Unit 7, Psychotherapeutics Flashcards
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
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 MAOIs should be withdrawn at least 14 days before an SSRI is started.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.
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 the sedative effects.
c. take the medication once daily in the late afternoon.
d. take the medication once daily in the morning.
A
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.
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
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
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
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 the 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
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
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
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 non-drug therapies to augment the medication.
D
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 non-drug 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 for 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
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, B, C
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.
A patient whose spouse has died recently reports feeling down most of every 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
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 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
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 serotonin syndrome.
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
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 describes a drug holiday.
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 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.
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 APRN prescribes which medication for this patient?
a. Flurazepam
b. Trazodone [Desyrel]
c. Zaleplon [Sonata]
d. Zolpidem [Ambien
C
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.
A patient who is experiencing alcohol withdrawal is given a benzodiazepine. The nurse understands that this drug is effective because:
a. the alcohol does not interact with the benzodiazepine.
b. the benzodiazepine potentiates alcohol withdrawal symptoms.
c. the benzodiazepine relieves muscle spasms and spasticity.
d. the patient has a cross-dependence to the benzodiazepine.
D
Benzodiazepines are given to ease withdrawal from alcohol because of cross-dependence with these drugs and alcohol, enabling the benzodiazepine to suppress withdrawal symptoms.
Alcohol and benzodiazepines can potentiate one another.
The benzodiazepine does not potentiate withdrawal symptoms.
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. potentiates endogenous gamma-aminobutyric acid (GABA) producing a finite CNS depression.
D
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.
A hospitalized patient who is given one dose of flurazepam continues to show drowsiness the next day. A nursing student asks the APRN 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.”
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.
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 the benzodiazepine.
A
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.
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
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.”
A patient who has been taking alprazolam [Xanax] to treat generalized anxiety disorder (GAD) reports recently stopping the medication after symptoms have improved but reports having feelings of panic and paranoia. Which initial action by the nurse is correct?
a. Ask the patient if the medication was stopped abruptly.
b. Instruct the patient to resume taking the alprazolam.
c. Notify the provider that the patient is experiencing a relapse.
d. Suggest that the patient discuss taking buspirone [Buspar] with the provider.
A
Long-term use of benzodiazepines can cause physical dependence, with symptoms of panic, paranoia, and delirium occurring with abrupt withdrawal. These symptoms can be confused with symptoms of relapse of anxiety, so the nurse should evaluate this by first asking about how the medication was discontinued.
If the symptoms are caused by a relapse, the patient should resume taking the alprazolam.
Buspirone is not indicated.
A patient is diagnosed with anxiety after describing symptoms of tension, poor concentration, and difficulty sleeping that have persisted for over 6 months. Which medication will the nurse expect the provider to order for this patient?
a. Alprazolam [Xanax]
b. Amitriptyline [Elavil]
c. Buspirone [Buspar]
d. Paroxetine [Paxil]
C
This patient has symptoms of generalized anxiety disorder (GAD) that are not acute or severe.
Buspirone is as effective as benzodiazepines but without causing CNS depression or having the same abuse potential. Symptoms develop slowly, which is acceptable in this case, since symptoms are not acute or severe.
Alprazolam is a benzodiazepine and would be used in the short term to treat acute, severe anxiety.
Amitriptyline is a TCA used to treat panic disorder.
Paroxetine is an antidepressant used as a second-line drug for GAD.
A nurse is preparing a patient who will stop taking lorazepam [Ativan] for anxiety and begin taking 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
Ativan should not be withdrawn quickly; it must 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.
A patient reports having occasional periods of tremors, palpitations, nausea, and a sense of fear, which usually dissipate within 30 minutes. To treat this condition, the APRN will prescribe a drug in which drug class?
a. Benzodiazepines
b. Monoamine oxidase inhibitors
c. Selective serotonin reuptake inhibitors
d. Tricyclic antidepressants
C
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 their 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.
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. Posttraumatic stress disorder
e. Social anxiety disorder
A, B, C, E
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.
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 is usually is treated with alprazolam [Xanax].
C. It seems perfectly normal to the patient.
D. It will best respond to deep brain stimulation.
A
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.
Alprazolam 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%.
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
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.
