Final Exam Review

Question 1

A 32-year-old woman with bipolar disorder has been maintained on 900 mg/day of lithium. She was
doing well for a long time and had even been able to lose the weight she had initially gained with lithium. She broke up with her boyfriend 5 months ago and has been feeling depressed ever since. You augment her with 300 mg/day of quetiapine, but after several weeks she complains of weight gain and wants to change medications. Blockade of which two receptors was most likely responsible for this weight gain induced by quetiapine?
-Dopamine 2 and alpha 1 adrenergic
-Muscarinic 1 and serotonin 6
-Serotonin 2C and histamine 1
-Serotonin 2A and muscarinic 3

Answer 1

Blockade of serotonin 2C receptors and histamine 1 receptors has been linked to weight gain.

Question 2

A patient with bipolar depression has been treated for 6 months with lamotrigine plus an atypical
antipsychotic with partial response. The decision is made to stop the atypical antipsychotic; however, during down-titration, the patient develops withdrawal dyskinesias. No treatment for the dyskinesias is initiated, and after 2 weeks they still remain. Which of the following is true?
-An anticholinergic medication, such as Benztropine, should be started.
-If the withdrawal dyskinesias still remain after 2 weeks, they are likely to be permanent.
-The antipsychotic should be restarted.
-The patient’s withdrawal dyskinesias may take several weeks to months to resolve.

Answer 2

Withdrawal dyskinesias are often reversible with time and usually resolve within a few weeks; however, they can take several months to resolve, depending on their seriousness. Thus, although the patient’s withdrawal dyskinesias still remain after 2 weeks, this does not indicate that they are likely to be permanent.

Question 3

According to DSM-5 criteria, which of the following are characteristics of Schizophrenia? Select all that
apply.
-Disorganized Speech
-Hallucinations
-Compulsive Behaviors
-Delusions

Answer 3

Characteristic symptoms of Schizophrenia include Delusions, Hallucinations, Disorganized Speech, Grossly disorganized or catatonic behavior, and/or Negative symptoms.

Question 4

Based on thorough evaluation of a patient and his history, his care provider intends to begin treatment with a typical antipsychotic but has not selected a particular agent yet. Which of the following is most true about typical antipsychotics?
-They differ in therapeutic profile but are similar in side effect profile
-They are very similar in therapeutic profile but differ in side effect profile
-They differ in both therapeutic and side effect profile
-They are very similar in both therapeutic and side effect profile

Answer 4

They are very similar in therapeutic profile but differ in side effect profile.
Although individual effects may vary from patient to patient, in general conventional antipsychotics share
the same primary mechanism of action and do not differ much in their therapeutic profiles. There are,
however, differences in secondary properties, such as degree of muscarinic, histaminergic, and/or alpha adrenergic receptor antagonism, which can lead to different side effect profiles.

Question 5

A 34-year-old man is initiated on an atypical antipsychotic for the treatment of schizophrenia. The
majority of atypical antipsychotics:
-Have higher affinity for serotonin 2A receptors than for dopamine 2 receptors
-Don’t have affinity for dopamine 2 receptors or serotonin 2A receptors
-Have higher affinity for dopamine 2 receptors than for serotonin 2A receptors
-Have higher affinity for GABA receptors

Answer 5

Have higher affinity for serotonin 2A receptors than for dopamine 2 receptors.
Serotonin neurons originate in the raphe nucleus of the brainstem and project throughout the brain,
including to the cortex. They synapse there with glutamatergic pyramidal neurons, which project to the substantia nigra in the brainstem. The substantia nigra is the origin of dopaminergic neurons that project to the striatum. All serotonin 2A receptors are postsynaptic. When they are located on cortical pyramidal neurons, they are excitatory. Thus, when serotonin is released in the cortex and binds to serotonin 2A receptors on glutamatergic pyramidal neurons, this stimulates them to release glutamate in the brainstem, which in turn stimulates gamma-aminobutyric acid (GABA) release. GABA binds to dopaminergic neurons projecting from the substantia nigra to the striatum, inhibiting dopamine release.

Question 6

Atypical antipsychotics, the “pines”

Answer 6

The “pines” – clozapine, olanzapine,
quetiapine, asenapine, and zotepine – all bind much more potently to the 5HT2A receptor than they do to the D2 receptor.

Question 7

Atypical antipsychotics, the “dones” and “rone”

Answer 7

The “dones” and “rone” – risperidone, paliperidone, ziprasidone, iloperidone, lurasidone, and lumateperone – also bind more potently to the serotonin 2A receptor than to the dopamine 2 receptor or show similar potency at both receptors.

