A client taking sertraline is prescribed tramadol for back pain and develops agitation, fever, heavy sweating, tremor and overactive reflexes. Which condition should the nurse suspect?
Serotonin syndrome
✓
Neuroleptic malignant syndrome
Hypertensive crisis
Anticholinergic toxicity
Correct Answer
Serotonin syndrome
Tramadol inhibits serotonin reuptake, so adding it to an SSRI can produce excess serotonin with agitation, hyperthermia, sweating, tremor and hyperreflexia. Neuroleptic malignant syndrome follows antipsychotic use and causes severe rigidity rather than overactive reflexes. Hypertensive crisis centers on a sharp rise in blood pressure with headache, as with an MAOI and tyramine. Anticholinergic toxicity causes hot, dry skin rather than heavy sweating.
Category: SSRIs and SNRIs
Question 2
Why must a client wait longer after stopping fluoxetine than after stopping most other SSRIs before starting an MAOI?
It is excreted unchanged by the kidneys
Its long half-life keeps it in the body for weeks
✓
It strongly blocks histamine receptors
It must be tapered to prevent seizures
Correct Answer
Its long half-life keeps it in the body for weeks
Fluoxetine and its active metabolite have a very long half-life, so the drug lingers for weeks and could cause serotonin syndrome if an MAOI were started too soon. It is excreted unchanged by the kidneys describes lithium, not fluoxetine, which the liver metabolizes. It strongly blocks histamine receptors is wrong because fluoxetine has little antihistamine effect. It must be tapered to prevent seizures does not explain the waiting period, which is about drug clearance.
Category: SSRIs and SNRIs
Question 3
A client starting sertraline asks about over-the-counter pain relievers. Regular use of which drug should the nurse advise against because the combination raises the risk of gastrointestinal bleeding?
Acetaminophen
Loratadine
Ibuprofen
✓
Calcium carbonate
Correct Answer
Ibuprofen
SSRIs impair platelet aggregation, and NSAIDs such as ibuprofen injure the stomach lining and also affect platelets, so together they increase the risk of GI bleeding. Acetaminophen does not affect platelets or the gastric mucosa in the same way. Loratadine is a nonsedating antihistamine without a bleeding interaction. Calcium carbonate is an antacid and does not raise bleeding risk.
Category: SSRIs and SNRIs
Question 4
A client started on venlafaxine should have which vital sign checked regularly because the drug can raise it in a dose-related way?
Respiratory rate
Oxygen saturation
Body temperature
Blood pressure
✓
Correct Answer
Blood pressure
SNRIs such as venlafaxine increase norepinephrine activity, which can produce a sustained, dose-related rise in blood pressure, so they are avoided in uncontrolled hypertension. Respiratory rate is a key check with opioids and sedatives, not SNRIs. Oxygen saturation is not specifically affected by venlafaxine. Body temperature is not raised by venlafaxine in usual use.
Category: SSRIs and SNRIs
Question 5
Which antidepressant is also approved to treat diabetic peripheral neuropathic pain and fibromyalgia?
Duloxetine
✓
Bupropion
Phenelzine
Mirtazapine
Correct Answer
Duloxetine
Duloxetine, an SNRI, is approved for major depression and anxiety and also for diabetic peripheral neuropathic pain, fibromyalgia and chronic musculoskeletal pain. Bupropion is used for depression and smoking cessation, not pain. Phenelzine is an MAOI reserved for depression that has not responded to other drugs. Mirtazapine is approved for major depressive disorder.
Category: SSRIs and SNRIs
Question 6
Amitriptyline can slow conduction through the heart and prolong the QT interval. Which baseline test is recommended before starting it in an older adult client?
Pulmonary function test
Electrocardiogram
✓
Bone density scan
Hearing test
Correct Answer
Electrocardiogram
Tricyclic antidepressants are cardiotoxic and can cause dysrhythmias, so a baseline ECG is obtained, especially in older adults and clients with heart disease, and recent myocardial infarction is a contraindication. A pulmonary function test measures lung capacity, which amitriptyline does not affect. A bone density scan screens for osteoporosis. A hearing test is not needed for amitriptyline therapy.
Category: TCAs and MAOIs
Question 7
A client taking phenelzine asks about cold medicines. Which ingredient can trigger a hypertensive crisis when taken with this drug?
Guaifenesin
Acetaminophen
Pseudoephedrine
✓
Cetirizine
Correct Answer
Pseudoephedrine
Phenelzine is an MAOI, and sympathomimetic decongestants such as pseudoephedrine add to norepinephrine activity and can cause a dangerous rise in blood pressure. Guaifenesin is an expectorant without that sympathomimetic effect. Acetaminophen relieves pain and fever and does not raise blood pressure. Cetirizine is a second-generation antihistamine that does not cause a hypertensive interaction.
