Section 3 Test

Question 1

An NP works in a post concussive outpatient rehab program. A pt presents with chronic post concussive symptoms six weeks after sustaining a mild head injury while playing lacrosse. Pt was hit in occipital lobe with a lacrosse stick and experienced dizziness, ataxia, and visual disturbances proximal to the injury. An emergent evaluation and neuro exam did not show any gross abnormal findings.
The pt was released home on a graduated release to a regular exercise regimen. However, after 3 weeks, the patient began experiencing chronic headaches and insomnia. These symptoms have negatively affected the pt’s quality of life and cause irritability and daytime sleepiness. Which med should the NP use to treat both conditions?
1. Quetiapine (Seroquel)
2. Duloxetine (Cymbalta)
3. Trazodone (Desyrel)
4. Amitriptyline (Elavil)

Answer 1

Amitriptyline (Elavil).

Amitriptyline has off-label indications for both insomnia and the management of headaches; it is recommended for use in TBI populations as a dual purpose for both.

Question 2

An NP works at a post concussive outpatient rehab program. Pt presents with chronic post concussive symptoms (short-term memory difficulties, problems concentrating, daytime fatigue, and PTSD) after suffering a moderate TBI due to aggravated battery and sexual assault. After a course of eye movement desensitization and reprocessing (EMDR), the pt continues to struggle with most of their PTSD symptoms, most specifically mood instability, irritability, and nightmares. After discussing different treatment options, the pt requested to be treated with both sertraline (Zoloft) and prazosin (Minipress).
How should the NP prescribe this)?

Answer 2

Start sertraline 25mg for 7 days; increase after 2 weeks to 50mg; start prazosin after one week.

Clinical practice guidelines recommend that meds for pts with brain injuries be initiated at lowest possible doses and titrated slowly; additional recommendations include not initiating multiple meds at once or making changes to several meds at one time.

Question 3

An NP is treating a patient with a history of non adherence to schizophrenic medication. The pt needs an antipsychotic to control symptoms. The patient agrees to injections but wants as few injections as possible. Which medication should the NP prescribe for this patient?
1. Risperidone (Risperdal Consta)
2. Paliperidone (Invega Trina)
3. Olanzapine (Zyprexa Relprevv)
4. Aripiprazole (Abilify Maintena)

Answer 3

Paliperidone (Invega Trina)

Given every 3 months.

Question 4

NP treating pt for major depressive disorder and GAD. Pt takes escitalopram 20mg daily with reasonable symptom control and wants to keep this medication. Pt recently experienced divorce and has noted rebound depression over the past 6 weeks, including anhedonia, poor sleep, depressed mood, and increased appetite. Pt does not want to discontinue current medication.
What med should NP add to current med regimen as adjunctive therapy?

1. Naltrexone (Revia)
2. Alprazolam (Xanax)
3. Fluoxetine (Prozac)
4. Brexpiprazole (Rexulti)

Answer 4

Brexpiprazole (Rexulti).

Brexpiprazole (Rexulti) is indicated for depression uncontrolled with antidepressants and can be added to an antidepressant for improved symptom control.

Question 5

NP is treating a 29-yr-old pt diagnosed with bipolar disorder. The patient has been stable on lithium (Eskalith) for some time but is now exhibiting symptoms of mania. The NP wants to prescribe an FDA-indicated medication as an adjunct treatment to lithium. Which medication should the NP prescribe?

1. Fluphenazine (Prolixin)
2. Iloperidone (Fanapt)
3. Asenapine (Saphris)
4. Lamotrigine (Lamictal)

Answer 5

Asenapine (Saphris).

Asenapine (Saphris) is FDA approved as an adjunct treatment for both lithium and valproate in the treatment of acute mania. Asenapine is also FDA approved as a monotherapy for treating acute and mixed mania, bipolar maintenance, and schizophrenia. It is used off-label to treat other psychotic disorders, bipolar depression, bipolar care, treatment-resistant depression, behavioral disturbances in children and adolescents, dementia, disorders associated with impulse control, and PTSD.

Question 6

An NP receives a referral from an outpatient therapist. The pt is a 22-yr-old diagnosed with bulimia nervosa. Which med is FDA-indicated for this patient?