Question 8

Atypical antipsychotics, aripiprazole and caripazine

Answer 8

Aripiprazole and cariprazine bind
more potently to the dopamine 2 receptor than to the serotonin 2A receptor; however, they are also
partial agonists at dopamine 2 receptors

pneumonic: Ari and the Car Dare for D2, leaving 5HT2A behind!

Question 9

Atypical antipsychotics, brexipiprazole

Answer 9

Brexpiprazole (also a dopamine 2 partial agonist) has comparable binding affinity to the dopamine 2 and serotonin 2A receptors.

Question 10

A 34-year-old male recently began experiencing breast secretions while receiving perphenazine. After
switching to quetiapine, the secretions ceased. Which of the following is the most likely pharmacological explanation for the resolution of this side effect?
-Dopamine 2 antagonism
-Serotonin 2C antagonism
-Histamine 1 antagonism
-Serotonin 2A antagonism

Answer 10

Dopamine 2 antagonism. Prolactin secretion is directly regulated by dopamine acting on D2 receptors in the hypothalamus and pituitary gland.
Perphenazine, as a potent D2 antagonist, increases prolactin levels, leading to breast secretions.
Quetiapine, with its weaker D2 antagonism, allows prolactin levels to normalize, resolving the side effect.

Question 11

A 22-year-old male diagnosed with paranoid schizophrenia has been taking haloperidol for the past 6
months. During this visit, the PMHNP acknowledges involuntary repetitive muscle movements and
excessive eye-blinking that were not documented at his last visit. An appropriate next course of action
would be to:
-Measure serum creatinine
-Administer AIMS questionnaire and compare to baseline value
-Measure serum ALT/AST
-Administer PHQ-9 questionnaire and compare to baseline value

Answer 11

This patient is showing new Extrapyramidal symptoms and possible drug-induced acute dystonia. An AIMS (Abnormal Involuntary Movement Scale) Questionnaire should be administered and compared to
the patient’s baseline questionnaire. A possible change in medication or addition of an anticholinergic agent may be necessary.

Question 12

A 44-year-old woman with schizophrenia has developed tardive dyskinesia after taking haloperidol 15 mg/day for 2 years. Which of the following would be the most appropriate pharmacological mechanism to manage her tardive dyskinesia?
-Antagonism of beta-adrenergic receptors
-Inhibition of vesicular monoamine transporter 2
-Antagonism of muscarinic acetylcholine receptors
-Antagonism at serotonin 2A receptors

Answer 12

Inhibition of vesicular monoamine transporter 2.
The best evidenced (including approved) medications to treat tardive dyskinesia are selective inhibitors of vesicular monoamine transporter 2 (VMAT2), which packages monoamines, including dopamine, into synaptic vesicles of presynaptic neurons in the central nervous system.

Question 13

A 28-year-old man was recently diagnosed with schizophrenia. He has a body mass index of 30, fasting triglycerides of 220 mg/dL, and fasting glucose of 114 mg/dL. Which of the following is least likely to worsen his metabolic profile?
-Ziprasidone
-Quetiapine
-Risperidone
-Olanzapine

Answer 13

Ziprasidone in general seems to be weight neutral and has been shown to lower triglyceride levels. It is
therefore a recommended choice for individuals for whom metabolic issues are a primary concern. Other
newer antipsychotics that may be less likely to cause weight gain or metabolic side effects include
aripiprazole (although data suggest that weight gain may occur more in children and adolescents),
lurasidone, and lumateperone.

Question 14

Carol is a 47-year-old patient with schizophrenia. She was taking a conventional antipsychotic but
decided to stop taking it when she developed parkinsonian symptoms. Secondary to stopping her conventional antipsychotic, Carol’s auditory hallucinations and paranoia returned, and she was rehospitalized. You recommend that she be started on an atypical antipsychotic. Which of the following has the lowest risk of drug-induced parkinsonism associated with it?
-Asenapine
-Iloperidone
-Olanzapine
-Paliperidone

Answer 14

iloperidone has a relatively
lower risk of drug-induced parkinsonism. Other agents with a relatively lower risk of drug-induced
parkinsonism include clozapine, lumateperone, and quetiapine

Question 15

A 10-year-old girl is referred for evaluation of behavioral difficulties. Her teachers report that she is easily distracted and fails to complete any class work, and often stares off into space or tries to chat with her neighbor. Her mother reports that mornings are the most difficult because of her general disorganization and forgetfulness. Otherwise, she is socially engaged and enjoys many activities. Which of the following is the most likely diagnosis?
-Attention deficit disorder
-Conduct disorder
-Disruptive behavior
-Oppositional defiant disorder

Answer 15

Attention deficit disorder inattentive type: She is very distractible and forgetful in school as well as at
home with impaired ability to function. There are no displays of aggression, destruction of property,
deceitfulness, theft, or serious violations of rules that are associated with conduct disorders and
oppositional defiant disorder. Disruptive behavior disorder is reserved for conduct disorders not meeting
full DSM-5 diagnostic criteria.

