1. Which of the following patients with generalized anxiety disorder is most likely to be
a CYP 2C19 poor metabolizer and have an exaggerated response to diazepam
(Valium) 5 mg TID with increased sedation, central nervous system, and cognitive
side effects?
A. 40yearold Asian male
B. 30yearold African American male
C. 20yearold African American male
D. 50yearold Caucasian male
40yearold Asian male
Rationale: The frequency of poor metabolizers of CYP 2C19 is low among Caucasians
(3%), intermediate among African Americans (18%), and higher in Asian and Japanese
populations (up to 20%).
2. Which serotonin receptor antagonism makes an antipsychotic "atypical"?
A. 5HT2A
B. 5HT1A
C. 5HT4A
D. 5HT3A
5HT2A
Rationale: The mechanism of action that makes an antipsychotic medication "atypical" is
related to the 5HT2A receptor antagonism and D2 receptor antagonism.
5HT1A
5HT4A
5HT3A
3. Which mood stabilizer is most associated with a potentially lifethreatening rash?
lamotrigine (Lamictal)
Lamotrigine is associated with a rare, serious, and potentially lifethreatening rash (Steven
Johnsons syndrome
,4. Which of the following findings would raise concern in a preschool wellness exam
for a 5yearold girl?
height 43 inches, weight 55 lbs
Rationale: Body Mass Index (BMI) calculated for this height and weight is 21, which is
greater than 95th percentile for her age, placing her in overweight category. Calculation:
Weight (lbs) /Stature (inches) / Stature (inches) x 703 = BMI
BMI = 703 x weight (lbs) = 703 x 55
[Height (in)]2 432
Or Weight (kg)/ Stature (cm)/ Stature (cm) x 10,000 = BMI.
BMI = weight (kg)
[height (m)]2
Further evaluation is indicated: 1) assessment of daily activity level and dietary intake; 2)
lab work to rule out medical etiology such as hypothyroidism and diabetes mellitus; and 3)
family history of obesity, diabetes, hypertension, etc. Parental counseling for child’s
nutritional and exercise needs to begin addressing childhood obesity and prevention of
secondary medical problems. Other vital signs are within normal limits and immunizations
are complete for a 5yearold.
Completed immunizations: MMR, Varicella, DTap, IPV, PCV, Hib, HepB
Blood pressure 92/52
Pulse 102, respirations 30
5. Which of the following findings on MRI and PET scans would be uncommon in
individuals with schizophrenia?
A. decreased electrical activity in the frontal lobes
B. decreased total brain volume
C. decreased size of cerebral ventricles
D. decreased glutamate and GABA release
decreased size of cerebral ventricles
Rationale: Individuals with schizophrenia have enlarged cerebral ventricles. There is
decreased electrical activity in frontal lobes, decreased glutamate and GABA release, and
decreased total brain volume.
,6. A client is suffering from schizophrenia. Which of the FF would be the appropriate
question for the PMHNP to ask when assessing side effects produced by dopamine
antagonism in the tuberoinfundibular pathway?
A. are you experiencing drooling?
B. are you experiencing dizziness?
C. are you experiencing breast discharge?
Rationale: Galactorrhea is caused from dopamine blockade in the tuberoinfundibular
pathway by antipsychotic drugs.
are you experiencing tremors?
are you experiencing breast discharge?
Rationale: Galactorrhea is caused from dopamine blockade in the tuberoinfundibular
pathway by antipsychotic drugs.
7. You have a 17yearold female patient who suffers with bipolar disorder. The patient
has a history of impulsive acting out and promiscuity. You make a decision to add
Folic acid 0.8 mg to her medication regimen of Lamotrigine (Lamictal) 200 mg PO
QHS and Quetiapine XR (Seroquel XR) 50 mg PO QHS. Why is it important?
A. The folic acid is important to help her with her hypotension induced by the Quetiapine
XR (Seroquel XR) 50 mg PO QHS.
B. The folic acid supports neural tube development during the first month that a woman
is pregnant.
C. The folic acid is important for the continuing development of the patient's
neuroendocrine system.
D. The folic acid is important to help her with the sleepiness induced by her bipolar
medications.
The folic acid supports neural tube development during the first month that a woman is
pregnant.
Rationale: The patient’s acting out behaviors may include sexual acting out. This could
lead to pregnancy. The United States Preventive Services Task Force (USPSTF) recommends
that all women planning or capable of pregnancy take a daily supplement containing 0.4 to
0.8 mg (400 to 800 mcg) of folic acid. This recommendation is an A level recommendation.
The purpose is to lower the number of neural tube defects in fetuses.
, 8. Which of the following statements reflect the current understanding of dopamine
(DA) pathways and clinical symptoms in schizophrenia?
