Woo & Robinson Chapter 12

An APN evaluates a 75-year-old female patient for major depression. She has been on phenelzine (Nardil) for many years. The patient has a history of type 2 diabetes mellitus, and the APN decides to switch the medication due to new mildly impaired renal studies. Which medication of choice and approach are most appropriate for this patient? 1. A washout period of 14 days and switch to escitalopram (Lexapro) 2. A washout period of 2 to 4 days and switch to fluoxetine (Prozac) 3. A washout period of 14 days and switch to desipramine (Norpramin) 4. No washout period is necessary. Switch to citalopram (Celexa).

1. A washout period of 14 days and switch to escitalopram (Lexapro) Option 1: Escitalopram (Lexapro) is a good choice because it truly is a selective serotonin reuptake inhibitor (SSRI). It can be prescribed in the presence of mild renal impairment, but severe impairment would need further analysis. The washout period of 14 days is adequate. . Rationales Option 2: Fluoxetine (Prozac), is not as selective as another selective serotonin reuptake inhibitor (SSRI) and can have adverse effects related to its action on dopamine. The 2- to 4-day washout period is not adequate and puts the patient at risk for serotonin syndrome. Option 3: Although the 14-day washout period might be adequate, a tricyclic antidepressant (TCA) is not recommended over a selective serotonin reuptake inhibitor (SSRI) for older people due to their anticholinergic and many adverse effects. Option 4: Although citalopram (Celexa) is a good choice because it truly is a selective serotonin reuptake inhibitor (SSRI), lack of a washout period will put the patient at risk for serotonin syndrome.

Seizures for a 25-year-old female patient with epilepsy have been managed best with oral phenytoin (Dilantin). The patient has just discovered she is pregnant. Which measure can reduce teratogenesis to the fetus? 1. Administration of daily oral folic acid 2. Administration of vitamin K-dependent clotting factors 3. Administration of the intravenous route of phenytoin (Dilantin) instead of the oral route 4. Maintenance of a therapeutic plasma drug level of 18 mcg/mL

1. Administration of daily oral folic acid Option 1: The administration of phenytoin (Dilantin) during pregnancy may be necessary to avoid seizures. Administering folic acid supports DNA synthesis and can reduce malformations. Rationales Option 2: Administration of vitamin K-dependent clotting factors to the newborn at birth is recommended when a mother takes phenytoin (Dilantin) to control seizures during pregnancy, but this will not reduce the incidence of teratogenesis that has already occurred. Option 3: Intravenous and oral phenytoin (Dilantin) both have teratogenic risks. Option 4: The therapeutic plasma drug level of phenytoin (Dilantin) is 10 to 20 mcg/mL. The risk of teratogenesis remains with a therapeutic level but it can be reduced.

Which postmarketing adverse effect of levetiracetam is reversible when the drug is stopped? 1. Alopecia 2. Erectile dysfunction 3. Visual disturbances 4. Tinnitus

1. Alopecia Option 1: Alopecia has been reported as an adverse effect and is reversible when the drug is stopped. Rationales Option 2: Erectile dysfunction is not a noted postmarketing adverse effect of levetiracetam. Option 3: Visual disturbances are not a noted postmarketing adverse effect of levetiracetam. Option 4: Tinnitus is not a noted postmarketing adverse effect of levetiracetam.

A 53-year-old patient was prescribed a monoamine oxidase inhibitor (MAOI), isocarboxazid (Marplan), while in an acute psychiatric unit for drug-resistant, refractory depression. The APN would include teaching about which food interactions? 1. Avoid cured meats. 2. Avoid peanut products. 3. Avoid grapefruit juice. 4. Avoid fresh, dark green, leafy vegetables.

1. Avoid cured meats. Option 1: Concurrent MAOIs and ingestion of foods rich in tyramine may cause sudden and extreme hypertension. These foods include aged cheeses, cured meats, fava beans, soy sauce, alcohol, dried fish, sour cream, caffeine, and fermented vegetables, such as sauerkraut. Rationales Option 2: Peanut products do not need to be avoided with use of MAOIs. Option 3: Grapefruit juice does not need to be avoided with use of MAOIs. Option 4: Fresh, dark green, leafy vegetables do not need to be avoided with use of MAOIs.

The APN is considering an antiepileptic drug for a patient suffering from partial seizures. Prescribing zonisamide will be avoided if the patient has a known anaphylactic reaction to which drug? 1. Bactrim 2. Ciprofloxacin 3. Amoxicillin 4. Vancomycin

1. Bactrim Option 1: Bactrim and zonisamide are both sulfa drugs and chemically related. Sulfonamides should not be given to patients with a history of hypersensitivity. Rationales Option 2: Anaphylactic reaction to ciprofloxacin would not be a contraindication for prescription of zonisamide. Option 3: Anaphylactic reaction to amoxicillin would not be a contraindication for prescription of zonisamide. Option 4: Anaphylactic reaction to vancomycin would not be a contraindication for prescription of zonisamide.

