ADULT-GERONTOLOGY ACUTE
CARE NURSE PRACTITIONER
CERTIFICATION 2024-25
QUESTIONS AND ANSWERS
Exam 1
1. The patient is a 27-year-old woman who presents to your health care facility
with a history of depressed mood that has worsened during the past few weeks.
She gained 8 kg in the past 2 months; she reports that she is eating when she is
not sleeping. She is very stressed and worried about her job. She has passive
thoughts of harming herself but no definite plan. Her medical history includes
anxiety, and she takes 0.5 mg of alprazolam three times daily. Which medication
is the best to treat this patient?
1. Paroxetine.
2. Fluoxetine.
3. Imipramine.
4. Mirtazapine.
2. Fluoxetine.
Rationale: The patient presents with signs and symptoms of major depressive disorder.
Selective serotonin receptor inhibitors are considered a first-line agent in treatment for
this patient. The patient gained 8 kg in the past 2 months; therefore paroxetine (answer
1) is not recommended for her case because it leads to increased appetite and causes
somnolence. Fluoxetine (answer 2) is the best medication for this patient because it
does not affect weight or appetite. In addition, fluoxetine could concomitantly relieve her
symptoms of anxiety. Imipramine is a tricyclic antidepressant agent (TCA) that has a
warning that patients with passive suicidal ideas should not receive TCAs (answer 3).
Mirtazapine (answer 4), like paroxetine, could increase appetite and lead to weight gain.
2. The patient is a 43-year-old Hispanic man who is getting ready to be
discharged from your health care facility after a myocardial infarction. He has a
23-year history of cigarette smoking and smokes 1 pack/day. He has tried to quit
several times, but he was unsuccessful. He tried 2-mg nicotine gum, and to save
money, he chewed only 6 pieces daily. He has a history of depression along with
his cardiac problems. Which medication is the best for this patient?
1. Nicotine 4-mg gum.
2. Varenicline 0.5 mg once daily.
,3. Bupropion SR 150 mg twice daily.
4. Nicotine patch 21 mg/day.
3. Bupropion SR 150 mg twice daily.
Rationale: The patient's previous attempt to quit smoking with nicotine gum was
probably unsuccessful because the gum strength (2 mg) and the frequency of use
(fewer than 9 pieces a day) were too low to manage his nicotine craving; therefore his
previous use of nicotine gum is not a true treatment failure. Varenicline (answer 2) is not
contraindicated because of the cardiac problems, but it is contraindicated because the
patient has a depression history. Bupropion (answer 3) is a better fit because of its
appropriateness for depressive disorders. Nicotine gum (answer 1) or patch (answer 4)
are appropriate and can be added when bupropion fails as monotherapy to treat his
nicotine craving.
3. The patient is a 53-year-old African American woman (weight 95 kg, height 73
inches) who comes to your clinic for management of her type 2 diabetes, mild
congestive heart disease, neuropathy, and recurrent major depression. Her
medications are metformin 1000 mg twice daily, carvedilol 12.5 mg twice daily,
citalopram 40 mg daily, and ramipril 10 mg daily. She still has depressive
symptoms and wants to change her medication. What is the best action for her?
1. Duloxetine.
2. Desipramine.
3. Sertraline.
4. Bupropion.
1. Duloxetine.
Rationale: This patient still has depressive symptoms and diabetic neuropathy;
therefore duloxetine (answer 1) is the best choice for this patient. Although desipramine
(answer 2) could be used for treating her neuropathy, it is not a good choice because of
her heart disease. Sertraline (answer 3) would be a better choice for her depression, but
it does not help diabetic neuropathy. However, bupropion can lead to weight loss, but
data are not strong for treatment of neuropathy (answer 4).
4. The patient is a 58-year-old Asian man with a 25-year history of alcoholic
dependence. He drinks 1 cup of vodka every day. He has tried to quit several
times without success. His laboratory tests reveal aspartate aminotransferase
135 international units/L, alanine aminotransferase 75 international units/L,
albumin 4 g/dL, total bilirubin 0.3 mg/dL, prothrombin time 0.8 seconds, platelet
count 350,000/mm3, and creatinine clearance 35 mL/min. After detoxification,
which maintenance treatment is most appropriate?
1. Chlordiazepoxide.
2. Disulfiram.
3. Naltrexone.
4. Acamprosate.
,4. Acamprosate.
