Pharmacology for Canadian Health Care Practice 3rd Edition - Chapters 13, 14, 17. Pharmacology III: Psychotropic Pharmacology

A 50-year-old male who has been taking a benzodiazepine for 1 week is found unresponsive. His wife states that he takes no other prescription drugs and that he did not take an overdose—the correct number of pills is in the bottle. What might have happened?
a. He took a multivitamin.
b. He drank a glass of wine.
c. He took a dose of Aspirin.
d. He developed an allergy to the drug.

ANS: B
Potential drug interactions with the benzodiazepines are significant because of their intensity, particularly when they involve other central nervous system (CNS) depressants (e.g., alcohol, opioids, muscle relaxants).
DIF: Cognitive Level: Analysis REF: p. 253

Which is a true statement about sedatives and hypnotics?
a. The two terms mean the same thing.
b. A hypnotic causes sleep.
c. Low doses of sedatives will cause sleep.
d. Compared with sedatives, hypnotics have a less potent effect on the central nervous system.

ANS: B
A sedative reduces nervousness, excitability, and irritability without causing sleep, whereas a hypnotic causes sleep.
DIF: Cognitive Level: Knowledge REF: p. 251

A patient who has been taking phenobarbital for 2 weeks as part of therapy for epilepsy reports feeling tense and that the "least little thing" is a bother now. What is the nurse's best explanation to the patient?
a. These adverse effects will often subside after a few weeks.
b. The drug should be stopped immediately because of possible adverse effects.
c. This drug causes the rapid eye movement (REM) sleep period to increase, resulting in nightmares and restlessness.
d. This drug causes deprivation of REM sleep and may cause the patient's inability to deal with normal stress.

ANS: D
Barbiturates deprive people of REM sleep, which can result in agitation and an inability to deal with normal stress. A rebound phenomenon occurs when the drug is stopped, and the proportion of REM sleep increases, sometimes resulting in nightmares.
DIF: Cognitive Level: Application REF: p. 251/p. 253

A patient has been taking temazepam (Restoril®) for intermittent insomnia. She tells the nurse that when she takes it, she sleeps well, but the next day she feels "so tired." What is the nurse's best explanation to the patient?
a. Long-term use results in a sedative effect.
b. She should take the drug every night to reduce this hangover effect.
c. Benzodiazepines affect the sleep cycle, thus causing a hangover effect.
d. Benzodiazepines increase CNS activity, thus causing tiredness the next day.

ANS: C
Benzodiazepines suppress rapid eye movement REM sleep to a degree (though not as much as barbiturates) and thus result in a hangover effect.
DIF: Cognitive Level: Application REF: p. 253

A patient who is recovering from a minor automobile accident that occurred 1 week ago is taking cyclobenzaprine (Novo-Cycloprine®) for muscular pain and goes to physical therapy three times a week. Which nursing diagnosis would be appropriate for him?
a. Risk for falls related to decreased sensorium
b. Risk for addiction related to psychological dependency
c. Excess fluid volume related to potential adverse effects
d. Disturbed sleep pattern related to the drug's interference with REM sleep

ANS: A
Musculoskeletal relaxants have a depressant effect on the CNS; lightheadedness, dizziness, drowsiness, and fatigue can occur, thus putting the patient at risk for falls. The patient should be taught the importance of taking measures to minimize self-injury and falls related to decreased sensorium.
DIF: Cognitive Level: Analysis REF: p. 258/p. 261

A patient is taking flurazepam (Apo-Flurazepam®) 3 to 4 nights a week for sleeplessness. She is concerned that she cannot get to sleep without taking the medication. What measures are appropriate for this patient?
a. Trying to establish set sleep patterns
b. Exercising before bedtime to become tired
c. Consuming heavy meals in the evening to promote sleepiness
d. Drinking warm beverages, such as tea or coffee, just before bedtime

ANS: A
Nonpharmacological approaches to induce sleep include establishing set sleep patterns. The patient should avoid heavy exercise before bedtime, avoid heavy meals late in the evening, and should drink warm decaffeinated drinks, such as warm milk, before bedtime.
DIF: Cognitive Level: Application REF: p. 260

Which is the best treatment of an acute overdose of diazepam?
a. Infusion with diluted bicarbonate solution
b. Administration of medications to decrease blood pressure
c. Administration of flumazenil
d. Administration of nalbuphine as an antagonist

