1
NR 546 Week 4 Anxiolytic Assessment – Advanced
Psychopharmacology Comprehensive Study Guide &
Practice Exam
PART 3: PRACTICE QUESTIONS (50 QUESTIONS)
Question 1
A 45-year-old female with generalized anxiety disorder has been on sertraline for
8 weeks with partial response. She reports persistent anxiety and difficulty
sleeping. Which of the following would be the most appropriate next step?
A. Discontinue sertraline and start alprazolam
B. Add buspirone to the sertraline
C. Increase the sertraline dose
D. Start trazodone for sleep
C. Increase the sertraline dose
RATIONALE: SSRIs are first-line for GAD, and dose optimization should be
attempted before adding or switching medications. Sertraline doses can be
titrated up to 200 mg/day for anxiety disorders. Buspirone may be added but is
not first-line augmentation. Trazodone can help with sleep but does not address
the underlying anxiety. Discontinuing sertraline and starting alprazolam would be
inappropriate as benzodiazepines are not first-line for chronic anxiety.
Question 2
A 28-year-old male with panic disorder is started on paroxetine. He returns 2
weeks later reporting increased anxiety, jitteriness, and insomnia. What is the
most appropriate response?
A. Discontinue paroxetine and start alprazolam
B. Reassure the patient that this is a common initial side effect and may improve
pg. 1
,2
C. Increase the paroxetine dose to achieve faster response
D. Add hydroxyzine for immediate symptom relief
B. Reassure the patient that this is a common initial side effect and may
improve
RATIONALE: SSRIs commonly cause initial activation (increased anxiety,
jitteriness, insomnia) during the first 1-2 weeks of treatment. This typically
resolves as the patient adjusts to the medication. Reassurance and education are
key. The dose should not be increased until the patient has been on the
medication for at least 4 weeks. Adding another medication may be appropriate if
symptoms persist, but the first step is education and reassurance.
Question 3
A 62-year-old male with a history of hepatic cirrhosis and generalized anxiety
disorder is prescribed lorazepam. Why is lorazepam preferred in this patient?
A. It has a shorter half-life
B. It is metabolized by glucuronidation, not CYP450
C. It has no active metabolites
D. It is less sedating
B. It is metabolized by glucuronidation, not CYP450
RATIONALE: Lorazepam, oxazepam, and temazepam are metabolized by
glucuronidation (conjugation) rather than CYP450 enzymes. This makes them
preferred in patients with hepatic impairment, as liver disease does not
significantly affect glucuronidation. Benzodiazepines that require CYP450
metabolism (alprazolam, diazepam, clonazepam) may accumulate in hepatic
impairment.
Question 4
A patient with social anxiety disorder is prescribed propranolol for performance
anxiety. What instruction should the PMHNP include?
pg. 2
,3
A. "Take this medication daily for best results"
B. "Take this medication 30-60 minutes before the anxiety-provoking event"
C. "This medication will help with both the physical and psychological symptoms
of anxiety"
D. "You may experience withdrawal if you stop this medication abruptly"
B. "Take this medication 30-60 minutes before the anxiety-provoking event"
RATIONALE: Propranolol is used PRN for performance anxiety and should be
taken 30-60 minutes before the event. It addresses somatic symptoms (tremor,
tachycardia, palpitations) but does not treat the psychological symptoms of
anxiety. It is not taken daily for this indication and does not cause significant
withdrawal when used PRN.
Question 5
Which of the following anxiolytics has the longest onset of action and requires
consistent daily dosing?
A. Alprazolam
B. Buspirone
C. Lorazepam
D. Hydroxyzine
B. Buspirone
RATIONALE: Buspirone has a delayed onset of action (2-4 weeks) and must be
taken consistently (not PRN). It is not effective for acute anxiety or panic disorder.
Alprazolam, lorazepam, and hydroxyzine have more rapid onsets and can be used
PRN for acute symptoms.
Question 6
A 35-year-old female with generalized anxiety disorder and a history of substance
use disorder is started on buspirone. Which statement accurately reflects the
advantage of buspirone over benzodiazepines?
pg. 3
, 4
A. Buspirone has a faster onset of action
B. Buspirone has no potential for dependence or withdrawal
C. Buspirone is more effective for panic disorder
D. Buspirone has stronger sedative effects
B. Buspirone has no potential for dependence or withdrawal
RATIONALE: Buspirone is not a controlled substance and does not cause
dependence, tolerance, or withdrawal. This makes it a safer choice for patients
with a history of substance use disorder. However, it has a delayed onset (2-4
weeks), is not effective for panic disorder, and does not have sedative effects.
Question 7
A patient on alprazolam for panic disorder reports needing to increase the dose to
achieve the same effect. This phenomenon is known as:
A. Dependence
B. Tolerance
C. Withdrawal
D. Sensitization
B. Tolerance
RATIONALE: Tolerance is the need for increasing doses to achieve the same
therapeutic effect. This is a well-known consequence of chronic benzodiazepine
use. Dependence refers to the physical adaptation to the drug, where withdrawal
symptoms occur upon discontinuation. Tolerance develops to the anxiolytic and
sedative effects of benzodiazepines but not to the anticonvulsant effects.
Question 8
Which of the following benzodiazepines is most appropriate for a patient with
hepatic impairment?
