Exam 1 Review

Question 1

SSRIs for PTSD?

Answer 1

SSRIs are approved as a first-line treatment of PTSD.

Question 2

A 51-year-old male veteran with chronic PTSD has agreed to begin pharmacotherapy for his debilitating symptoms of arousal and anxiety associated with his experiences in Iraq 2 years ago. Which of the following would be appropriate as first-line treatment?
-Paroxetine, lorazepam, d-cycloserine, or quetiapine
-Paroxetine, lorazepam, d-cycloserine
-Paroxetine
-Paroxetine or lorazepam

Answer 2

Paroxetine, a selective serotonin reuptake inhibitor (SSRI), is approved for use in PTSD. The SSRI sertraline is also approved for PTSD. Lorazepam is a benzodiazepine. Benzodiazepines do not have
evidence of efficacy in PTSD and are not generally recommended for first-line use in PTSD. d-cycloserine, an N-methyl-d-aspartate (NMDA) agonist, has been theorized to be useful in facilitating fear extinction, and may be useful in conjunction with exposure therapy. However, it is not a first-line choice. Quetiapine, an atypical antipsychotic, is not approved as first-line treatment for PTSD but may be useful
in selected cases as a third-line treatment, specifically for sleep and possible reduction of nightmares.

Question 3

A 38-year-old man with a history of treatment-resistant PTSD has now experienced improvement on quetiapine 300 mg/day, duloxetine 90 mg/day, and zolpidem 10 mg at bedtime. However, he complains of ongoing nightmares and difficulty staying asleep. He was previously initiated on prazosin 3 mg at bedtime, but he experienced intolerable dizziness, and it was discontinued. Can this patient be rechallenged with prazosin? If so, at what dose?
-No; prazosin is contraindicated with quetiapine
-Yes; dose should be initiated at 3 mg at bedtime
-No; prazosin should not be reattempted in patients with previous intolerability
-Yes; dose should be initiated at 1 mg at bedtime

Answer 3

Yes; dose should be initiated at 1 mg at bedtime. Prazosin, an alpha 1 antagonist, can be an effective treatment for nightmares in PTSD. The initial dose of prazosin should be 1 mg at bedtime and titrated up 1 mg every 2–3 days to decrease the risk of syncope and Orthostatic Hypotension.

Question 4

SSRIs (list drugs)

Answer 4

Citalopram
Escitalopram
Paroxetine
Sertraline
Fluoxetine
Fluvoxamine

Question 5

Fluvoxamine (prescriber notes)

Answer 5

Brand name: Luvox
used mostly for OCD
SSRI

Question 6

OCD treatment

Answer 6

SSRIs for first-line pharma tx (start at half dose IF: elderly/worried about adverse effects/comorbid GAD)
CBT first-line therapy
Clomipramine is second-line
Other meds: Venlafaxine, Pindolol, Phenelzine, Buspirone, 5-HT, L-Tryptophan, Clonazepam, and Risperidone

Question 7

OCD diagnosis

Answer 7

To meet criteria: either obsessions or compulsions that take up more than 1 hour per day or significantly interfere with normal functioning
Obsessions: intrusive, inappropriate, recurrent and persistent thoughts that cause marked anxiety and distress
Compulsions: repetitive behaviors or mental acts done by the individual in response to the obsession or according to rules that must be rigidly applied

Question 8

Criteria for PTSD diagnosis

Answer 8

-Exposure to actual or threatened death, serious injury, or sexual violence
-1 or more intrusion symptoms (e.g., distressing memories/dreams, reliving experience)
-Persistent efforts to avoid trauma stimuli
-2 or more persistent negative alterations in cognitions and mood
-2 or more marked alterations in arousal and reactivity
Symptoms present for 1 month or longer, cause sign clinical distress or impairment in area of functioning, not caused by substance or other underlying medical condition

Question 9

What medications could be used to augment OCD treatment?

Answer 9

Mood stabilizers (valproate, lithium, carbamazepine)

Question 10

Cataplexy

Answer 10

A sudden, brief loss of voluntary muscle tone triggered by strong emotions such as laughter, excitement, anger or fear. There is a strong association between cataplexy and narcolepsy

Question 11

Sodium Oxybate

Answer 11

A medication that improves nighttime sleep architecture and reduces excessive daytime sleepiness (EDS) and cataplexy in narcolepsy by modulating GABA receptors.

