MH701 - Exam 1 - Big Set

When treating depression w/ anxiety:

-Use less energizing SSRI, Venlafaxine or Duloxetine. Consider Viibryd if others fail. -If using Fluoxetine -- start low and titrate slowly to avoid activation of anxiety -Avoid Wellbutrin as this is too activating; can cause increased anxiety

how to choose antidepressant

-What are the most bothersome symptoms? (Anxious, Energized, Vegetative, Altered Sleep, Altered Sex Drive, Appetite Change, Fatigue, Hypersomnia) -Take advantage of the side effects

Buspirone Acts as

-a partial agonist for serotonin 5-HT1a receptors in the brain -Less sedation and psychomotor impairment -Lack of interaction with alcohol

Acetylcholine (Ach):

-all parasympathetic nerves -major role in attention -learnin -memory Alzheimer's disease is a result of degeneration of ________________ neurons.

positive indications for benzodiazapines

-anxiety/ panic disorders -etoh withdrawal -seizures , insomnia, muscle spasm, -pre-anesthesia sedation, IBS, restless leg, chemo induced n/v

All benzodiazepines have:

-anxiolytic effects -Can cause paradoxical hyperexcitability -Induction of sleep -Anterograde amnesia -Anticonvulsant Effect -Tolerance occurs

Treatment of panic disorder combines

-cognitive-behavioral therapy -self-management techniques -medications *antidepressants *anxiolytic agents

Pharm for Anxiety Pearls

-conservative approach = paroxetine, sertraline citalopram in isolated panic disorder -rapid control of symptoms = brief alprazolam concurrently with ssri and taper benzo -long term Fluoxetine (prozac) effective for panic / depression 1st couple of weeks mimic panic symptoms Klonopin can be taken prn for anticipate panic 0.5-1 mg

In pre-anesthetic doses BZDs will:

-decreases blood pressure -increases heart rate

Panic disorder is associated with

-high utilization of multiple medical services -poor quality of life -high incidence of suicide.

Gamma-amino butyric acid (GABA):

-inhibits transmission from one nerve to the next in CNS -predominant inhibitory neurotransmitter in CNS

Serotonin (5-hydroxytryptamine or 5-HTseries):

-involved with sleep/wake cycles -mood -chronic pain -hunger -more than 20 different receptors.

When treating depression w/ anxiety:

-less energizing SSRI, Venlafaxine or Duloxetine -Viibryd if others fail -if fluoxetine w/ anxiety be sure to start low and titrate slowly to avoid activation of anxiety -Avoid Wellbutrin too activating; increased anxiety

OCD physical abnormality

-lies in pathway that links the frontal lobes of the cerebral cortex with the basal ganglia *MRI suggests loss of tissue in the caudate nuclei, areas in the basal ganglia that filter messages, fails to dampen the obsessional thinking

Dopamine

-most basic neurotransmitter -drives sex, anger/rage -motor behavior -learning -attention =motivation -pleasure -emotion -at least 5 different receptors

Anxiety disorders are linked with marked impairment in:

-physical function -psychological function -quality of life

Choosing/ switching antidepressants : clinical pearls

< 1/3 receive remission with 1st med tried switching is nml if no resp 4-8 wk after optimal dose Pt just as likely to respond to another drug in same class once pt failed 2 drugs in same class consider diff class Careful with elderly, sexual dysfunction common (wellbutrin added helpful)

Cholinesterase inhibitors

A class of drugs to treat people with dementia that help increase levels of acetylcholine in the brain.

CP450

DEFINITIONS: SUBSTRATE: any drug metabolized by P450 enzymes (from baseline) INHIBITOR: any drug that inhibits metabolism of a P450 substrate (strong, moderate, weak) - inverse relationship -- causes INCREASE in drug levels of the other drug INDUCER: any drug that increases the amount of P450 enzymes (strong, moderate, weak) - inverse relationship -- causes DECREASE in drug levels of the other drug

Haldol (haloperidol)

DRA Antipsychotic cardiac side effects safest first gen antipsychotic

Acetylcholine -- too much

Delirium/confusion

Mirtazapine (Remeron) Noradrenergic and specific serotonergic antidepressant Indications

Depression (especially with insomnia), anxiety, appetite stim, severge gi disturbance, nightmare suppression, helpful for sleep with kids/ adolescents minimal sexual dysfunction

Norepinephrine -- too little

Depression, ADD, or ADHD

Nefazodone (serzone) (usually for sleep) Trazadone (Desyrel) Indications

Depression, anxiety, off label sleep, best as augmenting therapies and not monotherapy

Serotonin (5-HT2A) -- too little

Depression-OCD, Increased pain sensitivity, Anxiety

TCA has the least anticholinergic side effects

Desipramine

45. Can DRAs lower the seizure threshold and should consideration be given in regards to DRA use if the patient already has a seizure disorder?

Yes, DRAs may lower seizure threshold. Chlorpromazine, thioridazine, and other low-potency drugs are thought to be more epileptogenic than are high-potency drugs. Consideration should be given to the client's history of seizure disorder or brain lesion.

What are "Z" compounds?

Zolpidem (Ambien), Eszopiclone (Lunesta) & Structurally unrelated to benzodiazepines

ADHD (Attention-Deficit Hyperactivity Disorder)

a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity by age 12

3. On the sixth anniversary of her spouse's death a widow says, "Sometimes life does not seem worth living anymore. I wish I could go to sleep and never wake up." Which response by the nurse has priority? a. "Are you considering suicide?" b. "You still have so much to live for." c. "Grief can sometimes last for many years." d. "Why do you continue to grieve something from long ago?"

a. "Are you considering suicide?"

3. A patient tells the nurse, "I was raped 8 years ago but never told anyone. Nevertheless, the memories haunt me every day. I should be over it by now." Which comment should the nurse offer next? a. "It sounds like you're judging yourself for continuing to struggle with your reaction." b. "Rape is criminal behavior. You should have reported the incident to law enforcement." c. "Are you now ready to engage in counseling to deal with your reactions to this experience?" d. "While it's important to learn from such life events, it's more important to put things in the past."

a. "It sounds like you're judging yourself for continuing to struggle with your reaction."

2. An emergency department nurse talks with a newly admitted victim of reported rape. Which communication should the nurse offer to comfort this patient? a. "You are safe now. I will stay with you in this private room." b. "Would you like your friend to stay with you during your examination?" c. "You made a good decision to come to the hospital after you were raped." d. "What questions do you have about your examination by the sexual assault nurse examiner?"

a. "You are safe now. I will stay with you in this private room."

3. Which newly hospitalized patient should the nurse monitor closely for development of delirium? a. 48-year-old who usually drinks a six-pack of beer daily b. 68-year-old who takes aspirin 650 mg twice daily for arthritic pain c. 72-year-old who says, "I have a glass of wine every evening to stimulate my appetite." d. 78-year-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL

a. 48-year-old who usually drinks a six-pack of beer daily

35. Treatment of acute bipolar depression would include?

a. Antidepressant monotherapy may precipitate mania or induce rapid-cycling disorders between mania and depression; therefore, use of antidepressants should be avoided entirely or used only short term with a mood stabilizer. b. Antidepressant drugs are often enhanced by a mood stabilizer in the first-line treatment for a first or isolated episode of bipolar depression. A fixed combination of olanzapine and fluoxetine (Symbyax) has been shown to be effective in treating acute bipolar depression for an 8-week period without inducing a switch to mania or hypomania. c. Many patients who are bipolar in the depressed phase do not respond to treatment with standard antidepressants. In these instances, lamotrigine or low-dose ziprasidone (20 to 80 mg per day) may prove effective. d. Electroconvulsive therapy may also be useful for patients with bipolar depression who do not respond to lithium or other mood stabilizers and their adjuncts, particularly in cases in which intense suicidal tendency presents as a medical emergency. (last resort; do not over refer)

5. A university football coach invites the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include? a. Appropriate behavior with intimate partners b. University resources for counseling and support c. The importance of role modeling for children and teens d. Public recognition of children with life-threatening illnesses

a. Appropriate behavior with intimate partners

38. Preliminary evidence tells us that which medication(s) would likely have efficacy for symptom reduction in comorbid mania, depression and anxiety?

a. Atypical antipsychotics i. Quetiapine (Seroquel) ii. Aripiprazole (Abilify) iii. Olanzapine (Zyprexa) b. Mood Stabilizers i. Carbamazepine (Tegretol) ii. Valproate (Depakote) iii. Lamotrigine (Lamictal)

23. Class and MOA of BuSpar?

a. Class: Anxiolytic b. MOA: i. Binds to serotonin type 1A receptors ii. Partial agonist actions postsynaptically may theoretically diminish serotonergic activity and contribute to anxiolytic actions iii. Partial agonist actions at presynaptic somatodendritic serotonin autoreceptors may theoretically enhance serotonergic activity and contribute to antidepressant actions

1. A parent tells the nurse about the death of a child 2 years ago. Which comment by this parent warrants the nurse's priority attention? a. "I still have some of my child's toys and clothes." b. "A parent should never live longer than their child." c. "I never returned to church again after the death of my child." d. "My child has been dead a long time, but it seems like only yesterday."

b. "A parent should never live longer than their child."

