Question 1

An older adult patient who is to begin taking imipramine (Tofranil) asks the nurse when the drug should be taken. The nurse will instruct the patient to:

Accepted Answer

For many patients, taking the entire dose of a TCA at bedtime is advantageous for facilitating adherence, minimizing daytime sedation, and promoting sleep. However, older adult patients are at greater risk for cardiotoxicity and may experience intolerable effects on the heart if the entire dose is taken at once; therefore, twice-daily dosing is recommended in the elderly.

Question 2

A patient taking an MAOI is seen in the clinic with a blood pressure of 170/96 mm Hg. What will the nurse ask this patient?

Accepted Answer

Patients taking an MAOI should be counseled to follow strict dietary restrictions and to avoid all foods containing tyramine. Patients who consume such foods when taking an MAOI experience a hypertensive episode. Antihypertensive medications, given with an MAOI, will result in hypotension. Grapefruit juice does not alter the metabolism of an MAOI. SSRIs and MAOIs, when administered together, cause a serotonin syndrome.

Question 3

Which patients are candidates for MAOIs? (Select all that apply.)

Accepted Answer

Patients who have not responded to SSRIs or TCAs, patients with atypical depression, and patients with bulimia nervosa are candidates for MAOIs. MAOIs contribute to hypotension and therefore are contraindicated in patients with hypotension. MAOIs are not recommended for the treatment of postpartum depression.

Question 4

A patient is brought to the emergency department after taking a handful of TCA pills. The nurse will expect to provide what when caring for this patient? (Select all that apply.)

Accepted Answer

Patients who overdose with a TCA should have cardiac monitoring, because cardiac side effects can occur. Cholinesterase inhibitors are given to counteract anticholinergic side effects. Gastric lavage followed by activated charcoal can reduce absorption of the TCA. Sedative drugs would only increase the sedative effects of the TCA. Procainamide causes cardiac depression and is not recommended to treat TCA dysrhythmias.

Question 5

A patient who has fibromyalgia is diagnosed with major depression. The provider orders a TCA. The nurse will teach this patient to:

Accepted Answer

Orthostatic hypotension can occur with TCAs. Patients should be advised to sit or lie down if they feel lightheaded to prevent falls. Foods containing tyrosine cause adverse effects in patients taking MAOIs. Patients taking TCAs should be counseled to avoid all alcohol. Because TCAs cause sedation, the medication should be taken at bedtime.

Question 6

A patient is diagnosed with major depression with severe symptoms and begins taking an antidepressant medication. Three weeks after beginning therapy, the patient tells the nurse that the drug is not working. The nurse will counsel this patient to ask the provider about:

Accepted Answer

Patients with severe depression benefit more from a combination of drug therapy and psychotherapy than from either component alone, so this patient should ask the provider about nondrug therapies. Once a drug has been selected for treatment, it must be used for 4 to 8 weeks before its efficacy can be assessed. Until a drug has been used at least 1 month without success, it should not be considered a failure. Adding a second medication, changing to a different medication, and increasing the dose of this medication should all be reserved until the current drug is deemed to have failed after at least 4 weeks.

Question 7

A patient taking fluoxetine (Prozac) complains of decreased sexual interest. A prescriber orders a "drug holiday." What teaching by the nurse would best describe a drug holiday?

Accepted Answer

Sexual dysfunction may be managed by having the patient take a drug holiday, which involves discontinuing medication on Fridays and Saturdays. Cutting the tablet in half anytime to reduce the dosage is an inappropriate way to manage drug administration effectively. In addition, it does not describe a drug holiday. The patient should not take the drug every other day, nor should it be discontinued for a week at a time, because this would diminish the therapeutic levels of the drug, thereby minimizing the therapeutic effects. In addition, neither of those options describe a drug holiday.

Question 8

A neonate is born to a patient who reports taking venlafaxine (Effexor XR). The nurse caring for the infant will observe the infant for:

Accepted Answer

Use of venlafaxine late in pregnancy can result in a neonatal withdrawal syndrome characterized by irritability, abnormal crying, tremor, respiratory distress, and possibly seizures. Poor appetite and disturbed sleep are not part of this withdrawal syndrome. Serotonin syndrome is not likely. Sustained mydriasis occurs as an adverse effect in patients taking the drug.

Question 9

A patient whose spouse has died recently reports feeling down most of each day for the past 2 months. On further questioning, the nurse learns that the patient has quit participating in church and social activities, has difficulty falling asleep, and has lost 5 pounds. The patient reports feeling tired and confused all the time but does not have suicidal thoughts. What does the nurse suspect?

