Midterm Exam: NR546/ NR 546 (Latest Update 2024/ 2025) Psychopharmacology for the Psychiatric-Mental Health Nurse Practitioner Guide |Weeks 1-4 Covered| Questions and Verified Answers| 100% Correct- Chamberlain
Midterm Exam: NR546/ NR 546 (Latest
Update 2024/ 2025) Psychopharmacology for
the Psychiatric-Mental Health Nurse
Practitioner Guide |Weeks 1-4 Covered|
Questions and Verified Answers| 100%
Correct- Chamberlain
Q: FGA side effects
Answer:
hyperprolactinemia, extrapyramidal symptom (EPS), QT pro- longation, tornadoes de pointes,
blood dyscrasias, sedation, orthostatic hypoten- sion, dizziness.
Q: Clozapine
Answer:
not indicated for use in acute presentation of schizophrenia, ab- solute neutrophil count (ANC)
must be >1500, highest risk for weight gain.
Q: Clozapine and lurasidone
Answer:
noted for decreased risk of death by suicide.
Q: Risperidone
Answer:
atypical antipsychotic. off-label use for psychosis assoc. with de- mentia despite black box
warning.
Q: Benzodiazepines
Answer:
effective immediately. can be used to treat panic disorders and generalized anxiety disorder. for
short-term use. enhance GABAs inhibitory effects.
Q: NMS treatment
Answer:
dantrolene, bromocriptine
Q: NMS symptoms
Answer:
symptoms include diaphoresis, anxiety, tachypnea, muscle stiffness, altered mental status,
tachycardia, high fever.
Q: tardive dyskinesia symptoms
Answer:
facing alterations
-lip smacking
-grimaces
-tongue protrusion
-twisting or jerking movements
Q: Tardive dyskinesia treatment
Answer:
-Benzos
-Botulinum
-Tetrabenzine
-Anti-cholinergics
Q: Akathisia symptoms
Answer:
restless, trouble standing still, paces the floor, feet in constant motion, rocking back and forth
Q: Akathisia treatment
Answer:
beta blockers, benzodiazepines
Q: Acute dystonia symptoms
Answer:
Muscle spasms of face, tongue, neck, and back
Facial grimacing
Involuntary upward eye movements
Laryngeal spasms
Q: Acute dystonia treatment
Answer:
Benztropine, diphenhydramine
Q: which is more harmful in pregnancy?
Answer:
atypical antipsychotics
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Nigrostriatal pathway
the dopaminergic tract from the substantia nigra to the striatum (basal ganglia)
mesolimbic pathway
VTA to nucleus accumbens
mesocortical pathway
VTA to prefrontal cortex (DLPFC & VMPFC)
Tuberoinfundibular pathway
Hypothalamus to anterior pituitary
Nigrostriatal function
Part of extrapyramidal system, controls posture and voluntary movements
Mesolimbic function
Regulates emotional behaviors, motivation, pleasure, and reward
Tuberoinfundibular function
regulates prolactin release
Nigrostriatal adverse effects
can cause movement disorders (Parkinsonism, tremor), akathisia, dystonia, dyskinesias, chorea, TD
Mesolimbic adverse effects
can cause positive symptoms of schizophrenia, artificial reward of substance abuse, anhedonia, apathy, lack of energy.
Tuberoinfundibular adverse effects
can cause galactorrhea, gynecomastia, amenorrhea, and sexual dysfunction
first generation antipsychotics
used for schizophrenia and psychosis. Blocks D2 receptors in mesolimbic pathway.
second generation antipsychotics
are associated with metabolic adverse effects (eg. weight gain, dyslipidemia, hyperglycemia, and increased risk of diabetes). Olanzapine and clozapine carry the greatest risk.
Pines, 2 dones and a rone, 2 pips and a rip.
dorsolateral prefrontal cortex
cognitive symptoms
Mesocortical and ventromedial prefrontal cortex
negative and affective symptoms
orbitofrontal and connections to the amygdala
aggressive, impulsive symptoms
FGA side effects
hyperprolactinemia, extrapyramidal symptom (EPS), QT prolongation, tornadoes de pointes, blood dyscrasias, sedation, orthostatic hypotension, dizziness.
Clozapine
not indicated for use in acute presentation of schizophrenia, absolute neutrophil count (ANC) must be >1500, highest risk for weight gain.
Clozapine and lurasidone
noted for decreased risk of death by suicide.
Risperidone
atypical antipsychotic. off-label use for psychosis assoc. with dementia despite black box warning.
Benzodiazepines
effective immediately. can be used to treat panic disorders and generalized anxiety disorder. for short-term use. enhance GABAs inhibitory effects.
