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PHARMACOLOGY NURS 251 MIDTERM EXAM
PORTAGE LEARNING QUESTIONS & VERIFIED
ANSWERS GRADED A
Question 1
- Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use?
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“Clozapine blood levels are significantly lowered by cigarette smoking and by other hepatic enzyme-inducers.” Which of the following medications is best to AVOID in maintenance treatment of bipolar disorder and why?
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“As noted previously, antidepressants may contribute to an increase in mood episode frequency.” Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered? Which of the following are NOT primary target(s) symptom for antipsychotic agents in schizophrenia? i. Depression, anxiety, demoralization, suicidality, excitability, and agitation ii. Delusions, hallucinations, disorganized thoughts iii. Affective flattening, alogia, avolition, anhedonia, social withdrawal iv. Attention, memory, and executive functions
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“For schizophrenia, the primary target symptoms for antipsychotic agents fall into three categories: psychotic symptoms (e.g., hallucinations, delusions, disorganization); agitation (e.g., distractibility, affective lability, tension, increased motor activity); and negative symptoms (e.g. apathy, diminished affect, social withdrawal, poverty of speech.” AND “Although cognitive deficits are an important contributor to disability in schizophrenia, cognitive deficits usually are not considered a target for antipsychotic agents because they are not very responsible to current agents.” A 32 - year-old males calls you complaining of decreased libido since starting Paroxetine 20 mg 2 weeks ago. He reported stopping the medication 1 day ago and is now experiencing extreme irritability and nervousness. He wishes to stop this medication due to side effects. What do you recommend?
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• Question 3
• Question 2
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under selective serotonin re-uptake inhibitors discontinuation syndrome subtitle: “The risk of such adverse events occurring seems to be
- Question 16 violence, and victimization as well as worse overall quality of life?
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“Moreover, non-adherent patients with schizophrenia are at greater risk for substance use, violence, and victimization as well as worse overall quality of life.” An 81 - year-old male comes to your clinic today complaining of dry mouth, blurred vision, and constipation. He has a past medical history significant for hypertension, heart failure, and depression. Of the following medications, which one is likely contributing to these side effects?
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Only TCA is listed with most anticholinergic effects; Page 39 for TCA side effect profile: “dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia, memory difficulties, and ejaculatory difficulties” Choose the appropriate statement regarding lamotrigine dosing.
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Carbamazepine induced metabolism of lamotrigine – increase dose of lamotrigine; Valproate may inhibit clearance of lamotrigine, so dose reduction of lamotrigine is needed Of the following medications used in the treatment of social anxiety disorder, which one would you AVOID in a patient who has uncontrolled hypertension?
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Phenelzine reported to have hypertensive reactions as a limitation/primary side effect What is the therapeutic plasma level of carbamazepine? Which of the following statements below is NOT considered an appropriate treatment strategy for treatment-resistant depression?
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“Combination of an SSRI OR an SNRI with a norepinephrine-dopamine re-uptake inhibitor (bupropion) or a serotonin-norepinephrine antagonist (mirtazapine or mianserin) is a commonly used combination” Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY.
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- Question 23**
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under pharmacokinetics and pharmacodynamics subtitle
_- “NSAIDs or other COX- 2 inhibitors may decrease renal blood flow and thereby increase lithium levels by up to 25%.”
- “Therefore, thiazide diuretics, which act distally, will tend to increase lithium levels by up to 50% while those that act more proximally generally have less of an effect on lithium levels.”_ How do you manage a patient who develops neuroleptic malignant syndrome while on an atypical antipsychotic? When initiating lithium, how long should you wait before checking a lithium level? What is the therapeutic goal level of lithium? K. B. never felt relief from his depressive symptoms, even after appropriate time and dose titration of Venlafaxine. He was switched to Bupropion 150 mg about 2 months ago and is following up with you today. He reported feeling “great” and that his relationship with his girlfriend is “better than ever now.” Because he is feeling so well at this time, he is wondering when he can stop taking Bupropion. How long must the patient be symptom- free before he may begin a trial to taper off the antidepressant therapy?
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“Therefore, in treatment-responders, most experts favor a continuation of antidepressant therapy for a minimum of 6 months following the achievement of remission.” Choose the appropriate pair regarding acetylcholine receptors.
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“There are two classes of ACh receptors: muscarinic and nicotinic. While muscarinic receptors are G-protein-coupled, nicotinic receptors are ion channels, which allows for rapid influx of NA+ and Ca2+ into the post-synaptic neuron.” Which neurotransmitter is considered the major inhibitory neurotransmitter? M. B. was just diagnosed with Generalized Anxiety Disorder and pharmacotherapy is needed. Which of the following would be a first-line treatment option for M. B.? i. Duloxetine ii. Quetiapine iii. Diazepam iv. Escitalopram
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Which atypical antipsychotic(s) require a meal for better absorption? i. Quetiapine ii. Ziprasidone iii. Asenapine iv. Olanzapine v. Lurasidone
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_- Ziprasidone – best with a fatty meal
- Lurasidone – best with a meal of at least 350 calories (no effect of fat composition)_ ii. Question 30 K. T. is a 35 - year-old woman who was diagnosed with Generalized Anxiety Disorder about 4 weeks ago. She was prescribed Clonazepam 2 mg at bedtime but was referred to you to determine chronic treatment. K. T. states the new medication has been helping a lot but worries about all the side effects that come with it. She wants to discontinue the medication. What is the appropriate next step to help K. T.?