Question 16

According to DSM-5 criteria, what is the maximum age threshold for symptom onset when making a
diagnosis of ADHD?
-12
-7
-5
-15

Answer 16

12. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the maximum age
    threshold for symptom onset for diagnosing ADHD changed from 7 to 12. Other revisions included the
    fact that, although symptoms must have been present prior to age 12, there does not have to have been
    impairment prior to age 12 when diagnosing someone who is older. The symptom count threshold also
    changed for adults (defined as age 17 and older), with five (instead of six) symptoms required in the
    inattention and/or hyperactive/impulsive categories.

Question 17

A 15-year-old with inattentive-type ADHD has a hard time staying focused on the task at hand, has
trouble organizing her work, and relies heavily on her mother to follow through with her homework.
Problem solving is one of the hardest tasks for her. Her difficulty with sustained attention could be
related to deficient activation in the:
-Orbital frontal cortex
-Prefrontal motor cortex
-Supplementary motor cortex
-Dorsolateral prefrontal cortex

Answer 17

DLPFC. Sustained attention is hypothetically modulated by the cortico-striatal-thalamic-cortical loop involving
the dorsolateral prefrontal cortex (DLPFC). Inefficient activation of the DLPFC can lead to problems
following through or finishing tasks, disorganization, and trouble sustaining mental effort; the patient
exhibits all these symptoms. The dorsal anterior cingulate cortex is important in regulating selective
attention, and is associated with behaviors such as losing things, being distracted, and making careless
mistakes. This area is certainly also inefficient in this patient.

Question 18

Irina is a 35-year-old patient with untreated ADHD who reports abusing alcohol to manage severe anxiety. Irina’s symptoms may represent a case where the firing of __________ and __________ neurons innervating her prefrontal cortex is dysregulated and causing excessive arousal.
-Dopamine; serotonin
-Dopamine; glutamate
-Norepinephrine; glutamate
-Norepinephrine; dopamine

Answer 18

When norepinephrine (NE) and dopamine (DA) neurotransmission in the prefrontal cortex are optimally
tuned, modest stimulation of postsynaptic alpha 2A receptors and dopamine 1 receptors allows for
efficient cognitive functioning. If NE or DA neurotransmission is excessive, as in situations of stress or
comorbid conditions such as anxiety or substance abuse, this can lead to overstimulation of postsynaptic
receptors and consequently to cognitive dysfunction as well as other symptoms.

Question 19

Aggregate data suggest that, compared to stimulants, nonstimulants have:
-Approximately the same effect sizes
-Larger effect sizes
-No effect on ADHD symptoms
-Smaller effect sizes

Answer 19

Smaller effect sizes. Multiple meta-analyses assessing the effects of stimulant medications have shown that, as a class,
nonstimulants have smaller effect sizes than stimulants. Due to differences in study design, these meta
analyses do not address potential differences in efficacy among specific medications.

Question 20

Isaac is an 8-year-old patient with ADHD. Among male children with ADHD, which of the following is the
most commonly seen comorbidity?
-Learning Disability
-Depression
-Oppositional defiant disorder
-Anxiety

Answer 20

ODD. Argumentative, disobedient, and aggressive behaviors are often seen in patients suffering from ADHD
and oppositional symptoms. The presence of comorbid disruptive behavior disorders such as
oppositional defiant disorder, or conduct disorder, within children with ADHD has been well established.
About five in ten children with ADHD have a behavior or conduct problem and this is seen at a higher
rate in boys than in girls in studies.

Question 21

Which of the following is considered a first-line treatment for ADHD in children and adolescents?
-Cognitive-behavioral therapy (CBT)
-Prescription stimulant medication
-Nutritional supplements
-Mindfulness meditation

Answer 21

Prescription stimulant medication, such as methylphenidate or amphetamine-based medications, is often
considered a first-line treatment for ADHD in children and adolescents due to their proven effectiveness
in managing symptoms.

