Psychopharm Exam 1 practice questions

1. A 28-year-old female is referred from her employee assistance program from a tech company for poor hygiene and erratic behaviors interfering with her work. The patient states her company is spying on her and setting her up to fail for the last 9 months. While speaking she stops herself and begins to talk back to someone who is not present. These symptoms are most consistent with: a. Psychosis b. Delusions c. Hallucinations d. Depression

A

A 16-year-old male with a history of smoking cigarettes and marijuana is being evaluated at the request of the school and parents. The child states that the reason he smokes is it "helps calm me down" as he is anxious all the time. Which of the following medications would be the best choice? a. Fluoxetine 20mg PO daily b. Clonazepam 0.5mg PO daily c. Vortioxetine 20mg daily d. Citalopram 5mg PO daily

A

A 22-year-old man is referred to the psychiatric emergency department for suicidal ideation. Upon interview the patient states that he is not trying to kill himself, and he really can fly if only people would let him. The patient is emphatic that he is not manic because he is "the best sleeper in the world." The patient has a bright reactive affect and is pressured at times. Which of the following best describes his condition? a. Grandiose delusion b. Hallucinations c. Erotomaniac delusions d. Persecutory delusions

A

A 24-year-old male with three past psychiatric hospitalizations for psychosis inquires if he will have to be on medication for the rest of his life as he is worried about developing diabetes. Which of the following circumstances reduces the likelihood of lifetime medication? a. Substance-induced psychosis b. Denovo psychosis c. Parent with history of schizophrenia d. Completing high school

A

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

A

A 35-year-old woman is being evaluated 7 months postpartum for recurrent thoughts about wanting to harm her baby by stabbing with a knife. She continues to breastfeed and care for the baby. Since having these thoughts, she has removed all sharp objects from the home and has started ordering take out food to feed her family. She is reluctant to share these thoughts with her husband. Which of the following medications would be most appropriate to prescribe? a. Sertraline b. Lorazepam c. Benztropine d. Doxepine

A

A 50-year-old woman with no past psychiatric history is evaluated for anhedonia, fatigue, apathy, and psychomotor agitation. She tells you that she has been refusing care from her husband because he has been replaced by an alien from outer space and only appears like her husband. Which of the following describes this psychotic depression? a. Capgras syndrome b. Cotard's syndrome c. Folieadeux d. Schizophrenia

A

A 60-year-old man has been treated for depression for the last 2 years with a medication he cannot remember. He reports that he has had increasing urinary hesitancy, xerostomia, and intermittent lightheadedness. Which of the following medications is this patient most likely prescribed? a. Doxepin b. Fluoxetine c. Lithium d. Lamictal

A

A 79-year-old female with no past psychiatric history is admitted with new onset auditory hallucinations. The patient states her most bothersome symptom is the voices, which have kept her from sleeping through the night for the last 3 weeks, and as a result, she is tired and irritable. Which medication should the PMHNP order for bedtime for sleep? a. Olanzapine 2.5mg PO b. Lorazepam 1mg PO c. Chlorpromazine 50mg PO Sertraline 50mg PO

A

A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the teaching was effective when they state which of the following should be reported immediately? a. Elevated temperature b. Tremor c. Decreased blood pressure d. Weight gain

A

A condition characterized by abnormal involuntary movements in a rhythmic pattern often affecting the mouth, tongue, and jaw that is potentially irreversible is known as? a. Tardive dyskinesia b. Neuroleptic malignant syndrome c. Pseudo-Parkinson's d. Dystonia

A

A hospitalized client with schizophrenia is receiving antipsychotic medications. While assessing the client, you identify signs and symptoms of a dystonic reaction. Which agent would you expect to administer? a. Diphenhydramine (Benadryl) b. Propranolol (Inderal) c. Risperidone (Risperdal) d. Aripiprazole (Abilify)

A

A medication that works by receptor activation to produce a biological response is an: a. Agonist b. Enzyme inhibitor c. Inverse agonist d. Antagonist

A

A nursing instructor is developing a class lecture that compares and contrasts schizoaffective disorder with schizophrenia. When describing one of the differences between these two diagnoses, which of the following would the instructor include as reflecting schizoaffective disorder? a. It is episodic in nature. b. It involves difficulties with self-care. c. It has less severe hallucinations. d. It is associated with a lower suicide risk.

A

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

A

A patient is requesting the PMHNP to complete his disability application for schizophrenia because he got fired for disruptive behavior. He states the constant voices ask him questions and interfere with his sleep, so he has started smoking marijuana to help him relax. Which of the following statements is true regarding auditory hallucinations? a. Auditory hallucinations coincide with a delusion b. Auditory hallucinations are contrary to delusions c. Auditory hallucinations are constant in nature d. Auditory hallucinations usually ask the patient questions

A

A patient who was recently started on haloperidol for psychosis begins to manifest hand tremor, and a shuffling gait. What is the most likely explanation for these symptoms? a. Dopamine transmission in the nigrostriatal pathway b. Dopamine transmission in the tuberoinfundibular pathway c. Dopamine transmission in the mesolimbic pathway d. Dopamine increases throughout the basal ganglia

A

A pregnant woman with depression is reluctant to take medication for fear of causing her baby neonatal abstinence syndrome due to selective serotonin reuptake inhibitor (SSRI) medication. Her husband states they would like to use a faith healer instead. Which of the following is most accurate regarding the prognosis of depression during pregnancy? a. The actual course of depression cannot be predicted b. If the patient does not take medication she will continue to deteriorate c. There is no risk of adverse effect associated with SSRIs d. The patient will likely require involuntary commitment to a mental institution

A

A woman in her 20th week of pregnancy has been resumed on lithium for bipolar disorder. The PMHNP knows that the patient may become subtherapeutic despite taking the medication as prescribed due to: a. Increased blood volume b. Increased fetal metabolism c. Reduced muscle mass d. Reduced blood volume

A

Neurons that only travel from the body to the brain are called: a. Sensory neurons b. Motor neurons c. Inter neurons d. Astrocytes

A

The PMHNP is evaluating a 30-year-old female who reports intermittent auditory hallucinations in which a familiar female voice is commenting on her as she eats. In an effort to deal with the voices she has been using headphones and listens to podcasts and music all the time, but it is interfering with her ability to do her work. Which of the following questions would help in formulating a diagnosis? a. "How long have you been experiencing the voices?" b. "Do the voices bother you?" c. "Are you able to ignore the voices?" d. "What has helped you deal with the voices?"

A

The PMHNP is evaluating a 68-year-old man for symptoms of major depression. While assessing the appearance of the patient, an obvious left-sided ptosis is noted. Which cranial nerve is directly linked to this condition? a. III b. IV c. V d. VI

A

The nurse is caring for a client who has been taking clozapine (Clozaril) for 2 weeks. The client tells the nurse, My throat is sore, and I feel weak. The nurse assesses the clients vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test? a. A white blood cell count b. Liver function studies c. Serum potassium level d. Serum sodium level

A

The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurses understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority? a. Suicide b. Aggression c. Substance abuse d. Eating disorder

A

The part of the neuron that takes in and receives messages is called: a. Dendrite b. Axon c. Synapse d. Node of Ranvier

A

Which of the following receives messages and conducts impulses to the soma? a. Dendrite b. Axon c. Synapse d. Myelin sheath

A

You are caring for an elderly client who has been taking an antipsychotic medication for 1 week. You observe that the client has muscle rigidity that resembles Parkinsons disease. Which agent would you prescribe? a. Anticholinergic b. Anxiolytic c. Benzodiazepine d. Beta-blocker

A

Based on thorough evaluation of a patient and his history, his care provider intends to begin treatment with a conventional antipsychotic but has not selected a particular agent yet. Which of the following is most true about conventional antipsychotics? a. They are very similar in therapeutic profile but differ in side-effect profile b. They are very similar in both therapeutic and side-effect profile c. They differ in therapeutic profile but are similar in side-effect profile They differ in both therapeutic and side-effect profile

A Although individual effects may vary from patient to patient, in general conventional antipsychotics share the same primary mechanism of action and do not differ much in their therapeutic profiles. There are, however, differences in secondary properties, such as degree of muscarinic, histaminergic, and/or alpha adrenergic receptor antagonism, which can lead to different side-effect profiles.

A 32-year-old woman with major depressive disorder has been taking a selective serotonin reuptake inhibitor (SSRI) with good response for 9 months. She presents now with complaints that she feels numb, and that even when she's sad she can't cry. Her clinician is considering reducing the dose of her SSRI in an effort to alleviate this problem. Is this a reasonable option? a. Yes, data suggest that SSRI-induced indifference is dose-dependent and can be alleviated by reducing the dose b. No, although data suggest that SSRI-induced indifference is dose-dependent, patients who develop this side effect generally require switch to a different medication c. No, SSRI-induced indifference is not dose-dependent and thus cannot be alleviated by reducing the dose

A Apathy and emotional blunting can be symptoms of depression, but they are also side effects associated with selective serotonin reuptake inhibitors (SSRIs). These symptoms - termed "SSRI-induced indifference" - are under-recognized but can be very distressing for patients. They are theoretically due to an increase in serotonin levels and a consequent reduction of dopamine release. The first recommended strategy for addressing SSRI-induced indifference is to lower the SSRI dose, if feasible. Additional options include adding an augmenting agent, or switching to an antidepressant in another class.

