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NURS-6630 Midterm Exam
NURS-6630 Midterm Exam

Question 1

Alprazolam, phenobarbital, and alcohol all bind allosterically to GABAA receptors. What occurs to the GABAA receptor when these substances bind to the receptor?


Response Feedback:
The receptor becomes more sensitive to GABA. GABA is the major inhibitory neurotransmitter within the CNS.

Question 2

A 27-year-old female presents to your emergency room today with a rash that started about 1 week ago and has now spread to covering her whole body. She has a past medical history significant for type 2 diabetes, hypertension, and bipolar disorder. The patient reports, “The only thing that is different is that I’ve been on this new medication for my bipolar for a few weeks.” Of the following medications, which one is likely to be causing this severe rash?


Response Feedback:
Lamotrigine can cause a severe rash than can be life threatening

Question 3

You have been consulted to evaluate a 72-year-old male with a past medical history significant for atrial fibrillation and COPD with a new diagnosis of major depression disorder. Based on his comorbid conditions, what antidepressant would you recommend as first-line?


Response Feedback:
(Options C & D are both TCA antidepressants and, based on the patient’s age and comorbid conditions, a TCA would likely result in more side effects, such as increased fall risk due to potential for orthostatic hypotension and anticholinergic-related side effects. In addition, patient has a history for cardiac abnormalities due to A. fib diagnosis – TCAs result in electrocardiographic changes in susceptible individuals, therefore, would likely avoid. Choice B is used more for ADHD purposes than as an antidepressant)
Page numbers used: Page 39 for TCA side-effect profile

Question 4

Austin is one of your clients and he asks you why exercise makes him feel better and lifts his mood. You tell him that his body is releasing _____________ which you know is a naturally occurring _______________.


Response Feedback:
The client is releasing a naturally occurring opioid (endorphins) that are considered peptides. The other neurotransmitters mentioned are not released during exercise and do not match the correct classification

Question 5

What is the therapeutic plasma level of carbamazepine?

Question 6

Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered?

NURS-6630 Midterm Exam Question 7

Which of the following symptoms is NOT part of the diagnostic features for bipolar disorder?


Response Feedback:
“Psychosis is not represented in the diagnostic features for BPD.”
– “Psychosis typically resolves along with the mood symptoms, though diagnostic criteria acknowledge that psychotic symptoms may linger beyond the end of the episode.”

Question 8

When initiating lithium, how long should you wait before checking a lithium level? What is the therapeutic goal level of lithium?

Question 9

R.J. never felt relief from his depressive symptoms, even after appropriate time and dose titration of Venlafaxine. He was switched to Bupropion 150 mg about 2 months ago and is following up with you today. He reported feeling “great” and that his relationship with his girlfriend is “better than ever now.” Because he is feeling so well at this time, he is wondering when he can stop taking Bupropion. How long must the patient be symptom-free before he may begin a trial to taper off the antidepressant therapy?


Response Feedback:
“Therefore, in treatment-responders, most experts favor a continuation of antidepressant therapy for a minimum of 6 months following the achievement of remission.”

Question 10

Which of the following statements below is NOT considered an appropriate treatment strategy for treatment-resistant depression?


Response Feedback:
“Combination of an SSRI OR an SNRI with a norepinephrine-dopamine re-uptake inhibitor (bupropion) or a serotonin-norepinephrine antagonist (mirtazapine or mianserin) is a commonly used combination”

Question 11

The serotonin system is involved in many processes in psychiatry, including, most prominently, mood, sleep, and psychosis. Of the following neurons listed, from where is serotonin synthesized?


Response Feedback:
under serotonin subheading and figure 1-18 on page 16:
Locus Coeruleus: Norepinephrine
Nucleus basalis: cholinergic neurons
Substantia Nigra: dopamine Ventral
Tegmental area: dopamine

Question 12

In order for the NMDA receptor to fully open and allow an influx of calcium, both glutamate and glycine must bind to cause a depolarization of the cell that will ultimately displace which ion? Is the NMDA receptor an ionotropic or metabotropic receptor?

Question 13

Which neurotransmitter is considered the major inhibitory neurotransmitter?

Question 14

It is appropriate to start lamotrigine in combination with another atypical antipsychotic in treatment of an acute manic episode in bipolar disorder.


Response Feedback:
“Lamotrigine has also been extensively studied in bipolar depression as well….”

Question 15

Which statement is TRUE regarding the use of selective serotonin reuptake inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) in patients with Generalized Anxiety Disorder?


