodiazepine or beta blocker may be prescribed.

20. A patient complains of chronic insomnia and reports being tired of being tired all the time. The patient is reluctant to try pharmacologic remedies and asks the nurse what to do. What will the nurse suggest? a. "Eat a large meal in the evening to induce drowsiness." b. "Get out of bed for a while if you can't fall asleep." c. "Have a glass of wine at bedtime to relax." d. "Take a short nap early in the afternoon every day."

b. "Get out of bed for a while if you can't fall asleep."

30. A patient with bipolar disorder is admitted to the hospital. The patient has been taking lithium (Lithobid) for several years and has not been evaluated by a provider for over a year. Besides obtaining a lithium level, the nurse caring for this patient will anticipate orders for which laboratory tests? (Select all that apply.) a. Calcium level b. Complete blood count with differential c. Liver function tests d. Renal function tests e. Serum potassium f. Thyroid function tests

b. Complete blood count with differential d. Renal function tests f. Thyroid function tests Patients taking lithium can develop a mild, reversible leukocytosis, so annual CBC evaluation with differential is recommended. Chronic lithium use is associated with degenerative changes in the kidneys, so renal function should be assessed annually. Lithium can reduce the incorporation of iodine into thyroid hormone and can inhibit thyroid secretion; therefore, thyroid hormone and thyroid-stimulating hormone (TSH) levels should be measured annually. Lithium is affected by sodium levels but not by calcium or potassium levels. Because lithium is excreted by the kidneys, hepatic function tests are not indicated.

27. A patient with bipolar disorder who is taking divalproex sodium (Valproate) has just been admitted to the hospital. During the admission assessment, the patient tells the nurse about recent suicidal ideation. The nurse observes several areas of bruising over soft tissue areas and notes a weight gain of 10 pounds since the last admission 1 year ago. What will the nurse do? a. Ask the patient whether the bruises are self-inflicted. b. Contact the provider to report these findings. c. Give the patient information about weight loss. d. Request an order for an increased dose to help with depressive symptoms.

b. Contact the provider to report these findings. Divalproex sodium is used to control symptoms during manic episodes and can prevent relapse into mania. It is less effective than lithium at reducing the risk of suicide. It can cause thrombocytopenia, which results in bruising and is an indication for immediate drug withdrawal. Weight gain can be serious and chronic. All of these findings are an indication for withdrawing the drug and should be reported to the provider. Until platelet levels determine whether the bruises are drug induced, it is not appropriate to ask the patient if they are self-inflicted. Because weight gain is common and can be severe with this drug, information about weight loss is not likely to have an effect. Divalproex sodium is better than lithium at treating depression; however, in light of the other symptoms, it is probably not the best choice.

85. Which side effects of opioid analgesics can have therapeutic benefits? (Select all that apply.) a. Biliary colic b. Cough suppression c. Suppression of bowel motility d. Urinary retention e. Vasodilation

b. Cough suppression c. Suppression of bowel motility e. Vasodilation Individual effects of morphine may be beneficial, detrimental, or both. Cough suppression is usually beneficial; suppression of bowel motility and vasodilation can be either beneficial or detrimental. Biliary colic and urinary retention are always detrimental side effects.

36. A patient has been taking fluoxetine (Prozac) for 11 months and reports feeling cured of depression. The nurse learns that the patient is sleeping well, participates in usual activities, and feels upbeat and energetic most of the time. The patient's weight has returned to normal. What will the nurse tell this patient? a. Indefinite drug therapy is necessary to maintain remission. b. Discuss gradual withdrawal of the medication with the provider. c. Stop the drug while remaining alert for the return of symptoms. d. Take a drug holiday to see whether symptoms recur.

b. Discuss gradual withdrawal of the medication with the provider. Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) can cause a withdrawal syndrome, so these drugs should be withdrawn gradually. After symptoms are in remission, treatment should continue for 4 to 9 months to prevent relapse; these drugs are not taken indefinitely. It is incorrect to counsel the patient to stop taking the drug without tapering it. Drug holidays are used to minimize sexual dysfunction side effects, not to monitor symptoms

40. A provider has indicated that a serotonin/norepinephrine reuptake inhibitor (SNRI) will be prescribed for a patient who is experiencing major depression. When conducting a pretreatment health history, the nurse learns that the patient has a recent history of alcohol abuse. Which SNRI would be contraindicated for this patient? a. Desvenlafaxine (Pristiq) b. Duloxetine (Cymbalta) c. Escitalopram (Lexapro) d. Venlafaxine (Effexor SR)

b. Duloxetine (Cymbalta) Duloxetine can cause elevation of serum transaminases, indicating liver disease. Patients with existing liver disease or alcohol abuse should not receive this drug. This side effect is not likely with desvenlafaxine or venlafaxine. Escitalopram is an SSRI.

68. A patient is being treated for an infection with erythromycin. The nurse obtains a health history and learns that the patient has migraine headaches. The nurse will tell the patient to avoid which medication while taking the erythromycin? a. Acetaminophen b. Ergotamine (Ergomar) c. Sumatriptan (Imitrex) d. Topiramate

b. Ergotamine (Ergomar) Macrolide antibiotics, such as erythromycin, are potent inhibitors of CYP3A4; these drugs can raise ergotamine to dangerous levels, so this combination should be avoided. It is safe to take acetaminophen, sumatriptan, and topiramate with erythromycin.

50. A patient who is taking an antipsychotic drug for schizophrenia comes to the clinic for evaluation. The nurse observes that the patient has a shuffling gait and tremors and is drooling. The nurse will ask the patient's provider about which course of action? a. Administering a direct dopamine antagonist b. Giving an anticholinergic medication c. Increasing the dose of the antipsychotic drug d. Stopping the antipsychotic drug

b. Giving an anticholinergic medication The patient is showing signs of parkinsonism, an extrapyramidal effect associated with antipsychotic medications. Anticholinergic medications are indicated. A direct dopamine antagonist would counter the effects of the antipsychotic and remove any beneficial effect it has. Increasing the dose of the antipsychotic medication would only worsen the extrapyramidal symptoms. Stopping the antipsychotic medication would cause the symptoms of schizophrenia to worsen.

72. A patient on the unit complains of cluster headaches. A new graduate nurse is asked to differentiate between a migraine headache and cluster headaches. The graduate nurse is correct to state that manifestations and/or risk factors for a patient with cluster headaches include what? (Select all that apply.) a. Female gender b. Male gender c. Complaints of nausea and vomiting d. Short duration (15 minutes to 2 hours) e. Auras before the onset of headache pain f. Throbbing, sometimes piercing pain

b. Male gender d. Short duration (15 minutes to 2 hours) f. Throbbing, sometimes piercing pain Cluster headaches are more common in males, are short in duration, and present as throbbing and piercing pain. Migraine headaches are more common in females and are manifested by nausea and vomiting and the presence of an aura before the onset of headache pain.

