NCLEX Psychopharmacology

Question 1

The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics:

a. Remain in the system longer
b. Act more quickly to reduce delusions
c. Produce fewer extrapyramidal effects
d. Are risk free for neuroleptic malignant syndrome (NMS)

Answer 1

ANS: C
Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quickly to reduce delusions. The atypicals are not risk free for NMS.

Question 2

The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a:

a. 30 mm Hg decrease in blood pressure reading
b. Respiratory rate of 24 respirations per minute
c. Temperature reading of 104° F
d. Pulse rate of 70 beats per minute

Answer 2

ANS: C
Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate

Question 3

A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms?

a. Decreased dopamine at receptor sites
b. Blockade of histamine
c. Cholinergic blockade
d. Adrenergic blocking

Answer 3

ANS: C
Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation.

Question 4

Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)?

a. Grimacing and lip smacking
b. Falling asleep in the chair and refusing to eat lunch
c. Experiencing muscle rigidity and tremors
d. Having excessive salivation and drooling

Answer 4

ANS: A
TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine.

Question 5

When the nurse realizes that a patient diagnosed with schizophrenia is not taking the prescribed oral haloperidol (Haldol), which intervention would promote medication compliance?

a. Instructing the patient to have friends monitor his medications
b. Beginning administration of haloperidol (Haldol) decanoate
c. Writing instructions in detail for the patient to follow
d. Changing haloperidol to an atypical antipsychotic

Answer 5

ANS: B
Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks. It is unknown whether the patient has a support system. The patient probably received education, including written instructions prior to discharge. Changing to another classification of medication would not necessarily improve compliance.

Question 6

When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse should respond that they:

a. Decrease available dopamine.
b. Increase availability of norepinephrine and serotonin.
c. Make available increased amounts of monoamine oxidase.
d. Increase the effects of the chemical gamma-aminobutyric acid.

Answer 6

ANS: B
Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. Decreasing dopamine is the action of typical antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics. Benzodiazepines, not tricyclics, increase the effects of GABA.

Question 7

A severely depressed patient has been prescribed clomipramine (Anafranil). For which medication side effects should the patient be monitored?

a. Excess salivation and drooling
b. Muscle rigidity and restlessness
c. Polyuria and coarse hand tremors
d. Orthostatic hypotension and constipation

Answer 7

ANS: D
Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. Mild tremors and urinary retention may occur. Drooling and excessive salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with antipsychotics

Question 8

Which of these statements made by a patient taking the MAOI phenelzine (Nardil) would warrant further instruction?

a. “I often forget to wear sunscreen when I go outside.”
b. “I need to restrict the amount of sodium in my diet.”
c. “I should not use over-the-counter cold medications.”
d. “I usually order liver and onions when my wife and I eat out.”

Answer 8

ANS: D
MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine. The remaining options have no relevance for MAOI therapy

Question 9

Which patient complaint should receive priority from a patient who is taking the MAOI tranylcypromine (Parnate)?

a. “I haven’t had a bowel movement in 2 days.”
b. “Will you take my temperature? I feel too warm.”
c. “I get a headache when I drank several cups of coffee.”
d. “My legs get stiff when I sit in the chair for any length of time.”

Answer 9

ANS: C
Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign of hypertensive crisis. The nurse should assess BP and inquire about other symptoms of hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis.

Question 10

Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major depression. Which factor was probably most important in the physician’s decision to use an SSRI?

a. Good side-effect profile
b. Less expense for the patient
c. Increase in medication compliance
d. Rapid rate of absorption from the GI tract

Answer 10

ANS: A
Compared to other antidepressant medication groups, SSRIs have the best side-effect profile. SSRIs are more costly. No studies have shown that SSRIs result in better compliance. These drugs are absorbed slowly from the GI tract.

Question 11

Which statement made by a patient who will be maintained on lithium following discharge will require further instruction by the nurse?

a. “I will have my blood work done regularly.”
b. “When I get home, I may go on a salt-free diet.”
c. “I have learned not to restrict my intake of water.”
d. “I understand some people gain weight on lithium.”

Answer 11

ANS: B
This statement shows that the patient does not understand the relationship between lithium and sodium. The patient must be taught that changing dietary salt intake will affect lithium levels. Adding salt can cause lower levels; reducing salt can result in toxicity. The remaining options reflect correct information regarding lithium therapy.

