WGU D449 Psych& Mental Health Nursing HESI Latest updated version with expert curated questions and answers

Which of the following are priority nursing interventions when administering a monoamine oxidase inhibitor (MAOI) like phenelzine (Nardil)? (Select all that apply)SN:MAOIs - Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (Emsam), Tranylcypromine (Parnate)

Monitor for signs of hypertensive crisis, such as severe headache or chest pain.Instruct the patient to avoid foods containing tyramine, such as aged cheese and cured meats.Monitor liver function tests regularly.

Which of the following is the most common side effect of selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac)?rationale:SSRIs: Citalopram (Celexa), Fluoxetine (Prozac), Paroxetine (Paxil)

Sexual dysfunction

When administering lorazepam (Ativan) to a patient withdrawing from alcohol, which interventions should the nurse prioritize? (Select all that apply)SN:(Benzo)Benzodiazepines: Diazepam (Valium), Alprazolam (Xanax), Lorazepam (Ativan)

Monitor the patient for signs of respiratory depression.Assess vital signs frequently, especially blood pressure and heart rate.Monitor for signs of delirium tremens.

A patient on lithium carbonate (Lithium) presents with nausea, vomiting, and tremors. What are the priority actions the nurse should take?

Assess lithium levels to check for toxicity.

Notify the healthcare provider immediately if lithium levels exceed the therapeutic range.

Monitor hydration status and encourage the patient to maintain adequate fluid intake.

A patient with schizophrenia is prescribed haloperidol (Haldol). What is the nurse's priority assessment when starting this medication?

Extrapyramidal symptoms (EPS)

A first-generation antipsychotic, is known to cause extrapyramidal symptoms (EPS), such as tremors, rigidity, and akathisia.

Haloperidol

Which of the following are important nursing considerations when administering benztropine (Cogentin) to a patient with Parkinson's disease or drug-induced parkinsonism? (Select all that apply)

Monitor for dry mouth and constipation.Assess for urinary retention.Monitor for signs of hyperthermia.

Which of the following is the hallmark sign of delirium tremens in a patient undergoing alcohol withdrawal?

Hallucinations and confusion

Hallucinations, with severe confusion, tremors, and seizures, usually within 48-72 hours of the last alcohol intake.

Delirium tremens (DTs)

Which of the following are key patient education points when administering disulfiram (Antabuse) for alcohol dependence? (Select all that apply)

Avoid all forms of alcohol, including in medications, mouthwash, and food.Report any symptoms of nausea, vomiting, or palpitations immediately.Alcohol consumption while on Antabuse can result in severe hangover symptoms.

Disulfiram(Antabuse)causes severe reactions?

Nausea, vomiting, palpitations when alcohol is consumed, so avoiding alcohol in all forms is critical.

Which of the following is the most important intervention for a nurse to prioritize when treating depression in adolescents?

Encourage open discussion about self-harm or suicidal thoughts.

MAOIs (Monoamine Oxidase Inhibitors)Medications:

Isocarboxazid (Marplan)

Phenelzine (Nardil)

Selegiline (Emsam)

Tranylcypromine (Parnate)

MAOIs (monoamine oxidase inhibitors) Signs/Symptoms of Concern:

SX:Risk of hypertensive crisis when combined with tyramine-rich foods (aged cheese, cured meats, etc.).

Potential for serotonin syndrome if combined with other serotonergic drugs.

S:Dizziness, headache, insomnia, weight gain, sexual dysfunction, and dry mouth.

MAOIs (Monoamine Oxidase Inhibitors)Nursing Interventions/Priorities:

Educate patients on avoiding tyramine-rich foods to prevent hypertensive crisis.

Monitor for signs of serotonin syndrome (e.g., agitation, increased temperature, muscle rigidity).Blood pressure monitoring is crucial, especially when starting therapy.Patient Teaching: Advise against combining MAOIs with other antidepressants (SSRIs, SNRIs, etc.), alcohol, or certain medications like sympathomimetics.

MAOIs (Monoamine Oxidase Inhibitors)Goal/Outcome:

Improved mood and reduction in depressive symptoms.Prevention of hypertensive crisis through dietary modifications.

Other Antidepressants

Mirtazapine (Remeron),Bupropion (Wellbutrin),Trazodone (Desyrel)

Antidepressants Signs/Symptoms of Concern:

Mirtazapine: Weight gain, sedation, and potential for increased appetite.

