Question 1

The nurse is working in the emergency department. Which client should the nurse see first?

Accepted Answer

The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome (NMS), an uncommon but life-threatening adverse reaction to anti-psychotic medications. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Due to the life-threatening nature of NMS, this client needs to be seen first to assess for generalized muscle rigidity. (Option A) Severe neck spasms in an individual taking haloperidol (and other psychotropic medications) indicate a dystonic reaction. This client is in no immediate danger but needs treatment with IV benztropine (Cogentin) as soon as possible. The client should be seen second. (Option B) Benzodiazepines can cause paradoxical worsening of agitation in elderly clients. This client needs a change in medication but does not need to be seen immediately. (Option D) Dry mouth, blurry vision, and constipation are common anti-cholinergic side effects of olanzapine (and other psychotropic medications). These symptoms usually resolve after the client has taken the medication for a few weeks; treatment is symptomatic (eg, increased fluids, sugar-free chewing gum, high-fiber foods, avoidance of driving). This client can be seen last. Educational objective: Neuroleptic malignant syndrome (NMS) usually presents with mental status changes, fever, muscle rigidity, and autonomic instability after starting antipsychotic medications. Treatment involves discontinuation of the medication and supportive care (eg, rehydration, cooling body temperature). NMS is a life-threatening condition.

Question 2

The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD).  The nurse advises the parent that the child might experience which side effects?

Accepted Answer

Stimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: Decreased appetite and weight loss - can lead to growth delays Cardiovascular effects - hypertension and tachycardia (particularly in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction (Option A) Growth delays are a common side effect. The medications may cause hypertension, not hypotension. (Option B) Heart palpitations are a common side effect; weight loss, not weight gain, can be a problem. (Option D) Trouble sleeping is a common side effect, but the medications do not cause a dry cough. Educational objective: Methylphenidate (Ritalin) is a central nervous system stimulant with the following potential side effects: anorexia and weight loss/growth delays, restlessness and insomnia, hypertension and tachycardia, vocal or motor tics, and abuse potential.

Question 3

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

Accepted Answer

Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity (Option C). (Option A) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the effects of lithium are known or this side effect subsides. (Option B) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. (Option D) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excessive urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective: Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy.

Question 4

The registered nurse supervises a student nurse who is caring for a client newly prescribed lithium for the treatment of bipolar disorder. Which action by the student indicates a need for further teaching?

Accepted Answer

11ecbb05_ccb1_399e_b433_a5e295bc0a16_MD0009_00 Lithium carbonate is a mood stabilizer used for the treatment of bipolar disorder. Lithium levels take some time to reach therapeutic levels, often up to a few weeks (Option D). Clients will need to have their lithium levels carefully monitored when starting therapy, as the therapeutic range is narrow (0.6-1.2 mEq/L [0.6-1.2mmol/L]). Blood sodium levels affect the renal excretion of lithium, as lithium and sodium are excreted in a parallel mechanism by the kidney. If sodium intake is limited or the body is depleted of its normal sodium (eg, excessive perspiration, vomiting, diarrhea), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity (Option C). Therefore, clients on lithium must consume adequate sodium in the diet. Care should be taken to avoid dehydration, so diuretic medications and substances with a diuretic effect (eg, coffee, cola, tea, alcoholic beverages) must be limited or avoided, and clients are advised to drink 2-3 liters of water each day (Options A and B). Educational objective: Clients initiating lithium therapy should be instructed that therapeutic effects may take several weeks to achieve. Clients taking lithium should maintain a normal dietary sodium intake, consume 2-3 liters of fluids per day, and be advised to avoid diuretics or products with diuretic effects (eg, coffee, cola, tea).

Question 5

A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate?

Accepted Answer

Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan (Option B). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option A) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options C and D) Sexual dysfunction Side effects should gradually diminish over 3 months, although some may persist. If symptoms are intolerable or a particular SSRI is ineffective, the client may be switched to a different antidepressant. Educational objective: Selective serotonin reuptake inhibitors (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). A client reporting increased energy with little or no reduction of depression needs immediate assessment for suicide risk.

Question 6

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine.  Which instruction is appropriate to include in the teaching?