A. Negative symptoms are related to DA deficit in the mesolimbic system; positive
symptoms are related to DA excess in the substantia nigra and ventral tegmental area
B. Negative symptoms are related to DA excess in the mesolimbic system; positive
symptoms are related to DA deficit in the substantia nigra and ventral tegmental area
C. Negative symptoms are related to DA deficit in the mesolimbic system; positive
symptoms are related to DA excess in the substantia nigra and ventral tegmental area
D. Negative symptoms are related to DA deficit in the cerebral cortex; positive
symptoms are related to DA excess in the nucleus accumbens and mesolimbic system
Negative symptoms are related to DA deficit in the cerebral cortex; positive symptoms are
related to DA excess in the nucleus accumbens and mesolimbic system
Rationale: Negative symptoms and cognitive impairment are thought to be related to
hypoactivity of the mesocortical dopaminergic tract, which by association with the prefrontal
and neocortex contributes to motivation, planning, sequencing of behaviors in time,
attention, and social behavior. Positive symptoms of schizophrenia (hallucinations and
delusions) are thought to be caused by dopamine hyperactivity in the mesolimbic tract, which
regulates memory and emotion. This hyperactivity could result from overactive modulation
of neurotransmission from the nucleus accumbens. Another explanation for dopaminergic
hyperactivity in the mesolimbic tract is the hypoactivity of the mesocortical tract, which
normally inhibits dopamine activity in the mesolimbic tract by some type of feedback
mechanism. In schizophrenia, the primary defect may be in the mesocortical tract, where
dopaminergic function is diminished, thereby decreasing the inhibitory effects on the
mesolimbic tract. This disinhibition may be responsible for the overactivity of dopamine in
the mesolimbic tract, resulting in positive symptom cluster.
9. Which cytochrome (CYP) enzyme is implicated as a tobacco inducer when an
individual is treated on clozapine?
A. 2D6
B. 2C19
C. 1A2
D. 2C9
1A2
Rationale: When an individual is treated on clozapine and decreases tobacco use, the
clozapine level will increase, as the tobacco is an inducer to the clozapine, and the patient no
longer needs the higher dose of clozapine.
When patients enter the hospital, they may have to stop smoking abruptly if the hospital
has a ‘no smoking’ policy. Abrupt smoking cessation can affect the metabolism of drugs.
a CYP 2C19 poor metabolizer and have an exaggerated response to diazepam
(Valium) 5 mg TID with increased sedation, central nervous system, and cognitive
side effects?
A. 40yearold Asian male
B. 30yearold African American male
C. 20yearold African American male
D. 50yearold Caucasian male
40yearold Asian male
Rationale: The frequency of poor metabolizers of CYP 2C19 is low among Caucasians
(3%), intermediate among African Americans (18%), and higher in Asian and Japanese
populations (up to 20%).
2. Which serotonin receptor antagonism makes an antipsychotic "atypical"?
A. 5HT2A
B. 5HT1A
C. 5HT4A
D. 5HT3A
5HT2A
Rationale: The mechanism of action that makes an antipsychotic medication "atypical" is
related to the 5HT2A receptor antagonism and D2 receptor antagonism.
5HT1A
5HT4A
5HT3A
3. Which mood stabilizer is most associated with a potentially lifethreatening rash?
lamotrigine (Lamictal)
Lamotrigine is associated with a rare, serious, and potentially lifethreatening rash (Steven
Johnsons syndrome
,4. Which of the following findings would raise concern in a preschool wellness exam
for a 5yearold girl?
height 43 inches, weight 55 lbs
Rationale: Body Mass Index (BMI) calculated for this height and weight is 21, which is
greater than 95th percentile for her age, placing her in overweight category. Calculation:
Weight (lbs) /Stature (inches) / Stature (inches) x 703 = BMI
BMI = 703 x weight (lbs) = 703 x 55
[Height (in)]2 432
Or Weight (kg)/ Stature (cm)/ Stature (cm) x 10,000 = BMI.
BMI = weight (kg)
[height (m)]2
Further evaluation is indicated: 1) assessment of daily activity level and dietary intake; 2)
lab work to rule out medical etiology such as hypothyroidism and diabetes mellitus; and 3)
family history of obesity, diabetes, hypertension, etc. Parental counseling for child’s
nutritional and exercise needs to begin addressing childhood obesity and prevention of
secondary medical problems. Other vital signs are within normal limits and immunizations
are complete for a 5yearold.
Completed immunizations: MMR, Varicella, DTap, IPV, PCV, Hib, HepB
Blood pressure 92/52
Pulse 102, respirations 30
5. Which of the following findings on MRI and PET scans would be uncommon in
individuals with schizophrenia?
