Quiz questions

Question 1

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

Answer 1

Pharmacokinetics
(effect the organism has on the drug)

Question 2

Pharmacodynamics

Answer 2

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

Question 3

First-pass effect

Answer 3

the uptake and conversion of the drug in the liver after enteric absorption

Question 4

After a drug is absorbed, the substrate binds to protein for transport. Which portion of the drug is available for therapeutic effects?

Answer 4

Unbound

Question 5

The part of the drug that binds to protein and fat in
preparation for excretion

Answer 5

Bound

Question 6

Metabolization

Answer 6

the process in which a drug is prepared for excretion

Question 7

Excretion

Answer 7

the process in which a substance leaves the body

Question 8

A 19-year-old male is referred to the PMHNP by the student health office for alcohol use disorder. The patient states that on one occasion he passed out much sooner than he usually would with far less than he would usually drink. Upon further interview, the patient reveals the time he passed out was during a fraternity hazing in which he was butt-chugging (receiving a beer and vodka enema). What pharmacokinetic process was bypassed by this rectal administration route?

Answer 8

First-pass effect. The first-pass effect is the pre-circulation process of uptake and conversion by which a substrate is significantly reduced through the CYP450 pathway. Non-enteric routes of administration bypass this effect.

Question 9

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 9

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

Question 10

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 10

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 11

A patient who has been stable on quetiapine (Seroquel XR) for 3 months has decided to start to drink grapefruit juice twice daily because she has heard it helps with weight loss. She calls to report that since her new diet she has been feeling fatigue and difficulty waking up in the morning. What is the best response by the PMHNP?

Answer 11

Tell pt to stop drinking the grapefruit juice and schedule an appointment to discuss weight gain/weight loss. Grapefruit is a known inhibitor of the CYP450 pathway; stopping this will reduce the sedation over time. It is not appropriate to prescribe this patient a stimulant as the cause has not been determined. Deferring the patient to primary care is not suitable as there is a potential psychotropic drug interaction.

Question 12

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 12

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 13

A medication that works by receptor activation to produce a biological response is an:

Answer 13

Agonist

Question 14

Inverse agonist

Answer 14

medication that binds to the same receptor as an agonist but induces an opposite biological response

Question 14

Enzyme inhibitor

Answer 14

slows the catalytic action of the enzyme and allows neurotransmitters to remain in circulation

Question 15

Antagonist

Answer 15

medication that blocks a receptor and inhibits a biological response, even from endogenous agonists

Question 16

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 16

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 17

A 52-year-old man presents to the emergency room with symptoms of hypertensive crisis after an evening dining out with friends. He is currently taking a monoamine oxidase inhibitor (MAOI). Which of the following foods must be avoided by patients taking MAOIs?
-Aged cheese
-Bottled beer
-Bananas
-Fresh fish

Answer 17

Aged cheeses in general have high tyramine content and must be
avoided when a patient is taking an MAOI. Banana peels and bananas that are overripe should also be avoided.

Question 18

A 56-year-old male patient with major depression is brought to the emergency room with cardiac arrhythmia and possible cardiac arrest. While at the hospital, he suffers a seizure. His wife states that he may have ingested an increased dose of his medication. Which of the following is most likely responsible for this apparent overdose reaction?
-Clomipramine
-Fluvoxamine
-Atomoxetine
-Venlafaxine

Answer 18

Clomipramine, a tricyclic antidepressant (TCA), may be most likely to
cause these effects in overdose. TCAs block voltage-sensitive sodium channels (VSSCs) in both the brain and the heart. This action is weak at therapeutic doses, but in overdose may lead to coma, seizures, and cardiac arrhythmia, and may even prove fatal.