APA recommednations: Initial therapy -- severe depression For patients who request a CAM St. John's Wart (SAMe) may be tried but efficacy is unclear. Other CAM includes light therapy and exercise.

combination of medications and psychotherapy

seratonin syndrome

concurrent with MAOI, Triptan, Tramadol, Linezolid, lithium, St. Johns Wort may start 2-72 hours after- can be LETHAL confusion, fever, agitation, anxiety, hallucination, hyperflexia, diaphoresis, tremors, hypertension

What is the function of the limbic system related to psychiatric disorders?

motivation, emotion, learning, and memory. operates by influencing the endocrine system and the autonomic nervous system. • Anatomical loop for emotional processing/amygdala • Assigns emotional significance to sensory experiences • May regulate learned fear responses (panic/anxiety) • Houses emotional association areas (associating emotion to other person's voice or expression)

37. Of the biogenic amines, these two neurotransmitters are most implicated in the pathophysiology of mood disorders such as bipolar disorder.

norepinephrine & serotonin

APA recommendations: Initial therapy -- mild or moderate depression

options include pharmacotherapy alone, psychotherapy alone or a combination.

most common SSRI to cause weight gain is

paroxetine (Paxil)

Buspar has no:

physical dependence/withdrawal/abuse potential

GABA is the

predominant inhibitory neurotransmitter in the CNS.

Buspirone (Buspar) (anxiolytic) Contraindication

pregnancy, taking MAOI's use/ dependance on benzos caution - kidney/liver impairment, elderly

most n/v

prozac, effexor, cymbalta

41. This syndrome generally includes symptoms such as disorganized speech, disorganized behavior, and gross distortions of reality.

psychosis

Life-threatening side effects of stimulants

psychotic episodes, seizures, palpitations, tachycardia, hypertension, hypomania

6. The Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 is a

reference manual by the American Psychiatric Association to classify mental disorders.

Tolerance and physical dependence are not as common as seen in benzodiazepine use

"Z" compounds

Important benzodiazepine issues

-potential retrograde amnesia (formation and consolidation of memory) - >12 weeks high risk abuse/ dependance -long term memory / concentration may be permanent -Slow taper over months (chronic use) -7th on list of addictive sub, lethality lowest dose/ shortest period possible

Choice of Antidepressant

-response history (if not initial episode) -Comorbidities -Depressive symptoms -Safety/tolerability -Drug interactions -Pharmacokinetics -Cost -Patient preference

Norepinephrine

-stimulates appetite -reinforcement pathways -involved in arousal -learning -mood regulation

DSM diagnosis (6 steps )

1) ruling out Malingering and Factitious Disorder, 2) ruling out a substance etiology, 3) ruling out an etiological medical condition, 4) determining the specific primary disorder(s), 5) differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions 6) establishing the boundary with no mental disorder.

SSRIs from most energizing to most sedating:

1-Fluoxetine (Prozac) 2-Sertraline (Zoloft) 3-Citalopram (Celexa) 4-Escitalopram (Lexapro) 5-Paroxetine (Paxil)

These drugs are most likely to cause this discontinuation syndrome

1-Paxil 2-Effexor

Social Anxiety Disorder (1st line therapy)

1. SSRI, 2. Benzo 3. venalfaxine (effexor) 4. Buspirone (buspar) buspirone shown best to augment

TCA contraindication

10% phenyl and suicidal patients; exacerbate adrenergic effects and can cause HTN crisis hepatic / renal disease, not for kids, eCT, concurrent use of opiates, benzos, etoh, cold medicine NOT in PREGNANCY

med tx for OCD

1st SSRI or clomipramine

first-line treatments for PTSD

1st sertraline (Zoloft) and paroxetine (Paxil) 2nd imipramine (Tofranil) and amitriptyline (Elavil)

If no response is seen in

4 to 8 weeks with maximally tolerated dose then: -switch to a different med in the same or different class.

MDD s/s

5 of 9 -sleep (too much/too little) -decrease interest -guilt/worthlessness -energy (decreased) -concentration problems -appetite (too much/too little) -psychomotor agitation/retardation -suicidality

donepezil dose

5-10 mg at night

Adderall Dosing

5-10mg/30-40mg

With antidepressant therapy, response can be expected in:

50-75% of pts

How long onset of therapeutic action donepaezil

6 weeks to months

Combining pearls

>25% improvement on single, augment can further improve and retain current benefit watch for serotonin syndrome trazodone for sleep, wellbutrin weight issue, mirtazapine for appetite increase augmenting agents most evidence atypicals, lithium, cytomel

Dopamine

A neurotransmitter associated with movement, attention and learning and the brain's pleasure and reward system.

Armodafinil (Nuvigil) Indications

A stimulant that is not related to the ampetamine class for ADH D is ths

Acetylcholine -- drugs affecting

ACHEIs

What is meant by a drug causing an agonist type of action at a receptor site?

AGONIST = full agonist. Binds to receptor with full effect, like that of a neurotransmitter.

-What is meant by a drug causing an Antagonist type of action at a receptor site?

ANTAGONIST = Stops or significantly reduces signal. Binds to receptor, blocking-action of an agonist Competitive antagonists Non-competitive antagonists - Antagonize agonists by other means than direct competition

Amphetaime/ Dextroamphetamine

Adderall - ADHD/Narcolepsy - Class II

GABA, Drugs that increase or mimic:

Alcohol, barbiturates (phenobarbital), benzodiazepines (Valium), GHB, baclofen, neurosteroids (alphaxolone), muscimol

Acetylcholine -- too little

Alzheimer's

TCAs (tricyclic antidepressants)

Amitriptyline (Elavil) is an example. Clomipramine (Anafranil) Anticholinergic effects and orthostatic hypotension may occur. LETHAL in OVERDOSE, weight gain and sexual side effects

5-HT (Serotonin), Drugs that increase or mimic:

Amphetamine, cocaine, LSD, psychedelics (mushrooms, mescaline), SSRIs (Prozac, Zoloft), tricyclic antidepressants, MAOIs, BuSpar, triptans (sumatriptan, for migraines)

DA (Dopamine), Drugs that increase or mimic:

Amphetamine, cocaine, Parkinson's drugs (levodopa, bromocriptine, benztropine), MAOIs, Wellbutrin, LSD

NE (Norepinephrine), Drugs that increase or mimic:

Amphetamine, cocaine, SNRIs (Effexor, Cymbalta), tricyclic antidepressants, MAOIs, Wellbutrin, LSD, pseudoephedrine (Sudafed), albuterol, pyridostigmine

39. Which medications can worsen a manic episode and potential induce cycling?

Antidepressant monotherapy

Dopamine -- drugs affecting this neurotransmitter

Antipsychotics L-dopa

DA (Dopamine), Drugs that decrease or block:

Antipsychotics (Haldol), reserpine, tetrabenazine, AMPT

ACh (Acetylcholine), Drugs that decrease or block:

BZ atropine scopolamine benztropine biperiden curare Botox mecamylamine α-bungarotoxin

FDA approved for GAD

BZD: Alprazolam SRIs: Duloxetine (Cymbalta) Escitalopram (Lexapro) Paroxetine (Paxil) SNRI: Venlafaxine (Effexor)

30. The drug class that has been significantly minimized due to its high abuse and addiction potential and narrow therapeutic range with low therapeutic index and unfavorable side effect profile is

Barbiturates e.g. Phenobarbital

Anatomical Localization -- Anxiety

Basolateral amydgala projections to bed nucleus of stria terminalis

Anatomical Localization -- Fear

Basolateral, central, and medial nuclei of amygdala

Histamine, Drugs that decrease or block:

Benadryl, antipsychotics, Tagamet, Zantac

Drugs that affect GABA slowing down neurotransmission and decreasing the reactivity of brain

Benzo Short acting intermediate long acting triazolam alprazolam flurazepam Barbiturates thiopental secobarbital phenobarbital

MOA of amphetamines

Block MAO, Reverse reuptake transporter, increase synthesis of DA (7X more than normal), Get's inside vesicle via VMAT2 allowing for more free monoamine inside cell

weight neutral/loss

Bupropion (Wellbutrin) and fluoxetine (Prozac)

may cause dose-dependent HTN

Buproprion (Wellbutrin), venlafaxine (Effexor), duloxetine and desvenlafaxine (Pristiq)

What anxiolytic drug would be a good choice for a young adult patient with hx of addictions, not currently using illicit drugs or alcohol, however high risk for relapse, has anxiety but no depression. Has not tolerated SSRIs or SNRIs, has very low BP?