1. Zonisamide (Zonegran)
2. Nefazodone (Serzone)
3. Fluoxetine (Prozac)
4. Vortioxetine (Trintellix)

Answer 6

Fluoxetine (Prozac).

Fluoxetine is FDA approved for the treatment of bulimia nervosa. It is also FDA approved for treating major depressive disorder, OCD, pre menstrual dysphoric disorder, and panic disorder.

Question 7

NP is working with a pt who is stabilized on paliperidone palmitate one month (Invega Sustenna) 117 mg IM every 4 weeks for the last 6 months. The pt is transitioning to paliperidone palmitate three-month (Invega Trinza). How should the NP order this transition?

Answer 7

Start paliperidone palmitate 3-month ((Invega Trinza) 410mg IM every 3 months.

paliperidone palmitate is a long-acting injectable 2nd generation antipsychotic. Treatment guidelines for long-acting paliperidone palmitate injectables require the pt to receive paliperidone palmitate (Invega Sustenna) injection for at least 4 months before transitioning to Invega Trinza. The conversion dose from 117mg of Invega Sustenna to Invega Trinza is 410 mg (about 3.5 x’s the dose).

Question 8

A patient in the assertive community treatment (ACT) program continues to have psychotic symptoms despite trials of several antipsychotics over the past years. The patient has a documented diagnosis of benign ethnic neutropenia (BEN). The NP starts the pt on clozapine (Clozaril). The NP provides psychoeducation to the pt following the risk evaluation and mitigation strategy (REMS) guidelines for clozapine.
Which psychoeducation should the NP provide to this patient?

Answer 8

Patients with BEN are not at higher risk for developing neutropenia induced by clozapine.

BEN is a condition specific to certain ethnic groups whose average absolute neutrophil (ANC) is lower than the general population or standard lab ranges for neutrophils. Pts diagnosed with BEN have a separate ANC monitoring algorithm when treated with clozapine. Despite this difference in monitoring, patients with BEN are not at a higher risk of developing neutropenia induced by clozapine.

Question 9

A pt diagnosed with schizophrenia been stable on clozapine for one year. Today, the pt’s absolute neutrophil count (ANC) level is 482ul. The pt is not diagnosed with benign ethnic neutropenia. NP will follow this pt’s risk evaluation and mitigation strategy (REMS) guidelines. How should the NP manage this pt’s treatment?

Answer 9

Hold medication for suspected clozapine/induced neutropenia; refer for hematology consult.

An ANC of less than 500ul indicates the patient has severe neutropenia, placing them at increased risk for repeated and severe infections. According to REMS guidelines for clozapine, treatment should be interrupted and hematology consulted (as medication-induced neutropenia is considered a blood disorder)

Question 10

Pt being treated in an outpatient psychiatric clinic for severe opioid use disorder. After discussing medication-assisted treatment (MAT) options, the NP starts the pt on buprenorphine/naloxone (Suboxone) according to the buprenorphine/naloxone transmucosal products for opioid dependence (BTOD) risk evaluation and mitigation strategies (REMS). How should the NP manage this pt’s treatment within the REMS guidelines?

Answer 10

Discuss the potential for fatal additive effects with benzodiazepines and other CNS depressants.

BTOD REMS requires a discussion about the potential fatal additive effects of benzodiazepines and other CNS depressants that could cause respiratory arrest and death. Buprenorphine/naloxone is a highly potent opioid receptor partial agonist with a high affinity for opioid receptors displacing full opioid agonists without respiratory depression. Despite this fact, it still produces some CNS depression. Therefore, combining Buprenorphine/naloxone with other CNS depressants increases the risk of respiratory arrest and death.

Question 11

An NP treating a 33-yr-old pt with a long history of major depressive disorder (MDD). Pt is prescribed citalopram 20mg PO QD. Pt is stable on the citalopram but reports side effects of anorgasmia and decreased libido. Pt was recently diagnosed with ADHD. The NP wants to prescribe a med that can treat ADHD and alleviate the pt’s symptoms. Which med should the NP prescribe?
1. Atomoxetine (Strattera)
2. Clonidine (Catapres)
3. Amoxapine (Asendin)
4. Bupropion (Wellbutrin)

Answer 11

Bupropion (Wellbutrin).