Rationale: This patient has alcoholic hepatitis, as indicated by his elevated liver
enzymes; thus it could improve with abstinence. His liver function is normal, as
evidenced by his albumin, prothrombin time. and platelet count. Chlordiazepoxide
(answer 1) has an important role in acute alcohol detoxification, but there are limited
data about its role for the maintenance treatment. Disulfiram (answer 2) requires a
strong recommendation from the patient to abstain. Moreover, it should be used with
caution for patients with active liver disease. Naltrexone (answer 3) should be used with
caution for patients with acute liver disease. Acamprosate (answer 4) is the most
appropriate medication for this patient. In addition, the dose of Acamprosate should be
reduced for patients with a creatinine clearance between 50 and 30 mL/min.
5. The patient is a 35-year-old white woman admitted to the emergency
department with agitation, diaphoresis, and fever (103.5°F). Also, her eyelid has
been twitching for 2 hours. She reports cold symptoms for the past 3 days, and
she took dextromethorphan and pseudoephedrine. Her medical history includes
depression, hypertension, and osteoarthritis. She currently takes sertraline 100
mg daily, glipizide 5 mg daily, diltiazem XR 240 mg daily, calcium 500 mg daily,
and acetaminophen 650 mg every 6 hours. Which combination of medications is
most likely contributing to her symptoms?
1. Dextromethorphan and paroxetine.
2. Paroxetine and acetaminophen.
3. Paroxetine and glipizide.
4. Dextromethorphan and pseudoephedrine.
1. Dextromethorphan and paroxetine.
Rationale: The patient presents to the emergency department with signs and symptoms
of serotonin syndrome (myoclonus, agitation, and diaphoresis). The medications most
likely contributing to her symptoms are dextromethorphan and paroxetine because both
agents have serotonergic activity. Moreover, paroxetine inhibits CYP2D6, which is
responsible for metabolism of dextromethorphan, so it could increase the serotonergic
activity (answer 1). Thus none of the other choices leads to serotonergic activity, so
answers 2, 3, and 4 are incorrect.
6. The patient is a 23-year-old Asian woman with a 2-year history of heroin
addiction. She has successfully been maintained on methadone 40 mg daily for 1
year. Now, she does not want to go to a daily opioid treatment program to get her
methadone dose. Which treatment regimen could be changed and is appropriate
for her?
1. Initiate naltrexone.
2. Administer naltrexone/buprenorphine.
3. Change to buprenorphine × 2 days, then administer naltrexone/buprenorphine.
4. Taper to methadone 30 mg, then change to buprenorphine.
, 4. Taper to methadone 30 mg, then change to buprenorphine.
Rationale: Initiation of naltrexone as monotherapy is inappropriate because it could
precipitate withdrawal symptoms of methadone (answer 1). Patients who take long-
acting opioids such as methadone should be changed to buprenorphine first before
being advanced to buprenorphine/naltrexone (answer 2). Initiation of buprenorphine
with a higher dose of methadone could precipitate the withdrawal symptoms because of
higher binding affinity of buprenorphine for the mu receptor with less activity and the
added antagonism at the kappa receptor (answer 3). Therefore patients who take long-
acting opioid should be tapered, to avoid withdrawal symptoms, before changing to
buprenorphine (answer 4).
7. A 29-year-old woman presents to the psychiatric clinic complaining of losing
interest in her job and she wants to be alone. She has a 6-year history of type I
bipolar disorder and takes lithium 300 mg twice daily. She states that she takes
her medicine every day just as prescribed. Her lithium level today is 1.0 mEq/L.
She has been without manic disorders for the past 5 years. Which medication is
the best for her acute depression symptoms?
1. Venlafaxine.
2. Quetiapine.
3. Aripiprazole.
4. Lamotrigine.
2. Quetiapine.
Rationale: This patient has a history of type I bipolar disorder. She has been on lithium
for 6 years, with an acceptable therapeutic range, which is long enough to derive any
antidepressant effects. Venlafaxine (answer 1) is a serotonin and norepinephrine
reuptake inhibitor that could lead to mania. Moreover, the effect of antidepressants for
treatment of depression disorders associated with bipolar disorders is still questionable.
Quetiapine (answer 2) has a Food and Drug Administration indication for the treatment
of depression symptoms associated with bipolar disorders because of its rapid onset of
action. Aripiprazole (answer 3) is inappropriate for treatment of depression symptoms
associated with bipolar disorders because it is not effective and there is not enough
data to support its effectiveness. Lamotrigine (answer 4) is appropriate for maintenance
treatment because of its slow onset and it requires a slow titration to reach therapeutic
doses.
8. A 29-year-old woman presents to the psychiatric clinic complaining of losing
interest in her job and wants to be alone all the time. She has a 6-year of history
of type I bipolar disorder and takes lithium 300 mg twice daily. She states that she
takes her medicine every day just as prescribed. Her lithium level today is 1.0
mEq/L. She has been without manic disorders for the past 5 years. Which therapy
would be the best for the maintenance depression symptoms?
