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Pharmacology Exam 3 > Psychopharmacology > Flashcards

Psychopharmacology Flashcards

1
Q

Depressive disorders are multi-factorial. What are some of those factors?

A

Genetics

NT changes

Altered neuroendocrine function

Psychosocial factors

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2
Q

Methohexital helps facilitate

A

Seizures

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3
Q

5-HT3 is associated with

A

Anti-emetics

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4
Q

5-HT outside the CNS can cause

A

GI Motility

PLT Aggregation

Vascular Tone

Inflammatory Response

Henatopoiesis

Genital Arousal

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5
Q

Physiological effects of Serotonin include

A

Social

Affective

Cognition

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6
Q

5- HT 1A is

A

Inhibitory

Regulates serotonergic neuronal activity

Affects neurogenic effects of antidepressants

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7
Q

5- HT 2A is

A

Excitatory

Regulates cognition, attention, working memory revenant to psychosis

Implicates in serotonin syndrome

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8
Q

5 HT 2A is antagonized by

A

2nd generation atypical antipsychotics

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9
Q

5 HT 2A agonist is by

A

Hallucinogens

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10
Q

Which serotonin receptor is targeted by anesthesia?

A

5HT3

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11
Q

Which serotonin receptor regulates N/V and beneficial target of psychotropic drugs?

A

5HT3

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12
Q

Common SSRIs include?
(Shay Ford Can Play)

A

Sertraline
Fluoxetine
Citalopram
Paroxetine

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13
Q

SSRIs most commonly treat

A

Mild-Moderate depression
Panic
OCD
Phobias
PTSD

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14
Q

Where do SSRIs work?

A

At the serotonin trip take transporter

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15
Q

MOA for SSRIs

A

Blockade of 5HT reuptake transporter, which increases synaptic serotonin

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16
Q

SSRIs will eventually cause

A

A down-regulation of serotonin receptors since they are overwhelmed by agonists

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17
Q

5HT 1A has what effects?

A

Antidepressant
Anxiolytic

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18
Q

5HT 2A has what effects

A

Anxiety
Insomnia
Sexual dysfunction

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19
Q

5 HT3 has what effects

A

Nausea
Headache

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20
Q

Most common side effects of SSRIs

A

Insomnia
Agitation
Headache
Nausea
Diarrhea

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21
Q

SSRIs can cause this in the elderly, women, & in CV disease

A

Hyponatremia

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22
Q

What is the black box warning with SSRIs?

A

Shouldn’t be used in children and adolescents

Can cause suicidal thoughts & behaviors

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23
Q

SSRIs can inhibit

A

CYP 450 (Fluoxetine), increasing plasma concentrations (warfarin, phenytoin, antiarrhythmics, beta blockers)

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24
Q

SSRI can cause this due to its effects on warfarin & increased anti platelet activity

A

Bleeding risk

Increases anticoagulant effect on warfarin (paroxetine,fluoxetine)

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25
Q

SSRI has this effect in the heart

A

Can prolong QT (citalopram & escitalopram)

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26
Q

Should SSRI be continued perioperatively?

A

YES

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27
Q

What happens if SSRI is stopped abruptly?

A

Can lead to Discontinuation Syndrome

major depressive episode

Dizzy

Parenthesis

Myalgias

Irritable

Insomnia

Visual Disturbances

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28
Q

What is serotonin syndrome?

A

Excessive CNS serotonergic activity

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29
Q

Phenylpiperidine opioids (fent & meperidine), ondansetron, metoclopramide, erythromycin, metronidazole should all be

A

Used in caution since there’s a risk of Serotonin Syndrome

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30
Q

Serotonin syndrome symptoms include

A

Tachycardia
HTN
Hyperthermia
Tachypnea
Diaphoresis
HOTN

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31
Q

What are the neuromuscular abnormalities of Serotonin Syndrome

A

Hyperreflexia

Tremors

Myoclonus

Trismus

Muscle rigidity

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32
Q

Serotonin syndrome can cause what mental status changes?

A

Restlessness

Agitation

Visual Hallucinations

Disoriented

Confusion

Seizures

Coma

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33
Q

What does SNRI stand for?

A

Serotonin Norepinephrine Reuptake Inhibitors

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34
Q

Common SNRI drugs are

A

Venlafaxine
Duloxetine
Desvenlafaxine

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35
Q

SNRIs can be what type of therapy?

