Which of the following are basic responsibilities of nurses who administer psychotherapeutic drugs? (Select One that does not apply.)
Rationale:
C: Adjusting medication dosages according to therapeutic levels. Nurses are responsible for administration and monitoring of psychotherapeutic medications but do not typically make dosage adjustments, which are generally reserved for prescribing professionals.
A: Monitoring and evaluating the client's response to the medication involves ongoing observation, making it a fundamental duty of nursing in psychopharmacological care.
B: Continually assessing the client's condition ensures that nurses remain aware of any changes that may affect treatment efficacy, a key component of their responsibilities.
D: Assisting in the coordination of the client's care reflects a collaborative role, essential for holistic treatment, thus fitting within the scope of nursing duties in mental health.
The nurse is administering medications to a client with a diagnosis of paranoid schizophrenia. The nurse would expect to see which medication ordered for this client?
Rationale:
D: Risperdal
Risperdal, an atypical antipsychotic, is commonly prescribed for individuals with paranoid schizophrenia, effectively reducing symptoms like delusions and hallucinations. Its efficacy in targeting these specific manifestations makes it a suitable choice for this client's treatment.
A: Lithium
Lithium primarily treats bipolar disorder and is not indicated for schizophrenia, lacking the necessary action to address the specific symptoms associated with this diagnosis.
B: Depakene
Depakene is an anticonvulsant that manages seizures and mood stabilization but does not directly address the psychotic symptoms characteristic of paranoid schizophrenia, rendering it ineffective for this case.
C: Neurontin
Neurontin, mainly used for neuropathic pain and seizures, does not possess antipsychotic properties, making it unsuitable for the management of paranoid schizophrenia symptoms in this client.
A female client is 3-days postoperative and has been receiving meperidine (Demerol) for pain control. The family mentions to the nurse that the client has been taking phenelzine (Nardil) for years for her depression. The client did not list this medication on admission. What signs and symptoms should the nurse look for in case of reaction between these two medications?
Rationale:
Sedation, disorientation, and hallucinations are signs of a potential interaction between meperidine and phenelzine, as both substances can lead to central nervous system depression and increased risk of severe adverse effects.
A: Increased pulse and respirations. These symptoms typically indicate a state of excitement or stress, not a direct result of combining meperidine with phenelzine.
B: Hyperactivity and difficulty concentrating. Such symptoms suggest stimulation rather than the sedative effects expected from the interaction of these two medications.
C: Increased tearing and increased urinary output. These symptoms are not associated with the interaction of meperidine and phenelzine and do not indicate significant CNS effects.
A female client who has had bipolar disorder for several years decides to stop all of her medications because she is tired of the side effects. She also cancels all appointments with her therapist, stating that it is just too difficult to plan the visits in her hectic schedule. This client is considered:
Rationale:
B: Noncompliant
The client's decision to stop all medications and cancel therapy appointments indicates a refusal to adhere to prescribed treatment. This noncompliance can exacerbate her bipolar disorder, risking destabilization of her mental health.
A: Depressed
While depressive symptoms may coexist, the client's actions reflect noncompliance rather than a specific depressive episode. Her choices focus more on rejecting treatment than exhibiting signs of depression.
C: Suffering from an anxiety disorder
The scenario does not provide evidence of anxiety symptoms. The focus is on her withdrawal from treatment and managing her schedule, not on anxiety-related behaviors or concerns.
D: Possessing obsessive-compulsive tendencies
There is no indication of obsessive thoughts or compulsive behaviors. The client’s actions stem from frustration with treatment, not from compulsions typically associated with obsessive-compulsive disorder.
A male client with the diagnosis of depression is taking a monoamine oxidase inhibitor (MAOI). Which is the most important teaching point the nurse must include in his care plan?
Rationale:
Avoid alcoholic beverages. Consuming alcohol while taking a monoamine oxidase inhibitor (MAOI) can lead to severe hypertensive reactions, which pose serious health risks and can complicate the client's treatment for depression.
A: Avoid foods high in sodium content. While sodium intake has health implications, it does not pose a direct risk when combined with MAOIs, making this advice less critical for the client.
C: Ensure that protein intake is 60 g/day. Protein intake is generally important but is not specifically relevant to MAOI therapy, which focuses on dietary restrictions regarding tyramine-rich foods instead.
D: Take a potassium supplement. This recommendation is unrelated to MAOI therapy, as potassium supplementation does not address the significant dietary restrictions necessary for safe management of depression with these medications.
What is the most common cause of nonadherence to antipsychotic pharmacologic treatment?
Rationale:
Nonadherence to antipsychotic pharmacologic treatment is primarily due to extrapyramidal effects. These side effects, which include tremors and rigidity, can significantly impact a patient's quality of life, leading to avoidance of medication.
A: Expense High costs may deter some patients, but they are not the leading cause of nonadherence compared to the debilitating side effects of antipsychotic medications.
B: Increased symptoms of chemical dependency While this can affect adherence, it does not directly correlate as a primary reason for noncompliance compared to the discomfort of extrapyramidal symptoms.
D: Inability of the patient to understand the need to take medications Cognitive barriers can contribute, yet they are overshadowed by the physical and psychological impact of extrapyramidal side effects on patient adherence.
____ is a side effect that can occur while a client is taking an antipsychotic medication, causing muscle rigidity, high fever, unstable vital signs, confusion, and agitation.
Rationale:
Neuroleptic malignant syndrome (NMS) is a side effect that can occur while a client is taking an antipsychotic medication, causing muscle rigidity, high fever, unstable vital signs, confusion, and agitation.
NMS is characterized by a combination of severe symptoms, including hyperthermia and autonomic instability, indicating a life-threatening reaction to antipsychotic drugs. Prompt recognition and treatment are critical to prevent complications and ensure patient safety.
A: Drug-induced parkinsonism manifests with tremors and bradykinesia, primarily affecting motor control rather than causing the severe symptoms associated with NMS, such as high fever and confusion.
C: Tardive dyskinesia presents as involuntary movements, typically in the face or limbs, and does not include the acute symptoms like muscle rigidity and high fever seen in NMS.
D: Dystonia involves sustained muscle contractions or spasms but lacks the systemic symptoms like fever and unstable vital signs, which are hallmark features of neuroleptic malignant syndrome.
Lithium levels are considered toxic when they become higher than ____ mEq/L.