Buspar

Misc. (Sedative Hypnotics)

Buspirone Chloral Hydrate Eszopiclone Ramelteon Zaleplon Zolpidem

FDA approved Anxiety

Buspirone, chlordiazepoxide, diazepam, hydroxyzine, lorazepam, oxazepam, trifluoperazine

49. In person taking this drug they should be educated that a photosensitivity reaction that resembles a severe sunburn may occur, thus they should spend no more than 30 to 60 minutes in the sun, and should use sunscreens, may develop a relatively benign pigmentation of the eyes and long term use is associated with blue-gray discoloration of skin areas exposed to sunlight.

Chlorpromazine

b. Which have the lowest risk for drug:drug interactions?

Citalopram

Off Label for GAD

Citalopram (Celexa) Desvenlafaxine (Pristiq) Fluoxetine (Prozac) Fluvoxamine (Luvox) Mirtazapine (Remeron) Pregabalin (Lyrica) Sertraline (Zoloft)

Off Label for OCD

Citalopram (Celexa), Venlafaxine (Effexor), Vilazodone (Viibryd)

FDA for OCD

Clomipramine (Anafranil), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft)

GAD treatment when not responding to SSRI

Consider Venlafaxine (Effexor) Duloxetine (cymbalta) Consider anxiolytic buspirone (buspar) benzo alprazolam (xanax) for short term use (FDA +) Vistaril (hydroxyzine) histamine blocker help s/s may cause sedation

42. T/F - Conventional antipsychotics are very similar in therapeutic profile and side-effect profile.

False, same MOA, similar in therapeutic profile, but differ much in side-effect profile

GABA, Drugs that decrease or block:

Flumazenil, bicuculline, bemegride, Ro 15-4513, phaclofen

27. Which SSRI anecdotally causes activating side effects particularly in those with panic disorder?

Fluoxetine (Prozac)

SSRI Most likely to have drug interaction

Fluoxetine, fluvoxamine and paroxetine

15. Which SSRI(s) has a marked effect on several of the CYP enzymes and thus is at: a. high risk for drug:drug interactions?

Fluoxetine- according to lecture also fluvoxamine, and paroxetine

Dexmethylphenidate

Focalin

10. The main inhibitory neurotransmitter of the central nervous system is

GABA

benzodiazepine receptors modulate

GABA activity.

GABA sequence

GABA binds to GABAa receptor -> Increase of influx of Cl ions -> Hyperpolarization of neuronal cell membrane -> Decreased excitability

50. Which FGAs is considered the safest in overdose?

Haloperidol (Haldol)

SSRI contraindications

Hypersensitivity, renal dysfunction, hepatic dysfunction, Citalopram -QT interval, increases with antipsychotic Paroxetine = NO in pregnancy and lactation (mostly no in Fluoxetine)

What if methylphenidate not working?

If this drug is not working for ADHD, you should wait several weeks then consider adjusting dose or formulation or change to another agent; add behavioral therapy, consider non-compliance, evaluate for another disorder

TCA's used for PTSD

Imipramine (tofranil) amitriptyline (elavil)

44. If neuroleptic malignant syndrome is suspected what are the treatments?

In addition to supportive medical treatment, the most commonly used medications for the condition are dantrolene (Dantrium) and bromocriptine (Parlodel), although amantadine (Symmetrel) is sometimes used. Bromocriptine and amantadine pose direct DRA effects and may serve to overcome the antipsychotic-induced dopamine receptor blockade.

What is the most common dose dependent side effect of Venlafaxine?

Increase in blood pressure

MOA Methylphenidate (Ritalin)

Inhibits reuptake of dopamine and norepinephrine

16. What are the most common clinical mistake leading to an unsuccessful trial of an antidepressant drug is?

Keeping a patient on too low of a dose for too short of time. The starting dose should be maintained at least 4-5 weeks before we say it is unsuccessful

Life threatening side effects TCA

Lethal in Overdose, not for pts with current SI, cardiac disease

31. This drug is recommended for suicidal ideation. Risk of suicide is reduced 13-fold with long-term maintenance therapy with

Lithium

40. The drug which causes a generally benign and often transient diminution in the concentration of circulating thyroid hormones.

Lithium

Anesthesia

Loss of consciousness associated with absence of response to pain

"Z" compound approved for long term use

Lunesta

ADHD Prodrug

Lysdesamfetamine MOA

Bupropion (Wellbutrin)

NDRI antidepressant

memantine

NMDA antagonist; reduces glutamate transmission

MOA of Strattera

NRI (boosts norepinephrine and may also increase dopamine in pre-frontal cortex. Used for ADHD. Non-addictive

Opioids, Drugs that decrease or block:

Naloxone, naltrexone

ACh (Acetylcholine), Drugs that increase or mimic:

Nicotine muscarine Chantix nerve gases (VX, Sarin) Alzheimer's drugs (Aricept, Exelon) physostigmine Tensilon pilocarpine

Strattera

Non-stimulant for ADHD/atomexatine

3 most common neurotransmitters with anxiety

Norepinephrine serotonin GABA

MAOIs contraindications/ issues

On an SSRI or other that affects reuptake of serotonin Uncontrolled HTN, severe liver/ kidney, non compliant with non-tyramine diet, anesthesia, CV, Pheochromocytoma Taking diuretics, meperidine, antihistamines, otc old med, etoh, barbiturates, tca's

Straterra Dosing

Once Daily/long-acting

Histamine, Drugs that increase or mimic:

Opiates, betahistine

47. What is the most common side effect of low-potency antipsychotics particularly chlorpromazine, thioridazine, and chlorprothixene?

Orthostatic hypotension

-What is meant by a drug causing a Partial agonist type of action at a receptor site?

PARTIAL AGONISTS = Mixed agonists - Affinity for, (and even when fully bound to receptor) gives partial response.

Glu (Glutamate), Drugs that decrease or block:

PCP, ketamine, Namenda (for Alzheimer's), dextromethorphan (Robitussin), dizocilpine

priaprism

Painful erection lasting longer than 3 hours

Dopamine -- too little

Parkinson's Disease, ADD, or ADHD

REM sleep

Phase of sleep associated with rapid eye movements; most dreaming takes place during REM sleep

Barbiturates (long-acting)

Phenobarbital

29. What drug would be a good choice for the treatment of PTSD related nightmares?

Prazosin (Minipress)

life threatening side effect to Trazodone

Priapism, seizure, RARE- induction of mania, SI

This Beta-Blocker is used off label for PTSD, GAD, Violence/Aggressive Behavior

Propanolol

NE (Norepinephrine), Drugs that decrease or block:

Propranolol, clonidine, phentolamine, reserpine, AMPT

Dopamine -- too much

Psychoses, Tourette's Syndrome

Citalopram (Celexa) is associated with

QT interval prolongation and torsade de pointe --FDA recommends against using doses > 40 mg/day

Sedation

Reduction of anxiety

Cannabinoids, Drugs that decrease or block:

Rimonabant

14. MOA of: Mirtazapine [Remeron]:

SN-RAn (Serotonin Norepinephrine Receptor Antagonist)- i. Boost neurotransmitters serotonin and norepinephrine/noradrenaline ii. Blocks alpha 2 adrenergic presynaptic receptor, thereby increasing norepinephrine neurotransmission iii. Blocks alpha 2 adrenergic presynaptic receptor on serotonin neurons (heteroreceptors), thereby increasing serotonin neurotransmission; this is a novel mechanism independent or norepinephrine and serotonin reuptake; blocks 5HT2A, 5HT2C, and 5HT3 serotonin receptors iv. Blocks H1 histamine receptors

Venlafaxine (Effexor)

SNRI Also inhibits dopamine reuptake high dose = high BP antidepressant

Description -- Fear

Short-term, stimulus-specific response

Serotonin (5-HT2A) -- too much

Sleep-hallucinations

Amitryptyline (Elavil)

TCA/SNRI antidepressant

Glu Glutamate

The most common excitatory neurotransmitter

Glu (Glutamate), Effects:

The most common excitatory neurotransmitter

Dependence

The state of response to a drug whereby removal of the drug evokes unpleasant, possibly life-threatening symptoms, often the opposite of the drug's effects

Barbiturates - Ultra Short Acting

Thiopental

MOA methylphenidate

Tx for ADHD that is a dopamine and norepinephrine reuptake inhibitor; improves attention, concentration, executive function, wakefulness and hyperactivity; also depression, fatigue, sleepiness

32. This mood stabilizer may be especially problematic for adolescent and young women. Cases of polycystic ovarian disease have been reported in women using this mood stabilizer. Even when the full syndromal criteria for this syndrome are not met, many of these women develop menstrual irregularities, hair loss, and hirsutism.