Question 12

Valporic acid treatment precautions

Answer 12

Valproic acid = Valproate = Depakote
Adverse effects include pancytopenia (thrombocytopenia) and liver toxicity
Order complete blood count (CBC) and liver function labs before starting Valproic acid/Depakote

Question 13

What laboratory parameter should be closely monitored to prevent the development of thrombocytopenia in a patient on Valproic Acid therapy?
-Platelet count
-White blood cell count
-Serum creatinine levels
-Serum albumin levels

Answer 13

Valproic Acid can lead to a decrease in platelet count, a condition known as thrombocytopenia. Monitoring platelet count is crucial to detect this side effect early and prevent complications such as
bleeding.

Question 14

Lamotrigine (Lamictal) adverse effects

Answer 14

Can cause life-threatening rash (Steven Johnson Syndrome Rash also known as toxic epidermal necrolysis); minimize risk by very slow up-titration
Avoid interactions with valproate as they raise lamotrigine levels
Educate patients to look out for rashes daily and if rash is developed contact doctor and stop lamotrigine immediately, seek immediate care

Question 15

Which of the following symptoms should be closely monitored during the initiation of Lamotrigine therapy?
-Dry mouth
-Skin rashes
-Increased appetite
-Muscle weakness

Answer 15

Lamotrigine is associated with a risk of severe skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Patients should be closely monitored for any signs of skin rash, especially during the initial weeks of treatment.

Question 16

How often should patients be monitored for potential skin rashes during the titration phase of Lamotrigine treatment?
-Monthly
-Daily
-Weekly
-Every 3 months

Answer 16

Daily. During the titration phase of Lamotrigine treatment, patients should be monitored for potential skin rashes on a daily basis. Skin reactions, if they occur, often appear early in treatment. Close monitoring allows for prompt intervention in case of any rash development, which is important to prevent the progression of severe skin reactions.

Question 17

A woman in her 20th week of pregnancy has been resumed on lithium for bipolar disorder. The PMHNP knows that the patient may become subtherapeutic despite taking the medication as prescribed due to:

Answer 17

Increased blood volume occurs as pregnancy progresses and patients may need higher doses of medication to maintain concentration effects. Fetal metabolism has no impact on maternal metabolism, but caution is exercised for potential adverse effects to the fetus. Pregnant women do not have decreased muscle mass or reduced blood volume.

Question 18

Sertraline (prescriber notes)

Answer 18

Brand name: Zoloft
Best tolerated, best choice for pregnancy
SSRI

Question 19

A patient with schizophrenia was discharged from the hospital on olanzapine 5 mg twice a day. He immediately resumed smoking cigarettes and escalated to one pack per day. Upon presenting for his 1-week follow-up appointment, the patient reports he is having trouble sleeping and the voices have started to return. Which of the following actions should the PMHNP take?
- increase his olanzapine and schedule a FU visit in 2 days
- send the patient to the ED for stabilization
- change to another antipsychotic med and refer to psychiatrist
- tell him to stop smoking and give him a nicotine patch

Answer 19

Increase his olanzapine and schedule a follow up visit because the patient’s symptoms are no longer controlled and smoking is a known inducer of the CYP450 pathway. The patient has not indicated a threat of harm to self or others; changing to another antipsychotic
medication requires re-titration and is not indicated. Telling a patient to stop smoking may trigger a psychological paradox and can erode
therapeutic alliance.

Question 20

Bupropion

Answer 20

Brand name: Wellbutrin
NE and DA reuptake inhibitor
Appropriate first-line treatment for MDD
Can be used to augment (usually SSRI)
Can be used for smoking cessation and ADHD
Dose in the morning

Question 21

CYP450 1A2 Inducers

Answer 21

Smoking (can affect the metabolism of antipsychotics like clozapine and olanzapine)
Rifampin (antibiotic)
Carbamazepine (anticonvulsant, mood stabilizer)

Question 22

When explaining the means by which neurotransmitters relate to mental illness, a patient asks, “What is a neurotransmitter?” The best answer is:
-The space between nerve cells
-A fatty layer covering the axon
-A chemical messenger
-A nerve cell

Answer 22

A neurotransmitter is a chemical messenger, created from dietary substrates, that transmits information between neurons.