Rationale:
Lithium levels are considered toxic when they become higher than 1.5 mEq/L. High lithium concentrations above this threshold can lead to serious health complications, including neurological disturbances and renal impairment, making 1.5 mEq/L the critical limit for toxicity in patients undergoing lithium treatment.
B: 0.9 This level is below the toxicity threshold and is generally considered a safe range for therapeutic lithium levels.
C: 6.5 This level is excessively high and would indicate severe toxicity, but it is not the established threshold for considering lithium toxic.
D: 2.5 This level is above the toxicity threshold but is not the lowest benchmark for defining lithium toxicity, which is set at 1.5 mEq/L.
Psychotropic medications can cause a parasympathetic and/or sympathetic response from the autonomic nervous system. Which of the following is considered a sympathetic response?
Rationale:
Pupil dilation. This response is a hallmark of sympathetic activation, often referred to as the "fight or flight" response, which prepares the body for heightened alertness and potential threats by enhancing vision.
B: Increased saliva production. This response typically indicates a parasympathetic reaction, promoting digestion and relaxation rather than the alertness associated with sympathetic responses.
C: Decreased heart rate. This reflects a parasympathetic effect, promoting calmness and energy conservation, contrasting sharply with the elevated heart rate expected from sympathetic stimulation.
D: Constricted airway. This condition is associated with parasympathetic activity, which aims to conserve energy and facilitate calm, opposing the dilation needed for increased airflow during sympathetic activation.
A patient is prescribed lorazepam. What does the nurse know to be true regarding lorazepam?
Rationale:
Lorazepam is used to treat anxiety. This medication is classified as a benzodiazepine, effectively alleviating symptoms of anxiety disorders and providing rapid relief, which is crucial for patient care in various settings.
B: status epilepticus Lorazepam can indeed be used for status epilepticus but is not primarily prescribed for this condition, making its use here less relevant in the context of general anxiety treatment.
C: insomnia While lorazepam may help with sleep issues, its primary indication is for anxiety management rather than insomnia, focusing on anxiety disorders rather than sleep disturbances in this scenario.
D: and sedation induction Although lorazepam can induce sedation, the primary context for its prescription focuses on anxiety disorders, not specifically for sedation induction, which is a secondary use.
____ side effects can occur when antipsychotic medications are taken that manifest as abnormal movements such as akathisia and pseudo-Parkinson symptoms.
Rationale:
Extrapyramidal side effects can occur when antipsychotic medications are taken that manifest as abnormal movements such as akathisia and pseudo-Parkinson symptoms. These effects specifically arise from disruptions in the extrapyramidal system, which governs motor control, leading to the described symptoms in patients treated with these medications.
B: Neuroleptic Malignant Syndrome involves severe symptoms like muscle rigidity and fever, rather than abnormal movements. It is a distinct and life-threatening condition unrelated to the specific movement disorders mentioned.
C: Autonomic Nervous System pertains to involuntary bodily functions and does not directly relate to abnormal movements. This choice fails to address the specific motor symptoms caused by antipsychotic medications.
D: Cardiovascular primarily relates to heart and blood vessel conditions. This option does not encompass the movement-related side effects, making it irrelevant to the question concerning extrapyramidal symptoms.
Which statement is true regarding the adverse effects associated with antipsychotic medications?
Rationale:
Painful dystonic reactions can occur in the first 72 hours of initiation of therapy. This statement is accurate as acute dystonia often manifests shortly after starting antipsychotic treatment, necessitating timely management to prevent discomfort and complications.
A: Tardive dyskinesia is a common, reversible condition. Tardive dyskinesia is typically irreversible and develops after prolonged use of antipsychotics, making this assertion misleading and contrary to established medical understanding.
C: Neuroleptic malignant syndrome (NMS) is a common adverse effect. NMS is a rare but severe reaction to antipsychotics, not commonly seen compared to other side effects, thus overstating its prevalence.
D: Pseudoparkinsonian symptoms can cause Parkinson's disease. While pseudoparkinsonism mimics Parkinson's symptoms, it does not lead to the actual neurological condition; it is a side effect of medication rather than a causative factor.
A female client calls the clinic for advice after forgetting to take her morning dose of twice-daily lithium 5 hours ago. Which instructions should the nurse give the client?
Rationale:
Eliminate the dose missed, and take the second dose at the normal time. When a dose of lithium is missed, it's advisable to skip the missed dose if it's close to the next scheduled dose, ensuring stable medication levels while preventing potential toxicity from double dosing.
A: Take the dose immediately, and then take the second dose 3 hours late. This approach risks exceeding the recommended dosage within a short timeframe, which can lead to lithium toxicity.
B: Take half of a dose now, and then take the second dose at the normal time. Taking half a dose does not address the need for stable lithium levels and can lead to inadequate therapeutic effect.
D: Immediately take the missed dose, and take the second dose at the normal time. This method can cause an overdose situation, as it disregards the timing of the next scheduled dose.
A patient is taking tranylcypromine sulfate for depression. What advice should the nurse include in the teaching plan for this medication?
Rationale:
Avoiding beer and cheddar cheese is essential for patients taking tranylcypromine sulfate due to the risk of hypertensive crisis from tyramine, which is found in these foods and beverages.
A: Warn the patient about severe hypotension. While hypotension can occur, the primary concern with tranylcypromine is hypertensive crisis, not severe hypotension, making this advice less relevant.
C: Encourage the patient to take ginseng and ephedra. These substances can interact negatively with tranylcypromine, potentially leading to increased side effects or dangerous reactions, and should be avoided.
D: Encourage the patient to eat fruit such as bananas. While fruits are generally healthy, bananas contain tyramine; hence, recommending them could inadvertently risk hypertensive reactions in patients on this medication.
During client teaching, the nurse must inform the client prescribed a tricyclic antidepressant (TCA) to not expect to see a difference in mood or anxiety level for up to:
Rationale:
A: 5 days. A five-day timeframe is insufficient for tricyclic antidepressants to exert their full effect. It generally takes longer for these medications to adequately influence mood and anxiety levels.
C: 4 to 5 weeks. While some improvement may occur by this time, the expected therapeutic effects of tricyclic antidepressants typically manifest within a shorter period of 2 to 3 weeks.
D: 6 weeks. A six-week duration exceeds the usual expected time frame for observing significant mood or anxiety improvements from tricyclic antidepressants, which generally occurs within 2 to 3 weeks.
The CMA is administering an antianxiety medication to a client. Monitoring side effects is the responsibility of which member of the health care team?
