Foundations of Psychiatric Mental Health Nursing A Clinical Approach, 5th Edition by Elizabeth M. Varcarolis – Test Bank
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Varcarolis: Foundations of Psychiatric Mental Health Nursing: A
Clinical Approach, 5th Edition
Test Bank
Chapter 3: Biological Basis for Understanding Psychotropic Drugs
MULTIPLE CHOICE
1) A client asks the nurse, “What are
neurotransmitters? My doctor says they are at the root of my problem.” The best
reply would be
|
A. |
“You must feel relieved to
know that your problem has a physical basis.” |
|
B. |
“It is a rather high-level
concept to explain. Perhaps you should ask the doctor to tell you more.” |
|
C. |
“Neurotransmitters are
substances we eat daily that influence the brain functions of memory and
mood.” |
|
D. |
“Neurotransmitters are
chemicals manufactured in the brain that are responsible for passing messages
between brain cells.” |
ANS: D
Option D gives the most accurate information. Neurotransmitters
are chemical substances that function as neuromessengers. They are released
from the axon terminal and diffuse across the synapse and attach to specialized
receptors on the postsynaptic neuron. Option A does not answer the client’s
question. Option B does not answer the client’s question and is somewhat
demeaning. Option C provides untrue, misleading information.
DIF: Cognitive Level: Application
REF: Text Page: 38, Text Page: 39, Text Page:
40
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
2) The mother of an adolescent client with
obsessive-compulsive disorder tells the nurse, “My daughter’s doctor wants her
to be in a research study and to have a PET [positron emission tomography]
scan. I do not want her to have to go through any tests that are painful. What
should I do?” The best reply for the nurse would be
|
A. |
“The doctor has made the
diagnosis, but having a PET scan would confirm it.” |
|
B. |
“You might want to ask who
will pay for the PET scan because they are very expensive.” |
|
C. |
“PET scans involve an
injection and lying still while a machine visualizes brain activity.” |
|
D. |
“PET scans involve passing
an electrical current through the brain and can be uncomfortable.” |
ANS: C
The mother is seeking information about PET scans. Option C is
the only option that provides factual information on which the mother can base
a decision.
DIF: Cognitive Level: Application
REF: Text Page: 44, Text Page: 45, Text Page:
46
TOP: Nursing Process:
Implementation MSC: NCLEX:
Psychosocial Integrity
3) The physician mentions that a client’s dementia
may be associated with either Alzheimer’s disease or multiple infarcts. For the
physician to make a differential diagnosis with the least expensive test, the
nurse should expect to prepare the client for a
|
A. |
computed tomography (CT)
scan. |
|
B. |
magnetic resonance imaging
(MRI) scan. |
|
C. |
PET scan. |
|
D. |
single-photon emission
computed tomography (SPECT) scan. |
ANS: A
The CT scan could be expected to show the presence or absence of
cortical atrophy, ventricular enlargement, and areas of infarct, information
that would be helpful to the physician. The CT scan is the least expensive of
the imaging techniques listed.
DIF: Cognitive Level:
Application
REF: Text Page: 44
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
4) A client has delusions and hallucinations. Before
beginning treatment with psychotropic drugs, the physician wishes to rule out
the presence of a brain tumor. For which test will the nurse need to prepare
the client?
|
A. |
CT or MRI scan |
|
B. |
PET or SPECT scan |
|
C. |
Cerebral arteriogram |
|
D. |
Neuronal depolarization |
ANS: A
CT and MRI scans visualize neoplasms and other structural
abnormalities. Options B and C: A scan giving information about brain function
is not called for, and an arteriogram would not be appropriate. Option D:
Neuronal depolarization is not a diagnostic test.
DIF: Cognitive Level:
Application
REF: Text Page: 44
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
5) A client who is being admitted for depression
should be assessed for disturbances in circadian rhythms. The question that
best implements this assessment is
|
A. |
“What time of day do you
feel worst and when do you feel best?” |
|
B. |
“Do you ever see or hear
things that others do not?” |
|
C. |
“How would you describe
your thinking?” |
|
D. |
“Would you say your memory
is failing?” |
ANS: A
Mood changes throughout the day are related to circadian
rhythms. Questions about sleep pattern would also be relevant to circadian
rhythms. Option B is relevant to the assessment for illusions and
hallucinations. Option C is relevant to the assessment of thought processes.
Option D is relevant to the assessment of memory.