Atypical antipsychotics can be preferred over typical antipsychotics due to their improved adverse effect profile. Which of these describes this profile? 1. Better patient tolerability, less cognitive impairment, and less extrapyramidal symptoms 2. Improved selectivity and blood pressure regulation and less crossing of placenta barrier 3. Better glycemic control, lipid profiles, and reduced cardiovascular risks 4. Less immunosuppression, somnolence, and weight gain

1. Better patient tolerability, less cognitive impairment, and less extrapyramidal symptoms Option 1: The typical antipsychotics may be better in treating severe psychosis, but the atypical antipsychotics generally have better patient tolerability, less cognitive impairment, and less extrapyramidal symptoms. Rationales Option 2: Improved selectivity and blood pressure regulation and less crossing of placenta barrier are not included in the adverse effect profile of atypical antipsychotics. Option 3: Better glycemic control, lipid profiles, and reduced cardiovascular risks are not included in the adverse effect profile of atypical antipsychotics. Option 4: Less immunosuppression, somnolence, and weight gain are not included in the adverse effect profile of atypical antipsychotics.

A 22-year-old female patient with bipolar disorder is treated with valproate (Depakote). She has a positive human chorionic gonadotropin (hCG) test. Which action taken by the APN is most appropriate? 1. Change the valproate to a nonclassified mood stabilizer and avoid the first trimester. 2. Continue the therapy as previously ordered. 3. Lower the dose of valproate until the plasma level is less than 50 mcg/mL. 4. Taper the valproate and switch to lithium.

1. Change the valproate to a nonclassified mood stabilizer and avoid the first trimester. Option 1: Based on the pregnancy registry, there is no evidence of harm to the fetus with the use of nonclassified mood stabilizers. Rationales Option 2: Valproate is associated with neural tube defects including spina bifida. It is Pregnancy Category D and should be restricted unless absolutely necessary and beyond the first trimester. Option 3: Less than 50 mcg/mL is subtherapeutic, which remains teratogenic and adds to the patient's risk of experiencing adverse effects without the therapeutic benefit of the drug. Option 4: Lithium has teratogenic risks of Epstein's cardiac problems and tricuspid valve prolapse during the first trimester. During the third trimester, it has significant risk for lithium toxicity, hypertonicity, congenital hypothyroidism, and congenital goiter.

The nurse practitioner is evaluating a patient who is prescribed lithium for bipolar disorder. Which laboratory result suggests that a lower dose or change of medication should be considered? 1. Creatinine 2.7 mg/dL 2. Potassium 4.2 mEq/L 3. Sodium 133 mEq/L 4. Lithium level of 0.9 mEq/L

1. Creatinine 2.7 mg/dL Option 1: A high creatinine level is suggestive of renal impairment. Lithium can cause renal failure with long-term use or toxic levels. Rationales Option 2: This potassium level is normal. Option 3: The slightly low sodium level has more potential for a toxic lithium level, but this laboratory result is not of greatest concern. Option 4: The therapeutic level for lithium is 0.6 to 1.5 mEq/L.

A patient is dependent on lorazepam (Ativan), which has been prescribed for a year. Which strategy should be employed to reduce the risk of severe withdrawal symptoms? 1. Decrease the dose by 0.5 mg per week, then by 0.25 mg for the last few weeks. 2. Switch the patient to an equivalent dose of clonazepam, then titrate the dose. 3. Concurrent use of an antihistamine agent for 3 days and then discontinue. 4. Coadminister a barbiturate for 3 days then discontinue.

1. Decrease the dose by 0.5 mg per week, then by 0.25 mg for the last few weeks. Option 1: This approach is correct. The tapering can take weeks to months to accomplish. . Rationales Option 2: An alternative dosing to avoid withdrawal can include switching to a shorter-acting benzodiazepine, not a long-acting agent. Option 3: Concurrent use of an antihistamine has risks for central nervous system (CNS) depression and is not advised. Option 4: Concurrent use of a barbiturate has risks for central nervous system (CNS) depression and is not advised.

A patient with bipolar disorder is prescribed lithium. Which medical complication could increase the lithium level and cause toxicity for the patient? 1. Gastroenteritis 2. Diabetic ulcer 3. Water intoxication 4. Asthma

1. Gastroenteritis Option 1: Vomiting due to gastroenteritis can cause dehydration, which has a risk for lithium toxicity. Rationales Option 2: Diabetic ketoacidosis would raise the risk for lithium toxicity, but an ulcer does not imply that the fluids or sodium are depleted. Option 3: Water intoxication can cause the lithium level to be subtherapeutic. Dehydration and low sodium can cause the lithium level to be toxic. Option 4: Asthma alone does not contribute to lithium toxicity.

Which medication would both reduce the pain relief of a pure opioid and initiate an abstinence syndrome if given to a narcotic-addicted patient? 1. Pentazocine (Talwin) 2. Propoxyphene (Darvon) 3. Methadone (Dolophine) 4. Methamphetamine (Desoxyn)

1. Pentazocine (Talwin) Option 1: A mixed agonist-antagonist will block the mu receptor, prompting an abstinence syndrome. Its antagonism will also reduce the pain relief of a pure opioid. Rationales Option 2: Propoxyphene is an agonist, and so it is not noted to have the described effect. Option 3: Methadone is an agonist, and so it is not noted to have the described effect. Option 4: Methamphetamine is a stimulant, which will not prompt an abstinence syndrome.