Category: TCAs and MAOIs
Question 8
A client taking mirtazapine reports fever, chills, sore throat and muscle aches. The nurse recognizes that these symptoms may signal which problem?
A low platelet count
A high blood glucose level
A low thyroid hormone level
A low white blood cell count
✓
Correct Answer
A low white blood cell count
Mirtazapine can rarely cause agranulocytosis, and flu-like symptoms with sore throat and fever may be the first sign of a low white blood cell count, so the provider should be notified. A low platelet count shows as bruising or bleeding rather than fever and sore throat. A high blood glucose level causes thirst and frequent urination. A low thyroid hormone level causes fatigue, cold intolerance and weight gain, not acute fever.
Category: Antidepressant Safety
Question 9
When a young adult starts an antidepressant, at which times does the boxed warning call for especially close watching for worsening depression and suicidal thinking?
Early in treatment and after dose changes
✓
Once the full therapeutic effect is reached
After the drug has been discontinued
During long-term maintenance therapy
Correct Answer
Early in treatment and after dose changes
The boxed warning asks that children, adolescents and young adults be watched closely for clinical worsening, suicidal thinking and unusual changes in behavior, particularly in the first months of therapy and whenever the dose is raised or lowered. Once the full therapeutic effect is reached is not the period the warning highlights, because the risk centers on the start of treatment. After the drug has been discontinued is not the time named in the warning. During long-term maintenance therapy is also not the emphasized period, although mood is still assessed at every visit.
Category: Antidepressant Safety
Question 10
Some weeks after starting haloperidol, a client has a shuffling gait, cogwheel rigidity and a masklike face. Which extrapyramidal effect is this?
Akathisia
Pseudoparkinsonism
✓
Tardive dyskinesia
Acute dystonia
Correct Answer
Pseudoparkinsonism
Blocking dopamine in the motor pathways can produce signs that mimic Parkinson's disease, including tremor, cogwheel rigidity, shuffling gait, drooling and a stiff face. Akathisia is a feeling of restlessness and an inability to sit still. Tardive dyskinesia is a late effect with involuntary movements of the mouth, tongue and face. Acute dystonia is a sudden muscle spasm of the neck, tongue, back or eyes.
Category: Antipsychotics
Question 11
Which antipsychotic carries an FDA warning about compulsive urges such as gambling, binge eating and shopping?
Haloperidol
Chlorpromazine
Aripiprazole
✓
Fluphenazine
Correct Answer
Aripiprazole
Aripiprazole, a second-generation drug that stabilizes dopamine signaling, has been linked to intense, uncontrollable urges to gamble, shop, binge eat or engage in sexual behavior, so the nurse asks the client and family about new urges, and the problem usually improves when the dose is lowered or the drug is stopped. Haloperidol is a high-potency first-generation drug best known for extrapyramidal effects. Chlorpromazine is a low-potency first-generation drug that causes marked sedation and anticholinergic effects. Fluphenazine is a high-potency first-generation drug that is also available as a long-acting injection.
Category: Antipsychotics
Question 12
Which group of adverse effects is especially common with second-generation antipsychotics such as olanzapine?
Ringing in the ears and hearing loss
Hair loss, mouth sores and diarrhea
Dry cough, angioedema and hyperkalemia
Weight gain, hyperglycemia and dyslipidemia
✓
Correct Answer
Weight gain, hyperglycemia and dyslipidemia
Second-generation antipsychotics often cause metabolic effects, including weight gain, high blood glucose, new diabetes and abnormal lipids, so weight, glucose and lipids are monitored. Ringing in the ears and hearing loss suggest salicylate or ototoxic drug effects. Hair loss, mouth sores and diarrhea are typical of chemotherapy. Dry cough, angioedema and hyperkalemia are linked to ACE inhibitors.
Category: Antipsychotics
Question 13
Both first- and second-generation antipsychotics carry an FDA boxed warning for increased mortality in which group?
Older adults with dementia-related psychosis
✓
Adolescents with schizophrenia
Adults with bipolar mania
Children with autism-related irritability
Correct Answer
Older adults with dementia-related psychosis
Older adults with dementia who are treated with antipsychotics for psychosis have a higher death rate than those given placebo, so these drugs carry a boxed warning for that group. Adolescents with schizophrenia are not the group named in this warning. Adults with bipolar mania are not the group named either. Children with autism-related irritability can be treated with drugs such as risperidone and are not the subject of this warning.