21. A nurse recognizes that the actions of benzodiazepines include which findings? (Select all that apply.) a. Sleep deprivation b. Relief of general anxiety c. Suppression of seizures and/or seizure activity d. Development of tardive dyskinesia e. Increase in muscle spasms

b. Relief of general anxiety c. Suppression of seizures and/or seizure activity Benzodiazepines are indicated to relieve the symptoms of general anxiety and to suppress the central nervous system, thereby suppressing seizures and/or seizure activity. Benzodiazepines cause sleepiness, not sleep deprivation. Benzodiazepines do not cause tardive dyskinesia. Benzodiazepines relax muscles; they do not increase muscle spasms.

58. A patient in whom drug therapy has failed several times in the past is readmitted to a hospital to begin therapy for schizophrenia. What will the nurse do to help improve adherence? a. Encourage the patient to take responsibility for medication management. b. Teach the patient about drug side effects and how to manage them. c. Tell the patient that an abstinence syndrome will occur if the drug is stopped. d. Tell the patient that the drug may be taken as needed to control symptoms.

b. Teach the patient about drug side effects and how to manage them. One way to promote adherence to a medication regimen is to teach patients about drug side effects and how to minimize undesired responses. Family members should be encouraged to oversee medication management for outpatients, because patients themselves may fail to appreciate the need for therapy or may be unwilling to take prescribed medications. It is not true that an abstinence syndrome occurs when these drugs are withdrawn. These drugs are not used PRN; they must be given on a regular basis.

92. A preoperative patient receives atropine before induction of anesthesia. The nurse caring for this patient understands that this agent is used to prevent: a. anxiety. b. bradycardia. c. dry mouth. d. hypertension.

b. bradycardia. Atropine, an anticholinergic drug, is used as an adjunct to anesthesia to counter the effects of vagal stimulation, which is caused by surgical manipulations that trigger parasympathetic reflexes, resulting in bradycardia. Atropine is not an anxiolytic. Atropine causes dry mouth and sometimes is used to minimize bronchial secretions

19. A nurse is obtaining a health history from an older adult patient in an outpatient clinic. The patient reports chronic difficulty falling asleep and staying asleep. The nurse knows that the best treatment for this patient will be: a. alternative medications. b. improved sleep hygiene. c. short-term barbiturates. d. triazolam (Halcion).

b. improved sleep hygiene. Research has shown that cognitive behavioral therapy is superior to drug therapy for both short-term and long-term management of chronic insomnia in older adults. Alternative remedies have not been proven effective. Barbiturates may elicit paradoxical effects in elderly patients. Triazolam does not help to maintain sleep.

75. A patient with moderate to severe chronic pain has been taking oxycodone (OxyContin) 60 mg every 6 hours PRN for several months and tells the nurse that the medication is not as effective as before. The patient asks if something stronger can be taken. The nurse will contact the provider to discuss: a. administering a combination opioid analgesic/acetaminophen preparation. b. changing the medication to a continued-release preparation. c. confronting the patient about drug-seeking behaviors. d. withdrawing the medication, because physical dependence has occurred.

b. changing the medication to a continued-release preparation. Oxycodone is useful for moderate to severe pain, and a continued-release preparation may give more continuous relief. Dosing is every 12 hours, not PRN. A combination product is not recommended with increasing pain, because the nonopioid portion of the medication cannot be increased indefinitely. This patient does not demonstrate drug-seeking behaviors. Physical dependence is not an indication for withdrawing an opioid, as long as it is still needed; it indicates a need for withdrawing the drug slowly when the drug is discontinued.

67. A patient arrives in the emergency department complaining of numbness in the extremities. The nurse notes that the patient's hands and feet are cool and pale. When conducting a health history, the nurse learns that the patient has a history of migraine headaches. The nurse recognizes this patient's symptoms as: a. ergotamine withdrawal. b. ergotism. c. severe migraine symptoms. d. sumatriptan side effects.

b. ergotism. Ergotism is a serious toxicity caused by acute or chronic overdose of ergotamine. The toxicity results in ischemia, causing the extremities to become cold, pale, and numb. Symptoms associated with ergotamine withdrawal include headache, nausea, vomiting, and restlessness. These are not symptoms of a severe migraine or side effects of sumatriptan.

23. A patient with bipolar disorder has frequent manic episodes alternating with depressive episodes. The prescriber orders risperidone (Risperdal) in addition to the lithium (Lithobid) that the patient is already taking. The patient asks the nurse why another drug is needed. The nurse will tell the patient that the risperidone is used to: a. elevate mood during depressive episodes. b. help control symptoms during manic episodes. c. manage tremors associated with lithium use. d. prevent recurrence of depressive episodes.

b. help control symptoms during manic episodes. Risperidone is an antipsychotic often used in conjunction with lithium to help manage symptoms during manic episodes, regardless of whether psychotic symptoms occur. Risperidone does not elevate mood and is not used during depressive episodes. It is not used to counter side effects associated with lithium. It does not prevent recurrence of depressive episodes.

64. A woman with moderate migraine headaches asks a nurse why the provider has ordered metoclopramide (Reglan) as an adjunct to aspirin therapy, because she does not usually experience nausea and vomiting with her migraines. The nurse will tell her that the metoclopramide is used to: a. help induce sleep. b. improve absorption of the aspirin. c. prevent gastric irritation caused by the aspirin. d. prolong the effects of the aspirin.

b. improve absorption of the aspirin. Besides reducing nausea and vomiting, metoclopramide also reverses gastric stasis and improves absorption of oral antimigraine drugs. It is not used to induce sleep. It does not prevent gastric irritation or prolong the effects of the aspirin.

11. A nursing student asks a nurse what criteria are used to determine which benzodiazepine is prescribed in different situations. The nurse correctly states that selection is based on differences in the onset and duration of effects, as well as on: a. differences in sites of action in the central nervous system. b. marketing decisions of pharmaceutical companies. c. relative differences in abuse potential. d. variations in adverse effects and drug interactions.

b. marketing decisions of pharmaceutical companies. The principal factors determining the applications of a particular benzodiazepine are the pharmacokinetic properties having to do with absorption, metabolism, and excretion and the research and marketing decisions of the drug makers. All of the benzodiazepines produce a similar spectrum of responses, and all act at various sites in the CNS. All benzodiazepines have a lower abuse potential than barbiturates. Drug effects and drug interactions are similar for all benzodiazepines.