ANS: C
Flumazenil, a benzodiazepine antidote, can be used to acutely reverse the sedative effects of benzodiazepines. Flumazenil antagonizes the action of benzodiazepines on the CNS by directly competing with them for binding at the receptors. Flumazenil is used in cases of oral overdose or excessive intravenous sedation. Infusion with diluted bicarbonate solution and the administration of medications to decrease blood pressure are not appropriate treatments. There are no antagonists for barbiturates.
DIF: Cognitive Level: Analysis REF: p. 253

A 45-year-old female has been taking dantrolene as part of the treatment for multiple sclerosis. Which laboratory value should the nurse monitor while the patient receives dantrolene?
a. Creatinine
b. Sedimentation rate
c. Liver function studies
d. Hemoglobin and hematocrit

ANS: C
Dantrolene can cause liver damage; therefore, liver function studies should be performed during therapy.
DIF: Cognitive Level: Comprehension REF: p. 259

What is an adverse effect of barbiturate administration?
a. Vasoconstriction
b. Thrombocytopenia
c. Hypertension
d. Excitement

ANS: B
An adverse effect of barbiturate use is thrombocytopenia. Some other effects include hypotension, vasodilation, and drowsiness and lethargy.
DIF: Cognitive Level: Comprehension REF: p. 256

Which natural health product is used by some people to promote sleep and to relieve anxiety and restlessness?
a. Kava
b. Garlic
c. Ginger
d. Ginkgo

ANS: A
Kava may be used to promote sleep and for relief of anxiety and restlessness.
DIF: Cognitive Level: Comprehension REF: p. 254

The nurse is preparing to administer a barbiturate. Which condition(s) or disorder(s) are contraindications to the use of these drugs? (Select all that apply.)
a. Gout
b. Pregnancy
c. Epilepsy
d. Severe chronic obstructive pulmonary disease
e. Peripheral vascular disease
f. Advanced liver disease
g. Current use of an opioid analgesic

ANS: B, D, F, G
Contraindications to barbiturates include pregnancy, significant respiratory difficulties, and severe liver disease. In addition, coadministration of barbiturates with alcohol, opioids, benzodiazepines, and some medications from other drug groups can result in additive CNS depression.
DIF: Cognitive Level: Analysis REF: p. 256

Which condition is an indication for a central nervous system (CNS) stimulant drug?
a. Insomnia
b. Depression
c. Appetite enhancement
d. Appetite suppression

ANS: D
CNS stimulant drugs can be used as appetite suppressants (anorexiants) for appetite control.
DIF: Cognitive Level: Knowledge REF: p. 271

Caffeine should be used with caution in which patient?
a. A male with a history of peptic ulcers
b. A female with a history of migraine headaches
c. A teenager with a history of asthma
d. A male with a history of kidney stones

ANS: A
Caffeine should be used with caution in patients who have a history of peptic ulcers or cardiac dysrhythmias or who have recently had a myocardial infarction.
DIF: Cognitive Level: Comprehension REF: p. 276

A patient has a new prescription for orlistat as part of his treatment for weight loss. What important information should the nurse include when providing patient education about orlistat?
a. This medication is a CNS stimulant.
b. This medication reduces fat absorption by about 30%.
c. This drug is used for obese patients with a body mass index (BMI) of 25 or higher.
d. This drug is most effective for individuals with Crohn's disease.

ANS: B
Orlistat (Xenical®) works by binding to gastric and pancreatic enzymes called lipases. Blocking these enzymes reduces fat absorption by approximately 30%. Orlistat is not a CNS stimulant. It is used for patients with a BMI greater than 30. It is contraindicated in individuals with Crohn's disease.
DIF: Cognitive Level: Application REF: pp. 271-272

A 6-year-old boy has been started on methylphenidate hydrochloride (Ritalin) for the treatment of attention deficit hyperactivity disorder (ADHD). His mother tells the nurse that she has been giving the medication at bedtime so that it will be "in his system" when he goes to school the next morning.
Which is the nurse's best response to the patient's mother?
a. The medication dosage is being given appropriately.
b. The medication should not be taken until the boy is at school.
c. The medication should be taken with meals for optimal absorption.
d. The medication should be given 4 to 6 hours before bedtime to diminish the insomnia it causes.