A 36-year-old patient has only partially responded to his second monotherapy with a first-line antidepressant. Which of the following has the best evidence of efficacy for augmenting antidepressants in patients with inadequate response? a. Adding an atypical antipsychotic b. Adding buspirone c. Adding a stimulant

A Atypical antipsychotics have been studied as adjuncts to selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), with approvals for aripiprazole, quetiapine XR, olanzapine (in combination with fluoxetine), and brexpiprazole. Overall, most studies of atypical antipsychotics show a benefit of combination treatment over monotherapy, although effect sizes have been modest. Although atypical antipsychotics have the best evidence of efficacy for augmenting antidepressants in patients with inadequate response, their adverse event profiles may still put them later in the treatment algorithm.

Ten-year-old Rebecca experienced seizures as a toddler. Her mother took her to a psychiatrist at age 8, because she had violent outbursts of anger, was attacking her older brother, and was severely irritable. That behavior had been going on for the last 6 months. After screening her for ADHD, and other conduct disorders, Dr. Jones had diagnosed her with bipolar I disorder and put her on 800 mg/day of carbamazepine. Over the last few years she has only had a couple of manic episodes but has recently started having frequent debilitating migraines. She has gained weight as well, and now weighs 30 kg (height of 100 cm, BMI=30) and her mother does not want her to start a medication that could lead to more weight gain. Which medication, and at which dose, could be added to her current treatment? a. 150 mg/day of topiramate (= 5 mg/kg/day) b. 400 mg/day of topiramate (=13 mg/kg/day) c. 900 mg/day of lithium d. 1800 mg/day of lithium e. 10 mg/day of olanzapine f. 30 mg/day of olanzapine

A Besides being used off-label as an adjunct in bipolar disorder, topiramate is FDA approved as an anti-migraine medication. It has no weight gain potential, and might even lead to weight loss. Children should be given a lower dose than adults, and the normal dose range for children is 5-9 mg/kg/day.

A 24-year-old woman with depression has just had genetic testing, including testing of the genes for catechol-O- methyltransferase (COMT) and methylenetetrahydrofolate reductase (MTHFR). Her symptoms are theoretically consistent with severe dopamine deficiency with apathy, anhedonia, psychomotor retardation, and cognitive slowing. Based on current literature, what genetic testing results might be most likely? a. COMT Val/Val and MTHFR (T/T) or (C/T) b. COMT Val/Val and MTHFR (C/C) c. COMT Met/Met and MTHFR (T/T) or (C/T) d. COMT Met/Met and MTHFR (C/C)

A Carrying both the COMT 158 Val/Val and the MTHFR 677 (T/T) or (C/T) genotypes theoretically would result in increased degradation of dopamine in the prefrontal cortex, leading to decreased dopamine signaling and associated cognitive dysfunction, apathy, and psychomotor retardation ("prefrontal dopamine" hypothesis).

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

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

A 36-year-old man with major depressive disorder has lab work done to assess his levels of inflammatory markers. The results come back indicating elevated levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6). Elevated cytokine levels may indirectly lead to: a. Excessive glutamate and reduced serotonin b. Excessive glutamate and excessive serotonin c. Reduced glutamate and reduced serotonin d. Reduced glutamate and excessive serotonin

A Cytokines can influence neurotransmitter levels, including both serotonin and glutamate. In fact, excessive glutamate activity is hypothesized to be an underlying cause of depression.

A 48-year-old woman with a history of treatment-resistant depression is currently taking duloxetine 60 mg/day with partial response as well as trazodone 50 mg/day for insomnia. She states that she feels empty and useless, and she admits to having thoughts of death. She states that she does not have plans to kill herself because it would harm her family and pets. Her clinician decides to try tranylcypromine, a monoamine oxidase inhibitor (MAOI) and one of the few agents that she has not yet tried. Which of the patient's current medications would you discontinue BEFORE initiating tranylcypromine? a. Duloxetine b. Trazodone c. Both duloxetine and trazodone d. Neither duloxetine nor trazodone

A Duloxetine is a serotonin norepinephrine reuptake inhibitor. Inhibition of the serotonin transporter leads to increased synaptic availability of serotonin. Similarly, inhibition of MAO leads to increased serotonin levels. In combination, these two mechanisms can cause excessive stimulation of postsynaptic serotonin receptors, which has the potential to cause a fatal "serotonin syndrome" or "serotonin toxicity." Because of the risk of serotonin toxicity, complete washout of duloxetine is necessary before starting an MAOI. Duloxetine must be down-titrated as tolerated, after which one must wait 5 half- lives of duloxetine (at least 3-4 days) before initiating the MAOI.

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

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

A 24-year-old male initially presents with acute auditory hallucinations and is treated with medication. Four days later he arrives at your office for evaluation. You observe that he is neatly dressed, avoids eye contact, and gives very short answers to your initial questions. Which of the following questions would be most beneficial for determining his degree of negative symptoms? a. How often have you visited with friends in the past week? b. Have the voices you've heard persisted or returned? c. Have you ever thought about hurting yourself or someone else? d. In the past week have you had difficulty concentrating?

A How often have you visited with friends in the past week: This is a useful question when assessing for negative symptoms, as an important component of negative symptoms is reduced social drive.

In a G protein-linked signal transduction cascade, the second messenger can be synthesized: a. In the postsynaptic neuron b. In the synaptic cleft c. A and B d. Neither A nor B

A Inside the postsynaptic neuron, an activated ligand-gated receptor binds to a G protein. The G protein changes shape so it can bind to an enzyme. The enzyme then synthesizes a second messenger.

A 24-year-old patient with schizophrenia who has prominent cognitive symptoms and social impairment is being evaluated for treatment. Her care provider is considering initiating ziprasidone, quetiapine, or aripiprazole, all of which share the property of serotonin 1A agonism. This receptor binding property is expected to have clinical effects in schizophrenia most similar to: a. Serotonin 2A antagonism b. Dopamine 2 antagonism c. Histamine 1 antagonism d. Serotonin transporter blockade

A Serotonin 2A antagonism: Serotonin 1A partial agonism has similar net effects to serotonin 2A antagonism. That is, it enhances dopamine release and thus may theoretically improve extrapyramidal side effects, hyperprolactinemia, and cognitive and negative symptoms.

A 24-year-old woman with no history of psychiatric symptoms presents with a major depressive episode and is prescribed an antidepressant. She quickly experiences improved mood and exhibits symptoms suggestive of hypomania. Recommendations from the International Society for Bipolar Disorders (ISBD) state that the patient's antidepressant should be: a. Discontinued b. Maintained, but ONLY IF a mood stabilizer is added

A The ISBD does not recommend maintaining an antidepressant if patient shows signs of (hypo)mania or increased psychomotor agitation during antidepressant treatment.

Communication between human CNS neurons at synapses is: a. Chemical b. Electrical c. Both A and B d. Neither A nor B

A The communication between neurons at synapses is mediated by neurotransmitter molecules and is therefore chemical.

A 36-year-old man with major depressive disorder is having lab work done to assess his levels of inflammatory markers. Based on the current evidence regarding inflammation in depression, which of the following results would you most likely suspect for this patient? a. Elevated levels of tumor necrosis factor-alpha (TNF-alpha) b. Reduced levels of interleukin 6 (IL-6) c. Both A and B d. Neither A nor B

A There is growing evidence that inflammation may play an important role in the pathophysiology of major depression. Clinical studies have shown that depressed patients have significantly higher concentrations of several inflammatory markers, including the pro-inflammatory cytokines TNF-alpha, interleukin 6, and interleukin 1. Patients with depression also have higher concentrations of C-reactive protein, which is synthesized by the liver in response to pro-inflammatory cytokines. Furthermore, both cytokines and cytokine inducers can cause symptoms of depression. For example, as many as 50% of patients receiving chronic therapy with the cytokine interferon develop symptoms consistent with idiopathic depression.

The "bipolar storm" refers to the concept that unstable, unregulated, and excessive neurotransmission occurs at synapses in specific brain regions, and both voltage-sensitive sodium channels and voltage-sensitive calcium channels are involved in this excessive stimulation of glutamate release. Which drugs would theoretically reduce glutamate release by blocking voltage-sensitive sodium channels? a. Valproate and lamotrigine b. Pregabalin and gabapentin c. Levetiracetam and amantadine

A Valproate is a nonspecific voltage-sensitive sodium channel modulator and lamotrigine also blocks voltage-sensitive sodium channels, hypothesized to lead to reduction in glutamate release.

A 38-year-old man was diagnosed with schizophrenia 14 years ago, and over the course of his illness has taken several different antipsychotics, all with partial response and no severe side effects. He now presents with acute exacerbation of hallucinations and delusions. He recently had bowel resection due to a gastrointestinal disorder, and blood levels reveal that he is not absorbing his medications well. One option for this patient would be to prescribe heroic oral doses of his antipsychotic. Aside from this approach, which of the following antipsychotics have formulations that may be good long-term options for bypassing his problem with absorption? a. Asenapine, paliperidone, risperidone b. Paliperidone, risperidone, quetiapine c. Risperidone, quetiapine, ziprasidone d. Quetiapine, ziprasidone, asenapine

A or patients with difficulty absorbing medications, the best options in order to reach therapeutic blood levels would be to prescribe heroic oral doses or to use parenteral, sublingual, or suppository administration. Asenapine has a sublingual formulation, while paliperidone is available in a 4-week and a 3-month formulation and risperidone is available as an intramuscular depot administered every 2 weeks. A 4-week olanzapine depot is also available. Additional antipsychotics with depot formulations include flupenthixol, fluphenazine, haloperidol, pipothiazine, and zuclopenthixol. Clozapine, olanzapine, and risperidone have orally disintegrating tablets; however, these medications are not absorbed sublingually and must be swallowed in order to undergo absorption in the gut. Chlorpromazine has a suppository formulation, and other antipsychotics may also be able to be administered as suppositories. Aripiprazole has two long-acting injectable formulations: one that is administered every 4 weeks and another that can be administered every 4 or 6 weeks. Iloperidone is in early trials for a 4-week depot.