An antiepileptic drug can be useful when combined to form an anorexiant. Which mechanisms promote these beneficial effects? 1. Potentiates gamma-aminobutyric acid (GABA) and promotes weight loss in up to 16% of patients 2. Antagonizes glutamate and causes excitation, which speeds the metabolism for weight loss 3. Modulates sodium channels, which keeps the channel inactive longer and requires more energy expenditure and weight loss 4. Slows the influx of sodium in neurons and slows the spread of abnormal seizure activity, which promotes gastrointestinal motility and weight loss

1. Potentiates gamma-aminobutyric acid (GABA) and promotes weight loss in up to 16% of patients Option 1: Topiramate, which is included with phentermine, branded as Qsymia, can have a central nervous system (CNS) adverse effect of anorexia. Rationales Option 2: Perampanel inhibits glutamate, but it reduces the neuronal activity. Option 3: This is the mechanism for rufinamide. The drug may cause nausea, vomiting, and a decreased appetite, but it is not an approved anorexiant. Option 4: This is the mechanism for carbamazepine. The drug may cause nausea and vomiting but it is not an approved anorexiant.

The APN administers an IV dose of morphine for a fractured ankle. Fifteen minutes after the administration, the APN notes the patient's respirations have decreased from 28 breaths/minute to 20/minute. Which action is the priority? 1. Reassess the patient's current pain. 2. Provide a smaller dose for the next administration. 3. Change the medication due to this adverse reaction. 4. Assess for adverse effect of constipation.

1. Reassess the patient's current pain. Option 1: After an IV dose of morphine, it is important to assess the patient's respiratory rate (RR) and pain level. An RR of 20 is normal and improved. Rationales Option 2: A respiratory rate (RR) of 20 is normal and improved. This dose appears to be adequate. Option 3: A respiratory rate (RR) of 20 is normal and improved. This medication appears to be appropriate. Option 4: Although this is an adverse effect to be monitored for, it is not the greatest priority.

A 24-year-old patient with a history of Lennox-Gastaut syndrome and has a shortened QT interval should avoid which antiseizure medication? 1. Rufinamide 2. Phenytoin 3. Valproic acid 4. Topiramate

1. Rufinamide Option 1: Rufinamide modulates sodium channels and is contraindicated in patients with familial short QT syndrome. Rationales Option 2: With IV use, phenytoin can cause adverse effects of bradycardia or atrioventricular block, but it does not cause a short QT interval. Option 3: Valproic acid is not contraindicated in patients with Lennox-Gastaut syndrome or shortened QT interval. Option 4: Topiramate is not contraindicated in patients with Lennox-Gastaut syndrome or shortened QT interval.

Topiramate (Topamax) is being prescribed to a school-aged child for partial seizures. As the summer approaches and temperatures rise, the nurse practitioner needs to include which teaching? 1. Stay hydrated and avoid extreme high temperatures due to risk of decreased sweating and high fever. 2. Take a probiotic with topiramate to reduce the adverse effects. 3. Take an aspirin with topiramate to reduce the adverse effect profile. 4. Avoid the sun and wear sunblock due to increased photosensitivity.

1. Stay hydrated and avoid extreme high temperatures due to risk of decreased sweating and high fever. Option 1: Topiramate can cause oligohidrosis and hyperthermia. Rationales Option 2: Taking a probiotic with antibiotics can reduce bowel infection, but this is not the case with topiramate. Option 3: Aspirin is not recommended in children. There is also no evidence that taking aspirin will reduce the adverse effect potential. Option 4: Topiramate does not increase photosensitivity. This is a potential effect of typical antipsychotics.

Which mechanism explains the development of extrapyramidal symptoms (EPSs) when using typical antipsychotics? 1. The excessive blocking of dopamine-2 2. The excessive agonism of dopamine-2 3. The effects of comorbid hyperthyroidism at start of treatment 4. The lowering of the prolactin level

1. The excessive blocking of dopamine-2 Option 1: Too much dopamine antagonism leads to parkinsonism and possibly extrapyramidal symptoms with high potency typical antipsychotics. Rationales Option 2: Too much dopamine antagonism (not agonism) leads to parkinsonism and possibly extrapyramidal symptoms with high potency typical antipsychotics. Option 3: Comorbid hyperthyroidism does not explain the development of EPSs when using typical antipsychotics. Option 4: The lowering of the prolactin level does not explain the development of EPSs when using typical antipsychotics.

A 32-year-old patient, who has been prescribed rufinamide for 1 year, has had an occasional seizure. To gain better control, carbamazepine was added to the regimen. The patient suddenly complains of more seizure activity. Which explanation is most plausible? 1. The patient has experienced a drug interaction causing rufinamide to be subtherapeutic. 2. The patient's seizure type is changing. 3. The patient has factitious disorder. 4. The patient has Munchausen syndrome.

1. The patient has experienced a drug interaction causing rufinamide to be subtherapeutic. Option 1: When rufinamide is coadministered with carbamazepine, there is a 19% to 26% decrease in rufinamide and 7% to 13% decrease in carbamazepine. Rationales Option 2: A changing seizure type is not the most plausible explanation for the increased seizure activity. Option 3: Factitious disorder is when a patient falsely claims that another person has symptoms of illness. This is not the most likely problem here. Option 4: Munchausen syndrome is a rare type of mental disorder in which a person fakes an illness. Nothing in this scenario suggests this.