Question 12

To educate a patient regarding what to expect following the administration of a benzodiazepine, the nurse must understand that benzodiazepines:

a. Have a rapid onset of peak action
b. Reduce availability of GABA
c. Generally diminish the activity of GABA
d. Interact with serotonin to increase availability

Answer 12

ANS: A
Benzodiazepines do have a more rapid onset. There is no effect on the availability or function of GABA. Benzodiazepines do not diminish GABA activity; they enhance it.

Question 13

A patient prescribed alprazolam (Xanax) for symptoms of anxiety shares with the nurse that, “I’m concerned about getting off this medication.” Upon which fact will the nurse base the response to the patient’s concern?

a. Long elimination half-life will result in a manageable withdrawal treatment plan.
b. Rapid absorption and distribution to brain cells make withdrawal more difficult to manage.
c. Sensitivity of the mesencephalic reticular activating system makes addiction unlikely.
d. The combination of medication with an antidepressant often positively impacts withdrawal.

Answer 13

ANS: B
In general, shorter-acting benzodiazepines are more difficult to taper and potentially cause more problems with withdrawal. The remaining options are neither true nor relevant.

Question 14

Which patient outcomes would be most applicable for the patient who has been taking benzodiazepines? Patient will state:

a. That there are specific foods to avoid while on this medication
b. An understanding of how to increase medication dosage
c. That alcohol is a substance to avoid while on the medication
d. An understanding that he or she can return to work while on this medication

Answer 14

ANS: C
Combining a benzodiazepine with alcohol or other CNS depressant is potentially fatal. No food restrictions exist. Dosage should not be changed without consultation with the physician. Patients may return to work unless experiencing sedation. In this case, they would be cautioned not to operate machinery

Question 15

Which person with mania is the least likely candidate to receive lithium? The patient who is:

a. Six weeks pregnant
b. Recovering from a hysterectomy
c. Taking hormone replacement therapy
d. Displaying symptoms of postpartum depression

Answer 15

ANS: A
Lithium is contraindicated during pregnancy because of teratogenic effects. The remaining options would not be contraindicative to lithium therapy.

Question 16

An individual with poststroke depression is receiving an SSRI. What is the rationale for giving the medication at breakfast and again at midday?

a. Prevent insomnia
b. Prevent toxic reactions
c. Decrease afternoon sleepiness
d. Give an opportunity to monitor behavior closely

Answer 16

ANS: A
CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of excessive medication in the system, not when it is administered. The drowsiness resulting from SSRI use would not be minimized if taken as described. There is no expectation that resulting behaviors will need to be so closely monitored.

Question 17

A patient who has received lithium for 3 weeks to control acute mania has the following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion. The priority nursing action should be to:

a. Administer prn Cogentin to relieve the symptoms.
b. Provide reassurance that the symptoms are transient.
c. Obtain a stat lithium level; hold lithium pending results.
d. Assist the patient to decrease the sodium in their daily diet.

Answer 17

ANS: C
The symptoms the patient is experiencing are consistent with moderate lithium toxicity. The nurse should hold lithium, obtain a stat lithium level, and notify the physician. Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the patient but cannot suggest that the symptoms will resolve over time. Minimizing salt would worsen lithium toxicity.

Question 18

A patient with rapid cycling bipolar disorder is not responding well to lithium. The patient tells the nurse, “It feels as though I’ll never get well. I get better, and then I get worse.” The reply that is based on knowledge of current therapy would be:

a. “You’re feeling very discouraged aren’t you?”
b. “It’s not all bad, is it? Sometimes you like being high.”
c. “Another drug, valproic acid, is proving effective for rapid cycling.”
d. “If your kidneys hold out, the lithium will eventually control the symptoms.”

Answer 18

ANS: C
Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly effective with rapid cycling. The other options are not responsive to the question stem, which asks for knowledge of current therapy.

Question 19

Which statement by a patient with generalized anxiety disorder for whom lorazepam (Ativan) is prescribed as needed (prn) suggests the patient understands the purpose of the medication?

a. “I can talk with my therapist more easily after my medication takes effect.”
b. “I wonder if I will have to take this medication for the rest of my entire life.”
c. “I’m embarrassed and don’t want anyone to know I’m on this kind of medication.”
d. “I’m going to ask for my prn dose so I can sleep instead of worrying about my kids.”

Answer 19

ANS: A
The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. The remaining options show questions and inappropriate use of the medication.

Question 20

A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly attribute these behaviors to:

a. Akinesia
b. Tardive dyskinesia
c. Pseudoparkinsonism
d. Neuroleptic malignant syndrome

Answer 20

ANS: C
These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive dyskinesia occurs after long-term therapy. The remaining options are not associated with the symptoms mentioned.

