NURS-6630N,Approaches to Treatment.2020 Winter Qtr 11/30-02/21...QUESTIONS AND ANSWERS..

disorder who also suffer from an alcohol use disorder? Response Feedback: “Suggested that treatment with the SSRI paroxetine decreased the anxiety and may have reduced the alcohol use as well” M. B. was just diagnosed with Generalized Anxiety Disorder and pharmacotherapy is needed. Which of the following would be a first-line treatment option for M. B.? i. Duloxetine ii. Quetiapine iii. Diazepam iv. Escitalopram Response Feedback: “As is true for panic and the other anxiety disorders, the SSRIs and SNRIS are generally considered first-line agents for the treatment of GAD because of their favorable side effect profile….” 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 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.” 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.” It is appropriate to start lamotrigine in combination with another atypical antipsychotic in treatment of an acute manic episode in bipolar disorder. Response Feedback: “Lamotrigine has also been extensively studied in bipolar depression as well….” • Question 16 Which antiepileptic drugs should we avoid in pregnant women in the treatment of bipolar disorder? i. Depakote ii. Lamotrigine iii. Topiramate iv. Carbamazepine v. Gabapentin Response Feedback: All the others listed except for lamotrigine are not used in treatment of bipolar disorder. • Question 17 A 23-year-old female was just diagnosed with major depressive disorder and is being started on escitalopram 10 mg daily. The patient should be counseled about which Black Box warning? Response Feedback: “In 2004, the FDA asked manufacturers of almost all the new antidepressant drugs to include in their labeling a warning statement that recommends close observation of adult and pediatric patients treated with these drugs for worsening depression or the emergence of suicidality." • Question 18 Which statement is TRUE regarding the use of selective serotonin reuptake inhibitors (SSRI)/serotonin-norepinephrine reuptake inhibitors (SNRI) in patients with Generalized Anxiety Disorder? Response Feedback: “Because the SSRI/SNRIs have the potential to cause initial restlessness, insomnia, and increased anxiety, and because the patients are commonly sensitive to somatic sensations, the starting doses should be low, typically half (or less) of the usual starting dose….” • Question 19 Which of the following statements below is NOT considered an appropriate treatment strategy for treatment-resistant depression? Response Feedback: “Combination of an SSRI OR an SNRI with a norepinephrine-dopamine re-uptake inhibitor (bupropion) or a serotonin-norepinephrine antagonist (mirtazapine or mianserin) is a commonly used combination” • Question 20 Which atypical antipsychotic(s) require a meal for better absorption? i. Quetiapine ii. Ziprasidone iii. Asenapine iv. Olanzapine v. Lurasidone Response Feedback: - Ziprasidone – best with a fatty meal - Lurasidone – best with a meal of at least 350 calories (no effect of fat composition) • Question 21 Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY. Response Feedback: under pharmacokinetics and pharmacodynamics subtitle - “NSAIDs or other COX-2 inhibitors may decrease renal blood flow and thereby increase lithium levels by up to 25%.” - “Therefore, thiazide diuretics, which act distally, will tend to increase lithium levels by up to 50% while those that act more proximally generally have less of an effect on lithium levels.” • Question 22 Which of the following are NOT primary target(s) symptom for antipsychotic agents in schizophrenia? i. Depression, anxiety, demoralization, suicidality, excitability, and agitation ii. Delusions, hallucinations, disorganized thoughts iii. Affective flattening, alogia, avolition, anhedonia, social withdrawal iv. Attention, memory, and executive functions Response Feedback: “For schizophrenia, the primary target symptoms for antipsychotic agents fall into three categories: psychotic symptoms (e.g., hallucinations, delusions, disorganization); agitation (e.g., distractibility, affective lability, tension, increased motor activity); and negative symptoms (e.g. apathy, diminished affect, social withdrawal, poverty of speech.” AND “Although cognitive deficits are an important contributor to disability in schizophrenia, cognitive deficits usually are not considered a target for antipsychotic agents because they are not very responsible to current agents.” • Question 23 Of the following antipsychotic medications listed below, which one has a Black Box Warning for seizure, agranulocytosis, and seizures? Response Feedback: Box 7-5 * indicated clozapine-specific black box warnings • Question 24 Which neurotransmitter is considered the major inhibitory neurotransmitter? • Question 25 A 27-year-old female presents to your emergency room today with a rash that started about 1 week ago and has now spread to her whole body. She has a past medical history significant for type 2 diabetes, hypertension, and bipolar disorder. The patient reports, “The only thing that is different is that I’ve been on this new medication for my bipolar for a few weeks.” Of the following medications, which one is likely to be causing this severe rash? • Question 26 Glia cells play a supportive role in the neuron. A few of the functions of the glial cells include