Question 1

An 80-year-old patient experiences prolonged sadness after the death of a spouse.The patient reports being unable to sleep or eat.The primary care NP should prescribe _____ mg _____ daily.&#10;A) trazodone 50; three times&#10;B) trazodone 100; three times&#10;C) mirtazapine 15; at bedtime&#10;D) mirtazapine 30; at bedtime

Accepted Answer

Mirtazapine side effects include sedation and increased appetite,and sedation is more likely with a lower dose.Mirtazapine is often used in nursing homes to stimulate appetite in older adults.

Question 2

The primary care NP sees a 16-year-old patient who reports feeling hopeless and sad.The child's parent reports increased aggression and a decline in school performance.The NP should consider prescribing:

A) fluoxetine (Prozac).
B) nortriptyline (Pamelor).
C) tranylcypromine (Parnate).
D) venlafaxine hydrochloride (Effexor).

fluoxetine (Prozac).

Accepted Answer

Fluoxetine may be used in children 8 years of age and older.Nortriptyline may be used in children 12 years of age and older but is not a first-line drug.The other drugs are not indicated in adolescents younger than 18 years.

Question 3

A patient has been taking fluoxetine 20 mg every morning for 5 days and calls the primary care NP to report decreased appetite,nausea,and insomnia.The NP should:&#10;A) suggest taking a sedative at bedtime.&#10;B) change the medication to bupropion.&#10;C) add trazodone to the patient's regimen.&#10;D) reassure the patient that these effects will subside.

Accepted Answer

Side effects are seen with the first few doses but resolve in approximately 7 days.Patients should avoid taking sedatives while taking antidepressants.

Question 4

A patient reports having feelings of hopelessness and anxiety for the past few months.The primary care nurse practitioner (NP)performs a history and learns that these feelings occur almost daily.The patient also reports having headaches and difficulty concentrating at work along with wanting to sleep all the time.The patient has gained 5 lb in the past 6 months.The NP should:

A) tell the patient that these symptoms should resolve on their own.
B) reassure the patient that these are symptoms of minor depression.
C) tell the patient that an exercise regimen alone should be effective.
D) assess the patient for alcohol and drug use and for suicidal ideation.

Accepted Answer

The patient is having symptoms of major depression,but other factors such as drug or alcohol abuse that may be contributing to the diagnosis must be ruled out first.Patients should be asked about suicidal ideation so that measures can be taken to prevent a suicide attempt.Symptoms of major depression require treatment.Exercise should be a part of any plan but should not be the only intervention.

Question 5

A patient who has symptoms of depression also reports chronic pain.The primary care NP should begin therapy with:&#10;A) fluoxetine (Prozac).&#10;B) duloxetine (Cymbalta).&#10;C) bupropion (Wellbutrin).&#10;D) nortriptyline (Pamelor).

Accepted Answer

Duloxetine is an antidepressant that also has uses for pain syndromes associated with depression.

Question 6

A patient reports feelings of sadness and hopelessness along with difficulty sleeping and weight loss.The primary care NP learns that the patient's mother died 6 months earlier.The NP should:&#10;A) offer a referral to a bereavement counselor.&#10;B) begin pharmacologic treatment with fluoxetine.&#10;C) determine whether medications are causing these symptoms.&#10;D) tell the patient that these symptoms will go away in a few months.

Accepted Answer

Bereavement over the loss of a loved one may be associated with symptoms of major depression.Although only 17% of these patients receive pharmacologic treatment,94% of symptoms have been found to resolve in 13 months or less.Bereavement counseling should be the first step.Pharmacologic treatment may be warranted if symptoms do not improve.This patient has a clear cause for depression.It is not enough to reassure the patient that the symptoms will resolve because this belittles their concerns.

Question 7

A patient has been taking paroxetine (Paxil)for major depressive symptoms for 8 months.The patient tells the primary care NP that these symptoms improved after 2 months of therapy.The patient is experiencing weight gain and sexual dysfunction and wants to know if the medication can be discontinued.The NP should:

A) change to a tricyclic antidepressant medication.
B) begin to taper the paroxetine and instruct the patient to call if symptoms increase.
C) tell the patient to stop taking the medication and to call if symptoms get worse.
D) continue the medication for several months and consider adding bupropion (Wellbutrin).

Accepted Answer

Once a patient achieves remission,a continuation phase of 16 to 20 weeks followed by a maintenance phase of 4 to 9 months should be carried out.Some responders,called apathetic responders,may have a decrease in most symptoms but continue to have lack of pleasure,decreased libido,and lack of energy.Bupropion can be added to therapy to treat these symptoms.Patients should not change medications during this phase,should not begin a drug taper,and should never stop the medication abruptly.

Question 8

The primary care NP has prescribed sertraline (Zoloft)for a patient who initially reported daily symptoms of hopelessness,sadness,insomnia,and weight loss.After several months of therapy,the patient no longer feels hopeless or sad but continues to have difficulty eating and sleeping.The NP should contact the patient's psychiatrist to discuss:

A) adding mirtazapine (Remeron).
B) changing to duloxetine (Cymbalta).
C) adding another selective serotonin reuptake inhibitor (SSRI) antidepressant.
D) an inpatient admission to the hospital.

Accepted Answer

Mirtazapine may be added to the drug regimen for partial responders who continue to feel anxious.Changing medications is not recommended.Adding another SSRI is contraindicated because of the risk of serotonin syndrome.An inpatient hospital admission is not warranted.

Question 9

A 15-year-old patient who is seeing a psychiatrist began taking an antidepressant 1 week before a clinic visit with the primary care NP.The NP should:&#10;A) schedule weekly clinic visits to evaluate response to the medication.&#10;B) encourage the child to report feelings of self-harm to a school counselor.&#10;C) contact the patient by phone every 2 weeks to see how the medication is working.&#10;D) instruct the child's parents to report changes in behavior to the child's psychiatrist.

Accepted Answer

Pediatric patients should have face-to-face contact with a provider at least weekly during the first 4 weeks of treatment to evaluate for clinical worsening,suicidality,or unusual changes in behavior.

Question 10

A patient has been taking fluoxetine (Prozac)for depression and comes to the clinic to report nausea and jitteriness.The primary care NP notes tremors and sees that the patient is confused.The patient has a heart rate of 95 beats per minute.The NP should:

A) change to bupropion (Wellbutrin).
B) ask the patient about other medications.
C) discontinue the fluoxetine immediately.
D) add mirtazapine (Remeron) to treat anxiety.

Accepted Answer

Serotonin syndrome is a potentially lethal set of symptoms such as these.The NP should evaluate whether the patient is taking other SSRIs,monoamine oxidase inhibitors,bupropion,serotonin-norepinephrine reuptake inhibitors,or other medications that can precipitate this.Changing medication is not indicated.Patients should never abruptly discontinue an SSRI.Adding mirtazapine is not indicated.

Deck 47: Antidepressants