Question 19

A 65-year-old patient on theophylline for chronic obstructive pulmonary disease (COPD) and fluvoxamine for recurring depressive episodes required a decreased dose of theophylline due to increased blood levels of the drug. Which of the following pharmacokinetic properties may be responsible for this?
-Induction of CYP450 1A2 by fluvoxamine
-Inhibition of CYP450 1A2 by fluvoxamine
-Induction of CYP450 3A4 by fluvoxamine
-Induction of CYP450 2D6 by fluvoxamine

Answer 19

Inhibition of CYP450 1A2 by fluvoxamine. Fluvoxamine is a strong inhibitor of CYP450 1A2. Theophylline is metabolized in part by CYP450 1A2, and thus strong inhibition of this enzyme by fluvoxamine may require a dose reduction of theophylline
if the two are given concomitantly, so as to avoid increased blood
levels of the drug.

Question 20

CYP450 1A2 Inhibitors

Answer 20

Fluvoxamine (SSRI)
Ciprofloxacin (antibiotic)
Cimetidine (H2 blocker for acid reflux)

Question 21

CYP450 2D6 Inhibitors

Answer 21

Fluoxetine (Prozac; SSRI)
Paroxetine (Paxil; SSRI)
Bupropion (Wellbutrin; antidepressant)
Quinidine (antiarrhythmic)

Question 22

CYP450 3A4 Inhibitors

Answer 22

Grapefruit juice (can significantly inhibit CYP3A4 in the gut)
Fluvoxamine (Luvox; SSRI)
Ketoconazole (antifungal)
Itraconazole (antifungal)
Erythromycin (antibiotic)
Clarithromycin (antibiotic)

Question 23

CYP450 2C19 Inhibitors

Answer 23

Omeprazole (proton pump inhibitor)
Fluoxetine (Prozac;SSRI)
Fluvoxamine (Luvox; SSRI)

Question 24

CYP450 1A2 Inducers

Answer 24

Smoking (polycyclic aromatic hydrocarbons in cigarette smoke)
Rifampin (antibiotic)
Carbamazepine (anticonvulsant, mood stabilizer)

Question 25

CYP450 3A4 Inducers

Answer 25

Carbamazepine (anticonvulsant, mood stabilizer)
Phenytoin (anticonvulsant)
Rifampin (antibiotic)
St. John’s Wort (herbal antidepressant)
Phenobarbital (barbiturate)

Question 26

CYP450 2C19 Inducers

Answer 26

Carbamazepine (anticonvulsant, mood stabilizer)
Rifampin (antibiotic)
Phenobarbital (barbiturate)

Question 27

A 55-year-old woman has been referred for a psychiatric evaluation for a change in personality, lack of impulse control, and increasingly reckless decision-making. Which area of the brain would be responsible for these symptoms?
-Wernicke’s area
-Broca’s area
-Frontal lobe
-Parietal lobe

Answer 27

Frontal lobe. Frontal lobe controls voluntary movement, ability to project future consequences, governs social cues, reasoning, planning, and parts of speech.

Question 28

Parietal lobe function?

Answer 28

The parietal lobe is associated with sensory integration,
attentiveness, and spatial awareness.

Question 29

Broca’s area function?

Answer 29

Broca’s area (although located in the frontal lobe of the dominant
hemisphere) specifically is associated with speech production (fluency)

Question 30

Wernicke’s area function?

Answer 30

Wernicke’s area is associated with comprehension

Question 31

A 72-year-old man with a comorbid history of uncontrolled hypertension is referred to the PMHNP for dementia secondary to depression. The mental status exam reveals difficulty speaking fluently, inappropriate and confabulated responses, incongruent affect, and poor judgment. A cerebrovascular accident in which region of the brain would better explain these symptoms?
-Broca’s area
-Wernicke’s area
-Occipital lobe
-Parietal lobe

Answer 31

Broca’s area, located in the dominant hemisphere of the brain, is associated with speech production and
fluency; dysfunctions in this area are associated with incongruent affect, decreased motivation, impaired
judgment and attention, and confabulation.

Question 32

Occipital lobe function?

