Signs of hepatotoxicity: jaundice, dark urine, severe fatigue, anorexia - report immediately.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is reviewing baseline labs before starting valproic acid (divalproex) for bipolar disorder. Which baseline test is most important to obtain?
Answer: A. Valproic acid is hepatotoxic and can also cause thrombocytopenia and pancreatitis. Baseline and periodic liver function tests (and a CBC with platelets) are essential. Liver enzymes are the priority baseline before and during therapy.
Question 2 of 5
A client receiving valproic acid as a mood stabilizer requires monitoring of which laboratory values for serious adverse effects?
Answer: B. Valproic acid can cause hepatotoxicity and thrombocytopenia. Baseline and periodic liver function tests (LFTs) and complete blood counts (including platelets) are required. Clients should report bruising, jaundice, or persistent abdominal pain.
Question 3 of 5
A client is prescribed omeprazole for GERD. The nurse explains that this medication works by which mechanism?
Answer: A. Omeprazole is a proton pump inhibitor that blocks the final step of gastric acid secretion, reducing acid production. It does not neutralize acid (antacids do) or coat the ulcer (sucralfate does).
Question 4 of 5
A client taking allopurinol for gout should be taught to:
Answer: B. Allopurinol lowers uric acid for prevention (not for acute attacks); increase fluids to prevent stones, take it consistently, and report rash (risk of serious hypersensitivity). It is not a quick fix for an acute flare.
Question 5 of 5
A client receiving high-dose methotrexate is prescribed leucovorin (folinic acid). The nurse understands that leucovorin is given to:
Answer: A. Leucovorin rescue provides reduced folate to normal cells, limiting the toxic effects of high-dose methotrexate (a folate antagonist) on healthy tissues such as bone marrow and the GI tract. It does not enhance the antitumor effect, treat nausea, or prevent hair loss.
Keep the streak going with more questions like these, each with a full rationale.
What is valproic acid?
It requires monitoring of serum levels, liver function, and platelets because of risks of hepatotoxicity, pancreatitis, and thrombocytopenia. It is highly teratogenic (neural tube defects) and is avoided in pregnancy.
Key points to remember
- Therapeutic serum level is 50-100 mcg/mL (some sources up to 125); levels are monitored routinely.
- Risk of hepatotoxicity and pancreatitis - monitor LFTs and watch for abdominal pain/nausea.
- Can cause thrombocytopenia; monitor platelet counts and watch for bruising/bleeding.
- Highly teratogenic (neural tube defects); contraindicated in pregnancy - women need effective contraception.
- Used both as an anticonvulsant and as a first-line mood stabilizer for acute mania.
- Causes GI upset, sedation, weight gain, tremor, and possible hair thinning.
Nursing priorities
- Monitor serum valproate levels and report values outside the therapeutic range.
- Monitor liver function tests and platelet/CBC results.
- Assess for signs of pancreatitis (severe abdominal pain, vomiting) and hepatotoxicity (jaundice, anorexia).
- Verify pregnancy status and counsel on contraception due to teratogenicity.
- Give with food to reduce GI upset; do not crush extended-release tablets.
Labs & values
Patient teaching
- Keep all lab appointments for drug levels, liver tests, and platelet counts.
- Report yellowing of skin/eyes, severe abdominal pain, or unusual bruising/bleeding.
- Take with food and swallow extended-release tablets whole.
- Use reliable contraception and tell the provider if pregnancy is possible - this drug causes birth defects.
Red flags: report now
- Signs of hepatotoxicity: jaundice, dark urine, severe fatigue, anorexia - report immediately.
- Signs of pancreatitis: severe epigastric/abdominal pain, persistent vomiting - report now.
- Unusual bruising or bleeding (thrombocytopenia).
- Use in pregnancy - contraindicated due to neural tube defect risk.
References
Clinical references for this topic