A serotonin molecule binds to a 5HT2A receptor causing electrical impulses to be sent down a GABA neuron's axon terminal, eventually releasing GABA to the GABA-a receptor of its postsynaptic neuron. Which type of neurotransmission does this describe? a. Classic synaptic neurotransmission b. Retrograde neurotransmission c. Volume neurotransmission d. Signal transduction cascade

A. Classic synaptic neurotransmission is the most common and well-known process of neurotransmission. It involves the anterograde transduction of a chemical signal to electrical impulses and back to chemical signals for the next neuron.

A neuron is infected with a toxin and causes a rather sudden inflammatory reaction. You detect a high concentration of cytokines in the surrounding area. Which process has taken place? a. Necrosis b. Synaptogenesis c. Excitotoxicity d. Apoptosis e. Neurogenesis

A. Necrosis is the neural selection process in which a cell is poisoned, suffocated, or otherwise destroyed by a toxin after which the cell explodes and causes an inflammatory reaction.

A 19-year-old male is attending his post hospital discharge appointment where he was diagnosed with psychosis. He has been taking risperidone 4 mg by mouth twice daily. Which of the following is the top priority during this first encounter with the PMHNP? a. Baseline EKG, weight, hemoglobin A1C b. Establish therapeutic alliance c. Draw a prolactin level d. Administer a long-acting injectable

B

A 30-year-old man was recently terminated from his job for impulsive corporate spending. He was brought to the ED by the police for public nudity. The urine toxicology is negative, and all labs are normal. The patient is pressured and difficult to interrupt. He is demanding to leave and wants to speak to his lawyer, and he states that "the founding fathers declare that all men are created with the inalienable right to life and liberty, and President Trump has caused the Federal Bureau of Investigation (FBI) to trample my rights, which is a high crime and he should be impeached." Which of the following is the most likely diagnosis? a. Adjustment disorder b. Bipolar disorder c. Major depression d. Posttraumatic stress disorder (PTSD)

B

A 30-year-old woman is convinced her neighbor is hypnotizing her into performing sexual acts in her sleep because he is turned on by her doing yoga for the last 3 months. She presented to the emergency department requesting a sexual assault forensic exam to prove her claim. The examiner finds her story bizarre and requests a psychiatric evaluation for capacity to consent to forensic examination. When obtaining collateral information, the police reveal that the patient has a restraining order against her from her neighbor for harassment. Which of the following best describes the patient's condition? a. Psychosis b. Erotomanic delusion c. Somatic delusion d. Post-traumatic stress disorder

B

A 35-year-old woman 7 days postpartum is brought by the mobile crisis team to the ED at the request of the husband. The patient has no past psychiatric history and takes only prenatal vitamins. He reports that his wife has not been sleeping and has noticed her walking around their apartment in the middle of the night crying and talking to nobody. In addition, she has been ignoring the baby, but last night she told him that it was "Lucifer's seed and it must be destroyed." Which of the following is the most likely diagnosis? a. Delusional disorder b. Depression with psychosis c. Schizoaffective disorder d. Schizophrenia

B

A 40-year-old senior associate in a law firm presents for care complaining of fatigue and poor motivation to the degree that he has been avoiding work. His boss has encouraged him to take some time off. The patient also reports that his wife recently kicked him out of the house after discovering his third extramarital affair. For the last 2 weeks he has been sleeping 16 hours a day, poor appetite, and has overdrawn his account. He says that this is most unlike him in that he used to be able to get by on 5 hours of sleep a night, party hard, and work harder. What is the most likely diagnosis for this patient? a. Bipolar 1 b. Bipolar 2 c. Major depressive disorder d. Narcissistic personality disorder

B

A 55-year-old female recently accepted a severance package for early retirement from her job as a fashion buyer for a major retail store. Over the past 6 months she has increasingly become isolated, neglecting her self-care, and collecting various things of no real value. Her appearance is unkempt, and her affect is flat. Before being called back to the consultation room the PMHNP notices that the patient seems to be talking to herself audibly. During the consultation the patient makes poor eye contact and wants frequent reassurance that no one is listening in. Which of the following would be the best action for the PMHNP to take? a. Send the patient to the psychiatric emergency department b. Speak in a calm reassuring voice and evaluate for comorbid conditions c. Prescribe an antipsychotic medication for atypical psychosis d. Order an MRI of the brain to rule out a mass

B

A client with schizoaffective disorder is having difficulty adhering to the medication regimen that requires the use of several agents. The client also is experiencing several side effects contributing to this nonadherence. The physician plans to change the clients medication. Which agent would the nurse anticipate that the physician would prescribe? a. Lithium b. Aripiprazole c. Clozapine d. Olanzapine

B

A couple presents with their 18-year-old son who was referred by his primary care provider for evaluation of symptoms related to perceptual disturbances, oddly related interpersonal communication, neglect of basic hygiene, and increasing isolative behaviors. These symptoms are most consistent with: a. Active psychosis b. Schizophrenia prodrome c. Residual psychosis d. Schizophrenia

B

A drug that binds to the same receptor as an agonist, but induces an opposite biological response, is a(n): a. Antagonist b. Inverse agonist c. Agonist d. Partial agonist

B

A family member of a client diagnosed with schizoaffective disorder asks a nurse what causes the disorder. Which response by the nurse would be most appropriate? a. Dysfunctional family dynamics has been identified as a strong link. b. Research has suggested that the cause is predominately genetic. c. Dopamine, a substance in the brain, appears to be underactive. d. Studies have indicated that birth order is strongly associated with this disorder

B

A patient has been prescribed sertraline 50 mg daily for the past year without adverse effects and remission of symptoms. The patient has missed the last two appointments but leaves a message that he feels "fantastic!" The wife called to reschedule a follow-up appointment, saying he has been giddy lately, emotionally labile, and spending money so frivolously that their account has been overdrawn. During the appointment the patient becomes hostile and tells the PMHNP that he is a phony, and not even a real doctor, and is having an affair with his wife. The patient is uninterruptible, with pressured speech. What pharmacological change is indicated? a. Start lithium, increase sertraline b. Start valproic acid, stop sertraline c. Start valproic acid d. Stop sertraline

B

A patient has been taking valproic acid for mood stabilization from a manic episode but is still not sleeping through the night. His last drug level was 50 mcg/mL. The PMHNP notices the patient seems disoriented to time and is flapping his wrists. What should the PMHNP do next? a. Give the patient lactulose 20g PO b. Draw an ammonia level c. Increase the dose of valproic acid Augment with an atypical antipsychotic

B

A patient has had a pharmacogenomic test, which reveals he is an extensive metabolizer on CYP450, 1A2, 2D6, and 3A4. The PMHNP should prescribe: a. A lower than usual dose b. The usual dose c. A higher than usual dose A different medication

B

A patient presents with atypical symptoms of psychosis that include inconsistent auditory hallucinations without disorganization. What is the best definition of an EEG and its utility? a. Radiologic test utilizing magnets and radio waves to provide a detailed image of the structures of the brain b. Electrophysiologic test that depicts electrical activity on the surface of the brain c. A serum test to indicate nutritional deficiencies that inhibit the formation of neurotransmitters d. A neuropsychological test to distinguish psychosis from a psychosomatic illness.

B

A patient was recently started on a dopamine antagonist, and complains of breast tenderness and a milky discharge. What is the most likely explanation for these symptoms? a. Dopamine transmission in the nigrostriatal pathway b. Dopamine transmission in the tuberoinfundibular pathway c. Dopamine transmission in the mesolimbic pathway d. Dopamine increases throughout the basal ganglia

B

A patient who had previously reported feeling much better on her antidepressant suddenly says the "drug seems to have stopped working. This is known as: a. Tolerance b. Tachyphylaxis c. Side effect d. Adverse effect

B

A patient who has been stable on his long-acting injectable medication tells the PMHNP that he would like to quit smoking. What is the best response? a. "Good for you, I can prescribe you a nicotine patch to help." b. "Let us make an appointment as your medication dose may need to be lowered." c. "I will refer you to a smoking cessation support group." d. "I am glad you have decided to quit smoking."

B

A patient who has been stable on quetiapine (Seroquel XR) for 3 months has decided to start to drink grapefruit juice twice daily because she has heard it helps with weight loss. She calls to report that since her new diet she has been feeling fatigue and difficulty waking up in the morning. What is the best response by the PMHNP? a. "I will put in a new prescription for a lower dose of your medication." b. "Stop drinking the grapefruit juice and schedule an appointment to discuss the matter further." c. "I will prescribe you a stimulant and see you in 2 weeks." d. "You should make an appointment with your primary care provider for evaluation."