Valproate / Valproic Acid / Depakote

med approved for GAD tx

Venlafaxine

may cause weight loss

Venlafaxine (Effexor)

Pharmodynamics

a clinical response to a drug including adverse reactions, results from the interaction between that drug and a patient's susceptibility to those action

MAOs when combined with SSRIs, SNRIs and TCAs can cause

a hypertensive crisis

24. What are the key neurotransmitters involved in anxiety and in the anxiolytic action of many drugs used to treat the spectrum of anxiety disorders?

a. Norepinephrine b. Serotonin c. GABA

standard treatments for OCD are

behavior therapy and medications

galantamine

cholinesterase inhibitor

Distribution

delivering the goods from the blood to the site of action

metabolism

enzymatically mediated alteration of drug structure

Benzodiazepines long acting

flurazepam

Less addictive drugs for ADHD

lysdesamfetamine, strattera

excretion

movement of drugs and their metabolites out of the body

switching from benzo to buspirone

must wean off benzo if long-term usage, can start buspirone while weaning

Common side effects of acetylcholinesterase inhibitors

nausea, diarrhea, appetite loss , insomnia

Timeline for binge eating dx

occurrs at least once per week for three months

Obsessions are

persistent thoughts, images or impulses experienced as alien intrusions that must be neutralized or suppressed

least likely to cause discontinuation syndrome

prozac

recovery

s/s free more than 6 months

Risk of using buspirone and SSRI for trmt of anxiety

small chance of increasing risk of serotonin syndrome

Benzodiazepines short acting

triazolam

propranolol

use for PTSD prophylaxis

most diarrhea

zoloft

Quietiapine (Seroquel)

atypical antipsychotic bipolar depression treatment

what is usually added first to an acetycholinesterase inhibitor to improve action

atypical, memantine

NE Norepinephrine

↑Heart rate ↑Alertness ↑Happiness ↓Blood circulation ↓Pain

Cannabinoids

↑Hunger

Cannabinoids, Effects:

↑Hunger

GABA, Effects:

↑Sleepiness ↓Anxiety ↓Alertness ↓Memory ↓Muscle tension

Opioids, Effects:

↑Sleepiness ↓Anxiety ↓Pain

GABA

↑Sleepiness ↓Anxiety ↓Alertness ↓Memory ↓Muscle tension

Opioids

↑Sleepiness ↓Anxiety ↓Pain

Histamine, Effects:

↑Wakefulness ↑Stomach acid ↑Itchiness ↓Hunger

Histamine

↑Wakefulness ↑Stomach acid ↑Itchiness ↓Hunger

ACh (Acetylcholine) Effects:

↓Heart rate ↑Secretions (sweat, saliva) ↑Memory ↑Muscle contractions

ACh Acetylcholine

↓Heart rate ↑Secretions (sweat, saliva) ↑Memory ↑Muscle contractions

Individuals who have had three or more episodes of depression

most likely will need continuous maintenance therapy.

behavior therapy for OCD

-Thought stopping -saturation therapy

Clomipramine

TCA antidepressant non SRI 1st line for OCD

Factors favoring treatment with an antidepressant:

(response expected in 50-75% of pts.) -Agitation -Problems w/ sleep and/or appetite -hx response to antidepressant, patient preference and moderate to severe symptoms.

olanzapine/fluoxetine

(symbyax) bipolar disorder, depression

What are the primary side effects and risks of TCAs

* contraindicated in suicidal patients* a. Anticholinergic SE i. Altered mental status ii. Urinary frequency iii. Blurred vision b. Sedation c. Weight gain d. Tachycardia e. Orthostatic hypotension f. Tremor g. Constipation h. Aggravation of closed angle glaucoma i. Lethal arrhythmia with overdose

Contraindications of Benzos

- Known drug allergy - Narrow-angle glaucoma - Pregnancy - hepatic/ renal disease - <6 years old

What do "Z" compounds do?

-Act as agonists on the benzodiazepine site of the GABAa receptor

Factors favoring treatment with an antidepressant:

-Agitation -Problems with sleep and/or appetite -hx of response to antidepressant -patient preference -moderate to severe symptoms.

Choice of antidepressant is largely based on the following factors

-Antidepressant response history (if not initial episode) -Comorbidities -Depressive symptoms -Safety/tolerability (MAOIs and TCA's are not appropriate first-line) -Drug interactions -Pharmacokinetics -Cost -Patient preference

Barbituates

-High abuse and addiction potential -Narrow therapeutic range -low therapeutic index -unfavorable side effects Used much less d/t benzodiazepines and hypnotics

Common treatment for PTSD

-SSRI : sertraline / Paroxetine (paxil) considered 1st line d/t efficacy, tolerability and safety ratings -Buspirone (Buspar) is serotonergic and may also be of use -Benzo "relatively contraindicated"

What would you recommend to patients who request a CAM therapies?

-St. John's Wart (SAMe) -light therapy -exercise

APA recommendations: For pts who request a CAM

-St. John's Wart (SAMe) -- efficacy is unclear. -light therapy and exercise

Autism Spectrum Disorder

A disorder characterized by deficits in social relatedness and communication skills that are often accompanied by repetitive, ritualistic behavior.

Hypnotic

A drug that produces drowsiness and facilitates the onset and maintenance of a state of sleep that resembles natural sleep

Anxiolytic

A drug that reduces anxiety, a sedative

Norepinephrine -- too much

Anxiety, panic, anorexia, excitability, insomnia

Alprazolam (Xanax)

Anxiolytic- Benzodiazepine FDA approved for panic disorder

What are the most bothersome symptoms?

Anxious, Energized, Vegetative, Altered Sleep, Altered Sex Drive, Appetite Change, Fatigue, Hypersomnia

5-HT (Serotonin), Drugs that decrease or block:

Atypical antipsychotics (Risperdal, Seroquel), Zofran, reserpine, TPH inhibitors, tryptophan-depleted drink

Gamma-amino Butyric Acid(GABA) -- drugs affecting

Benzodiazepines, Sedatives/Hypnotics

sedative-hypnotics

Benzos Barbituates Misc Agents

meds approved by FDA for panic disorder

Benzos: Alprazolam (Xanax) Clonazepam (Klonipin) SRIs: paroxetine (Paxil) fluoxetine sertraline

SAD pharm for performance situations

Beta blocker (b-adrenergic receptor antagonist) shortly before Tenormin 50-100 mg 1 hr, or propranolol 20-40 mg or lorazepam/ alprazolam

how does Melatonin Congeners e.g. Ramelteon work?

Binds selectively to melatonin 1 and 2 receptors as a full agonist

Agonist = Full Agnist

Binds to receptor with full effect, like that of a neurotransmitter

34. Neurobiological psychiatric disorder characterized by sustained extreme mood swings from extremely low (depression) to extremely high (manic) and an abnormal increase in energy and activity is

Bipolar Mood Disorder.

Gamma-amino Butyric Acid(GABA) -- too much

CNS depression, Respiratory depression, Sedation

SSRI's

Citalopram celexa Escitalopram lexapro Fluoxetine prozac Fluvoxamine luvox Paroxetine paxil Sertraline zoloft

Glu (Glutamate), Drugs that increase or mimic:

D-cycloserine, domoic acid (shellfish)

Education on Benzos

avoid ETOH or other CNS depressant meds avoid driving/ operating when used in short periods 1/2 weeks usually have no tolerance/ dependance/ withdrawal > 12 weeks high rate of dependance

What is the primary mechanism of action of the following drugs: b. Bupropion [Wellbutrin]- NDRI (Norepinephrine

Dopamine Reuptake Inhibitor) i. Boosts norepinephrine/noradrenaline ii. Boosts Dopamine iii. Blocks norepinephrine reuptake pump iv. Blocks dopamine reuptake pump

greatest potential for inhibition of metabolism of other drugs among the SNRIs

Duloxetine (Cymbalta)

Dysthmia (vs MDD)

Dysthymia = 2 years = normal MDD >2 weeks and not the baseline normal

SSRIs (selective serotonin reuptake inhibitors) indications

MDD, GAD, OCD, Panic disorder, PTSD, social anxiety disorder, Bulimia nervosa, PMDD

What drug class is considered first line for maintenance treatment of bipolar disorder?