32. A patient taking fluoxetine (Prozac) complains of decreased sexual interest. A prescriber orders a "drug holiday." What teaching by the nurse would best describe a drug holiday? a. "Cut the tablet in half anytime to reduce the dosage." b. "Discontinue the drug for 1 week." c. "Don't take the medication on Friday and Saturday." d. "Take the drug every other day."

c. "Don't take the medication on Friday and Saturday. Sexual dysfunction may be managed by having the patient take a drug holiday, which involves discontinuing medication on Fridays and Saturdays. Cutting the tablet in half anytime to reduce the dosage is an inappropriate way to manage drug administration effectively. In addition, it does not describe a drug holiday. The patient should not take the drug every other day, nor should it be discontinued for a week at a time, because this would diminish the therapeutic levels of the drug, thereby minimizing the therapeutic effects. In addition, neither of those options describe a drug holiday.

29. A patient with bipolar disorder takes lamotrigine (Lamictal). Which statement by the patient would prompt the nurse to hold the drug and notify the prescriber for further assessment? a. "I get a little dizzy sometimes." b. "I had a headache last week that lasted for about an hour." c. "I've broken out in a rash on my chest and back." d. "Last night I woke up twice with a bad dream."

c. "I've broken out in a rash on my chest and back." Evidence of a rash in a patient taking lamotrigine requires further assessment, because this may indicate the development of Stevens-Johnson syndrome. Although dizziness and headaches are side effects of lamotrigine, they are not potentially life threatening. A bad dream is not necessarily related to the lamotrigine.

55. A patient with schizophrenia shows suicidal behaviors, and the provider orders clozapine (Clozaril). The nurse teaches the family about the medication and its side effects. Which statement by a family member indicates a need for further teaching about this drug? a. "Blood counts are necessary for several weeks after discontinuation of the drug." b. "Fever, sore throat, and sores in the mouth should be reported immediately." c. "If the ANC is less than 3000, the drug will be discontinued permanently." d. "Use of this drug requires weekly evaluation of blood work."

c. "If the ANC is less than 3000, the drug will be discontinued permanently." Clozapine can cause agranulocytosis. If the absolute neutrophil count (ANC) drops below 1000/mcL, the drug must be discontinued permanently. Blood counts must be evaluated weekly, and this evaluation should be continued for several weeks after withdrawal of the drug. Fever, sore throat, and mouth ulcers are symptoms of agranulocytosis and should be reported immediately.

90. An anesthesiologist completes preoperative teaching for a patient the night before surgery. The patient asks the nurse to clarify the reason thiopental sodium will be given as an adjunct to the anesthetic. Which statement by the patient indicates understanding? a. "Pentothal allows a larger amount of inhaled anesthetic to be used without increased side effects." b. "Pentothal is given to enhance the analgesic and muscle relaxation effects of the inhaled anesthetic." c. "Pentothal is used to produce rapid unconsciousness before administration of the inhaled anesthetic." d. "Pentothal is used to reduce cardiovascular and respiratory depression caused by the inhaled anesthetic.

c. "Pentothal is used to produce rapid unconsciousness before administration of the inhaled anesthetic." Thiopental sodium, a short-acting barbiturate, is given intravenously for induction of anesthesia. It has a rapid onset and short duration and must be followed immediately by an inhalation anesthetic. It does not alter the side effects of inhalation anesthetics. Most adjuncts to inhalation anesthetics are given so that lower doses of the anesthetic may be used. Thiopental sodium has very weak analgesic and muscle relaxation effects. Thiopental sodium causes cardiovascular and respiratory depression.

41. A nurse is teaching a group of nursing students about tricyclic antidepressants (TCAs). Which statement by a student indicates a need for further teaching? a. "TCAs block receptors for histamine, acetylcholine, and norepinephrine." b. "TCAs block the uptake of norepinephrine and 5-HT." c. "TCAs have many side effects, but none of them are serious." d. "TCAs have other uses than for depression."

c. "TCAs have many side effects, but none of them are serious." TCAs can adversely affect cardiac function, and these effects can be serious in patients with pre-existing cardiac impairment. TCAs do block receptors for histamine, acetylcholine, and norepinephrine; they do block the uptake of norepinephrine and 5-HT; and they do have other uses besides depression.

99. A nurse is discussing the use of cocaine as a local anesthetic with a nursing student. Which statement by the student indicates understanding of this agent? a. "Anesthetic effects develop slowly and persist for several hours." b. "Cocaine is a local anesthetic administered by injection." c. "Vasoconstrictors should not be used as adjunct agents with this drug." d. "When abused, cocaine causes physical dependence."

c. "Vasoconstrictors should not be used as adjunct agents with this drug." Cocaine should not be combined with epinephrine or other vasoconstrictors, because it causes vasoconstriction itself, and the combination could precipitate severe hypertension. Cocaine has a rapid onset of effects, which last about 1 hour. It is used only topically for anesthesia. Although subject to widespread abuse with profound psychologic dependence, it does not cause substantial physical dependence

56. A patient with schizophrenia receives a dose of risperidone (Risperdal Consta) IM. The nurse teaching this patient about this medication will make which statement? a. "You will experience therapeutic levels of this drug in 1 to 2 weeks." b. "You will need injections of this drug every 6 weeks." c. "You will need to take an oral antipsychotic drug for 3 weeks." d. "You probably will not have extrapyramidal symptoms with this drug."

c. "You will need to take an oral antipsychotic drug for 3 weeks." Risperidone given intramuscularly is a depot preparation used for long-term therapy. Significant release of the drug does not occur until 2 to 3 weeks after injection; therefore, patients must take an oral antipsychotic medication until drug levels are raised. Therapeutic levels are reached 4 to 6 weeks after injection. Patients need injections every 2 weeks. With IM dosing, the incidence of extrapyramidal symptoms is substantial.

59. A nurse in a mental health hospital finds a patient with schizophrenia who takes haloperidol (Haldol) lying rigid in bed with a temperature of 41.3° C. A cardiac monitor shows cardiac dysrhythmias. What will be included in the treatment of this patient? (Select all that apply.) a. Anticholinergic medications b. Beta blockers c. Dantrolene d. Intravenous fluids e. Withdrawal of haloperidol

c. Dantrolene d. Intravenous fluids e. Withdrawal of haloperidol Neuroleptic malignant syndrome is characterized by "lead pipe" rigidity, sudden high fever, and autonomic instability. Treatment requires supportive measures, drug therapy, and immediate withdrawal of the antipsychotic medication. Dantrolene is used to relax muscles and reduce heat production. Intravenous fluids are used to maintain hydration. Anticholinergic medications and beta blockers are not helpful.

