Pharm Midterm 1-45

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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.

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.

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Ativan should not be withdrawn quickly; it needs to be tapered to prevent withdrawal symptoms.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.

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.

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

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%.

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.

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."

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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."

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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