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NURS 6630 MIDTERM EXAM WITH 4 VERSIONS COMBINED
QUESTIONS & ANSWERS WALDEN UNIVERSITY
Treatment adherence is affected by several different factors. Clinical factors include mood, anxiety, psychosis, and substance misuse. There are also patient factors such as knowledge, attitude, and beliefs; economic and racial/ethnic disparities, and clinical encounters. A patient who presents hopeless, with decreased energy, and poor concentration is affected by which factor?
Selected
Answer:
D.
Mood
Answers: A.
Substance misuse
B.
Knowledge deficits
C.
Attitude ad belief system
D.
Mood
Response
Feedback:
These are signs of an altered mood. Serotonin (5HT) is a neurotransmitter associated with mood, sleep, and psychosis. There are several serotonin receptors all over the human body. A unique aspect of the second generation antipsychotics is their ability to block 5HT2a receptors. What is the effect of this inhibition?
Selected
Answer:
A.
Stabilizes dopamine concentrations in the CNS
Answers: A.
Stabilizes dopamine concentrations in the CNS
B.
Induces anxiety
C.
Causes hallucinations
D.
Reduces platelet function
Response
Feedback:
B represents antagonism of 5HT1a, C represents a 5HT2a agonist, and D represents what happens when you inhibit SERT.
• Question 2
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Receptors trigger one of two effector pathways resulting in changes in neuronal activity. These changes will, ultimately, effect gene expression. Which effector pathway is characterized by ion flux through transmitter-activated channels resulting in an altered membrane potential and neuronal activity?
Selected
Answer:
D.
NMDA glutamate receptor pathways
Answers: A.
Slow effector pathways
B.
Modulated effector pathways
C.
Rapid effector pathways
D.
NMDA glutamate receptor pathways
Response
Feedback:
Answer B is fictitious, D is a type of rapid effector pathway, and A represents G-protein coupled receptors. G-protein coupled receptors are targets for several psychiatric medications. Given what we know about these receptors, what is the ultimate result we will see when one of them is activated in a way that would potentiate an action?
Selected
Answer:
A.
Intracellular activation of second messengers
Answers: A.
Intracellular activation of second messengers
B.
Protein phosphorylation
C.
Modification of gene expression
Response
Feedback:
A and B are both steps in the activities seen leading up to modification of gene expression. The human brain is subcategorized into four major structures. These structures include
- Question^5
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- Question 4
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- Question^3
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- Question 8
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seriously thinking about overcoming it, has not yet committed to a plan of action?
Selected
Answer:
C.
Contemplat ion
Answers: A.
Preparation
B.
Action
C.
Contemplat ion
D.
Maintenanc e Neurotransmitters are defined by four essential characteristics. These are:
Selected
Answer:
E.
A, C, and D only
Answers: A.
Neurotransmitters are synthesized within presynaptic neurons.
B.
Depolarization of a neuron results in the release of a neurotransmitter, which exerts a multitude of actions on the postsynaptic neuron.
C.
Their action on postsynaptic neurons can be replicated by administering a drug that mimics the activity of the endogenous neurotransmitter.
D.
Their action in the synaptic cleft is terminated by a specific action.
E.
A, C, and D only
Response
Feedback:
Answer B should read a “discrete” (not multitude) action on the post synaptic neuron. The synaptic cleft is best characterized by which of the following statements?
Selected
Answer:
C.
The synaptic cleft is an area where dendrites and axon terminals are within
- Question^9
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close proximity, allowing for the release of a neurotransmitter from a presynaptic neuron that can interact with receptors on dendritic cells of a post synaptic neuron, which is the main basis for intercellular communication of neurons.
Answers: A.
The synaptic cleft is the space between a single neuron’s dendrites and axon terminals in which intracellular communication occurs through the release of neurotransmitters allowing for signal conduction throughout the central nervous system.
B.
The synaptic cleft is the space between the cell body and axon terminals that allows for release of neurotransmitters from the presynaptic neuron for intercellular communication with an adjacent neuron (post synaptic neuron).
C.
The synaptic cleft is an area where dendrites and axon terminals are within close proximity, allowing for the release of a neurotransmitter from a presynaptic neuron that can interact with receptors on dendritic cells of a post synaptic neuron, which is the main basis for intercellular communication of neurons.
