CHAPTER 23: Antidepressants and Mood Stabilizers

3. A selective serotonin reuptake inhibitor is prescribed for a patient. The nurse knows that which drug is a selective serotonin reuptake inhibitor?

a. Paroxetine

b. Amitriptyline

c. Divalproex sodium

d. Bupropion hydrochloride

a. Paroxetine

A nurse performs a medication history on a newly admitted patient. The patient reports taking amitriptyline (Elavil) 75 mg at bedtime for 6 weeks to treat depression. The patient reports having continued fatigue, lack of energy, and no improvement in mood. The nurse will contact the provider to discuss which intervention?

a. Beginning to down-taper the amitriptyline

b. Changing to a morning dose schedule

c. Giving the amitriptyline twice daily

d. Increasing the dose of amitriptyline

ANS: A

The response to tricyclic antidepressants (TCAs) should occur after 2 to 4 weeks of therapy. If there is no improvement at that time, the TCA should be gradually withdrawn and an agent from another class should be prescribed. TCAs should never be stopped abruptly. TCAs cause fatigue and drowsiness, so they should be given at bedtime. Changing the dose or the dosing schedule is not indicated in this scenario.

The nurse is teaching a patient who will begin taking doxepin (Sinequan) to treat depression. Which statement by the patient indicates a need for further teaching?

a. "I should expect results within 2 to 4 weeks."

b. "I should increase fluids and fiber while taking this medication to avoid

constipation."

c. "I should take care when rising from a sitting to standing position."

d. "I will take the medication in the morning before breakfast."

ANS: D

Tricyclic antidepressants (TCAs) should begin to show effects within 1 to 4 weeks. Tricyclic antidepressants are known to cause orthostatic hypotension and constipation, so patients should be counseled on how to manage these side effects. TCAs should be taken at bedtime because of their tendency to cause drowsiness.

A patient who is taking amitriptyline (Elavil) reports constipation and dry mouth. The patient notes that these side effects are a nuisance, but not severe. The nurse will give the patient which instruction?

a. Increase fluid intake.

b. Notify the provider.

c. Request another antidepressant.

d. Stop taking the medication immediately.

ANS: A

Constipation and dry mouth are common side effects of tricyclic antidepressants (TCAs), and patients should be taught to manage these symptoms. There is no need to notify the provider or to switch medications unless the side effects become too uncomfortable. Patients should not stop taking TCAs abruptly.

A patient who has had a loss of interest in most activities, weight loss, and insomnia is diagnosed with major depressive disorder and will begin taking fluoxetine (Prozac) daily. The patient asks about the weekly dosing that a family member follows. What will the nurse tell the patient about a weekly dosing regimen?

a. It can be used after daily maintenance dosing proves effective and safe.

b. It is used after a trial of tricyclic antidepressant medication fails.

c. It is not effective for this type of depression and its symptoms.

d. It will cause more adverse effects than daily dosing regimens.

ANS: A

Before weekly dosing is begun, the patient should respond to a daily maintenance dose of 20 mg/day without serious effects. It is not necessary to undergo a trial of tricyclic antidepressants (TCAs). Weekly dosing is used for this type of depression, and although it may have some adverse effects, these are not more common than with daily dosing.

A patient has been taking sertraline (Zoloft) 20 mg/mL oral concentrate, 1 mL daily for several weeks and reports being unable to sleep well. The patient's depressive symptoms are well managed on the current dose. What will the nurse do next?

a. Ask the patient what time of day the medication is taken.

b. Counsel the patient to take the medication at bedtime.

c. Recommend asking the provider about weekly dosing.

d. Suggest that the patient request a lower dose.

ANS: A

Selective serotonin reuptake inhibitors (SSRIs) can cause nervousness and insomnia. Patients can minimize these effects by taking the drug in the morning. The nurse should assess this with this patient. Taking the medication at bedtime will only increase the insomnia. Requesting a lower dose or changing to weekly dosing is not recommended.