Bupropion: Risk of seizures (especially in those with eating disorders or alcohol use).

Trazodone: Sedation and orthostatic hypotension (especially at night).

OtherAntidepressantsNursing Interventions/Priorities:

Monitor weight and appetite for Mirtazapine.

Monitor for seizures with Bupropion, especially in at-risk populations.Monitor for dizziness and fainting with Trazodone, especially in the elderly.

other AntidepressantsSigns/Symptoms of Concern:

Improved depressive symptoms with minimal side effects.Patient education on managing side effects such as sedation (Trazodone) or weight changes (Mirtazapine).

Other Antidepressants Nursing Interventions/Priorities:

Monitor weight and appetite for Mirtazapine.

Monitor for seizures with Bupropion, especially in at-risk populations.

Monitor for dizziness and fainting with Trazodone, especially in the elderly.

Other Antidepressants Goal/Outcome

Improved depressive symptoms with minimal side effects.Patient education on managing side effects such as sedation (Trazodone) or weight changes (Mirtazapine).

Anxiolytics

Benzodiazepines:

Chlordiazepoxide (Librium) - Used for alcohol withdrawal.

Alprazolam (Xanax)

Clonazepam (Klonopin)

Diazepam (Valium)

Lorazepam (Ativan) - Used in alcohol withdrawal (ETOH WD) to prevent seizures.

Anxiolytics

Benzodiazepines:Signs/Symptoms of Concern:

Sedation, respiratory depression, and dependency potential.Tolerance and withdrawal symptoms may develop with prolonged use.

Amnesia and ataxia are also potential adverse effects.

Nursing Interventions/Priorities:Anxiolytics

Benzodiazepines:

Monitor for signs of respiratory depression, especially in high doses or when combined with other CNS depressants.

Avoid abrupt discontinuation to prevent withdrawal symptoms.Patient Teaching: Educate patients about the risk of dependence and the importance of tapering. Advise patients to avoid alcohol and other CNS depressants.

Monitor for signs of overdose, including extreme sedation and depressed respiration.

Anxiolytics

Benzodiazepines:Goals

Decreased anxiety and promotion of relaxation without significant side effects or dependence.

SSRIs (Selective Serotonin Reuptake Inhibitors):

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac)

Paroxetine (Paxil)

Sertraline (Zoloft)

SSRIs (Selective Serotonin Reuptake Inhibitors):Signs/Symptoms of Concern:

Nausea, insomnia, weight changes, sexual dysfunction, and increased risk of suicidal thoughts in adolescents and young adults.

Serotonin syndrome when combined with other serotonergic medications.

Nursing Interventions/Priorities:SSRIs (Selective Serotonin Reuptake Inhibitors)

Monitor for increased suicidal ideation in the initial stages of treatment, especially in younger populations.

Assess for serotonin syndrome (e.g., hyperreflexia, fever, agitation).

Monitor electrolytes and electrocardiogram changes (especially with Citalopram).

Patient Teaching: Advise patients to avoid alcohol and inform them about possible sexual dysfunction.

Goal/Outcome:SSRIs (Selective Serotonin Reuptake Inhibitors):

Stabilization of mood and prevention of manic/depressive episodes with minimal toxicity.

First Generation Antipsychotics (Typical Antipsychotics):

Chlorpromazine (Thorazine)

Fluphenazine (Prolixin)

Haloperidol (Haldol)

Second Generation Antipsychotics (Atypical Antipsychotics):

Clozapine (Clozaril)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Signs/Symptoms of Concern:Schizophrenia Medications 1st &2nd generation.

Extrapyramidal symptoms (EPS) such as dystonia, tardive dyskinesia, and akathisia.Weight gain and metabolic syndrome (more common with atypicals).

Agranulocytosis (especially with Clozapine).

Sedation, orthostatic hypotension, and sexual dysfunction.

Nursing Interventions/Priorities:Schizophrenia Medications

Monitor for EPS and administer anticholinergic medications (e.g., Benztropine) to treat symptoms.Monitor white blood cell count with Clozapine due to agranulocytosis risk.

Patient Teaching: Educate patients about the need for medication adherence, potential side effects, and lifestyle changes (e.g., exercise for metabolic syndrome).

Schizophrenia MedicationsGoal/Outcome:

Improvement in psychotic symptoms (e.g., hallucinations, delusions) with minimal side effects.

