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100
1. A patient who has been started on several antidepressants is resistant to drug compliance due to the side effect of libido loss. Which medication would be a good next choice? A. Bupropion B. Fluoxetine C. imipramine D. Isocarboxazid
What is A. bupropion For a patient with sexual dysfunction, choose bupropion, a drug that enhances libido. P. 341
100
Which psychiatric disorder is the most common? A. Seasonal affective disorder B. Bulimia nervosa C. ADHD D. Depression
What is D. depression Depression is the most common psychiatric disorder. In the United States, about 30% of the population will experience some form of depression during their lives. P. 339
100
1. A patient who has been treated effectively with venlafaxine, an SNRI, for 6 weeks states they are feeling “much better,” but would now like to be discontinued from the drug, complaining of a headache that has been present since starting taking the drug. Which is the nurse’s best response? A. Stop taking the drug immediately and notify the physician if the headache persists. B. A headache is an expected side effect, and is not grounds for discontinuing the drug. C. The drug must be slowly tapered to avoid withdrawal syndrome, and may take 2-4 weeks to do so safely. D. A new prescription for isocarboxazid, an MAOI, has been written. You can stop taking the venlafaxine as soon as you pick up the isocarboxazid.
What is C. The drug must be slowly tapered to avoid withdrawal syndrome, and may take 2-4 weeks to do so safely. Abrupt discontinuation can cause an intense withdrawal syndrome. Symptoms include anxiety, agitation, tremors, headache, vertigo, nausea, tachycardia, and tinnitus. Worsening of pretreatment symptoms may also occur. Withdrawal symptoms can be minimized by tapering the dosage over 2 to 4 weeks. Warn patients not to stop venlafaxine abruptly. Combined use of venlafaxine with MAOIs and other serotonergic drugs increases the risk of serotonin syndrome, a potentially fatal reaction. Accordingly, MAOIs should be withdrawn at least 14 days before starting venlafaxine. When switching from venlafaxine to an MAOI, venlafaxine should be discontinued 7 days before starting the MAOI.
200
The nurse should question which prescribed medication for a patient with a preexisting cardiac impairment? A. Bupropion B. Fluoxetine C. Imipramine D. Isocarboxazid
What is C. imipramine The most common adverse effects are sedation, orthostatic hypotension, and anticholinergic effects. The most dangerous effect is cardiac toxicity. When taken in overdose, TCAs can readily prove lethal. P. 349
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What diagnostic criteria is used to qualify for peripartum depression, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition? A. A major depressive episode starting within 3 months of delivery B. A major depressive episode starting within 4 weeks of delivery C. Tearfulness, sadness, nervousness, irritability, anxiety, and difficulty eating and sleeping D. Feeling inadequately prepared to care for the new baby
What is B. A major depressive episode starting within 4 weeks of delivery p. 338
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1. A patient comes to the clinic having recently been prescribed fluoxetine, and complains “it’s been 3 weeks that I’ve been taking this every day, and I don’t feel any different.” What is the nurse’s best response? A. The doctor may need to add in an additional medication, such as isocarboxazid. B. This drug takes about 4 weeks to produce steady-state plasma drug levels, so this is a normal finding. C. Taking a “drug holiday” may help to stabilize your response to the drug, and improve sensitivity to its effects. D. The doctor may need to increase your dosage to achieve sufficient levels of the medication in your system.
What is B.This drug takes about 4 weeks to produce steady-state plasma drug levels, so this is a normal finding. MAOIs increase 5-HT availability, and hence greatly increase the risk of serotonin syndrome. Accordingly, use of MAOIs with SSRIs is contraindicated. MAOIs should be withdrawn at least 14 days before starting an SSRI. At least 5 weeks should elapse between stopping fluoxetine and starting an MAOI. Sexual dysfunction, as a side effect of fluoxetine, can be managed in several ways. In some cases, reducing the dosage or taking “drug holidays” (eg, discontinuing the medication on Fridays and Saturdays) can help. P. 344
300
Which medication is the treatment of choice for a patient with atypical depression? A. Bupropion B. Isocarboxazid C. Imipramine D. Fluoxetine
What is B. isocarboxazid Because MAOIs can be hazardous, they are generally reserved for patients who have not responded to SSRIs, TCAs, and other safer drugs. However, there is one group of patients- those with atypical depression- for whom MAOIs are the treatment of choice. P. 353
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Describe an MAO, and the action of an MAOI on it
