NURS 660 ACTUAL 2026 EXAM QUESTIONS AND
SOLUTIONS RATED A+
✔✔Bupropion neurotransmitters and moa - ✔✔-Boosts neurotransmitters
norepinephrine/noradrenaline and dopamine
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing norepinephrine neurotransmission
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, bupropion can increase dopamine
neurotransmission in this part of the brain
-Blocks dopamine reuptake pump (dopamine transporter), presumably increasing
dopaminergic neurotransmission
✔✔Bupropion pregnancy risk - ✔✔Controlled studies have not been conducted in
pregnant women
Epidemiological studies do not indicate increased risk of congenital malformations
overall or of cardiovascular malformations
In animal studies, no clear evidence of teratogenicity has been observed; however,
slightly increased incidences of fetal malformations and skeletal variations were
observed in rabbit studies at doses approximately equal to and greater than the
maximum recommended human doses, and greater and decreased fetal weights were
observed in rat studies at doses greater than the maximum recommended human
doses
Pregnant women wishing to stop smoking may consider behavioral therapy before
pharmacotherapy
Not generally recommended for use during pregnancy, especially during first trimester
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
✔✔Clomipramine (Anafranil) major side effects TCA
Commonly Prescribed for
*Obsessive-compulsive disorder
Depression
Severe and treatment-resistant depression
Cataplexy syndrome
Anxiety
Insomnia
Neuropathic pain/chronic pain - ✔✔Blurred vision, constipation, urinary retention,
increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth,
weight gain
Fatigue, weakness, dizziness, sedation, headache, anxiety, nervousness, restlessness
Sexual dysfunction, sweating
,✔✔Clomipramine major adverse reactions - ✔✔-paralytic ileus, hyperthermia (TCAs +
anticholinergic agents)
-Lowered seizure threshold and rare seizures
-Orthostatic hypotension, sudden death, arrhythmias, tachycardia
-QTc prolongation
-Hepatic failure, extrapyramidal symptoms
-Increased intraocular pressure
-Rare induction of mania
-Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Clomipramine major drug interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or at least for 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing clomipramine
-Use of TCAs with anticholinergic drugs may result in paralytic ileus or hyperthermia
-Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors may
increase TCA concentrations
-Fluvoxamine, a CYP450 1A2 inhibitor, can decrease the conversion of clomipramine to
desmethyl-clomipramine, and increase clomipramine plasma concentrations
-Cimetidine may increase plasma concentrations of TCAs and cause anticholinergic
symptoms
-Phenothiazines or haloperidol may raise TCA blood concentrations
-May alter effects of antihypertensive drugs
-Use of TCAs with sympathomimetic agents may increase sympathetic activity
-TCAs may inhibit hypotensive effects of clonidine
-Methylphenidate may inhibit metabolism of TCAs
-Activation and agitation, especially following switching or adding antidepressants, may
represent the induction of a bipolar state, especially a mixed dysphoric bipolar II
condition sometimes associated with suicidal ideation, and require the addition of
lithium, a mood stabilizer or an atypical antipsychotic, and/or discontinuation of
clomipramine
✔✔Clomipramine lab tests - ✔✔-Baseline ECG is recommended for patients over age
50
-Monitoring of plasma drug levels is potentially available at specialty laboratories for the
expert
-Since tricyclic and tetracyclic antidepressants are frequently associated with weight
gain, before starting treatment, weigh all patients and determine if the patient is already
overweight (BMI 25.0-29.9) or obese (BMI ≥30)
-Before giving a drug that can cause weight gain to an overweight or obese patient,
consider determining whether the patient already has pre-diabetes (fasting plasma
glucose 100-125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or
, dyslipidemia (increased total cholesterol, LDL cholesterol and triglycerides; decreased
HDL cholesterol), and treat or refer such patients for treatment, including nutrition and
weight management, physical activity counseling, smoking cessation, and medical
management
-Weight and BMI during treatment
While giving a drug to a patient who has gained >5% of initial weight, consider
evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider
switching to a different antidepressant
-EKGs may be useful for selected patients (e.g., those with personal or family history of
QTc prolongation; cardiac arrhythmia; recent myocardial infarction; uncompensated
heart failure; or taking agents that prolong QTc interval such as pimozide, thioridazine,
selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.)