Accepted Answer

When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortriptyline) to a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine), a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This timing is based on the half-life value and allows for the first medication to leave the system. Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome. (Option A) A tyramine-restricted diet is indicated for clients on an antidepressant regimen containing an MAOI to decrease the risk of hypertensive crisis. Because this client is starting an MAOI, the diet should be initiated 2 weeks prior to starting the medication. If the switch was from an MAOI inhibitor to another antidepressant, the client would need to continue to follow the dietary restrictions for 2 weeks after discontinuing the MAOI. (Option B) An overnight washout period is inadequate to clear the imipramine from the client's system before starting the phenelzine. (Option D) TCAs and MAOIs cannot be taken at the same time due to the risk of a hypertensive crisis. Educational objective: Caution must be taken when a client switches from a tricyclic antidepressant to a monoamine oxidase inhibitor to avoid adverse reactions (eg, hypertensive crisis, discontinuation syndrome). Usually, antidepressants are withdrawn gradually with a drug-free period before the new antidepressant is initiated.

Question 7

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication?

Accepted Answer

Clozapine (Clozaril) is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option B). (Option A) Weight gain is a common side effect. Clients should be educated about weight management. (Option C) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option D) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve. Educational objective: Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (eg, fever, flulike symptoms).

Question 8

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse?

Accepted Answer

Although methylphenidate (eg, Ritalin, Concerta) is classified as a stimulant, in children with ADHD it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. For many years, the effects of methylphenidate in children were labeled as paradoxical. Now, research has shown that methylphenidate significantly increases levels of dopamine in the central nervous system (CNS) that lead to stimulation of the inhibitory system of the CNS. Methylphenidate works quickly; symptom relief is often seen after the first dose. (Option A) This is a true statement; methylphenidate is generally safe for most children, adolescents, and adults. Methylphenidate can cause adverse reactions, but these affect a very small percentage of users. However, this response does not address the parent's question about how the drug works. (Option B) This is a true statement but does not give the parent information about the benefits of methylphenidate. In addition, it contains language that most clients would not understand. (Option C) A child's school grades may improve due to the benefits of methylphenidate. This would be seen over time as a secondary benefit; the immediate therapeutic effects are often observed with the first dose. Educational objective: The therapeutic effects of methylphenidate can be observed very quickly in children with ADHD. Methylphenidate improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills.

Question 9

The nurse is providing education to a client diagnosed with a trichomoniasis vaginal infection who has been prescribed a onetime dose of oral metronidazole. Which of the following statements by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_ccb5_0a31_b433_bf7777410f7d_MD0009_00 Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis. Infected clients may be asymptomatic but usually seek care when a profuse, frothy, yellow-green, malodorous vaginal discharge is noted. Pruritus, dysuria, and dyspareunia (ie, pain during sex) may also occur. Oral metronidazole (Flagyl) is the most common drug used to treat trichomoniasis. Client education includes: Abstain from sexual intercourse until the infection is cleared (ie, about 1 week after treatment) (Option A). Avoid drinking alcohol while taking metronidazole and for 3 days after completion of therapy because the combination can cause flushing, nausea/vomiting, and severe abdominal pain (Option B). Have partner(s) treated simultaneously to avoid reinfection. Use condoms to prevent the infection in the future (Option C). Know that potential side effects of metronidazole may include a metallic taste, gastrointestinal upset, or dark-colored urine (Option D). (Option E) Vaginal douching is not recommended as it gets rid of good bacteria and alters the pH of the vagina, increasing the risk for infection (eg, bacterial vaginosis). Teach the client to cleanse the exterior vulva using only unscented products, wear breathable undergarments, and report persisting odors/discharge to the health care provider. Educational objective: Trichomoniasis is a sexually transmitted infection that may cause a frothy, malodorous, yellow-green vaginal discharge. Appropriate teaching for clients undergoing treatment with oral metronidazole includes avoidance of alcohol, treatment of sexual partners, abstinence from sexual activity until the symptoms resolve (ie, about 1 week after treatment), and awareness of possible side effects (eg, dark-colored urine).

Question 10

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.

Accepted Answer

11ecbb05_ccb6_69c2_b433_33be250bfdb6_MD0009_00 The use of hormonal contraception (ie, estrogen with or without progestin) places women at a 2- to 4-fold increased risk for developing blood clots due to resulting hypercoagulability. Hormone levels vary among contraceptives, and higher levels of hormone content correlate to an increased risk of adverse thrombotic events (eg, stroke, myocardial infarction). Clients who are prescribed oral contraceptive pills (OCPs) containing estrogen should be educated on potential warning signs (eg, chest pain, vision loss, severe leg pain) (Options A and E). In addition, clients should be instructed not to smoke while taking combined OCPs due to an increased risk of blood clots (Option C). (Option B) Irregular bleeding and spotting between menses are common side effects of combined OCPs. These side effects may be bothersome but are not serious and may improve within 3 months of initiation. If the client cannot tolerate side effects, a different OCP may be considered. (Option D) Clients should be counseled that breast tenderness is a common side effect of combined OCPs and does not warrant emergent reporting to the health care provider. Educational objective: Clients who are prescribed oral estrogen contraceptives (with or without progestin) have an increased risk for developing blood clots. Clients should be educated on warning signs to report to the health care provider (eg, severe leg pain, vision loss) versus common side effects (eg, breast tenderness, spotting).