Mood stabilizers

Opioids, Drugs that increase or mimic:

Morphine, heroin, fentanyl, hydrocodone (Vicodin)

Chloral Hydrate

Rarely used due to numerous safer options such as benzodiazepines

benzos -- Long acting are better

anxiolytics and anticonvulsant drugs

response

at least a 50% improvement of symptoms.

Tolerance

Reduction in drug effect requiring an increase in dosage to maintain the same response

14. MOA of: Venlafaxine [Effexor]-

SNRI (Serotonin Norepinephrine Reuptake Inhibitor) i. Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine ii. Blocks serotonin reuptake pump (serotonin transporter), presumably increasing serotonergic neurotransmission iii. Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing noradrenergic neurotransmission; presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors iv. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, venlafaxine can increase dopamine neurotransmission in this part of the brain v. Weakly blocks dopamine reuptake pump (dopamine transporter), and may increase dopamine neurotransmission.

Paroxetine (Paxil)

SRI Antidepressant FDA approved for panic disorder

Sertraline (Zoloft)

SRI antidepressant

Vilazodone

SRI antidepressant inhibits 5ht reuptake improves sexual dysfunction

What is the primary mechanism of action of the following drugs: c. Escitalopram [Lexapro]

SRI (Serotonin Reuptake Inhibitor) i. Boosts serotonin ii. Blocks serotonin reuptake pump iii. Desensitizes serotonin receptors

What is the primary mechanism of action of the following drugs: d. Fluoxetine [Prozac]

SRI (Serotonin Reuptake Inhibitor) i. SSRIs in general 1. Boosts serotonin 2. Blocks the serotonin reuptake pump 3. Desensitizes serotonin receptors ii. Fluoxetine Specific: 1. Antagonist properties at 5HT2C receptors which a. Increase norepinephrine transmission b. Increase dopamine transmission

Fluvoxamine

SRI - HIGH interaction risk antidepressant

Fluoxetine (Prozac)

SRI - LOW interaction risk antidepressant MAY increase norepinephrine & dopamine by antagonizing 5ht2c ACTIVATING - go low and slow

Citalopram (Celexa)

SRI - desensitize serotonin 1a receptors antidepressant

GAD 1st line pharm

SSRI FDA approved : Escitalopram (lexapro) *Paroxetine (Paxil) off label but EBP *citalopram (celexa) Fluoxetine (prozac) *Sertraline (zoloft) reasonable to begin treatment with SSRI plus benzo and then taper benzo after 2-3 weeks

1st line pharm for Agoraphobia

SSRI (1st line panic w or w-out agoraphobia) benzo rapid onset PRN xanax, ativan TCA's most effective dosage must be titrated slowly to avoid jitteriness and may not be achieved for 8-12 wks

MOA of Sertraline [Zoloft]

SSRI (Serotonin Reuptake Inhibitor) i. Boosts neurotransmitter serotonin ii. Blocks serotonin reuptake pump (serotonin transporter) iii. Desensitizes serotonin receptors, especially serotonin 1A receptors iv. Presumably increases serotonergic neurotransmission

What is the primary mechanism of action of the following drugs: a. Citalopram [Celexa]-

SSRI (Serotonin Reuptake Inhibitor) i. SSRIs in general 1. Boosts serotonin 2. Blocks the serotonin reuptake pump 3. Desensitizes serotonin receptors ii. Citalopram Specific: 1. Mild antagonist actions at H1 histamine receptors b. Bupropion [Wellbutrin]- NDRI (Norepinephrine

Serotonin Syndrome More commonly seen with

SSRI combined with: -triptan -tramadol -linezolid *most severe when combined with a MAOI

Common treatment for OCD

SSRI fluoxetine (Prozad) fluvoxamine (luvox), Paroxetine (paxil) sertraline (zoloft) TCA = clomipramine

first line pharm for panic disorder

SSRI paxil (paroxetine) Fluoxetine (prozac) Sertraline (zoloft) are FDA approved for panic SSRI > Benzo BUT alprazolam (xanax) & clonazepam (klonopin) also FDA approved

11. Drug class currently recommended as first-line medications in the treatment of childhood anxiety and child/adolescent major depressive disorder is

SSRIs

Serotonin (5-HT2A) -- drugs affecting

SSRIs, SNRIs, Atypicals, TCAs , MAOIs

Norepinephrine -- drugs affecting this transmitter

SSRIs, Tricyclic Anti-depressants, MAOIs

Gamma-amino Butyric Acid(GABA) -- too little

Seizures

buspar -- onset of action

Slow (1 - 2 weeks)

In children, montherapy or adjuncts is better

Stahl says monotherapy is better in this population

Anxiety treatment options

Start SSRI, then SNRI; TCA and Benzo Then augment with SRPA Buspirone Benzo (GABA agonist) long-acting = less abuse librium (chlordiazepoxide), valium (diazepam) ativan (lorazepam)

Atomexetine

Strattera ADHD

4 tracks basal ganglia lead to psych/ neuro disorders

Striatum The corpus striatum modulation of motor acts, and plays a role in OCD, Tourette's, Parkinson's, Huntington's, associative/cognitive processes. NML= goal directed motor system. gateway fails = OCD. • the pallidum input from corpus striatum, damaged in Wilson's & carbon monoxide poisoning = dystonic & flapping movements of extremities •the substantia nigra *degenerates in Parkinson's = rigidity/ tremor & is ass w-depression > 30% of cases • the subthalamic nucleus. *Subthalmic nucleus lesions - ballistic movements, sudden limb jerks like projectile movement

Description -- Anxiety

Sustained response influencing behavior after the stimulus is removed

Goal of antidepressant therapy:

Symptom remission and return to baseline functioning

14. MOA of: Amitriptyline [Elavil]-

TCA (Tricyclic Antidepressant) i. Boosts neurotransmitters serotonin and norepinephrine/noradrenaline ii. Blocks serotonin reuptake pump (serotonin transporter), presumably increasing serotonergic neurotransmission iii. Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably increasing noradrenergic neurotransmission; presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors iv. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, amitriptyline can increase dopamine neurotransmission in this part of the brain.

12. What antidepressants would NOT be the best choice for a patient with a history of suicidal ideation?

TCAs

Cannabinoids, Drugs that increase or mimic:

THC (marijuana, hashish), nabilone

Mirtazapine (Remeron) Noradrenergic and specific serotonergic antidepressant Contraindications

Taking MAOI, ETOH use, Caution with seizures & bipolar overweight/ obese hyperlipidemia

Addiction

The state of response to a drug whereby the drug taker feels compelled to use the drug and suffers anxiety when separated from it

Glutamate

This is an activating neurotransmitter associated with learning, thought, and emotion.

Escitalopram (Lexapro)

This medication desensitizes serotonin 1a receptors and acts as an antidepressant

Endorphins

This neurotransmitter provides relief from pain and promotes feelings of pleasure/well-being

1. T/F - Both genetic and environmental factors influence individual response to, and tolerability of, psychotropic agents.

True

2. T/F - FDA approved psychotropics are similar in overall effectiveness for their indicated disorder.

True

SNRIs (serotonin-norepinephrine reuptake inhibitors)

Venlafaxine/ Effexor Desvenlafaxine / Pristiq Duloxetine/ Cymbalta

20. Which antidepressant inhibits 5-HT reuptake and acts as a 5-HT1Areceptor partial agonist?

Vilazodone [Viibryd]

Lysdexamfetamine

Vyvanse

Mirtazapine (Remeron)

atypical antidepressant - Increase norepinephrine and serotonin

Lurasidone (Latuda)

atypical antipsychotic bipolar depression treatment

3. A physician informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day the patient says to the nurse, "My doctor said I have breathing problems, right?" Which nursing diagnosis is applicable? a. Denial related to acceptance of new diagnosis b. Chronic sorrow related to unresolved life conflicts c. Situational low self-esteem related to stress of new diagnosis d. Acute confusion related to metastatic changes to cerebral function

a. Denial related to acceptance of new diagnosis

51. Contraindications to the use of DRAs include what?

a. History of serious allergic response b. Possible ingestion of a substance that will interact with the antipsychotic to induce i. CNS depression 1. Alcohol 2. Opioids 3. Barbiturates 4. Benzodiazepines ii. Anticholinergic delirium 1. Scopolamine 2. Possibly phencyclidine [PCP] c. Presence of a severe cardiac abnormality d. A high risk for seizures e. Presence of narrow-angle glaucoma or prostatic hypertrophy if a drug with high anticholinergic activity is to be used f. Presence or a history of tardive dyskinesia.