37. A patient has been taking an SSRI antidepressant for major depression and reports having headaches and jaw pain. What will the nurse tell the patient? a. This represents an irreversible extrapyramidal side effect. b. Discuss discontinuing the antidepressant with the provider. c. Discuss these symptoms with a dentist. d. Try stress-relieving methods and relaxation techniques.

c. Discuss these symptoms with a dentist. Bruxism is a side effect of SSRIs and can result in headache and jaw pain. Patients who experience these signs should be evaluated for bruxism by a dentist, who can determine whether the patient may benefit from use of a mouth guard. Headache and jaw pain are not signs of extrapyramidal side effects. Discontinuing the antidepressant is not indicated, because depression may return. Stress-relieving methods and relaxation techniques are not recommended, because these symptoms occur during sleep.

15. A patient is brought to the emergency department by friends, who say that they were at a party where alcohol and a mix of barbiturates and benzodiazepines were all available. They tell the nurse that the patient was among the first to arrive at the party, which started several hours ago. The patient is nonresponsive and has pinpoint pupils and respirations of 6 breaths per minute. After oxygen has been administered, the nurse should prepare the patient for which intervention? a. A central nervous system stimulant and IV fluids b. Activated charcoal and flumazenil (Romazicon) c. Gastric lavage and possible hemodialysis d. Naloxone (Narcan) and a cathartic

c. Gastric lavage and possible hemodialysis Because time has elapsed, enough medication is present in the system to warrant elimination by hemodialysis, and any remainder in the stomach may be eliminated by gastric lavage. A central nervous system stimulant is contraindicated, and intravenous fluids do not address the overdose. Although activated charcoal may assist in absorption of medication in the gut, flumazenil will be effective only for the benzodiazepines. Naloxone, a narcotic antagonist, is not effective for barbiturates and benzodiazepines

33. A patient whose spouse has died recently reports feeling down most of each day for the past 2 months. On further questioning, the nurse learns that the patient has quit participating in church and social activities, has difficulty falling asleep, and has lost 5 pounds. The patient reports feeling tired and confused all the time but does not have suicidal thoughts. What does the nurse suspect? a. Grief and sadness b. Hypomania c. Major depression d. Situational depression

c. Major depression This patient has symptoms of major depression, which include depressed mood, loss of pleasure in usual activities, insomnia, weight loss, and feelings of fatigue. For a diagnosis of major depression, these symptoms must be present most of the day, nearly every day, for at least 2 weeks. Grief and sadness and situational depression are common responses to the death of a loved one, but this patient's symptoms go beyond this normal response. This patient does not show signs of hypomania.

A postoperative patient is reporting pain as a 7 on a scale from 1 to 10, with 10 being the worst pain. The nurse caring for the patient assesses vital signs of HR, 76; RR, 16; and BP, 110/70. The patient has vomited twice. Which postoperative medications will the nurse expect to administer? a. Atropine and morphine b. Bethanechol and ibuprofen c. Morphine and ondansetron (Zofran) d. Promethazine and clonidine (Catapres)

c. Morphine and ondansetron (Zofran) This patient is experiencing postoperative symptoms of moderate to severe pain and nausea and vomiting. Morphine is used postoperatively for this degree of pain, and ondansetron is one of the most effective antiemetics. Atropine is an anticholinergic drug and usually is given preoperatively or perioperatively to prevent bradycardia. Bethanechol is a muscarinic agonist that is used to counter postoperative abdominal distention and urinary retention. Ibuprofen can be used, but it is effective only for mild postoperative pain. Promethazine is less effective as an antiemetic and can be used, but clonidine, marketed as Catapres, is used for postoperative hypertension.

61. What are negative symptoms of schizophrenia? (Select all that apply.) a. Delusions b. Disordered thinking c. Poor judgment d. Poor self-care e. Poverty of speech

c. Poor judgment d. Poor self-care e. Poverty of speech Poor judgment, poor self-care, and poverty of speech are all negative symptoms of schizophrenia. Delusions and disordered thinking are positive symptoms.

31. A patient with bipolar disorder who wants to minimize the need for drug therapy asks the nurse what else can be done to treat the disorder. The nurse will recommend which measures? (Select all that apply.) a. Electroconvulsive therapy b. Moderate use of alcohol to reduce stress c. Psychotherapy d. Regular sleep and exercise e. Using a chart to monitor mood changes

c. Psychotherapy d. Regular sleep and exercise e. Using a chart to monitor mood changes BPD should be treated with a combination of drugs and adjunctive psychotherapy, because drug therapy alone is not optimal. Other measures, such as regular sleep and exercise and recognizing early symptoms of mood change, help minimize extreme mood swings. Electroconvulsive therapy is effective, but it is not the first-choice treatment; it is reserved for patients who have not responded to other therapies. Avoidance of alcohol is recommended.

28. A patient who has recently begun taking carbamazepine (Tegretol) for bipolar disorder reports having vertigo and headaches. Which action by the nurse is appropriate? a. Ask the provider whether another medication can be used for this patient, because the patient is showing signs of toxicity. b. Contact the provider to request a complete blood count (CBC) to evaluate for other, more serious side effects. c. Reassure the patient that these effects occur early in treatment and will resolve over time. d. Review the patient's chart for cytochrome P450 enzymes to see whether an increased dose is needed.

c. Reassure the patient that these effects occur early in treatment and will resolve over time. Carbamazepine can cause several neurologic side effects early in treatment, including vertigo and headaches. These resolve with continued drug use. These side effects are not related to drug toxicity. A CBC should be obtained at baseline and periodically thereafter. Carbamazepine can cause changes in hematologic laboratory values. The side effects reported by this patient are not associated with hematologic side effects. Carbamazepine induces cytochrome P450 enzymes and can accelerate its own metabolism, which would reduce the amount of drug and decrease side effects, so an increased dose is not appropriate.

69. A young woman with migraine headaches who has recently begun taking sumatriptan (Imitrex) calls the nurse to report a sensation of chest and arm heaviness. The nurse questions the patient and determines that she feels pressure and not pain. What will the nurse do? a. Ask the patient about any history of hypertension or coronary artery disease. b. Determine whether the patient might be pregnant. c. Reassure the patient that this is a transient, reversible side effect of sumatriptan. d. Tell the patient to stop taking the medication immediately.

c. Reassure the patient that this is a transient, reversible side effect of sumatriptan. Some patients taking sumatriptan experience unpleasant chest symptoms, usually described as "heavy arms" or "chest pressure." These symptoms are transient and are not related to heart disease. Patients experiencing angina-like pain when taking sumatriptan, as a result of coronary vasospasm, should be asked about hypertension or coronary artery disease (CAD); they should not take sumatriptan if they have a history of either of these. The symptoms this patient describes are not characteristic of pregnancy. There is no need to stop taking the medication.