B

A patient who has been taking paroxetine for 3 years wants to come off due to sexual side effects. He had gradually tried to wean the dose on his own but noticed feelings of dizziness, fatigue, headaches, anxiety, and electric-like shocks in his head. These findings are most consistent with SSRI discontinuation. What would be a reasonable action for the PMHNP to take? a. Reassure the patient that the symptoms will go away eventually b. Prescribe the patient fluoxetine for 1 week c. Have the patient resume the paroxetine and prescribe the patient a PD5-inhibitor d. Start the patient on an antipsychotic for his somatic delusions

B

A patient with alcohol use disorder is admitted for detox in anticipation of admission to an inpatient rehabilitation facility. The patient takes metoprolol for hypertension, which he has forgotten to take today, and his last drink was 72 hours ago. Which tool should the PMHNP use to evaluate for symptoms of withdrawal? a. Hamilton Rating Scale for Depression b. Clinical Institute Withdrawal Assessment c. Vital signs d. Quick Inventory of Depressive Symptomatology

B

After a drug is absorbed the substrate binds to protein for transport. Which portion of the drug is available for therapeutic effects? a. Bound b. Unbound c. Metabolized d. Excreted

B

An uninsured patient was who discharged from the hospital on haloperidol 10 mg twice daily presents to the PMHNP for a 2-week follow-up medication check visit. On exam the patient has tachypnea, tachycardia, and tremors, the skin is hot to the touch, and is overall very rigid. What should the PMHNP do first? a. Prescribe Benadryl 25mg PO stat b. Call 911 for transfer to the emergency department c. Discontinue the Haldol d. Attempt to establish peripheral IV access

B

Neurogenesis has recently been discovered to occur in adults: a. Only in the dentate gyrus of the hippocampus b. In the dentate gyrus of the hippocampus and in the olfactory bulb c. In the dentate gyrus of the hippocampus, in the olfactory bulb, and in the lateral nucleus of the amygdala d. Throughout the brain e. Adult neurogenesis does not occurs

B

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

B

The PMHNP knows that the study of how the body absorbs, distributes, metabolizes, and excretes a medication is known as: a. Breakdown b. Pharmacokinetics c. Pharmacodynamics d. First-pass effect

B

The PMHNP prescribes fluoxetine to treat depression. Which neurotransmitter will be made readily available in the synapse? a. Dopamine b. Serotonin c. Gamma-amino benzoic acid (GABA) d. Acetylcholine

B

When explaining the means by which neurotransmitters relate to mental illness, a patient ask, "What is a neurotransmitter?" The best answer is: a. A fatty layer covering the axon b. A chemical messenger c. A nerve cell d. The space between nerve cells

B

When providing anticipatory guidance for the parents of a 23-year-old male with schizophrenia, which of the following statements is most accurate? a. Medications are most effective for the anhedonia, apathy, and lack of motivation b. Medications are most effective for hallucinations, disorganization, and delusions c. Schizophrenia is caused by the use of marijuana d. Most patients with schizophrenia can live a normal life without medication

B

When providing psychoeducation to a patient with treatment-resistant depression about electroconvulsive therapy (ECT), you tell the patient that the most common adverse effect of treatment is which of the following? a. Arrhythmia b. Amnesia c. Respiratory depression d. Psychosis

B

When providing psychoeducation to the parents of a 20-year-old male with psychosis, which of the following is considered a good prognostic indicator? a. Early onset b. Substance induced c. First degree family member with schizophrenia d. Delayed treatment with antipsychotics

B

Which of the following is considered a protective factor for suicide in a patient with schizophrenia? a. Previous attempted suicide b. Sense of purpose c. Frequent hospitalizations d. Presence of medication side effects

B

A 16-year-old female is brought to the hospital by her mother because she is complaining that her neighbors spy on her and submit their observations to the government. After evaluation, she is diagnosed with schizophrenia and prescribed risperidone. Which of the following is the appropriate target therapeutic dose for this patient? a. 0.5 mg/day b. 3 mg/day c. 6 mg/day d. 12 mg/day

B 3 mg/day: This is the recommended therapeutic dose for adolescents (ages 13 to 17) with schizophrenia.

A 52-year-old man presents to the emergency room with symptoms of hypertensive crisis after an evening dining out with friends. He is currently taking a monoamine oxidase inhibitor (MAOI). Which of the following foods must be avoided by patients taking MAOIs? a. Fresh fish b. Aged cheese c. Bottled beer d. All of these must be avoided e. None of these must be avoided

B Aged cheeses in general have a high tyramine content and must be avoided when a patient is taking an MAOI.

A 36-year-old woman with longstanding depression is currently experiencing a severe episode characterized by depressed mood, hypersomnia, lack of pleasure, and suicidality. She has not responded to multiple medication trials, including first-line agents, augmentation strategies, and a monoamine oxidase inhibitor. She has also failed to respond to electroconvulsive therapy. Her treatment team is now considering ketamine. This is based on a current leading hypothesis that posits that depression may be related to: a. Glutamate hypoactivity b. Glutamate hyperactivity c. NMDA receptor hypofunctioning d. NMDA receptor hyperfunctioning

B As evidenced by studies with ketamine, an NMDA receptor antagonist can have rapid antidepressant effects by reducing glutamate activity and thus compensating for glutamate hyperactivity.

A 38-year-old patient with depression presents with depressed mood, anhedonia, and loss of energy. These symptoms can be conceptualized as reflecting reduced positive affect; such a categorization is theoretically useful because it may direct treatment choice. Specifically, symptoms of reduced positive affect are hypothetically more likely to respond to agents that enhance: a. Serotonin and possibly dopamine function b. Dopamine and possibly norepinephrine function c. Norepinephrine and possibly serotonin function

B Because reduced positive affect is thought to be related to dopamine dysfunction and possibly norepinephrine dysfunction, enhancing one or both of these neurotransmitters would theoretically be most likely to improve these symptoms.

A 32-year-old woman with bipolar I disorder has just found out that she is 6 weeks pregnant. Her mania has been stable on a combination of lithium, valproate, and quetiapine, but she is unsure about the safety of maintaining her medications during her pregnancy. Which of the following is true regarding the use of these medications for bipolar disorder during pregnancy? a. Lithium has known teratogenic effects and is not a preferred treatment b. Lithium and valproate have known teratogenic effects and are not preferred treatments c. Lithium, valproate, and quetiapine have known teratogenic effects and are not preferred treatments

B Both lithium and valproate have known teratogenic effects. Lithium is Pregnancy Risk Category D and has evidence of increased risk of major birth defects and cardiac anomalies, especially Ebstein's anomaly, although a recent review suggested that the risk of cardiac anomalies may be over-emphasized. Valproate is also Pregnancy Risk Category D, with increased risk of neural tube defects (e.g., spina bifida) and other congenital anomalies.

A 36-year-old woman is suffering from her third major depressive episode. She has not experienced improvement despite adequate trials of several different antidepressants and is now undergoing electroconvulsive therapy (ECT). She did not respond until the 9th session, but has now shown progressive improvement following her 10th, 11th, and 12th sessions. What would be the recommended next step for this patient? a. Discontinue ECT and switch to a medication treatment b. Continue ECT until she reaches a plateau of improvement, then initiate medication treatment c. Continue ECT indefinitely (barring any significant side effects) to prevent relapse

B Existing data and expert clinical opinion support the idea that ECT response can be relatively rapid, often occurring after a few sessions. Consistent with this, the acute course of ECT treatment is typically 6-12 treatments and does not generally exceed 20 treatments. However, it is important that treatment continue until symptoms remit or plateau, because relapse rates are higher if ECT is discontinued prematurely.

A patient with bipolar depression has been treated for 6 months with lamotrigine plus an atypical antipsychotic with partial response. The decision is made to stop the atypical antipsychotic; however, during down-titration, the patient develops withdrawal dyskinesias. No treatment for the dyskinesias is initiated, and after 2 weeks, they still remain. Which of the following is true? a. If the withdrawal dyskinesias still remain after 2 weeks, they are likely to be permanent b. Her withdrawal dyskinesias may take several weeks to months to resolve

B It may take several weeks to months for the patient's withdrawal dyskinesias to resolve.

A receptor with four-transmembrane regions changes conformation as GABA binds. Which system is this process describing? a. Presynaptic transporter b. Ligand -gated ion channel c. Voltage-sensitive ion channel

B Ligand-gated ion channels are four-transmembrane region ion channels that open and close under instruction from bound neurotransmitters

A 24-year-old woman suffering from a major depressive episode (moderate) presents to your office. She has previously taken an SSRI for depression but expresses a desire to try something "natural." Which of the following has the best evidence of efficacy for treating symptoms of depression? a. Melatonin b. Omega 3 fatty acids c. Vitamin D

B Multiple meta-analyses have demonstrated modest efficacy for omega 3 fatty acids in major depressive disorder. In particular, eicosapentaenoic acid (EPA) is the effective component (vs. docosahexaenoic acid (DHA)), with 60% EPA (of total EPA+DHA) needed.

Carol is a 47-year-old patient with schizophrenia. She was taking a conventional antipsychotic but decided to stop taking it when she developed parkinsonian symptoms. Secondary to stopping her conventional antipsychotic, Carol's auditory hallucinations and paranoia returned, and she was rehospitalized. You recommend that she be started on an atypical antipsychotic. Which of the following has the lowest risk of extrapyramidal symptoms associated with it? a. Asenapine b. Iloperidone c. Olanzapine d. Paliperidone

B Of the agents listed here, iloperidone has a relatively lower risk of EPS. Other agents with a relatively lower risk of EPS include clozapine and quetiapine.

A 38-year-old woman was diagnosed with schizophrenia approximately 2 years ago and after multiple trials of different medications she has been maintained on haloperidol for the last several months with good response. Two weeks ago she began exhibiting mild motor symptoms of parkinsonism. Which of the following would be the most appropriate adjunct medication for this patient? a. Cholinesterase inhibitor b. Muscarinic 1 antagonist c. Alpha 1 adrenergic agonist d. Histamine 1 antagonist

B On the other hand, antagonism of the muscarinic 1 receptor for acetylcholine would prevent it from binding there and thus reduce its effects, potentially relieving EPS.