DIF: Cognitive Level:
Application
REF: Text Page: 37, Text Page: 38
TOP: Nursing Process:
Assessment
MSC: NCLEX: Psychosocial Integrity
6) When the wife of a client with schizophrenia asks
which neurotransmitter is implicated in the development of schizophrenia, the
nurse should state “The current thinking is that the thought disturbances are
related to
|
A. |
excess dopamine.” |
|
B. |
serotonin deficiency.” |
|
C. |
histamine decrease.” |
|
D. |
increased γ-aminobutyric
acid [GABA].” |
ANS: A
Dopamine plays a role in integration of thoughts and emotions,
and excess dopamine is implicated in the thought disturbances of schizophrenia.
Option B: Serotonin deficiency is implicated in some forms of depression.
Option C: Histamine decrease is associated with depression. Option D: Increased
GABA is associated with anxiety reduction.
DIF: Cognitive Level: Application
REF: Text Page: 40
TOP: Nursing Process:
Implementation MSC: NCLEX:
Physiologic Integrity
7) Ongoing assessment and outcome planning for a
client with schizophrenia are facilitated if the nurse understands that the
medication prescribed to reduce the client’s symptoms targets the
neurotransmitter
|
A. |
dopamine. |
|
B. |
serotonin. |
|
C. |
norepinephrine. |
|
D. |
acetylcholine. |
ANS: A
Dopamine is a neurotransmitter found in areas of the brain
responsible for decision making and integrating thoughts and emotions. Knowing
this, the nurse can formulate related outcomes. Because dopamine is a
neurotransmitter found in the extrapyramidal system, the nurse can also provide
ongoing assessment for movement disorders. Option B: Serotonin is the target of
selective serotonin reuptake inhibitors (SSRIs). Option 3: Norepinephrine is
targeted by selected antidepressant medications. Option D: Acetylcholine is
affected by drugs with cholinergic effects.
DIF: Cognitive Level:
Application
REF: Text Page: 50
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
8) The nurse should provide ongoing assessment for a
client receiving medication that potentiates the action of GABA relative to
|
A. |
reduced anxiety. |
|
B. |
improved memory. |
|
C. |
more organized thinking. |
|
D. |
fewer sensory perceptual
alterations. |
ANS: A
Increased levels of GABA reduce anxiety; thus any potentiation
of GABA action should result in anxiety reduction. Option B: Acetylcholine and
substance P, rather than GABA, are associated with memory enhancement. Option
C: Thought disorganization is associated with dopamine rather than GABA. Option
D: GABA is not associated with sensory perceptual alterations.
DIF: Cognitive Level:
Application
REF: Text Page: 40
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
9) On the basis of current knowledge of
neurotransmitter effects, the nurse could anticipate that the treatment plan
for a client with memory difficulties might include orders to administer
medication designed to
|
A. |
inhibit GABA. |
|
B. |
increase dopamine at
receptor sites. |
|
C. |
decrease dopamine at
receptor sites. |
|
D. |
prevent destruction of
acetylcholine. |
ANS: D
Increased acetylcholine plays a role in learning and memory.
Preventing destruction of acetylcholine by acetylcholinesterase would result in
higher levels of acetylcholine, with the potential for improved memory. Option
A: GABA is known to affect anxiety level rather than memory. Option B:
Increased dopamine would cause symptoms associated with schizophrenia or mania
rather than improve memory. Option C: Decreasing dopamine at receptor sites is
associated with Parkinson’s disease rather than improving memory.
DIF: Cognitive Level:
Application
REF: Text Page: 40
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
10) A client demonstrates disorganized and
delusional thinking. The tentative diagnosis is schizophrenia. The nurse can
anticipate that a PET scan would be most likely to show dysfunction in the part
of the brain called the
|
A. |
temporal lobe. |
|
B. |
cerebellum. |
|
C. |
brainstem. |
|
D. |
frontal lobe. |
ANS: D
The frontal lobe is responsible for intellectual functioning.
Option A: The temporal lobe is responsible for the sensation of hearing. Option
B: The cerebellum regulates skeletal muscle coordination and equilibrium.
Option C: The brainstem regulates internal organs.
