Question 1
What is the strongest established risk factor for bipolar disorder? Family History
Response
Feedback:
“The strongest established risk
... [Show More] factor for BPD is a family
history of BPD.”
Question 2
Which of the following medications are known as selective serotonin re-uptake inhibitors
(SSRIs)?
i. Nortriptyline
ii. Citalopram
iii. Duloxetine
iv. Fluoxetine
v. Venlafaxine
Question 3
Which disease state of a non-adherent patient is at greater risk for substance use,
violence, and victimization as well as worse overall quality of life? Schizophrenia
Response
Feedback:
“Moreover, non-adherent patients with schizophrenia are at greater
risk for substance use, violence, and victimization as well as worse
overall quality of life.”
Question 4
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
NURS 6630N MIDTERM EXAM WEEK 6 WALDEN
conditions, what antidepressant would you recommend as first-line?
Response
Feedback:
(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
Question 5
Which of the following is an appropriate strategy for managing treatment-resistant
depression?
Use both SSRI and SNRI
Question 6
Which of the following medications is best to AVOID in maintenance treatment of bipolar
disorder and why?
Response
Feedback:
“As noted previously, antidepressants may contribute to an
increase in mood episode frequency.”
Question 7
With second-generation antipsychotics, what is the main side effect that requires
frequent monitoring?
Response
Feedback:
table 7-6 & page 80, table 7-7; Page 78: “However, attention over the
past decade has focused on effect of second-generation antipsychotics
on glucose metabolism and lipids and associated metabolic syndrome.”
Question 8
Which amino acid is involved in the synthesis of both norepinephrine and dopamine?
Question 9
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?
Response
Feedback:
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”
Question 10
Which medication has been studied and recommended in patients with a social anxiety
disorder who also suffer from an alcohol use disorder?
Response
Feedback:
“Suggested that treatment with the SSRI paroxetine decreased the
anxiety and may have reduced the alcohol use as well”
Question 11
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
Response
Feedback:
“As is true for panic and the other anxiety disorders, the SSRIs and
SNRIS are generally considered first-line agents for the treatment of
GAD because of their favorable side effect profile….”
Question 12
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?
Response
Feedback:
under serotonin subheading and figure 1-18
on page 16:
Locus Coeruleus: Norepinephrine
Nucleus basalis: cholinergic neurons
Substantia Nigra: dopamine Ventral
Tegmental area: dopamine
Question 13
Which of the following symptoms is NOT part of the diagnostic features for bipolar
disorder?
Response
Feedback:
“Psychosis is not represented in the diagnostic features for BPD.”
- “Psychosis typically resolves along with the mood symptoms, though
diagnostic criteria acknowledge that psychotic symptoms may linger
beyond the end of the episode.”
Question 14
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?
Response
Feedback:
under selective serotonin re-uptake inhibitors discontinuation syndrome
subtitle: “The risk of such adverse events occurring seems to be inversely
related to the half-life of the SSRI, with fluoxetine reported as having a
significantly lower risk than paroxetine in two studies. For more severe
discontinuation-related adverse events, re-institution of the SSRI and slow
taper may be necessary to alleviate these symptoms.”
Question 15
It is appropriate to start lamotrigine in combination with another atypical antipsychotic in
treatment of an acute manic episode in bipolar disorder.
Response
Feedback:
“Lamotrigine has also been extensively studied in bipolar
depression as well….”
Question 16
Which antiepileptic drugs should we avoid in pregnant women in the treatment of bipolar
disorder?
i. Depakote
ii. Lamotrigine
iii. Topiramate
iv. Carbamazepine
v. Gabapentin
Response
Feedback:
All the others listed except for lamotrigine are not used in
treatment of bipolar disorder.
Question 17
A 23-year-old female was just diagnosed with major depressive disorder and is being
started on escitalopram 10 mg daily. The patient should be counseled about which Black
Box warning?
Response
Feedback:
“In 2004, the FDA asked manufacturers of almost all the new
antidepressant drugs to include in their labeling a warning statement
that recommends close observation of adult and pediatric patients
treated with these drugs for worsening depression or the emergence of
suicidality."
Question 18
Which statement is TRUE regarding the use of selective serotonin reuptake
inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) in patients with
Generalized Anxiety Disorder?
Response
Feedback:
“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 dose….”
Question 19
Which of the following statements below is NOT considered an appropriate treatment
strategy for treatment-resistant depression?
Response
Feedback:
“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”
Question 20
Which atypical antipsychotic(s) require a meal for better absorption?
i. Quetiapine
ii. Ziprasidone
iii. Asenapine
iv. Olanzapine
v. Lurasidone
Response
Feedback:
- Ziprasidone – best with a fatty meal
- Lurasidone – best with a meal of at least 350 calories (no effect
of fat composition)
Question 21
Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY.
Response
Feedback:
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.”
Question 22
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
Response
Feedback:
“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.”
Question 23
Of the following antipsychotic medications listed below, which one has a Black Box
Warning for seizure, agranulocytosis, and seizures?
Response
Feedback:
Box 7-5 * indicated clozapine-specific black
box warnings
Question 24
Which neurotransmitter is considered the major inhibitory neurotransmitter?
Question 25
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?
Question 26
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?
Question 27
Which of the following medications used for treatment of bipolar disorder may increase
stroke risk among older patients, particularly those with dementia?