Response Feedback:
“Because the SSRI/SNRIs have the potential to cause initial restlessness, insomnia, and increased anxiety, and because the patients are commonly sensitive to somatic sensations, the starting doses should be low, typically half (or less) of the usual starting dose….”

Question 16

Which anticonvulsant below induces its own metabolism over time?

Question 17

What is the strongest established risk factor for bipolar disorder?


Response Feedback:
“The strongest established risk factor for BPD is a family history of BPD.”

Question 18

Close-ended questions will help identify when patients are taking medications incorrectly.

Question 19

K. B. is a 28-year-old male who was started on Venlafaxine 75 mg about 2 weeks ago and is now calling you asking how long it should take for this medication to begin to work. He is concerned his girlfriend will leave him if he doesn’t get better quickly. What is the appropriate amount of time to allot to see a therapeutic response?


Response Feedback:
“It has been consistently observed and reported that remission of depression often requires 4 weeks of treatment or more;” Page 33: “Use of antidepressant for at least 6–12 weeks to determine whether it is helping or not”

Question 20

Is this a TRUE or FALSE statement? The following patient case is considered an example of treatment-resistant depression.
B. B. is a 26-year old-female at your clinic today with the diagnosis, “treatment-resistant depression.” She is currently on Bupropion 300 mg daily and has been at this dose for 6 weeks with no alleviation in depressive symptoms.
She has trialed the following medications in the past with treatment duration listed:
– Paroxetine 40 mg daily for 6 weeks
– Citalopram 20 mg daily for 2 weeks


Response Feedback:
“At least one trial with an antidepressant with established efficacy in MDD (with sufficient duration and doses) is considered to be adequate antidepressant treatment.”

Question 21

A patient presents to your clinic with generalized anxiety disorder. Her past medical history is significant for type II diabetes and uncontrolled hypertension. Which of the following agents would be least appropriate to start her on?


Response Feedback:
Venlafaxine has been associated with increased hypertension and should not be used as an initial treatment option.

Question 22

Which one of the anticonvulsants mentioned below has sufficient data to support its use in bipolar disorder?


Response Feedback:
Carbamazepine has data to support its use in the treatment of bipolar disorder. The other medications listed do not have data to support the use in any phase of bipolar disorder.

Question 23

Scott is a 70-year-old man that is taking citalopram 40 mg daily. You discuss changing citalopram to another medication or decreasing the dose. He is hesitant to change medications since citalopram works for him. You end up decreasing his dose to 20 mg/day. He asks why you are wanting to change his medication or lower his dose. Which of the following reasons is the main reason you made the decision to decrease his dose.


Response Feedback:
A maximum daily dose of 20 mg/day is recommended in patients greater than 60 years of age due to the increased risk of QT prolongation.

Question 24

A 32-year-old males calls you complaining of decreased libido since starting Paroxetine 20 mg 2 weeks ago. He reported stopping the medication 1 day ago and is now experiencing extreme irritability and nervousness. He wishes to stop this medication due to side effects. What do you recommend?


Response Feedback:
under selective serotonin re-uptake inhibitors discontinuation syndrome subtitle: “The risk of such adverse events occurring seems to be inversely related to the half-life of the SSRI, with fluoxetine reported as having a significantly lower risk than paroxetine in two studies. For more severe discontinuation-related adverse events, re-institution of the SSRI and slow taper may be necessary to alleviate these symptoms.”

Question 25

Patient is a 59-year-old male with a past medical history significant for bipolar disorder I, hypertension, and COPD. He calls your clinic today complaining of extreme fatigue and a new tremor in his hand. He reports starting lithium 600 mg at bedtime about 5 days ago and thinks that may be the cause. What is the appropriate next step for this patient?


Response Feedback:
“Other bothersome adverse effects” Patient is likely experiencing lithium toxicity and labs should be verified first before continuing with other treatments for the tremor.

Question 26

Which answer choice includes all the components of patient-focused interventions to enhance adherence?
I.         Education
II.         Motivation
III.         Skills
IV.         Logistics

NURS-6630 Midterm Exam Question 27

You are currently evaluating a patient with major depressive disorder. One of his major complaints is insomnia. He states that he is awake all night and cannot get any rest. You decide to prescribe an antidepressant that will help his depression and his insomnia. The best option is _______________.


Response Feedback:
The best option for this patient is trazodone. Trazodone is helpful in patients that have depression and insomnia. Trazodone is taken at night to help the patient obtain sleep/rest.

Question 28

Choose the appropriate pair regarding acetylcholine receptors.