A patient has been taking paroxetine (Paxil) 20 mg per day for 2 weeks and reports a decrease in libido. Which action will the nurse take?

a. Counsel the patient to take the medication with food.

b. Reassure the patient that this side effect can decrease over time.

c. Suggest that the patient discuss a lower dose with the provider.

d. Tell the patient to stop taking the drug and contact the provider.

ANS: B

Sexual side effects can occur with paroxetine, but often improve or ceae after 1 to 4 weeks of use. Taking the medication with food will not improve this side effect. Lowering the dose is not indicated. Patients should not abruptly stop taking SSRIs. If the patient continues to have sexual side effects after continued use they should discuss with their provider.

A patient who has been diagnosed with social anxiety disorder will begin taking venlafaxine (Effexor). The nurse who performs a medication and dietary history will be concerned about ingestion of which substance or drug?

a. Coffee

b. Grapefruit juice

c. Oral hypoglycemic drug

d. St. John's wort

ANS: D

The concurrent interaction of venlafaxine and St. John's wort may increase the risk of serotonin syndrome and neuroleptic malignant syndrome. Oral hypoglycemic drugs are concerning for patients who take lithium. Coffee and grapefruit juice are to be avoided by patients who take monoamine oxidase inhibitors.

A male patient has been taking venlafaxine (Effexor) 37.5 mg daily for 2 weeks and reports an increase in blood pressure. The

nurse understands that this is due to which of the following?

a. Increased serotonin levels.

b. Increased norepinephrine levels.

c. Increased dopamine levels.

d. Increased acetylcholine levels.

ANS: B

Venlafaxine is a serotonin norepinephrine reuptake inhibitor (SNRI) by reducing norepinephrine reuptake, norepinephrine levels are increased which can result in an increase in blood pressure.

A patient who has been taking a monoamine oxidase (MAO) inhibitor for several months will begin taking amoxapine (Asendin) instead of the MAO inhibitor. The nurse will counsel the patient to begin taking the amoxapine:

a. along with the MAO inhibitor for several months.

b. at least 14 days after discontinuing the MAO inhibitor.

c. the day after the last dose of the MAO inhibitor.

d. while withdrawing the MAO inhibitor over several weeks.

ANS: B

Amoxapine is an atypical antidepressant that should not be taken with MAO inhibitors and should not be used within 14 days of taking a MAO inhibitor.

A patient who has been diagnosed with depression asks why the provider has not ordered a monoamine oxidase (MAO) inhibitor to treat the disorder. The nurse will explain to the patient that MAO inhibitors:

a. are more expensive than other antidepressants.

b. are no longer approved for treating depression.

c. can cause profound hypotension.

d. require strict dietary restrictions.

ANS: D

MAO inhibitors have many food and drug interactions that can be fatal, and patients must adhere to strict dietary restrictions while taking these drugs. They are not more expensive than the newer antidepressants. They remain approved for treating depression. MAO inhibitors can cause profound hypertension in the presence of excess tyramine consumption.

A patient who takes a monoamine oxidase (MAO) inhibitor asks the nurse about taking over-the-counter medications to treat cold symptoms. Which medication will the nurse counsel the patient to avoid while taking a MAO inhibitor?

a. Diphenhydramine

b. Guaifenesin

c. Pseudoephedrine

d. Saline nasal spray

ANS: C

MAO inhibitors can cause hypertensive crises, which can be fatal when taken with sympathomimetic drugs such as pseudoephedrine.

A patient who has major depressive disorder has been taking fluoxetine (Prozac) 20 mg daily for 3 months and reports improved mood, less fatigue, and an increased ability to concentrate. The patient's side effects have diminished. The only complaint from the patient is regarding the number of medications she has to take daily. What will the nurse counsel this patient to discuss with the

provider?

a. Changing to once-weekly dosing

b. Decreasing the dose to 10 mg daily

c. Discontinuing the medication

d. Increasing the dose to 30 mg daily

ANS: A

Once patients have demonstrated control of symptoms with decreased side effects on the maintenance dose of 20 mg daily, patients may be considered for once-weekly dosing. The 20-mg dose is maintenance dosing, so decreasing or increasing the dose is not indicated. Patients should not stop taking the medication abruptly.