49. A patient with schizophrenia has been taking an antipsychotic drug for several days. The nurse enters the patient's room to administer a dose of haloperidol (Haldol) and finds the patient having facial spasms. The patient's head is thrust back, and the patient is unable to speak. What will the nurse do? a. Administer the haloperidol as ordered. b. Discuss increasing the haloperidol dose with the provider. c. Request an order to give diphenhydramine. d. Request an order to give levodopa.

c. Request an order to give diphenhydramine. An early reaction to antipsychotic drugs is acute dystonia. Initial treatment consists of an anticholinergic medication, such as diphenhydramine. Administering more antipsychotic medication would increase the symptoms and could be life threatening. Levodopa is not given for extrapyramidal symptoms, because it could counteract the beneficial effects of antipsychotic treatment.

14. A patient in the emergency department is given intravenous diazepam (Valium) for seizures. When the seizures stop, the nurse notes that the patient is lethargic and confused and has a respiratory rate of 10 breaths per minute. The nurse will expect to administer which of the following? a. Flumazenil (Romazicon) b. Gastric lavage c. Respiratory support d. Toxicology testing

c. Respiratory support When benzodiazepines are administered IV, severe effects, including profound hypotension, respiratory arrest, and cardiac arrest, can occur. Respiration should be monitored, and the airway must be managed if necessary. Flumazenil (Romazicon) is a competitive benzodiazepine receptor antagonist and is used to reverse the sedative effects but may not reverse respiratory depression. Gastric lavage would not be effective, because the benzodiazepine has been given IV. Without further indication of the ingestion of other drugs, toxicology testing is not a priority.

4. A patient reports having occasional periods of tremors, palpitations, nausea, and a sense of fear. To treat this condition, the nurse anticipates the provider will prescribe a drug in which drug class? a. Benzodiazepines b. Monoamine oxidase inhibitors c. Selective serotonin reuptake inhibitors d. Tricyclic antidepressants

c. Selective serotonin reuptake inhibitors This patient is showing characteristics of panic disorder. All three major classes of antidepressants are effective, but selective serotonin reuptake inhibitors are first-line drugs. Benzodiazepines are second-line drugs and are rarely used because of their abuse potential. MAOIs are effective but are difficult to use because of side effects and drug and food interactions. Tricyclic antidepressants are second-line drugs, and their use is recommended only after a trial of at least one SSRI has failed.

57. A patient with schizophrenia has been taking an oral FGA for 1 week. The patient has been taking the drug daily in two divided doses. The individual complains of daytime drowsiness. The patient's family reports a decrease in the person's hostility and anxiety but states that the patient remains antisocial with disordered thinking. What will the nurse tell the patient and the family? a. An increased dose of the drug may be needed. b. Intramuscular dosing may be needed. c. Some symptoms take months to improve. d. The entire dose may be taken at bedtime.

c. Some symptoms take months to improve. When patients begin therapy with antipsychotic medications, some symptoms resolve sooner than others. During the first week, agitation, hostility, anxiety, and tension may resolve, but other symptoms may take several months to improve. It is not necessary to increase the dose in the first week. IM dosing is indicated for patients with severe, acute schizophrenia and for long-term maintenance. Sedation is normal, and once an effective dose has been determined, the entire dose can be taken at bedtime, but not in the initial days of therapy.

13. A patient has been taking high doses of clorazepate (Tranxene) for several months for an anxiety disorder. The nurse assessing the patient observes that the patient is agitated, euphoric, and anxious. What will the nurse do? a. Double-check the chart to make sure the last dose was given. b. Request an order for a longer acting benzodiazepine. c. Suspect a possible paradoxical reaction to the clorazepate. d. Withhold the next dose until a drug level can be drawn.

c. Suspect a possible paradoxical reaction to the clorazepate. Patients taking benzodiazepines for anxiety sometimes develop paradoxical responses to the drug, which include insomnia, excitation, euphoria, heightened anxiety, and rage. A missed dose would trigger withdrawal symptoms, which would include anxiety, insomnia, sweating, tremors, and dizziness. Because this is a paradoxical reaction to the drug, a longer acting drug would make the symptoms worse. This is not caused by overdose, which would manifest as drowsiness, lethargy, and confusion, so a drug level is not warranted.

76. A patient with cancer has been taking an opioid analgesic four times daily for several months and reports needing increased doses for pain. What will the nurse tell the patient? a. PRN dosing of the drug may be more effective. b. The risk of respiratory depression increases over time. c. The patient should discuss increasing the dose with the provider. d. The patient should request the addition of a benzodiazepine to augment pain relief.

c. The patient should discuss increasing the dose with the provider. This patient is developing tolerance, which occurs over time and is evidenced by the need for a larger dose to produce the effect formerly produced by a smaller dose. This patient should be encouraged to request an increased dose. PRN dosing is less effective than scheduled, around-the-clock dosing. The risk of respiratory depression decreases over time as patients develop tolerance to this effect. Benzodiazepines are CNS depressants and should not be given with opioids, as they increase the risk of oversedation.

44. A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient? a. Whether any antihypertensive medications are used b. Whether the patient drinks grapefruit juice c. To list all foods eaten that day d. Whether SSRIs are taken in addition to the MAOI

c. To list all foods eaten that day Patients taking an MAOI should be counseled to follow strict dietary restrictions and to avoid all foods containing tyramine. Patients who consume such foods when taking an MAOI experience a hypertensive episode. Antihypertensive medications, given with an MAOI, will result in hypotension. Grapefruit juice does not alter the metabolism of an MAOI. SSRIs and MAOIs, when administered together, cause a serotonin syndrome.

16. A patient who travels frequently for business reports occasional instances of being unable to fall asleep. The patient tells the nurse that job demands require staying up late and then getting up early for meetings. The nurse expects that the provider will prescribe which medication for this patient? a. Flurazepam b. Trazodone (Desyrel) c. Zaleplon (Sonata) d. Zolpidem (Ambien)

c. Zaleplon (Sonata) Zaleplon (Sonata) works well for people who have trouble falling asleep and, because of its short duration of action, can be taken late at night without causing a hangover or next-day sedation early in the morning. Zolpidem (Ambien) has a longer duration and is a good choice for patients who have difficulty maintaining sleep. Flurazepam has a long duration of action. Trazodone causes daytime grogginess.

66. A prescriber orders sumatriptan (Imitrex) for a patient for a migraine headache. Before administration of this drug, it would be important for the nurse to assess whether the patient: a. has a family history of migraines. b. has taken acetaminophen in the past 3 hours. c. has taken ergotamine in the past 24 hours. d. is allergic to sulfa compounds.

c. has taken ergotamine in the past 24 hours. Sumatriptan, other triptans, and ergot alkaloids all cause vasoconstriction and should not be combined, or excessive and prolonged vasospasm could result. Sumatriptan should not be used within 24 hours of an ergot derivative and another triptan. A family history is important, but it is not vital assessment data as it relates to this scenario. Acetaminophen has no drug-to-drug interaction with sumatriptan. Sulfa is not a component of sumatriptan and therefore is not relevant.