NMS treatment
dantrolene, bromocriptine
NMS symptoms
symptoms include diaphoresis, anxiety, tachypnea, muscle stiffness, altered mental status, tachycardia, high fever.
tardive dyskinesia symptoms
facing alterations
-lip smacking
-grimaces
-tongue protrusion
-twisting or jerking movements
Tardive dyskinesia treatment
-Benzos
-Botulinum
-Tetrabenzine
-Anti-cholinergics
Akathisia symptoms
restless, trouble standing still, paces the floor, feet in constant motion, rocking back and forth
Akathisia treatment
beta blockers, benzodiazepines
Acute dystonia symptoms
Muscle spasms of face, tongue, neck, and back
Facial grimacing
Involuntary upward eye movements
Laryngeal spasms
Acute dystonia treatment
Benztropine, diphenhydramine
which is more harmful in pregnancy?
atypical antipsychotics
antipsychotics to avoid during pregnancy
clozapine, ziprasidone, olanzapine, risperidone, and quetiapine.
all antipsychotics
which antipsychotics are excreted in breast milk?
Haloperidol, ziprasidone, and olanzapine
increased risk of CVA, cognitive decline, and death in older adults with dementia and dementia related psychosis
aripiprazole black box warning
medication with increased risk of suicide in children
quetiapine black box warning
increased risk of suicidal behavior in adolescents/young adults during initial 1-2 months of treatment
olanzapine
use with caution in suspected alcohol withdrawal, stimulant intoxication, or anticholinergic intoxication.
EPS related to use of halide can be controlled with
promethazine
increased risk of sudden death
combining benzos with IM olanzapine can cause
risk of respiratory failure
IM benzo’s with clozapine can cause
generalized anxiety disorder
has genetic heritability of approx. 30%
hypothalamus initiates
initiates flight or fight response
symptoms which may occur in response to sympathetic stimulation from fear
hyperventilation, hypertension, hyperglycemia, and chest pain.
amygdala to periaqueductal gray
fight/flight or freeze pathway
amygdala-centered circuit
fear, panic (phobia)
Cortico-striato-thalamo-cortical (CSTC) circuit
anxious misery, apprehensive expectation, obsessions.
SSRIs
Fluoxetine, paroxetine, sertraline, citalopram. Prevent reuptake of 5HT.
SNRIs
Venlafaxine, duloxetine, levamilnacipran. Not used for OCD. Prevent reuptake of 5HT and norepinephrine (NE).
Buspirone
azapirones. approved for short-term anxiety treatment. Bind to serotonin and dopamine receptors to increase norepinephrine metabolism.
a2d ligands
Pregabalin. off-label use for general anxiety disorder. bind with glutamate calcium channel blockers (Glu-CB) to inhibit release of several neurotransmitters.
generalized anxiety disorder treatment
SSRIs, SNRIs, buspirone. Drug therapy for at least 1 year.
panic disorder treatment
paroxetine, sertraline, fluoxetine. drug therapy 6-9 months
OCD treatment
fluoxetine, fluvoxamine, sertraline, paroxetine, clomipramine, drug therapy for at least 1 year.
social anxiety disorder treatment
sertraline, paroxetine, drug therapy takes 4 weeks to see effects.
PTSD
paroxetine, sertraline.
clonazepam contraindications
Benzodiazepine not recommended with breastfeeding
lorazepam contraindications
benzodiazepine not recommended if breastfeeding or pregnant.
paroxetine contraindication
contraindicated in pregnancy d/t risk of atrial septal defects
hydroxyzine
contraindicated in 1st trimester
use of benzos during pregnancy can cause
intrauterine growth restriction, over sedation at birth, potential for learning disabilities, autism, and ADHD, neonatal withdrawal syndrome.
contraindicated when breastfeeding
gabapentin, benzodiazepines, histamine receptor agents, a2 ligands
CYP450
Enzyme family most important in metabolizing drugs
Always available in the liver
5HT2A
hallucinations
5HT1A
somatodendridic and presynaptic
partial agonists
the pines, many tones and a tone, two pips and a rip
5HT, NE, DA, Ach, Glu, GABA
6 main neurotransmitters
one-third of psychotropics bind to _ and one-third bind to _
a neurotransmitter, G-protein-linked receptors
Cytochrome P450
convert a drug into a bio-transformed product in the bloodstream
higher blood concentrations of the drug
poor metabolizers have a lower concentration of the necessary enzyme which results in
Tardive dyskinesia
associated with long-term use of antipsychotics, especially high potency FGAs.
GABA
amino acid. inhibitory neurotransmitter – decreases neuroexcitability (helps relax, destress, and sleep). Decreased levels can cause anxiety/schizophrenia. Can slow breathing.