DIF: Cognitive Level: Analysis
REF: Text Page: 43, Text Page: 44, Text Page:
45, Text Page: 46, Text Page: 47
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiologic Integrity
11) The nurse should assess clients taking a drug
known to have anticholinergic properties for symptoms of inhibition of function
of the
|
A. |
parasympathetic nervous
system. |
|
B. |
sympathetic nervous system. |
|
C. |
reticular activating
system. |
|
D. |
medulla oblongata. |
ANS: A
Acetylcholine is the neurotransmitter found in high
concentration in the parasympathetic nervous system. When acetylcholine action
is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred
vision, dry mouth, constipation, and urinary retention appear. Options B, C,
and D: The functions of these parts of the nervous system are not affected by
anticholinergics.
DIF: Cognitive Level:
Application
REF: Text Page: 51
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
12) The nurse can explain the therapeutic action of
monoamine oxidase (MAO) inhibitors as blocking neurotransmitter reuptake,
causing
|
A. |
increased concentration of
neurotransmitter in the synaptic gap. |
|
B. |
decreased concentration of
neurotransmitter in the synaptic gap. |
|
C. |
destruction of receptor
sites. |
|
D. |
limbic system stimulation. |
ANS: A
If the reuptake of a substance is inhibited, it accumulates in
the synaptic gap and its concentration increases, permitting ease of
transmission of impulses across the synaptic gap. Normal transmission of
impulses across synaptic gaps is consistent with normal rather than depressed
mood. The other options are not associated with blocking neurotransmitter
reuptake.
DIF: Cognitive Level:
Comprehension REF: Text
Page: 41
TOP: Nursing Process:
Implementation MSC: NCLEX:
Physiologic Integrity
13) A client taking medication for his mental
illness develops a profound sense of restlessness and an uncontrollable need to
be in motion. The nurse can correctly hypothesize that these symptoms are
related to the drug’s
|
A. |
dopamine-blocking effects. |
|
B. |
anticholinergic effects. |
|
C. |
endocrine-stimulating
effects. |
|
D. |
ability to stimulate spinal
nerves. |
ANS: A
Medication that blocks dopamine is often seen to produce
disturbances of movement such as akathisia because dopamine affects neurons
involved in both thought processes and movement regulation. Option B:
Anticholinergic effects include dry mouth, blurred vision, urinary retention,
and constipation. Options C and D: Akathisia is not caused by endocrine
stimulation or spinal nerve stimulation.
DIF: Cognitive Level:
Application
REF: Text Page: 50, Text Page: 51
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
14) A nurse makes the assessment that the client
demonstrates anxiety and a number of responses consistent with sympathetic
nervous system stimulation. The nurse would suspect the presence of a high
concentration of brain
|
A. |
GABA. |
|
B. |
histamine. |
|
C. |
acetylcholine. |
|
D. |
norepinephrine. |
ANS: D
Norepinephrine is the neurotransmitter associated with
sympathetic nervous system stimulation, preparing the individual for “fight or
flight.” Option A: GABA is a mediator of anxiety level. Option B: A high
concentration of histamine is associated with an inflammatory response. Option
C: A high concentration of acetylcholine is associated with parasympathetic
nervous system stimulation.
DIF: Cognitive Level:
Application
REF: Text Page: 40
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
15) A client’s laboratory reports show marked
deficiencies of both serum sodium and potassium. On the basis of this finding,
the nurse should assess the client for symptoms of electrical conduction
problems
|
A. |
throughout the body. |
|
B. |
in skeletal muscle function
only. |
|
C. |
in the central nervous
system only. |
|
D. |
in the cardiac conduction
system only. |
ANS: A
The brain is involved in mental activity, maintenance of
homeostasis, and control of all physiological functions. Brain neuronal
activity involves conducting electrical impulses from one end of the cell to
the other, involving inward movement of sodium followed by outward movement of
potassium. Without sufficient sodium and potassium, electrical conduction of
impulses is impaired. Physical and mental symptoms result.
DIF: Cognitive Level:
Application
REF: Text Page: 38
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
16) A client is seen in the emergency department for
symptoms of acute anxiety related to the death of her mother in an automobile
accident 2 hours ago. To prepare a care plan, the nurse must correctly
hypothesize that the client will need teaching about a drug from the group
called
|
A. |
tricyclic antidepressants. |
|
B. |
antimanic drugs. |
|
C. |
benzodiazepines. |
|
D. |
neuroleptic drugs. |
ANS: C
Benzodiazepines provide anxiety relief. Option A: Tricyclic
antidepressants are used to treat symptoms of depression. Option B: Antimania
drugs are used to treat bipolar disorder. Option D: Neuroleptic drugs are major
tranquilizers and are used to treat psychosis.