Rationale:
Monitoring side effects of an antianxiety medication is primarily the responsibility of the nurse, who is trained to assess patient responses and intervene when necessary to ensure safety.
B: CMA The Certified Medical Assistant (CMA) has limited scope in monitoring medications and primarily assists with administrative and clinical tasks rather than direct patient assessment of side effects.
C: Physician While the physician prescribes medications, their role is typically focused on diagnosis and treatment planning, not on the continuous monitoring of patient responses to medications.
D: Therapist The therapist’s focus is on providing psychotherapy and behavioral interventions, which does not include the monitoring of physiological side effects related to medication administration.
Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect?
Rationale:
Extrapyramidal symptoms. These reactions are characterized by movement disorders resulting from antipsychotic medications, affecting motor control and leading to symptoms such as dystonia, akathisia, and tardive dyskinesia, all categorized under this term.
B: Allergic reactions. This option refers to immune system responses to allergens, which do not encompass the movement-related side effects described in the question, making it irrelevant.
C: Idiosyncratic reactions. This term signifies unusual responses to drugs based on individual variability, which does not specifically relate to the common movement disorders listed in the question.
D: Therapeutic responses. This choice implies beneficial effects of treatments, whereas dystonic reactions and similar symptoms are adverse effects and thus lie outside the scope of therapeutic outcomes.
Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient?
Rationale:
Combination therapy with antipsychotic agents and benzodiazepines assists in calming the psychotic patient effectively. This synergy quickly alleviates agitation and anxiety, enabling a more manageable treatment environment for both the patient and healthcare providers.
A: Antipsychotics are not effective for 2 days. This statement overlooks that some antipsychotics can provide rapid relief, especially when paired with benzodiazepines for immediate calming effects.
B: Benzodiazepines allow for higher dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high-dose therapy. This option misinterprets the role of benzodiazepines, which primarily focus on immediate agitation rather than dosage adjustments.
D: It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations. This reasoning misconstrues the purpose, as the combination primarily aims to manage agitation rather than solely enhance antipsychotic dosing for hallucinations.
Which of the following are basic responsibilities of nurses who administer psychotherapeutic drugs? (Select one that does not apply..)
Rationale:
C: Adjusting medication dosages according to therapeutic levels. Nurses do not adjust medication dosages; this responsibility typically falls to physicians or other licensed prescribers who have the authority and training for such modifications.
A: Monitoring and evaluating the client's response to the medication involves assessing effectiveness and side effects, which is a fundamental duty of nurses in psychotropic care.
B: Continually assessing the client's condition is vital for ensuring safety and effectiveness in treatment, enabling nurses to respond promptly to any changes in the patient's mental state.
D: Assisting in the coordination of the client's care is crucial for holistic treatment, involving collaboration with other healthcare professionals to optimize patient outcomes and ensure comprehensive support.
The ____ constitute a class of drugs that are commonly prescribed for cardiac arrhythmias but also have been found to be effective treatment for social phobias.
Rationale:
Beta-blockers constitute a class of drugs that are commonly prescribed for cardiac arrhythmias but also have been found to be effective treatment for social phobias.
Beta-blockers are effective in managing cardiac arrhythmias by regulating heart rate and rhythm. Their ability to alleviate physical symptoms of anxiety, such as palpitations, makes them beneficial for treating social phobias, providing patients with relief from anxiety-related symptoms.
A: Benzodiazepines Primarily prescribed for anxiety and insomnia, benzodiazepines do not directly address cardiac arrhythmias. Their action focuses on enhancing GABA activity, which does not align with treating social phobias effectively.
B: Tricyclics These antidepressants may impact mood disorders but are not first-line treatments for cardiac arrhythmias. Their side effects and mechanism do not specifically target social phobia symptoms.
C: Azaspirones While used for anxiety, azaspirones lack established efficacy for cardiac arrhythmias. Their unique mechanism focuses on serotonin receptors, making them less relevant for treating social phobias compared to beta-blockers.
Valium is administered to a client anxious about impending surgery. Which of the following side effects is the client at risk for?
Rationale:
Falls can occur as a side effect of Valium due to its sedative properties, which may impair coordination and balance, increasing the risk of accidents, particularly in anxious clients before surgery.
A: Seizures Valium is typically used to manage anxiety and does not commonly induce seizures; rather, it may help prevent them in certain circumstances, making this option unlikely.
C: Hypertensive crisis Valium generally has a calming effect and does not typically lead to a hypertensive crisis, which is more associated with other types of medications or conditions.
D: Tachycardia While some medications may cause tachycardia, Valium's sedative effects usually result in a calming response, making an increased heart rate an unlikely side effect.
Selective serotonin reuptake inhibitors (SSRIs) are most health care providers' drug of choice for the treatment of depression because:
Rationale:
SSRIs are the preferred choice for treating depression due to their manageable side effects compared to other antidepressants. These characteristics enhance patient adherence and overall satisfaction with treatment, making them a favored option among healthcare providers.
B: They are the only class safe for long-term therapy. Other antidepressants may also be utilized safely over extended periods, so this statement does not encompass the full range of options available.
C: This is the oldest class of antidepressants. SSRIs are not the oldest class; tricyclic antidepressants and monoamine oxidase inhibitors predate them, making this assertion inaccurate in context.
D: They are fast-acting medications. SSRIs typically take several weeks to show full effects, contrasting with the perception of them being quick solutions for depression, which misrepresents their actual pharmacological profile.
A male client with schizophrenia lives in an assisted-living complex for individuals with mental health disorders. He is tired of the Parkinson-like symptoms he experiences with his antipsychotic medication and therefore stops taking his medication after much discussion with his treatment team. He is progressively withdrawing from reality but is not a safety risk at this point to himself or others. What is the best response of the nurse and treatment team?
Rationale:
Ensure that the client and those around him are safe, and monitor for additional symptoms of his schizophrenia while maintaining trust with the client.
This response prioritizes the client’s safety while respecting his autonomy. By monitoring his symptoms and fostering trust, the treatment team can encourage cooperation and potentially facilitate a return to medication adherence when he is ready.
A: Try to coerce him into taking his medication. Coercion undermines the therapeutic relationship, potentially leading to resistance and increased withdrawal. Respecting the client’s decision is crucial for effective mental health care.
C: Crush his antipsychotic medications and put them in his food to stop the process of his withdrawal from reality. This violates ethical standards and patient autonomy, potentially causing harm and mistrust rather than fostering cooperation.