Norepinephrine (NE)
monoamine neurotransmitter. Helps with focus and productivity. Excess causes nervousness, being antsy, decreased focus. Plays role in fight or flight.
Acetylcholine (ACh)
a key neurotransmitter that psychotropic drugs target. Affects CNS (arousal, motivation, attention, learning, and REM sleep), also affects PNS (sweating, salivating). Link between brain and muscle – substances that block this can cause paralysis. Decreased levels cause Alzheimer’s and Parkinson’s. Plays a role in addiction (“brain’s own nicotine”).
Serotonin (5HT)
monoamine transmitter. Helps regulate mood. Synthesized from tryptophan. Helps feel relaxed, less stressed, regulates sleep, arousal, libido, aggression, and pain perception.
Dopamine (DA)
monoamine neurotransmitter. Involved in executive function (ability to perform well, be organized, emotional intelligence). Essential to movement and coordination. Decreased levels cause loss of interest, alertness, and self-confidence. Excess causes hallucinations. Has reward properties (can lead to addictions).
Glutamate (Glu)
Amino acid neurotransmitter, excitatory. “Workhorse” of the brain. Affects energy, memory, learning, and neural plasticity. Relays sensory information and regulates spinal and motor reflexes. Excess causes schizophrenia, epilepsy, and mania. NMDA and AMPA are its receptors.
Neurotransmitters responsible for depression
↑ acetylcholine
↑ glutamate
↓ norepinephrine
↓ histamine
citalopram FYI
20 mg max dose due to increased risk of QT prolongation
vortioxetine FYI
max dose is 10 mg for 2D6 poor metabolizer
aripiprazole, brexpiprazole, iloperidone FYI
max dose is half of the normal max dose for a 2D6 poor metabolizer.
if prescribed with CYP 3A4 inhibitor, dose should be 1/4 of the recommended max dose.
atomexotine FYI
client has a 5-fold higher peak concentration if they are a 2D6 poor metabolizer.
SSRI effects
inhibits reuptake of serotonin. Can cause nausea, agitation, headache, and sexual dysfunction
SNRIs effects
inhibits reuptake of serotonin and norepinephrine. Can cause nausea, sweating, insomnia, tremors, and sexual dysfunction
tricyclic antipressant effects
inhibit reuptake of serotonin and norepinephrine (sexual dysfunction).
blocks norepinephrine receptors (hypotension and tachycardia)
blocks histamine receptors (sedation and weight gain)
blocks acetylcholine receptors (dry mouth, constipation, blurred vision, urinary retention).
MOAIs (monoamine oxidase inhibitors) effects
increases norepinephrine and serotonin by inhibiting enzyme that activates it. Can cause sedation, dizziness, sexual dysfunction, and hypertensive crisis.
Benzodiazepines effects
increases receptor affinity for GABA, can cause dependence and confusion
bupropion effects
inhibits reuptake of norepinephrine and dopamine. Can cause insomnia, dry mouth, tremors, seizures.
SSRIs, SNRIs, and tricyclic antidpressants
these antidepressants increase serotonin levels
benzodiazepines have what effect on serotonin levels
no effect on serotonin levels.
gray matter
Cerebellum, cerebrum, brain stem, and butterfly-shaped portion of central spinal cord are comprised of this.
Contains cell bodies, axon terminals, dendrites, and all nerve synapses.
Associated with learning.
Changes are linked to psychiatric diagnoses such as Alzheimer’s disease, schizophrenia, and MDD.
white matter
Contains nerve fibers connecting neurons from different regions into functional circuits.
Transit system.
Abnormalities are associated with autism and vascular dementia.
electrical impulse transmission
myelin coating neuronal axons is necessary for
frontal lobes function
lobe is associated with movement, intelligence, abstract thinking, ability to organize, personality, behavior, and emotional control.
TBI’s can result in personality changes, difficulty controlling emotions, and other cognitive functions.
central sulcus
Separates frontal lobe from parietal lobe
parietal lobe
portion of the cerebral cortex lying at the top of the head and toward the rear.
Responsible for proprioception and somatic senses.
Help a person identify spatial relationships, interpret pain and touch in the body, and identify and give meaning to objects.
Damage to anterior portion of this lobe can cause asterogenesis.
asterogenesis
loss of ability to recognize objects via the sense of touch
occipital lobe
controls visual processing.
Damage can result in inability to form visual memories.
B/L lobe damage results in inability to recognize items by sight.
Seizures in this lobe can cause hallucinations such as lines of color.
temporal lobe
involved in short-term memory, speech, auditory signals, and smell recognition.
Identifies “what” things are (object identification).
Containts the limbic system, amygdala, and hippocampus.