Question 11

The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer.  Which client statement shows a correct understanding of the nurse's teaching?

Accepted Answer

Lavender aromatherapy is a safe, low-risk intervention to implement in conjunction with anxiolytic medications (Option C). The nurse must evaluate the client's use of all complementary and alternative therapies to ensure that there are no potential interactions with prescribed medications and therapies. The active compounds in lavender essential oil promote relaxation and sleep without interacting with prescription medications. Essential oils can be inhaled directly as a vapor, diffused via a mist, or dropped onto linens. (Options A and D) The herbal supplements kava and valerian root-both used for anxiety, insomnia, and depression-may increase central nervous system (CNS) depression when used with benzodiazepines (eg, clonazepam). Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity. (Option B) Melatonin is a hormone supplement used at bedtime to promote sleep and may increase drowsiness and CNS depression when taken with clonazepam. Combining melatonin with benzodiazepine medications can exaggerate side effects of the benzodiazepine (eg, dizziness, impaired concentration, daytime sleepiness). Educational objective: Lavender aromatherapy is a safe, low-risk, complementary intervention for clients experiencing anxiety. Valerian root, kava, and melatonin may potentiate the adverse effects of clonazepam or other benzodiazepines, and should not be combined with them.

Question 12

A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which combination of medications does the nurse question?

Accepted Answer

Clients are often prescribed medications from more than one class to effectively treat anxiety and depression; however, monoamine oxidase inhibitors (MAOIs) (eg, selegiline [Emsam]) interact with many medications, including many antidepressants. Concurrent use of MAOIs with selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram [Lexapro]) may precipitate life-threatening adverse reactions (eg, serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis). If a client's prescribed medication regimen will change to or from an MAOI, the existing medication should be tapered and discontinued, followed by a 2-week "washout" period without either medication. The client can then begin taking the new medication. (Options A and D) SSRIs (eg, citalopram [Celexa], escitalopram, sertraline [Zoloft]) can be given safely with benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan]) or hypnotics (eg, zolpidem [Ambien]). Benzodiazepines control acute anxiety and SSRIs help treat long-term anxiety without abuse potential. (Option B) Clients with bipolar disorder often need antipsychotic medication (eg, risperidone [Risperdal], haloperidol [Haldol]) to control acute psychosis and lithium for long-term maintenance therapy. Educational objective: Monoamine oxidase inhibitors (MAOIs) (eg, selegiline [Emsam]) interact with many medications, including many antidepressants. MAOIs and selective serotonin reuptake inhibitors should not be given within 2 weeks of each other to prevent adverse reactions (eg, serotonin syndrome, neuroleptic malignant syndrome, hypertensive crisis).

Question 13

A client with bipolar disorder is admitted to the psychiatric unit with acute mania and dehydration. Which prescription does the nurse question?

Accepted Answer

11ecbb05_ccb2_4b0f_b433_b34bda75fc38_MD0009_00 Lithium is a mood stabilizer commonly prescribed for mania (eg, bipolar disorder) as long-term maintenance therapy. Because lithium has a narrow therapeutic range (eg, 0.6-1.2 mEq/L [0.6-1.2 mmol/L]), serum levels should be monitored regularly (eg, following dose changes) to prevent toxicity (>1.5 mEq/L [1.5 mmol/L]). Lithium is excreted through the kidneys. To prevent toxicity the nurse should hold doses and clarify prescriptions for clients who have: Conditions/illnesses in which the kidneys try to conserve sodium (eg, hyponatremia, dehydration) as sodium and lithium are absorbed in proximal tubules simultaneously (Option B) Decreased glomerular filtration rate (eg, severe renal dysfunction) as less of the drug is filtered into the urine Consistent amounts of fluid (2-3 L/day) and sodium prevent fluctuations in serum lithium. Clients should report signs (eg, weight changes, dizziness) and precipitating factors (eg, vomiting, diarrhea, increased sweating) of fluid and electrolyte imbalance. (Option A) Zolpidem (Ambien) is a hypnotic medication that induces sleep for clients with sleep disturbances (eg, acute mania). (Option C) Haloperidol (a first-generation antipsychotic) and lorazepam (a benzodiazepine) are commonly administered together to depress the central nervous system and decrease aggressive behaviors. (Option D) Isotonic IV fluid boluses (eg, normal saline) are often required to reverse moderate to severe dehydration and prevent lithium toxicity. Educational objective: Lithium, a mood stabilizer commonly prescribed for clients with mania, has a narrow therapeutic range. Clients with conditions that increase serum lithium levels (eg, dehydration, hyponatremia, severe renal dysfunction) are at increased risk for toxicity (>1.5 mEq/L [1.5 mmol/L]).