DIF: Cognitive Level:
Application
REF: Text Page: 57, Text Page: 58
TOP: Nursing Process: Planning
MSC: NCLEX: Physiologic Integrity
17) A client is hospitalized for severe depression.
Of the medications listed below, the nurse can expect to provide the client
with teaching about
|
A. |
clozapine (Clozaril). |
|
B. |
chlordiazepoxide (Librium). |
|
C. |
tacrine (Cognex). |
|
D. |
fluoxetine (Prozac). |
ANS: D
Fluoxetine is an SSRI. It is an antidepressant that blocks the
reuptake of serotonin with few anticholinergic and sedating side effects.
Option A: Clozapine is an antipsychotic. Option B: Chlordiazepoxide is an
anxiolytic. Option C: Tacrine is used to treat Alzheimer’s disease.
DIF: Cognitive Level:
Application
REF: Text Page: 55
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
18) A client hospitalized with a mood disorder
displays an elevated, unstable mood, aggressiveness, agitation, talkativeness,
and irritability. The nurse can begin care planning based on the expectation
that the psychiatrist is most likely to prescribe a medication classified as
a(n)
|
A. |
anticholinergic. |
|
B. |
mood stabilizer. |
|
C. |
psychostimulant. |
|
D. |
antidepressant. |
ANS: B
The symptoms describe a manic attack. Mania is effectively
treated by the antimania drug lithium and selected anticonvulsants such as
carbamazepine, valproic acid, and lamotrigine. No drugs from the other
classifications listed are effective in the treatment of mania.
DIF: Cognitive Level:
Application
REF: Text Page: 53
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
19) The Physician’s
Desk Reference gives the nurse information that a certain drug
causes muscarinic receptor blockade. This alerts the nurse to assess the client
for
|
A. |
gynecomastia. |
|
B. |
pseudoparkinsonism. |
|
C. |
orthostatic hypotension. |
|
D. |
dry mouth. |
ANS: D
Muscarinic receptor blockade includes atropinelike side effects
such as dry mouth, blurred vision, and constipation. Option A: Gynecomastia is
associated with decreased prolactin levels. Option B: Movement defects are
associated with dopamine blockade. Option C: Orthostatic hypotension is
associated with α1 antagonism.
DIF: Cognitive Level:
Application
REF: Text Page: 51
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
20) When the nurse understands that clozapine
preferentially blocks dopamine receptors in the limbic system rather than in
the basal ganglia, the nurse will plan to assess the client for
|
A. |
seizures. |
|
B. |
marked motor disturbances. |
|
C. |
strong suicidal tendencies. |
|
D. |
greatly increased appetite. |
ANS: A
Clozapine has the potential for inducing convulsions in
approximately 3% of clients. All clients receiving this drug should be
monitored for seizure activity. Option B: The blockade of dopamine receptors in
the basal ganglia is responsible for movement disorders associated with
administration of standard antipsychotics. Clozapine selectively targets the
limbic system, which is not involved in movement. Option C: Clozapine therapy
is not associated with producing suicidal ideation. Option D: Clozapine therapy
is not associated with increased appetite.
DIF: Cognitive Level:
Application
REF: Text Page: 52
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
21) A client has begun phenothiazine therapy. What
teaching should the nurse provide related to the drug’s strong dopaminergic
effect?
|
A. |
Chew sugarless gum |
|
B. |
Eat plenty of roughage |
|
C. |
Arise slowly from bed |
|
D. |
Report muscle stiffness |
ANS: D
Phenothiazines block dopamine receptors in both the limbic
system and basal ganglia. The movement disorder dystonia is likely to occur
early in the course of treatment and is often heralded by sensations of muscle
stiffness. Early intervention with anti-Parkinson medication can increase the
client’s comfort and prevent dystonic reactions.
DIF: Cognitive Level:
Application
REF: Text Page: 50, Text Page: 51
TOP: Nursing Process:
Implementation MSC: NCLEX:
Physiologic Integrity
22) During the administration of the abnormal
involuntary movement scale, the nurse should
|
A. |
have the client sit with
hands over the head. |
|
B. |
ask the client to protrude
the tongue. |
|
C. |
have the client lie prone
on the floor. |
|
D. |
direct the client to touch
the nose with the tip of each finger. |
ANS: B
The client is asked to protrude the tongue for several seconds
to enable the nurse to assess for fine movements of the tongue, a possible
indicator of tardive dyskinesia related to long-term phenothiazine therapy.