Question 23

DSM-5 Criteria for MDD (unipolar depression)

Answer 23

5 or more of the following symptoms (including at least 1 depressed mood and loss of interest or pleasure) in the same 2-week period; each of these represents a change from previous functioning:
-Depressed mood (subjective or observed)
-Loss of interest or pleasure
-Change in weight or appetite
-Insomnia or hypersomnia
-Psychomotor retardation or agitation (observed)
-Loss of energy or fatigue
-Worthless or guilt
-Impaired concentration or indecisiveness
-Thoughts of death or suicidal ideation or suicide attempt

Question 24

Major Depressive Disorder SIGECAPS

Answer 24

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor Agitation/Retardation
Suicide
5 or more of the above symptoms must be present within a 2 week time period to diagnose.
Symptoms MUST interfere with social, occupational, OR interpersonal functioning.
Cannot be accounted for by another psychiatric disorder.
No past manic or hypomanic episodes
(Mania = at least 7 days; Hypomania = at least 4 days)

Question 25

Underlying Bipolar? DIGFAST

Answer 25

Distractibility
Indiscretion
Grandiosity
Flight of Ideas
Activities Increase
Sleep Deficit
Talkativeness
-If having these ^ symptoms in response to antidepressant treatment (or in general), may indicate underlying bipolar disorder

Question 26

First line treatments for MDD

Answer 26

SSRIs, SNRIs, Bupropion (Wellbutrin), Mirtazapine (Remeron)

Question 27

Margaret is a 42-year-old patient with untreated depression. She is reluctant to begin antidepressant treatment due to concerns about treatment-induced weight gain. Which of the following antidepressant treatments is associated with the greatest risk of weight gain?
-Vilazodone
-Mirtazapine
-Fluoxetine
-Escitalopram

Answer 27

Mirtazapine. Meta-analysis has shown that mirtazapine, an alpha 2 antagonist, may cause both short- and long-term weight gain. This is consistent with its secondary pharmacological properties: mirtazapine is an antagonist at both serotonin 2C and histamine 1 receptors, the combination of which has been proposed to cause weight gain. However, it should be noted that average weight gain with any antidepressant is small, and rather than a widespread effect it may instead be that a small number of individuals experience significant weight gain due to their genetic predispositions and other factors.

Question 28

Adverse effects of SSRIs

Answer 28

-Transient = nausea, bowel changes, headaches, fatigue, agitation
-Sexual (up to 75% incidence)
-Serotonin syndrome/toxicity

Question 29

Serotonin Syndrome (Serotonin Toxicity)

Answer 29

Start with and escalates to :
1)Diarrhea/restlessness
2)Mydriasis (dilated pupils), Diaphoresis, HTN, tachycardia
3)Extreme agitation, tremor, rigidity, increased reflexes
4)Autonomic instability, hyperthermia, delirium, seizures
5)coma, respiratory failure, renal failure, death
Educate patient on early signs and when to call office

Question 30

Escitalopram (prescriber notes)

Answer 30

Brand name: Lexapro
Fewest adverse effects
SSRI

Question 31

Fluoxetine (prescriber notes)

Answer 31

Brand name: Prozac
Best for children 8+ and adolescents; longest half-life; can give weak dose (90mg once weekly after starting on daily dose); good for forgetful/noncompliant patients
SSRI

Question 32

Citalopram (prescriber notes)

Answer 32

Brand name: Celexa
Adverse effects = prolonging QT interval (–>abnormal heart rhythms; sudden cardiac death); AVOID IF CARDIAC HISTORY; limit dose to 40mg daily, in patients 60+ limit to 20mg daily
SSRI

Question 33

Paroxetine (prescriber notes)

Answer 33

Brand name: Paxil
Highest amount of adverse effects in SSRI class; worst sexual side effects; can treat premature ejaculation
SSRI
(Add wellbutrin (low and slow!) to reduce sexual side effects, can increase risk for serotonin toxicitiy)

Question 34

Which class of anxiolytic medications is often considered a first-line treatment for generalized anxiety disorder and has a lower risk of dependence compared to benzodiazepines?
-Beta-blockers
-Selective Serotonin Reuptake Inhibitors (SSRIs)
-Benzodiazepines
-Antihistamines

Answer 34

SSRIs are a class of antidepressant medications that are commonly used as first-line treatment for generalized anxiety disorder. They work by increasing serotonin levels in the brain, which helps regulate
mood and reduce anxiety. Unlike benzodiazepines, SSRIs have a lower risk of dependence and are generally considered safer for long-term use.