Response
Feedback:
Answer A represents a neuron communicating with itself and Answer B states that the synapse is the space between the cell body (not dendrites) and axon terminals. When dopamine (subtype 2) receptors are blocked in this pathway (system), it is evident by EPS.
Selected
Answer:
C.
Nigrostriatal
Answers: A.
Mesocortical
B.
Tuberoinfundib ular
C.
Nigrostriatal
D.
Mesolimbic
Response
Feedback:
D is associated with positive symptoms in schizophrenia, B is associated with lactation, A is associated with affect.
- Question 11
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- Question 10
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iii. Histological classification includes bipolar, unipolar, and multipolar. iv. Classifications using a combination of structural, functional, and neurotransmitter type provide the most robust and useful description. v. Classification by neurotransmitter type alone provides the most useful description.
Selected
Answer:
E.
I, III, and IV
Answers: A.
I only
B.
III only
C.
I, II, and V only
D.
I, II, III, IV, and V
E.
I, III, and IV
Response
Feedback:
Statement II would need to include modulatory function to be correct, and Statement V does not include structural and functional classification systems. Neurotransmission is unidirectional insofar as chemical and electrical conduction is concerned within the individual neuron. Of the following descriptions, which best characterizes the order of neurotransmitter/receptor interaction that results in an electrical signal impulse and the release of another neurotransmitter for interaction in the synaptic cleft (signal conduction through a neuron)?
Selected
Answer:
C.
Dendrites, Cell body, Axon, Axon terminals
Answers: A.
Cell body, dendrites, Axon, Axon terminals
B.
Dendrites, Axon, Cell body, Axon, Axon terminals
C.
Dendrites, Cell body, Axon, Axon terminals
D.
Axon terminals, Axon, Cell body,
- Question 14
3.75 out of 3.75 points
Response
Feedback:
Dendrites All of the other options are mis-sequenced in signal conduction. Upon blocking a Serotonin reuptake pump, what happens in the synaptic cleft and on the post synaptic cell membrane?
Selected
Answer:
D.
The result will be an increase in Serotonin in the synaptic cleft resulting in a decrease in reuptake pumps on the pre-synaptic neuron.
Answers: A.
The result will be an increase in available Serotonin in the synaptic cleft causing the post synaptic cell to increase the number of Serotonin receptors.
B.
The result will be an increase in the available Serotonin in the synaptic cleft causing the post synaptic neuron to reduce the number of Serotonin receptors.
C.
The result will be an increase in Serotonin in the synaptic cleft resulting in an increase in reuptake pumps on the presynaptic neuron.
D.
The result will be an increase in Serotonin in the synaptic cleft resulting in a decrease in reuptake pumps on the pre-synaptic neuron.
Response
Feedback:
A, C, and D are misrepresentations of what occurs when you increase Serotonin in the synaptic cleft. There is no effect on the pre-synaptic neuron, and the increases in Serotonin result in a reduction of receptor concentration on the post-synaptic neuron. Which of the following consists of all the known major neurotransmitters that are relevant in psychiatry?
Selected
Answer:
B.
glutamate, GABA, dopamine, norepinephrine, serotonin, acetylcholine, histamine, endogenous opioids, steroids, cannabinoids, nitric oxide
Answers: A.
glutamate, GABA, dopamine, serotonin, norepinephrine, histamine, steroids, nitric oxide
B.
glutamate, GABA, dopamine, norepinephrine, serotonin, acetylcholine, histamine, endogenous opioids, steroids, cannabinoids, nitric oxide
- Question 16
3.75 out of 3.75 points
- Question 15
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Response
Feedback:
Options B and C are mismatched, and Option A shows effects days to weeks after activation. Of the components of patient-focused interventions to enhance adherence, which component includes the following strategies: adaptive thinking, use of cues, and support?
Selected
Answer:
A.
Motivati on
Answers: A.
Motivati on
B.
Skills
C.
Logistics
D.
Educatio n
Response
Feedback:
Skills include adaptive thinking, problem solving, use of cues, and support. If a patient admits to taking his medication every other day (instead of daily, as prescribed), a potential concern would be:
Selected
Answer:
A.