1. Venlafaxine.
CARE NURSE PRACTITIONER
CERTIFICATION 2024-25
QUESTIONS AND ANSWERS
Exam 1
1. The patient is a 27-year-old woman who presents to your health care facility
with a history of depressed mood that has worsened during the past few weeks.
She gained 8 kg in the past 2 months; she reports that she is eating when she is
not sleeping. She is very stressed and worried about her job. She has passive
thoughts of harming herself but no definite plan. Her medical history includes
anxiety, and she takes 0.5 mg of alprazolam three times daily. Which medication
is the best to treat this patient?
1. Paroxetine.
2. Fluoxetine.
3. Imipramine.
4. Mirtazapine.
2. Fluoxetine.
Rationale: The patient presents with signs and symptoms of major depressive disorder.
Selective serotonin receptor inhibitors are considered a first-line agent in treatment for
this patient. The patient gained 8 kg in the past 2 months; therefore paroxetine (answer
1) is not recommended for her case because it leads to increased appetite and causes
somnolence. Fluoxetine (answer 2) is the best medication for this patient because it
does not affect weight or appetite. In addition, fluoxetine could concomitantly relieve her
symptoms of anxiety. Imipramine is a tricyclic antidepressant agent (TCA) that has a
warning that patients with passive suicidal ideas should not receive TCAs (answer 3).
Mirtazapine (answer 4), like paroxetine, could increase appetite and lead to weight gain.
2. The patient is a 43-year-old Hispanic man who is getting ready to be
discharged from your health care facility after a myocardial infarction. He has a
23-year history of cigarette smoking and smokes 1 pack/day. He has tried to quit
several times, but he was unsuccessful. He tried 2-mg nicotine gum, and to save
money, he chewed only 6 pieces daily. He has a history of depression along with
his cardiac problems. Which medication is the best for this patient?
1. Nicotine 4-mg gum.
2. Varenicline 0.5 mg once daily.
,3. Bupropion SR 150 mg twice daily.
4. Nicotine patch 21 mg/day.
3. Bupropion SR 150 mg twice daily.
Rationale: The patient's previous attempt to quit smoking with nicotine gum was
probably unsuccessful because the gum strength (2 mg) and the frequency of use
(fewer than 9 pieces a day) were too low to manage his nicotine craving; therefore his
previous use of nicotine gum is not a true treatment failure. Varenicline (answer 2) is not
contraindicated because of the cardiac problems, but it is contraindicated because the
patient has a depression history. Bupropion (answer 3) is a better fit because of its
appropriateness for depressive disorders. Nicotine gum (answer 1) or patch (answer 4)
are appropriate and can be added when bupropion fails as monotherapy to treat his
nicotine craving.
3. The patient is a 53-year-old African American woman (weight 95 kg, height 73
inches) who comes to your clinic for management of her type 2 diabetes, mild
congestive heart disease, neuropathy, and recurrent major depression. Her
medications are metformin 1000 mg twice daily, carvedilol 12.5 mg twice daily,
citalopram 40 mg daily, and ramipril 10 mg daily. She still has depressive
symptoms and wants to change her medication. What is the best action for her?
1. Duloxetine.
2. Desipramine.
3. Sertraline.
4. Bupropion.
1. Duloxetine.
Rationale: This patient still has depressive symptoms and diabetic neuropathy;
therefore duloxetine (answer 1) is the best choice for this patient. Although desipramine
(answer 2) could be used for treating her neuropathy, it is not a good choice because of
her heart disease. Sertraline (answer 3) would be a better choice for her depression, but
it does not help diabetic neuropathy. However, bupropion can lead to weight loss, but
data are not strong for treatment of neuropathy (answer 4).
4. The patient is a 58-year-old Asian man with a 25-year history of alcoholic
dependence. He drinks 1 cup of vodka every day. He has tried to quit several
times without success. His laboratory tests reveal aspartate aminotransferase
135 international units/L, alanine aminotransferase 75 international units/L,
albumin 4 g/dL, total bilirubin 0.3 mg/dL, prothrombin time 0.8 seconds, platelet
count 350,000/mm3, and creatinine clearance 35 mL/min. After detoxification,
which maintenance treatment is most appropriate?
1. Chlordiazepoxide.
2. Disulfiram.
3. Naltrexone.
4. Acamprosate.
,4. Acamprosate.