Category: Antipsychotics
Question 14
A client who is stable on lithium is started on hydrochlorothiazide. What should the nurse anticipate?
Lithium levels falling below range
Increased risk of lithium toxicity
✓
Rapid onset of hypothyroidism
Loss of the diuretic effect
Correct Answer
Increased risk of lithium toxicity
Thiazide diuretics cause sodium loss, and the kidneys respond by reabsorbing more sodium and lithium, so lithium levels can rise to toxic levels; levels and signs of toxicity are monitored closely. Lithium levels falling below range is the opposite of what occurs. Rapid onset of hypothyroidism is not caused by the diuretic, although long-term lithium can affect the thyroid. Loss of the diuretic effect is not the expected interaction.
Category: Mood Stabilizers
Question 15
Long-term lithium therapy can cause goiter. Which lab test is checked periodically for this reason?
Serum amylase
Serum ammonia
Thyroid-stimulating hormone
✓
Serum cortisol
Correct Answer
Thyroid-stimulating hormone
Lithium can interfere with thyroid hormone production and cause goiter and hypothyroidism, so TSH is checked at baseline and periodically. Serum amylase is used to assess the pancreas. Serum ammonia is followed in liver failure and with valproate toxicity. Serum cortisol assesses adrenal function and is not a routine lithium test.
Category: Mood Stabilizers
Question 16
A client started on lamotrigine for bipolar disorder notices a new skin rash. What should the nurse instruct?
Apply a steroid cream and keep taking it
Double the next dose to overcome it
Ignore it because rashes are harmless
Report the rash to the provider right away
✓
Correct Answer
Report the rash to the provider right away
Lamotrigine can cause serious, potentially life-threatening rashes such as Stevens-Johnson syndrome, so any new rash is reported to the provider at the first sign. Apply a steroid cream and keep taking it could let a dangerous reaction progress. Double the next dose to overcome it is unsafe, and rash risk rises with faster dose increases. Ignore it because rashes are harmless is wrong because the rash may be the start of a severe reaction.
Category: Mood Stabilizers
Question 17
A client is prescribed sodium oxybate for cataplexy and daytime sleepiness from narcolepsy. Which substance must the client avoid completely?
Alcohol
✓
Grapefruit juice
Dairy products
Vitamin C
Correct Answer
Alcohol
Sodium oxybate is the sodium salt of GHB, a CNS depressant with a boxed warning for respiratory depression, so it is contraindicated with alcohol and sedative-hypnotics, which add to that depression. Grapefruit juice changes the metabolism of some other drugs but is not a contraindication to sodium oxybate. Dairy products do not interact with it. Vitamin C does not interact with it either.
Category: Stimulants and Nonstimulants
Question 18
A benzodiazepine should be avoided in a client with which condition because it depresses respiration?
Essential hypertension
Obstructive sleep apnea
✓
Osteoarthritis
Hypothyroidism
Correct Answer
Obstructive sleep apnea
Benzodiazepines are CNS depressants that can worsen breathing, so they are contraindicated in sleep apnea and severe respiratory insufficiency. Essential hypertension is not a contraindication to benzodiazepines. Osteoarthritis does not involve breathing and is not a contraindication. Hypothyroidism is not listed as a contraindication to these drugs.
Category: Anxiolytics and Hypnotics
Question 19
Which instruction is correct for a client prescribed zolpidem for insomnia?
Take it with a glass of wine to relax
Take it in the late afternoon
Take it immediately before going to bed
✓
Take it each morning with breakfast
Correct Answer
Take it immediately before going to bed
Zolpidem acts quickly, so it is taken just before lying down, when the client can stay in bed for a full night, to reduce the risk of falls and complex sleep behaviors such as sleep driving. Take it with a glass of wine to relax is dangerous because alcohol adds to CNS and respiratory depression. Take it in the late afternoon would cause drowsiness while the client is still active. Take it each morning with breakfast would cause daytime sedation and does not treat insomnia.
Category: Anxiolytics and Hypnotics
Question 20
Which ADHD drug is a norepinephrine reuptake inhibitor that is not a controlled substance?
Methylphenidate
Lisdexamfetamine
Dextroamphetamine
Atomoxetine
✓
Correct Answer
Atomoxetine
Atomoxetine is a nonstimulant that selectively blocks norepinephrine reuptake, has low abuse potential and is not controlled, but it carries a boxed warning for suicidal thinking. Methylphenidate is a Schedule II stimulant. Lisdexamfetamine is a stimulant prodrug of dextroamphetamine with high misuse potential. Dextroamphetamine is a stimulant amphetamine with high misuse potential.
Category: Stimulants and Nonstimulants