Lithium (Lithium Carbonate)

Brand Name: Lithobid

Drug Class: Antimanic

Lithium (Lithium Carbonate)

Signs/Symptoms of Concern:

Tremors,Polyuria,Polydipsia

Weight gain,Hypothyroidism

Kidney dysfunction,Nausea/vomiting,Confusion, ataxia (signs of toxicity)

Lithium (Lithium Carbonate)is

Bipolar med, mood stabilizer

Assessment & Nursing Priorities:Lithium (Lithium Carbonate)

Lithium blood levels (Normal therapeutic range: 0.6-1.2 mEq/L)

Assess for renal function and thyroid function

Monitor for signs of lithium toxicity (e.g., tremors, vomiting, diarrhea)

Hydration is crucial to avoid dehydration

Monitor electrolyte balance (especially sodium levels)

Nursing Interventions:Lithium

Monitor kidney and thyroid function regularly

Ensure adequate hydration to avoid toxicity

Educate on avoiding NSAIDs (increase risk of toxicity)

Teach signs of toxicity to the patient (tremors, confusion, nausea)

Therapeutic Communication:Lithium

Please notify me if you experience tremors or unusual symptoms, as these could be signs of toxicity."

"It's important to stay hydrated, and we will monitor your kidney function closely."

Lithium CarbonatePatient Teaching:

Signs of toxicity include hand tremors, nausea, diarrhea, and confusion. Regular blood tests to monitor lithium levels are important. Avoid dehydration and stay well-hydrated.

Avoid NSAIDs due to increased risk of toxicity

Dietary considerations: Maintain a consistent salt intake.

Goals/Outcomes:lithium

Stabilization of mood without significant adverse effects

Avoidance of toxicity.Improvement in manic symptoms

Sertraline

(SSRI Antidepressant)

Brand Name: Zoloft

Drug Class: Selective Serotonin Reuptake Inhibitor (SSRI)

Sertraline (Zoloft)Assessment & Nursing Priorities:

Assess for suicidal ideation, especially in younger patients.Monitor for signs of serotonin syndrome

Assess sleep patterns, appetite, and weight

Assess mental status (for improvement or worsening depression)

Sertraline (Zoloft)Nursing Interventions:

Educate on the risk of suicidal thoughts and the importance of immediate reporting.Monitor for serotonin syndrome (e.g., agitation, fever).Provide reassurance and coping strategies for managing side effects (e.g., sexual dysfunction).Monitor for weight changes, as SSRIs can affect appetite.

Sertraline (Zoloft)Therapeutic Communication:

Let me know if you feel more anxious or have changes in mood, as this could be a sign that the medication is affecting you."

"SSRIs can sometimes cause changes in sexual function; please don't hesitate to talk about it."

Sertraline (Zoloft)Patient Teaching:

Report any signs of serotonin syndrome (agitation, fever, muscle rigidity)

Inform about sexual side effects and the possibility of them improving over time

Avoid alcohol as it can increase sedative effects

Adhere to prescribed dose and do not abruptly stop taking the medication

Sertraline (Zoloft)SsRI:Signs/Symptoms of Concern:

Sexual dysfunction (decreased libido, delayed ejaculation)

Insomnia or drowsiness

Nausea, headache, dry mouth

Increased risk of suicidal thoughts (especially in adolescents and young adults)

Serotonin syndrome (hyperreflexia, confusion, fever, agitation)

Goals/Outcomes:Sertraline (Zoloft)SsRI:

Decreased depressive symptoms

Improved mood stabilization with minimal side effects

Increased adherence to therapy.

Furosemide

Brand Name: Lasix

Drug Class: Loop Diuretic

Signs/Symptoms of Concern:Furosemide (Lasix)

Hypokalemia (low potassium)

Dehydration

Orthostatic hypotension

Tinnitus (high doses)

Elevated blood sugar (especially in diabetic patients)

Hyperuricemia (risk of gout)

Assessment & Nursing Priorities:Furosemide (Lasix)

Monitor electrolyte levels, especially potassium

Monitor urine output and assess for signs of dehydration (dry mouth, dizziness)

Assess vital signs, particularly blood pressure (risk of hypotension)

Daily weight and monitor for fluid retention

Assess for renal function (creatinine, BUN)

Nursing Interventions:Furosemide (Lasix)

Administer in the morning to avoid nocturia

Encourage potassium-rich foods (bananas, potatoes)

Monitor vital signs, especially blood pressure

Report signs of dehydration (dry skin, dizziness, weakness)

Therapeutic Communication:Furosemide (Lasix)

"You might feel lightheaded when standing up; please take your time and rise slowly to avoid falls."