35. A young adult patient has been taking an antidepressant medication for several weeks and reports having increased thoughts of suicide. The nurse questions further and learns that the patient has attempted suicide more than once in the past. The patient identifies a concrete plan for committing suicide. The nurse will contact the provider to discuss: a. changing the medication to another drug class. b. discontinuing the medication immediately. c. hospitalizing the patient for closer monitoring. d. requiring more frequent clinic visits for this patient.

c. hospitalizing the patient for closer monitoring. Patients with depression often think of suicide, and during treatment with antidepressants, these thoughts often increase for a time. Patients whose risk of suicide is especially high should be hospitalized. All antidepressants carry this risk, so changing medication is not recommended. Discontinuing the medication is not recommended. More frequent clinic visits are recommended for patients with a low to moderate risk of suicide.

63. A patient who has occasional migraine headaches tells a nurse that the abortive medication works well, but she would like to do more to prevent the occurrence of these headaches. The nurse will suggest that the patient: a. ask the provider about an adjunct medication, such as prochlorperazine. b. discuss the use of prophylactic medications with the provider. c. keep a headache diary to help determine possible triggers. d. take the abortive medication regularly instead of PRN.

c. keep a headache diary to help determine possible triggers. Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications are used when headaches are more frequent. To prevent medication overuse headache, abortive medications should not be used more than 1 to 2 days at a time.

89. A nurse administers atropine to a patient before induction of anesthesia for a surgical procedure. When evaluating the effects of this medication, the nurse will: a. assess for excessive bronchial secretions. b. expect a reduction in the patient's anxiety. c. monitor the patient's heart rate. d. observe for muscle paralysis.

c. monitor the patient's heart rate. Anticholinergic drugs, such as atropine (Sal-Tropine), may be given to reduce the risk of bradycardia during surgery. Atropine can alter bronchial secretions, but the effect would be to reduce them, not increase them. It is not used to reduce anxiety. It does not cause muscle paralysis.

18. A patient with a history of depression and suicidal ideation is taking fluoxetine (Prozac). The patient reports difficulty maintaining sleep and is prescribed secobarbital (Seconal) as a sedative-hypnotic. The nurse preparing this patient for discharge from the hospital will: a. contact the provider to suggest an order for ramelteon (Rozerem). b. instruct the patient to use alcohol in moderation. c. request an order to change to trazodone (Desyrel) for sleep. d. suggest that the patient try alternative remedies for sleep

c. request an order to change to trazodone (Desyrel) for sleep. Trazodone is an atypical antidepressant with sedative actions and can be used to prolong sleep duration. It is useful for treating insomnia related to antidepressants such as Prozac. Ramelteon is not a drug of choice to treat patients who have difficulty maintaining sleep. Patients who are depressed or at increased risk for suicide should not take barbiturates, because overdose can readily cause death. Alcohol is contraindicated when taking barbiturates. Alternative remedies have not shown effectiveness in treating insomnia.

77. A woman in labor receives meperidine (Demerol) for pain. The nurse caring for the infant will observe the infant closely for: a. congenital anomalies. b. excessive crying and sneezing. c. respiratory depression. d. tremors and hyperreflexia.

c. respiratory depression. Use of morphine or other opioids during delivery can cause respiratory depression in the neonate, because the drug crosses the placenta. Infants should be monitored for respiratory depression and receive naloxone if needed. Opioids given during delivery do not contribute to birth defects in the newborn. Excessive crying and sneezing and tremors and hyperreflexia are all signs of neonatal opioid dependence, which occurs with long-term opioid use by the mother during pregnancy and not with short-term use of these drugs during labor.

43. A patient who has fibromyalgia is diagnosed with major depression. The provider orders a TCA. The nurse will teach this patient to: a. avoid foods containing tyrosine. b. consume alcohol in moderation. c. sit or lie down when feeling lightheaded. d. take the medication in the morning.

c. sit or lie down when feeling lightheaded. Orthostatic hypotension can occur with TCAs. Patients should be advised to sit or lie down if they feel lightheaded to prevent falls. Foods containing tyrosine cause adverse effects in patients taking MAOIs. Patients taking TCAs should be counseled to avoid all alcohol. Because TCAs cause sedation, the medication should be taken at bedtime.

87. A nurse is teaching nursing students about inhalation anesthesia and asks, "What is balanced anesthesia?" Which response by a student is correct? a. "An anesthesia that has a brief induction period with a rapid emergence from its effects." b. "An inhalation anesthesia that produces both muscle relaxation and unconsciousness." c. "An anesthesia that provides maximum analgesia with minimal respiratory side effects." d. "An anesthesia that combines other drugs with inhalation anesthesia to produce the desired effects."

d. "An anesthesia that combines other drugs with inhalation anesthesia to produce the desired effects." Balanced anesthesia is the use of a combination of drugs, along with an inhaled anesthetic, to produce effects that cannot safely be accomplished with inhalation anesthesia alone. These adjunct drugs are used to help induce anesthesia, provide muscle relaxation, and increase analgesia so that a lower and safer dose of the inhalation anesthetic can be used. The other three options describe characteristics of an ideal anesthetic, which does not exist; to get these effects, a combination of other drugs must be used.

3. A nurse is preparing a patient to change from taking lorazepam (Ativan) for anxiety to buspirone (Buspar). Which statement by the patient indicates a need for further teaching? a. "I can drink alcohol when taking Buspar, but not grapefruit juice." b. "I may need to use a sedative medication if I experience insomnia." c. "I may not feel the effects of Buspar for a few weeks." d. "I should stop taking the Ativan when I start taking the Buspar."

d. "I should stop taking the Ativan when I start taking the Buspar." Ativan should not be withdrawn quickly; it needs to be tapered to prevent withdrawal symptoms. Moreover, Buspar does not have immediate effects. Because no cross-dependence occurs with these two medications, they may be taken together while the benzodiazepine is tapered. Because Buspar does not have sedative effects, patients can consume alcohol without increasing sedation. Levels of Buspar can be increased by grapefruit juice, leading to drowsiness and a feeling of dysphoria. Buspar can cause nervousness and excitement and does not have sedative effects, so patients with insomnia must use a sedative. Buspar does not have immediate effects.