Answer 32

The occipital lobe is associated with the visual cortex and receives signals through the optic tract and interprets color, form, and movement of visually perceived objects

Question 33

A patient appears internally preoccupied and responding to auditory hallucination. This patient may have a pathology affecting which lobe of the brain?
-Parietal lobe
-Occipital lobe
-Temporal lobe
-Cerebellum

Answer 33

The temporal lobe is the primary auditory area of the brain.

Question 34

Neurons that only travel from the body to the brain are called:
-Interneurons
-Astrocytes
-Motor neurons
-Sensory neurons

Answer 34

Sensory neurons are afferent fibers transmitting information from stimuli from the body to the brain.

Question 35

What direction do motor neurons travel?

Answer 35

Motor neurons are efferent fibers conducting impulses from the brain to the body.

Question 36

Interneurons

Answer 36

Interneurons are a neuronal circuit allowing for communication between motor and sensory neurons, especially within the
reflex arc.

Question 37

Astrocytes

Answer 37

Astrocytes are star-shaped cells; they provide nutrients and maintain the extracellular ionic balance involved in growth and repair of nerve cells to maintain the blood-brain barrier.

Question 38

The part of the neuron that takes in and receives messages is called:
-Axon
-Synapse
-Node of Ranvier
-Dendrite

Answer 38

Answer: Dendrites transmit information to the soma.

More info: Axons transmit information from the soma. A synapse is the gap between two nerve cells. The node of Ranvier is a gap between the myelin sheaths of Schwann cells and the uninsulated ion channel.

Question 39

The junction between two neurons is known as the:
-Soma
-Synapse
-Dendrite
-Node of Ranvier

Answer 39

Synapse

Question 40

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 40

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

Question 41

A patient is diagnosed with major depressive disorder with the most prominent feature of apathy, anhedonia, and isolation. Which neurotransmitter is associated with these symptoms?
-Acetylcholine
-Dopamine
-Cannabinoids
-Gamma-aminobenzoic acid (GABA)

Answer 41

Dopamine increases a sense of well-being and satisfaction; it is the primary driver of the reward system.

Question 42

Serotonin clinical effect?

Answer 42

Serotonin reduces pain perception and enhances satiety

Question 43

Gamma-aminobenzoic acid (GABA) clinical effect?

Answer 43

Gamma-aminobenzoic acid (GABA) is primarily inhibitory; it increases sleepiness and reduces anxiety, memory, and alertness.

Question 44

Cannabinoids clinical effect?

Answer 44

Cannabinoids increase hunger and reduce motivation and sex drive.

Question 45

The PMHNP in the ED is evaluating a 68-year-old woman who was recently diagnosed with mild cognitive impairment and cannot remember the name of the medication that she has recently started 1 week ago. The patient is complaining of increased heart rate, sweating, and muscle spasms progressively worsening for the last 3 days. Which neurotransmitter is associated with this adverse effect?
-Gamma-aminobenzoic acid (GABA)
-Serotonin
-Acetylcholine
-Dopamine

Answer 45

Acetylcholine increases heart rate, muscle contractions, salivation, and sweating; it is prescribed to enhance memory.

Question 46

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 46

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

Question 47

During a panic attack, symptoms tend to peak at approximately how many minutes into the episode?
-2 minutes
-20 minutes
-5 minutes
-10 minutes

Answer 47

Panic attack symptoms typically peak at about 10 minutes into the panic episode

Question 48

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 48

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

Question 49

Criteria for diagnosing Panic Disorder

Answer 49

Panic Disorder is described as the abrupt onset of 4 or more physical symptoms and 1 or more psychological symptoms. These symptoms typically occur out of nowhere with no precipitating event. Psychological symptoms include intense fear, discomfort, fear of losing control or going crazy, or the fear
of dying.
Physical symptoms include palpitations, pounding heart, or fast heart rate, sweating, trembling or shaking, sensation of shortness of breath, feeling of choking, chest pain or discomfort, nausea or
abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, feelings of unreality known as derealization or being detached from oneself known as depersonalization, paresthesias, chills or hot
flashes.