Which risk is highest in tricyclic antidepressants (TCAs) compared with newer antidepressants? 1. The risk of fatal overdose for high-risk suicidal patients 2. The risk of serotonin syndrome if a patient takes another serotonergic at the same time 3. The risk of suicidal thoughts and behavior 4. The risk of postural hypotension and suppression of myocardial pain

1. The risk of fatal overdose for high-risk suicidal patients Option 1: TCAs have more risk for individuals suffering suicidal ideations because they are fatal in an overdose compared with new antidepressants. Rationales Option 2: This is a risk for the newer agents such as selective serotonin reuptake inhibitors as well. Option 3: All categories of antidepressants carry a U.S. Food and Drug Administration (FDA) Black Box Warning regarding increased risk of suicidal thoughts and behavior. It is not necessarily higher in TCAs than in newer antidepressants. Option 4: This is a risk associated with monoamine oxidase inhibitors (MAOIs), not TCAs.

Historically, barbiturates were used to treat seizure disorders, anxiety, and insomnia, but new agents have fewer adverse effects. Which risk associated with barbiturates represents the biggest concern for using them over other anxiolytics or sedative-hypnotics? 1. Their risk for tolerance and dependence 2. Their risk for intractable nausea and vomiting 3. Their risk for megacolon 4. Their risk for tardive dyskinesia

1. Their risk for tolerance and dependence Option 1: Because of their tolerance and dependence, short-acting barbiturates are Schedule II drugs. They are now limited in their use and are approved for preanesthesia sedation, short-term treatment of insomnia, and status epilepticus. Rationales Option 2: Barbiturates have a risk for nausea and vomiting, but this is not the greatest concern with their use. Option 3: Megacolon is not noted as a concern for use with barbiturates. Option 4: Tardive dyskinesia is not the greatest concern with the use of barbiturates.

Which phenobarbital result suggests that it is in the therapeutic range? 1. 50 mcg/mL 2. 20 mcg/mL 3. 5 mcg/mL 4. 60 mcg/mL

2. 20 mcg/mL Rationales The therapeutic range for phenobarbital is 12 to 40 mcg/mL.

Which statement describes the absorption and distribution of anorexiants? 1. Anorexiants carry a high risk of tolerance and dependence. 2. Anorexiants are lipid-soluble, widely distributed, and cross the blood-brain barrier. 3. Anorexiants are chemically changed by the liver and eliminated by the kidneys. 4. When anorexiants are combined with monoamine oxidase inhibitors, they have the potential to cause a hypertensive crisis.

2. Anorexiants are lipid-soluble, widely distributed, and cross the blood-brain barrier. Option 2: This statement is correct and supports pharmacokinetic principles. Rationales Option 1: Although this statement is correct, it describes a precaution/contraindication. It is not a pharmacokinetic description. Option 3: Although this statement is correct, it describes metabolism and excretion and not absorption and distribution. Option 4: Although this statement is correct, it describes a drug-drug interaction and not absorption and distribution.

Which classes of drugs can eliminate the extrapyramidal symptoms (EPSs) from typical antipsychotics? 1. Antibiotics, antihistamines, and beta agonists 2. Antiparkinson, antihistamine, and anticholinergic drugs 3. Beta-adrenergic antagonists, antiparkinson drugs, and muscarinic agonists 4. Anticholinergic, anti-inflammatory, and antiparkinson drugs

2. Antiparkinson, antihistamine, and anticholinergic drugs Option 2: EPSs from typical antipsychotics can be relieved by antiparkinson, antihistamine, and anticholinergic drugs. Rationales Option 1: Antibiotics and beta agonists cannot eliminate EPSs from typical antipsychotics. Option 3: Beta-adrenergic antagonists and muscarinic agonists cannot eliminate EPSs from typical antipsychotics. Option 4: Anti-inflammatory drugs cannot eliminate EPSs from typical antipsychotics

Which medications are first-line agents to treat Parkinson's disease in its mild to moderate stages? 1. Levodopa, entacapone, or selegiline 2. Bromocriptine, pergolide, pramipexole, or ropinirole 3. Entacapone, pergolide, pramipexole, or ropinirole 4. Selegiline, amantadine, or bromocriptine

2. Bromocriptine, pergolide, pramipexole, or ropinirole Option 2: Bromocriptine, pergolide, pramipexole, or ropinirole are first-line agents in treating mild to moderate Parkinson's disease. Rationales Option 1: Levodopa is an agent that is reserved as symptoms worsen because it is the cornerstone of Parkinson's disease management, yet it has a "wearing off" effect. It is not a first-line agent for these reasons. Option 3: Entacapone is an agent that is given with levodopa and carbidopa to reduce the "wearing off" effect. Levodopa is reserved as symptoms worsen because it is the cornerstone of Parkinson's disease management, yet it has a "wearing off" effect. Therefore, entacapone would not be used early in treatment. Option 4: Selegiline and amantadine are used to improve the levodopa response, which is usually not introduced in the early phases of Parkinson's disease.

