NURS-FPX4030 Assessment 2: Medication Management for Generalized Anxiety Disorder

Capella University | School of Nursing and Health Sciences | Making Evidence-Based Decisions

Assessment Type: Written Case Analysis with Decision Documentation

Length: 5 pages (excluding title page and references)

Format: APA 7th Edition

Weight: 25% of Course Grade

Due: End of Week 5, Sunday, 11:59 PM CT

Submission: Word document via Capella courseroom

Assessment Context

NURS-FPX4030 Assessment 2 requires you to apply evidence-based decision-making to a psychiatric medication management case. This assessment aligns with the course competency: interpret research and apply an evidence-based practice model to make informed decisions in care planning. The case involves a 46-year-old white male presenting with generalized anxiety disorder (GAD) symptoms following an emergency room visit where myocardial infarction was ruled out. You will evaluate three sequential medication decision points using primary literature and clinical practice guidelines, documenting your rationale, rejected alternatives, expected outcomes, and ethical considerations at each juncture.

This assessment builds on the diagnostic reasoning skills developed in NURS-FPX4015 and prepares you for the evidence synthesis required in NURS-FPX4030 Assessment 3. The patient’s HAM-A score of 26 at intake indicates moderate to severe anxiety, and your decisions must account for his mild hypertension, alcohol use, caregiving responsibilities, and employment stress. Pharmacokinetic and pharmacodynamic factors specific to this patient profile must inform every decision you defend.

Introduction to the Case (1 page)

Summarize the case in your own words. Identify the specific patient factors that may impact your prescribing decisions, including medical history, psychosocial stressors, current substance use, and objective assessment data. State the diagnosis and explain why the HAM-A score is clinically meaningful for treatment planning. Do not simply restate the scenario; analyze which factors carry the most weight for medication selection and why.

Decision #1 (1 page)

State which of the three provided options you selected: (a) begin buspirone 10 mg orally twice daily, (b) begin paroxetine 10 mg orally daily, or (c) begin imipramine 25 mg orally twice daily.

Defend your selection using clinically relevant, patient-specific evidence from the primary literature. Explain why you did not select the other two options, addressing their pharmacokinetic profiles, adverse effect burdens, and suitability for this patient’s presentation. Describe what you hoped to achieve with this decision, citing the Learning Resources and at least one peer-reviewed source. Address ethical considerations that may impact your treatment plan and communication with this patient, providing specific examples relevant to his alcohol use, caregiving role, and employment fears.

Decision #2 (1 page)

Following the four-week return visit, the client reports a slight decrease in symptoms with buspirone but still feels very anxious, and the HAM-A score has dropped only from 26 to 23. State which option you selected: (a) discontinue buspirone and begin escitalopram (Lexapro) 10 mg orally daily, (b) increase buspirone to 10 mg twice daily, or (c) increase buspirone to 10 mg three times daily.

Defend your selection with specific reference to the patient’s response at decision point one, the pharmacology of the chosen agent, and clinical guidelines for GAD management. Explain why the alternative options were less appropriate, particularly regarding buspirone’s ceiling effect and the patient’s need for faster symptom relief. Support your rationale with primary literature and Learning Resources. Explain the ethical considerations relevant to this transition, including informed consent for medication change and management of the patient’s expectations about onset of action.

Decision #3 (1 page)

At the second four-week return visit, the client reports feeling “great” with an HAM-A score of 13, a 50% symptom reduction, but notes sleepiness for a few hours after taking escitalopram. State which option you selected: (a) continue the same dose of escitalopram but change administration time to bedtime, (b) increase escitalopram to 15 mg orally daily in the morning, or (c) restart buspirone 10 mg orally three times daily in addition to escitalopram.

Defend your selection by analyzing the patient’s current symptom trajectory, the pharmacology of escitalopram at the current dose, and the risk-benefit balance of dose adjustment versus administration timing change. Explain why increasing the dose or adding buspirone was less prudent given the patient’s response and side effect profile. Cite primary literature and Learning Resources to support your reasoning. Address ethical considerations including patient autonomy in medication timing decisions, the importance of avoiding unnecessary polypharmacy, and communication about the expected duration of treatment.