ANS: D
CNS stimulants should be taken 4 to 6 hours before bedtime to decrease insomnia.
DIF: Cognitive Level: Application REF: p. 279

A 22-year-old nursing student has been taking Excedrin Extra-Strength tablets for the past few weeks to "make it through" the end of the semester and examination week. The feeling of being "exhausted" has brought the patient to the clinic today. Which nursing diagnosis is appropriate?
a. Nonadherence
b. Impaired physical mobility
c. Disturbed sleep pattern
d. Imbalanced nutrition (less than body requirements)

ANS: C
Excedrin Extra-Strength is acetaminophen 500 mg with caffeine 65 mg, which is a CNS stimulant that can be used to increase mental alertness. Restlessness, anxiety, and insomnia are common adverse effects.
DIF: Cognitive Level: Analysis REF: p. 277/p. 279

Which CNS stimulant drug is used to treat acute migraines?
a. zolmitriptan (Zomig®)
b. Amphetamines
c. modafinil (Alertec®)
d. methylphenidate hydrochloride (Ritalin®)

ANS: A
Zolmitriptan is a CNS stimulant that can be used to treat migraines.
DIF: Cognitive Level: Knowledge REF: p. 272

A 10-year-old boy has been on methylphenidate hydrochloride (Ritalin) for almost 6 months. His mother reports that he seems to have stopped growing.
Which is the nurse's best answer to the patient's mother?
a. Growth will occur with the onset of puberty.
b. Growth can be promoted with a high-protein diet.
c. Growth in 10-year-old children tends to be slower.
d. Temporary slowing of growth is expected with Ritalin therapy.

ANS: D
Methylphenidate hydrochloride may cause a temporary slowing of growth in prepubescent children.
DIF: Cognitive Level: Application REF: p. 279

A 10-year-old will be started on methylphenidate hydrochloride (Ritalin) therapy. What important baseline assessment should be done before therapy with this drug is started?
a. Eye examination
b. Height and weight
c. Liver studies
d. Cognitive function

ANS: B
Assessment of baseline height and weight is important before beginning methylphenidate hydrochloride therapy because this drug may cause a temporary slowing of growth in prepubescent children.
DIF: Cognitive Level: Application REF: p. 278

Before administering sumatriptan (Imitrex®) to a patient for the treatment of a migraine headache, the nurse should assess for the presence of which condition?
a. Hypotension
b. Renal disease
c. Liver damage
d. Coronary artery disease

ANS: D
Antimigraine medication is contraindicated in patients with peripheral vascular disease, coronary artery disease, sepsis, impaired renal or hepatic function, or severe hypertension.
DIF: Cognitive Level: Comprehension REF: p. 272

The nurse is evaluating a patient who is taking modafinil (Alertec). Which is an intended therapeutic effect?
a. Increased wakefulness
b. Increased appetite
c. Suppressed appetite
d. Decreased hyperactivity

ANS: A
Modafinil is given to treat narcolepsy. Therefore, an intended therapeutic effect is increased wakefulness.
DIF: Cognitive Level: Analysis REF: p. 268/p. 274

Ginkgo biloba is a natural health product that is used for treatment of which condition what purpose?
a. Improving memory
b. Suppressing appetite
c. Treating ADHD
d. Stimulating appetite

ANS: A
Ginkgo biloba is a natural health product used for improving memory.
DIF: Cognitive Level: Knowledge REF: p. 278

Which CNS stimulant is commonly used in conjunction with supportive measures to treat the respiratory depression that may occur in postoperative recovery?
a. theophylline
b. amphetamine
c. benzphetamine
d. methylphenidate hydrochloride (Ritalin)

ANS: A
Theophylline is an analeptic commonly used with supportive measures to hasten arousal and to treat respiratory depression associated with postoperative recovery, among other causes.
DIF: Cognitive Level: Knowledge REF: p. 275

When administering an intramuscular injection of risperidone (Risperdal Consta®), the nurse tells the patient that this medication dosage will be effective for how long?
a. 24 hours
b. 48 hours
c. 1 week
d. 2 weeks

ANS: D
The long-acting injectable form of risperidone Risperdal Consta®, and one intramuscular injection lasts approximately 2 weeks.
DIF: Cognitive Level: Application REF: p. 345

Before beginning therapy with fluoxetine (Prozac), the nurse should assess for concurrent use of which medication?
a. acetylsalicylic acid
b. warfarin sodium
c. Diuretics
d. Nonsteroidal anti-inflammatory drugs

ANS: B
The use of second-generation antidepressants (such as fluoxetine) with warfarin results in an increased anticoagulant effect.
DIF: Cognitive Level: Comprehension REF: p. 348

When the nurse is teaching the patient about monoamine oxidase inhibitors (MAOIs), which is important to emphasize?
a. Serum blood levels should be drawn every 2 weeks.
b. If drowsiness occurs, stop the medication immediately.
c. Drowsiness should decrease after the first few weeks of therapy.
d. Foods high in tyramine—such as cheese, beer, and wine—must be avoided.