A

1st or 2nd line

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36
Q

SNRIs can be used to treat

A

Depressions
Anxiety
Chronic Pain

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37
Q

MOA of SNRI

A

Blockade of 5HT & NE reuptake transporters

Increasing synaptic levels of serotonin & NE

MOST selective for NE reuptake inhibition

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38
Q

SNRI adverse effects include

A

HTN
Inhibition of CYP 2D6 enzymes

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39
Q

Common TCAs include

A

Amitriptyline
Nortriptyline
Imipramine

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40
Q

TCAs treat

A

MDD
Chronic Pain Syndromes
OCD

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41
Q

TCAs affect what Neuro chemical system?

A

Serotonin

NE

Histamine

ACh

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42
Q

MOA for TCA

A

Inhibit 5 HT & NE reuptake transporters

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43
Q

TCAs can causes a depletion in

A

Catecholamines, so use Ketamine & Ephedrine with caution since they also release catecholamines

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44
Q

What happens if TCA and ketamine/ephedrine are given together?

A

CV collapse

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45
Q

TCA receptor antagonism include

A

5HT 2A
Alpha 1
NMDA
H1 H2
mACh receptors

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46
Q

TCAs cause what common CNS side effect?

A

Anticholinergic
(Dry mouth, blurred vision, tachycardia, urinary retention, lieu’s, sedation, delirium risk with elderly)

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47
Q

TCAs cause what in pediatric population?

A

Lowers seizure threshold

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48
Q

TCA is toxic with MAOIs as it will cause

A

Hyperthermia
Seizure
Coma

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49
Q

TCAs can cause

A

Extrapyramidal symptoms & tremors

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50
Q

TCA CV side effects

A

Ortho HOTN

Increased HR

Widen QRS

Inverted T wave

QT prolongation

Slowed AV conduction

Enhanced cardiac depressant effects of anesthesia

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51
Q

Characteristics of TCA overdose

A

Rapid

Fatal

Agitation, seizures

Cardio respiratory & Neuro depression

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52
Q

How do you treat TCA overdose?

A

Treat seizure with Diazepam or phenytoin

Treat dysthymias with lidocaine & sodium bicarbonate

Treat HOTN with IVF, sympathomimetics, & inotropes

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53
Q

TCAs will _________anesthetic requirements

A

Increase

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54
Q

TCAs will cause a/an_________response to Anticholinergic s like________ & ________as it passes the BBB

A

Exaggerated; Atropine; Scopolamine,

(Will place the patient at risk for delirium & confusion)

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55
Q

TCAs will cause a/an________response to indirect acting vasopressin’s & SNS stimulation

A

Exaggerated
(Should use smaller doses or direct acting vasopressors)

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56
Q

TCAs will cause a/an________ ventilators depressant effect on opioids

A

Exaggerated
( avoid pancuronium, ketamine, meperdine & epinephrine)

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57
Q

What should be used in small doses when treating HOTN due to TCAs?

A

Neosynephrine

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58
Q

Common MAOIs

A

Isocarboxazid

Phenelzine

Selegiline

Tranylcypromine

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59
Q

MAOIs treat

A

MDD

Panic

Parkinson’s

Phobias

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60
Q

Monoamine oxidase is a______enzyme & _____& _______ NE, E, DA, & 5 HT

A

Mitochondrial enzyme

Inactivates & Removes

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61
Q

Older MAOIs increase_______& are stable & ______complex with cerebral neuronal MAO leading to _____

A

NT Release

Irreversible; Inhibition

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62
Q

Newer MAOIs are ______ of monoamine oxidase

A

Reversible

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63
Q

MAOI side effects include

A

Ortho HOTN

Anticholinergic like effects

Paresthesia

Wt gain

Hepatitis

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64
Q

MAOIs cause this side effect that’s a crisis

A

Hyperadrenergic crisis related to tyramine in the diet
Causing HT , hyperpyrexia, CVA, & dysrhythmias

