NSG 6001 – Advanced Pharmacology
Week 5 Quiz: Central Nervous System & Psychiatric
Pharmacotherapy
Graduate Nursing Program – 2026/2027 Curriculum
Q1: A 24-year-old female is started on sertraline 50 mg daily for major depressive
disorder. Two weeks later, she reports increased anxiety, restlessness, and insomnia.
Which statement best explains these symptoms?
A. These indicate treatment failure and require immediate discontinuation of sertraline
B. These are expected early activation side effects that typically resolve within 1-2
weeks
C. These indicate emergent bipolar disorder and require mood stabilizer addition
D. These suggest serotonin syndrome requiring emergency intervention
Correct Answer: B
Rationale: [CORRECT] B: SSRIs frequently cause early activation symptoms (anxiety,
agitation, insomnia, akathisia) during the first 1-3 weeks of therapy due to initial
serotonergic enhancement before downstream adaptive changes occur. These are
typically transient and managed with temporary dose reduction, short-term anxiolytic, or
reassurance. Full antidepressant effect requires 4-6 weeks. A: Premature
discontinuation; these are not treatment failure. C: While antidepressants can unmask
bipolar disorder, isolated early anxiety/insomnia without mood elevation, decreased
sleep need, or impulsivity does not indicate bipolar switch. D: Serotonin syndrome
,requires autonomic instability (hyperthermia, hypertension, tachycardia), neuromuscular
changes (clonus, hyperreflexia, rigidity), and altered mental status—not present here.
Clinical pearl: Counsel patients about expected early side effects to improve adherence;
30% discontinue SSRIs prematurely due to misunderstood early effects.
Q2: Which antidepressant class is MOST likely to cause orthostatic hypotension,
anticholinergic effects, and cardiac conduction abnormalities?
A. SSRIs (Selective Serotonin Reuptake Inhibitors)
B. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
C. TCAs (Tricyclic Antidepressants)
D. MAOIs (Monoamine Oxidase Inhibitors)
Correct Answer: C
Rationale: [CORRECT] C: TCAs (amitriptyline, nortriptyline, imipramine) are non-selective
and block muscarinic receptors (anticholinergic: dry mouth, constipation, urinary
retention, confusion), alpha-1 adrenergic receptors (orthostatic hypotension), and fast
sodium channels in myocardium (QT prolongation, conduction delays). These side
effects limit TCA use in elderly and cardiac patients. A: SSRIs have minimal
anticholinergic or cardiac effects; primary concerns are GI upset, sexual dysfunction,
SIADH. B: SNRIs (venlafaxine, duloxetine) may increase BP at higher doses but lack
significant anticholinergic effects. D: MAOIs primarily cause hypertensive crisis with
tyramine, not orthostatic hypotension or anticholinergic effects. Black box warning:
TCAs are second-line due to lethality in overdose (cardiac arrhythmias, seizures).
, Q3: A 68-year-old male with Parkinson's disease and comorbid depression is prescribed
an antidepressant. Which agent should be AVOIDED due to risk of worsening
extrapyramidal symptoms?
A. Sertraline
B. Mirtazapine
C. Paroxetine
D. Bupropion
Correct Answer: C
Rationale: [CORRECT] C: Paroxetine is the most anticholinergic SSRI (unique among
SSRIs due to its chemical structure), which can worsen extrapyramidal symptoms in
Parkinson's disease by further impairing the already compromised
cholinergic-dopaminergic balance. Additionally, paroxetine is a potent CYP2D6 inhibitor,
potentially interfering with metabolism of levodopa/carbidopa. A: Sertraline has
minimal anticholinergic effects and is preferred in Parkinson's. B: Mirtazapine has
minimal extrapyramidal effects and may improve appetite/weight loss. D: Bupropion is
dopaminergic/noradrenergic and generally well-tolerated in Parkinson's, though may
worsen anxiety or tremor in some. Clinical pearl: In Parkinson's disease, prefer sertraline,
mirtazapine, or moclobemide; avoid anticholinergic antidepressants.