Bupropion (Wellbutrin) is used off-label to treat ADHD and can also be combined with SSRIs to treat sexual dysfunction from SSRIs.

Question 12

NP works as psychiatric consult liaison in a hospital. NP is called to consult on a pt who presents to the ED with a high fever (103.4), tachycardia, tachypnea, profuse sweating, muscle rigidity, and slight confusion at times. The pt reports, “The voices were getting worse and would not stop, and I thought more of my medicine would make them go away.” Which medication is associated with this patient’s symptoms?

1. Rivastigmine (Exelon)
2. Doxepin (Silenor)
3. Haloperidol (Haldol)
4. Brexanolone (Zulresso)

Answer 12

Haloperidol (Haldol).

Potent first/generation antipsychotics, such as Haloperidol (Haldol), fluophenazine (Prolixin), chlorpromazine (Thorazine), and trifluoperazine (Stelazine), are most frequently associated with the patient’s symptoms, which are consistent with neuroleptic malignant syndrome (NMS).

Question 13

NP is treating a 15-yr-old pt diagnosed with major depressive disorder, recurrent, moderate. Pt is also diagnosed with a seizure disorder. Pt has had 2 trials of SSRIs (escitalopram and fluoxetine) with minimal response. Pt’s primary symptoms are fatigue and feeling sad most of the time. Which med should the NP prescribe next?
1. Venlafaxine (Effexor)
2. Nortriptyline (Pamelor)
3. Bupropion (Wellbutrin)
4. Hydroxyzine (Vistaril)

Answer 13

Venlafaxine (Effexor).

Although Venlafaxine, an SNRI, is not FDA approved for treating major depressive disorder in adolescents, an SNRI would be the appropriate next step. 2 SSRI’s have been trialed with minimal success.

Question 14

NP is treating an older adult pt diagnosed with Alzheimer’s, recently placed in memory care. Nursing staff reports the pt is often restless, agitated, and paranoid. NP observes the pt wandering all over the day room before meeting with the pt.
Which med should the NP prescribe to treat this pt’s symptoms?
1. Caprylidene (Axona)
2. Selegiline (Eldepryl)
3. Memantine (Namenda)
4. Donepezil (Aricept)

Answer 14

Donepezil (Aricept).

Donepezil is FDA approved for treating mild, moderate, and severe cognitive impairment in Alzheimer’s disease. It treats the cognitive, behavioral, and psychological symptoms of the disease.

Question 15

A 4-yr-old pt presents to NP with their parents. Child is hyperactive and distractible. Parents explain that child was removed from their preschool and referred to a mental health clinic. NP informs the parents that a trial of a med might prove helpful. With FDA approved med should this NP prescribe?
1. Lisdexamfetamine (Vyvanse)
2. Clonidine (Catspres)
3. Atimoxetine (Strattera)
4. Amphetamine-D, L (Adderall)

Answer 15

Amphetamine-D, L (Adderall).

Child presents with ADHD symptoms. Amphetamine-D, L (Adderall) is a first-line medication for children of this age.

Question 16

75-yr-old pt referred to NP at community health clinic by their PCP due to bereavement-related depression. Pt reports they lost their loved one eight months ago and continue to have issues with lack of motivation, sleep disturbances, and loss of appetite. Which meds should the NP prescribe?
1. Lithium (Lithobid)
2. Sertraline (Zoloft)
3. Haloperidol (Haldol)
4. Olanzapine (Zyprexa)

Answer 16

Sertraline (Zoloft).

Sertraline (Zoloft) is an SSRI, which is a first-line medication for depression. It can also be used for premenstrual dysohoric disorder, panic disorder, PTSD, social anxiety disorder, and OCD.

Question 17

NP is completing an evaluation on an 8-yr-old pt. NP diagnoses her with major depressive disorder and PTSD. Which class of medication should the provider prescribe?
1. Beta-blockers
2. SSRIs
3. Anticonvulsant
4. MAOIs

Answer 17

SSRIs.

First line treatment for both major depressive disorder and PTSD are SSRIs.