An MAO (monoamine oxidase inhibitor) is an enzyme found in the liver, the intestinal wall, and terminals of monoamine-containing neurons. MAO in neuros converts monoamine neurotransmitters (NE, 5-HT, and dopamine) into inactive products. In the liver and intestine, MAO serves to inactivate tyramine and other biogenic amines in food. There are two types; MAO-A and MAO-B. In the brain, MAO-A inactivates NE and 5-HT, and MAO-B inactivates dopamine. All of the MAOIs used for depression are nonselective- they inhibit both types. Antidepressant effects of the MAOIs results from inhibiting MAO-A in nerve terminals. By inhibiting intraneuronal MAO-A, these drugs increase the amount of NE and 5-HT available for release, and thereby intensify transmission at noradrenergic and serotonergic junctions. All of the MAOIs in current use cause irreversible inhibition. P. 352
300
Which foods should a patient taking isocarboxazid avoid (SATA)? A. Smoked salmon B. Yogurt C. Avocado D. Chocolate E. Grapes
What is A. smoked salmon C. Avocado D. Chocolate Foods high in tyramine promote the release of norepinephrine from sympathetic neurons, possibly leading to hypertensive crisis. Those high in tyramine include avocado (especially if overripe), figs, bananas in large amounts, fermented curd, fermented soybean, fermented meats, dried, fermented, smoked, or otherwise aged fish, practically all cheeses, foods with yeast extract, protein dietary supplements, some imported beers, and Chianti wine. Foods containing nontyramine vasopressors include chocolate, fava beans, ginseng, and caffeinated beverages. p. 354
400
Which drug, if prescribed while a patient is breastfeeding, should be questioned? A. Fluoxetine B. Nortriptyline C. Sertraline D. Venlafaxine
What is A. fluoxetine Sertraline appears safe. Studies show that drug activity in breast-fed infants is extremely low, and no adverse reactions have been observed. The TCAs (nortriptyline, desipramine) also appear safe: levels are too low for detection in breast-fed infants, and follow-up studies have found no developmental deficits. In contrast to sertraline and the TCAs, fluoxetine appears unsafe: the drug and its metabolites reach therapeutic levels in breast-fed infants; potential consequences include colic and impaired weight gain. P. 338
400
What is an expected regimen of ECT? A. 2-3 treatments per day for a total of 6 to 12 treatments a week B. 1-2 treatments per day for a total of 3 to 8 treatments a week C. 2-3 per week for a total of 6 to 12 treatments D. Daily 40-minute sessions for 6 weeks
What is C. 2-3 per week for a total of 6 to 12 treatments A single treatment consists of delivering an electrical shock to the scalp that is sufficient to induce a generalized seizure lasting 20 to 30 seconds. Success requires a series of these treatments, typically 2-3 per week for a total of 6 to 12 treatments. P. 358
400
1. Which symptoms in a patient prescribed imipramine would be most concerning to the nurse? (SATA) A. Dysrhythmia B. Hyperthermia C. Dry mouth D. Confusion E. Diaphoresis F. Agitation
What is A. Dysrhythmias B. Hyperthermia C. Dry mouth D. confusion F. Agitation Overdose with a TCA can be life threatening. Symptoms result primarily from anticholinergic and cardiotoxic actions. The combination of cholinergic blockade and direct cardiotoxicity can produce dysrhythmias, including tachycardia, intraventricular blocks, complete AV block, ventricular tachycardia, and ventricular fibrillation. Responses to peripheral muscarinic blockade include hyperthermia, flushing, dry mouth, and dilation of pupils. CNS symptoms are prominent. Early responses are confusion, agitation, and hallucinations. Seizures and coma may follow. Diaphoresis is a side effect, but is not the most concerning. P. 351
500
Which medication should the nurse question for a patient with a history of head trauma? A. Bupropion B. Ixocarboxazid C. Imipramine D. Fluoxetine
What is A. Bupropion Seizures are the side effect of greatest concern. Avoid bupropion in patients with seizure risk factors, such as head trauma, preexisting seizure disorder, CNS tumor, and use of other drugs that lower seizure threshold. P. 356
500
Which dosage of imipramine should the nurse question? A. 25-50 mg/day B. 100-200 mg/day C. 400-600 mg/day D. 800-1600 mg/day
What is D. 800-1600 mg/day A typical initial dose of imipramine is 25-50 mg/day. A typical maintenance dose is 100-200 mg/day. Overdose with a TCA can be life threatening. The lethal dose is only 8 times the average therapeutic dose. Pp. 341, 351
500
A patient prescribed fluoxetine this week complains of a fever, sweating profusely, and shivering. What is the nurse’s best response? A. Patients taking fluoxetine should receive a flu shot each year to prevent illness. B. Stop taking the drug immediately. C. Contact the prescriber immediately. D. These are normal side effects of fluoxetine.
What is C. Contact the prescriber immediately. By increasing serotonergic transmission in the brainstem and spinal cord, fluoxetine and other SSRIs can cause serotonin syndrome. This syndrome usually begins 2 to 72 hours after treatment onset. S/sx include altered mental status, as well as incoordination, myoclonus, hyperreflexia, excessive sweating, tremor, and fever. Deaths have occurred. The syndrome resolves spontaneously after discontinuing the drug. The risk of serotonin syndrome is increased by concurrent use of MAOIs and other drugs. P. 344