A. Alprazolam
B. Lorazepam
pg. 4
NR 546 Week 4 Anxiolytic Assessment – Advanced
Psychopharmacology Comprehensive Study Guide &
Practice Exam
PART 3: PRACTICE QUESTIONS (50 QUESTIONS)
Question 1
A 45-year-old female with generalized anxiety disorder has been on sertraline for
8 weeks with partial response. She reports persistent anxiety and difficulty
sleeping. Which of the following would be the most appropriate next step?
A. Discontinue sertraline and start alprazolam
B. Add buspirone to the sertraline
C. Increase the sertraline dose
D. Start trazodone for sleep
C. Increase the sertraline dose
RATIONALE: SSRIs are first-line for GAD, and dose optimization should be
attempted before adding or switching medications. Sertraline doses can be
titrated up to 200 mg/day for anxiety disorders. Buspirone may be added but is
not first-line augmentation. Trazodone can help with sleep but does not address
the underlying anxiety. Discontinuing sertraline and starting alprazolam would be
inappropriate as benzodiazepines are not first-line for chronic anxiety.
Question 2
A 28-year-old male with panic disorder is started on paroxetine. He returns 2
weeks later reporting increased anxiety, jitteriness, and insomnia. What is the
most appropriate response?
A. Discontinue paroxetine and start alprazolam
B. Reassure the patient that this is a common initial side effect and may improve
pg. 1
,2
C. Increase the paroxetine dose to achieve faster response
D. Add hydroxyzine for immediate symptom relief
B. Reassure the patient that this is a common initial side effect and may
improve
RATIONALE: SSRIs commonly cause initial activation (increased anxiety,
jitteriness, insomnia) during the first 1-2 weeks of treatment. This typically
resolves as the patient adjusts to the medication. Reassurance and education are
key. The dose should not be increased until the patient has been on the
medication for at least 4 weeks. Adding another medication may be appropriate if
symptoms persist, but the first step is education and reassurance.
Question 3
A 62-year-old male with a history of hepatic cirrhosis and generalized anxiety
disorder is prescribed lorazepam. Why is lorazepam preferred in this patient?
A. It has a shorter half-life
B. It is metabolized by glucuronidation, not CYP450
C. It has no active metabolites
D. It is less sedating
B. It is metabolized by glucuronidation, not CYP450
RATIONALE: Lorazepam, oxazepam, and temazepam are metabolized by
glucuronidation (conjugation) rather than CYP450 enzymes. This makes them
preferred in patients with hepatic impairment, as liver disease does not
significantly affect glucuronidation. Benzodiazepines that require CYP450
metabolism (alprazolam, diazepam, clonazepam) may accumulate in hepatic
impairment.
Question 4
A patient with social anxiety disorder is prescribed propranolol for performance
anxiety. What instruction should the PMHNP include?
pg. 2
,3
A. "Take this medication daily for best results"
B. "Take this medication 30-60 minutes before the anxiety-provoking event"
C. "This medication will help with both the physical and psychological symptoms
of anxiety"
D. "You may experience withdrawal if you stop this medication abruptly"
B. "Take this medication 30-60 minutes before the anxiety-provoking event"
RATIONALE: Propranolol is used PRN for performance anxiety and should be
taken 30-60 minutes before the event. It addresses somatic symptoms (tremor,
tachycardia, palpitations) but does not treat the psychological symptoms of
anxiety. It is not taken daily for this indication and does not cause significant
withdrawal when used PRN.
Question 5
Which of the following anxiolytics has the longest onset of action and requires
consistent daily dosing?
A. Alprazolam
B. Buspirone
C. Lorazepam
D. Hydroxyzine
B. Buspirone
RATIONALE: Buspirone has a delayed onset of action (2-4 weeks) and must be
taken consistently (not PRN). It is not effective for acute anxiety or panic disorder.
Alprazolam, lorazepam, and hydroxyzine have more rapid onsets and can be used
PRN for acute symptoms.
Question 6
A 35-year-old female with generalized anxiety disorder and a history of substance
use disorder is started on buspirone. Which statement accurately reflects the
advantage of buspirone over benzodiazepines?
pg. 3
, 4
A. Buspirone has a faster onset of action
B. Buspirone has no potential for dependence or withdrawal
C. Buspirone is more effective for panic disorder
D. Buspirone has stronger sedative effects
B. Buspirone has no potential for dependence or withdrawal
RATIONALE: Buspirone is not a controlled substance and does not cause
dependence, tolerance, or withdrawal. This makes it a safer choice for patients
with a history of substance use disorder. However, it has a delayed onset (2-4
weeks), is not effective for panic disorder, and does not have sedative effects.
Question 7
A patient on alprazolam for panic disorder reports needing to increase the dose to
achieve the same effect. This phenomenon is known as:
A. Dependence
B. Tolerance
C. Withdrawal
D. Sensitization
B. Tolerance
RATIONALE: Tolerance is the need for increasing doses to achieve the same
therapeutic effect. This is a well-known consequence of chronic benzodiazepine
use. Dependence refers to the physical adaptation to the drug, where withdrawal
symptoms occur upon discontinuation. Tolerance develops to the anxiolytic and
sedative effects of benzodiazepines but not to the anticonvulsant effects.
Question 8
Which of the following benzodiazepines is most appropriate for a patient with
hepatic impairment?
A. Alprazolam
B. Lorazepam
pg. 4