Question 35

A 28-year-old female presents for help in managing a generalized anxiety disorder. An appropriate first-line agent would be:
-Duloxetine
-Sertraline
-Nortriptyline
-Bupriopion

Answer 35

Sertraline. SSRIs are suggested as a first-line treatment for Generalized Anxiety D/O.

Question 36

A 35-year-old female presents to your office and begins to divulge her frequent worries: ever since she was young, she was worried someone close to her would die in a freak accident. As she grew older, this worry was exacerbated by the fear that she would pass away without telling her friends and family how important they are to her. Additionally, once she had children, she became so worried for their safety that she rarely lets them leave the house. Furthermore, she has constant worries about how things will work
out for her in the future, and recently experienced a panic attack. Based only on what you know here, how might you currently diagnose this patient?
-PTSD
-Panic disorder
-Social anxiety disorder
-Generalized anxiety disorder

Answer 36

Generalized anxiety disorder. This patient is displaying core symptoms of generalized anxiety disorder via generalized anxiety and worry. Although she did have a panic attack, a single panic attack is insufficient for a diagnosis of either panic disorder or social anxiety disorder.

Question 37

Ashely, 26 years old, presents for a psychiatric evaluation stating, “The doctor thought I might have panic disorder.” She states that she has had 2 panic attacks that caused her to go to the emergency department (ED) where she had a thorough work-up that did not reveal any serious physical health problems. She was told to seek psychiatric care. Which of the following statements would not be consistent with the diagnosis of panic disorder?
-“I felt a sense that I wasn’t really present”
-“It came from nowhere, I had to pull the car over, my heart was pounding.”
-“I’m afraid it might happen again so I’m hesitant to go too far from home.”
-“My attacks always happen after I’ve had a bad argument with my boyfriend.”

Answer 37

“My attacks always happen after I’ve had a bad argument with my boyfriend.”

Question 38

A 26-year-old patient with panic disorder is ready to begin pharmacotherapy. Which of the following would be appropriate treatment options?
-Depakote
-Trazodone
-Sertraline or Alprazolam
-Clomipramine

Answer 38

Sertraline or Alprazolam. SSRIs are appropriate first-line treatment options for panic disorder as well as for generalized anxiety disorder, social anxiety disorder, and PTSD. For panic disorder, benzodiazepines are an appropriate treatment option, although many clinicians prefer not to use them as the first-line option.
Benzodiazepines are also appropriate treatment options for generalized anxiety disorder or social anxiety disorder, although again may not be the first-line choice. They do not have evidence of efficacy for PTSD. Most patients with anxiety or stress-related disorders may benefit most from combined treatment with both nonpharmacological options, such as cognitive behavioral therapy, and pharmacological
options.

Question 39

In treating an acute manic episode of Bipolar Disorder, which class of medications is often used as first-line treatment due to its rapid onset of action?
-Tricyclic Antidepressants (TCAs)
-Antipsychotics
-Selective Serotonin Reuptake Inhibitors (SSRIs)
-Benzodiazepines

Answer 39

Antipsychotics

Question 40

What is the first-line mood stabilizer often prescribed for the maintenance treatment of Bipolar Disorder?
-Venlafaxine
-Lithium
-Fluoxetine
-Quetiapine

Answer 40

Lithium is a well-established mood stabilizer and is often considered a first-line treatment for the maintenance phase of Bipolar Disorder. It helps to prevent both manic and depressive episodes.

Fluoxetine is an antidepressant and should be used cautiously in Bipolar Disorder due to the risk of
triggering manic episodes.
Venlafaxine is an antidepressant that can potentially induce mania, and quetiapine is an atypical antipsychotic used to manage acute manic and depressive episodes.