Question 14

The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription for methylphenidate immediate-release tablet.  Which statement by the parent demonstrates that teaching has been effective?

Accepted Answer

Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM (Option C). The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response. (Option A) Contrary to popular myth, sugar does not increase hyperactivity; although an additive-free diet may be a healthy approach for children, eliminating additives or food colorings does not decrease the symptoms of ADHD. (Option B) A team approach (parents, teachers, health care providers) is the most effective way to help a child with ADHD. School-based interventions may include specific classroom modifications or accommodations to be incorporated into the treatment plan. (Option D) Children should be monitored closely during initial treatment for development of tics and continuously for adherence and response to therapy. Educational objective: Methylphenidate is a stimulant drug with the potential to cause insomnia. Parents are instructed to administer the last dose no later than 6 PM to prevent sleep disruption.

Question 15

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first?

Accepted Answer

Commonly used monoamine oxidase inhibitors (MAOIs) include isocarboxazid, phenelzine, and tranylcypromine. These first-generation antidepressants are used only for resistant depression due to serious adverse affects. These medications inhibit the enzyme that breaks up norepinephrine, serotonin, and dopamine, thereby increasing their availability in the body. Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present (Option D). (Option A) MAOIs should be administered in the morning, as sleep dysfunction is common. This client statement should prompt a discussion of current medication habits, but is not the priority. (Option B) Clients taking MAOIs need to avoid tyramine-containing foods (eg, cheese, overripe fruit, liquor, beef/chicken liver, fermented products) due to risk of hypertensive crisis. A medication change might be considered if a client is unable to adhere to the restrictions, but would not be priority. (Option C) Nausea and constipation are adverse effects of MAOIs. Although strategies for management of adverse effects should be discussed, this is not priority. Educational objective: MAOIs and other antidepressants are associated with increased risk of suicidal ideation during the first few weeks of treatment. Clients taking MAOIs need to avoid tyramine-containing foods due to risk of hypertensive crisis.

Question 16

The nurse is conducting a hospital admission history and assessment. The client informs the nurse of taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response?

Accepted Answer

The nurse should follow up regarding the quantity of the herb and how it is used. Black cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity. Herbs can cause harmful reactions when taken in combination with other drugs. It is most important to determine that an herb does not interfere with other medications. Herbal therapy is usually stopped 2-3 weeks before any surgery. (Option A) Although black cohosh is typically used for menopausal symptoms, this is not the most important issue. (Option B) Herbs are not routinely continued during a short hospitalization, especially when used for comfort symptomatic relief. (Option D) There is no established contraindication at this point. Some herbs, such as those starting with "g" (eg, garlic, ginger, gingko, ginseng) lead to an increased bleeding risk. St. John's wort interferes with the metabolism of other drugs. It is important to know about potential interactions and the necessary response (eg, delay surgery, change medication or dosing). Educational objective: Contact the pharmacy to determine possible drug-drug interaction in a client using herbal therapy.

Question 17

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit?

Accepted Answer

Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat ADHD and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control. A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants. (Option A) Therapeutic effects of methylphenidate include increased attention span and improvement in hyperactivity. These would be important components of a well-child assessment, but not the priority. (Option B) Evaluating dental health is part of any well-child assessment. Dry mouth is not a common side effect of methylphenidate. (Option D) Expected outcomes of methylphenidate therapy include improvement in schoolwork and social relationships. These would be important components of a well-child assessment, but not the priority. Educational objective: Side effects of methylphenidate therapy that require on-going monitoring are delayed growth and development and increased blood pressure. Children with ADHD should be weighed regularly at home or school; weight loss trends should be reported and discussed with the health care provider. Blood pressure and cardiac function also should be monitored on an on-going basis.

Question 18

A client recently diagnosed with a major depressive disorder reports use of herbal supplements. It is most important for the nurse to provide education about which supplement reported by the client?