Response Feedback:
“There are two classes of ACh receptors: muscarinic and nicotinic. While muscarinic receptors are G-protein-coupled, nicotinic receptors are ion channels, which allows for rapid influx of NA+ and Ca2+ into the post-synaptic neuron.”

Question 29

Which of the following is an appropriate strategy for managing treatment-resistant depression?

Question 30

Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY.


Response Feedback:
under pharmacokinetics and pharmacodynamics subtitle
– “NSAIDs or other COX-2 inhibitors may decrease renal blood flow and thereby increase lithium levels by up to 25%.”
– “Therefore, thiazide diuretics, which act distally, will tend to increase lithium levels by up to 50% while those that act more proximally generally have less of an effect on lithium levels.”

Question 31

M. M. is 27-year-old female student pharmacist who presents to the ER after experiencing extreme lightheadedness during her fourth-year seminar presentation. Her vitals are as follows: BP (107/65) and HR of 45. What medication below is likely the cause of these symptoms?


Response Feedback:
“The use of beta-blockers may be associated with orthostatic hypotension, lightheadedness, bradycardia, and nausea.”

NURS-6630 Midterm ExamQuestion 32

Which of the following medications is best to AVOID in maintenance treatment of bipolar disorder and why?


Response Feedback:
“As noted previously, antidepressants may contribute to an increase in mood episode frequency.”

Question 33

John presents with both autonomic symptoms and physical hyperarousal after abruptly stopping his chronic opioid therapy. He claims that he is afraid of taking his medication because of what he is seeing on the news regarding opioid-related deaths. You know that John is experiencing symptoms due to an increase in norepinephrine. You decide to treat John with a medication to dampen the symptoms of opioid withdrawal. Which medication do you prescribe John?


Response Feedback:
Clonidine dampens the symptoms associated with opioid withdrawal. The stimulation of the alpha-2 adrenoreceptors activate an inhibitory neuron.

Question 34

Which of the following medications used for treatment of bipolar disorder may increase stroke risk among older patients, particularly those with dementia?


Response Feedback:
“Notably, pharmacovigilance studies suggest that atypical antipsychotics may increase stroke risk among older patients, particularly those with dementia, so use of SGA requires more caution in this group.”

Question 35

Choose the appropriate statement regarding lamotrigine dosing.


Response Feedback:
Carbamazepine induced metabolism of lamotrigine – increase dose of lamotrigine; Valproate may inhibit clearance of lamotrigine, so dose reduction of lamotrigine is needed

Question 36

Jamie has major depressive disorder and you decide to prescribe an SSRI. Jamie wants to make sure her medication is covered by her insurance plan. You review a list of SSRIs and notice that one medication listed on the list is not FDA-approved for the treatment of depression. Which of the following medications do you decide to NOT prescribe for Jamie’s depression?


Response Feedback:
Only one of the SSRIs, fluvoxamine, is not approved for the treatment of depression in the United States, as it is approved only for the treatment of obsessive-compulsive disorder (OCD).

Question 37

Which of the following syndromes is characterized by disorientation + confusion, agitation, fever, diarrhea, and ataxia? This syndrome can occur when an MAOI is given with an SSRI


Response Feedback:
The serotonin syndrome is characterized by alterations in cognition (e.g., disorientation and confusion), behavior (e.g., agitation and restlessness), autonomic nervous system function (e.g., fever, shivering, diaphoresis, and diarrhea), and neuromuscular activity (e.g., ataxia, hyperreflexia, and myoclonus). Since MAO enzymatic activity requires approximately 14 days to be restored, such food or medications should be avoided for 2 weeks after the discontinuation of an irreversible MAOI (“MAOI washout period”). Serotonergic and dopaminergic antidepressants are typically discontinued 2 weeks before the initiation of an MAOI, with the exception of fluoxetine, which needs to be discontinued 5 weeks in advance due to its relatively longer half-life.

Question 38

Which of the following medications are known as selective serotonin re-uptake inhibitors (SSRIs)?
i.         Nortriptyline
ii.         Citalopram
iii.         Duloxetine
iv.         Fluoxetine
v.         Venlafaxine

Question 39

Of the following medications, which ones are considered first-line in treatment of an acute manic episode of bipolar disorder (assuming monotherapy)?
.         Lithium
I.         Fluoxetine
II.         Aripiprazole
III.         Risperidone
IV.         Ziprasidone
V.         Venlafaxine
VI.         Quetiapine
VII.         Valproate

Question 40

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