Response
Feedback:
“Notably, pharmacovigilance studies suggest that atypical
antipsychotics may increase stroke risk among older patients,
particularly those with dementia, so use of SGA requires more caution in
this group.”
Question 28
Which of the following receptors below would likely result in extra-pyramidal symptoms,
tardive dyskinesia, and hyperprolactinemia?
Response
Feedback:
first generation antipsychotics all share the common property of D2
blockade, which can produce EPS, TD, and hyperprolactinemia
Question 29
Which anticonvulsant below induces its own metabolism over time?
Question 30
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?
Response
Feedback:
“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”
Question 31
Selection of an antipsychotic agent is usually guided by the side-effect profile and by
available formulations.
Response Which drug below has an interaction with cigarette smoking and
should be adjusted based on patient’s tobacco use/non-use?
Feedback:
Question 32
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?
Response
Feedback:
“Therefore, in treatment-responders, most experts favor a continuation
of antidepressant therapy for a minimum of 6 months following the
achievement of remission.”
Question 33
Close-ended questions will help identify when patients are taking medications incorrectly.
Question 34
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.?
Response
Feedback:
“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.
Question 35
Which answer choice includes all the components of patient-focused interventions to
enhance adherence?
i. Education
ii. Motivation
iii. Skills
iv. Logistics
Question 36
Of the following medications, which ones are considered first-line in treatment of an
acute manic episode of bipolar disorder (assuming monotherapy)?
i. Lithium
ii. Fluoxetine
iii. Aripiprazole
iv. Risperidone
v. Ziprasidone
vi. Venlafaxine
vii. Quetiapine
viii. Valproate
Question 37
Which drug below has an interaction with cigarette smoking and should be adjusted
based on patient’s tobacco use/non-use?
Response
Feedback:
“Clozapine blood levels are significantly lowered by cigarette
smoking and by other hepatic enzyme-inducers.”
Question 38
In order for the NMDA receptor to fully open and allow an influx of calcium, both
glutamate and glycine must bind to cause a depolarization of the cell that will ultimately
displace which ion? Is the NMDA receptor an ionotropic or metabotropic receptor?
Question 39
When initiating lithium, how long should you wait before checking a lithium level? What is
the therapeutic goal level of lithium?
Question 40
Choose the appropriate pair regarding acetylcholine receptors.
Response
Feedback:
“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 postsynaptic neuron.”
Question 41
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?
Response
Feedback:
“Other bothersome adverse effects” Patient is likely experiencing
lithium toxicity and labs should be verified first before continuing with
other treatments for the tremor.
Question 42
Choose the appropriate statement regarding lamotrigine dosing.
Response
Feedback:
Carbamazepine induced metabolism of lamotrigine – increase dose of
lamotrigine; Valproate may inhibit clearance of lamotrigine, so dose
reduction of lamotrigine is needed
Question 43
Choose the correct option regarding the major classes of GABA receptors and the ions
involved in inhibition of the neurotransmitter pathway
Response
Feedback:
“GABAB receptors, akin to the metabotropic glutamate receptors, are Gprotein-coupled receptors rather than ion channels. Activation of GABAB
causes downstream changes in potassium (K+) and Ca+2 channels,
largely via G-protein-mediated inhiation of cAMP.”
Question 44
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?
Response
Feedback:
“Valproic acid may produce
teratogenic effects.”
Question 45
How do you manage a patient who develops neuroleptic malignant syndrome while on an
atypical antipsychotic?
Question 46
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
Response
Feedback:
“At least one trial with an antidepressant with established efficacy in
MDD (with sufficient duration and doses) is considered to be adequate
antidepressant treatment.”
Question 47
What is the therapeutic plasma level of carbamazepine?
Question 48
Of the following medications used in the treatment of social anxiety disorder, which one
would you AVOID in a patient who has uncontrolled hypertension?
Response
Feedback:
Phenelzine reported to have hypertensive reactions as a
limitation/primary side effect
Question 49
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?
Response
Feedback:
“The use of beta-blockers may be associated with orthostatic
hypotension, lightheadedness, bradycardia, and nausea.”
Question 50
Which drug below differs from other atypical antipsychotics in causing persistent
hyperprolactinemia?
Response
Feedback:
“Risperidone differs from other second-generation antipsychotics in
causing persistent hyperprolactinemia.”
Question 51
When completing this exam, did you comply with Walden University’s Code of Conduct
including the expectations for academic integrity?
Explanation:
Question:
Which of the following is an appropriate strategy for managing treatment-resistant
depression?
A.Switch from one SSRI to another SSRI
B.Switch from one SSRI to a SNRI
C.Combine two antidepressants with different mechanisms of action
D.Augment with lithium
E.Any of the above would be an appropriate strategy
"SACO, a mnemonic developed to aid in the selection of treatment options, aligns with
current guidelines' recommendations of Switching therapies, Augmentation, Combination of
antidepressant classes, and Optimization as appropriate approaches for managing TRD."
Reference: https://www.uspharmacist.com/article/managing-treatmentresistant-depression
Which of the following medications is best to AVOID in maintenance treatment of bipolar
disorder and why?
A.Valproate, because it is only used in the treatment of acute manic episodes.
B.Lithium, because it is only used in the treatment of acute manic episodes. [Show Less]