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65
Q

MAOIs can cause there 2 reactions

A

Type 1- excitatory

Type 2- inhibitory

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66
Q

In MAOI Type 1 (excitatory) reactions, what medications are safe to give

A

Morphine & hydromorphone

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67
Q

Type 1 excitatory reactions resemble

A

Serotonin Syndrome

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68
Q

Type 1 excitatory reactions happens with the administration of

A

Meperidine & dextromethorphan

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69
Q

Type 1 excitatory reactions will cause

A

Agitation
Headache
Muscle rigidity
Hyperpyrexia
High temp

AVOID GIVING PIPERDINES

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70
Q

Type 2 depressive reactions are reversed with

A

Naloxone

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71
Q

Type 2 depressive reactions will cause

A

Neurological depression & coma

Ventilators depression

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72
Q

MAOI of hepatic enzymes ________effects of all_______

A

Enhancing

Opioids

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73
Q

MAOIs given with indirect sympathomimetics such as ephedrine will_______

A

Place the patient at increased risk for fatal hypertensive crisis

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74
Q

What sympathomimetics is preferred over ephedrine?

A

Indirect acting Neosynephrine at smaller doses

(Has hypersensitivity, risking exaggerated effects)

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75
Q

What anesthetic medications should be avoided when a patient is taking MAOIs?

A

Ketamine

Ephedrine

Pancuronium

Epinephrine in LA mixtures

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76
Q

(MAOI) Phenezine decreased plasma cholinesterase levels, prolonging_____

A

NMB SCh

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77
Q

MAOIs cause a reduced metabolism of____, requiring a decrease in dose

A

Barbiturates

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78
Q

What anesthetic medications are okay to give when a patient in on MAOIs

A

Propofol

Etomidate

BZs

Inhalation agents

Anticholinergic

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79
Q

Trazadone, a monoamine, has the MOA of

A

STI activity

5 HT 2A antagonism

Alpha 1 antagonism

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80
Q

Side effects of Trazadone

A

Ortho HOTN

Dry mouth

Rare dysrhythmias

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81
Q

Buspirone is used to treat________

Mechanism________

May elevate___________

A

Generalized Anxiety

Partial agonist at 5 HT receptors

May elevate NE & DA levels

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82
Q

Mirtazapine/tetracycline have multimodal mechanisms such as

A

Alpha 2 antagonism ( increases NE)

5 HT 2A/3 antagonism

H1 antagonism

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83
Q

Mirtazapine/tetracycline is associated with

A

Lower risk of serotonin syndrome

84
Q

Buprion MOA

A

Inhibition of DA & NE reuptake

85
Q

Side effects of Bupropion includes

A

Seizures

Stimulant like effects

86
Q

Bupropion may have some benefit in

A

Neuropathic pain

87
Q

Mania is treated with

A

Lithium
Antipsychotics+ BZ

88
Q

Lithium is good for treat resistant_____

89
Q

Lithium is an _______ion with a variety of

A

Inorganic; Neurobiologic effects

90
Q

Lithium inhibits_______neurotransmission of _____&______

A

Excitatory; dopamine; glutamate

91
Q

Lithium causes ________of __________ receptors

A

Downtegulation; NMDA

92
Q

Lithium increases _______neurotransmission in the CSF & presynaptic release, _________ __________receptors

A

GABA; up-regulating GABA

93
Q

Renal side effects of Lithium include

A

Polydipsia
Polyuria
Nephrogenic DI
CKD

94
Q

Endocrine side effects of Lithium includes

A

Hypothyroidism

95
Q

Cardiac side effects of Lithium include

A

T wave changes
SA Nodal Block (sick sinus syndrome)
Bradycardia

Changes reversible within 2 weeks of discontinuation

96
Q

There are increased lithium levels with the administration of

A

Thiazides
Loops
NSAIDS
ACEIs

97
Q

Lithium can cause increased neurotoxicity, causing

A

Extrapyramidal symptoms ( neuroleptic drugs)

Anticonvulsants

98
Q

Beta blocker and Lithium

A

Decreased lithium induced tremor

99
Q

Depolarizing + non- depolarizing MR

A

Prolonged blockade

100
Q

Lithium+inhaled+ IV anesthetics

A

Possible decrease in anesthetic requirements

101
Q

Lithium + Barbs

A

Delayed recovery

102
Q

Lithium has a narrow

A

Therapeutic index

103
Q

Patients need regular____ for a goal of______

A

Monitoring or serum levels

Goal 1-1.2 mEq/L

104
Q

Lithium toxicity may occur_____

A

At doses close to therapeutic
(High risk of toxicity)