Conclusion (1 page)

Summarize your three medication management decisions and the clinical reasoning that connected them. Justify your final recommendation for this patient using evidence from primary literature and clinical guidelines. Explain how your decisions addressed the patient’s specific pharmacokinetic and pharmacodynamic factors, including his mild hypertension, alcohol use, and age. Discuss the ethical framework that guided your decision-making across all three points. Conclude with a brief statement about monitoring parameters and follow-up intervals for this patient.

Grading Rubric

Research, Writing, Citation and Referencing Guide

Quick Answer Summary

Medication management for generalized anxiety disorder requires matching agent pharmacology to patient-specific factors. Buspirone offers a favorable adverse effect profile but a delayed onset and limited efficacy in severe presentations. Escitalopram, a first-line SSRI, demonstrates superior efficacy for GAD with a manageable side effect profile. Ethical prescribing demands attention to informed consent, avoidance of dependence-producing agents when alternatives exist, and recognition of the patient’s social context. The case’s three decision points illustrate how evidence-based reasoning adapts as clinical response data accumulate.

Frequently Asked Question

Can buspirone and escitalopram be used together for generalized anxiety disorder?

Combining buspirone with an SSRI remains an off-label strategy supported by limited evidence. A 2021 systematic review found insufficient high-quality data to recommend routine augmentation, and clinical guidelines prioritize optimizing the SSRI dose or switching agents before adding buspirone (Katzman et al., 2024). For the patient in this case, escitalopram monotherapy at 10 mg produced a 50% HAM-A reduction within four weeks, indicating adequate response without augmentation. Adding buspirone would introduce unnecessary polypharmacy, additional adverse effect risk, and dosing complexity without clear benefit. Reserve combination therapy for patients who fail to achieve adequate response after an optimized SSRI trial of 8 to 12 weeks.

Why This Matters in Practice

Prescribing decisions in GAD carry consequences that extend beyond symptom reduction. Buspirone’s lack of dependence liability makes it attractive for patients with substance use concerns, yet its modest effect size and two-to-four-week onset limit its utility in severe presentations. Escitalopram’s efficacy in GAD is well established, but clinicians must monitor for activation, sexual dysfunction, and discontinuation syndrome. The patient’s alcohol use, while not at dependence levels, warrants caution with any sedating agent. His caregiving responsibilities and employment stress require a medication regimen that does not impair daytime functioning. Ethical prescribing in this context means resisting the temptation to over-medicate distress and instead selecting agents with evidence for the specific presentation, communicating honestly about expected timelines, and involving the patient in decisions about timing and dose.

References

Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2024). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry, *24*(Suppl 1), Article 23. https://doi.org/10.1186/s12888-024-05523-8

Rosenthal, L. D., & Burchum, J. R. (2026). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed.). Elsevier.

Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, *32*(1), 50–55. https://doi.org/10.1111/j.2044-8341.1959.tb00467.x

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, *166*(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092

Maust, D. T., Lin, L. A., & Blow, F. C. (2023). Benzodiazepine prescribing and the ethics of managing anxiety in older adults. JAMA Internal Medicine, *183*(4), 312–313. https://doi.org/10.1001/jamainternmed.2023.0159

Sample Answer Excerpt

Introduction and Decision #1 Analysis

The patient’s presentation complicates straightforward GAD treatment. His mild hypertension, while diet-controlled, rules out agents with significant cardiovascular effects. The nightly alcohol use, though below dependence thresholds, signals a need for caution with sedating medications. His caregiving role for aging parents and fear of job loss create ongoing psychosocial stressors that pharmacotherapy alone cannot resolve. The HAM-A score of 26 indicates moderate to severe anxiety, and the client’s report of “anxiety attacks” with chest tightness and impending doom suggests that his presentation may overlap with panic symptomatology. The HAM-A demonstrated acceptable reliability and concurrent validity in the original validation studies, though internal validity analysis revealed structural limitations (Hamilton, 1959). These factors narrow the reasonable pharmacologic options considerably.