Accepted Answer

This patient has symptoms of major depression, which include depressed mood, loss of pleasure in usual activities, insomnia, weight loss, and feelings of fatigue. For a diagnosis of major depression, these symptoms must be present most of the day, nearly every day, for at least 2 weeks. Grief and sadness and situational depression are common responses to the death of a loved one, but this patient's symptoms go beyond this normal response. This patient does not show signs of hypomania.

Question 10

A nurse is teaching a group of nursing students about tricyclic antidepressants (TCAs). Which statement by a student indicates a need for further teaching?

Accepted Answer

TCAs can adversely affect cardiac function, and these effects can be serious in patients with pre-existing cardiac impairment. TCAs do block receptors for histamine, acetylcholine, and norepinephrine; they do block the uptake of norepinephrine and 5-HT; and they do have other uses besides depression.

Question 11

A provider has indicated that a serotonin/norepinephrine reuptake inhibitor (SNRI) will be prescribed for a patient who is experiencing major depression. When conducting a pretreatment health history, the nurse learns that the patient has a recent history of alcohol abuse. Which SNRI would be contraindicated for this patient?

Accepted Answer

Duloxetine can cause elevation of serum transaminases, indicating liver disease. Patients with existing liver disease or alcohol abuse should not receive this drug. This side effect is not likely with desvenlafaxine or venlafaxine. Escitalopram is an SSRI.

Question 12

A young adult patient has been taking an antidepressant medication for several weeks and reports having increased thoughts of suicide. The nurse questions further and learns that the patient has attempted suicide more than once in the past. The patient identifies a concrete plan for committing suicide. The nurse will contact the provider to discuss:

Accepted Answer

Patients with depression often think of suicide, and during treatment with antidepressants, these thoughts often increase for a time. Patients whose risk of suicide is especially high should be hospitalized. All antidepressants carry this risk, so changing medication is not recommended. Discontinuing the medication is not recommended. More frequent clinic visits are recommended for patients with a low to moderate risk of suicide.

Question 13

A patient who has been taking a monoamine oxidase inhibitor (MAOI) for depression for several months tells the provider that the medication has not helped with symptoms. The provider plans to switch the patient to an SSRI. The nurse will teach this patient to:

Accepted Answer

MAOIs increase 5-HT availability, thus greatly increasing the risk of serotonin syndrome. MAOIs should be withdrawn at least 14 days before an SSRI is started. An SSRI should never be given at the same time as an MAOI. It is not necessary to wait 5 weeks before starting an SSRI.

Question 14

A patient has been taking fluoxetine (Prozac) for 11 months and reports feeling cured of depression. The nurse learns that the patient is sleeping well, participates in usual activities, and feels upbeat and energetic most of the time. The patient's weight has returned to normal. What will the nurse tell this patient?

Accepted Answer

Abrupt discontinuation of selective serotonin reuptake inhibitors (SSRIs) can cause a withdrawal syndrome, so these drugs should be withdrawn gradually. After symptoms are in remission, treatment should continue for 4 to 9 months to prevent relapse; these drugs are not taken indefinitely. It is incorrect to counsel the patient to stop taking the drug without tapering it. Drug holidays are used to minimize sexual dysfunction side effects, not to monitor symptoms.

Question 15

A patient has been taking an SSRI antidepressant for major depression and reports having headaches and jaw pain. What will the nurse tell the patient?

Accepted Answer

Bruxism is a side effect of SSRIs and can result in headache and jaw pain. Patients who experience these signs should be evaluated for bruxism by a dentist, who can determine whether the patient may benefit from use of a mouth guard. Headache and jaw pain are not signs of extrapyramidal side effects. Discontinuing the antidepressant is not indicated, because depression may return. Stress-relieving methods and relaxation techniques are not recommended, because these symptoms occur during sleep.

Question 16

A patient who has been taking an SSRI tells the nurse that the drug has caused reduced sexual performance, weight gain, and sedation. The nurse will suggest that the patient ask the provider about using which drug?

Accepted Answer

Bupropion does not cause weight gain, sexual dysfunction, or sedation, so it may be a useful adjunct to or substitute for an SSRI when those side effects become intolerable. Imipramine causes sedation. Isocarboxazid is an MAOI and is not used unless other drugs are ineffective. Trazodone causes sedation.

Question 17

A first-time parent of a 6-week-old infant tells the nurse that she feels anxious and sad, cries a lot, and has difficulty sleeping. What will the nurse do?

Accepted Answer

Women who experience depressive symptoms after childbirth can be screened using a quick test: the Edinburgh Postnatal Depression Scale, which may be administered 6 to 8 weeks after delivery. Reassuring her that her feelings are normal does not acknowledge her concerns; also, without objective screening, this reassurance may not be warranted. Increased sleep and activity may help, but screening is necessary to determine the severity of the depression. Until the patient is diagnosed as having postpartum depression, an SSRI is not indicated.

Quiz 32: Antidepressants