ANS: D
If a patient is taking an MAOI, caution the patient to avoid over-the-counter (OTC) cold and flu products. Foods or beverages high in tyramine must also be avoided.
DIF: Cognitive Level: Application REF: p. 353

A patient has been taking haloperidol for 3 months for a psychotic disorder. Because the nurse is concerned about the development of extrapyramidal symptoms, the patient will be monitored for which symptom?
a. Cogwheel rigidity and blurred vision
b. Drowsiness and dizziness
c. Motor restlessness and muscle spasms
d. Dry mouth and constipation

ANS: C
Extrapyramidal symptoms are involuntary motor symptoms similar to those associated with Parkinson's disease. This drug-induced state is known as pseudoparkinsonism and is characterized by symptoms such as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms).
DIF: Cognitive Level: Application REF: p. 341

A patient has been taking the MAOI phenelzine (Nardil®) for 6 months. The patient says he's going out to the local bar to meet a few friends for a beer. What important information should the nurse tell this patient?
a. Drinking beer is permitted as long as there is a designated driver.
b. He has no further dietary restrictions because he has taken the last dosage.
c. If he begins to experience a throbbing headache, rapid pulse, or nausea, he should stop drinking.
d. He needs to avoid foods with tyramine while on this medication.

ANS: D
Patients taking an MAOI need to be cautioned about avoiding OTC cold and flu products as well as foods or beverages high in tyramine.
DIF: Cognitive Level: Analysis REF: p. 353

A 22-year-old female has been taking lithium (Carbolith®) for 6 months. She has blood work every month, and the nurse assesses her for signs of toxicity. What are the indications of toxicity?
a. Serum lithium level of 0.8 mmol/L and excitability
b. Serum lithium level of 1.0 mmol/L and palpitations
c. Serum lithium level of 1.3 mmol/L and hypertension
d. Serum lithium level of 2.3 mmol/L and cardiac dysrhythmias

ANS: D
Lithium levels exceeding 2.0 mmol/L produce moderate to severe toxicity, and cardiac dysrhythmias are possible adverse effects.
DIF: Cognitive Level: Application REF: p. 331

A patient taking clozapine has shown marked improvement. Which statement by this patient indicates the experiencing of a common adverse effect of clozapine?
a. "I have been losing weight."
b. "I don't feel like eating at all."
c. "Look at how red my hands are."
d. "My mouth has been so dry lately."

ANS: D
Adverse effects of clozapine include tachycardia, akathisia, agitation, asthenia, ataxia, seizures, dyskinesia, dizziness, drowsiness, headache, insomnia, dry mouth, dyspepsia, anxiety, increased appetite, and weight gain.
DIF: Cognitive Level: Application REF: p. 342

A 44-year-old patient has been taking sertraline (Zoloft®), a selective serotonin reuptake inhibitor (SSRI), for 4 months. The patient tells the nurse about having an interest in natural health products and wants to start taking St. John's wort. Which statement to the patient is an appropriate response from the nurse?
a. "That should be no problem."
b. "Soon you'll be able to stop taking the Zoloft!"
c. "Be sure to stop taking the herb if you notice a change in adverse effects."
d. "Taking St. John's wort with Zoloft may cause severe interactions and is not recommended."

ANS: D
The herbal product St. John's wort should not be used with SSRIs. Potential interactions include confusion, agitation, muscle spasms, twitching, and tremors.
DIF: Cognitive Level: Analysis REF: p. 335

Which ethnic group often requires lower doses of benzodiazepines and tricyclic antidepressants?
a. Indigenous peoples
b. Asians
c. Latin Americans
d. Somalis

ANS: B
Asians have a lower activity of drug metabolism and thus often require lower doses of benzodiazepines and tricyclic antidepressants than with White people require.
DIF: Cognitive Level: Comprehension REF: p. 351

St. John's wort is a natural health product that some people use for the treatment of mild to moderate symptoms of depression. Use of St. John's wort is contraindicated in patients with which conditions?
a. Schizophrenia, Alzheimer's disease
b. Benign prostatic hypertrophy, diabetes
c. Dementia, emphysema
d. Heart disease, schizophrenia