Question 22

What is the primary goal of medication treatment for ADHD?
-Eliminating all symptoms of ADHD
-Inducing sleep and relaxation
-Reducing impulsivity and hyperactivity
-Enhancing intelligence and cognitive abilities

Answer 22

The primary goal of medication treatment for ADHD is to reduce impulsivity and hyperactivity and
improve the individual’s ability to focus and concentrate, rather than eliminating all ADHD symptoms.

Question 23

Which of the following is an evidence-based non-pharmacological treatment option for ADHD in both
children and adults?
- Herbal supplements like ginkgo biloba
-Behavioral therapy and psychoeducation
-Daily caffeine consumption
-Dietary restriction of carbohydrates

Answer 23

Behavioral therapy and psychoeducation are evidence-based non-pharmacological treatment options for
ADHD in both children and adults. They can help individuals develop coping strategies and improve their
executive functioning skills.

Question 24

What is a potential side effect of stimulant medication commonly used to treat ADHD?
-Slower heart rate
-Enhanced emotional regulation
-Improved sleep quality
-Increased appetite

Answer 24

Increased appetite

Question 25

The PMHNP is consulted to see a 70-year-old female who was admitted to the skilled nursing facility 3 days ago from the hospital, where she was treated for urinary tract infection, pneumonia, and dehydration. The staff reports that the patient is restless and agitated, awake most of the night, intermittently sleeping during the day, and has poor PO intake. What should the PPMHNP do first? -Prescribe quetiapine 12.5 mg PO at bedtime and every 6 hours as needed for agitation -Call family members for collateral information on her baseline functioning -Transfer the patient to the ED -Physical exam and diagnostic tests (complete blood count, basic metabolic profile, and urinalysis)

Answer 25

Physical exam and diagnostic tests are used to rule out delirium given the patient’s history, age, and clinical presentation. Prescribing medication can worsen delirium and mask symptoms of an underlying cause. Transferring the patient to the ED may worsen or trigger delirium. Obtaining collateral information is helpful in helping to establish a baseline pattern of function, but the acute problem of delirium must be addressed and ruled out first

Question 26

A 53-year-old man presents to the emergency department with complaint of sore throat progressively worsening for 3 days with intermittent fever. In triage he tells the RN that he has taken ibuprofen 400 mg 4 hours ago for the pain, and currently his vital signs are blood pressure 120/80, heart rate 88, respiratory rate 12, SPO2 96% on room air. While waiting for the results of the rapid strep test the patient becomes agitated, restless, confused, and increasingly difficult to redirect. He is transferred to the psychiatric emergency department because it is a locked unit. Which of the following is the most likely diagnosis? -Mixed delirium -Mood disorder -Presenile dementia -Personality disorder

Answer 26

Mixed delirium is characterized by a cyclical manifestation of psychomotor retardation and agitation with a disturbance in consciousness; risk factors include infectious process, fever, and relocation. Dementia is a slowly progressive process that impairs cognition with the preservation of level of consciousness. Personality disorder is characterized by a historical pattern of rigid maladaptive coping mechanisms that cause distress. Mood disorder is a diagnosis of exclusion in which there are an insufficient number of symptoms to meet full criteria for major depressive disorder, bipolar disorder, or generalized anxiety disorder.

Question 27

A 55-year-old woman reports to the PMHNP that since she accepted early retirement last year she finds that her memory has gotten worse and she has trouble sleeping at night. She denies any medical problems. What should the PMHNP do first? -Prescribe mirtazapine 15 mg PO at bedtime to help her sleep -Encourage her to volunteer with something she feels passionate about -Perform a Mini-Mental State Exam and Confusion Assessment Methods Instrument -Refer her to her primary care provider for a physical exam

Answer 27

MMSE.A formalized assessment such as the Mini-Mental State Exam and Confusion Assessment Methods Instrument provides a reproducible means of establishing baseline function and distinguishing delirium from reversible cognitive impairment. Mirtazapine is indicated for major depressive disorder and anxiety but both are a diagnosis of exclusion and are lower priority than delirium. Encouraging volunteer activity may be a good way to develop psychological activation in a patient with a mood disorder, but there is no evidence to support this diagnosis. Referring the patient to her primary care provider for a physical exam does negates the PMHNP’s responsibility to evaluate for neurocognitive disorders.