Question 50

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 50

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 51

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 51

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 52

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 52

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 53

Which of the following drugs can diminish anxiety but does NOT have sedative, hypnotic, anticonvulsant, or musculoskeletal relaxing activity?
-Haloperidol
-Mirtzapine
-Buspirone
-Diazepam

Answer 53

Buspirone is a serotonin 5HT1A receptor partial agonist used to treat anxiety. Buspirone’s partial agonist actions at presynaptic somatodendritic serotonin autoreceptors may theoretically enhance serotonergic activity and contribute to antidepressant actions. The partial agonist actions postsynaptically may theoretically diminish serotonergic activity and contribute to anxiolytic actions. It does not produce significant sedation, hypnotic, anticonvulsant, or musculoskeletal relaxing effects.

Question 54

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 54

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 55

Which of the following is a potential side effect associated with anxiolytic medications, especially benzodiazepines, when used for an extended period or at high doses?
-Memory impairment
-Increased heart rate
-Increased blood pressure
-Increased appetite

Answer 55

Prolonged use of anxiolytic medications, particularly benzodiazepines, may lead to memory impairment
and cognitive problems. This is a well-known side effect associated with these drugs, especially when used at higher doses or for an extended period. It is essential for patients to be aware of this potential side effect and use these medications judiciously under the guidance of a healthcare professional.

Question 56

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 56

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 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 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
-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. Unlike GABA/galanin levels, hypocretin/orexin levels steadily decrease during the first couple of hours of sleep, plateau, and then steadily increase before waking. Acetylcholine levels fluctuate throughout the sleep cycle, reaching their lowest levels during stage 4 sleep and peaking during REM sleep. Histamine levels fluctuate throughout the sleep cycle, peaking during stage 2 sleep, and are at their lowest during REM sleep.

Question 59

A clinician is planning to prescribe eszopiclone for a 34-year-old male patient with insomnia. What is the correct starting dose for this patient?
-3 mg/night
-1 mg/night
-2 mg/night
-0.5 mg/night

Answer 59

In 2014, the US Food and Drug Administration (FDA) reduced the recommended starting dose of eszopiclone from 2 mg/night to 1 mg/night for both men and women. This is because, in some patients, eszopiclone blood levels may be high enough the next morning to cause impairment in activities that require alertness, including driving. In 2013, the FDA issued new dosing requirements for zolpidem due to the risk of next-morning impairment. However, the label change applied only to dosing in women (5 mg IR, 6.25 mg XR).

Question 60

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 60

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 61

A 45-year-old patient has been unable to sleep more than 4 hours every night for the past 3 months. Chronic insomnia is believed to be due to:
-All of the above
-Hypo-arousal during the day
-Hyper-arousal at night
-Hypo-arousal at night

Answer 61

Insomnia is conceptualized as being related to hyperarousal at night. Recent neuroimaging data suggest that insomnia is the result of an inability to switch off arousal-related circuits, rather than an inability to switch on sleep-related circuits. Some patients with insomnia experience hyperarousal during the day as well. To treat insomnia, one can administer medications that enhance the sleep drive, such as the GABAergic benzodiazepines or Z-drugs. Alternatively, one can administer medications that reduce arousal by inhibiting neurotransmission involved in wakefulness; notably, with antagonists at orexin, histamine, serotonin, or norepinephrine receptors.

Question 62

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

Answer 62

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. SSRls (A) are commonly used for depression and anxiety, but they are not the primary treatment for narcolepsy. Antipsychotic medications (B) are not indicated for the treatment of narcolepsy. Benzodiazepines (D) may help with sleep, but they are generally not the first-line treatment for narcolepsy and can have undesirable side effects.