Rationale: This patient has alcoholic hepatitis, as indicated by his elevated liver
enzymes; thus it could improve with abstinence. His liver function is normal, as
evidenced by his albumin, prothrombin time. and platelet count. Chlordiazepoxide
(answer 1) has an important role in acute alcohol detoxification, but there are limited
data about its role for the maintenance treatment. Disulfiram (answer 2) requires a
strong recommendation from the patient to abstain. Moreover, it should be used with
caution for patients with active liver disease. Naltrexone (answer 3) should be used with
caution for patients with acute liver disease. Acamprosate (answer 4) is the most
appropriate medication for this patient. In addition, the dose of Acamprosate should be
reduced for patients with a creatinine clearance between 50 and 30 mL/min.
5. The patient is a 35-year-old white woman admitted to the emergency
department with agitation, diaphoresis, and fever (103.5°F). Also, her eyelid has
been twitching for 2 hours. She reports cold symptoms for the past 3 days, and
she took dextromethorphan and pseudoephedrine. Her medical history includes
depression, hypertension, and osteoarthritis. She currently takes sertraline 100
mg daily, glipizide 5 mg daily, diltiazem XR 240 mg daily, calcium 500 mg daily,
and acetaminophen 650 mg every 6 hours. Which combination of medications is
most likely contributing to her symptoms?
1. Dextromethorphan and paroxetine.
2. Paroxetine and acetaminophen.
3. Paroxetine and glipizide.
4. Dextromethorphan and pseudoephedrine.
1. Dextromethorphan and paroxetine.
Rationale: The patient presents to the emergency department with signs and symptoms
of serotonin syndrome (myoclonus, agitation, and diaphoresis). The medications most
likely contributing to her symptoms are dextromethorphan and paroxetine because both
agents have serotonergic activity. Moreover, paroxetine inhibits CYP2D6, which is
responsible for metabolism of dextromethorphan, so it could increase the serotonergic
activity (answer 1). Thus none of the other choices leads to serotonergic activity, so
answers 2, 3, and 4 are incorrect.
6. The patient is a 23-year-old Asian woman with a 2-year history of heroin
addiction. She has successfully been maintained on methadone 40 mg daily for 1
year. Now, she does not want to go to a daily opioid treatment program to get her
methadone dose. Which treatment regimen could be changed and is appropriate
for her?
1. Initiate naltrexone.
2. Administer naltrexone/buprenorphine.
3. Change to buprenorphine × 2 days, then administer naltrexone/buprenorphine.
4. Taper to methadone 30 mg, then change to buprenorphine.
, 4. Taper to methadone 30 mg, then change to buprenorphine.
Rationale: Initiation of naltrexone as monotherapy is inappropriate because it could
precipitate withdrawal symptoms of methadone (answer 1). Patients who take long-
acting opioids such as methadone should be changed to buprenorphine first before
being advanced to buprenorphine/naltrexone (answer 2). Initiation of buprenorphine
with a higher dose of methadone could precipitate the withdrawal symptoms because of
higher binding affinity of buprenorphine for the mu receptor with less activity and the
added antagonism at the kappa receptor (answer 3). Therefore patients who take long-
acting opioid should be tapered, to avoid withdrawal symptoms, before changing to
buprenorphine (answer 4).
7. A 29-year-old woman presents to the psychiatric clinic complaining of losing
interest in her job and she wants to be alone. She has a 6-year history of type I
bipolar disorder and takes lithium 300 mg twice daily. She states that she takes
her medicine every day just as prescribed. Her lithium level today is 1.0 mEq/L.
She has been without manic disorders for the past 5 years. Which medication is
the best for her acute depression symptoms?
1. Venlafaxine.
2. Quetiapine.
3. Aripiprazole.
4. Lamotrigine.
2. Quetiapine.
Rationale: This patient has a history of type I bipolar disorder. She has been on lithium
for 6 years, with an acceptable therapeutic range, which is long enough to derive any
antidepressant effects. Venlafaxine (answer 1) is a serotonin and norepinephrine
reuptake inhibitor that could lead to mania. Moreover, the effect of antidepressants for
treatment of depression disorders associated with bipolar disorders is still questionable.
Quetiapine (answer 2) has a Food and Drug Administration indication for the treatment
of depression symptoms associated with bipolar disorders because of its rapid onset of
action. Aripiprazole (answer 3) is inappropriate for treatment of depression symptoms
associated with bipolar disorders because it is not effective and there is not enough
data to support its effectiveness. Lamotrigine (answer 4) is appropriate for maintenance
treatment because of its slow onset and it requires a slow titration to reach therapeutic
doses.
8. A 29-year-old woman presents to the psychiatric clinic complaining of losing
interest in her job and wants to be alone all the time. She has a 6-year of history
of type I bipolar disorder and takes lithium 300 mg twice daily. She states that she
takes her medicine every day just as prescribed. Her lithium level today is 1.0
mEq/L. She has been without manic disorders for the past 5 years. Which therapy
would be the best for the maintenance depression symptoms?
1. Venlafaxine.