Administration of the abnormal involuntary movement scale does not call for any
of the other client actions.
DIF: Cognitive Level: Application
REF: Text Page: 50
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
23) The client tells the nurse “My doctor prescribed
Prozac [fluoxetine]. I suppose I’ll have to get used to the side effects like
the ones I experienced when I was taking Tofranil [imipramine].” The nurse’s
reply should be based on the knowledge that fluoxetine is a(n)
|
A. |
tricyclic antidepressant. |
|
B. |
MAO inhibitor. |
|
C. |
SSRI. |
|
D. |
selective norepinephrine
reuptake inhibitor. |
ANS: C
Fluoxetine is an SSRI and will not produce the same side effects
as imipramine, a tricyclic antidepressant. The client will probably not
experience dry mouth, constipation, or orthostatic hypotension.
DIF: Cognitive Level: Application
REF: Text Page: 55
TOP: Nursing Process:
Implementation MSC: NCLEX:
Physiologic Integrity
24) A nurse can anticipate that anticholinergic side
effects may occur when a client is taking
|
A. |
lithium. |
|
B. |
risperidone. |
|
C. |
buspirone. |
|
D. |
fluphenazine. |
ANS: D
Fluphenazine, a first-generation antipsychotic, exerts
muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and
urinary retention. Option A: Lithium therapy is more often associated with
fluid balance problems, including polydipsia, polyuria, and edema. Option B:
Risperidone therapy is more often associated with movement disorders,
orthostatic hypotension, and sedation. Option C: Buspirone is associated with
anxiety reduction without major side effects.
DIF: Cognitive Level:
Application
REF: Text Page: 50, Text Page: 51
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
25) The teaching plan for a client taking clozapine
should include which of the following instructions?
|
A. |
Report sore throat and
fever immediately. |
|
B. |
Avoid foods high in
polyunsaturated fats. |
|
C. |
Practice unprotected sex. |
|
D. |
Use over-the-counter
preparations for rashes. |
ANS: A
Clozapine therapy may produce agranulocytosis; therefore signs
of infection should be immediately reported to the physician. In addition, the
client should have white blood cell levels measured weekly. The other options
are not relevant to clozapine administration.
DIF: Cognitive Level:
Application
REF: Text Page: 52
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
26) The nurse is caring for clients taking various
medications, including buspirone (Buspar), haloperidol (Haldol), carbamazepine
(Tegretol), trazodone (Desyrel), phenelzine (Nardil), and risperidone
(Risperdal). The nurse must check to ensure that a special diet has been
ordered for each client receiving
|
A. |
buspirone and haloperidol. |
|
B. |
trazodone and
carbamazepine. |
|
C. |
phenelzine. |
|
D. |
risperidone. |
ANS: C
Clients taking phenelzine, an MAO inhibitor, must be on a
tyramine-free diet to prevent hypertensive crisis.
DIF: Cognitive Level: Application
REF: Text Page: 55, Text Page: 56
TOP: Nursing Process: Planning
MSC: NCLEX: Safe, Effective Care Environment;
27) The nurse must tell a client taking a drug that
acts by inhibiting MAO to avoid certain foods and drugs or risk
|
A. |
hypotensive shock. |
|
B. |
hypertensive crisis. |
|
C. |
cardiac dysrhythmia. |
|
D. |
cardiogenic shock. |
ANS: B
Clients taking MAO inhibiting drugs must be on a tyramine-free
diet to prevent hypertensive crisis. In the presence of MAO inhibitors,
tyramine is not destroyed by the liver and in high levels produces intense
vasoconstriction, resulting in elevated blood pressure.
DIF: Cognitive Level:
Application
REF: Text Page: 55, Text Page: 56
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance; NCLEX:
Safe, Effective Care Environment;
28) The nurse caring for a client taking SSRIs will
develop evaluation parameters and outcome criteria related to
|
A. |
mood improvement. |
|
B. |
logical thought processes. |
|
C. |
reduced levels of motor
activity. |
|
D. |
increased extrapyramidal
symptoms. |
ANS: A
SSRIs affect mood, relieving depression in many cases. Option B:
SSRIs do not act to reduce thought disorders. Option C: SSRIs reduce depression
but have little effect on motor hyperactivity. Option D: SSRIs do not produce
extrapyramidal symptoms.