ANS: A
St. John's wort is contraindicated in patients with bipolar disorder, schizophrenia, Alzheimer's disease, and other forms of dementia.
DIF: Cognitive Level: Comprehension REF: p. 335

A nurse is monitoring a depressed patient who has just started antidepressant therapy. During which time period does the patient have the highest potential for self-injury and suicide?
a. At the beginning, before drug therapy is started
b. The period between the start of therapy and symptomatic improvement
c. Between 1 and 4 weeks of drug therapy
d. After 6 months of drug therapy

ANS: B
Several weeks may pass before the therapeutic effects of antidepressants are evident. After the start of therapy and before symptomatic improvement, careful monitoring of the patient (being readily available) and providing supportive care are critical to the therapeutic approach because during this time period, the patient may be at highest risk for self-harm and suicide.
DIF: Cognitive Level: Application REF: p. 353

Which is a reason that SSRIs are more widely prescribed today than are tricyclic antidepressants (TCAs)?
a. SSRIs have fewer sexual adverse effects.
b. Unlike TCAs, SSRIs do not have drug-food interactions.
c. TCAs can cause serious cardiac toxicities if an overdose occurs.
d. SSRIs therapeutically respond faster than tricyclic antidepressants.

ANS: C
These newer antidepressants offer several attractive advantages over the traditional TCAs and MAOIs. SSRIs are associated with significantly fewer and less-severe adverse effects and systemic adverse effects.
DIF: Cognitive Level: Comprehension REF: p. 348

The wife of a patient who has been diagnosed with depression calls the office and says, "It's been an entire week since he started that new medicine for his depression, and there's no change! What's wrong with him?" Which statement is the best response from the nurse?
a. "The medication may not be effective for him. He may need to try another type."
b. "It may take up to 4 weeks to notice any therapeutic effects. Let's wait a little longer to see how he does."
c. "It sounds like he is tolerant to the drug. I'll check about increasing the dosage."
d. "Some patients never recover from depression. He may not respond to this therapy."

ANS: B
Patients should be told that antidepressant drugs commonly require several weeks before full therapeutic effects can be noted and that these drug can take up to 6 weeks to reach their full therapeutic effect.
DIF: Cognitive Level: Application REF: p. 353

A patient with a history of anxiety attacks is given a medication for these episodes. Which medication is appropriate for this problem?
a. fluphenazine
b. phenobarbital
c. bupropion
d. buspirone hydrochloride

ANS: D
Buspirone hydrochloride is a nonbenzodiazepine that is indicated for treatment of anxiety.
DIF: Cognitive Level: Comprehension REF: p. 346

Which breakfast choice by a patient taking an MAOI indicates the need for additional teaching?
a. Orange juice
b. Fried eggs
c. Cheddar cheese omelet
d. French toast

ANS: C
Aged cheeses, such a cheddar cheese, contain tyramine. Patients who are taking MAOIs need to avoid tyramine-containing foods because of a severe hypertensive reaction that may occur.
DIF: Cognitive Level: Application REF: p. 336

Which statements are true regarding SSRIs? (Select all that apply.)
a. Foods and beverages containing tyramine should be avoided.
b. The nurse should monitor for extrapyramidal symptoms.
c. A potentially hazardous effect called serotonin syndrome may occur.
d. Therapeutic effects may not be seen for about 8 weeks after the medication is started.
e. If the patient has been on an MAOI, a 2- to 5-week or longer span of time should elapse before beginning an SSRI medication.
f. These drugs have anticholinergic effects, including constipation, urinary retention, dry mouth, and blurred vision.
g. SSRIs are associated with fewer side effects than are the older first-generation antidepressants.
h. St. John's Wort is often recommended to reduce the side effects that may occur with SSRIs.

ANS: C, D, E, G
"A potentially hazardous effect called serotonin syndrome may occur," "Therapeutic effects may not be seen for about 8 weeks after the medication is started," "If the patient has been on an MAOI, a 2- to 5-week or longer span of time should elapse before beginning an SSRI medication," and "SSRIs are associated with fewer side effects than are the older first-generation antidepressants" are true statements that apply to SSRIs. The other statements apply to other classes of psychotherapeutic agents. St. John's Wort is contraindicated when a patient is taking an SSRI.
DIF: Cognitive Level: Analysis REF: p. 335/p. 348