105
Q

It’s important to avoid this with lithium

A

Avoid Na+ depletion

106
Q

What medications are avoided with lithium

A

Diuretics & NSAIDS
Avoid hypotonic solutions

107
Q

Lithium toxicity will present with

A

Widen QRS, AV block, dysrhythmias, HOTN

Seizures & confusion

108
Q

How to treat lithium toxicity

A

Dialysis
Sodium Bicarbonate

109
Q

What is psychosis

A

Lost contact w/ reality

110
Q

What’s is Hallucination

A

False perceptions

111
Q

Delusion

A

False beliefs

112
Q

Typical neuroleptic 1st generation antipsychotic include

A

Haldol
Chlorpromazine
Perphenazine
Fluphenazine
Dopamine ( D2 ) receptor antagonist

113
Q

Typical neuroleptic 1st generation antipsychotic can cause

A

Extrapyramidal side effects

114
Q

Atypical antipsychotic 2nd generation drugs include

A

Clozapine
Olanzapine
Risperidone
Quetiapine
Aripiprazole

115
Q

Atypical antipsychotic 2nd generation drugs have this antagonism + these effects

A

D2 antagonism + effects on H1, 5 HT2, mACh, & alpha

116
Q

Atypical antipsychotic 2nd generation drugs cause

A

Low/ no tendency to cause extrapyramidal side effects

117
Q

Typical FGA are less

A

Favorable due to side effects

118
Q

Typical FGA are commonly used

A

In emergency & acute care settings

119
Q

Typical FGA have a high

A

Therapeutic index

120
Q

Typical FGA cause no

A

Physical dependence

121
Q

Typical FGA have this effect

A

Antiemetic effects by working on the DA receptor in CRTZ

Helps with opioid induced N/V

122
Q

Haldol may decrease

A

Psychosis relate anxiety & has an off label use of ICU delirium, severe acute agitation & agression

123
Q

MOA of Haldol

A

D1 & D2 antagonism

RAS Depression

Inhibition of hypothalamic hormone release

124
Q

Common dose of Haldol IV & IM. May repeat dose & double initial dose every_____

A

2-10mg IV
5mg IM

Repeat q15-30min

125
Q

Haldol onset IV & IM

A

IV: 3-20min

IM: 30 min

126
Q

Duration of Haldol IV & IM

A

IV: 3-24 hours
IM: 2 hours

127
Q

How long can postoperative & emergence delirium last?

A

Minutes to 7 days

128
Q

What are risk factors of postoperative/ emergence delirium?

A

Age

Gender

Cognitive function/mental health/emotional status

Substance use, ETOH, BZ use

Prolonged surgery

Residual NM Blockade

Temp/BP changes

Hypoxemia

Pain

Sleep/wake disturbances

Presence of ETT

129
Q

Differential diagnosis of postoperative/ emergence delirium

A

Hypoxia, hypercarbia, acidemia, hypothermia,hypoglycemia, stroke, seizure, central cholinergic syndrome

RASS, CAM-ICU, PAED

130
Q

Symptoms of delirium

A

Disturbed attention, cognition & impaired awareness

Disoriented & memory deficit

Verbal & physical agitation

131
Q

Treatment for delirium

A

Control pain & agitation with pre-emotive multimodal analgesia & sedation

132
Q

Droperidol, a typical FGA, is a/an__________&________

A

Anti dopaminergic antiemetic

Sedative

133
Q

Droperidol, a typical FGA is a great

A

Antiemetic

134
Q

Droperidol, a typical FGA can cause this unwanted off label side effect

A

Delirium- immediate effects for undifferentiated agitation, alcohol intoxication & other etiology

135
Q

Off label, Droperidol, a typical FGA, is a good

A

GA adjunct- neuroleptic anesthesia/analgesia

136
Q

What is neuroleptanalgesia?

A

Combination of a neurolept AP + potent opioid

137
Q

What is an example of a neuroleptanalgesia?

A

Droperidol+ Fentanyl (Innovar)

(Butyrophenone + phenylpiperidine)

138
Q

Neuroleptanalgesia can cause

A

CNS depression w/ altered pain response cause a detached trance like & pain- free state, immobility & variable amnesia

139
Q

What is Droperidol black box warning

A

High doses can cause cardiac risks

(effective & safe treatment for nausea, HA & agitation)

140
Q

What is the dose of Droperidol?