providing nutrition, maintaining homeostasis, stabilizing synapses, and myelinating axons. The glial cells are categorized as microglia or macroglia. Of the macroglia cells, which one plays a role in myelinating axons, which may contribute to mood disorders if altered? • Question 27 Which of the following medications used for treatment of bipolar disorder may increase stroke risk among older patients, particularly those with dementia? Response Feedback: “Notably, pharmacovigilance studies suggest that atypical antipsychotics may increase stroke risk among older patients, particularly those with dementia, so use of SGA requires more caution in this group.” • Question 28 Which of the following receptors below would likely result in extra-pyramidal symptoms, tardive dyskinesia, and hyperprolactinemia? Response Feedback: first generation antipsychotics all share the common property of D2 blockade, which can produce EPS, TD, and hyperprolactinemia • Question 29 Which anticonvulsant below induces its own metabolism over time? • Question 30 K. B. is a 28-year-old male who was started on Venlafaxine 75 mg about 2 weeks ago and is now calling you asking how long it should take for this medication to begin to work. He is concerned his girlfriend will leave him if he doesn’t get better quickly. What is the appropriate amount of time to allot to see a therapeutic response? Response Feedback: “It has been consistently observed and reported that remission of depression often requires 4 weeks of treatment or more;” Page 33: “Use of antidepressant for at least 6–12 weeks to determine whether it is helping or not” • Question 31 Selection of an antipsychotic agent is usually guided by the side-effect profile and by available formulations. Response Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use? Feedback: • Question 32 K. B. never felt relief from his depressive symptoms, even after appropriate time and dose titration of Venlafaxine. He was switched to Bupropion 150 mg about 2 months ago and is following up with you today. He reported feeling “great” and that his relationship with his girlfriend is “better than ever now.” Because he is feeling so well at this time, he is wondering when he can stop taking Bupropion. How long must the patient be symptom-free before he may begin a trial to taper off the antidepressant therapy? Response Feedback: “Therefore, in treatment-responders, most experts favor a continuation of antidepressant therapy for a minimum of 6 months following the achievement of remission.” • Question 33 Close-ended questions will help identify when patients are taking medications incorrectly. • Question 34 K. T. is a 35-year-old woman who was diagnosed with Generalized Anxiety Disorder about 4 weeks ago. She was prescribed Clonazepam 2 mg at bedtime but was referred to you to determine chronic treatment. K. T. states the new medication has been helping a lot but worries about all the side effects that come with it. She wants to discontinue the medication. What is the appropriate next step to help K. T.? Response Feedback: “The regular use of benzodiazepines for more than 2 to 3 weeks may be associated with physiological dependence and the potential for significant withdrawal symptoms with discontinuation. Discontinuation of benzodiazepines is best done with a gradual taper to minimize withdrawal symptoms.” - Answer choice A: Honor the patient’s request of discontinuing the medication. - Answer Choice C: An abrupt stop of a benzodiazepine will likely send the patient into having withdrawal symptoms. - Answer D: Patient will likely experience withdrawal symptoms due to how often the patient uses it OR patient will experience withdrawal symptoms after missing one dose, thus the therapy wouldn’t have changed at all from how she has been taking it. • Question 35 Which answer choice includes all the components of patient-focused interventions to enhance adherence? i. Education ii. Motivation iii. Skills iv. Logistics • Question 36 Of the following medications, which ones are considered first-line in treatment of an acute manic episode of bipolar disorder (assuming monotherapy)? i. Lithium ii. Fluoxetine iii. Aripiprazole iv. Risperidone v. Ziprasidone vi. Venlafaxine vii. Quetiapine viii. Valproate • Question 37 Which drug below has an interaction with cigarette smoking and should be adjusted based on patient’s tobacco use/non-use? Response Feedback: “Clozapine blood levels are significantly lowered by cigarette smoking and by other hepatic enzyme-inducers.” • Question 38 In order for the NMDA receptor to fully open and allow an influx of calcium, both glutamate and glycine must bind to cause a depolarization of the cell that will ultimately displace which ion? Is the NMDA receptor an ionotropic or metabotropic receptor? • Question 39 When initiating lithium, how long should you wait before checking a lithium level? What is the therapeutic goal level of lithium? • Question 40 Choose the appropriate pair regarding acetylcholine receptors. Response Feedback: “There are two classes of ACh receptors: muscarinic and nicotinic. While muscarinic receptors are G-protein-coupled, nicotinic receptors are ion channels, which allows for rapid influx of NA+ and Ca2+ into the post- synaptic neuron.” • Question 41 Patient is a 59-year-old male with a past medical history significant for bipolar disorder I, hypertension, and