Question 28

A 66-year-old woman employed as a federal appeals lawyer is being seen by the PMHNP accompanied by her son, who has been concerned about progressive memory problems. Which of the following would be most helpful in distinguishing between common forgetfulness and cognitive impairment? -Montreal Cognitive Assessment (MoCA) -Brain MRI with and without contrast -Family history -Hamilton Depression Scale (HAM-D)

Answer 28

MoCA. The Montreal Cognitive Assessment is a psychometrically validated screening tool for mild cognitive impairment including visuospatial abilities, short-term recall, trail making, attention, concentration, language, and orientation. A brain MRI is helpful in identifying structural changes that may account for behavior if the affected brain region correlates with the impairment. Family history is important for stratifying risk factors and genetic predisposition but does not confirm a current diagnosis. The Hamilton Depression Scale is used to screen for major depressive disorder which can affect cognition, but the chief complaint was related to cognition.

Question 29

The primary treatment for delirium is: -Mood stabilizing medications -Anticipatory guidance and psychoeducation -Antipsychotic medications -Identifying and treating the underlying cause

Answer 29

Identifying and treating the underlying cause is the primary treatment for delirium. Adding medications to a patient with delirium with an unknown underlying cause may worsen or compound the delirium as polypharmacy is another causative factor. Anticipatory guidance and psychoeducation is appropriate when tailored to a specific condition

Question 30

Delirium characterized by apathy, psychomotor retardation, and inattentiveness is known as: -Mania -Mixed delirium -Hyperactive delirium -Hypoactive delirium

Answer 30

Hypoactive delirium is characterized by psychomotor retardation and apathy. Hyperactive delirium is characterized by psychomotor agitation, restlessness, and hypervigilance. Mixed delirium is characterized by cycling through psychomotor agitation and retardation ranging from apathy to hypervigilance. Mania is characterized by grandiosity, reduced need for sleep, more talkative than usual, flight of ideas and racing thoughts, distractibility, and psychomotor agitation with an increase in goal directed, pleasure-seeking behaviors.

Question 31

A middle-aged man brings his 72-year-old mother in for an appointment because he is concerned that his mother may have Alzheimer’s disease. The mother does not feel that anything is wrong, but her son states that she seems somewhat depressed and forgetful lately. Data have shown that: (Select all that apply) -Depression may increase the risk of developing Alzheimer’s disease -There is no link between Depression and Alzheimer’s disease -Depression is often comorbid with Alzheimer’s disease -Depression may be a prodromal symptom of Alzheimer’s disease

Answer 31

1st, 3rd, and 4th choice. Mood symptoms can occur as part of Alzheimer’s disease and in fact are typically the first notable symptom (often manifested as apathy rather than sadness). In addition, depression is a common comorbid illness in patients with Alzheimer’s disease. Depression has been hypothesized to be a possible risk factor for Alzheimer’s disease. Depression has been hypothesized to be a possible prodromal symptom of Alzheimer’s disease, with some evidence suggesting that it may exacerbate the progression of Alzheimer’s pathology

Question 32

Marie, a 70-year-old mid-stage Alzheimer’s patient, has been on donepezil, 10 mg/day for approximately 8 months to aid in stabilizing her cognitive functioning. Her daughter has noticed a loss of effectiveness over the past month, and they present today to determine a new course of action. You decide to augment Marie’s donepezil with 5 mg/day of memantine. Which of the following properties of memantine may be useful in treating Alzheimer’s disease? - N-methyl-D-aspartate (NMDA) antagonism -D2 Antagonism -Sigma antagonism -Serotonin 3 (5HT3) antagonism

Answer 32

NMDA. Memantine is an NMDA antagonist that binds to the magnesium site. It works as an uncompetitive open channel NMDA receptor antagonist (i.e., low–moderate affinity, voltage dependence, fast blocking/unblocking kinetics). Memantine is quickly reversible if phasic bursts of glutamate occur but is able to block tonic glutamate release from having negative downstream effects. This hypothetically stops the excessive glutamate from interfering with the resting glutamate neuron’s physiological activity, thus improving memory

Question 33

A 79-year-old man presents to your office with his wife. She lists significant medical history, such as chronic renal failure, mild cirrhosis, arrhythmia, and a recent diagnosis of moderately severe Alzheimer’s disease by their family physician. Which of the following medications for Alzheimer’s disease has a “do not use” warning for patients with renal and hepatic impairment? -Rivastigmine -Donepezil -Memantine -Galantamine

Answer 33

Galantamine has a “do not use” warning in patients with renal and hepatic impairment, as well as a caution warning when used in cardiac impaired patients. Furthermore, galantamine, a cholinesterase inhibitor, is often prescribed as one of the first-line treatments for early-stage Alzheimer’s, rather than moderately severe cases.