A patient who has been diagnosed with major depression disorder has been ordered to take doxepin (Sinequan). The nurse will contact the provider if the patient's medical history reveals a history of which condition?

a. Asthma

b. Glaucoma

c. Hypertension

d. Hypoglycemia

ANS: B

Antidepressants, such as doxepin, that cause anticholinergic-like symptoms are contraindicated if the patient has glaucoma.

The nurse is preparing to administer a dose of lithium (Lithobid) to a patient who has been taking the drug as maintenance therapy to treat bipolar disorder. The nurse assesses the patient and notes tremors and confusion. The patient's latest serum lithium level was 2 mEq/L. Which action will the nurse take?

a. Administer the dose.

b. Hold the dose and notify the provider.

c. Request an order for a higher dose.

d. Request an order for a lower dose.

ANS: B

The patient has symptoms of lithium toxicity, and the serum drug level is in the toxic range. The nurse should hold the dose and notify the provider.

The nurse assesses a patient who is taking lithium (Lithobid) and notes a large output of clear, dilute urine. The nurse suspects which cause for this finding?

a. Cardiovascular complications

b. Expected lithium side effects

c. Increased mania

d. Lithium toxicity

ANS: D

An increased output of dilute urine is a sign of lithium toxicity.

The nurse provides teaching for a patient who will begin taking lithium (Lithobid). Which statement by the patient indicates understanding of the teaching?

a. "I may drink tea or cola but not coffee."

b. "I may stop taking the drug when mania symptoms subside."

c. "I should consume a sodium-restricted diet."

d. "I should drink 2 to 3 liters of fluid each day."

ANS: D

Patients taking lithium should be encouraged to maintain adequate fluid intake of 2 to 3 L/day initially and then 1 to 2 L/day as maintenance. Patients should not drink any caffeine-containing drinks, including tea and cola. Patients must continue taking lithium even when symptoms subside, or else symptoms will recur. It is not necessary to consume a sodium-restricted diet.

A patient who has recently begun taking lithium (Lithobid) calls the clinic to report nausea, vomiting, anorexia, and hand tremor. What will the nurse do next?

a. Contact the provider to obtain an order for a serum lithium level.

b. Reassure the patient that these symptoms are common and transient.

c. Tell the patient that the lithium dose is probably too low.

d. Tell the patient to stop taking the medication immediately.

ANS: A

Early symptoms of lithium toxicity include nausea, vomiting, anorexia, and tremor. The nurse should obtain an order for a lithium level to evaluate this. Patients should be encouraged to report these symptoms if they occur. Patients should never be counseled to stop the medication abruptly.

The nurse is preparing to administer paroxetine HCl (Paxil) to a 70-year-old patient. The nurse understands that this patient may require

a. a decreased dose.

b. an increased dose.

c. every other day dosing.

d. more frequent dosing.

ANS: A

Older adults usually need a lower dose of antidepressants.

A patient who has a history of migraine headaches is diagnosed with bipolar disorder. The nurse might expect the provider to order

which medication for this patient?

a. Carbamazepine (Tegretol)

b. Divalproex (Valproate)

c. Lamotrigine (Lamictal)

d. Lithium citrate (Eskalith)

ANS: B

All of these medications may be used to treat bipolar disorder, but divalproex also carries an indication for migraine prophylaxis.

The nurse is teaching a patient about foods to avoid when taking isocarboxazid (Marplan). Which foods will the nurse instruct the patient to avoid? (Select all that apply.)

a. Bananas

b. Bread

c. Eggs

d. Red wine

e. Sausage

f. Yogurt

ANS: A, D, E, F

Aged cheeses and wines are the chief foods that are prohibited. Any food containing tyramine, which has sympathomimetic effects, can cause a hypertensive crisis. This includes bananas, red wine, sausage, and yogurt.

Question 1 of 10

The nurse is reviewing a patient’s medication history and notes that the patient recently began taking lithium. What intervention is a priority for this patient?