For decision point one, I selected buspirone 10 mg orally twice daily. Buspirone offers a favorable adverse effect profile for a patient who must remain alert for welding work and caregiving responsibilities. The drug does not potentiate alcohol effects, a relevant consideration given the patient’s nightly consumption. Buspirone’s lack of dependence liability distinguishes it from benzodiazepines, which are not first-line for GAD and carry dependence risk. The starting dose of 10 mg twice daily aligns with the recommended titration schedule. Buspirone’s onset of action spans two to four weeks, and the decision point one results showing a slight decrease in symptoms at four weeks with an HAM-A reduction from 26 to 23 are consistent with the drug’s pharmacodynamic timeline. The modest response may reflect a subtherapeutic dose rather than treatment failure, though the patient’s severe baseline warrants consideration of a more robustly effective agent.

I did not select paroxetine 10 mg orally daily because of its adverse effect profile and discontinuation syndrome risk. Paroxetine is effective for GAD, but its anticholinergic effects and sexual dysfunction burden make it less suitable for a first trial, particularly for a patient who may require long-term treatment. The 10 mg starting dose is also subtherapeutic for GAD, potentially prolonging the time to adequate symptom control. Imipramine 25 mg orally twice daily was also rejected. Tricyclic antidepressants carry anticholinergic, orthostatic, and cardiac conduction risks that are problematic for a patient with mild hypertension. The 25 mg twice-daily dose is subtherapeutic for GAD, and imipramine’s lethality in overdose presents a safety concern. Neither alternative offered advantages over buspirone for this patient’s specific presentation.

Ethical considerations at this decision point center on informed consent and the management of expectations. The patient’s use of alcohol to combat worry suggests he may be self-medicating, and a conversation about the limitations of pharmacotherapy alone is warranted. I would explain that buspirone is not habit-forming and does not interact dangerously with alcohol, which may improve his adherence. His fear of job loss and caregiving stress require acknowledgment; medication will not resolve these stressors. The principle of beneficence supports selecting an agent with a favorable safety profile, while nonmaleficence supports avoiding benzodiazepines and TCAs. Respect for autonomy requires presenting the rationale for buspirone and inviting the patient’s questions about the plan.

Clinical Guidelines and Stepped Care

Clinical practice guidelines recommend SSRIs and SNRIs as first-line pharmacologic treatments for generalized anxiety disorder (Katzman et al., 2024). Buspirone occupies a second-line position, appropriate when first-line agents are contraindicated, not tolerated, or refused. The patient’s response at decision point one, an HAM-A reduction of only 3 points over four weeks, suggests that buspirone at 20 mg daily is providing minimal benefit. A meta-analysis of pharmacologic treatments for GAD reported an effect size of 0.17 for azapirones compared with 0.36 for SSRIs, indicating that buspirone is substantially less effective than escitalopram or paroxetine for this indication. Switching to a first-line agent after an inadequate buspirone trial is consistent with stepped-care models. The decision point two results showing an HAM-A drop from 23 to 13 on escitalopram 10 mg confirm that an SSRI produced the response buspirone failed to achieve.

Managing Side Effects Without Changing Doses

A common question when students encounter decision point three concerns whether the patient’s sedation justifies a dose increase or the addition of a second agent. The sleepiness the patient reports after morning escitalopram administration is a predictable adverse effect that often attenuates with continued use. Increasing the dose to 15 mg daily would likely intensify sedation without proportionate anxiolytic benefit, as the 10 mg dose already achieved a 50% symptom reduction. Restarting buspirone would add a second medication without addressing the timing issue and would introduce unnecessary complexity. Changing the administration time to bedtime is the most parsimonious intervention. It addresses the side effect directly, may improve sleep quality, and avoids escalating treatment when the current regimen is working. This reasoning reflects the principle of using the lowest effective dose for the shortest necessary duration and aligns with clinical guidance to optimize tolerability before adjusting dose or adding agents.

• The HAM-A’s 14-item structure captures both psychic and somatic anxiety symptoms, and a 50% score reduction is generally considered a clinically meaningful treatment response.

• Escitalopram’s half-life of approximately 27 to 32 hours supports once-daily dosing and means that timing changes will not produce abrupt fluctuations in plasma concentration.