A. decreased electrical activity in the frontal lobes
B. decreased total brain volume
C. decreased size of cerebral ventricles
D. decreased glutamate and GABA release
decreased size of cerebral ventricles
Rationale: Individuals with schizophrenia have enlarged cerebral ventricles. There is
decreased electrical activity in frontal lobes, decreased glutamate and GABA release, and
decreased total brain volume.
,6. A client is suffering from schizophrenia. Which of the FF would be the appropriate
question for the PMHNP to ask when assessing side effects produced by dopamine
antagonism in the tuberoinfundibular pathway?
A. are you experiencing drooling?
B. are you experiencing dizziness?
C. are you experiencing breast discharge?
Rationale: Galactorrhea is caused from dopamine blockade in the tuberoinfundibular
pathway by antipsychotic drugs.
are you experiencing tremors?
are you experiencing breast discharge?
Rationale: Galactorrhea is caused from dopamine blockade in the tuberoinfundibular
pathway by antipsychotic drugs.
7. You have a 17yearold female patient who suffers with bipolar disorder. The patient
has a history of impulsive acting out and promiscuity. You make a decision to add
Folic acid 0.8 mg to her medication regimen of Lamotrigine (Lamictal) 200 mg PO
QHS and Quetiapine XR (Seroquel XR) 50 mg PO QHS. Why is it important?
A. The folic acid is important to help her with her hypotension induced by the Quetiapine
XR (Seroquel XR) 50 mg PO QHS.
B. The folic acid supports neural tube development during the first month that a woman
is pregnant.
C. The folic acid is important for the continuing development of the patient's
neuroendocrine system.
D. The folic acid is important to help her with the sleepiness induced by her bipolar
medications.
The folic acid supports neural tube development during the first month that a woman is
pregnant.
Rationale: The patient’s acting out behaviors may include sexual acting out. This could
lead to pregnancy. The United States Preventive Services Task Force (USPSTF) recommends
that all women planning or capable of pregnancy take a daily supplement containing 0.4 to
0.8 mg (400 to 800 mcg) of folic acid. This recommendation is an A level recommendation.
The purpose is to lower the number of neural tube defects in fetuses.
, 8. Which of the following statements reflect the current understanding of dopamine
(DA) pathways and clinical symptoms in schizophrenia?
A. Negative symptoms are related to DA deficit in the mesolimbic system; positive
symptoms are related to DA excess in the substantia nigra and ventral tegmental area
B. Negative symptoms are related to DA excess in the mesolimbic system; positive
symptoms are related to DA deficit in the substantia nigra and ventral tegmental area
C. Negative symptoms are related to DA deficit in the mesolimbic system; positive
symptoms are related to DA excess in the substantia nigra and ventral tegmental area
D. Negative symptoms are related to DA deficit in the cerebral cortex; positive
symptoms are related to DA excess in the nucleus accumbens and mesolimbic system
Negative symptoms are related to DA deficit in the cerebral cortex; positive symptoms are
related to DA excess in the nucleus accumbens and mesolimbic system
Rationale: Negative symptoms and cognitive impairment are thought to be related to
hypoactivity of the mesocortical dopaminergic tract, which by association with the prefrontal
and neocortex contributes to motivation, planning, sequencing of behaviors in time,
attention, and social behavior. Positive symptoms of schizophrenia (hallucinations and
delusions) are thought to be caused by dopamine hyperactivity in the mesolimbic tract, which
regulates memory and emotion. This hyperactivity could result from overactive modulation
of neurotransmission from the nucleus accumbens. Another explanation for dopaminergic
hyperactivity in the mesolimbic tract is the hypoactivity of the mesocortical tract, which
normally inhibits dopamine activity in the mesolimbic tract by some type of feedback
mechanism. In schizophrenia, the primary defect may be in the mesocortical tract, where
dopaminergic function is diminished, thereby decreasing the inhibitory effects on the
mesolimbic tract. This disinhibition may be responsible for the overactivity of dopamine in
the mesolimbic tract, resulting in positive symptom cluster.
9. Which cytochrome (CYP) enzyme is implicated as a tobacco inducer when an
individual is treated on clozapine?
A. 2D6
B. 2C19
C. 1A2
D. 2C9
1A2
Rationale: When an individual is treated on clozapine and decreases tobacco use, the
clozapine level will increase, as the tobacco is an inducer to the clozapine, and the patient no
longer needs the higher dose of clozapine.
When patients enter the hospital, they may have to stop smoking abruptly if the hospital
has a ‘no smoking’ policy. Abrupt smoking cessation can affect the metabolism of drugs.