93. A patient will receive intravenous midazolam (Versed) combined with fentanyl while undergoing an endoscopic procedure. The nurse is explaining the reasons for this to a nursing student before the procedure. Which statement by the student indicates understanding of the teaching? a. "The patient may appear anxious and restless during the procedure." b. "The patient will be unconscious during the procedure." c. "The patient will not need cardiorespiratory support during the procedure." d. "The patient will not remember the procedure."

d. "The patient will not remember the procedure." Midazolam, combined with an opioid analgesic, is used for conscious sedation for minor surgeries and endoscopic procedures. It does not cause anesthesia during this state, which is characterized by sedation, analgesia, amnesia, and lack of anxiety. The patient will not remember the events even though the person will be able to respond to commands during the procedure. The patient will appear unperturbed and passive and not anxious or restless. The patient is sedated, not unconscious. Midazolam can cause dangerous cardiorespiratory effects, including respiratory depression and respiratory and cardiac arrest

10. A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the nurse the reason for this, because the drug's half-life is only 2 to 3 hours. Which response by the nurse is correct? a. "Benzodiazepines commonly cause residual effects lasting into the day after the dose is given." b. "The patient is having a paradoxical reaction to this medication." c. "This patient must have developed a previous tolerance to benzodiazepines." d. "When this drug is metabolized, the resulting compound has longer lasting effects."

d. "When this drug is metabolized, the resulting compound has longer lasting effects." Flurazepam has a half-life of 2 to 3 hours; however, its metabolite has a long half-life, so giving the drug results in long-lasting effects. Barbiturates, not benzodiazepines, are commonly associated with residual, or hangover, effects. A paradoxical reaction to a sedative would manifest as insomnia, euphoria, and excitation, not drowsiness. Tolerance means that the patient would need increased amounts of a drug to get the desired effects and would not have prolonged effects of the medication.

65. A patient who uses ergotamine (Ergomar) to abort migraine headaches reports nausea and vomiting with the headaches. What will the nurse tell the patient? a. "Ask your provider about using another antimigraine medication." b. "Nausea and vomiting are signs of ergotamine toxicity." c. "These symptoms occur with migraine headaches and will diminish over time." d. "You should talk to your provider about an adjunct antiemetic medication."

d. "You should talk to your provider about an adjunct antiemetic medication." Nausea and vomiting, which occur with migraines, can increase with ergotamine use, because the drug can stimulate the chemoreceptor trigger zone. Patients should be treated with metoclopramide or a phenothiazine antiemetic. It is not necessary to change antimigraine medications at this time. Nausea and vomiting do not indicate ergotamine toxicity. These symptoms will not diminish over time.

1. An agitated, extremely anxious patient is brought to the emergency department. The prescriber orders a benzodiazepine. The nurse understands that benzodiazepines are used in this clinical situation based on which principle? a. Benzodiazepines have a very short half-life. b. Physical dependence is not a risk when taking benzodiazepines. c. Benzodiazepines are known to cure generalized anxiety. d. Benzodiazepines have a rapid onset of action.

d. Benzodiazepines have a rapid onset of action. The patient is clearly in a state of extreme, uncontrolled anxiety. Benzodiazepines are the drug of choice for acute episodes of anxiety because of their rapid onset of action. Benzodiazepines do not have a very short half-life. Benzodiazepines are associated with physical dependence. Benzodiazepines do not cure generalized anxiety, nor do any other drugs.

91. A patient in the postanesthesia recovery unit received ketamine (Ketalar) for right open reduction internal fixation surgery. What drug would be beneficial as a premedication to help minimize adverse reactions? a. Thiopental sodium (Pentothal) b. Sevoflurane (Ultane) c. Atropine (Sal-Tropine) d. Diazepam (Valium)

d. Diazepam (Valium) To minimize the effects of ketamine, the patient should be premedicated with diazepam or midazolam to reduce the risk of an adverse reaction. Thiopental sodium would further sedate the patient. Sevoflurane would further complicate sedation and would not be indicated. Atropine would not reduce the risk of an adverse reaction.

9. A patient who has been using secobarbital for several months to treat insomnia tells the nurse that the prescriber has said the prescription will be changed to temazepam (Restoril) because it is safer. The patient asks why this agent is safer. The nurse is correct in telling the patient that temazepam: a. does not depress the central nervous system. b. shows no respiratory depression, even in toxic doses. c. mimics the actions of a central nervous system inhibitory neurotransmitter. d. only potentiates the action of endogenous gamma-aminobutyric acid (GABA).

d. only potentiates the action of endogenous gamma-aminobutyric acid (GABA). Benzodiazepines potentiate the actions of GABA, and because the amount of GABA in the CNS is finite, these drugs' depressive effect on the CNS is limited. Benzodiazepines depress the CNS but not to the extent that barbiturates do. Benzodiazepines are weak respiratory depressants at therapeutic doses and moderate respiratory depressants at toxic doses. Barbiturates mimic GABA; therefore, because they produce CNS depression, this effect is limited only by the amount of barbiturate administered.

74. A patient who has had abdominal surgery has been receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. The nurse assesses the patient and notes that the patient's pupils are dilated and that the patient is drowsy and lethargic. The patient's heart rate is 84 beats per minute, the respiratory rate is 10 breaths per minute, and the blood pressure is 90/50 mm Hg. What will the nurse do? a. Discuss possible opiate dependence with the patient's provider. b. Encourage the patient to turn over and cough and take deep breaths. c. Note the effectiveness of the analgesia in the patient's chart. d. Prepare to administer naloxone and possibly ventilatory support.

d. Prepare to administer naloxone and possibly ventilatory support. Opioid toxicity is characterized by coma, respiratory depression, and pinpoint pupils. Although pupils are constricted initially, they may dilate as hypoxia progresses, which also causes blood pressure to drop. This patient has a respiratory rate of fewer than 12 breaths per minute, dilated pupils, and low blood pressure; the patient also is showing signs of central nervous system (CNS) depression. The nurse should prepare to give naloxone and should watch the patient closely for respiratory collapse. Patients with opioid dependence show withdrawal symptoms when the drug is discontinued. When postoperative patients have adequate analgesia without serious side effects, encouraging patients to turn, cough, and breathe deeply is appropriate. This patient is probably relatively pain free, but providing emergency treatment is the priority.

53. A patient is taking an FGA for schizophrenia. The nurse notes that the patient has trouble speaking and chewing and observes slow, wormlike movements of the patient's tongue. The nurse recognizes which adverse effect in this patient? a. Acute dystonia b. Akathisia c. Parkinsonism d. Tardive dyskinesia

d. Tardive dyskinesia Tardive dyskinesia can occur in patients during long-term therapy with FGAs. This patient shows signs of this adverse effect. Acute dystonia is characterized by severe spasm of muscles in the face, tongue, neck, or back and by opisthotonus. Akathisia is characterized by constant motion. Parkinsonism is characterized by bradykinesia, drooling, tremor, rigidity, and a shuffling gait.