A 24-year-old man with bipolar disorder is being initiated on lithium, with monitoring of his levels until a therapeutic serum concentration is achieved. Once the patient is stabilized, how often should his serum lithium levels be monitored (excluding one-off situations such as dose or illness change)? a. Every 2 to 3 months b. Every 6 to 12 months c. Every 1 to 2 years d. Routine monitoring is not necessary

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

Mike is a 31-year-old patient with major depressive disorder (MDD) whose depression is responding well to the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine XR (150 mg/day). However, the patient acknowledges that he and his wife have been having relationship problems because of the patient's poor libido. The patient experienced this problem prior to being diagnosed and treated for MDD, but he has found that the venlafaxine has worsened this troubling symptom despite the fact that his mood has improved. Which of the following treatment strategies would you recommend for this patient? a. Decrease venlafaxine dose b. Switch to a norepinephrine and dopamine reuptake inhibitor (NDRI) c. Switch to a selective serotonin reuptake inhibitor (SSRI) d. Augment current venlafaxine dose with a phosphodiesterase-5 (e.g., sildenafil)

B Pharmacological agents that increase dopaminergic neurotransmission and/or decrease serotonergic neurotransmission are often effective in ameliorating sexual dysfunction. Switching to (or augmenting with) an NDRI such as bupropion would be expected to increase dopaminergic neurotransmission and improve sexual function.

A 28-year-old woman presents with a depressive episode. She has previously been hospitalized and treated for a manic episode but is not currently taking any medication. The agents with the strongest evidence of efficacy in bipolar depression are: a. Lamotrigine, lithium, quetiapine b. Quetiapine, olanzapine-fluoxetine, lurasidone c. Olanzapine-fluoxetine, lurasidone, lamotrigine d. Lurasidone, lamotrigine, lithium

B Quetiapine, olanzapine-fluoxetine, and lurasidone have all demonstrated consistent efficacy in bipolar depression and are approved for this stage of the disorder.

An excitatory signal is received at the dendrite of a pyramidal glutamate neuron. When the signal is released from the incoming presynaptic dopaminergic axon, it is received as an inhibitory signal. However, this signal is not integrated properly with other incoming signals to that neuron. Which is the most likely site at which the error of integrating this signal with other incoming signals occurred? a. Dendritic Membrane b. Soma c. Axonal Zone d. Presynaptic Zone

B Soma is the site that integrates chemical encoding of signal transduction from all incoming signals; improper signal integration is most likely at this site

A 34-year-old male recently began experiencing breast secretions while receiving perphenazine. After switching to quetiapine the secretions ceased. Which of the following is the most likely pharmacological explanation for the resolution of this side effect? a. Dopamine 2 antagonism b. Serotonin 2A antagonism c. Serotonin 2C antagonism d. Histamine 1 antagonism

B Stimulation of serotonin 2A receptors stimulates prolactin release. Since they have opposing effects on prolactin, adding serotonin 2A antagonism to dopamine 2 antagonism results in a neutral effect on prolactin and may relieve breast secretions caused by dopamine 2 antagonism alone.

A 17-year-old girl presents with symptoms of depression. She has always been a good student and a caring and responsible sister to her two younger siblings. Recently, she has become somewhat withdrawn and reports feeling sad much of the time. Her MADRS score is 29, indicating moderate depression. This patient has also gained a significant amount of weight over the past several months, is irritable, and endorses hypersomnia. There is no information regarding family history, as the patient is adopted. Although not definitive, this particular symptom profile may be more suggestive of: a. Unipolar depression b. Bipolar depression

B The patient's presentation includes multiple factors that may be more likely to occur with bipolar disorder rather than with unipolar depression. This is not definitive but does suggest caution when making treatment decisions. Although also not definitive, family history and input from someone close to the patient are generally more valuable than specific symptoms.

A 34-year-old man who has been taking a conventional antipsychotic for 6 years has begun demonstrating extrapyramidal side effects (EPS), and his clinician elects to switch him to an atypical antipsychotic with serotonin 2A antagonism. The majority of atypical antipsychotics: a. Have higher affinity for dopamine 2 receptors than for serotonin 2A receptors b. Have higher affinity for serotonin 2A receptors than for dopamine 2 receptors

B Theoretically, low EPS has been linked to high affinity for blocking serotonin 2A receptors. Because nearly all atypical antipsychotics have actions at serotonin 2A receptors, it may be beneficial to understand how stimulating or blocking these receptors can regulate dopamine release.

The direct role of transcription factors is to: a. Cause neurotransmitter release b. Influence gene expression c. Synthesize enzymes d. Trigger signal transduction cascades

B Transcription factors are proteins that bind to promoter sequences of DNA to turn gene expression on and off.

A 27-year-old male who has been treated with quetiapine for the last 8 weeks is now having his medication changed to aripiprazole. What is the recommended starting dose for aripiprazole? a. Low dose b. Middle dose c. Full dose

B When switching from quetiapine (or asenapine or olanzapine) to aripiprazole, the "pine" should be tapered over 3 to 4 weeks to allow patients to readapt to the withdrawal of blocking cholinergic, histaminic, and alpha-1 receptors. This should help reduce the risk of agitation or rebound psychosis. In addition, a benzodiazepine or anticholinergic medication can be administered to help alleviate these effects if they occur. Aripiprazole can be initiated at a middle dose and titrated up over 1 to 2 weeks, so that it reaches full dose while the pine is still being tapered. This results in short-term polypharmacy; however, the pine should ultimately be discontinued completely.

A 26-year-old woman began treatment for a major depressive episode 8 months ago. Two months into her treatment she began to experience noticeable symptom improvement, and for the last 5 months she has been nearly symptom free. According to the general consensus, her current state could be classified as a: a. Response b. Remission c. Recovery d. Relapse e. Recurrence

B When treatment of depression results in removal of essentially all symptoms, as with this patient, it is called remission for the first several months (e.g., up to 6 months).

After assessing a client with schizophrenia, you suspect that the client is experiencing an anticholinergic crisis. Which of the following would you most likely have assessed? Select all that apply. a. Dilated reactive pupils b. Blurred vision c. Ataxia d. Coherent speech e. Facial pallor f. Disorientation

B, C, F

Presynaptic reuptake transporters are a major method of inactivation for which of the following? a. Serotonin b. Serotonin and GABA c. Serotonin, GABA, and histamine Serotonin, GABA, histamine, and neuropeptides

B.

1. A 45-year-old man who takes olanzapine 5 mg twice daily for psychosis reports a perpetual sense of restlessness and an inability to sit still. He says, "sometimes it gets so bad I want to jump out of my own skin." Which of the following is the most likely explanation? a. Dystonia b. Akinesia c. Akathisia d. Tardive dyskinesia

C

A 21-year-old man had his first drink at his birthday party with friends last night. He presented the following morning to the emergency department with psychomotor agitation, cognitive impairment, depressed mood, flat affect, and anhedonia. His heart rate is 110, his blood pressure is 90/60, and he complains of abdominal pain. He received 2 L of normal saline IV and is referred to psychiatry for evaluation of mood disorder. Which of the following tests should the consulting PMHNP order given these symptoms? a. Blood alcohol level b. Urinalysis c. Urinary porphobilinogen d. Acetaminophen level

C

A 30-year-old G1P0,1 has become increasingly oddly related, neglecting self-care, sleeping much of the day, eating minimally, crying easily, and despite reassurance that her pregnancy is progressing normally, worries that she will lose the pregnancy. Which of the following medications is considered least harmful in pregnancy? a. Lithium b. Divalproex c. Sertraline d. Haloperidol

C

A 32-year-old man presents to the emergency department with acute onset disorganization, paranoid delusions, and visual hallucinations of flying bugs, which he tries to crush because he thinks they contain listening devices. The patient is accompanied by the police, who were called because the man was smashing things in a store. Which of the following can the PMHNP diagnose during the initial encounter? a. Schizophrenia b. Schizophreniform disorder c. Brief psychotic disorder d. Schizoaffectivedisorder

C

A 34-year-old man with depression characterized by depressed mood, sleep difficulties, and concentration problems has not responded well to a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor. His clinician elects to switch him to vortioxetine, which has prominent 5HT7 antagonism. What may be a primary function of these receptors? a. Regulation of serotonin-acetylcholine interactions b. Regulation of serotonin-dopamine interactions c. Regulation of serotonin-glutamate interactions Regulation of serotonin-norepinephrine interactions

C

A 36-year-old man has been readmitted five times in the past year for medication nonadherence despite the use of a long-acting injectable antipsychotic for schizophrenia. The patient is often brought in by police when bystanders report reckless behavior. Which of the following would provide him with the best chance of reduced morbidity and autonomous living? a. State hospitalization b. Supportive housing c. Court ordered assertive community treatment Psycho social clubhouse

C

A 38-year-old investment banker reveals that on weekends he visits the Delightful Dungeon and pays a dominatrix to tie him up, humiliate him, and whip him. He finds these sessions painful but very sexually arousing. He is able to become aroused and climax without this experience but finds this activity novel and has no desire to stop. Which of the following diagnosis is most likely? a. Atypical depression b. Sexual sadism c. No diagnosis d. Sexual masochism

C

A 48-year-old divorced Black woman is admitted to the inpatient psychiatric unit after a serious suicide attempt by overdosing on acetaminophen. She has been admitted seven times with similar presentations after failing multiple treatments with antidepressants. She has been unable to work and has lost interest in all activities she once enjoyed. For the last 2 weeks she has had increased sleep latency, early morning awakening, difficulty concentrating, fatigue, hopelessness, and poor appetite. Which of the following factors would make the PMHNP recommend electroconvulsive therapy (ECT) in lieu of other medication trials? a. Poor compliance with medications b. History of bipolar illness c. Melancholic depression with a history of poor response to medications Persistent depression with psychotic symptoms