Question 41

Katherine is a 24-year-old patient who presents with symptoms of depression (including sadness, feelings of worthlessness, and suicidal ideation) occurring every day for the past month. Clinical
interview with Katherine reveals that she has a maternal aunt with bipolar disorder I. Further assessment reveals that this patient also feels distracted and as though her thoughts are racing. Upon speaking with the patient’s mother, it is discovered that Katherine has been, at times, more talkative than usual and irritable with her friends and family. Which class of medication would not be recommended as monotherapy for this patient?
-A mood stabilizer
-All of these would be recommended as monotherapy
-An antipsychotic
-An antidepressant

Answer 41

Expert consensus and published guidelines recommend that antidepressant monotherapy not be used (and is contraindicated) in patients with depression who exhibit mixed features and a positive family history of bipolar disorder.

Question 42

A 24-year-old man with bipolar disorder is being initiated on lithium, with monitoring of his levels until a therapeutic serum concentration is achieved. Once the patient is stabilized, how often should his serum lithium levels be monitored (excluding one-off situations such as dose or illness change)?
-Every 2 to 3 months
-Every 1 to 2 years
-Every 6 to 12 months
-Routine monitoring is not necessary

Answer 42

Once a patient is stabilized, lithium levels need only be monitored every 6 to 12 months.

Question 43

A 38-year-old male reports excessive daytime sleepiness for the last 2 weeks in the setting of restructuring at his job. He is unable to tell if he is having more trouble falling asleep or staying asleep. Sometimes he wakes up at 4 a.m. and is unable to fall back asleep. What should the PMHNP do first?
-Prescribe mirtazapine 15 mg at bedtime
-Request the patient complete a sleep log
-Add an extra blanket to his bed covers
-Prescribe zolpidem 10 mg at bedtime as needed

Answer 43

Request the patient complete a sleep log to gather more information regarding sleep latency, sleep efficiency, and sleep maintenance in order to make appropriate recommendations. Zolpidem as a sedative hypnotic is primarily used for patients who have trouble falling asleep. Mirtazapine is an antidepressant that is sometimes used off label in insomnia and for difficulty staying asleep. Environmental factors conducive to sleep include reducing the temperature of the environment and adding a blanket warmer.

Question 44

Which of the following medications can be used to manage cataplexy in patients with narcolepsy?
-Methylphenidate
-Zolpidem
-Diphenhydramine
-Sodium Oxybate

Answer 44

Sodium Oxybate. It is an effective treatment for cataplexy, a symptom of narcolepsy characterized by sudden muscle weakness triggered by strong emotions.

Question 45

Methylphenidate

Answer 45

Stimulant that can help with daytime sleepiness
Increases DA levels in the synapse
Also used for ADHD

Question 46

Diphenhydramine

Answer 46

Brand name: Benadryl
An antihistamine with sedative properties
Antagonist at H1

Question 47

Acetylcholine (associated pathology)

Answer 47

ACh too high = Parkinsonism
ACh too low = Dementia

Question 48

Acetylcholine (effect)

Answer 48

Increases: HR, secretions, sweating, salivation, memory, muscle contractions

Question 49

Norepinephrine (associated pathology)

Answer 49

NE too high = anxiety
NE too low = depression

Question 50

Norepinephrine (effect)

Answer 50

Increases: HR, alertness, well-being.
Decreases: pain sensitivity &circulation

Question 51

Dopamine (associated pathology)

Answer 51

DA too high = Psychosis
DA too low = PD, Anhedonia, Addiction

Question 52

Dopamine (effect)

Answer 52

Increases: sense of well-being and satiety
Decreases: hunger and cravings

Question 53

Serotonin (associated pathology)

Answer 53

5HT too high = Serotonin syndrome
5HT too low = Depression, OCD, Anxiety

Question 54

Serotonin (effect)

Answer 54

Increases: well-being, satiety
Reduces pain perception

Question 55

GABA (associated pathology)

Answer 55

GABA too high = sedated/asleep
GABA too low = anxiety

Question 56

GABA (effect)

Answer 56

Increases sleepiness.
Decreases: anxiety, alertness, memory, muscle tension

Question 57

Denise is a 32-year-old patient with shift work disorder who reports that she is having difficulty in her job as a pastry chef due to excessive sleepiness during her shift. Which of the following is a potential therapeutic mechanism to promote wakefulness?
-Inhibit histamine activity
-Inhibit Dopamine activity
-Inhibit gamma-aminobutyric acid (GABA) activity
-Inhibit orexin activity

Answer 57

Inhibit gamma-aminobutyric acid (GABA) activity. When the VLPO is active and GABA is released to the TMN, the sleep promoter is on and the wake promoter is inhibited. Thus, inhibiting GABA activity can promote wakefulness.

