GEORGETTE LMR PMHNP SCRIPT
TESTED SOLUTIONS
⫸ What should you do when a mother reports her child woke up
screaming in the middle of the night? Answer: Ask her if it's happened
before to assess for sleep issue patterns
⫸ What do you do if a patient comes in with fungus on their toenail?
Answer: Scrape nail and send for testing
⫸ What do you do if a patient on lithium has dark brown urine?
Answer: Check renal function
⫸ What do you do if a patient presents with fever while on Clozaril?
Answer: Check ANC level to assess for agranulocytosis
⫸ What can cause serotonin syndrome? Answer: Antidepressants, St.
John's Wort, Same-E, Kava Kava, and Tryptophan
⫸ What labs are indicative of NMS? Answer: Elevated WBC (over
11,000) and elevated CPK
⫸ S/S of NMS Answer: muscle rigidity, hyperthermia, tachycardia,
abnormal bp, sweating, altered mental status, cherry colored urine
,⫸ What should you do if a patient presents with cherry colored urine?
Answer: Check for rhabdo with CPK
⫸ s/s of serotonin syndrome Answer: hyperreflexia, muscle spasms,
myoclonus (involuntary muscle jerk), fever, tachycardia, HTN, shits and
shivers
⫸ What two medications to give with NMS? Answer: bromocriptine
(Parlodel)- D2 agonist dantrolene- muscle relaxer
⫸ What medication to give during SS? Answer: cyproheptadine
(Periactin)- 5HT-2A receptor antagonist
⫸ What is the onset and typical length of NMS? Answer: Slow onset (1-
2 weeks after changing or starting therapy) and resolves within 9-14
days
⫸ What is the onset of SS? Answer: Within 24 hours of
starting/changing medication and resolves within a few days
⫸ How do you distinguish between NMS and acute dystonia? Answer:
NMS has a slower onset while acute dystonia occurs within hours
⫸ What happens with lithium and NSAIDs? Answer: Increased risk of
lithium toxicity (gout meds, ibuprophen, naproxen, etc.)
,⫸ What happens with lithium and ACE inhibitors? Answer: Increased
risk of lithium toxicity related to the increased urination from the ACE
inhibitors
⫸ Why should a patient on lithium avoid calcium channel blockers?
Answer: Risk of fatal nephrotoxicity
⫸ What is a fetal side effect of lithium? Answer: Epstein's anomaly
⫸ What lab should you check for athletes on lithium? Answer: Specific
gravity to assess for dehydration (dehydration is >1.015)
⫸ What do you do if the lithium level is 1.3? Answer: Do not give the
next dose and assess for s/s
⫸ At what level is lithium toxicity a medical emergency? Answer: >3
⫸ S/S of lithium toxicity Answer: vomiting, diarrhea, slurred speech,
hand tremor, dry mouth/thirst, muscle weakness/twitching
⫸ Why check an EKG with lithium? Answer: Inverted T-waves
⫸ What medication should treat hypothyroidism caused by lithium use?
Answer: Synthroid
, ⫸ What do you do if patient is prescribed both depakote and lamictal?
Answer: Decreased lamictal dose by 50%
⫸ Depakote and pregnancy Answer: Spina bifida
⫸ What emergency may be occuring if patient on depakote reports
upper abdominal pain? Answer: Pancreatitis
⫸ What lab should you check if patient has right upper quadrant pain
and dark brown urine? Answer: LFTs
⫸ What lab means pregnancy? Answer: HCG
⫸ Why is Clozaril used? Answer: Treatment resistant schizophrenia,
improves SI, and improves negative symptoms of schizophrenia
⫸ What two medications have the highest risk of agranulocytosis and
aplastic anemia? Answer: Clozaril and Tegretol
⫸ What symptoms may mean a Clozaril induced infection? Answer:
Sore throats, sores in mouth/gums, fever
⫸ When should you discontinue Clozaril or Tegretol? Answer: WBC <
2000 or ANC <1000
TESTED SOLUTIONS
⫸ What should you do when a mother reports her child woke up
screaming in the middle of the night? Answer: Ask her if it's happened
before to assess for sleep issue patterns
⫸ What do you do if a patient comes in with fungus on their toenail?