Question 21

What intervention will the nurse request for a patient reporting gastrointestinal side effects related to valproate therapy?

a. Mild laxative
b. Low-fat diet
c. Oral antacid
d. Histamine-2 antagonist

Answer 21

ANS: D
Indigestion, heartburn, and nausea are common side effects of valproate therapy. The administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes helpful. The other options would have no impact on the complaint.

Question 22

A patient’s serum lithium level is reported as 1.9 mEq/L. The nurse should immediately:

a. Restrict sodium and fluid intake.
b. Assess for signs and symptoms of toxicity.
c. Seek to have the patient transferred to ICU.
d. Notify the patient’s physician immediately.

Answer 22

ANS: B
A serum lithium level this high suggests that the patient may be experiencing symptoms of lithium toxicity. Clinical assessment is essential to determine what, if any, signs and symptoms are present. After the clinical assessment has been made, the nurse can provide the physician with a complete picture. Restricting sodium and fluids would raise the serum level. Transferring may not be necessary and would require a physician’s order.

Question 23

To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in:

a. Affective mobility
b. Positive symptoms
c. Self-care activities
d. Cognitive functioning

Answer 23

ANS: B
Typical antipsychotic medications produce improvement in the positive symptoms of schizophrenia such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement.

Question 24

During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an assaultive patient. During the next 2 hours, it is of primary importance that the nurse assess for:

a. Tardive dyskinesia
b. Anticholinergic effects
c. Orthostatic hypotension
d. Pseudoparkinsonism

Answer 24

ANS: C
The side effect most likely to appear is orthostatic hypotension related to alpha1 receptor blockade preventing peripheral blood vessels from automatically responding to positional change. Anticholinergic effects are of lesser concern. The remaining options are less likely to occur at this point in therapy.

Question 25

A patient who began haloperidol (Haldol) therapy 24 hours ago tells the nurse that he feels jittery and unable to sit or stand still. The nurse can hypothesize that this report is related to:

a. Dystonia
b. Akathisia
c. Serotonin syndrome
d. Neuroleptic malignant syndrome

Answer 25

ANS: B
Akathisia, an extrapyramidal side effect, is characterized by restlessness, inability to sit still, and the need to pace. It usually occurs early in the course of treatment with a typical antipsychotic drug. The symptomology is not related or seen in the other options.

Question 26

When reviewing the medications being taken by an elderly patient diagnosed with Alzheimer’s disease, the nurse should consult with the patient’s physician when noting a prescription for:

a. Risperidone (Risperdal)
b. Fluphenazine (Prolixin)
c. Lorazepam (Ativan)
d. Sertraline (Zoloft)

Answer 26

ANS: A
Patients with dementia-related psychosis who were treated with atypical (second-generation) antipsychotics such as Risperdal were at an increased risk of death as compared with patient taking a placebo. The other medications are not currently known to have that risk.

Question 27

When a patient for whom haloperidol has been prescribed tells the nurse, “I’m burning up and my muscles are stiff and sore,” the nurse suspects neuromuscular malignant syndrome and recognizes the possibility that the physician may order:

a. Olanzapine (Zyprexa)
b. Benztropine (Cogentin)
c. Venlafaxine (Effexor)
d. Dantrolene (Dantrium)

Answer 27

ANS: D
Dantrolene, a direct-acting skeletal muscle relaxant, is a drug often used to treat NMS. The other drugs mentioned would have no therapeutic effect on NMS.

Question 28

A patient with schizophrenia is seen in the ED in an acutely agitated state resulting from threatening auditory hallucinations. The patient’s medical record indicates he has had severe dystonic reactions to parenteral administration of typical antipsychotic medication. The nurse can anticipate that the physician will order:

a. Ziprasidone (Geodon)
b. Fluphenazine (Prolixin) decanoate
c. Clozapine (Clozaril)
d. Paroxetine (Paxil)

Answer 28

ANS: A
This atypical antipsychotic comes in an injectable form and is effective in controlling agitated and assaultive behaviors. Fluphenazine (Prolixin) decanoate is a typical antipsychotic. Clozapine (Clozaril) is used only for refractory schizophrenia. Paroxetine (Paxil) is an SSRI.