Question 34

Mitchell is a 90-year-old patient with Lewy body dementia. His daughter, who is his full-time caregiver, reports that her father has started to exhibit worsening of agitation, wandering, and confusion in the early evening – also known as sundowning. Which of the following treatments has actually been shown to worsen sundowning behavior? -Benzodiazepines -Bright light therapy -Melatonin -Cholinesterase inhibitors

Answer 34

The use of benzodiazepines and other hypnotics has been linked with a paradoxical increase in behavioral issues, such as sundowning, in patients with dementia. Furthermore, benzodiazepines are particularly not recommended in elderly patients with dementia as they may greatly increase the risk of falls, fractures, and death as well as worsening cognitive impairment.

Question 35

One of the most common electrolyte abnormalities associated with the use of psychotropic medication is: -Hyponatremia -Hypernatremia -Hypercalcemia -Hyperkalemia

Answer 35

Hyponatremia is the most common electrolyte abnormality associated with psychotropic medication; the condition is called drug-induced syndrome of inappropriate 93antidiuretic hormone secretion.

Question 36

Hyperkalemia

Answer 36

related to renal insufficiency, which can be acute or chronic

Question 37

Hypercalcemia

Answer 37

associated with neoplastic disorders and abnormal bone metabolism and resorption

Question 38

Hypernatremia

Answer 38

related to a water deficit

Question 39

A patient has been taking valproic acid for mood stabilization from a manic episode but is still not sleeping through the night. His last drug level was 50 mcg/mL. The PMHNP notices the patient seems disoriented to time and is flapping his wrists. What should the PMHNP do next? -Augment with an atypical antipsychotic -Increase the dose of valproic acid -Give the patient lactulose 20 g PO -Draw an ammonia level

Answer 39

Draw an ammonia level. Patients can develop encephalopathy due to hyperammonemia when taking valproic acid. It is essential to check the ammonia level before treating the patient. Increasing the dose of medication would worsen the situation, and adding another agent does not address the underlying problem.

Question 40

A patient who has been taking paroxetine for 3 years wants to come off due to sexual side effects. He had gradually tried to wean the dose on his own but noticed feelings of dizziness, fatigue, headaches, anxiety, and electric-like shocks in his head. These findings are most consistent with SSRI discontinuation. What would be a reasonable action for the PMHNP to take? -Have the patient resume the paroxetine and prescribe the patient a PD5-inhibitor -Prescribe the patient fluoxetine for 1 week -Start the patient on an antipsychotic for his somatic delusions -Reassure the patient that the symptoms will go away eventually

Answer 40

Prescribing the patient fluoxetine (a long half-life selective serotonin reuptake inhibitors [SSRI]) will reduce the discontinuation syndrome symptoms. Resuming the medication and prescribing a second agent for sexual dysfunction does not solve the present problem. There is no evidence that the patient is having a somatic delusion as discontinuation syndrome is well documented in the literature associated with paroxetine.

Question 41

A 60-year-old man has been treated for depression for the last 2 years with a medication he cannot remember. He reports that he has had increasing urinary hesitancy, xerostomia, and intermittent lightheadedness. Which of the following medications is this patient most likely prescribed? -Lithium -Fluoxetine -Doxepin -Lamictal

Answer 41

Doxepin is a tricyclic antidepressant known for its anticholinergic properties including dry mouth, orthostasis, urinary hesitancy, and retention leading to dysuria. Fluoxetine is a selective serotonin reuptake inhibitor mostly associated with GI upset and sexual dysfunction. Lithium is most often associated with nephrogenic diabetes insipidus, and symptoms include polyuria, polydipsia, altered mental status, and tremor. Lamictal is an antiepileptic drug commonly used for mood stabilization associated with GI upset and, during periods of titration, Stevens-Johnson syndrome.

Question 42

In addition to baseline monitoring, which laboratory parameter should be assessed regularly during Depakote therapy to monitor for potential hematologic side effects? -Serum creatinine -Serum amylase -Complete blood count (CBC) -Serum albumin

Answer 42

Complete blood count (CBC). Regular monitoring of the CBC is essential to assess for any hematologic side effects associated with Depakote, such as thrombocytopenia and leukopenia.

