A patient being treated for insomnia is prescribed ramelteon (Rozerem). Which comorbid mental health condition would make this medication the hypnotic of choice for this particular patient?

Correct Answer: D

Rationale: The correct answer is D, Substance use disorder. Ramelteon is preferred for patients with substance use disorder because it lacks abuse potential. This makes it a safer choice for individuals with a history of substance misuse. Choosing a medication with a lower risk of abuse in this population is crucial to prevent potential misuse or dependence issues.

Correct Answer: B

Rationale: Antipsychotics (Choice B) are the correct answer because they are strongly associated with the risk of extrapyramidal symptoms (EPS) and other movement disorders due to their dopamine receptor blockade in the nigrostriatal pathway. These disorders include acute dystonia, akathisia, parkinsonism, and tardive dyskinesia, which can develop even at therapeutic doses. First-generation (typical) antipsychotics like haloperidol have a higher risk, but second-generation (atypical) antipsychotics such as risperidone and aripiprazole can also cause these effects. Nurses must monitor for early signs, such as muscle stiffness, restlessness, or involuntary movements, as tardive dyskinesia can become irreversible. SSRIs (Choice A) primarily affect serotonin reuptake and are not typically linked to movement disorders. While they can cause side effects like agitation or tremors, these are not classified as extrapyramidal symptoms. Rare cases of SSRI-induced akathisia exist, but it is not a hallmark concern like with antipsychotics, making this choice incorrect. Benzodiazepines (Choice C) act on GABA receptors and are used for anxiety, insomnia, or muscle relaxation. They do not cause EPS or tardive dyskinesia. Instead, they may lead to sedation, dizziness, or dependence, but movement disorders are outside their usual adverse effect profile, ruling them out as the correct answer. Tricyclic antidepressants (Choice D) primarily inhibit norepinephrine and serotonin reuptake and have anticholinergic effects. While they can cause side effects like dry mouth, constipation, or orthostatic hypotension, they are not associated with EPS or tardive dyskinesia. Their mechanism does not involve dopamine blockade, so movement disorders are not a clinical concern, making this choice incorrect. The key distinction lies in the pharmacological action: antipsychotics directly interfere with dopamine pathways critical for motor control, while the other drug groups lack this mechanism. Nursing assessments for movement abnormalities are thus essential for antipsychotics but not for SSRIs, benzodiazepines, or tricyclics.

Correct Answer: A

Rationale: Lithium (Eskalith) is the correct choice because it has a narrow therapeutic index and is excreted almost entirely by the kidneys, making patients highly susceptible to fluid and electrolyte imbalances. Lithium levels are directly influenced by sodium and water balance—dehydration or sodium loss can lead to lithium retention and toxicity, manifesting as confusion, tremors, seizures, or even coma. Patients on lithium require strict monitoring of serum levels (typically 0.6–1.2 mEq/L), renal function, and hydration status. Diuretics, excessive sweating, or gastrointestinal losses (e.g., vomiting/diarrhea) further increase the risk, necessitating vigilant assessment. Clozapine (Clozaril) primarily requires monitoring for agranulocytosis, metabolic disturbances (e.g., weight gain, dyslipidemia), and myocarditis, but it does not directly cause electrolyte imbalances. While it may induce hypersalivation or constipation, these side effects are less likely to disrupt fluid or electrolyte homeostasis compared to lithium. Diazepam (Valium), a benzodiazepine, has minimal impact on fluid or electrolyte balance. Its primary risks include sedation, respiratory depression, and dependence. Any fluid-related issues (e.g., dehydration) would be secondary to reduced oral intake due to excessive drowsiness, not a direct pharmacological effect. Amitriptyline, a tricyclic antidepressant, can cause anticholinergic effects (e.g., dry mouth, urinary retention) and orthostatic hypotension, but these do not typically lead to significant electrolyte disturbances. While overdose can cause cardiac arrhythmias due to sodium channel blockade, routine therapeutic use does not necessitate the same level of fluid/electrolyte monitoring as lithium. The critical distinction lies in lithium’s unique pharmacokinetics: its renal excretion and dependence on sodium balance create a direct, dose-dependent risk for life-threatening toxicity if hydration or electrolytes are not meticulously managed. No other drug listed poses such an immediate and predictable threat to fluid-electrolyte equilibrium. Monitoring for clozapine, diazepam, or amitriptyline focuses on entirely different adverse effects, none of which are as intrinsically tied to fluid and electrolyte status.

Correct Answer: B

Rationale: Monoamine oxidase inhibitors are less suitable for patients with intellectual disabilities due to the need for dietary restrictions and close monitoring. These restrictions can be challenging for patients with mild intellectual disabilities to follow, making this drug class a concern for this patient population.

Correct Answer: C

Rationale: Assessing suicidal thoughts, judgment, insight, and the need for a therapeutic environment are crucial factors in determining the appropriate treatment setting for a patient experiencing psychotic symptoms. Past experiences with mental healthcare facilities do not play a direct role in deciding between a community outpatient or inpatient setting.