4. A patient who had a stroke 3 days ago tearfully tells the nurse, "What's the use in living? I'm no good to anybody like this." Which action should the nurse employ first when caring for a patient demonstrating hopelessness? a. Implement the institutional protocol for suicide risk. b. Support the patient to clarify and express feelings of grief. c. Educate the patient about the success of stroke rehabilitation. d. Offer the patient an opportunity to confer with the pastoral counselor.

a. Implement the institutional protocol for suicide risk.

43. Presentation of Neuroleptic Malignant Syndrome (NMS) would include?

a. Motor and behavioral symptoms i. Muscular rigidity and dystonia ii. Akinesia iii. Mutism iv. Obtundation v. Agitation b. Autonomic symptoms i. Hyperthermia ii. Diaphoresis iii. Increased pulse and blood pressure c. Laboratory findings i. Increased white blood cell count ii. Increased levels of creatinine phosphokinase iii. Increased liver enzymes iv. Increased plasma myoglobin v. Increased myoglobinuria, occasionally associated with renal failure

1. Sixteen years ago a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parents' behavior? a. Mourning b. Bereavement c. Complicated grief d. Disenfranchised grief

a. Mourning

1. While entering the building, an elementary school nurse observes a person in the distance emerging from a forest and approaching the school. The person is dressed in black from head to toe, wearing a backpack and carrying a long, narrow, dark object. Which action should the nurse take first? a. Move to a secure location b. Observe the intruder's features c. Take note of the intruder's location d. Activate the school code for an intruder

a. Move to a secure location

3. The dopamine systems highly relevant to psychiatry include:

a. Nigrostriatal i. Degeneration leads to Parkinson's ii. Drugs that inhibit dopamine here cause EPS b. Mesocorticolimbic- i. Reward pathway (addiction) ii. Target of antipsychotic properties (dopamine receptor antagonist drugs) controlling positive symptoms (hallucinations, delusions) iii. May simultaneously worsen negative symptoms c. Tuberohypophyseal- i. drugs that work here may disinhibit prolactin release and lead to galactorrhea

25. The three major neurotransmitters associated with anxiety on the bases of animal studies and responses to drug treatment include

a. Norepinephrine b. Serotonin c. GABA

5. Three weeks after being assaulted by a patient, a nurse develops headaches, insomnia, and gastrointestinal problems. The nurse has four absences from work over a 2-week period. Which action should the nursing supervisor employ? a. Refer the nurse for counseling and support. b. Ask the nurse about current personal problems. c. Direct the nurse to take paid vacation for the following week. d. Schedule the nurse for administrative tasks rather than patient care.

a. Refer the nurse for counseling and support.

26. The two drugs FDA approved for panic disorder are

a. alprazolam (Xanax) b. paroxetine (Paxil)

Insomnia may be reduced through

a.m. dosing, good sleep hygiene, CBT, melatonin or adding trazodone, a serotonin reuptake inhibitor/antagonist

Ketamine

ability to produce rapid / robust effects in mood/ anxiety resistant to treatment short term 2-3 week course 2/3 x a week and taper scarcity of safety and long term

MOA of donepezil (Aricept)

acetylcholinesterase inhibitor used in mild-mod dementia

Galantamine MOA

acetylcholinesterase inhibitor also works on nicotinic receptors, increasing GABA, serotonin, dopamine and acetylcholine

Prazosin

alpha 1 antagonist use for PTSD nightmares

Benzodiazepines intermediate acting

alprazolam (Xanax)

TCA having the greatest anticholinergic side effects

amitriptyline

compulsion

an unreasonable need to behave in a certain way to prevent a feared outcome

48. Both men and women taking DRAs can experience both as side effects.

anorgasmia and decreased libido

TCAs can cause

anticholinergic symptoms -mental status changes -urinary retention -blurred vision.

After complete remission of symptoms,

antidepressant therapy should continue for at least four to nine months.

what are 7 general classes of psychotropic medications

antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, cognitive enhancers, and stimulants

Dantrolene

antidote for neuroleptic malignant syndrome

diphenhydramine

antidote for neuroleptic malignant syndrome

to little GABA

anxiety and anxiety disorder ETOH and seizure disorder

9. GABAergic deficit has been associated with

anxiety and anxiety disorders, schizophrenia, alcohol dependence, seizure disorders.

Buspirone (Buspar)

anxiolytic no habits, non-lethal, no taper, HAS interactions

3. A patient tells the nurse, "After many years, I finally quit smoking. Now I use e-cigarettes only." Which response should the nurse provide? a. "Using e-cigarettes is now more socially acceptable than using traditional cigarettes." b. "Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals." c. "Nicotine is a powerful addiction. Quitting smoking is a big step toward adopting a healthier lifestyle." d. "I am glad you have quit smoking. Your loved ones will no longer be exposed to the hazards of secondhand smoke."

b. "Congratulations on quitting, but e-cigarettes contain nicotine and other hazardous chemicals."

. A female nurse is appointed to a committee with seven men. At the beginning of the meeting, the chairman asks the nurse to be the secretary. The nurse responds, "No. You're just asking me to be secretary because I'm the only the woman here." Which response would have been more effective? a. "There are others more qualified than I am to be secretary." b. "I would be glad to perform another role for our committee." c. "I'm probably overreacting, but I find your request offensive." d. "Thank you for asking, but your request is sexually discriminatory."

b. "I would be glad to perform another role for our committee."

4. An 84-year-old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: a. "It is more important for you to have physical activity every day." b. "Let's think of some other activities we can add to your daily routine." c. "Repetition of the same activity is not helpful for keeping your brain healthy." d. "There are some herbal preparations that will also help keep your brain sharp."

b. "Let's think of some other activities we can add to your daily routine."

2. An emergency department nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services? a. "We do not believe in immunization of our children." b. "This child is always creating problems for the family." c. "Our child would rather play alone than with other children." d. "We homeschool our children in order to include religious education."

b. "This child is always creating problems for the family."

3. The nurse in a high school meets with small groups of students the day after a school bus accident resulted in the death of five students. Which comment should the nurse use to begin the session? a. "Sometimes life is not fair. Yesterday's tragedy is an example of just how unfair it can be." b. "We're grateful that you are safe. Our discussion is to talk about feelings associated with yesterday's tragedy." c. "We've had a terrible loss. I also feel your pain. You need to talk about your feelings associated with the event." d. "Thank you for coming today. As school leaders, we know it is very important to respond to yesterday's tragedy."

b. "We're grateful that you are safe. Our discussion is to talk about feelings associated with yesterday's tragedy."

1. An emergency department nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? a. Leathery facial tone b. Injuries in a bikini pattern c. Reluctance to be examined d. Lack of eye contact with the nurse

b. Injuries in a bikini pattern

3. A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? a. Another beating by the abusive partner b. Love, gifts, and praise from the abusive partner c. A brief period during which the partners ignore each other d. The abusive partner leaves the relationship for a short time

b. Love, gifts, and praise from the abusive partner

2. A patient diagnosed with major depressive disorder was hospitalized for 2 weeks on an acute psychiatric unit. One day after discharge, the patient completed suicide. Recognizing likely reactions among staff, which action should the nursing supervisor implement first? a. Assess each staff member individually for suicidal intent and/or plans. b. Provide a private setting for staff members to talk about feelings associated with the event. c. Remind staff members that suicide is a risk for the patient population and they are not at fault. d. Invite a guest speaker to conduct an educational session for staff members about suicide risk factors.

b. Provide a private setting for staff members to talk about feelings associated with the event.

5. A woman experienced a double mastectomy yesterday. Now she cheerfully says to the nurse, "I didn't need those things anyway. No more wet T-shirt contests for me!" How should the nurse interpret this comment? a. The patient is realistically accepting her loss. b. The comment is sarcastic, which may reflect anger. c. The patient is experiencing a distorted body image. d. The comment suggests guilt regarding prior behavior.

b. The comment is sarcastic, which may reflect anger.