"It's important to watch for symptoms like muscle cramps or weakness, as these can be signs of low potassium."

Patient Teaching:Furosemide (Lasix)

Increase potassium intake (bananas, spinach, oranges)

Monitor weight regularly

Report dizziness, muscle cramps, or weakness

Take in the morning to avoid nighttime urination

Adhere to fluid restrictions if prescribed

Lasix (furosemide):Goals/Outcomes:

Reduction in fluid retention (for heart failure, edema)

Maintenance of electrolyte balance and hydration

Normalization of blood pressure.

Metformin

Brand Name: Glucophage

Drug Class: Biguanide (Antidiabetic)Brand Name: Glucophage for patients with type 2 diabetes.given type 2 diabetics

Signs/Symptoms of Concern:Metformin

Lactic acidosis (rare but severe)

Gastrointestinal upset (nausea, diarrhea)

Vitamin B12 deficiency (long-term use)

Hypoglycemia (rare, especially if combined with other diabetic medications)

Assessment & Nursing Priorities:Metformin (Glucophage)

Assess renal function (creatinine levels) before starting therapy

Monitor blood glucose levels regularly.Assess for signs of lactic acidosis (muscle pain, weakness, rapid breathing)

Monitor vitamin B12 levels with long-term use.

Nursing Interventions:Metformin (Glucophage)

Administer with meals to reduce gastrointestinal side effects. Monitor kidney function to ensure safe use of the medication. Educate patients on the signs of lactic acidosis and the importance of prompt reporting. Advise on dietary modifications and weight management.

Therapeutic Communication:Metformin (Glucophage)

"Let me know if you feel unusually weak, have trouble breathing, or experience muscle pain, as these could be signs of a serious side effect."

"Taking this medication with food can help reduce stomach upset."

Patient Teaching:Metformin (Glucophage)

Report any muscle pain, difficulty breathing, or weakness, which could indicate lactic acidosis

Take the medication with meals to decrease gastrointestinal upset. Monitor blood glucose regularly. Lifestyle changes (diet, exercise) to complement medication therapy.

Goals/Outcomes:Metformin (Glucophage)

Control of blood glucose levels within normal range

Prevention of diabetic complications

Minimal side effects and avoidance of lactic acidosis.

Which of the following are common signs of lithium toxicity? (Select all that apply)

Nausea and vomiting,Tremors and confusion,Increased thirst and urination.

Which of the following side effects are commonly associated with SSRIs like sertraline? (Select all that apply)

Sexual dysfunction,Weight gain,Insomnia.

Which of the following actions are appropriate for nursing interventions when administering furosemide? (Select all that apply)

Monitor potassium levels,Encourage high-potassium foods,Monitor blood pressure and vital signs.

Which of the following are important aspects of patient teaching for metformin? (Select all that apply)

Take the medication with meals to reduce gastrointestinal upset,Report muscle pain, difficulty breathing, or weakness immediately,Regularly monitor blood glucose levels.

A patient is prescribed lithium for bipolar disorder. Which of the following should the nurse include in the teaching plan for the patient regarding the use of lithium?

Monitor your fluid intake to ensure you do not become dehydrated,Avoid taking NSAIDs while on lithium."

A 25-year-old patient who has been prescribed sertraline for depression reports difficulty maintaining sexual function. The nurse should teach the patient which of the following?

This side effect will likely go away after a few weeks of treatment."

A patient is receiving furosemide for heart failure. Which of the following would indicate the need for further nursing assessment?

Potassium level of 3.2 mEq/L

A 60-year-old patient who is starting metformin therapy for type 2 diabetes asks the nurse about possible side effects. Which of the following should the nurse include as potential side effects?

Nausea and diarrhea,Risk of lactic acidosis.

Which of the following are common side effects associated with hydrochlorothiazide? (Select all that apply)

Dehydration,Hypokalemia,Hyperuricemia

Hydrochlorothiazide (HCTZ)

Brand Name: Microzide

Drug Class: Thiazide Diuretic

Enalapril (Vasotec)

Brand Name: Vasotec

Drug Class: ACE Inhibitor

Which of the following nursing interventions are appropriate for a patient taking enalapril? (Select all that apply)

Monitor blood pressure frequently,Monitor for a persistent dry cough,Assess for signs of angioedema.