All antidepressants hold a Black Box Warning risk of suicidal thoughts and behaviors. Under which circumstances does this risk increase most? 1. When the treatment regimen continues beyond 2 years and the depression is in remission 2. During the first 2 months of treatment and less than 24 years of age 3. When the drug is subtherapeutic 4. During drug holidays, when the drug is temporarily withdrawn

2. During the first 2 months of treatment and less than 24 years of age Option 2: Suicidal thoughts and behaviors are most likely to occur in children, adolescents, and young adults to age 24, and they are most likely to occur in the first 2 months of treatment. Rationales Option 1: Suicidal thoughts and behaviors are not most likely to occur when the treatment regimen continues beyond 2 years and the depression is in remission. Option 3: Suicidal thoughts and behaviors may be more likely to occur when the drug is subtherapeutic. However, this is not when they are most likely to occur. Option 4: Suicidal thoughts and behaviors are not most likely to occur during drug holidays.

An 8-year-old has been diagnosed with major depression. Which medication is preferred for this patient? 1. Paroxetine 2. Fluoxetine 3. Isocarboxazid 4. Vortioxetine

2. Fluoxetine Option 2: Fluoxetine is an approved serotonin reuptake inhibitor for children in treating major depression. Rationales Option 1: Paroxetine is not approved for children with major depression. Option 3: This monoamine oxidase inhibitor (MAOI) is not approved for children. It has more adverse effects in children and older people. Option 4: Data is not yet available on the safety or effectiveness of vortioxetine in children.

Which neurotransmitter is involved in the mechanism of action for the antiepileptic perampanel? 1. Serotonin 2. Glutamate 3. Gamma-aminobutyric acid (GABA) 4. Dopamine

2. Glutamate Option 2: Like lamotrigine, perampanel inhibits the release of glutamate and inhibits neuronal excitation. Rationales Option 1: Serotonin is primarily involved in improving depression. Option 3: Benzodiazepines, gabapentin, topiramate, and tiagabine potentiate GABA. Option 4: Dopamine helps regulate movement. Parkinson's disease is a degenerative disease with loss of dopaminergic neurons.

A 70-year-old patient is visiting the office for medication reconciliation. The APN recognizes that a drug combination prescribed is contraindicated. Which combination would cause this concern? 1. Imipramine (Tofranil) and lorazepam (Ativan) 2. Imipramine (Tofranil) and isocarboxazid (Marplan) 3. Amitriptyline (Elavil) and levetiracetam (Keppra) 4. Doxepin (Sinequan) and gabapentin (Neurontin)

2. Imipramine (Tofranil) and isocarboxazid (Marplan) Option 2: This combination has increased risk of serotonin syndrome and hypertension. tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are a contraindicated combination. Rationales Option 1: This concomitant treatment may increase the central nervous system (CNS) effect, cause respiratory depression, and may alter seizure control; thus, it should be monitored, but this combination is not contraindicated. Option 3: Caution is advised because amitriptyline can affect seizure control, and the combination can have central nervous system (CNS) depression, but it is not contraindicated. Option 4: Caution is advised because doxepin can decrease the seizure threshold, and the combination can have central nervous system (CNS) depression, but it is not contraindicated.

Due to increased risk of tolerance and dependence, patients taking anorexiants should also be screened for which medical condition? 1. Anxiety with posttraumatic stress disorder 2. Substance use disorder with cocaine 3. Constipation and overuse of bisacodyl 4. Hypothyroidism

2. Substance use disorder with cocaine Option 2: Anorexiants are contraindicated in patients who abuse cocaine. It is essential to screen for the history of this disorder. Rationales Option 1: Some anorexiants can contribute to psychosis, and this would be an important comorbid problem to be aware of before prescribing, but it is not a contraindication with anorexiants. Option 3: Caution is always advised with multiple medications, but this does not add to the tolerance and dependence of these agents. Misuse of laxatives may be associated with a purging type of eating disorder and should be evaluated further. Option 4: Starting an anorexiant during hyperthyroidism has significant risks due to the added stimulation to the hypothalamic-pituitary-adrenal axis, but hypothyroidism is deficient in the stimulation.

A 66-year-old who is prescribed nortriptyline (Pamelor) is complaining of dizziness upon standing, visual changes, sleepiness, dry mouth, low appetite due to nausea, and constipation. The APN would most suspect which problem? 1. Hyperpyrexia 2. Physical dependence 3. Anticholinergic adverse effects 4. Parkinsonism

3. Anticholinergic adverse effects Option 3: Anticholinergic adverse effects are a common problem of tricyclic antidepressants (TCAs). They include dry mouth, constipation, urinary hesitancy or retention, blurred vision, sedation, orthostatic hypotension, weight gain, nausea, vomiting, gynecomastia, and changes in libido. This is more problematic for the very young or old and when combined with more than one anticholinergic drug. Rationales Option 1: Hyperpyrexia is another term for a very high fever. This occurs when tricyclic antidepressants (TCAs) are combined with monoamine oxidase inhibitors (MAOIs). Option 2: Physical dependence can cause an abstinence syndrome, which includes cramping, delirium, tremors, hypertension, tachycardia, fever, and possibly seizures. This is not described in the question. Option 4: The symptoms described are anticholinergic. Parkinsonism can be induced by antipsychotic drugs and can be treated with anticholinergic drugs, such as diphenhydramine (Benadryl). The symptoms of parkinsonism include bradykinesia, resting tremor, posture instability, and rigidity.