C

A 68-year-old man with no past psychiatric history reports that for the last 2 weeks he believes his internal organs have been removed, and that he has no mouth and therefore does not need to eat or drink. Which of the following best describes the patient's condition? a. Schizophrenia b. Capgras syndrome c. Cotard's syndrome d. Folieadeux

C

A 70-year-old man with a history of hypertension is being evaluated for late effects of a cerebrovascular accident. Which of the following conditions is most associated with microvascular ischemia? a. Anxiety b. Obsessive compulsive disorder c. Depression d. Posttraumatic stress disorder (PTSD)

C

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

C

A drug that binds to a receptor but does not fully activate it, producing a muted biological response, is a(n): a. Agonist b. Enzyme inhibitor c. Partial agonist d. Antagonist

C

A drug that blocks receptors, inhibiting a biological response, is known as a(n): a. Partial agonist b. Inverse agonist c. Antagonist d. Agonist

C

A patient is diagnosed with major depressive disorder with the most prominent feature of apathy, anhedonia, and isolation. Which neurotransmitter is associated with the symptoms? a. Serotonin b. Gamma-amino benzoic acid (GABA) c. Dopamine d. Cannabinoids

C

A patient meeting criteria for major depressive disorder is prescribed fluoxetine 20 mg daily. The PMHNP is reviewing the chart for a meritorious negligence claim. Which of the following conditions should have been documented and excluded from the differentials before prescribing a selective serotonin reuptake inhibitor (SSRI)? a. Panic disorder b. Obsessive-compulsive disorder c. Bipolar disorder d. Generalized anxiety disorder

C

A patient who is considering electroconvulsive therapy (ECT) for resistant depression inquires as to the number of sessions she would likely require. Based on the best evidence currently available what is the best response? a. 40 b. 20 c. 10 d. 4

C

A patient with schizophrenia was discharged from the hospital on olanzapine 5 mg twice a day. He immediately resumed smoking cigarettes and escalated to one pack per day. Upon presenting for his 1- week follow-up appointment, the patient reports he is having trouble sleeping and the voices have started to return. Which of the following actions should the PMHNP take? a. Send the patient to the ED for stabilization b. Change to another antipsychotic medication, and refer to a psychiatrist c. Increase his olanzapine, and schedule a follow-up visit in 2 days Tell him to stop smoking and give him a nicotine patch

C

One of the most common electrolyte abnormalities associated with the use of psychotropic medication is: a. Hyperkalemia b. Hypercalcemia c. Hyponatremia d. Hypernatremia

C

Sasha is a 58-year-old patient with a history of depression who has been prescribed agomelatine. At present, she is relatively free of depressive symptoms, likely due in part to binding of agomelatine to what receptors in the suprachiasmatic nucleus? a. Melatonin receptors b. Serotonin 2C receptors c. Melatonin and serotonin 2C receptors

C

The PMHNP knows the relationship between drug concentration and effect on the body is known as: a. Pharmacology b. Pharmacokinetics c. Pharmacodynamics d. Physiology

C

The certified nurse midwife is evaluating a 29-year-old woman 2 weeks postpartum and finds her neglecting her self-care and minimally attentive to the baby and will not allow anyone else to care for the baby. During the visit a PMHNP is able to provide webcam consultation and liaison services. Based on the information provided, what is the priority in the management of this patient? a. Electronically prescribe an antipsychotic b. Electronically prescribe a mood stabilizer c. Admit the patient to the hospital d. Electronically prescribe an antidepressant

C

The junction between two neurons is known as the: a. Dendrite b. Node of Ranvier c. Synapse d. Soma

C

The mother of a 19-year-old male is convinced his bipolar condition was caused by his drinking and drug use. Which of the following statements is true regarding bipolar disorder? a. Patients with bipolar disorder have a better prognosis than patients with unipolar depression. b. Patients with bipolar disorder usually do not require lifelong treatment compared to patients with major depression if they abstain from drugs and alcohol. c. Bipolar disorder has a stronger genetic etiology than major depression. d. Bipolar disorder is more common than depression in the United States.

C

Which of the following as an example of a second- generation antipsychotic agent? a. Fluphenazine (Prolixin) b. Thiothixene (Navane) c. Quetiapine (Seroquel) d. Chlorpromazine (Thorazine)

C

Which of the following neurotransmitters exert inhibition over neuronal function? a. Acetylcholine b. Cannabinoids c. Gamma-amino benzoic acid (GABA) d. Dopamine

C

A 44-year-old woman with schizophrenia and a history of depression has developed tardive dyskinesia after taking haloperidol 15 mg/day for 2 years. Which of the following would be the most appropriate pharmacologic option to manage her tardive dyskinesia? a. Amantadine b. Benztropine c. Clonazepam d. Reserpine

C According to a recent review by the American Academy of Neurology, the treatments with the best evidence of efficacy for tardive dyskinesia are clonazepam and ginkgo biloba.

A 37-year-old woman with schizophrenia has failed to respond to two sequential adequate trials of antipsychotic monotherapy (first olanzapine, then aripiprazole). Which of the following are evidence-based treatment strategies for a patient in this situation? a. High dose of her current monotherapy (aripiprazole) b. Augmentation of her current monotherapy with another atypical antipsychotic c. Switch to clozapine d. A and C e. A, B, and C

C After failure of two sequential adequate trials of antipsychotic monotherapy, the recommended and evidence-based treatment strategy is to switch to clozapine.

A patient who has been taking an atypical antipsychotic for 6 months has experienced a 22-pound weight gain since baseline. Which of the following pharmacologic properties most likely underlies this patient's metabolic changes? a. Dopamine 2 antagonism b. Serotonin 2A antagonism c. Serotonin 2C antagonism d. Alpha 1 adrenergic antagonism

C Antagonism of serotonin 2C receptors is associated with increased risk for weight gain, perhaps in part due to stimulation of appetite regulated by the hypothalamus, and especially in combination with histamine 1 antagonism.

Which of the following is the most likely impetus for upregulation of D2 receptors on a striatal dopamine neuron? a. A bound receptor is taken out of circulation b. A new receptor is bound and put to use c. A D2 antagonist persistently binds to the receptor d. A D2 agonist persistently binds to the receptor

C Antagonists can oppose neurotransmitter actions, potentially signaling the neuron to upregulate synthesis of that receptor type.

A 27-year-old male who has been treated with risperidone for the last 8 weeks is now having his medication changed to quetiapine. What is the recommended switching method in this situation, assuming the need to do this expeditiously, but not urgently, as an outpatient? a. Maintain therapeutic dose of risperidone while uptitrating quetiapine to effective dose, then discontinue risperidone b. Down-titrate risperidone over several weeks while uptitrating quetiapine over the same time period c. Down-titrate risperidone over at least 1 week while uptitrating quetiapine over at least 2 weeks d. Down-titrate risperidone over at least 2 weeks while uptitrating quetiapine over 1 week

C Down-titrate risperidone over at least 1 week while uptitrating quetiapine over at least 2 weeks: Tolerability may be best if quetiapine can be titrated up over the course of 2 weeks, while keeping the estimated D2 receptor occupancy constant as the risperidone is stopped.

A 24-year-old man has just been diagnosed with schizophrenia. His clinician elects to prescribe iloperidone and begins treatment according to the dosing schedule in the label. What is the rationale for the slow dosing schedule with iloperidone? a. Minimize agitation b. Minimize sedation c. Prevent orthostatic hypotension d. Prevent gastrointestinal upset

C Iloperidone has a very slow titration schedule in order to avoid orthostatic hypotension, which is theoretically due to its potent alpha 1 antagonism.

A 39-year-old patient with major depressive disorder presents to your office after several months of trying various antidepressant drugs. It is suggested that he try augmenting his current regimen with L-methylfolate. Why might L- methylfolate boost the therapeutic efficacy of antidepressants? a. It increases synthesis of monoamines b. It increases the release of monoamines c. It both increases synthesis and inhibits metabolism of monoamines

C L-methylfolate assists in the formation of a critical cofactor for the synthesis of monoamines, known as tetrahydrobiopterin, or BH4. When L-methylfolate forms the critical amount of BH4, that BH4 can activate the enzymes tyrosine hydroxylase and tryptophan hydroxylase, which synthesize the trimonoamines serotonin, norepinephrine, and dopamine. In addition, L-methylfolate could hypothetically lead to methylation of the promoter for the gene of the enzyme COMT (catechol-O-methyltransferase), which inactivates dopamine and norepinephrine. This methylation silences the gene, and decreases the synthesis of COMT enzyme, and this reduces the metabolism of dopamine and norepinephrine.

Margaret is a 42-year-old patient with untreated depression. She is reluctant to begin antidepressant treatment due to concerns about treatment-induced weight gain. Which of the following antidepressant treatments is associated with the greatest risk of weight gain? a. Escitalopram b. Fluoxetine c. Mirtazapine d. Vilazodone

C Meta-analysis has shown that mirtazapine, an alpha 2 antagonist, may cause both short- and long-term weight gain. This is consistent with its secondary pharmacologic properties: mirtazapine is an antagonist at both serotonin 2C and histamine 1 receptors, the combination of which has been proposed to cause weight gain. However, it should be noted that average weight gain with any antidepressant is small, and rather than a widespread effect it may instead be that a small number of individuals experience significant weight gain due to their genetic predispositions and other factors.