Question 58

Neurotransmitters fluctuate not only on a circadian (24-hour) basis, but also throughout the sleep cycle.____ levels steadily increase during the first couple of hours of sleep, plateau, and then steadily decline before waking.
-GABA/galanin
-Acetylcholine
-Histamine
-Hypocretin/orexin

Answer 58

GABA and galanin levels steadily increase during the first couple of hours of sleep, plateau, and then steadily decline before waking.

Question 59

What pattern do hypocretin/orexin levels have during sleep?

Answer 59

Hypocretin/orexin levels steadily decrease during the first couple of hours of sleep, plateau, and then steadily increase before waking.

Question 60

What pattern do Acetylcholine (ACh) levels have during sleep?

Answer 60

Acetylcholine levels fluctuate throughout the sleep cycle, reaching their lowest levels during stage 4 sleep and peaking during REM sleep.

Question 61

What pattern do Histamine levels have during sleep?

Answer 61

Histamine levels fluctuate throughout the sleep cycle, peaking during stage 2 sleep, and are at their lowest during REM sleep.

Question 62

A 22-year-old college student stays up all night completing his thesis paper and then has to work the following day. While taking his break in the employee lounge he falls asleep in his chair. His fatigue and urge to sleep are hypothetically related to accumulation of which of the following neurotransmitters?
-Histamine
-Adenosine
-Melatonin
-Orexin

Answer 62

Adenosine. The sleep/wake cycle is mediated by two opposing drives: homeostatic sleep drive and circadian wake drive. Homeostatic sleep drive is dependent on the accumulation of adenosine, which increases the longer one is awake and decreases with sleep. Accumulated adenosine leads to disinhibition of the ventrolateral preoptic nucleus and thus the release of GABA in the tuberomammillary nucleus to inhibit wakefulness. Antagonists at adenosine receptors, therefore, can promote wakefulness by preventing accumulated adenosine from binding to its receptors. Caffeine is the most notable example of an adenosine receptor antagonist.

Question 63

Orexin

Answer 63

“The wake circuit”; peptide neurotransmitters produced in the lateral hypothalamus that promote wakefulness and stabilize the sleep-wake cycle. Orexin levels are low at the end of the day.
Orexin deficiency (loss or degeneration of orexin producing neurons) is associated with narcolepsy type 1 (with cataplexy)

Question 64

The PMHNP is monitoring a serum drug level for a medication with a 24-hour half-life. How many hours will it take to reach steady state?

Answer 64

120 hours; steady state is achieved in five half-lives of the medication
(5 × 24 = 120).

Question 65

Half-life of a medication

Answer 65

the time it takes for the amount of a drug’s active substance in your body to reduce by half (as compared to the peak of absorption)

Question 66

A 25-year-old woman reports frequently falling asleep during the day for the last 6 months. This has been affecting her work as a computer help desk agent, noting she sometimes nods off during calls but also during times of high volume. When her head hits the back of the chair she wakes up and realizes what has happened. She insists she consistently sleeps 8 hours each night. This is most consistent with which of the following?
-Circadian rhythm sleep disorder
-Night terrors
-Hypersomnia
-Narcolepsy

Answer 66

Narcolepsy is characterized by two or more episodes of sleep latency lasting less than 8 minutes and/or two or more episodes of rapid eye movement (REM) sleep; it commonly occurs in the late teens and 20s. Circadian rhythm sleep disorder is often caused by changes in scheduling (shift work, jet lag) and requires a period of acclimation. Primary hypersomnia is excessive daytime drowsiness not due to an environmental sleep disturbance, underlying medical condition, substance induced disorder, or mood disorder, and is not associated with sleep paralysis (cataplexy). Night terrors are episodes of screaming or intense fear and flailing 2 to 3 hours after falling asleep and is often paired with sleepwalking, unlike nightmares, which are not remembered, and are most common in children between the ages of 2 to 12