Amlodipine is

Brand Name: Norvasc

Drug Class: Calcium Channel Blocke

Which of the following are common side effects of amlodipine? (Select all that apply)

Swelling of the ankles, Dizziness or lightheadedness, Headache

A patient with hypertension is prescribed hydrochlorothiazide. Which of the following assessments should the nurse prioritize before administration?

Monitor serum potassium levels

A patient on enalapril reports developing a persistent dry cough. Which of the following actions should the nurse take?

Discontinue the medication and notify the provider

A patient receiving amlodipine for hypertension reports experiencing dizziness upon standing. Which of the following actions should the nurse take?

Instruct the patient to rise slowly from a sitting or lying position

Brand Name: Plavix

Drug Class: Anti platelet

Clopidogrel

Which of the following are priority nursing interventions when a patient is taking clopidogrel? (Select all that apply)

Assess for signs of bleeding, Monitor for gastrointestinal upset.Educate the patient to report any unusual bruising or bleeding.

Which of the following are important considerations for a patient taking warfarin? (Select all that apply)

Monitor prothrombin time (PT) and international normalized ratio (INR) regularly.Avoid foods rich in vitamin K.Wear a medical alert bracelet.Avoid aspirin and NSAIDs unless directed by the provider.

Warfarin

Brand Name: Coumadin

Drug Class: Anticoagulant

A patient on clopidogrel for stroke prevention asks the nurse if they can take aspirin in addition to their prescribed medication. Which of the following responses is correct?

Taking aspirin with clopidogrel can increase your risk of bleeding."

A patient taking warfarin for atrial fibrillation(afib)presents with bruising and a nosebleed. Which of the following actions should the nurse take?

Assess the patient's current INR level.

Which of the following are priority nursing interventions for a patient prescribed lisinopril? (Select all that apply)SN:Brand Name: Prinivil Drug Class: ACE Inhibitor

Monitor for signs of hyperkalemia, Monitor blood pressure regularly,Assess for signs of angioedema.

Which of the following are potential side effects of metformin? (Select all that apply)SN:Brand Name: Glucophage

Drug Class: Biguanide Antidiabetic

Lactic acidosis,Diarrhea, Gastrointestinal upset

Which of the following nursing interventions are appropriate for a patient on furosemide? (Select all that apply)

Monitor potassium levels regularly,Assess the patient's weight daily,Monitor renal function.

A patient on lisinopril develops a persistent dry cough. What is the nurse's next priority action?

Discontinue the medication and notify the healthcare provider.

A patient who is taking metformin reports feeling fatigued and has abdominal discomfort. What should the nurse do first?

Check for signs of lactic acidosis, such as rapid breathing and muscle pain

A patient taking furosemide for heart failure reports feeling weak and dizzy. The nurse checks the patient's potassium level and finds it is low. Which of the following actions should the nurse take?

Administer an oral potassium supplement

Aspirin (Bayer)

Brand Name: Bayer

Drug Class:

Antiplatelet

Which of the following are important nursing interventions for a patient prescribed aspirin? (Select all that apply)

Monitor for signs of bleeding, such as bruising or black stools, Advise the patient to take aspirin with food to reduce gastric irritation, Assess the patient for signs of salicylate toxicity, such as tinnitus,Teach the patient to avoid alcohol while taking the medication.

A patient with a history of gastric ulcers is prescribed aspirin. Which of the following actions should the nurse take?

Advise the patient to take aspirin with food to reduce gastric irritation

cloinidine:Brand name:Cataprese drug class: Alpha -2 Adrenergic.Which of the following are common side effects of clonidine? (Select all that apply

Drowsiness,Bradycardia,Dry mouth,Hypotension.

A patient who is prescribed clonidine for hypertension reports feeling drowsy and lightheaded. Which of the following actions should the nurse take?

Recommend that the patient take the medication at bedtime.

Which of the following should be monitored in a patient taking diltiazem? (Select all that apply)

Blood pressure, Heart rate,Liver function tests

Brand Name: Cardizem

Drug Class: Calcium Channel Blocker

A patient on diltiazem for atrial fibrillation is experiencing bradycardia. What should the nurse do first?

Notify the healthcare provider