• Buspirone’s metabolism via CYP3A4 creates interaction potential with agents that inhibit or induce this enzyme, though the patient’s current medication profile poses no such conflicts.

Conclusion

Managing GAD in a patient with cardiovascular concerns, alcohol use, and significant psychosocial stressors demands deliberate, evidence-guided decisions. The three decision points in this case illustrate how clinical reasoning evolves as new response data emerge. Buspirone was a reasonable first choice given its safety profile, but its modest efficacy at 20 mg daily justified a switch to escitalopram at decision point two. The 50% HAM-A reduction on escitalopram 10 mg confirmed the superiority of SSRI therapy for this patient. At decision point three, the sedation complaint did not warrant a dose change or the addition of buspirone. Shifting administration to bedtime resolved the side effect without compromising efficacy. Ethical prescribing throughout meant prioritizing patient safety, respecting autonomy, and avoiding unnecessary escalation. The final recommendation is to continue escitalopram 10 mg at bedtime, monitor HAM-A scores at four-week intervals, and address the patient’s alcohol use and psychosocial stressors through ongoing counseling and appropriate referrals.

Week 6 Assignment Preview

NURS-FPX4030 Assessment 3: PICO(T) Questions and an Evidence-Based Approach

Due: Week 8, Sunday, 11:59 PM CT

Length: 3–5 pages

For this assessment, select a practice issue related to medication management, patient safety, or care coordination that interests you. Develop a PICO(T) question that addresses the issue and evaluate the evidence you locate to answer it. Define the practice issue, explain its relevance to nursing practice, and describe the search strategy you used to locate credible evidence. Evaluate the strength and limitations of the evidence, and explain how the findings could inform care decisions. The assessment requires a minimum of four peer-reviewed sources published within the last five years, with at least two sources supporting your PICO(T) question and two sources providing context or contrasting perspectives. Format the paper in APA 7th edition and include a title page and reference list.

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Generalized Anxiety Disorder (GAD) is a mental health disorder characterized by persistent and excessive worry about a variety of topics, such as personal health, work, social interactions, and everyday routine life circumstances. People with GAD may find it difficult to control their worry, even though they recognize that it is excessive. This constant worry can interfere with daily functioning and can be debilitating.

Symptoms of GAD may include:

Difficulty controlling worry
Restlessness or feeling on edge
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Exaggerated startle response
GAD is typically treated with a combination of therapy, such as cognitive-behavioral therapy (CBT), and medication, such as antidepressants. It is important to speak with a mental health professional to determine the best treatment plan for you.
Sample Assignment:
Generalized Anxiety Disorder
Examine Case Study:
The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. The remainder of the physical exam was WNL.
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.
In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.
The client has never been on any type of psychotropic medication. Diagnosis is Generalized anxiety disorder.
Make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. Please see the decisions I made below:
Decision Point – – One begin buspirone 10mg orally twice a day Buspirone 10 mg orally BID
RESULTS OF DECISION POINT ONE
• Client returns to clinic in four weeks
• Client reports slight decrease in symptoms
• Client states that he still feels very anxious
• HAM-A score decreased from 26 to 23
Decision Point Two
Discontinue buspirone and begin Lexapro 10 mg orally daily
RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Client reports that he feels “great”
• Client states that his anxiety is getting “better”
• HAM-A score has decreased from 23 to 13
• Client does report that he sometimes feels sleepy for a few hours after taking the medication, but “perks up” by early to midafternoon
Decision Point Order Term Paper Writing Service & Research Report Writing – Three
Continue same dose of Lexapro but change administration time to bedtime
Guidance and feedback to Student
At this point, the client reports that he is feeling “great” with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trial can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the client’s symptoms. You could increase the dose, but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.
The most prudent course of action would be to continue the same dose of medication but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

Based on the information above, please answer questions below. 5 pages required.
Introduction to the case (1 page)
• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
• Which decision did you select?
• Why did you make this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options (which are paxil 10mg orally daily and imipramine 25mg orally twice a day) provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options (which are increase busiprone to 10mg twice a day or 10mg three times a day) provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options (which are increase Lexapro to 15mg by mouth daily in the morning and restart Buspar to 10mg by mouth three times a day) provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.