Question 67

John is a 22-year-old RN who has started his first job in the cardiothoracic ICU. After his orientation he began his full-time position working three 12-hour night shifts per week. On his days off he reports excessive fatigue during the day with periods of falling asleep while driving. He also reports difficulty staying awake at work during his first night back to work. Which of the following is the most likely diagnosis?
-Night terrors
-Hypersomnia
-Circadian rhythm sleep disorder
-Narcolepsy

Answer 67

Circadian rhythm sleep disorder is often caused by changes in scheduling (shift work, jet lag) and requires a period of acclimation. Primary hypersomnia is excessive daytime drowsiness not due to an environmental sleep disturbance, underlying medical condition, substance induced disorder, or mood disorder, and is not associated with sleep paralysis (cataplexy). Night terrors are episodes of screaming or intense fear and flailing 2 to 3 hours after falling asleep and is often paired with sleepwalking, unlike nightmares, which are not remembered, and are most common in children between the ages of 2 to 12. Narcolepsy is characterized by two or more episodes of sleep latency lasting less than 8 minutes and/or two or more episodes of rapid eye movement (REM) sleep; it commonly occurs in the late teens and 20s.

Question 68

Which of the following medications is considered a first-line treatment for narcolepsy?
-Selective serotonin reuptake inhibitors (SSRls)
-Modafinil
-Antipsychotic medications
-Benzodiazepines

Answer 68

Modafinil is considered a first-line treatment for narcolepsy. It is a wakefulness-promoting agent that helps improve daytime alertness without causing the same level of stimulation and potential abuse as other stimulant medications.
Benzodiazepines may help with sleep, but they are generally not the first-line treatment for narcolepsy and can have undesirable side effects.

Question 69

Insomnia treatment

Answer 69

1st line:
-“Z” drugs: zaleplon, zolpidem, zopiclone
-Dual orexin receptor antagonists (DORAs)
-H1 antagonists (doxepin, diphenhydramine)
-5HT2A Antagonists (trazodone)
-Alpha1 Antagonists
2nd line:
-Benzodiazepines (avoid in OSA and COPD)

Question 70

Circadian Rhythm Disorder treatment

Answer 70

Bright light and melatonergic agents

Question 71

Ion Channels

Answer 71

When activated by neurotransmitters, these channels open to allow ions (e.g., Na+, K+, Cl-) to pass into or out of the neuron, influencing its electrical activity

Question 72

G-Protein-Coupled Receptors (GPCRs)

Answer 72

Receptors that activate secondary messengers inside the cell to exert their effects indirectly

Question 73

Partial Agonists

Answer 73

Drugs that partially activate receptors but do not elicit the full effect, often used to balance neurotransmission (e.g., aripiprazole as a dopamine partial agonist)
In the presence of a full agonist, the partial agonist will actually turn down the strength of various downstream signals = stabilizers

Question 74

Cytochrome P450 (CYP450)

Answer 74

Most psychotropic drugs also target the CYP450 drug metabolizing enzymes either as a substrate, inhibitor, and/or inducer. CYP450 enzymes in the gut wall or liver convert the drug substrate into a biotransformed product in the bloodstream. After passing through the gut wall and liver, the drug will exist partially as unchanged drug and partially as biotransformed product in the bloodstream.

Question 75

Enzymes in Neurotransmitter Metabolism

Answer 75

Enzymes are responsible for breaking down neurotransmitters and terminating their action

Question 76

Monoamine Oxidase (MAO)

Answer 76

Breaks down monoamines like serotonin, norepinephrine, and dopamine. MAO inhibitors (e.g., phenelzine) block this enzyme, increasing the levels of these neurotransmitters

Question 77

Acetylcholinesterase

Answer 77

Breaks down acetylcholine in the synaptic cleft. Inhibitors like donepezil increase acetylcholine levels and are used in treating Alzheimer’s disease.

Question 78

Pharmacodynamics

Answer 78

the study of the relationship between drug concentration and effect on the body

Question 79

The PMHNP knows that the study of how the body absorbs, distributes, metabolizes, and excretes a medication is known as:

Answer 79

Pharmacokinetics
(effect the organism has on the drug)