5. A nurse who has worked for a community hospice organization for 8 years says, "My patients and their families experience overwhelming suffering. No matter how much I do, it's never enough." Which problem should the nursing supervisor suspect? a. The nurse is experiencing spiritual distress. b. The nurse is at risk for burnout and compassion fatigue. c. The nurse is not receiving adequate recognition from others. d. The nurse is at risk for overhelping, which creates dependency.

b. The nurse is at risk for burnout and compassion fatigue.

dopamine receptor antagonist side effects

breast enlargement and galactorrhea

If the pt is having sexual side effects but you do not want to change the antidepressant, what can you add on?

bupropion (welbutrin) buspirone (buspar) phosphodiesterase inhibitor (eg: viagra)

how do BZD reduce muscle tone?

by a central action on GABAa receptors primarily in the spinal cord

4. An emergency department nurse prepares to discharge a victim of reported rape. Which comment by the victim indicates that the nurse's teaching was effective? a. "I should bathe frequently over the next week." b. "I am required to follow up with law enforcement." c. "It's important for me to follow up with counseling." d. "I should delay any sexual activity for at least 3 months."

c. "It's important for me to follow up with counseling."

2. In a hostile voice, a patient experiencing mania yells at the nurse: "You WILL listen to me and not interrupt. I have some really important stuff to say. I'm tired of you nurses and doctors acting like you have all the answers." To facilitate effective communication, which initial response should the nurse provide? a. "You are our patient, so we always listen to you." b. "I can talk with you better if you use a calm voice." c. "It's our job to help you get through this manic episode." d. "Patients have an important role in treatment planning."

c. "It's our job to help you get through this manic episode."

2. An adult has had long-term serious medical problems resulting in decreased libido and sexual performance. The adult's spouse privately says to the nurse, "I don't feel loved anymore. I feel sexual urges but my partner is not interested." Select the nurse's therapeutic response. a. "Tell me about how your partner shows love for you." b. "You're describing a scenario that many couples face." c. "Let's consider some other ways you can satisfy your needs." d. "I'm glad you are able to talk about and accept your situation."

c. "Let's consider some other ways you can satisfy your needs."

5. A family member asks the nurse, "I know my uncle's Alzheimer's disease has progressed but is there any medication that can help him now?" Which response by the nurse is correct? a. "I'm sorry, but there are no medications that help with severe Alzheimer's disease." b. "Alzheimer's disease sometimes stabilizes. Let's hope that happens in this situation." c. "There are a few medications that may help. Let's discuss it with the health care provider." d. "It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings?"

c. "There are a few medications that may help. Let's discuss it with the health care provider."

5. A nurse teaches a patient diagnosed with an alcohol addiction about a new prescription for naltrexone (ReVia, Vivitrol). Which comment by the patient indicates the teaching was effective? a. "This medicine will stop my cravings for alcohol." b. "I should take this medication only when I feel cravings to drink alcohol." c. "This medicine is one part of a bigger treatment plan to help me stay sober." d. "I should not use products that contain alcohol, such as cough medicine and aftershave lotion."

c. "This medicine is one part of a bigger treatment plan to help me stay sober."

4. An 8-year-old tells a parent, "I like to scare kids at school by showing them pictures of clowns. Some kids are terrified." How should the nurse counsel the parents regarding this behavior? a. Recommend family therapy for the child, siblings, and parents. b. Suggest the parents enroll the child in an anger management program. c. Educate both parents about bullying, including possible origins and long-term effects. d. Teach the parents about the developmental phase and tasks for an 8-year-old child.

c. Educate both parents about bullying, including possible origins and long-term effects.

1. Select the completion of this sentence that demonstrates an adult is coping in a healthy way: "I am feeling so angry right now... a. I'm afraid I'm going to cry." b. I would like to punch something." c. I want to talk to someone about it." d. I want to curl up and sleep for a long time."

c. I want to talk to someone about it."

4. A young adult tells the nurse, "I have a new prescription for medical marijuana. I use it several times a day for my frequent muscle spasms." What information should the nurse provide first to this patient? a. Guidance that the prescription should not be shared with peers b. Directions to weigh self once a week and maintain a log of the results c. Instructions about safety issues associated with driving or operating machinery d. Information about the potential for amotivational syndrome and memory problems

c. Instructions about safety issues associated with driving or operating machinery

2. The nurse at a local medical clinic reviews phoned-in requests from patients for prescription refills. As the nurse confers with the health care provider about which prescription refill requests should be authorized, which refill request should be considered first? a. Codeine 10 mg PO q4h PRN for an adult with a persistent cough b. Hydroxyzine (Vistaril) 25 mg PO TID PRN for an adult who experiences uncomfortable muscle spasms c. Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety d. Paregoric (camphorated tincture of opium) 2 mg PO q6h PRN for an adult experiencing severe diarrhea

c. Lorazepam (Ativan) 1 mg PO BID for an adult who has taken it daily for 3 years for episodes of anxiety

1. An elderly widow tells the nurse, "Since my sister-in-law's death, her husband has been making advances at me. He tried to come in my home with a bottle of wine. Even though he's family, I'm afraid of what might happen if I let him in." Which action should the nurse take first? a. Support the widow to clarify her thoughts and feelings about the situation. b. Explain to the widow how to obtain an order of protection (restraining order). c. Positively reinforce the widow for addressing the problem with a caring professional. d. Educate the widow about sexual assault and violence, including the importance of prevention.

c. Positively reinforce the widow for addressing the problem with a caring professional.

. While interacting with a 62-year-old adult diagnosed with a progressive neurocognitive disorder, the nurse observes that the adult has slow responses and difficulty finding the right words. What is the nurse's best initial action? a. Suggest words that the adult may be trying to remember. b. Ask the adult, "Are you having problems saying what you mean?" c. Use silence to allow the adult an opportunity to compose responses. d. Discontinue the interaction to prevent further frustration for the adult.

c. Use silence to allow the adult an opportunity to compose responses.

GABA most abundant inhibitory neurotransmitter

causes calmness, sleepiness, reduced inhibition and decreased pain sensation

Rivastignmine, Exelon

cholinesterase inhibitor available in patch form; increased GI side effects

1. A young adult has heavily abused alcohol and prescription drugs since mid-adolescence. This individual now has an ataxic gait and uses a cane. Which comment by the nurse presents reality while demonstrating compassion? a. "I know you must feel self-conscious about using a cane at your age, but it will help prevent falls." b. "Addiction is a fatal disease. If you continue to drink like you have done in past, you will not live another 10 years." c. "It's time to face your addiction. You are disappointing your family and must stop drinking for the sake of the people who love you." d. "Addiction is powerful. You are young yet cannot walk without a cane. If you don't make changes, your health will continue to suffer."

d. "Addiction is powerful. You are young yet cannot walk without a cane. If you don't make changes, your health will continue to suffer."

4. The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance? a. "Sometimes I get so discouraged and frustrated with my job." b. "It's incredible that anyone could hurt a child or elderly person." c. "The abuser was probably a victim of abuse at some point in life." d. "I hope the abuser gets victimized so they know what it feels like."

d. "I hope the abuser gets victimized so they know what it feels like."

5. A victim of reported sexual assault tells the nurse, "This was entirely my fault. I should never have gone to that party alone." Which response by the nurse is most therapeutic? a. "This was a frightening experience for you." b. "What do you think you should have done differently?" c. "Would you like to tell me more about what happened?" d. "It sounds like you're blaming yourself for the assailant's behavior."

d. "It sounds like you're blaming yourself for the assailant's behavior."

4. A nurse leads a bereavement group. Which participant's comment best demonstrates that the work of grief has been successfully completed? a. "Our time together was too short. I only wish we had done more things together." b. "I know our life together was a blessing that I did not deserve. I wish I had said 'I love you' more often." c. "Other people knew my loved one as a good and helpful person. I hope people see me in the same way." d. "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

d. "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

4. A patient on an acute psychiatric unit removed the cap from the ceiling sprinkler, resulting in rapid flooding of the unit. After moving patients to a safe area, which action should the nurse take next? a. Conduct individual sessions with patients regarding the experience. b. Increase the volume of overhead music to distract patients from the event. c. Implement a psychomotor activity to reduce anxiety associated with the event. d. Lead a group session with patients to discuss feelings associated with the event.

d. Lead a group session with patients to discuss feelings associated with the event.

5. A single adult says to the nurse, "Both of my parents died several years ago and my only sibling committed suicide 2 weeks ago. I feel so alone." After determining that the adult has no suicidal ideation, the nurse should: a. Explore the adult's feelings of survivor's guilt. b. Assess the adult's cultural beliefs and spirituality. c. Refer the adult for cognitive behavioral therapy (CBT). d. Refer the adult to a self-help group for suicide survivors.

d. Refer the adult to a self-help group for suicide survivors.