Question 29

A patient whose schizophrenia has been refractory to treatment with other medications has been placed on clozapine (Clozaril). The priority discharge teaching should include:

a. Keep salt intake the same from day to day.
b. Maintain a strict tyramine-free daily diet.
c. Report for weekly blood tests for CBC level.
d. Use sunblocking agents when out of doors.

Answer 29

ANS: C
Clozaril has the potential to cause agranulocytosis; hence the need for weekly blood draws for CBCs for the first 6 months of therapy and every other week after that point. The other options are not relevant to Clozaril therapy. Salt intake refers to lithium therapy, tyramine to MAOI therapy, and sunblocking to phenothiazine therapy.

Question 30

30. The nurse must notify the physician of the need to suspend treatment for a patient receiving clozapine (Clozaril) when the weekly WBC monitoring shows:
    a. WBCs below 2000/mm3 and absolute neutrophils below 1000/mm3
    b. WBCs below 2500/mm3 and absolute neutrophils below 1500/mm3
    c. WBCs below 3000/mm3 and absolute neutrophils below 2000/mm3
    d. WBCs below 3500/mm3 and absolute neutrophils below 2500/mm3

Answer 30

ANS: A
Counts at this level indicate the presence of leukopenia. Agranulocytosis is a possible side effect of Clozaril therapy for which the patient is closely monitored. The other levels are high enough to be considered safe.

Question 31

A patient receiving haloperidol urgently calls to the nurse and reports that his eyes have rolled upward and he cannot redirect his gaze. The nurse contacts the physician to seek an order for:

a. Fluphenazine (Prolixin)
b. Citalopram (Celexa)
c. Benztropine (Cogentin)
d. Risperidone (Risperdal)

Answer 31

ANS: C
The nurse should recognize the patient’s problem as dystonia and know the treatment is IM administration of an antiparkinsonian drug, such as benztropine, or an antihistamine, such as diphenhydramine (Benadryl), for which a physician’s order is necessary. Fluphenazine (Prolixin) would worsen the condition. The remaining options would not be useful.

Question 32

An appropriate outcome for trihexyphenidyl (Artane) therapy used in conjunction with high potency typical antipsychotic medication therapy is that the patient will:

a. Demonstrate a brighter mood
b. Be less sedated and drowsy
c. Display fewer movement disorder symptoms
d. Display decreased anticholinergic symptoms

Answer 32

ANS: C
Trihexyphenidyl is used to treat extrapyramidal symptoms, such as pseudoparkinsonism. The other options are not expected outcomes of administration of this medication.

Question 33

An atypical antipsychotic has been prescribed for an elderly patient. The nurse developing the patient’s care plan includes:

a. Scheduling weekly WBC counts
b. Teaching about a tyramine-free diet
c. Requesting that a daily laxative be included
d. Teaching fall prevention strategies to both the patient and family

Answer 33

ANS: D
Orthostatic hypotension is a possible side effect due to alpha-adrenergic blockade. The nurse should teach the patient about changing position slowly and using handrails when walking to prevent falls. The remaining options are not related to antipsychotic medications.

Question 34

The nurse notes that a patient who has been receiving paroxetine (Paxil) for symptoms of major depression begins to behave in a confused and elated manner with the presence of restlessness, muscle jerking, and diaphoresis. The nurse should assess these symptoms as probable:

a. Neuroleptic malignant syndrome
b. Anticholinergic blockade
c. Serotonin syndrome
d. Dystonia

Answer 34

ANS: C
These are symptoms of serotonin syndrome, a condition that requires medical intervention. The other options are not associated with SSRI therapy.

Question 35

When following up on SSRI medication side effects, the nurse will need to make specific inquiries about:

a. Anticholinergic symptoms
b. Alpha-adrenergic blockade
c. GI tract symptoms
d. Sexual dysfunction

Answer 35

ANS: D
SSRIs often cause sexual dysfunction, a symptom patients may be reluctant to bring up voluntarily. Patients readily bring up the side effects mentioned in the other options.

Question 36

A patient taking SSRIs mentions to the nurse that his current medication causes fewer side effects than the tricyclic antidepressant he took several years earlier. The nurse understands that SSRIs advantage is due to:

a. Inhibiting both serotonin and norepinephrine uptake
b. Selectively inhibiting dopamine uptake
c. Blocking only serotonin reuptake
d. Making more GABA available

Answer 36

ANS: C
TCAs inhibit the reuptake of both norepinephrine and serotonin, producing more side effects than SSRIs that selectively block only serotonin reuptake. SSRIs do not affect dopamine or GABA availability.