70. A patient who has a history of asthma experiences three or four migraine headaches each month. The patient uses sumatriptan (Imitrex) as an abortive medication and has developed medication overuse headaches. The patient asks the nurse what can be done to prevent migraines. The nurse will suggest that the patient discuss which preventive medication with the provider? a. Botulinum toxin b. Meperidine (Demerol) c. Timolol d. Topiramate (Topamax)

d. Topiramate (Topamax) Topiramate can be used for migraine prophylaxis, and its benefits appear equal to those of the first line beta blockers. Botulinum toxin can be used for migraine prophylaxis in patients who have 15 or more headaches a month. Meperidine may be used as abortive therapy but has addictive potential. Timolol is a beta blocker; this patient has asthma, and because beta blockers cause bronchoconstriction, these agents are not recommended.

51. A patient taking a first-generation antipsychotic (FGA) medication develops severe parkinsonism and is treated with amantadine (Symmetrel). The amantadine is withdrawn 2 months later, and the parkinsonism returns. The nurse will expect the provider to: a. give anticholinergic medications. b. make a diagnosis of idiopathic parkinsonism. c. resume the amantadine indefinitely. d. try a second-generation antipsychotic (SGA).

d. try a second-generation antipsychotic (SGA). Neuroleptic-induced parkinsonism is treated with some of the same drugs used for idiopathic parkinsonism, such as amantadine. If parkinsonism is severe, switching to an SGA may help, because the risk of parkinsonism is much lower with these drugs. An anticholinergic medication may be used initially. A recurrence of parkinsonism when the drug is withdrawn does not indicate idiopathic parkinsonism. These drugs should not be used indefinitely

94. A patient receives a neuromuscular blocking agent as an adjunct to inhalation anesthesia. When caring for this patient, it is important for the nurse to remember that neuromuscular blocking agents: a. cause vagal slowing of the heart. b. increase the required dose of inhalation anesthetics. c. increase the depth of unconsciousness. d. prevent contraction of the diaphragm.

d. prevent contraction of the diaphragm. Neuromuscular blocking agents enhance skeletal muscle relaxation so that the dose of inhalation anesthetics can be reduced to a safer amount. Because these drugs prevent contraction of all skeletal muscles, including the diaphragm, mechanical ventilation is required to support respiration. These agents do not cause vagal slowing of the heart. They reduce the required dose of inhalation agents. They do not affect the level of consciousness

100. A nurse is assisting a physician who is preparing to suture a superficial laceration on a patient's leg. The physician asks the nurse to draw up lidocaine with epinephrine. The nurse understands that epinephrine is used with the lidocaine to: a. allow more systemic absorption to speed up metabolism of the lidocaine. b. increase the rate of absorption of the lidocaine. c. improve perfusion by increasing blood flow to the area. d. prolong anesthetic effects and reduce the risk of systemic toxicity from lidocaine.

d. prolong anesthetic effects and reduce the risk of systemic toxicity from lidocaine. Epinephrine causes vasoconstriction, which reduces local blood flow and delays systemic absorption of lidocaine, which prolongs local anesthetic effects and reduces the risk of systemic toxicity. Epinephrine slows the rate of absorption. Epinephrine delays systemic absorption of lidocaine, so metabolism is slowed and the effects are prolonged in the periphery. Epinephrine does not increase local blood flow.

38. A patient who has been taking a monoamine oxidase inhibitor (MAOI) for depression for several months tells the provider that the medication has not helped with symptoms. The provider plans to switch the patient to an SSRI. The nurse will teach this patient to: a. start taking the SSRI and stop the MAOI when symptoms improve. b. start taking the SSRI and then gradually withdraw the MAOI. c. stop taking the MAOI and wait 5 weeks before starting the SSRI. d. stop taking the MAOI 2 weeks before starting the SSRI.

d. stop taking the MAOI 2 weeks before starting the SSRI. MAOIs increase 5-HT availability, thus greatly increasing the risk of serotonin syndrome. MAOIs should be withdrawn at least 14 days before an SSRI is started. An SSRI should never be given at the same time as an MAOI. It is not necessary to wait 5 weeks before starting an SSRI.

34. A patient is diagnosed with major depression with severe symptoms and begins taking an antidepressant medication. Three weeks after beginning therapy, the patient tells the nurse that the drug is not working. The nurse will counsel this patient to ask the provider about: a. adding a second medication to complement this drug. b. changing the medication to one in a different drug class. c. increasing the dose of this medication. d. using nondrug therapies to augment the medication.

d. using nondrug therapies to augment the medication. Patients with severe depression benefit more from a combination of drug therapy and psychotherapy than from either component alone, so this patient should ask the provider about nondrug therapies. Once a drug has been selected for treatment, it must be used for 4 to 8 weeks before its efficacy can be assessed. Until a drug has been used at least 1 month without success, it should not be considered a failure. Adding a second medication, changing to a different medication, and increasing the dose of this medication should all be reserved until the current drug is deemed to have failed after at least 4 weeks.

79. A patient is brought to the emergency department by friends, who report finding the patient difficult to awaken. The friends report removing two fentanyl transdermal patches from the patient's arm. On admission to the emergency department, the patient has pinpoint pupils and a respiratory rate of 6 breaths per minute. A few minutes after administration of naloxone, the respiratory rate is 8 breaths per minute and the patient's pupils are dilated. The nurse recognizes these symptoms as signs of: a. a mild opioid overdose. b. decreased opioid drug levels. c. improved ventilation. d. worsening hypoxia.

d. worsening hypoxia. The classic triad of symptoms of opioid overdose are coma, respiratory depression, and pinpoint pupils. The pupils may dilate as hypoxia worsens, and this symptom, along with continued respiratory depression (fewer than 12 breaths per minute), indicates worsening hypoxia. Fentanyl is a strong opioid, so this is not likely to be a mild overdose, because the patient was wearing two patches. Fentanyl continues to be absorbed even after the patches are removed because of residual drug in the skin, so the drug levels are not likely to be decreasing. The patient does not have improved ventilation, because the respiratory rate is still fewer than 12 breaths per minute.

80. A patient with chronic pain has been receiving morphine sulfate but now has decreased pain. The prescriber changes the medication to pentazocine (Talwin). The nurse will monitor the patient for: a. euphoria. b. hypotension. c. respiratory depression. d. yawning and sweating

d. yawning and sweating Pentazocine is an agonist-antagonist opioid, and when given to a patient who is physically dependent on morphine, it can precipitate withdrawal. Yawning and sweating are early signs of opioid withdrawal. Pentazocine does not produce euphoria, hypotension, or respiratory depression.