Answer: Scrape nail and send for testing
⫸ What do you do if a patient on lithium has dark brown urine?
Answer: Check renal function
⫸ What do you do if a patient presents with fever while on Clozaril?
Answer: Check ANC level to assess for agranulocytosis
⫸ What can cause serotonin syndrome? Answer: Antidepressants, St.
John's Wort, Same-E, Kava Kava, and Tryptophan
⫸ What labs are indicative of NMS? Answer: Elevated WBC (over
11,000) and elevated CPK
⫸ S/S of NMS Answer: muscle rigidity, hyperthermia, tachycardia,
abnormal bp, sweating, altered mental status, cherry colored urine
,⫸ What should you do if a patient presents with cherry colored urine?
Answer: Check for rhabdo with CPK
⫸ s/s of serotonin syndrome Answer: hyperreflexia, muscle spasms,
myoclonus (involuntary muscle jerk), fever, tachycardia, HTN, shits and
shivers
⫸ What two medications to give with NMS? Answer: bromocriptine
(Parlodel)- D2 agonist dantrolene- muscle relaxer
⫸ What medication to give during SS? Answer: cyproheptadine
(Periactin)- 5HT-2A receptor antagonist
⫸ What is the onset and typical length of NMS? Answer: Slow onset (1-
2 weeks after changing or starting therapy) and resolves within 9-14
days
⫸ What is the onset of SS? Answer: Within 24 hours of
starting/changing medication and resolves within a few days
⫸ How do you distinguish between NMS and acute dystonia? Answer:
NMS has a slower onset while acute dystonia occurs within hours
⫸ What happens with lithium and NSAIDs? Answer: Increased risk of
lithium toxicity (gout meds, ibuprophen, naproxen, etc.)
,⫸ What happens with lithium and ACE inhibitors? Answer: Increased
risk of lithium toxicity related to the increased urination from the ACE
inhibitors
⫸ Why should a patient on lithium avoid calcium channel blockers?
Answer: Risk of fatal nephrotoxicity
⫸ What is a fetal side effect of lithium? Answer: Epstein's anomaly
⫸ What lab should you check for athletes on lithium? Answer: Specific
gravity to assess for dehydration (dehydration is >1.015)
⫸ What do you do if the lithium level is 1.3? Answer: Do not give the
next dose and assess for s/s
⫸ At what level is lithium toxicity a medical emergency? Answer: >3
⫸ S/S of lithium toxicity Answer: vomiting, diarrhea, slurred speech,
hand tremor, dry mouth/thirst, muscle weakness/twitching
⫸ Why check an EKG with lithium? Answer: Inverted T-waves
⫸ What medication should treat hypothyroidism caused by lithium use?
Answer: Synthroid
, ⫸ What do you do if patient is prescribed both depakote and lamictal?
Answer: Decreased lamictal dose by 50%
⫸ Depakote and pregnancy Answer: Spina bifida
⫸ What emergency may be occuring if patient on depakote reports
upper abdominal pain? Answer: Pancreatitis
⫸ What lab should you check if patient has right upper quadrant pain
and dark brown urine? Answer: LFTs
⫸ What lab means pregnancy? Answer: HCG
⫸ Why is Clozaril used? Answer: Treatment resistant schizophrenia,
improves SI, and improves negative symptoms of schizophrenia
⫸ What two medications have the highest risk of agranulocytosis and
aplastic anemia? Answer: Clozaril and Tegretol
⫸ What symptoms may mean a Clozaril induced infection? Answer:
Sore throats, sores in mouth/gums, fever
⫸ When should you discontinue Clozaril or Tegretol? Answer: WBC <
2000 or ANC <1000