D: Speak to his family about seeking an involuntary emergency hold in a mental health facility to get him back on his medications. Involuntary treatment can escalate conflict and diminish the client’s trust, which is counterproductive to his long-term care.
The psychiatric nurse is educating an elderly patient and family about antipsychotic drug therapy. When providing this education, the nurse will include which statement(s)? (Select one that does not apply..)
Rationale:
Hallucinations may be reduced within 1 week of starting. This statement does not apply, as antipsychotic medications typically take longer to show significant effects on hallucinations, often requiring several weeks for noticeable improvement.
B: Rapid increase in dosages will increase the frequency of adverse effects. Gradually adjusting dosages is crucial to manage potential side effects effectively, making this statement relevant to safe medication practices.
C: Full therapeutic response may require 6 to 8 weeks to be achieved. This accurately reflects the common timeline for antipsychotics to demonstrate their full efficacy, highlighting the patience needed in treatment.
D: Tardive dyskinesia may be reversible in early stages. This statement is misleading; while some symptoms might improve, tardive dyskinesia is often permanent and not reliably reversible, especially if treatment continues.
Which statement is true concerning lithium?
Rationale:
Lithium levels may rise when used concurrently with nonsteroidal antiinflammatory drugs (NSAIDs). This interaction occurs due to NSAIDs potentially impairing renal clearance of lithium, leading to elevated serum concentrations and increased risk of toxicity.
A: The maximum dose is 3.4 g/day. This figure exceeds standard recommendations, with typical maximum doses usually lower than this, ensuring patient safety and minimizing adverse effects.
B: The therapeutic drug range is 2.5 to 3.5 mEq/L. This range surpasses the accepted therapeutic window for lithium, which is generally much lower to avoid toxicity and ensure efficacy.
C: Lithium increases receptor sensitivity to gamma-aminobutyric acid. While lithium affects neurotransmitter systems, it does not primarily enhance sensitivity to GABA; its main actions involve mood stabilization and neurotransmitter regulation.
A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take?
Rationale:
C: Firmly redirect the patient to take the medication. This approach addresses the patient's aggression while emphasizing the importance of medication for his well-being, aiming to de-escalate the situation safely and effectively.
A: Support the patient's decision to refuse the medication. This option neglects the potential need for medication to manage the patient's condition, which could lead to further deterioration of his mental health.
B: Discreetly ask an assistant to put the medication in the patient's food. This method lacks transparency and could provoke greater distrust, exacerbating the patient's paranoia and further complicating the therapeutic relationship.
D: Speak privately with the patient and reinforce medication action. While this option promotes communication, it may not be sufficient to manage the immediate aggression or ensure compliance with medication administration effectively.
A female client who has had bipolar disorder for several years decides to stop all of her medications because she is tired of the side effects. She also cancels all appointments with her therapist, stating that it is just too difficult to plan the visits in her hectic schedule. This client is considered:
Rationale:
B: noncompliant. This client demonstrates noncompliance as she has chosen to discontinue her medications and canceled therapy appointments, indicating a lack of adherence to her treatment plan despite experiencing bipolar disorder.
A: depressed. While the client may experience depressive symptoms, her primary actions reflect a decision to abandon treatment rather than a state of pervasive sadness characteristic of depression.
C: suffering from an anxiety disorder. The client's difficulties with medication side effects and scheduling do not indicate an anxiety disorder; her actions are more aligned with noncompliance to treatment for bipolar disorder.
D: possessing obsessive-compulsive tendencies. The client’s situation does not illustrate obsessive-compulsive behaviors; instead, she is actively disengaging from her treatment, which contradicts the compulsive need for control typical of OCD.
A patient appears to have had an overdose of phenothiazines. The nurse anticipates that which intervention(s) may be used to treat phenothiazine overdose? (Select all that apply.)
Rationale:
C: Maintaining an airway. Ensuring the patient maintains a clear airway is critical in the event of phenothiazine overdose due to potential respiratory depression and impaired consciousness, which can compromise safety.
A: Gastric lavage. While gastric lavage might be considered in some overdose cases, its effectiveness diminishes after a certain time post-ingestion and may not be the primary intervention needed here.
B: Adequate hydration. Hydration is supportive but does not directly address the life-threatening aspects of phenothiazine overdose, such as airway management or respiratory support, which are more urgent.
D: Fluphenazine. Fluphenazine is a phenothiazine itself and would not be used in overdose treatment; administering it could exacerbate the situation rather than provide necessary therapeutic intervention.
The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication?
Rationale:
Agranulocytosis
Clozapine can severely reduce white blood cell counts, leading to agranulocytosis, a serious condition that increases the risk of infections. Weekly blood tests detect this complication early, ensuring patient safety during treatment.
B: Vitamin deficiencies
Monitoring for vitamin deficiencies does not relate to clozapine therapy. The primary concern involves the medication's impact on white blood cell levels rather than nutritional status.
C: Clotting abnormalities
Clozapine does not typically cause clotting issues, making this option irrelevant. The focus of monitoring is on hematological effects, specifically the risk of agranulocytosis.
D: Polycythemia
Polycythemia, characterized by increased red blood cell mass, is not a known complication of clozapine treatment. The significant risk involves white blood cell count, necessitating regular blood tests.
A patient is taking lithium. The nurse should be aware of the importance of which nursing intervention(s)? (Select all that apply.)
Rationale:
Observe the patient for motor tremors. This intervention is crucial as lithium can induce tremors in patients, indicating potential toxicity or dosage issues, thus necessitating close monitoring for safe management of the medication.
B: Monitor the patient for hypotension. Although hypotension can occur, it is not a primary concern specific to lithium therapy and is less directly related to its side effects.
C: Draw lithium blood levels immediately after a dose. Blood levels should be drawn at appropriate intervals rather than immediately after a dose to ensure accurate monitoring of lithium concentrations in the body.
D: Observe the patient for orthostatic hypotension. While relevant in some contexts, orthostatic hypotension is not a significant side effect of lithium therapy and does not warrant focused observation in this scenario.
Which of the following are basic responsibilities of nurses who administer psychotherapeutic drugs? (Select One that does not apply.)
Rationale:
C: Adjusting medication dosages according to therapeutic levels. Nurses typically do not have the authority to modify medication dosages, as this responsibility usually falls to physicians or other prescribing providers.
A: Monitoring and evaluating the client's response to the medication involves tracking effectiveness and side effects, essential tasks for nurses in ensuring safe and effective treatment.
B: Continually assessing the client's condition is vital for nurses, enabling them to detect changes in health status and respond appropriately to ensure effective patient care.
D: Assisting in the coordination of the client's care is a fundamental role of nurses, facilitating communication and collaboration among healthcare team members to optimize patient outcomes.
The nurse is administering medications to a client with a diagnosis of paranoid schizophrenia. The nurse would expect to see which medication ordered for this client?
Rationale:
D: Risperdal is commonly prescribed for individuals with paranoid schizophrenia as it is an atypical antipsychotic that effectively addresses symptoms such as delusions and hallucinations, promoting better overall mental health stability.
A: Lithium primarily treats mood disorders and is not specifically indicated for schizophrenia, lacking efficacy in managing the core symptoms associated with this condition.
B: Depakene is utilized for seizure control and mood stabilization, making it unsuitable for addressing the psychotic features of paranoid schizophrenia, which require targeted antipsychotic treatment.
C: Neurontin is an anticonvulsant often used for neuropathic pain and anxiety, but it doesn't address the primary symptoms of paranoid schizophrenia, thus failing to provide necessary antipsychotic intervention.
A female client is 3-days postoperative and has been receiving meperidine (Demerol) for pain control. The family mentions to the nurse that the client has been taking phenelzine (Nardil) for years for her depression. The client did not list this medication on admission. What signs and symptoms should the nurse look for in case of reaction between these two medications?
Rationale:
Sedation, disorientation, and hallucinations. Meperidine can cause central nervous system depression, which can be exacerbated by phenelzine, leading to significant sedation, altered mental status, and potential hallucinations in the client.
A: Increased pulse and respirations. While some medications may influence vital signs, the combination of meperidine and phenelzine primarily affects mental status rather than increasing pulse and respiratory rates.
B: Hyperactivity and difficulty concentrating. This scenario involves sedative effects rather than hyperactivity; the interaction can lead to decreased concentration and confusion instead of increased energy or focus.
C: Increased tearing and increased urinary output. The symptoms associated with the interaction of these medications primarily involve the central nervous system rather than causing changes in tear production or urinary output.
A female client who has had bipolar disorder for several years decides to stop all of her medications because she is tired of the side effects. She also cancels all appointments with her therapist, stating that it is just too difficult to plan the visits in her hectic schedule. This client is considered:
Rationale:
B: Noncompliant. The client’s decision to stop her medications and cancel therapy appointments demonstrates a refusal to adhere to the prescribed treatment plan, indicating noncompliance with her mental health care.
A: Depressed. While the client may experience depressive symptoms, her primary actions reflect noncompliance rather than a specific depressive episode, as she actively disengages from treatment rather than exhibiting classic depressive behaviors.
C: Suffering from an anxiety disorder. The client’s actions do not indicate anxiety disorder characteristics; instead, her choices highlight a rejection of treatment, which is distinct from the symptoms of anxiety disorders.
D: Possessing obsessive-compulsive tendencies. The situation does not suggest obsessive-compulsive behaviors; rather, it illustrates a lack of commitment to managing her bipolar disorder, focusing on noncompliance instead of compulsive patterns.
A male client with the diagnosis of depression is taking a monoamine oxidase inhibitor (MAOI). Which is the most important teaching point the nurse must include in his care plan?
Rationale:
Avoid alcoholic beverages. Clients on MAOIs must be educated about the risk of hypertensive crisis when consuming tyramine-rich foods and drinks, which are often found in alcoholic beverages, making this crucial for safety.
A: Avoid foods high in sodium content. While sodium intake can affect overall health, it is not specifically linked to MAOI interactions or contraindications in the same way as alcohol.
C: Ensure that protein intake is 60 g/day. Protein intake does not have a direct relationship with MAOI safety; the focus should be on managing tyramine levels rather than protein quantity.
D: Take a potassium supplement. Potassium supplementation is unrelated to MAOI therapy and does not address the critical dietary restrictions necessary for preventing adverse reactions in patients undergoing treatment.
What is the most common cause of nonadherence to antipsychotic pharmacologic treatment?
Rationale:
C: Extrapyramidal effects are the most common cause of nonadherence to antipsychotic treatment, as these side effects can significantly impair a patient's quality of life, leading to avoidance of medication.
A: Expense often influences medication adherence, but many patients prioritize health and may seek alternatives or assistance to manage costs, making it a less prevalent cause of nonadherence.
B: Increased symptoms of chemical dependency can complicate treatment, yet they do not universally affect all patients on antipsychotics, thus not being the primary reason for nonadherence.
D: Inability of the patient to understand the need to take medications can contribute to nonadherence, but many patients comprehend their treatment, with side effects being a more significant barrier.
____ is a side effect that can occur while a client is taking an antipsychotic medication, causing muscle rigidity, high fever, unstable vital signs, confusion, and agitation.
Rationale:
Neuroleptic malignant syndrome (NMS) is a side effect that can occur while a client is taking an antipsychotic medication, causing muscle rigidity, high fever, unstable vital signs, confusion, and agitation.
NMS is characterized by severe symptoms such as hyperthermia, muscle rigidity, and autonomic instability, which are directly related to the usage of antipsychotic medications. Recognizing these symptoms is crucial for timely intervention and treatment.
A: Drug-induced parkinsonism manifests as tremors and rigidity but typically lacks the severe hyperthermia and autonomic instability associated with NMS, making it distinct in symptomatology.
C: Tardive dyskinesia primarily involves involuntary movements, especially of the face and limbs, rather than the acute systemic symptoms seen in NMS, thus differentiating it clinically.
D: Dystonia presents as sustained muscle contractions or abnormal postures, which are localized and do not encompass the systemic reactions like fever and vital sign instability found in NMS.
Lithium levels are considered toxic when they become higher than ____ mEq/L.
Rationale:
Lithium levels are considered toxic when they become higher than 1.5 mEq/L. High lithium concentrations above this threshold can lead to significant toxicity, including severe neurological and gastrointestinal symptoms, necessitating immediate medical intervention to prevent serious health complications and manage potential overdose effects effectively.
B: 0.9 This level is below the toxic threshold, indicating a safe range where lithium can be effectively managed without causing adverse effects on the patient's health.
C: 6.5 This level is excessively high and far above the toxicity threshold, representing a critical state that would likely result in severe and life-threatening conditions requiring urgent care.
D: 2.5 Although elevated, this level does not represent the initial toxic threshold, as toxicity concerns typically arise when levels exceed 1.5 mEq/L, necessitating careful monitoring.
Psychotropic medications can cause a parasympathetic and/or sympathetic response from the autonomic nervous system. Which of the following is considered a sympathetic response?
Rationale:
Pupil dilation. This response is characteristic of the sympathetic nervous system, which prepares the body for 'fight or flight' situations. In contrast to the parasympathetic response, pupil dilation enhances vision by allowing more light to enter the eyes.
B: Increased saliva production. This action relates to the parasympathetic system, which promotes rest and digestion, rather than the activation associated with sympathetic responses.
C: Decreased heart rate. This is indicative of a parasympathetic response, which calms the body and conserves energy, thus not aligning with the sympathetic activation.
D: Constricted airway. This condition is associated with the parasympathetic nervous system, which facilitates relaxation, opposing the sympathetic response that typically leads to airway dilation for increased airflow.
A patient is prescribed lorazepam. What does the nurse know to be true regarding lorazepam?
Rationale:
Lorazepam is used to treat anxiety. This medication is a benzodiazepine that effectively alleviates symptoms of anxiety disorders by enhancing the effects of a neurotransmitter called gamma-aminobutyric acid (GABA) in the brain, promoting relaxation and reducing nervousness.
B: status epilepticus This option refers to a specific emergency condition where benzodiazepines may be utilized, but lorazepam is not primarily indicated for routine treatment of seizures.
C: insomnia While lorazepam can help with sleep issues, its primary designation is for anxiety management rather than as a first-line treatment for insomnia specifically.
D: and sedation induction Although lorazepam can induce sedation, this aspect is secondary to its primary use in treating anxiety disorders, making it less relevant in this context.
____ side effects can occur when antipsychotic medications are taken that manifest as abnormal movements such as akathisia and pseudo-Parkinson symptoms.
Rationale:
Extrapyramidal side effects can occur when antipsychotic medications are taken that manifest as abnormal movements such as akathisia and pseudo-Parkinson symptoms.
Extrapyramidal side effects are specifically linked to antipsychotic medications, resulting in movement disorders like akathisia and pseudo-Parkinsonism. These symptoms arise from the drugs' impact on the extrapyramidal system, which regulates motor control, thus making this option the most relevant to the question.
B: Neuroleptic Malignant Syndrome This syndrome involves severe muscle rigidity and autonomic dysfunction, not the abnormal movements specified in the question.
C: Autonomic Nervous System This system regulates involuntary bodily functions, but it does not pertain to the abnormal movements associated with antipsychotic medications.
D: Cardiovascular While cardiovascular side effects may occur with medications, they do not relate to the abnormal movements mentioned in the context of antipsychotic treatment.
Which statement is true regarding the adverse effects associated with antipsychotic medications?
Rationale:
Painful dystonic reactions can occur in the first 72 hours of initiation of therapy. This statement accurately reflects the timeline for the onset of such reactions, highlighting their acute nature in patients starting antipsychotic treatment.
A: Tardive dyskinesia is a common, reversible condition. Tardive dyskinesia is often irreversible and develops after prolonged use of antipsychotics, making this statement misleading regarding its commonality and reversibility.
C: Neuroleptic malignant syndrome (NMS) is a common adverse effect. NMS is rare but serious, occurring in a small percentage of patients, thus misrepresenting its prevalence as a common side effect.
D: Pseudoparkinsonian symptoms can cause Parkinson's disease. Pseudoparkinsonism mimics Parkinson's disease but does not cause it; instead, it is a side effect of certain medications, not a causative factor.
A female client calls the clinic for advice after forgetting to take her morning dose of twice-daily lithium 5 hours ago. Which instructions should the nurse give the client?
Rationale:
C: Eliminate the dose missed, and take the second dose at the normal time. Clients should skip a missed lithium dose if it's close to the next scheduled dose to avoid potential toxicity. Taking two doses too close together can lead to dangerously high levels of lithium in the body, increasing the risk of adverse effects.
A: Take the dose immediately, and then take the second dose 3 hours late. This approach risks lithium toxicity, as taking doses too close together can lead to elevated serum levels and adverse reactions.
B: Take half of a dose now, and then take the second dose at the normal time. Taking a partial dose is not recommended for lithium, as it may not maintain therapeutic levels effectively and could lead to inadequate treatment.
D: Immediately take the missed dose, and take the second dose at the normal time. This method poses a significant risk of lithium overdose, as it disregards the timing of the next scheduled dose.
A patient is taking tranylcypromine sulfate for depression. What advice should the nurse include in the teaching plan for this medication?
Rationale:
Patients taking tranylcypromine sulfate must avoid beer and cheddar cheese due to the risk of hypertensive crisis from tyramine, a substance in these foods that can interact dangerously with MAO inhibitors.
A: Warn the patient about severe hypotension. While hypotension can occur, the primary concern with tranylcypromine is dietary restrictions, not severe hypotension.
C: Encourage the patient to take ginseng and ephedra. These substances can increase blood pressure and may lead to adverse effects when combined with tranylcypromine, posing significant health risks.
D: Encourage the patient to eat fruit such as bananas. While bananas are generally safe, they can contain tyramine in large amounts, which is not advisable for patients on MAO inhibitors.
During client teaching, the nurse must inform the client prescribed a tricyclic antidepressant (TCA) to not expect to see a difference in mood or anxiety level for up to:
Rationale:
Mood or anxiety level improvements may not be noticeable for 2 to 3 weeks after starting a tricyclic antidepressant (TCA), as these medications require time to exert their effects.
A: 5 days. Initial effects of TCAs appear later than this short timeframe, making 5 days insufficient for any noticeable changes in mood or anxiety.
C: 4 to 5 weeks. While TCAs may continue to improve mood over this time, the initial expectation for noticeable effects is generally set at 2 to 3 weeks.
D: 6 weeks. This timeframe exceeds the typical expectation for initial mood or anxiety improvements with TCAs, which usually manifest within 2 to 3 weeks of treatment initiation.
The CMA is administering an antianxiety medication to a client. Monitoring side effects is the responsibility of which member of the health care team?
Rationale:
Monitoring side effects of antianxiety medication is the responsibility of the nurse. Nurses are trained to observe and assess clients for adverse reactions to medications, ensuring patient safety and effective treatment.
B: CMA The CMA supports medication administration but lacks the comprehensive training necessary to monitor complex side effects, which requires the clinical judgment of a nurse.
C: Physician While the physician prescribes the medication, ongoing monitoring of side effects falls to nursing staff, who directly oversee client responses to treatment on a day-to-day basis.
D: Therapist Therapists focus on emotional and psychological support rather than medical monitoring, making them ill-equipped to track medication side effects effectively, which is a nursing responsibility.
Dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia are types of which effect?
Rationale:
Extrapyramidal symptoms
These reactions, including dystonic reactions, pseudoparkinsonism, akathisia, and tardive dyskinesia, are all categorized as extrapyramidal symptoms due to their association with disturbances in motor control linked to antipsychotic medications.
B: Allergic reactions
Allergic reactions involve immune responses to substances, which does not pertain to the motor control side effects seen with the listed symptoms, making this option irrelevant.
C: Idiosyncratic reactions
Idiosyncratic reactions are unpredictable responses to drugs that differ from expected effects, whereas the listed symptoms are well-documented, consistent reactions to specific medications, thus distinct.
D: Therapeutic responses
Therapeutic responses refer to the intended beneficial effects of medication, contrasting sharply with the unwanted movement disorders described, which are adverse effects rather than therapeutic outcomes.
Why is a combination of antipsychotic agents with benzodiazepines useful in initial treatment of the agitated patient?
Rationale:
A: Antipsychotics are not effective for 2 days. This statement misrepresents the pharmacodynamics of antipsychotic medications, which can often begin to alleviate symptoms within hours, not days, of administration.
B: Benzodiazepines allow for higher dosages of antipsychotic agents to be used, thereby decreasing serious adverse effects seen with high-dose therapy. This option incorrectly assumes that benzodiazepines primarily facilitate dosage increases rather than focusing on immediate calming effects, which is critical for managing agitation.
D: It allows for rapid increase in dosing of the antipsychotic agents to expedite treatment of hallucinations. This choice overlooks the primary function of benzodiazepines, which is to provide immediate sedation and stabilization rather than accelerating antipsychotic dosing.
Which of the following are basic responsibilities of nurses who administer psychotherapeutic drugs? (Select one that does not apply..)
Rationale:
C: Adjusting medication dosages according to therapeutic levels. Nurses administering psychotherapeutic drugs primarily monitor and assess client responses, rather than adjust dosages, which typically falls under the physician's responsibilities and requires specific expertise.
A: Monitoring and evaluating the client's response to the medication. This is a fundamental duty of nurses, ensuring the medication's efficacy and identifying any adverse effects on the client promptly.
B: Continually assessing the client's condition. Ongoing assessment is crucial for nurses to provide appropriate care and respond effectively to any changes in the client's psychological state or medication effects.
D: Assisting in the coordination of the client's care. Nurses play a vital role in coordinating care among healthcare providers, ensuring comprehensive treatment and support for the client's overall well-being.
The ____ constitute a class of drugs that are commonly prescribed for cardiac arrhythmias but also have been found to be effective treatment for social phobias.
Rationale:
Beta-blockers constitute a class of drugs that are commonly prescribed for cardiac arrhythmias but also have been found to be effective treatment for social phobias.
Beta-blockers are effective in managing cardiac arrhythmias by blocking adrenaline effects, thus stabilizing heart rhythm. Their ability to reduce physical symptoms of anxiety, such as rapid heartbeat, makes them beneficial for treating social phobias, providing additional therapeutic use beyond their primary indication.
A: Benzodiazepines These medications primarily address anxiety and insomnia, lacking the specific application for cardiac arrhythmias and not being a standard treatment for social phobias.
B: Tricyclics While tricyclics can treat depression and anxiety, their association with cardiac issues and side effects limits their use for arrhythmias compared to beta-blockers.
C: Azaspirones This class focuses on anxiety treatment without any established efficacy in managing cardiac arrhythmias, thus failing to connect with both aspects of the question.
Valium is administered to a client anxious about impending surgery. Which of the following side effects is the client at risk for?
Rationale:
B: The client is at risk for falls due to Valium's sedative properties, which can impair coordination, balance, and cognitive function. These effects heighten the likelihood of accidents and injuries, especially in anxious patients preparing for surgery.
A: Seizures Valium is typically used to prevent seizures, making this option unlikely for a client receiving the medication.
C: Hypertensive crisis Valium does not generally cause significant increases in blood pressure, rendering this option irrelevant for someone taking the medication.
D: Tachycardia Valium is more associated with sedative effects than with increased heart rate, making tachycardia an uncommon risk.
Selective serotonin reuptake inhibitors (SSRIs) are most health care providers' drug of choice for the treatment of depression because:
Rationale:
Selective serotonin reuptake inhibitors (SSRIs) are the drug of choice for treating depression due to their more manageable side effects compared to other antidepressants, making them a preferred option for patients.
A: SSRIs offer a favorable side effect profile, allowing for better patient adherence and satisfaction. This contributes to their popularity among health care providers in managing depression effectively.
B: SSRIs are not the only class deemed safe for long-term therapy; other antidepressants also demonstrate safety over extended periods.
C: SSRIs are not the oldest class of antidepressants; tricyclics and monoamine oxidase inhibitors predate them, impacting their historical classification.
D: SSRIs are not considered fast-acting; they typically require several weeks to achieve therapeutic effects, unlike some other medications used for depression.
A male client with schizophrenia lives in an assisted-living complex for individuals with mental health disorders. He is tired of the Parkinson-like symptoms he experiences with his antipsychotic medication and therefore stops taking his medication after much discussion with his treatment team. He is progressively withdrawing from reality but is not a safety risk at this point to himself or others. What is the best response of the nurse and treatment team?
Rationale:
Ensure that the client and those around him are safe, and monitor for additional symptoms of his schizophrenia while maintaining trust with the client.
This response prioritizes the client's safety while respecting his autonomy. By monitoring his condition and nurturing trust, the treatment team can provide support without alienating him, which is crucial for effective mental health management in clients with schizophrenia.
A: Try to coerce him into taking his medication. Coercion undermines trust and may worsen his withdrawal from reality, leading to increased resistance and further deterioration of his mental health.
C: Crush his antipsychotic medications and put them in his food to stop the process of his withdrawal from reality. This approach violates ethical principles of consent and autonomy, potentially damaging the therapeutic relationship.
D: Speak to his family about seeking an involuntary emergency hold in a mental health facility to get him back on his medications. Involuntary measures may escalate his withdrawal from reality and damage trust, hindering future treatment efforts.