-Patients at risk for electrolyte disturbances (e.g., patients on diuretic therapy) should
have baseline and periodic serum potassium and magnesium measurements
✔✔Clomipramine neurotransmitters and moa - ✔✔-Boosts neurotransmitters serotonin
and norepinephrine/noradrenaline
-Blocks serotonin reuptake pump (serotonin transporter), presumably increasing
serotonergic neurotransmission
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing noradrenergic neurotransmission
-Presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, clomipramine can increase dopamine
neurotransmission in this part of the brain
✔✔Clomipramine pregnancy risk - ✔✔Controlled studies have not been conducted in
pregnant women
Clomipramine crosses the placenta
Adverse effects have been reported in infants whose mothers took a TCA (lethargy,
withdrawal symptoms, fetal malformations)
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
worsening of OCD, maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
✔✔Amitriptyline (Elavil) major side effects TCA
Commonly Prescribed for
*Depression
*Endogenous depression
Neuropathic pain/chronic pain
Fibromyalgia
Headache
Low back pain/neck pain
Anxiety
SOLUTIONS RATED A+
✔✔Bupropion neurotransmitters and moa - ✔✔-Boosts neurotransmitters
norepinephrine/noradrenaline and dopamine
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing norepinephrine neurotransmission
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, bupropion can increase dopamine
neurotransmission in this part of the brain
-Blocks dopamine reuptake pump (dopamine transporter), presumably increasing
dopaminergic neurotransmission
✔✔Bupropion pregnancy risk - ✔✔Controlled studies have not been conducted in
pregnant women
Epidemiological studies do not indicate increased risk of congenital malformations
overall or of cardiovascular malformations
In animal studies, no clear evidence of teratogenicity has been observed; however,
slightly increased incidences of fetal malformations and skeletal variations were
observed in rabbit studies at doses approximately equal to and greater than the
maximum recommended human doses, and greater and decreased fetal weights were
observed in rat studies at doses greater than the maximum recommended human
doses
Pregnant women wishing to stop smoking may consider behavioral therapy before
pharmacotherapy
Not generally recommended for use during pregnancy, especially during first trimester
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
✔✔Clomipramine (Anafranil) major side effects TCA
Commonly Prescribed for
*Obsessive-compulsive disorder
Depression
Severe and treatment-resistant depression
Cataplexy syndrome
Anxiety
Insomnia
Neuropathic pain/chronic pain - ✔✔Blurred vision, constipation, urinary retention,
increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth,
weight gain
Fatigue, weakness, dizziness, sedation, headache, anxiety, nervousness, restlessness
Sexual dysfunction, sweating
,✔✔Clomipramine major adverse reactions - ✔✔-paralytic ileus, hyperthermia (TCAs +
anticholinergic agents)
-Lowered seizure threshold and rare seizures
-Orthostatic hypotension, sudden death, arrhythmias, tachycardia
-QTc prolongation
-Hepatic failure, extrapyramidal symptoms
-Increased intraocular pressure
-Rare induction of mania
-Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not
show an increase in the risk of suicidality with antidepressants compared to placebo
beyond age 24)
✔✔Clomipramine major drug interactions - ✔✔-Tramadol increases the risk of seizures
in patients taking TCAs
-Can cause a fatal "serotonin syndrome" when combined with MAOIs, so do not use
with MAOIs or at least for 14 days after MAOIs are stopped
-Do not start an MAOI for at least 5 half-lives (5 to 7 days for most drugs) after
discontinuing clomipramine
-Use of TCAs with anticholinergic drugs may result in paralytic ileus or hyperthermia
-Fluoxetine, paroxetine, bupropion, duloxetine, and other CYP450 2D6 inhibitors may
increase TCA concentrations
-Fluvoxamine, a CYP450 1A2 inhibitor, can decrease the conversion of clomipramine to
desmethyl-clomipramine, and increase clomipramine plasma concentrations
-Cimetidine may increase plasma concentrations of TCAs and cause anticholinergic
symptoms
-Phenothiazines or haloperidol may raise TCA blood concentrations
-May alter effects of antihypertensive drugs
-Use of TCAs with sympathomimetic agents may increase sympathetic activity
-TCAs may inhibit hypotensive effects of clonidine
-Methylphenidate may inhibit metabolism of TCAs
-Activation and agitation, especially following switching or adding antidepressants, may
represent the induction of a bipolar state, especially a mixed dysphoric bipolar II
condition sometimes associated with suicidal ideation, and require the addition of
lithium, a mood stabilizer or an atypical antipsychotic, and/or discontinuation of
clomipramine
✔✔Clomipramine lab tests - ✔✔-Baseline ECG is recommended for patients over age
50
-Monitoring of plasma drug levels is potentially available at specialty laboratories for the
expert
-Since tricyclic and tetracyclic antidepressants are frequently associated with weight
gain, before starting treatment, weigh all patients and determine if the patient is already
overweight (BMI 25.0-29.9) or obese (BMI ≥30)
-Before giving a drug that can cause weight gain to an overweight or obese patient,
consider determining whether the patient already has pre-diabetes (fasting plasma
glucose 100-125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or
, dyslipidemia (increased total cholesterol, LDL cholesterol and triglycerides; decreased
HDL cholesterol), and treat or refer such patients for treatment, including nutrition and
weight management, physical activity counseling, smoking cessation, and medical
management
-Weight and BMI during treatment
While giving a drug to a patient who has gained >5% of initial weight, consider
evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider
switching to a different antidepressant
-EKGs may be useful for selected patients (e.g., those with personal or family history of
QTc prolongation; cardiac arrhythmia; recent myocardial infarction; uncompensated
heart failure; or taking agents that prolong QTc interval such as pimozide, thioridazine,
selected antiarrhythmics, moxifloxacin, sparfloxacin, etc.)
-Patients at risk for electrolyte disturbances (e.g., patients on diuretic therapy) should
have baseline and periodic serum potassium and magnesium measurements
✔✔Clomipramine neurotransmitters and moa - ✔✔-Boosts neurotransmitters serotonin
and norepinephrine/noradrenaline
-Blocks serotonin reuptake pump (serotonin transporter), presumably increasing
serotonergic neurotransmission
-Blocks norepinephrine reuptake pump (norepinephrine transporter), presumably
increasing noradrenergic neurotransmission
-Presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors
-Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which
largely lacks dopamine transporters, clomipramine can increase dopamine
neurotransmission in this part of the brain
✔✔Clomipramine pregnancy risk - ✔✔Controlled studies have not been conducted in
pregnant women
Clomipramine crosses the placenta
Adverse effects have been reported in infants whose mothers took a TCA (lethargy,
withdrawal symptoms, fetal malformations)
Must weigh the risk of treatment (first trimester fetal development, third trimester
newborn delivery) to the child against the risk of no treatment (recurrence of depression,
worsening of OCD, maternal health, infant bonding) to the mother and child
For many patients this may mean continuing treatment during pregnancy
✔✔Amitriptyline (Elavil) major side effects TCA
Commonly Prescribed for
*Depression
*Endogenous depression
Neuropathic pain/chronic pain
Fibromyalgia
Headache
Low back pain/neck pain
Anxiety