A

0.625-1.5mg IV/IM for antiemesis with a max dose of 2.5

5 mg IM for sedation

141
Q

What is the onset & duration of Droperidol

A

Onset 3-10 min IV/ IM

Duration 2-4 hours (up to 12)

142
Q

Perphenazine, a typical FGA is a/an

A

Anti dopaminergic antiemetic

143
Q

What is the dosing of Perphenazine?

A

5mg IV/IM

8-16 mg PO

144
Q

Which populations are okay to receive Perphenazine?

A

Less than 70 years

No history of EPS/Parkinson’s

No Class III antiarrhythmics

145
Q

Extrapyramidal effects are cause by a blockade of

A

Dopamine in the limbic system

146
Q

Extrapyramidal effects can cause tardive dyskinesia, which is

A

Abnormal involuntary movement of tongue, face, neck, extremities, & trunk

147
Q

Extrapyramidal effects can cause akathisia, which leads to

A

Restlessness & inability to tolerate activity

148
Q

Extrapyramidal effects can cause dystonia, which is

A

Acute muscle rigidity & cramping

Oculogyric crisis

Respiratory distress (laryngeal dyskinesia/spasm)

Tremors

149
Q

How is dystonia treated?

A

Diphenhydramine 25-50mg IV

150
Q

FGA CV side effects

A

HOTN (alpha blockade & hypothalamic effects)

Antidysrhythmic affects

QT prolongation

151
Q

FGA endocrine side effects

A

Excess prolactin (gynecomastia)

Wt gain

152
Q

FGA CNS side effects

A

Sedation

Skeletal muscle relaxation (CNS- mediated)

Abnormal thermoregulation & hypothermia

Decreased……

153
Q

FGA Hepatic side effects

A

Obstructive jaundice

Elevated liver Enzymes

154
Q

Do we know the cause of Neuroleptic Malignant Syndrome?

155
Q

Risk factors of Neuroleptic Malignant Syndrome

A

Young

Male

Dehydration

Iron deficiency

Illness

Catatonic state

156
Q

Neuroleptic Malignant Syndrome develops over

A

24-72 hours

157
Q

Neuroleptic Malignant Syndrome will cause

A

Hyperthermia

Generalized hypertonicity of skeletal muscle

Autonomic instability

Altered LOC

158
Q

With Neuroleptic Malignant Syndrome causing hypertonicity, how is this treated? What are its potential side effects?

A

May require mechanical ventilation

May elevate CK and cause renal failure

159
Q

Neuroleptic Malignant Syndrome may lead to autonomic instability, causing

A

Labile BP

Tachycardia

Dysrhythmias

160
Q

NDMRs produce this in Neuroleptic Malignant Syndrome

A

Flaccid paralysis

161
Q

How is Neuroleptic Malignant Syndrome treated

A

Dantrolene- direct acting muscle relaxant

Dopamine agonist (bromocriptine & amatadine)

Benzos to treat agitation & arousal

IV hydration

Cooling

Support

162
Q

FGA affects on the heart

A

Prone to increased HR

HOTN

increased risk of CV disease present

QT prolongation

T wave changes- arrhythmia risks

163
Q

FGA affects on endocrine system

A

Higher incidence of DM & glucose intolerance

Wt gain

164
Q

FGAs can cause a change in

A

Pain response

165
Q

FGA effect on temperature

A

Causes impaired regulation causing hypothalamic effects

Should monitor & do active warming

166
Q

FGAs can alter this function and cause

A

Altered HPA function causing abnormal autonomic nerve functioning

Antipsychotics decrease cortisol

167
Q

FGAs can cause this on skeletal muscles

A

Relaxation, which is synergistic with non depolarizers

You should monitor neuromuscular function

168
Q

FGAs combined with your anesthetic can cause

A

Risk for over sedation with the use of BZ & CNS depressants

You should monitor for serotonergic symptoms w/ phenylpiperidines

169
Q

Postoperative considerations with FGAs

A

Surgical stress may worsen psychotic symptoms in schizophrenia

Risk for postop confusion, which is associated with increased NE & cortisol in schizophrenia