Question 43

What is the recommended baseline blood serum monitoring requirement(s) for patients starting Depakote (divalproex sodium) therapy? (Select all that apply) -Thyroid function tests (TFTs) -No baseline monitoring is required -Complete blood count (CBC) -Liver function tests (LFTs)

Answer 43

Complete blood count (CBC) & Liver function tests (LFTs) Baseline monitoring for Depakote should include a CBC to assess for any potential hematologic issues, as it can cause blood dyscrasias. It should also include Liver Function Tests (LFTs) to monitor for liver damage (transaminitis)

Question 44

Which laboratory parameter should be regularly monitored during lithium therapy to assess kidney function? -Liver function tests (LFTs) -Thyroid function tests (TFTs) -Serum glucose levels -Serum creatinine levels

Answer 44

Regular monitoring of serum creatinine is important to assess kidney function because lithium can affect the kidneys, potentially leading to renal impairment.

Question 45

Which of the following is a characteristic clinical feature of Stevens-Johnson Syndrome (SJS)? -Isolated conjunctivitis -Painless oral ulcers -Mild itching and erythema on the palms and soles -Generalized blistering of the skin and mucous membranes

Answer 45

Generalized blistering of the skin and mucous membranes. SJS is characterized by widespread blistering of the skin and mucous membranes, which is a key clinical feature that distinguishes it from other skin conditions.

Question 46

What is the most common cause of Stevens-Johnson Syndrome (SJS) and its severe form, Toxic Epidermal Necrolysis (TEN)? -Fungal infection -Autoimmune disorders -Bacterial infection -Medications, especially sulfonamides and antiepileptic drugs

Answer 46

Medications, especially sulfonamides and antiepileptic drugs. Medications, particularly certain classes like sulfonamides and antiepileptic drugs, are the most common triggers for SJS and TEN.

Question 47

Which of the following is a serious potential complication of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) that may necessitate specialized care? -Isolated itching and discomfort -Ocular involvement, leading to corneal scarring and blindness -Mild mucous membrane involvement -Superficial skin peeling

Answer 47

Ocular involvement is a serious complication of SJS and TEN that may require specialized care to prevent corneal scarring and vision impairment.

Question 48

Presenting symptoms with stimulant use

Answer 48

agitation, restlessness, irritability, grandiosity, elatedness, euphoria, aggression, and mood lability (methamphetamine, amphetamines, cocaine)

Question 49

Presenting symptoms with depressant use

Answer 49

dysphoria, impaired attention/memory, disinhibition, psychomotor retardation, paranoia (alcohol/benzodiazepine/opiates)

Question 50

Tolerance

Answer 50

condition in which repeated administration of a dosage causes a decreased effect despite increasingly larger doses

Question 51

Addiction

Answer 51

Persistent and increased use of a substance or behavior that when discontinued causes distress and an urge to resume use despite related adverse consequences (psychological dependence)

Question 52

Dependence

Answer 52

repeated use of a substance for physical needs, leading to increased tolerance, and when discontinued results in physical withdrawal symptoms

Question 53

Withdrawal Syndrome dx

Answer 53

2 or more of the following are present: -Palpitations -Sweating -Sleep disturbance -Nausea/vomiting/diarrhea -Hallucinations -Agitation/restlessness/fidgety/irritable mood/depressed mood -Anxiety or nervousness -Seizures -Shaking -Fever/chills/cold sweats/piloerection (goosebumps) -Headache -Yawning -Muscle aches

Question 54

Medication for opioid withdrawal

Answer 54

Buprenorphine (reduces symptoms) Detox guided by Clinical Opioid Withdrawal scale (COWS)

Question 55

Medication for benzodiazepine and alcohol withdrawal

Answer 55

"LOT" drugs: Lorazepam, Oxazepam, Temazepam

Question 56

Disulfiram (Antebuse)

Answer 56

For alcohol addiction treatment. Only use once pt alcohol free for 12 hours. Avoid any alcohol containing products (mouthwash, vinegar, cough medicine) for up to 14 days after last dose of Antebuse. When using monitor pt liver enzymes and evaluate for elevated mood in pt with bipolar disorder.

Question 57

Antidepressants in pregnancy

Answer 57

CAN be used = SSRIs, Sertraline (Zoloft), Escitalopram (Lexapro)

Question 58

Valproic acid (Depakote) in pregnancy

Answer 58

Mood stabilizer. Sedating and cause neural tube defects/fetal toxicity. Also is excreted in breast milk

Question 59

Lithium (Lithobid) in pregnancy

Answer 59

Mood stabilizer. Toxic to thyroid and can cause damage over time. Contraindicated in first trimester of pregnancy (Ebstein’s anomaly; defect heart tricuspid valve). Excreted in breast milk.