Dominant lesion in this lobe can present as Wernicke’s aphasia.
Disorders in this lobe include dementia, affective disorders, and ADHD.
group of structures that make the striatum
caudate, putamen, and nucleus abbumbens. involved in facilitating voluntary movement
nucleus accumbens
involved in reward circuit and reinforces addictive behaviors
amygdala
located deep in temporal lobes.
Involved in emotional regulation and perception of odors.
Traumatic event can result in formation of fear response causing fight or flight reflex.
Involved in interpretation of facial expressions and sexual stimuli.
hippocampus
located deep in temporal lobes.
Involved in anxiety and memory, and shifting short-term to long-term memory.
Impaired in schizophrenia and dementia.
limbic system
associated with pleasure, reward, and reinforcing behavior.
Drug abuse affects this system, disrupting emotions and feelings associated with normal behavior.
Thalamus
egg shaped structure involved in sensory organ and motor command processing.
All sensory systems except the olfaction process through this, which is responsible for processing all external information.
Associated with symptoms r/t schizophrenia and PTSD.
corpus callosum
controls communication between the two brain hemispheres.
Involved in attention, impulse control, and emotion regulation.
Integrates impulses from both sides of brain.
If underdeveloped or missing intellectual impairment may result.
dorsal striatum
involved in complex motor actions and linkage of cognition to motor actions.
Main input area for the basal ganglia and is active when anticipating or engaging in pleasure.
Cerebellum
Balance and coordination
agnosia
the inability to recognize familiar objects.
temporal lobe damage
inability to copy a written word or drawing
6 most important enzymes for psychotropic drug metabolism
- 1A2
- 2B6, 2D6, 2C9, 2C19
- 3A4
retrograde neurotransmission
A method of neurotransmission in which the postsynaptic cell communicates with the presynaptic neuron.
signal transduction cascade
series of events occurring following stimulation of a postsynaptic receptor. Can stimulate third messenger enzymes (kinases) which add phosphate groups to proteins. Other third messengers (phosphatases) remove phosphates from phosphoproteins.
Phase 1 metabolism
Oxidation, reduction, hydrolysis
Inhibitors: decrease medication metabolism
“VISA gets you CK for GQ”
valproate, isoniazid, sulfona[mides], amiodarone. chloramphenicol, ketoconazole. grapefruit juice, quinidine.
Inducers
“CRAP i need GPS”
carbamazepine, rifampin, alcohol, phenytoin.
griseofulvin, phenobarbital, sulfonyl[ureas]
monoamines
serotonin, histamine, dopamine, norepinephrine, epinephrine
attention, cognition, emotion
amino acids
glutamate, GABA, glycine
most functions
peptides
endorphin (opioids)
pain
Other neurotransmitters
acetylcholine
ANS, motor neurons
SERT can transport
serotonin (endogenous)
ecstacy (MDMA) (false substrate)
NET can transport
norepinephrine (endogenous)
dopamine, epinephrine, amphetamine (false substrate)
DAT can transport
dopamine (endogenous)
norepinephrine, epinephrine, amphetamine (false substrate)
VMAT (vesicular monoamine transporter)
transports serotonin, norepinephrine, dopamine, histamine
VAChT (vesicular acetylcholine transporter)
transports acetylcholine
VIAAT (vesicular inhibitory amino acid transporter)
transports GABA
VGluT (vesicular glutamate transporter)
transports glutamate
Low potency typical antipsychotics
chlorpromazine, mesoridazine, thioridazine
medium potency typical antipsychotics
thiothixene, fluphenazine
High potency typical antipsychotics
haloperidol
Tardive dyskinesia (TD)
hyperkinetic movement disorder characterized by abnormal facial and tongue movements, and quick, jerky limb movements. can occur from long-term blockade of D2 receptors in nigrostriatal pathway. Occurs in approx 5% of pt’s annually. 25% of pt’s develop symptoms within 5 years of medication start. failure to d/c typical antipsychotics prior to symptom onset can result in permanency.
the -pines
sedation is common. These medications have least risk for EPS, but high risk for weight gain and metabolic abnormalities.
the -dones
less sedating and cause less weight gain, but higher risk for hyperprolactinemia and EPS
the pips and rip
low risk of metabolic side effects and weight gain, but have potential for EPS.
anxiolytics
azapirones, benzodiazepines
“other” medications for anxiety
a2d ligands, beta blockers, histamine receptor agonists.
glial cells (glia)
Cells of the nervous system that support, regulate, and augment the functions of neurons.
mRNA
messenger RNA; type of RNA that carries instructions from DNA in the nucleus to the ribosome
RNA
A single-stranded nucleic acid that passes along genetic messages