2. An adult diagnosed with stage 2 Alzheimer's disease begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the highest priority to add to the plan of care? a. Risk for constipation b. Risk for altered sensory perception c. Risk for impaired oral mucous membranes d. Risk for imbalanced nutrition, less than body requirements

d. Risk for imbalanced nutrition, less than body requirements

2. A recently widowed adult says, "I've been calling my neighbors often but they act like they don't want to talk to me. I just need to talk about it, you know?" What is the nurse's best action? a. Say to the person, "You may call me anytime you need to talk." b. Ask the person, "What do you mean by 'I just need to talk about it'?" c. Educate the person about the importance of finding alternative activities. d. Tell the person the location and time of a local bereavement support group.

d. Tell the person the location and time of a local bereavement support group.

Depression neurotransmitters

decreased dopamine, serotonin and norepinephrine increased acetylcholine

To little dopamine causes

depression and parkinson

SNRI indications

depression, anxiety, panic disorder may be helpful if fail SSRI Can help with melancholy depression helpful chronic pain some off label use ADHD

MAOIs: Indications

depression, bulimia nervosa, panic disorder, anxiety disorders, OCD, PTSD (if all others failed and pt is appropriate)

Bupriopion (Wellbutrin) - positive indications

depression, smoking cessation, SAD, ADHD, cocaine detox, hypoactive sexual desire disorder

Sildenafil (Viagra)

does reduce SSRI-induced sexual dysfunction in men

Duloxetine (Cymbalta) SNRI what is different about this for indications ?

efficacy for painful manifestations of depressions, approved in many countries for urinary incontinence

FDA-approved treatment of depression in adolescents

escitalopram and fluoxetine

Good clinical guidelines for prescribing SSRI

most common mistake to low for to short of time raise to max dose for 4-5 weeks b4 unsuccessful if improve don't raise unless benefit stops 0 resp within 2-3 weeks can check plasma / compliance

CYP450 Drug Interactions SSRIs with most significant enzyme inhibitors are

fluoxetine (Prozac), fluvoxamine (Luvox) and paroxetine (Paxil)

First-line treatment for depression in children and adolescents

fluoxetine, sertraline, escitalopram

4. The main excitatory neurotransmitter of the central nervous system is

glutamic acid [glutamate] a. It is required for learning and memory; Low levels can lead to fatigue and poor brain activity; neurodegenerative diseases such as Alzheimer's disease, Parkinson's, Huntington's, and Tourette's. b. Increased levels of glutamate can cause death to the neurons (nerve cells) in the brain, Depression, OCD, and Autism.

46. This drug has been linked to abnormal heart rhythm, ventricular arrhythmias, torsades de pointes, and sudden death when injected IV?

haloperidol (Haldol)

Nefazodone (serzone) (usually for sleep) Trazadone (Desyrel) Contraindications

hepatic impairment, MAOI, carbamazepine can decrease effects, lower seizure threshold with other antidepressants, can interfere w potency of htn drugs, interfere with warfarin

absorption

how the drug gets from the site of administration to the blood

SSRI absolute contraindications

hypersensitivity to SSRI bipolar 1 not used without mood stabilizer received MAOI in past 2 weeks hepatic/ renal insufficiency

Serotonin syndrome symptoms

hypertension, tachycardia; myoclonic jerking, tremors; nausea, diarrhea, sweating, hyperthermia; agitation, confusion lability of mood disorientation ataxia

monoamine oxidase inhibitors (MAOIs) adverse effects

hypertensive crisis, orthostatic hypertension, serotonin syndrome

Neuroleptic Malignant Syndrome

hyperthermia, rigidity, mutism, akinesia, confusion, agitation, increased hr&bp may occur any time during DRA treatment

benzos -- Short acting are better

hypnotics with reduced hang-over effect upon wakening

Initial improvement

in 1 to 2 weeks; maximum improvement ranges four to 12 weeks

akathisia

inner restlessness

Primary use of melatonin

insomnia -reduces time to sleep onset -increases total sleep time -may improve quality

Buspirone (Buspar) (anxiolytic) therapeutic indications

insomnia, anxiety, depression, lack sexual dysfunction issues, no dependence issues, good augmenting for anxiety, lacks interaction with etoh

33. Valproate is commonly prescribed as part of a regimen involving other psychotropic agents. If given concurrent with Valproate, Valproate more than doubles concentrations, increasing the risk of a serious rash (Stevens-Johnson syndrome, and toxic epidermal necrolysis)?

lamotrigine (Lamicatal)

Chlorprothixene

low potency antipsychotic orthostatic hypotension

thioridazine

low potency typical antipsychotic orthostatic hypotension

Chlorpromazine (Thorazine)

low potency typical antipsychotic orthostatic hypotension photosensitivity

7. In patients who are ultra-rapid or extensive metabolizers, the concentrations of a drug may be

lower than expected.

Tadalafil (Cialis)

may reduce SSRI-induced sexual dysfunction in men

13. Antidepressants with dual action on both serotonergic and noradrenergic receptors demonstrate greater efficacy in

melancholic depressions / the treatment of major depression.

Target symptoms of Ach-etase inhibitor drugs

memory, behavior, degenerative course

Phosphodiesterase Inhibitors

milrinone (Primacor)

Lamotrigine (Lamictal)

mood stabilizer go low and slow risk of Stevens Johnson

Valproate (Depakote)

mood stabilizer problematic for women of child bearing age. DOUBLES lamotrigine

lithium

mood stabilizer use for suicidal ideation decreases thyroid hormones

how long must s/s of depression be present

more than 2 weeks

remission

removal of almost all s/s for up to 6 months

Compulsions are

repetitive, purposeful behaviors performed in response to an obsession or according to certain rules

recurrence

return of depression s/s after recovery

relapse

return of s/s before full remission or in first several months following remission

to much dopamine

schizophrenia

Barbiturates (short-acting)

secobarbital

education with Buspirone (buspar)

sedation, takes longer to work than benzos, up to 4 weeks bid/tid dosing

Bupropion (Wellbutrin) Contraindications

seizures, HTN, bulimia, insomnia / agitation

donepezil

selective inhibitor of acetylcholinesterace

FDA-Approved for OCD in children

sertraline (6 and older); fluoxetine (7 and older) approved by the FDA for what condition?

Switching pearls

sertraline, escitalopram, venlafaxine, mirtazapine, vortioxetine or bupropion good second agent transient serotonergic may occur early but not usually safety issue Discontinuation most common from serotonergic to non serotonergic (venlafaxine or paroxetine)

Initial therapy with antidepressants

severe: combo of meds and therapy mild-mod: options: meds alone therapy alone combo

Buspar Requires BID - TID dosing due to

short 1/2

Advantages of Buspirone for treatment of Anxiety

similar to benzo in its effect no physical dependence, withdrawal/ abuse less sedation / psychomotor impairment lack of interaction with etoh

28. The standard approach to start (first line) treatment for OCD is (remember this is pharmacology)

start treatment with a SSRI or clomipramine and then move to other pharmacological strategies if the serotonin-specific drugs are not effective.

Education on Benzo

strong propensity for abuse (best for) 1-2 weeks while SSRI kicking in long term / high dose = depression /dementia increased GABA = decreased reactivity of brain benzo prevent pt working through root cause abrupt withdrawal can cause s/s seizures and can potentiate effects of etoh

General principles of psychopharm

study of how drugs interact with specific target sites in the Nervous System to induce changes in mood, thinking or behavior

Prazosin (Minipress) How helpful with PTSD

suppress nightmares, particularly associated with ptsd excessive adrenaline can cause nightmares , blocks the noradrenergic stimulation of the alpha 1 receptor

stepped care model childhood depression

takes into account individual circumstances in treatment of depression

8. Pharmacokinetics best describes what

the body does to the drug.

5. A relative measure of the toxicity or safety of a drug and is defined as the ratio of the median toxic dose to the median effective dose is referred to as

therapeutic index.

Norepinepherine (NE) fight or flight

to much w no actual danger = anxiety / hyperactive to little = depression

most common clinical mistake leading to an unsuccessful trial of an antidepressant drug is:

too low a dosage for too short a time

BZD Withdrawal symptoms

typically mimic those of anxiety disorders

SNRI Contraindications/Precautions

uncontrolled angle closure glaucoma caution cardiac disease bipolar (must have mood stabilizer also) seizure disorder HTN (effexor) agitation / insomnia

5-HT (Serotonin), Effects:

↑Happiness ↑Fullness ↓Pain

5-HT Serotonin

↑Happiness ↑Fullness ↓Pain

NE (Norepinephrine) Effects:

↑Heart rate ↑Alertness ↑Happiness ↓Blood circulation ↓Pain

DA (Dopamine), Effects:

↑Alertness ↑Happiness ↓Hunger

DA Dopamine

↑Alertness ↑Happiness ↓Hunger