Monitoring for the recurrence of seizure activity

Monitoring the patient’s intake and output

Asking the patient if they have ringing in the ears

Assessing lithium levels every other week

Assessing lithium levels every other week

Lithium is the drug of choice to treat manic episodes associated with bipolar disorders. It has a narrow therapeutic range, and levels should be monitored biweekly until the therapeutic level has been obtained and then monitored monthly on the maintenance dose. Tinnitus is not seen as a side effect of this medication. Intake and output should be monitored but the priority is to assess therapeutic efficacy.

What information should the nurse include on the care plan for a patient taking fluvoxamine?

This medication might not become therapeutic for 4 weeks.

This medication will interact with caffeine.

This medication must be given IV.

This medication is safe in those with liver disease, unlike other SSRIs.

This medication might not become therapeutic for 4 weeks.

This medication takes between 1 and 4 weeks to be therapeutic. The patient must be encouraged to remain on the medication. This medication is given PO and does not interact with caffeine. Fluvoxamine should not be taken by those with hepatic disease.

Question 3 of 10

A 6-year-old child is taking imipramine. What should the nurse monitor as a therapeutic outcome of the administration of this medication?

The child has no more nocturnal enuresis.

The child is free of manic episodes.

The child has no tonic-clonic seizures.

The child is free of obsessive-compulsive disorder behaviors.

The child has no more nocturnal enuresis.

Imipramine causes urinary retention and delayed micturition, side effects that make it useful to treat nocturnal enuresis (bedwetting) in children. This is most likely the reason a young child is on this medication. For adults, the drug can treat major depressive disorders.

When teaching a patient about the use of tricyclic antidepressants, what should the nurse emphasize?

The drugs are often given with monoamine oxidase inhibitors (MAOIs) for synergistic effect.

Dietary restrictions of beer and chocolate are needed to prevent a hypertensive crisis.

Common side effects can be relieved by increasing fluid and fiber intake and sucking hard candy.

The patient should notify the health care provider if therapeutic effects are not noted within 10 days.

Common side effects can be relieved by increasing fluid and fiber intake and sucking hard candy.

Tricyclic antidepressants (TCAs) cause anticholinergic side effects, including constipation and dry mouth. The time period required to produce therapeutic effects ranges from 2 to 4 weeks. Concurrent use of MAOIs with amitriptyline may lead to cardiovascular instability and toxic psychosis. The patient does not need to avoid beer and chocolate to prevent a hypertensive crisis as the patient would need to with MAOIs, but beer would potentiate central nervous system depression when taken with TCAs.

Question 5 of 10

A patient is being switched from amitriptyline to citalopram. Which statement made by the patient indicates understanding of medication instructions?

"I can stop taking my amitriptyline and start taking the citalopram as ordered."

"I can expect fewer cardiovascular side effects with the citalopram."

"I will need to limit my intake of cheese when taking citalopram to prevent a rise in my blood pressure."

"The doctor is switching me to this medication because it is less expensive but just as effective."

"I can expect fewer cardiovascular side effects with the citalopram."

Citalopram, an SSRI, produces minimal anticholinergic and cardiovascular side effects. The patient will need to wait 14 days after stopping amitriptyline (Elavil) before starting the citalopram. The patient does not need to limit cheese intake with citalopram.

Question 6 of 10

Which food will the nurse teach the patient to avoid while taking a monoamine oxidase inhibitor (MAOI)?

Coffee

White bread

Aged cheese

White meat

Aged cheese

Eating foods high in tyramine, including aged cheese, can cause a hypertensive crisis in patients taking MAOIs.

Question 7 of 10

The patient has been started on a treatment regimen that includes imipramine. The patient tells the nurse that he also is being treated with diazepam for a separate condition. What is the nurse’s priority action?

Notify the pharmacy because the dosage of the imipramine will need to be decreased.

Notify the pharmacy because the dosage of the imipramine will need to be increased.

Notify the health care provider because central nervous system (CNS) depression may result.

Notify the health care provider because the patient may experience an anaphylactic reaction.