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“The regular use of benzodiazepines for more than 2 to 3 weeks may be associated with physiological dependence and the potential for significant withdrawal symptoms with discontinuation. Discontinuation of benzodiazepines is best done with a gradual taper to minimize withdrawal symptoms.”
_- Answer choice A: Honor the patient’s request of discontinuing the medication.
- Answer Choice C: An abrupt stop of a benzodiazepine will likely send the patient into having withdrawal symptoms.
- Answer D: Patient will likely experience withdrawal symptoms due to how often the patient uses it OR patient will experience withdrawal symptoms after missing one dose, thus the therapy wouldn’t have changed at all from how she has been taking it._ iii. Question 31 The serotonin system is involved in many processes in psychiatry, including, most prominently, mood, sleep, and psychosis. Of the following neurons listed, from where is serotonin synthesized?
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under serotonin subheading and figure 1 - 18 on page 16: Locus Coeruleus: Norepinephrine Nucleus basalis: cholinergic neurons Substantia Nigra: dopamine Ventral Tegmental area: dopamine iv. Question 32 A 27 - year-old female presents to your emergency room today with a rash that started about 1 week ago and has now spread to her whole body. She has a past medical history significant for type 2 diabetes, hypertension, and bipolar disorder. The patient reports, “The only thing that is different is that I’ve been on this new medication for my bipolar for a few weeks.” Of the following medications, which one is likely to be causing this severe rash?
v. Question 33 The following patient case is considered an example of treatment-resistant depression. B. B. is a 26-year old-female at your clinic today with the diagnosis, “treatment-resistant depression.” She is currently on Bupropion 300 mg daily and has been at this dose for 6 weeks with no alleviation in depressive symptoms. She has trialed the following medications in the past with treatment duration listed:
- Paroxetine 40 mg daily for 4 weeks
- Citalopram 20 mg daily for 2 weeks
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“At least one trial with an antidepressant with established efficacy in MDD (with sufficient duration and doses) is considered to be adequate antidepressant treatment.” vi. Question 34 Patient is a 72 - year-old male with a past medical history significant for atrial fibrillation and COPD with a new diagnosis of major depression disorder. Based on his comorbid conditions, what antidepressant would you recommend as first-line?
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(Options C & D are both TCA antidepressants and, based on the patient’s age and comorbid conditions, a TCA would likely result in more side effects, such as increased fall risk due to potential for orthostatic hypotension and anticholinergic-related side effects. In addition, patient has a history for cardiac abnormalities due to A. fib diagnosis - TCAs result in electrocardiographic changes in susceptible individuals, therefore, would likely avoid. Choice B is used more for ADHD purposes than as an antidepressant) Page numbers used: Page 39 for TCA side-effect profile vii. Question 35 It is appropriate to start lamotrigine in combination with another atypical antipsychotic in treatment of an acute manic episode in bipolar disorder.
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“Lamotrigine has also been extensively studied in bipolar depression as well….” viii. Question 36 Which statement is TRUE regarding the use of selective serotonin reuptake inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) in patients with Generalized Anxiety Disorder?
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“Because the SSRI/SNRIs have the potential to cause initial restlessness, insomnia, and increased anxiety, and because the patients are commonly sensitive to somatic sensations, the starting doses should be low, typically half (or less) of the usual starting
xv. Question 43 A 25 - year-old female comes into your clinic today informing you she is ready to have a baby and wishes to discontinue her birth control at this time. After reviewing her chart, you notice she has a history of bipolar disorder and was previously prescribed valproic acid by another doctor. What is your concern with this medication in this specific patient?
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“Valproic acid may produce teratogenic effects.” xvi. Question 44 K. B. is a 28 - year-old male who was started on Venlafaxine 75 mg about 2 weeks ago and is now calling you asking how long it should take for this medication to begin to work. He is concerned his girlfriend will leave him if he doesn’t get better quickly. What is the appropriate amount of time to allot to see a therapeutic response?
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“It has been consistently observed and reported that remission of depression often requires 4 weeks of treatment or more;” Page 33: “Use of antidepressant for at least 6 – 12 weeks to determine whether it is helping or not” xvii. Question 45 Which of the following receptors below would likely result in extra-pyramidal symptoms, tardive dyskinesia, and hyperprolactinemia?
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first generation antipsychotics all share the common property of D blockade, which can produce EPS, TD, and hyperprolactinemia xviii. Question 46 Patient is a 59-year-old male with a past medical history significant for bipolar disorder I, hypertension, and COPD. He calls your clinic today complaining of extreme fatigue and a new tremor in his hand. He reports starting lithium 600 mg at bedtime about 5 days ago and thinks that may be the cause. What is the appropriate next step for this patient?
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“Other bothersome adverse effects” Patient is likely experiencing lithium toxicity and labs should be verified first before continuing with other treatments for the tremor. xix. Question 47 What is the strongest established risk factor for bipolar disorder?
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“The strongest established risk factor for BPD is a family history of BPD.” xx. Question 48 Selection of an antipsychotic agent is usually guided by the side-effect profile and by
available formulations.
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Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use? xxi. Question 49 Of the following antipsychotic medications listed below, which one has a Black Box Warning for seizure, agranulocytosis, and seizures?
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Box 7 - 5 * indicated clozapine-specific black box warnings xxii. Question 50 M. M. is 27-year-old female student pharmacist who presents to the ER after experiencing extreme lightheadedness during her fourth-year seminar presentation. Her vitals are as follows: BP (107/65) and HR of 45. What medication below is likely the cause of these symptoms?
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“The use of beta-blockers may be associated with orthostatic hypotension, lightheadedness, bradycardia, and nausea.” xxiii. Question 51