Question 18

NP seeing 6-yr-old with her mom. Mom has received notes from pt’s teacher related to poor focus in class, poor impulse control, and difficulty sitting still. Parent notes similar problems at home. Upon evaluation, the pt is diagnosed with ADHD. What should the NP prescribe for these symptoms?
1. Methylphenidate (Ritalin)
2. Escitalopram (Lexapro)
3. Aripiprazole (Abilify)
4. Risperidone (Risperdal)

Answer 18

Methylphenidate (Ritalin).

Methylphenidate (Ritalin) is a stimulant approved for ADHD in this age group and is considered a first-line treatment for ADHD.

Question 19

Pt being treated in outpatient psych clinic for severe opioid use disorder. NP starts pt on buprenorphine/naloxone (Suboxone). Pt’s spouse inquired about obtaining a prescription for naloxone (Narcan) nasal spray. What psychoeducation should NP provide about this nasal spray?

Answer 19

“It will reverse an opioid overdose if your spouse relapses; a prescription will be sent to the pharmacy today.”

Question 20

Pt had stabilized on Invega 9mg daily for 6 months and is transitioning to Invega Sustenna (1-month) long-acting injectable, maintaining equivalent dose to oral regimen and then eventually to Invega Trinza (3-month). Pt receives the initial loading dose of Invega Sustenna 234mg IM, then 156mg on day 8.
How should this transition proceed?

Answer 20

Continue 156mg IM for 4 weeks after the second loading dose, then every 4 weeks for 4 months; then start Invega Trinza at 546mg IM every 3 months.

Invega Sustenna need to be taken for at least 4 months before transitioning to Invega Trinza. Conversion dose from 9mg oral to Invega Sustenna IM is 156mg. The equivalent dose for transitioning to Invega Trinza is 546mg.

Question 21

NP treats pt with GAD with Paroxetine. Pt treated several antidepressants before this before achieving symptom resolution. Pt now wakes up every day for the first time in their life without feeling anxious. The pt is experiencing sexual side effects with paroxetine but is unwilling to change medications. What should the NP offer to help manage these side effects?

Answer 21

Take the dose at night.

Taking a dose at night and a larger dose at night and doing daytime exercise are all nonpharmacological strategies to help mitigate the sexual side effects of antidepressants.

Question 22

NP is treating pt with OCD with fluovoxamine ER 200mg PO QHS. CY-BOCS scores have reduced significantly while on med, pt reports feeling much better. Pt reports bruising easily and taking albuterol, vit D, levothyroxine, and ibuprofen for headaches. No allergies or other comorbidities. How should NP manage this situation?

Answer 22

Educate patient about antiplatelet effects of fluvoxamine and ibuprofen and recommend taking acetaminophen for pain.

Question 23

NP working in ER when pt comes in with generalized body aches, extreme fatigue and weakness, tachycardia, fever, diarrhea, twitching, and hyperreflexia. Pt reports history of major depressive disorder and migraines. Med list includes duloxetine 60mg PO daily, tramadol 50mg PO Q6 hrs PRN for migraines, Sumatriptan 50 mg PO PRN for migraine (may repeat dose after 2 hours, NTE 200mg/24 hrs), ondansetron 4mg PO PRN for nausea/vomiting r/t migraine (DNE 8mg/24 hrs).
Pt reports horrible migraine for a few days before symptoms started and subsequently had several dosages of both tramadol and sumatriptan. What is this adverse drug reaction?
1. Serotonin syndrome
2. Anticholinergic toxicity
3. Hemophagocytic lymph histocytosis
4. Neuroleptic malignant syndrome

Answer 23

Serotonin syndrome.

SSRI + Migraine meds + pain meds, all increase serotonin.

Question 24

NP is treating a 52-yr-old pt with bipolar, mixed features. Med change needed, NP knows pt has history of syndrome of inappropriate antidiuretic hormone secretion (SIADH) due to a med in the past. To assess potential findings associated with SIADH, NP plans to monitor patient’s urine and plasma sodium and pt’s urine and serum osmolality. Which FDA- indicated med can cause this ASE?
1. Cariprazine (Vraylar)
2. Carbamazepine (Equetro)
3. Loxapine (Loxitane)
4. Asenapine (Saphris)

Answer 24

Carbamazepine (Equetro).

Carbamazepine (Equetro) can cause SIADH, characterized by impaired water excretion leading to hyponatremia with hypervolemia or euvolemia.