Risk for postop infection due to immune system dysregulation

170
Q

What medications are favored if FGAs

A

Atypical SGA

171
Q

Atypical SGAs benefits over FGAs include

A

Greater benefit for cognitive + affective

5 HT2A antagonism & other serotonergic actions

Tolerated & efficacy in psychotics

172
Q

Other uses for Atypical SGA

A

Manic/ depressive episode

Irritability in autistic disorders

Tourette disorder

173
Q

Side effects of Clozapine, an SGA

A

Agranulocytosis

Fever

Myocarditis

Excessive salivation

174
Q

Clozapine is the most effective SGA due to

A

5 HT, mACh, Alpha 1 & little D2 antagonism

175
Q

Side effects of Olanzapine, an SGA

A

Sedation, HOTN
WT gain, metabolic syndrome

176
Q

What medication should be avoided when taking Olanzapine, an SGA

A

Benzodiazepine due to the risk of cardio respiratory depression

177
Q

Side effects of resperidone & paliperidone

A

HOTN
Gynecomastia

178
Q

Rispiridone & paliperidone are similar to

A

FGAs in dopamine antagonism & EPS risks

179
Q

Aripiprazole & brexpipeazole are mixed

A

Agonist/antagonist at D2

180
Q

Side effects of Aripiprazole & brexpipeazole

A

Akathisia

Engagement of risky behavior

181
Q

Aripiprazole & brexpipeazole are

A

Highly tolerable & effective in treating bipolar & MDD

182
Q

Side effects of Ziprasidone & lurasidone SGAs

A

QT prolongation & akathisia

These drugs are moderately effective

183
Q

SGA Quetiapine is primarily a

A

5 HT antagonism & little D2 antagonism with minimal EPS risk

184
Q

What is the active metabolite of SGA Quetiapine

A

Norquetiapine which inhibits NE transporter

185
Q

SGA Quetiapine is a _____& _____ antagonist

A

H1 & Alpha -1

186
Q

Sid effects of SGA Quetiapine

A

Sedation & ortho HOTN

187
Q

SGA side effects are similar to FGA as they can cause

A

Extrapyramidal effects like tardive dyskinesia & Neuroleptic Malignant Syndrome

188
Q

Metabolic side effects of SGAs

A

Wt gain

Hypercholesterolemia

Insulin resistance

Associated CV morbidity

189
Q

How are neurodevelopmental disorders treated?

A

Stimulant drugs, behavioral therapy & educational interventions

190
Q

Methylphenidate ( Ritalin) is a _______, indirect acting ________

A

CNS stimulant (psychostimulant)

Sympathomimetics

191
Q

Methylphenidate (Ritalin) blocks

A

Reuptake if NE & DA causing catecholamine depletion & receptor down regulation in chronic exposure

192
Q

Methylphenidate (Ritalin) increased release of

A

DA, increasing presynaptic firing

193
Q

Methylphenidate (Ritalin) side effects include

A

Increased HR& BP

Risk for arrhythmias

Wt loss

Insomnia

Anxiety

194
Q

Methylphenidate (Ritalin) is found to

A

Actively induce emergence in ISO & Propofol ( increased arousal & respiratory drive, resulting in higher anesthetic requirement)

195
Q

Mixed amphetamine salts (Adderall) consist of

A

Levoamphetamine + Dextroamphetamine

196
Q

Mixed amphetamine salts (Adderall) block

A

Reuptake of NE & DA

197
Q

With Mixed amphetamine salts (Adderall), there’s an increase in

A

Presynaptic DA release

198
Q

Mixed amphetamine salts (Adderall) side effects

A

Tolerance & dependency risk

Anxiety

Insomnia

Exacerbation if tics

Increased HR & BP

199
Q

What alpha 2 agonist medication is approved for ADHD

200
Q

Side effects of Clonidine

A

HOTN
Beadycardia

201
Q

Other uses of Clonidine

A

Anxiolytic

Opioid withdrawal

Personality disorders

Manage impulsivity & aggression in TBI

202
Q

Which part in Cannabis is psychotropically active

203
Q

PO peak of Cannabis

A

1-2 hours, duration 4-6 hours

204
Q

Uses of Cannabis

A

N/V

Analgesia

Chronic pain

Cachexia

205
Q

Acute cannabis intoxication causes

A

Euphoria

Relaxation

Altered perception & intensification of normal sensory experiences

Decreased reaction time

Poor motor skills

Trachycardia

HOTN

Increased appetite

206
Q

Anesthesia considerations when patient is taking Cannabis

A

Increase anesthetic

Will have CV, airway/pulmonary effects

Pharmacology Exam 3 (3 decks)

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