Question 63

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

Answer 63

Sodium Oxybate is a medication used to manage cataplexy in patients with narcolepsy. It is an effective treatment for cataplexy, a symptom of narcolepsy characterized by sudden muscle weakness triggered by strong emotions. Zolpidem is a sleep aid and not typically used for treating cataplexy. Methylphenidate is a stimulant that can help with daytime sleepiness but does not specifically target cataplexy. Diphenhydramine is an antihistamine with sedative properties, but it is not a primary treatment for cataplexy in narcolepsy.

Question 64

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 64

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 65

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 65

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 66

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 66

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 67

CYP450 Inhibitors

Answer 67

SICKFACES.COM
Decrease activity of CYP450 enzymes –> any drug clears slower and has a greater impact than expected.
S =sodium valproate
I
C
K
F
A = acute/binge alcohol
C = cranberry juice
E
S.
C
O
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Group = grapefruit juice

Question 68

CYP450 Inducers

Answer 68

BS CRAP GPS
Increase activity of CYP450 enzymes –>drugs clear faster and have lesser effect
B = barbituates
S = St. John’s wort
C = carbamazepine
R = rifampin (antibiotic)
A = alcohol (chronic use)
P = phenytoin (ant-seizure)
G = griseofulvin
P = phenobarbital (anti-seizure/sedative)
S = sulfonyureas ?

Question 69

A 24-year-old man has been taking lithium for 3 years to treat his bipolar disorder. What are two primary
candidates for the direct mechanisms of lithium?
-Inhibition of GSK-3β and activation of IMPase
-Inhibition of glycogen synthase kinase 3β (GSK-3β) and inositol monophosphatase (IMPase)
-Activation of GSK-3β and IMPase
-Activation of GSK-3β and inhibition of IMPase

Answer 69

Inhibition of glycogen synthase kinase 3β (GSK-3β) and inositol monophosphatase (IMPase).
Lithium has been a first-line treatment for bipolar disorder for decades, yet its mechanism of action is still not certain. There is, however, substantial evidence that lithium exerts neuroprotective effects that are likely downstream from its primary mode of action. Two primary candidates for the direct mechanisms of lithium are the inhibition of GSK-3β and the inhibition of IMPase. GSK-3β is involved in the regulation of inflammation and is, in general, pro-apoptotic. Specifically, it inhibits transcription factors that would otherwise induce production of cytoprotective proteins such as brain-derived neurotrophic factor (BDNF); thus, its inhibition may be neuroprotective. IMPase indirectly leads to an increase in protein kinase C, which is overactive in mania. Thus, inhibition of IMPase by lithium could potentially reduce manic symptoms.

Question 70

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 70

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

Question 71

Thomas, a 28-year-old patient with major depressive disorder with mixed features, complains of significant irritability and agitation that are affecting his family and work. Which psychotropic treatment(s)
can be considered as ALTERNATIVE maintenance treatments to antidepressants?
-A benzodiazepine such as lorazepam
-A mood stabilizer such as lamotrigine
-An atypical antipsychotic such as quetiapine
-An atypical antipsychotic or a mood stabilizer

Answer 71

An atypical antipsychotic or a mood stabilizer.

Question 72

A 38-year-old patient with bipolar disorder has been taking valproate with only partial control of depressive symptoms, and her clinician elects to add lamotrigine. Compared to lamotrigine monotherapy, what adjustment should be made to the lamotrigine titration schedule in the presence of valproate?
-Slower titration schedule, same target dose
-Slower titration schedule, half the target dose
-Same titration schedule, same dose
-Same titration schedule, half the target dose

Answer 72

Valproate increases the plasma levels of lamotrigine, so when adding lamotrigine to valproate, the target dose is lower and titration is slower (in comparison to initiating lamotrigine monotherapy):
For the first 2 weeks: 25 mg every other day
Week 3: increase to 25 mg/day
Week 5: increase to 50 mg/day
Week 6: increase to 100 mg/day

Question 73

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 73

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 74

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

Answer 74

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 75

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 75

Antipsychotics

Question 76

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 76

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 77

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

Answer 77

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 78

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

Answer 78

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 79

Half-life of a medication

Answer 79

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)