DIF: Cognitive Level:
Evaluation
REF: Text Page: 50
TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiologic Integrity
29) A client’s husband is a chemist. He asks the
nurse the action by which SSRIs lift depression. The nurse should explain that
SSRIs
|
A. |
make more serotonin
available at the synaptic gap. |
|
B. |
destroy increased amounts
of neurotransmitter. |
|
C. |
increase production of
acetylcholine and dopamine. |
|
D. |
block muscarinic and α1 norepinephrine
receptors. |
ANS: A
Depression is thought to be related to lowered availability of
the neurotransmitter serotonin. SSRIs act by blocking reuptake of serotonin,
leave a higher concentration available at the synaptic cleft. Option B: SSRIs
actually prevent destruction of serotonin. Option C: SSRIs have no effect on
acetylcholine and dopamine production. Option D: SSRIs do not produce
muscarinic or α1 norepinephrine blockade.
DIF: Cognitive Level:
Application
REF: Text Page: 55
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
30) A client has taken a number of conventional and
standard antipsychotic drugs over the years. The physician, concerned about the
client’s lack of response to these drugs and the development of tardive
dyskinesia, has prescribed risperidone. The nurse planning care for the client
must consider that atypical antipsychotics
|
A. |
are more readily available. |
|
B. |
are of higher potency. |
|
C. |
are less costly. |
|
D. |
produce fewer motor side
effects. |
ANS: D
Atypical antipsychotic drugs often exert their action on the
limbic system rather than the basal ganglia. The limbic system is not involved
in motor disturbances. Option A: These drugs are not more readily available.
Option B: These drugs are not considered to be of higher potency; rather, they
have different modes of action. Option C: The atypical antipsychotic drugs tend
to be more expensive.
DIF: Cognitive Level:
Application
REF: Text Page: 51
TOP: Nursing Process:
Planning
MSC: NCLEX: Physiologic Integrity
31) The laboratory reports for a client who is
taking clozapine show a white blood cell count of 3000 mm3 and
a granulocyte count of 1500 mm3. The
nurse should
|
A. |
give the next dose as
ordered. |
|
B. |
report the laboratory
results to the physician. |
|
C. |
repeat the laboratory
tests. |
|
D. |
give aspirin and force
fluids. |
ANS: B
These laboratory values indicate the possibility of
agranulocytosis, a serious side effect of clozapine therapy. These results must
be immediately reported to the physician. Option A: The drug should be withheld
because the physician will discontinue it. Option C: The physician may repeat
the test, but in the meantime the drug should be withheld. Option D: These
measures are less important than stopping administration of the drug.
DIF: Cognitive Level: Application
REF: Text Page: 52
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe, Effective Care Environment;
32) The nurse administering psychotropic medications
should be prepared to intervene when giving a drug that blocks the attachment
of norepinephrine to α1 receptors
because the client may experience
|
A. |
an increase in psychotic
symptoms. |
|
B. |
hypertensive crisis. |
|
C. |
orthostatic hypotension. |
|
D. |
severe appetite
disturbance. |
ANS: C
Sympathetic mediated vasoconstriction is essential for
maintaining normal blood pressure in the upright position. Blockage of α1 receptors
leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may
cause fainting and falls. Clients should be taught ways of minimizing this
phenomenon.
DIF: Cognitive Level:
Application
REF: Text Page: 50
TOP: Nursing Process:
Implementation MSC: NCLEX:
Physiologic Integrity
33) A nurse is caring for four clients who are
receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. In
which client should the nurse be most alert for alterations in cardiac or
cerebral electrical conductivity and fluid and electrolyte imbalance?
|
A. |
The client receiving
lithium (Lithobid) |
|
B. |
The client receiving
clozapine (Clozaril) |
|
C. |
The client receiving
fluoxetine (Prozac) |
|
D. |
The client receiving
venlafaxine (Effexor) |
ANS: A
Lithium is known to alter electrical conductivity, producing
cardiac dysrhythmias, tremor, convulsions, polyuria, edema, and other symptoms
of fluid and electrolyte imbalance. Option B: Clients receiving clozapine
should be monitored for agranulocytosis. Option C: Clients receiving fluoxetine
should be monitored for acetylcholine block. Option D: Clients receiving
venlafaxine should be monitored for heightened feelings of anxiety.
DIF: Cognitive Level:
Application
REF: Text Page: 53
TOP: Nursing Process:
Assessment
MSC: NCLEX: Physiologic Integrity
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