A 24-year-old woman is hospitalized after an altercation in which she screamed at and attacked her neighbor when he knocked on her door. Her mother reports that she has been increasingly erratic recently, with emotional outbursts and impulsive behavior. Which of the following brain regions is most likely associated with these symptoms? a. Dorsolateral prefrontal cortex b. Nucleus accumbens c. Orbital frontal cortex d. Substantia nigra

C Orbital frontal cortex: Aggressive symptoms such as those exhibited by this patient are hypothetically associated with impairment in impulse control, which is largely regulated by the orbital frontal cortex.

The labels for antidepressants (SSRIs in particular) include several warning statements about possible adverse effects of use during pregnancy. Which of the following has the most evidence suggesting an increased risk with antidepressant use during pregnancy? a. First trimester cardiac malformations b. Persistent pulmonary hypertension of the newborn (PPHN) c. Postnatal adaptation syndrome (PNAS) d. Long-term neurodevelopmental abnormalities

C Postnatal adaptation syndrome (PNAS) in infants is characterized by irritability, abnormal crying, tremor, lethargy, hypoactivity, decreased feeding, tachypnea, and respiratory distress. PNAS has most often been reported with paroxetine, fluoxetine, or venlafaxine, but could theoretically occur with any antidepressant.

A 44-year-old male with schizophrenia has been taking an antipsychotic medication since initial diagnosis 12 years ago. He has recently begun experiencing difficulty with fluid movement of his arms as well as involuntary facial grimaces. Which of the following likely underlies these symptoms? a. Upregulation of serotonin 2A receptors b. Downregulation of serotonin 2A receptors c. Upregulation of dopamine 2 receptors d. Downregulation of dopamine 2 receptors

C Tardive dyskinesia is associated with upregulation of dopamine 2 receptors. This upregulation can occur following long-term blockade of dopamine 2 receptors such as may occur with long-term antipsychotic treatment, particularly conventional antipsychotic treatment.

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

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

A 22-year-old man with a history of cognitive and social delay has just been diagnosed with schizophrenia. In early elementary school his language development was normal but he had difficulty reading and was diagnosed with a learning disability. He had increased academic difficulty beginning in high school but did graduate and began working at a supermarket. However, he began to exhibit difficulty functioning, including losing things, trouble following simple directions at work, disorganization, and deterioration in communication. These impairments led to his dismissal from his job; 6 months later he experienced a psychotic episode and was diagnosed with schizophrenia. What pattern of cognitive functioning would you expect for this patient over the long-term course of his illness? a. Progressive decline in cognitive functioning beyond what is expected with normal aging, with severity of cognitive symptoms independent of psychotic symptom status b. Progressive decline in cognitive functioning beyond what is expected with normal aging, with severity of cognitive symptoms fluctuating with psychotic symptom status c. No further decline in cognitive functioning beyond what is expected with normal aging, with severity of cognitive symptoms independent of psychotic symptom status d. No further decline in cognitive functioning beyond what is expected with normal aging, with severity of cognitive symptoms fluctuating with psychotic symptom status

C ike most individuals who ultimately develop schizophrenia, this man had cognitive impairment from an early age and showed substantial further decline in cognitive functioning during late adolescence (during the prodrome phase). However, a large body of research shows that after disorder onset cognitive deficits generally remain stable over the course of the disorder, and do not worsen beyond that expected with normal aging. Additionally, cognitive impairment in schizophrenia does not seem to be correlated with psychotic symptoms.

Agonists cause ligand-gated ion channels to: a. Open wider b. Open for longer duration of time c. Open more frequently d. A and B e. A and C

C.

Which of the following are involved in regulating neurotransmission via excitation-secretion coupling? a. Voltage-sensitive sodium channels b. Voltage sensitive calcium channels c. Both A and B d. Neither A nor B

C. Propagation of an action potential to the axon terminal is mediated by voltage-sensitive sodium channels. Influx of sodium through voltage-sensitive sodium channels at the axon terminal leads to opening of voltage-sensitive calcium channels, also at the axon terminal. Influx of calcium through the open voltage- sensitive calcium channels leads to docking of synaptic vesicles and secretion of neurotransmitter into the synapse.

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

D

A 25-year-old female is referred by her women's health nurse practitioner for evaluation. The patient reports that the week before her period every month she feels angrier and is increasingly irritable, and has difficulty concentrating, low energy, and a desire to sleep more and eat more ice cream. These symptoms all seem to stop the week after her period. What is the most likely diagnosis? a. Cyclothymic b. No diagnosis; normal female behavior c. Dysthymia d. Premenstrual dysphoric disorder

D

A 33-year-old female with history of schizoaffective disorder was brought to the emergency department by police for disruptive behavior, auditory hallucinations, and self-neglect. The patient screams that she had stopped taking her medication. The PMHNP orders Haldol 5 mg PO, which the patient willingly accepts. An hour later the patient demonstrates an involuntary upward deviation of the eyes, and hiccoughs. Which of the following should the PMHNP do first? a. Draw stat labs for complete blood count, creatinine phosphokinase b. Stat EKG c. Haldol 5mg IM stat d. Benadryl 25 mg IV push

D

A 34-year-old man has recently been diagnosed with bipolar disorder, 6 years after his symptoms began. He has had no mood stabilizing treatment in that time. According to the kindling model and allostatic load hypothesis, what progressive pattern of illness would you expect this patient to have exhibited over the course of the last 6 years? a. Longer interval between episodes, worsened emotionality, minimal change in cognitive impairment b. Shorter interval between episodes, worsened emotionality, minimal change in cognitive impairment c. Longer interval between episodes, worsened emotionality, worsened cognitive impairment d. Shorter interval between episodes, worsened emotionality, worsened cognitive impairment

D

A 45-year-old man presents for a follow-up visit after starting on an SSRI 2 weeks ago for major depressive disorder. Which assessment tool would be the best indicator of progress? a. Geriatric Depression Scale b. The Young Mania Rating Scale c. Yale-Brown Obsessive Compulsive Scale d. Quick Inventory of Depressive Symptomatology

D

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

D

A 61-year-old female is referred to the psychiatric emergency department with complaints of abdominal pain, nausea, and bloody stools. Despite an extensive evaluation, no underlying cause for her symptoms can be identified and her hemoglobin is normal. The patient insists there is something physically wrong with her. Which of the following best describes her condition? a. Persecutory delusion b. Grandiose delusion c. Jealous delusion Somatic delusion

D

A client hospitalized for treatment of schizophrenia has been receiving olanzapine (Zyprexa) for the past 2 months. The nurse would be especially alert for which of the following? a. Weight loss b. Hypertension c. Diarrhea d. Diabetes

D

A client who has a major depressive episode tells the nurse that for the past 2 weeks, he has been hearing voices and at times thinks that someone is following him. History reveals that he had these alternating symptoms before along with times when he has experienced neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which of the following? a. Paranoid schizophrenia b. Undifferentiated schizophrenia c. Brief psychotic disorder d. Schizoaffective disorder

D

After being treated with sertraline for over a year, a 23-year-old man continues to suffer from significant symptoms of depressed mood and intermittent anxiety. He has recently been admitted to a substance dependence treatment program for alcohol use (up to 15 drinks per day for the last 2 years) and has been sober for 2 weeks. Psychotherapy within the program reveals that his depressed mood predated the start of his heavy drinking. There is no current suicidal ideation and no history of attempted suicide. At this point, the patient has discontinued sertraline by choice. Is he a reasonable candidate for transcranial magnetic stimulation (TMS)? a. No; he has only had one medication trial, and at least two failed trials are required before considering TMS b. No; there is possible alteration of consciousness due to the need for anesthesia, which would interfere with his psychotherapy c. No; his recent alcohol dependence is a contraindication for TMS d. Yes; he fulfills criteria to qualify for a trial of TMS

D

The PMHNP is evaluating a 37-year-old man who takes a long-acting injectable paliperidone palmitate, who reports that he is glad to not have to take a pill every day. He reports that often, for the first few days after he gets his injection, he notices that he walks slower than usual and with a shuffling gait, feels stiffness in his joints, and people think he is depressed but the symptoms dissipate as the month progresses. Which of the following best describes this condition? a. Dystonia b. Akinesia c. Akathisia d. Pseudo-Parkinson's

D

The PMHNP is monitoring a serum drug level for a medication with a 24-hour half-life. How many hours will it take to reach steady state? a. 48hours b. 72hours c. 96hours d. 120hours

D

What is the fatty layer that prevents interference and increases the speed of impulse transmission along the axon? a. Dendrite b. Axon c. Synapse d. Myelin sheath

D

When assessing a client for possible disordered water balance, you check the clients urine specific gravity. Which result would lead you to suspect that the client is experiencing severe disordered water balance? a. 1.020 b. 1.011 c. 1.005 d. 1.002

D

Which region of the brain is associated with sensory integration, spatial awareness, and conscious awareness of the opposite side of the body? a. Occipital lobe b. Wernicke's area c. Broca's area d. Parietal lobe

D

You are caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential to monitor the client for which of the following? a. Weight loss b. Torticollis c. Hypoglycemia d. Tardive dyskinesia

D

You are caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would you prescribe for this client? a. Lithium b. Haloperidol c. Chlorpromazine d. Clozapine

D

Reggie is a 30-year-old male patient with schizophrenia. He is currently taking iloperidone 24 mg/day as well as aripiprazole 15 mg/day but continues to experience visual hallucinations. To improve this patient's psychosis, it is likely necessary to further increase the blockade of dopamine D2 receptors. Which treatment strategy is likely the best course of action? a. Increase iloperidone dose while keeping aripiprazole dose the same b. Increase iloperidone and aripiprazole doses c. Increase aripiprazole dose while keeping iloperidone dose the same d. Maintain iloperidone dose and discontinue aripiprazole

D Because aripiprazole may be reducing the level of D2 blockade relative to iloperidone monotherapy, the best strategy for increasing D2 blockade (and correspondingly improving psychotic symptoms) may be to use monotherapy.