Sufficient understanding or acceptance of the illness
Answers: A.
Sufficient understanding or acceptance of the illness
B.
Abuse of the medication
C.
Expense
D.
Is the desired effect recognized at a lower daily dose?
Response A^ represents^ a^ patient^ taking his medication^ sporadically,^ B represents
- Question 20
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- Question 19
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Feedback: a^ patient^ taking too^ much medication,^ and^ D^ represents^ a patient
taking a lower-than-prescribed dose but daily
**- Question 6
- Question 9
- Question 10
- Question 11** 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.” With second-generation antipsychotics, what is the main side effect that requires frequent monitoring?
Response
Feedback:
table 7 - 6 & page 80, table 7 - 7; Page 78: “However, attention over the past decade has focused on effect of second-generation antipsychotics on glucose metabolism and lipids and associated metabolic syndrome.” 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." Which anticonvulsant below induces its own metabolism over time? 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? Which of the following medications are known as selective serotonin re-uptake inhibitors (SSRIs)? i. Nortriptyline ii. Citalopram iii. Duloxetine iv. Fluoxetine v. Venlafaxine Which disease state of a non-adherent patient is at greater risk for substance use,
**- Question 8
- Question 16 violence, and victimization as well as worse overall quality of life?
Response
Feedback:
“Moreover, non-adherent patients with schizophrenia are at greater risk for substance use, violence, and victimization as well as worse overall quality of life.” An 81 - year-old male comes to your clinic today complaining of dry mouth, blurred vision, and constipation. He has a past medical history significant for hypertension, heart failure, and depression. Of the following medications, which one is likely contributing to these side effects?
Response
Feedback:
Only TCA is listed with most anticholinergic effects; Page 39 for TCA side effect profile: “dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia, memory difficulties, and ejaculatory difficulties” 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 Of the following medications used in the treatment of social anxiety disorder, which one would you AVOID in a patient who has uncontrolled hypertension?
Response
Feedback:
Phenelzine reported to have hypertensive reactions as a limitation/primary side effect What is the therapeutic plasma level of carbamazepine? 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” Choose the correct statement(s) regarding lithium levels. SELECT ALL THAT APPLY.
**- Question 17
- Question 15
- Question 14
- Question 13
- Question 12**
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….” II. Question 24 Close-ended questions will help identify when patients are taking medications incorrectly. III. Question 25 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 IV. Question 26 Which answer choice includes all the components of patient-focused interventions to enhance adherence? i. Education ii. Motivation iii. Skills iv. Logistics V. Question 27 Which medication has been studied and recommended in patients with a social anxiety 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” VI. Question 28 Choose the correct option regarding the major classes of GABA receptors and the ions involved in inhibition of the neurotransmitter pathway
Response
Feedback:
“GABAB receptors, akin to the metabotropic glutamate receptors, are G-protein-coupled receptors rather than ion channels. Activation of GABAB causes downstream changes in potassium (K+) and Ca+ channels, largely via G-protein-mediated inhiation of cAMP.” VII. Question 29
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)_ ii. Question 30 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._ iii. Question 31 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 iv. Question 32 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?
dose….” ix. Question 37 Which of the following is an appropriate strategy for managing treatment-resistant depression? x. Question 38 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.” xi. Question 39 Which amino acid is involved in the synthesis of both norepinephrine and dopamine? xii. Question 40 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.” xiii. Question 41 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. xiv. Question 42 Which drug below differs from other atypical antipsychotics in causing persistent hyperprolactinemia?
Response
Feedback:
“Risperidone differs from other second-generation antipsychotics in causing persistent hyperprolactinemia.”
xv. Question 43 A 25 - year-old female comes into your clinic today informing you she is ready to have a baby and wishes to discontinue her birth control at this time. After reviewing her chart, you notice she has a history of bipolar disorder and was previously prescribed valproic acid by another doctor. What is your concern with this medication in this specific patient?
Response
Feedback:
“Valproic acid may produce teratogenic effects.” xvi. Question 44 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” xvii. Question 45 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 D blockade, which can produce EPS, TD, and hyperprolactinemia xviii. Question 46 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. xix. Question 47 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.” xx. Question 48 Selection of an antipsychotic agent is usually guided by the side-effect profile and by