Carbamazepine has a Black Box Warning regarding the development of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). There is a strong association with the HLA-B*1202 allele variant. Patients of which ethnicity are most at risk and should be screened for this allele before starting the drug? 1. African American 2. Caucasian 3. Asian 4. Hispanic

3. Asian Option 3: The HLA-B*1202 allele variant, which is more common among patients of Asian descent, carries a higher risk of SJS and TEN. Rationales Option 1: The HLA-B*1202 allele variant is not most common among African American patients. Option 2: The HLA-B*1202 allele variant is not most common among Caucasian patients. Option 4: The HLA-B*1202 allele variant is not most common among Hispanic patients.

A 32-year-old patient is started on clonazepam (Klonopin), a benzodiazepine for anxiety. Which information would the APN include in patient education regarding clonazepam? 1. Red-green color blindness may occur and should be reported. 2. Doses should not be missed to remain effective. If a dose is missed, the patient can double the next dose. 3. Avoid alcohol when taking the clonazepam (Klonopin). 4. Ocular pain and visual changes are an expected adverse effect at the beginning of therapy. This usually resolves within a week of therapy.

3. Avoid alcohol when taking the clonazepam (Klonopin). Option 3: A benzodiazepine administered concurrently with alcohol can induce excessive sedation and impaired cognition. Rationales Option 1: Red-green color blindness is not an expected adverse effect of clonazepam. Option 2: Doubling a benzodiazepine dose may cause excessive drowsiness and is not recommended. Option 4: Ocular pain and visual changes are potential adverse effects and should be reported immediately. Benzodiazepines are contraindicated in acute narrow-angle glaucoma.

A 45-year-old patient is suffering from back pain due to severe muscle spasms. A centrally acting muscle relaxant, tizanidine (Zanaflex), is prescribed. By which mechanism of action does tizanidine act? 1. Inhibiting calcium ion channels to the muscle fibers 2. Agonizing the spinal synaptic reflexes 3. Binding to alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity 4. Binding to gamma-aminobutyric acid (GABA) benzodiazepine receptors complexes

3. Binding to alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity Option 3: Tizanidine (Zanaflex) binds to central alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity. Rationales Option 1: Centrally acting muscle relaxants do not work on the muscles but appear to act on the spinal reflexes. Option 2: Tizanidine binds to central alpha2 adrenergic receptors, which increases the presynaptic motor neuron inhibition and reducing spasticity. Option 4: Nonbenzodiazepine hypnotics act through this mechanism.

After being prescribed eszopiclone (Lunesta), a 45-year-old patient complains of daytime drowsiness. He rises for work at 5 a.m. and takes the medication if he cannot fall asleep, which is usually at midnight. Which explanation by the APN is most appropriate? 1. Eszopiclone has a long duration. 2. The patient must have used alcohol or some other sedative against the advice of the APN. 3. Daytime drowsiness is expected if eszopiclone (Lunesta) is taken 6 hours or less before awakening. 4. The patient may be more sensitive to the medication.

3. Daytime drowsiness is expected if eszopiclone (Lunesta) is taken 6 hours or less before awakening. Option 3: Eszopiclone (Lunesta) can cause daytime drowsiness when taken 6 hours or less before awakening. The patient is waking up about 5 hours after taking the medication. Rationales Option 1: Eszopiclone has a short duration. Option 2: This is possible and could cause excessive drowsiness, but daytime drowsiness is expected if taken 6 hours or less before awakening. Option 4: Great sensitivity to the medication is usually a problem for older people, but this patient is not in that category.

A 45-year-old female patient arrives to the clinic for a physical examination. Her body mass index (BMI) is 37. She has a history of type 2 diabetes mellitus with neuropathic pain. Her new complaints are depressed mood, loss of interest, sleeping too much, loss of concentration, and feelings of worthlessness. These symptoms have been bothersome for the past 2 months. Considering her past medical history, physical examination, and complaints, which drug is most appropriate? 1. Fluoxetine (Prozac) 2. Trazodone (Desyrel) 3. Duloxetine (Cymbalta) 4. Lorcaserin (Belviq)

3. Duloxetine (Cymbalta) Option 3: Duloxetine treats depression, it may cause weight loss, and it treats neuropathic pain. These are all things that the patient could benefit from. Duloxetine is also more activating, which could relieve the patient's complaint of sleeping too much. Rationales Option 1: Although fluoxetine does treat depression well, it usually causes weight gain. It might cause nausea and weight loss initially, but that usually goes away as the appetite increases. Weight gain is detrimental for the type 2 diabetes mellitus and obesity that this patient faces already. Option 2: Trazodone contributes to drowsiness, and this patient is sleeping too much already. This would not be a good choice. Option 4: Although lorcaserin will help the patient lose weight because it is an anorexiant, it does not treat depression. In fact, lorcaserin has the potential to cause psychiatric disorders and has potential risks for hypoglycemia in patients with type 2 diabetes mellitus on antidiabetic therapy.

Alterations in cardiac conduction are a significant risk when prescribing tricyclic antidepressants (TCAs). Which mechanisms cause this risk? 1. Increased availability of serotonin and histamine are contributing factors of cardiac conduction alterations. 2. Over time, regular use of TCAs can cause fibrosis of the heart muscle from its histamine interaction. 3. Increased availability of norepinephrine, anticholinergic effects, and a slowing of depolarization are contributing factors of cardiac conduction alterations. 4. Over time, regular use of TCAs can cause hypertension due to their beta adrenergic agonism, which leads to cardiac conduction problems.

3. Increased availability of norepinephrine, anticholinergic effects, and a slowing of depolarization are contributing factors of cardiac conduction alterations. Option 3: Sinus tachycardia can occur due to inhibition of norepinephrine uptake and anticholinergic effects when TCAs block acetylcholine. The slowing of depolarization by TCAs contributes to a prolonged QRS and subsequent QT interval. Rationales Option 1: Serotonin does not add to cardiac conduction problems. Increased histamine adds to sedation. Option 2: Fibrosis of the heart muscle through histamine interaction is not the mechanism that causes this risk. Option 4: Hypertension due to beta adrenergic agonism is not the mechanism that causes this risk.

Which malignant neoplasm is carbidopa-levodopa known to activate? 1. Colon cancer 2. Lung cancer 3. Melanoma 4. Leukemia

3. Melanoma Option 3: Studies suggest that carbidopa-levodopa can activate malignant melanoma, and for that reason it is contraindicated. Rationales Option 1: Studies have not suggested that carbidopa-levodopa can activate colon cancer. Option 2: Studies have not suggested that carbidopa-levodopa can activate lung cancer. Option 4: Studies have not suggested that carbidopa-levodopa can activate leukemia.

A 3-year-old patient with Lennox-Gastaut syndrome is being treated with valproate sodium, but seizures are not well controlled. Lamotrigine (Lamictal) is being started as adjunctive therapy. Which serious adverse drug reaction is more risky when lamotrigine is coadministered with valproate sodium? 1. Electrocardiogram (ECG) changes become an adverse effect when lamotrigine is administered with valproate. 2. Oligohidrosis can lead to hyperthermia and heatstroke when lamotrigine and valproate are coadministered. 3. Stevens-Johnson syndrome (SJS) is a risk of lamotrigine, and the combination of valproate increases the risk further. 4. Alopecia has been reported when lamotrigine is coadministered with valproate.

3. Stevens-Johnson syndrome (SJS) is a risk of lamotrigine, and the combination of valproate increases the risk further. Option 3: Lamotrigine has a Black Box Warning of SJS and toxic epidermal necrolysis. This risk is higher for pediatric patients. Coadministration with valproate increases this risk. Rationales Option 1: Toxic levels of carbamazepine can lead to ECG changes. Rapid administration of IV phenytoin can lead to ECG changes. Option 2: Oligohidrosis, hyperthermia, and resulting heatstroke is a precaution for children taking zonisamide. Option 4: Alopecia can be a distressing adverse effect of Levetiracetam, but it is not the riskiest adverse drug reaction.

A 13-year-old patient who suffered from tonic-clonic seizures was recently discharged from an acute care hospital. The patient and parents need continued teaching regarding the daily administration of phenytoin (Dilantin). Which statement by the APN demonstrates the important teaching needed when phenytoin (Dilantin) is administered? 1. If one dose is missed, the patient should double the next dose. If two doses are missed, the patient should triple the next dose. 2. Phenytoin (Dilantin) causes a fruity odor to the urine. 3. The patient should avoid alcohol. 4. Antifungal shampoos can be used to avoid dandruff, which is a common adverse effect.

3. The patient should avoid alcohol. Option 3: Recommended teaching is to avoid alcohol when phenytoin (Dilantin) is administered. Rationales Option 1: The patient should be instructed to take the medication exactly as directed and avoid missing doses. Option 2: Inform the patient that phenytoin may color the urine pink, red, or reddish-brown, but this color change is not a cause for alarm. Option 4: Dermatological adverse effects include Stevens-Johnson syndrome and toxic epidermal necrolysis, not dandruff or tinea.

Which antidepressant medication is devoid of the risk of serotonin syndrome? 1. Amitriptyline (Elavil) 2. Vortioxetine (Brintellix) 3. Desvenlafaxine (Pristiq) 4. Bupropion (Wellbutrin)

4. Bupropion (Wellbutrin) Option 4: This atypical antidepressant medication is devoid of the risk of serotonin syndrome because it inhibits the reuptake of norepinephrine and dopamine, but not serotonin. Rationales Option 1: This is a tricyclic antidepressant (TCA), which includes the mechanism of inhibiting the reuptake of serotonin, as well as acting on norepinephrine, histamine, and acetylcholine. Option 2: This is the newest selective serotonin reuptake inhibitor. It has the significant adverse effect of serotonin syndrome. Option 3: This drug is a serotonin-norepinephrine reuptake inhibitor and has greatest risk of serotonin syndrome when it is coadministered with a tricyclic antidepressant (TCA).

Parkinson's disease involves the deficiency of which neurotransmitter? 1. Serotonin 2. Norepinephrine 3. Gamma-aminobutyric acid (GABA) 4. Dopamine

4. Dopamine Option 4: Insufficient dopamine is responsible for the imbalance and musculoskeletal incoordination of Parkinson's disease. Rationales Option 1: Insufficient serotonin is not responsible for Parkinson's disease. Option 2: Insufficient norepinephrine is not responsible for Parkinson's disease. Option 3: Insufficient GABA is not responsible for Parkinson's Disease.

Most antiepileptic drugs, such as perampanel, carry an increased risk of suicidal behavior or ideation. In addition to this adverse effect, which other psychosocial precaution is included for perampanel? 1. Gaiety and a distorted time perception 2. Tolerance 3. Increased sense of relaxation and taste 4. Hostility, aggression, and homicidal ideation

4. Hostility, aggression, and homicidal ideation Option 4: Perampanel has a boxed warning for changes in mood, including hostility, aggression, and homicidal ideation. Rationales Option 1: Although perampanel has a precaution for aggressive behavior, it is not in the form of gaiety. Dronabinol (Marinol) can have these behavior effects. Option 2: Tolerance is when an increase dose is needed over time to achieve the same response. Perampanel does not have a characteristic of tolerance. Option 3: Perampanel can exacerbate depression or have an adverse effect of somnolence, but this is not a sense of relaxation.

Which pharmacokinetics are unique to levetiracetam compared with other antiepileptic drugs? 1. It has a highly variable half-life, which requires careful monitoring with drug levels. 2. It is highly protein bound and extensively metabolized by CYP450 enzymes, which gives it many drug-drug interactions. 3. To be effective, the concentration of levetiracetam needs to be close to toxic due to the short half-life. 4. It is unbound, metabolized by hydrolysis, and does not use CYP450 enzymes.

4. It is unbound, metabolized by hydrolysis, and does not use CYP450 enzymes. Option 4: These characteristics make levetiracetam almost devoid of drug-drug interactions. Rationales Option 1: Routine laboratory monitoring for levetiracetam is not necessary. Option 2: Levetiracetam has few, if any, drug-drug interactions. Option 3: The half-life of levetiracetam is 7 hours, and no routine monitoring is necessary.

Bipolar disorders, which present with depression and mania, are treated with which type of medication? 1. Benzodiazepines 2. Dopaminergics 3. Anorexiants 4. Mood stabilizers

4. Mood stabilizers Option 4: Mood stabilizers are used with patients who have bipolar disorders to restore the balance between depression and mania. Rationales Option 1: Benzodiazepines are most often prescribed for anxiety, insomnia, status epilepticus, preoperative sedation, or chemotherapy-related nausea and vomiting. Option 2: Dopaminergics are used to treat Parkinson's disease, although the drugs to treat bipolar disorder often have an effect on dopamine. Option 3: Anorexiants are used to treat obesity.

Assessing a patient following morphine administration, the nurse notes cold, clammy skin; heart rate of 40 bpm; blood pressure of 90/40 mm Hg; and respiratory rate of 8 breaths/minute. Which medication should the nurse practitioner prepare to administer? 1. Flumazenil 2. Acetylcysteine (Mucomyst) 3. Protamine sulfate 4. Naloxone (Narcan)

4. Naloxone (Narcan) Rationales Option 4: Naloxone (Narcan) is the antidote for an opioid overdose. Option 1: Flumazenil is the antidote for benzodiazepine overdose. Option 2: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. Option 3: Protamine sulfate is the antidote for anticoagulants, heparin, and Lovenox overdose.

A 45-year-old male patient is complaining of feeling tired for 2 weeks. He states he cannot fall asleep. Which initial treatment should be employed? 1. Ramelteon (Rozerem) 2. Zolpidem (Ambien) 3. Triazolam (Halcion) 4. Sleep hygiene

4. Sleep hygiene Option 4: Sleep hygiene only for short-term insomnia should be employed prior to considering medications. This includes using relaxation techniques 1 hour prior to bed, avoiding caffeine and television before bed, and keeping the room dark. Rationales Option 1: A melatonin receptor agonist does help initiate sleep onset, but it should not be initial treatment for short-term insomnia. Option 2: Nonbenzodiazepine hypnotics do help initiate sleep onset, but they should not be initial treatment for short-term insomnia. Option 3: Benzodiazepine hypnotics can help initiate sleep onset, but they should not be initial treatment for short-term insomnia.

Which statement describes the mechanism of action among tricyclic antidepressants (TCAs) versus a newer antidepressant, such as escitalopram (Lexapro)? 1. TCAs involve fewer neurotransmitter interactions. 2. TCAs are effective immediately and intended to be used short term. 3. TCAs do not involve receptors or chemical interactions. 4. TCAs are less selective.

4. TCAs are less selective. Option 4: TCAs have many sites of action. They bind to histamine, dopamine, serotonin, and norepinephrine, which makes them nonselective. Rationales Option 1: TCAs have many sites of action. Option 2: It takes 2 to 4 weeks before depressive symptoms abate. TCAs are usually prescribed for months to years and are not short term. Option 3: TCAs act on neurotransmitter receptors, such as serotonin, norepinephrine, histamine, and acetylcholine.

Which doses of zolpidem (Ambien) are recommended for women versus men? 1. The dose for women and men is the same. 2. The dose for women is 5 mg and for men is 10 mg. 3. The dose for women is 10 mg and for men is 5 mg. 4. The dose for women is 5 mg, but zolpidem is contraindicated for men with fertility potential.

Rationales Option 1: The dose for women is 5 mg and for men is 10 mg.