A 49-year-old clerk with bipolar disorder has been maintained on 900 mg/day of lithium. She was doing well for a long time and had even been able to lose the weight she had initially gained with lithium. She broke up with her boyfriend 5 months ago and has been feeling depressed ever since. You augment her with 300 mg/day of quetiapine, but after several weeks she complains of weight gain and wants to change medications. Blockade of which two receptors was most likely responsible for this weight gain induced by quetiapine? a. Serotonin 2A and muscarinic 3 b. Dopamine 2 and alpha 1 adrenergic c. Muscarinic 1 and serotonin 6 d. Serotonin 2C and histamine 1

D Blockade of serotonin 2C receptors and histamine 1 receptors has been linked to weight gain.

What is epigenetics? a. Acquired trait coded for by a change in DNA sequence b. Acquired trait not coded for by a change in DNA sequence c. Heritable trait coded for by a change in DNA sequence d. Heritable trait not coded for by a change in DNA sequence

D Genetics is the sequence of DNA that is inherited. Epigenetics is a parallel process that determines whether a given gene is expressed into its RNA or is silenced. Thus, epigenetics is a heritable phenotype not coded for by a change in DNA sequence. A good example of epigenetics is cell differentiation. Epigenetic molecular switches turn genes on and off by modifying the structure of chromatin in the cell nucleus. Chromatin is an octet of proteins called histones around which your DNA is wrapped. DNA contains genes as well as promoters that tell genes when to make RNA, which can then go on to make proteins. To silence genes, histones or gene promoter DNA sequences can be methylated. Methylation is often followed by another chemical process called deacetylation, which occurs at histones and inactivates nearby genes. To activate genes, the reverse is done: histones and genes are demethylated and histones are acetylated. All of these processes are regulated by numerous enzymes: methylation is also regulated by the availability of methyl donors.

A 23-year-old female presents complaining that her short temper has lost her important friendships and other relationships. She has already gotten in significant trouble in the dorms in college, stealing a fire extinguisher, driving on the common area lawn, and hostilely addressing a professor. Which of the following monoamine projections may account for her recent behavior? Projections to the: a. Ventromedial prefrontal cortex b. Orbital frontal cortex c. Striatum d. A and B e. A and C f. B and C

D Projections of all three monoamines to the ventromedial prefrontal cortex are thought to be associated with symptoms of mania such as irritable mood. Projections of all three monoamines to the orbital frontal cortex are thought to be associated with symptoms of mania, such as risk taking and impulsive control.

What is the correct order and direction of ion flow into and out of a neuron experiencing an action potential? a. Na+ in, K+ out, Ca2+ in b. Ca2+ in, K+ out, Na+ in c. K+ in, Na+ in, Ca2+ in d. Na+ in, Na+ out, K+ out e. Ca2+ in, Na+ out, K+ out f. K+ in, Ca2+ in, Na+ out

D Sodium enters the cell followed by an influx of calcium; potassium exits the neuron at the end of the action potential, restoring the baseline electrical charge in the cell.

A 24-year-old female patient, who recently moved from Germany, presents to your office during a manic episode that initiated following abrupt discontinuation of her medication as she ran out of her prescription. She informs you that she had been diagnosed with rapid-cycling bipolar disorder, and wants to be prescribed the same medication she used to take in Germany but does not remember the generic name of the medication. She gives you the following information: she was on 1250 mg/day; she gained weight when she started it, which she did not like, but she liked the sedating effects of the drug, which helped calm her down and sleep at night. Her German doctor had told her she could experience the following side effects: hair loss, hepatotoxicity, and seizure upon abrupt withdrawal. Also she knows that she should consider switching medications when she intends to become pregnant, as the medication can lead to birth defects. Which medication was she most probably taking? a. Lamotrigine b. Gabapentin c. Aripiprazole d. Valproate

D Valproate is one of the first-line treatments for rapid-cycling bipolar disorder, and can induce all the side effects mentioned by the patient. The dose range is 1200-1500 mg/day for mania, and rapid discontinuation increases the risk of relapse.

Denise is a 56-year-old perimenopausal patient with a history of depression. Her depressed mood seems to be responding to her current treatment with the selective serotonin reuptake inhibitor (SSRI) fluoxetine (40 mg/day); however, she is troubled by hot flashes and night sweats, and she reports some residual depressed mood. Which treatment strategy is likely to optimize this patient's chance for remission? a. Maintain current fluoxetine dose b. Decrease fluoxetine dose c. Switch to a different selective serotonin reuptake inhibitor (SSRI) d. Switch to a serotonin and norepinephrine reuptake inhibitor (SNRI)

D Vasomotor symptoms, including hot flashes and night sweats, are associated with estrogen fluctuations, such as those that occur during the perimenopausal period of the female lifespan. Estrogen fluctuations lead to dysregulation of the serotonergic and noradrenergic systems that are thought to mediate both vasomotor symptoms and depression. Vasomotor symptoms may signal vulnerability to the onset or recurrence of a major depressive episode; this is not surprising because the presence of vasomotor symptoms indicates that estrogen is in flux even if depressive symptoms are responding to antidepressant treatment. Although SSRIs may have some efficacy in the treatment of both depression and vasomotor symptoms, SNRIs have been shown to be more effective and are the treatment of choice for patients with these symptoms.

A 28-year-old man was recently diagnosed with schizophrenia. He has a body mass index of 30, fasting triglycerides of 220 mg/dL, and fasting glucose of 114 mg/dL. Which of the following is least likely to worsen his metabolic profile? a. Olanzapine b. Quetiapine c. Risperidone d. Ziprasidone

D Ziprasidone in general seems to be weight neutral and has been shown to lower triglyceride levels. It is therefore a recommended choice for individuals for whom metabolic issues are a primary concern.

A receptor synthesized with an erroneous amino acid sequence is sent via fast anterograde transport to its axonal destination. If you want to find the original site of error, which organelle would you elect to observe? a. Free polysome b. Golgi apparatus c. Mitochondria d. Rough endoplasmic reticulum

D. The rough endoplasmic reticulum, or membrane-bound ribosomes, is the site of integral protein synthesis; such proteins are destined for membrane insertion and travel via fast transport

Janet is a 43-year-old patient with bipolar disorder. She is currently depressed with some features of hypomania. Practice guidelines from the International Society for Bipolar Disorders (ISBD) recommend treatment with an antidepressant in patients with bipolar disorder under the following conditions: a. As adjunct for acute bipolar I or II depressive episode with ≥ 2 concomitant manic symptoms, psychomotor agitation, or rapid cycling b. As adjunct during manic and depressive episodes with mixed features c. As adjunct in patients with predominantly mixed states d. All of the above e. None of the above

E

A 28-year-old woman with bipolar disorder recently began taking a mood stabilizer and has experienced improvement in her symptoms. Which of the following are mechanisms by which different mood stabilizers may prevent mitochondrial dysfunction in bipolar disorder? a. Increasing levels of anti-apoptotic proteins b. Decreasing levels of pro-apoptotic proteins c. Increasing levels of key antioxidants d. A and B e. A, B, and C

E Both lithium and valproate have been shown to increase levels of the anti-apoptotic protein Bcl-2, thus maintaining the balance of pro- and anti-apoptotic proteins, restoring the integrity of the mitochondrial membrane, and preventing release of cytochrome C. Some atypical antipsychotics may reduce elevated levels of the pro-apoptotic protein Bax. Lithium and valproate have both been shown to increase levels of the antioxidant glutathione, which may help reduce the presence of free radicals and thus prevent activation of the mitochondrial pathway of apoptosis.

A 44-year-old man taking paroxetine for depression reports experiencing sexual dysfunction. He opts to discontinue pharmacotherapy, at which time he experiences akathisia and dizziness. Which of the following properties may be responsible for the side effects and withdrawal effects that he has experienced? a. Inhibition of CYP450 3A4 b. Inhibition of nitric oxide synthetase (NOS) c. Anticholinergic actions d. A and B e. B and C

E Inhibition of NOS may contribute to the sexual dysfunction this patient has experienced. Anticholinergic actions of paroxetine may be responsible for the patient's experience of akathisia and dizziness due to anticholinergic rebound when paroxetine is discontinued.

N-methyl-D-aspartate (NMDA) receptors are activated by: a. Glutamate b. Glycine c. Depolarization d. Glutamate and glycine e. Glutamate and depolarization f. Glycine and depolarization g. Glutamate, glycine, and depolarization

G. N-methyl-D-aspartate (NMDA) receptors are ligand-gated ion channels that regulate excitatory postsynaptic neurotransmission triggered by glutamate. In the resting state, NMDA receptors are blocked by magnesium, which plugs the calcium channel. Opening of NMDA glutamate receptors requires the presence of both glutamate and glycine, each of which bind to a different site on the receptor. When magnesium is also bound and the membrane is not depolarized, it prevents the effects of glutamate and glycine and thus does not allow the ion channel to open. In order for the channel to open and permit calcium entry, depolarization must remove magnesium while both glutamate and glycine are bound to their sites.