Accepted Answer

11ecbb05_ccae_7a7d_b433_dbf721c151d9_MD0009_00 St John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. The client with a newly diagnosed depressive disorder will likely be prescribed an antidepressant. The nurse should teach the client not to take St John's wort concurrently with SSRIs to prevent serotonin syndrome (Option D). (Option A) Echinacea is commonly used to prevent or treat the common cold/flu, although there is no evidence of its efficacy. It is thought to work by stimulating the immune system. Worsening asthma and anaphylaxis have been reported. (Option B) Garlic is used to improve cholesterol and lower blood pressure. Ginkgo, garlic, and ginseng (the 3 Gs) increase bleeding risk when taken with anticoagulants or thrombolytics. (Option C) Glucosamine is used to improve joint function. Hypoglycemia may result when it is taken with antidiabetic drugs. Educational objective: Selective serotonin reuptake inhibitors and St John's wort increase serotonin levels in the brain. Clients taking both products concurrently are at risk for potentially life-threatening serotonin syndrome (agitation, confusion, tachycardia, diaphoresis, tremors, hyperreflexia).

Question 19

The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine.  The nurse would administer a dose of benztropine on assessing which client behavior?

Accepted Answer

Benztropine (Cogentin) is an anticholinergic medication used to treat some extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia])Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos) Pseudoparkinsonism: Symptoms that resemble parkinsonism (eg, masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia]) Dystonia: Abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (eg, torticollis, oculogyric crisis, opisthotonos) (Options B, C, and D) Delusions are a symptom of schizophrenia. Tangentiality (deviating from the original topic of discussion) is an abnormal thought process seen in schizophrenia. Waxy flexibility (tendency to remain in an immobile posture) is a motor disturbance seen in schizophrenia. All are treated with antipsychotic medications. Educational objective: Benztropine (Cogentin) is an anticholinergic drug used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications.

Question 20

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? Select all that apply.

Accepted Answer

11ecbb05_ccb3_d1b0_b433_255e9456d0a6_MD0009_00 Clients with preexisting conditions (eg, asthma, hypertension, diabetes) may require changes to medication therapy if they become pregnant. In particular, teratogenic or unnecessary medications should be discontinued (before conception, when possible). The nurse should refer a client taking contraindicated medications to a health care provider immediately. For example: Doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus (Option B). Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception (Option D). ACE inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy because they can affect fetal renal function and lung development or cause fetal death (Option F). (Option A) Albuterol, an inhaled beta agonist, has not been conclusively proved to be safe during pregnancy but should be continued when medically indicated (eg, severe asthma) to prevent the risks of asthma during pregnancy (eg, preterm birth, growth restriction). (Option C) Insulin is safe for use during pregnancy and is commonly used to treat pregestational or gestational diabetes. (Option E) Levothyroxine (Synthroid) for treatment of hypothyroidism is safe but should be monitored carefully to ensure an appropriate dose due to physiological changes in pregnancy. Educational objective: Commonly used medications that are absolutely contraindicated in pregnancy include doxycycline, isotretinoin, and ACE inhibitors.

Exam 8: Pharmacology

The nurse is working in the emergency department. Which client should the nurse see first?

The nurse provides discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder (ADHD) . The nurse advises the parent that the child might experience which side effects?

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

The registered nurse supervises a student nurse who is caring for a client newly prescribed lithium for the treatment of bipolar disorder. Which action by the student indicates a need for further teaching?

A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate?

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching?

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication?

The parent of a child diagnosed with attention-deficit hyperactivity disorder (ADHD) , predominantly inattentive type, says to the nurse, "I hate the idea of my child taking a drug that's a stimulant. How will I know that the methylphenidate is even working?" Which is the best response by the nurse?

The nurse is providing education to a client diagnosed with a trichomoniasis vaginal infection who has been prescribed a onetime dose of oral metronidazole. Which of the following statements by the nurse are appropriate? Select all that apply.

The registered nurse and practical nurse are conducting a workshop on contraceptive methods for a group of outpatient clients. Which instructions should the nurses include when discussing combined estrogen-progestin oral contraceptives? Select all that apply.

The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?

A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which combination of medications does the nurse question?

A client with bipolar disorder is admitted to the psychiatric unit with acute mania and dehydration. Which prescription does the nurse question?

The registered nurse is counseling the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription for methylphenidate immediate-release tablet. Which statement by the parent demonstrates that teaching has been effective?

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first?

The nurse is conducting a hospital admission history and assessment. The client informs the nurse of taking the herb black cohosh (Actaea racemosa) daily. What is the best nursing response?

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit?

A client recently diagnosed with a major depressive disorder reports use of herbal supplements. It is most important for the nurse to provide education about which supplement reported by the client?

The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior?