Pharmacology Practice Test #8: Psychiatric Medications

Answer: B. Hold the next clozapine dose, take the client's vital signs, and notify the provider so a neutrophil count can be checked

Rationale: Clozapine can cause severe neutropenia (agranulocytosis), which leaves the client unable to fight infection. Sore throat, fever, chills, body aches or mouth sores in a client taking clozapine are treated as possible signs of neutropenia until proven otherwise. The nurse holds the next dose, assesses vital signs, and notifies the provider promptly so an absolute neutrophil count (ANC) can be drawn; the provider decides whether to continue, interrupt or stop the drug based on the result and the labeling. Clients on clozapine have ANC monitored on a schedule set by the labeling and the prescriber, and the risk is highest in the first months of therapy. Option A is wrong because treating the fever masks a possible serious infection and delays the blood count. Option C is wrong because it assumes a minor cause without ruling out neutropenia. Option D is wrong because sore throat and fever are not expected effects; they are warning signs.

Answer: D. Hold the haloperidol, notify the provider immediately, and begin cooling measures as ordered

Rationale: High fever, generalized "lead-pipe" muscle rigidity, altered mental status and unstable vital signs (fast heart rate, sweating, labile blood pressure) in a client taking an antipsychotic point to neuroleptic malignant syndrome (NMS). NMS is a medical emergency that can lead to rhabdomyolysis, kidney failure and death. The nurse stops the antipsychotic, notifies the provider at once, and starts supportive care as ordered: cooling, IV fluids, and close monitoring of vital signs, kidney function and creatine kinase. The provider may order drugs such as dantrolene or bromocriptine. Option A is wrong because more haloperidol worsens NMS. Option B is wrong because these findings need action now, not at the end of the shift. Option C is wrong because NMS is not an expected side effect, and an anticholinergic does not treat it.

Answer: A. Give the as-needed benztropine or diphenhydramine that is prescribed for this reaction, then stay with the client

Rationale: Sudden, painful muscle spasms of the neck (torticollis), eyes (oculogyric crisis) or tongue soon after starting a first-generation antipsychotic are signs of an acute dystonic reaction. It usually appears within hours to days of starting or raising the dose, and young adults are at higher risk. It is treated quickly with an anticholinergic such as benztropine or an antihistamine such as diphenhydramine, given IM or IV as prescribed, and it usually eases within minutes. The nurse stays with the client, watches the airway (laryngeal spasm is rare but dangerous), and reports the reaction so the provider can review the antipsychotic. Option B is wrong because this is a drug reaction, not a behavior problem. Option C is wrong because acute dystonia is reversible; the late, often lasting movement disorder is tardive dyskinesia. Option D is wrong because more haloperidol can worsen the reaction.

Answer: C. Fresh roasted chicken with rice and steamed green beans

Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the breakdown of tyramine, so foods high in tyramine can trigger a hypertensive crisis: a sudden, severe rise in blood pressure with a pounding occipital headache, stiff neck, palpitations, nausea and sweating. High-tyramine foods are usually aged, fermented, cured, smoked or spoiled: aged cheeses, cured and smoked meats such as salami and sausage, sauerkraut, soy sauce, tap or draft beer, and leftovers that are not fresh. Freshly cooked chicken, rice and fresh vegetables are low in tyramine. The client is also taught to report a severe headache at once, to keep the diet restrictions for the period after stopping the drug that the prescriber or labeling specifies, and to check with the prescriber or pharmacist before taking any other medicine, including cold remedies and supplements. Options A, B and D each contain high-tyramine foods.

Answer: A. The client was treated for bulimia nervosa last year

Rationale: Bupropion lowers the seizure threshold. The labeling lists a seizure disorder and a current or prior diagnosis of bulimia or anorexia nervosa as contraindications, because electrolyte problems from these eating disorders raise the seizure risk further. Abruptly stopping alcohol, benzodiazepines, barbiturates or antiseizure drugs is also a contraindication for the same reason. The nurse reports the eating disorder history so the provider can choose another treatment. As with all antidepressants, clients under 25 also need close watching for new or worsening suicidal thoughts in the first weeks and after dose changes. Option B is wrong because moderate caffeine use is not a contraindication. Option C is wrong because an old fracture has no bearing on bupropion. Option D is wrong because saline nasal spray does not interact with bupropion.

Answer: D. Respiratory rate, oxygen saturation and level of sedation

Rationale: Benzodiazepines such as alprazolam and opioids such as oxycodone both depress the central nervous system. Taken together they can cause profound sedation, slowed or stopped breathing, coma and death, which is the subject of an FDA boxed warning on both drug classes. Older adults are at higher risk. The nurse monitors respiratory rate and depth, oxygen saturation and sedation level (using the facility's sedation scale) before and after each opioid dose, holds the dose and notifies the provider if the client is too sedated, and keeps naloxone available per protocol. The benzodiazepine should not be stopped suddenly, but the provider should know about both drugs. Options A, B and C are reasonable routine checks, but they do not address the life-threatening risk of combined respiratory depression.

Answer: B. "I've had bad pain in my upper belly that goes through to my back, and I keep vomiting."

Rationale: Valproate (valproic acid and divalproex sodium) carries boxed warnings for liver failure, pancreatitis and harm to a developing fetus. Severe upper abdominal pain that goes through to the back, with nausea and vomiting, suggests pancreatitis, which can be life-threatening and has occurred both early and after years of use. The nurse reports it at once so the provider can assess the client (for example, with serum amylase and lipase) and decide whether to stop the drug. Clients are also taught to report yellow skin or eyes, dark urine, unusual tiredness, loss of appetite or easy bruising, and liver function is monitored as the prescriber orders. People who could become pregnant need counseling about fetal risk and contraception. Options A, C and D describe hair thinning, weight gain and a mild tremor: common side effects to mention at the next visit, not emergencies.

Answer: C. Weight and waist circumference, blood pressure, fasting glucose or A1C, and a fasting lipid panel

Rationale: Second-generation antipsychotics, especially olanzapine and clozapine, can cause metabolic syndrome: weight gain, raised blood glucose (including new diabetes), high cholesterol and triglycerides, and high blood pressure. Consensus guidelines recommend checking weight or BMI, waist circumference, blood pressure, fasting glucose or A1C and fasting lipids before starting and at regular intervals during treatment; the exact schedule is set by the prescriber and facility policy. The nurse also teaches the client to report increased thirst, frequent urination or rapid weight gain, and supports healthy eating and activity. Option A is wrong because these labs monitor lithium therapy. Option B is incomplete and misses the main metabolic risks. Option D is wrong because olanzapine does not call for respiratory monitoring of this kind.

Answer: D. "I'll give it in the morning, and we'll track appetite, sleep, height and weight."

Rationale: Methylphenidate is a central nervous system stimulant. Common side effects include trouble sleeping, poor appetite and weight loss, and it can slow growth in some children, so doses are usually given in the morning (and early in the day if a second dose is ordered) and the child's height, weight, heart rate and blood pressure are tracked over time. The parent should report chest pain, fainting, a racing heart or new behavior changes. Stimulants are controlled substances with a risk of misuse, so they are stored safely and given only as prescribed. Option A is wrong because a bedtime dose causes insomnia. Option B is wrong because extra doses are unsafe and are never given without a prescription. Option C is wrong because any change or stop is planned with the prescriber, not decided on one report.

Answer: A. "Mouthwash is fine to use because I don't swallow it."

Rationale: Disulfiram blocks the breakdown of alcohol, so even small amounts can cause a disulfiram-alcohol reaction: flushing, throbbing headache, nausea and vomiting, sweating, chest pain, a fast heart rate, low blood pressure and trouble breathing; severe reactions can be life-threatening. Alcohol in mouthwash, cough and cold syrups, some sauces and vinegars, and alcohol-based skin products such as aftershave or some hand sanitizers can be enough to trigger a reaction, so the statement about mouthwash shows a need for more teaching. The client is taught that a reaction can still occur for up to about 2 weeks after the last dose (per the labeling), and that disulfiram is never given to a person who is intoxicated or without the person's full knowledge. Options B, C and D are correct statements.