Question 60

Lamotrigine in pregnancy

Answer 60

Mood stabilizer. CAN be used in pregnancy with caution if benefits outweigh risk. Excreted in breastmilk ->Monitor infant for poor sucking, drowsiness, and apnea

Question 61

Fibromyalgia medications

Answer 61

SNRIs (Duloxetine, Milnacipran, Venlafaxine, Desvenlafaxine), Alpha 2 delta ligands (Gabapentin and Pregabalin), AD2 and SNRI combo OPIATES NOT EFFECTIVE

Question 62

Neuropathy medications

Answer 62

Alpha 2 delta ligands (Gabapentin and Pregabalin); Duloxetine (cymbalta) dosed at bedtime; antidepressants

Question 63

Pediatric ADHD Tx

Answer 63

1. Behavioral therapy for children 5 years and younger 2. Dextroamphetamine & amphetamine salts for 3 years and older 3. Methylphenidate for 6 years and older

Question 64

How to manage side effects of ADHD stimulants

Answer 64

Common Side Effects: Insomnia, reduced appetite, weight loss, irritability, and potential for increased anxiety. Cardiovascular side effects such as increased heart rate and blood pressure. Take the medication with food to minimize stomach upset, adjust the dosage with your doctor if needed, avoid caffeine, take the medication earlier in the day to avoid sleep disruption, eat small frequent meals to combat appetite loss, and use long-acting

Question 65

ADHD: DA and NE

Answer 65

Excessive noradrenergic neurotransmission can lead to impaired working memory due to stimulation of α1 (and β1) receptors. Excessive dopaminergic neurotransmission can lead to overstimulation of D1 receptors in the prefrontal cortex

Question 66

Amphetamines mechanism of action

Answer 66

Competitive inhibitor and pseudosubstrate for NETs and DATs, binding at the same site that the monoamines bind to the transporters, thus inhibiting NE and DA reuptake

Question 67

Diagnosing ADHD

Answer 67

-Symptoms must be present before the age of 12, cannot diagnose before age 3. -Impairment present in at least 2 different settings -Evidence of functional interference: Socially, Academically, or in Extracurricular activities -Subtypes = Inattentive, Hyperactive/Impulsive, and Combined

Question 68

ADHD Tx

Answer 68

1. Assess/manage substance abuse problems 2. Treat mood and anxiety 3. Evaluate for other common ADHD comorbidities 4. Stimulants or non-stimulants

Question 69

DLPFC is linked to ___________ symptoms

Answer 69

sustained attention and problem solving

Question 70

dACC is linked to ___________ symptoms

Answer 70

selective attention

Question 71

Prefrontal motor cortex is linked to ___________ symptoms

Answer 71

hyperactive

Question 72

Orbitofrontal cortex is linked to _________________symptoms

Answer 72

impulsive

Question 73

ADHD "causes"

Answer 73

-Genetic (75%) -Delayed maturation of prefrontal cortex circuitry -Ineffective "tonic" NE and DA neurotransmission/hypoactivity of dopamine and norepinephrine pathways in brain regions such as the prefrontal cortex (PFC)

Question 74

Donepezil (Aricept)

Answer 74

reversible long-acting inhibitor of acetylcholinesterase; without inhibition of BuChE; inhibits AChE at pre- and postsynaptic neurons and other CNS areas → boosts availability of ACh at remaining sites normally innervated by cholinergic neurons; also inhibits AChE in periphery → GI side effects GI side effects usually transient Most widely prescribed

Question 75

Galantamine (Razadyne)

Answer 75

dual mechanism of action AChE inhibition + positive allosteric modulation (PAM) of nicotinic and cholinergic receptors; no evidence this second action = clinical advantages

Question 76

Memantine (Namenda)

Answer 76

non-competitive, low affinity, NMDA receptor antagonist, binds to Mg site when channel is open → blocks downstream effects of excessive tonic Glu release by plugging up NMDA ion channel → improve memory and prevents neuronal death

Question 77

Brexpiprazole (Rexulti) for dementia

Answer 77

treats agitation in dementia

Question 78

Dextromethorphan-Bupropion (Auvelity)

Answer 78

treats agitation in dementia

Question 79

SSRIs in dementia

Answer 79

Sertraline, citalopram, escitalopram, fluoxetine treats depression some side effects: increased falls, osteoporosis, worsen PD symptoms