Notify the health care provider because central nervous system (CNS) depression may result.

The combination of the imipramine and the diazepam (Valium) will potentiate CNS depression.

Question 8 of 10

The nurse notes that the health care provider is considering starting the patient on a selective serotonin reuptake inhibitor (SRRI) drug. The nurse recognizes that the health care provider will select which drug?

Fluvoxamine

Amitriptyline

Imipramine

Doxepin

Fluvoxamine

Of the drugs listed, only the SRRI drug is fluvoxamine.

Question 9 of 10

The nurse notes in the patient's chart that the health care provider is considering adding a tricyclic antidepressant to the patient's treatment regimen. The nurse recognizes that the health care provider will select which drug?

Trazodone

Maprotiline

Amoxapine

Doxepin

Doxepin

Of the drugs listed, the only drug that is a tricyclic antidepressant is doxepin.

The patient is receiving a selective serotonin reuptake inhibitor (SSRI). Which item on the patient's breakfast tray should the nurse remove?

Grapefruit juice

A carbonated soda

Milk

Coffee

Grapefruit juice

Many SSRIs have an interaction with grapefruit juice that can lead to possible toxicity. It is recommended that daily intake be limited to 8 ounces of grapefruit juice or one half of a grapefruit.

1. A patient is admitted with bipolar affective disorder. The nurse acknowledges which medication as one used to treat this disorder for some patients in place of lithium?

a. Thiopental

b. Ginkgo biloba

c. Fluvoxamine

d. Divalproex

d. Divalproex

2. The nurse realizes that some complementary and alternative therapies interact with selective serotonin reuptake inhibitors. Which complementary and alternative therapy interactions may cause serotonin syndrome? (Select all that apply.)

a. Feverfew

b. Ma huang

c. St. John's wort

d. Ginkgo biloba

a. Feverfew

c. St. John's wort

4. A patient is taking tranylcypromine sulfate for depression. What advice should the nurse include in the teaching plan for this medication?

a. Warn the patient about weight loss.

b. Instruct the patient to avoid beer and cheddar cheese.

c. Encourage the patient to take ginseng and ephedra.

d. Encourage the patient to eat fruit such as bananas.

b. Instruct the patient to avoid beer and cheddar cheese.

5. Which statement is true concerning lithium?

a. The maximum dose is 3.4 g/day.

b. The therapeutic drug range is 2.5 to 3.5 mEq/L.

c. Lithium increases receptor sensitivity to gamma-aminobutyric acid.

d. Concurrent nonsteroidal antiinflammatory drugs (NSAIDs) may increase lithium levels.

d. Concurrent nonsteroidal antiinflammatory drugs (NSAIDs) may increase lithium levels.

6. When a patient is taking an antidepressant, what should the nurse do? (Select all that apply.)

a. Monitor the patient for suicidal tendencies.

b. Observe the patient for orthostatic hypotension.

c. Teach the patient to take the drug with food if gastrointestinal distress occurs.

d. Tell the patient that the drug may not have full effectiveness for 1 to 2 weeks.

e. Advise the patient to maintain adequate fluid intake of 2 L/day.

a. Monitor the patient for suicidal tendencies.

b. Observe the patient for orthostatic hypotension.

c. Teach the patient to take the drug with food if gastrointestinal distress occurs.

d. Tell the patient that the drug may not have full effectiveness for 1 to 2 weeks.

7. A patient is taking lithium. The nurse should be aware of the importance of which nursing intervention(s)? (Select all that apply.)

a. Observe the patient for motor tremors.

b. Monitor the patient for hypotension.

c. Draw lithium blood levels immediately after a dose.

d. Advise the patient to drink 750 mL/day of fluid in hot weather.

e. Advise the patient to avoid caffeinated foods and beverages.

f. Teach the patient to take lithium with meals to decrease gastric irritation.

a. Observe the patient for motor tremors.

b. Monitor the patient for hypotension.

e. Advise the patient to avoid caffeinated foods and beverages.

f. Teach the patient to take lithium with meals to decrease gastric irritation.