The psychiatric nurse is educating an elderly patient and family about antipsychotic drug therapy. When providing this education, the nurse will include which statement(s)? (Select one that does not apply..)
Rationale:
Hallucinations may be reduced within 1 week of starting. This statement is misleading as it oversimplifies the timeline for symptom improvement, which can vary considerably among individuals undergoing antipsychotic treatment.
B: Rapid increase in dosages will increase the frequency of adverse effects. This statement highlights the potential risks associated with hastily adjusting medication dosages, emphasizing the need for careful management to minimize complications.
C: Full therapeutic response may require 6 to 8 weeks to be achieved. This accurately reflects the gradual onset of antipsychotic medications, acknowledging that patients may need extended periods to experience the full benefits.
D: Tardive dyskinesia may be reversible in early stages. This statement suggests a possibility that is not universally accepted, as tardive dyskinesia can often become permanent, emphasizing the importance of early detection and treatment.
Which statement is true concerning lithium?
Rationale:
Concurrent nonsteroidal antiinflammatory drugs (NSAIDs) may increase lithium levels. This interaction can lead to elevated lithium concentrations in the bloodstream, which necessitates careful monitoring to prevent toxicity and ensure patient safety.
A: The maximum dose is 3.4 g/day. This dosage is not supported by standard guidelines, as the typical maximum daily dose for lithium is generally lower, around 2.4 g/day.
B: The therapeutic drug range is 2.5 to 3.5 mEq/L. This range is too high, as the accepted therapeutic range for lithium is typically between 0.6 to 1.2 mEq/L for effective treatment.
C: Lithium increases receptor sensitivity to gamma-aminobutyric acid. This statement misrepresents lithium's mechanisms, as its primary action involves modulating neurotransmitter systems rather than directly altering GABA receptor sensitivity.
A male patient becomes verbally aggressive and insists the nurse is poisoning him as she attempts to administer haloperidol (Haldol). Which action will the nurse take?
Rationale:
C: Firmly redirect the patient to take the medication. This approach addresses the patient's aggression directly while ensuring that he receives necessary treatment. By being assertive, the nurse can help manage the situation and prioritize the patient's safety and well-being.
A: Support the patient's decision to refuse the medication. Validating the patient's refusal without addressing his concerns may lead to worsening symptoms and further deterioration of his mental state.
B: Discreetly ask an assistant to put the medication in the patient's food. This tactic undermines trust and consent, potentially exacerbating the patient's paranoia and reinforcing his belief that he is being poisoned.
D: Speak privately with the patient and reinforce medication action. While this is a supportive approach, it lacks the necessary firmness to redirect the patient's aggressive behavior and may not effectively ensure medication compliance.
A female client who has had bipolar disorder for several years decides to stop all of her medications because she is tired of the side effects. She also cancels all appointments with her therapist, stating that it is just too difficult to plan the visits in her hectic schedule. This client is considered:
Rationale:
B: noncompliant.
The client’s decision to stop her medications and cancel therapy appointments indicates a refusal to adhere to prescribed treatment, demonstrating noncompliance. This behavior can exacerbate her bipolar disorder and lead to a deterioration of her mental health.
A: depressed.
While the client may experience depressive symptoms, her primary actions reflect noncompliance rather than a state of depression. Depressive states are not solely defined by treatment refusal.
C: suffering from an anxiety disorder.
The client’s behaviors do not exhibit signs typical of an anxiety disorder. Anxiety disorders involve excessive worry or fear, which are not evident in her decision-making process.
D: possessing obsessive-compulsive tendencies.
There are no indications of obsessive or compulsive behaviors in the client’s actions. Her choices reflect a disengagement from treatment rather than a struggle with intrusive thoughts or compulsions.
A patient appears to have had an overdose of phenothiazines. The nurse anticipates that which intervention(s) may be used to treat phenothiazine overdose? (Select all that apply.)
Rationale:
C: Maintaining an airway. Ensuring a clear airway is critical in managing phenothiazine overdose, as respiratory depression may occur, necessitating immediate interventions to prevent hypoxia and facilitate effective ventilation.
A: Gastric lavage. While gastric lavage can be a consideration in certain overdoses, it is not a primary intervention for phenothiazine overdose due to potential complications and limited effectiveness.
B: Adequate hydration. Although hydration is generally beneficial, it does not directly address the effects of phenothiazine overdose, which primarily involves managing airway and respiratory concerns rather than fluid balance.
D: Fluphenazine. This medication is a phenothiazine itself and would not be utilized in overdose situations; administering it could exacerbate the patient's condition rather than provide any therapeutic benefit.
The nurse is teaching a patient who is taking clozapine (Clozaril) to have weekly blood tests for the first 6 months of treatment to monitor for which potential complication?
Rationale:
Agranulocytosis
Clozapine, an atypical antipsychotic, can lead to agranulocytosis, a dangerous decrease in white blood cell count. Regular weekly blood tests are essential during the first six months to detect this potentially life-threatening complication early and ensure patient safety. Monitoring helps prevent severe infections and other serious health issues related to low immune function.
B: Vitamin deficiencies Vitamin deficiencies are not a recognized risk associated with clozapine, making regular blood tests unnecessary specifically for this concern. Monitoring focuses primarily on hematological effects rather than nutritional status.
C: Clotting abnormalities Clozapine does not typically induce clotting abnormalities, so weekly blood tests are not aimed at detecting such issues. The primary concern lies in blood cell counts, not coagulation factors.
D: Polycythemia Polycythemia is unrelated to clozapine treatment; thus, weekly blood tests are not required to monitor for this condition. The focus remains on white blood cell levels, particularly for agranulocytosis.
A patient is taking lithium. The nurse should be aware of the importance of which nursing intervention(s)? (Select all that apply.)
Rationale:
Observe the patient for motor tremors.
Monitoring for motor tremors is crucial as lithium can induce such side effects, indicating potential toxicity or dosage issues. Early identification of tremors allows for timely intervention and adjustment of therapy, ensuring patient safety and optimal treatment outcomes.
B: Monitor the patient for hypotension. While lithium can influence blood pressure, hypotension is not a primary concern associated with its use, making this monitoring less critical.
C: Draw lithium blood levels immediately after a dose. Blood levels should be taken at specific intervals to accurately assess lithium concentration; immediate post-dose levels do not reflect therapeutic effectiveness.
D: Observe the patient for orthostatic hypotension. Orthostatic hypotension is more relevant in other medications and conditions, thus not a primary concern when managing patients on lithium therapy.