Q4: A patient on phenelzine (MAOI) for treatment-resistant depression presents to the
emergency department with severe headache, hypertension (210/120 mmHg),
diaphoresis, and neck stiffness after eating at a restaurant. Which dietary component is
most likely responsible?
A. Fresh garden salad with vinegar dressing
Week 5 Quiz: Central Nervous System & Psychiatric
Pharmacotherapy
Graduate Nursing Program – 2026/2027 Curriculum
Q1: A 24-year-old female is started on sertraline 50 mg daily for major depressive
disorder. Two weeks later, she reports increased anxiety, restlessness, and insomnia.
Which statement best explains these symptoms?
A. These indicate treatment failure and require immediate discontinuation of sertraline
B. These are expected early activation side effects that typically resolve within 1-2
weeks
C. These indicate emergent bipolar disorder and require mood stabilizer addition
D. These suggest serotonin syndrome requiring emergency intervention
Correct Answer: B
Rationale: [CORRECT] B: SSRIs frequently cause early activation symptoms (anxiety,
agitation, insomnia, akathisia) during the first 1-3 weeks of therapy due to initial
serotonergic enhancement before downstream adaptive changes occur. These are
typically transient and managed with temporary dose reduction, short-term anxiolytic, or
reassurance. Full antidepressant effect requires 4-6 weeks. A: Premature
discontinuation; these are not treatment failure. C: While antidepressants can unmask
bipolar disorder, isolated early anxiety/insomnia without mood elevation, decreased
sleep need, or impulsivity does not indicate bipolar switch. D: Serotonin syndrome
,requires autonomic instability (hyperthermia, hypertension, tachycardia), neuromuscular
changes (clonus, hyperreflexia, rigidity), and altered mental status—not present here.
Clinical pearl: Counsel patients about expected early side effects to improve adherence;
30% discontinue SSRIs prematurely due to misunderstood early effects.
Q2: Which antidepressant class is MOST likely to cause orthostatic hypotension,
anticholinergic effects, and cardiac conduction abnormalities?
A. SSRIs (Selective Serotonin Reuptake Inhibitors)
B. SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
C. TCAs (Tricyclic Antidepressants)
D. MAOIs (Monoamine Oxidase Inhibitors)
Correct Answer: C
Rationale: [CORRECT] C: TCAs (amitriptyline, nortriptyline, imipramine) are non-selective
and block muscarinic receptors (anticholinergic: dry mouth, constipation, urinary
retention, confusion), alpha-1 adrenergic receptors (orthostatic hypotension), and fast
sodium channels in myocardium (QT prolongation, conduction delays). These side
effects limit TCA use in elderly and cardiac patients. A: SSRIs have minimal
anticholinergic or cardiac effects; primary concerns are GI upset, sexual dysfunction,
SIADH. B: SNRIs (venlafaxine, duloxetine) may increase BP at higher doses but lack
significant anticholinergic effects. D: MAOIs primarily cause hypertensive crisis with
tyramine, not orthostatic hypotension or anticholinergic effects. Black box warning:
TCAs are second-line due to lethality in overdose (cardiac arrhythmias, seizures).
, Q3: A 68-year-old male with Parkinson's disease and comorbid depression is prescribed
an antidepressant. Which agent should be AVOIDED due to risk of worsening
extrapyramidal symptoms?
A. Sertraline
B. Mirtazapine
C. Paroxetine
D. Bupropion
Correct Answer: C
Rationale: [CORRECT] C: Paroxetine is the most anticholinergic SSRI (unique among
SSRIs due to its chemical structure), which can worsen extrapyramidal symptoms in
Parkinson's disease by further impairing the already compromised
cholinergic-dopaminergic balance. Additionally, paroxetine is a potent CYP2D6 inhibitor,
potentially interfering with metabolism of levodopa/carbidopa. A: Sertraline has
minimal anticholinergic effects and is preferred in Parkinson's. B: Mirtazapine has
minimal extrapyramidal effects and may improve appetite/weight loss. D: Bupropion is
dopaminergic/noradrenergic and generally well-tolerated in Parkinson's, though may
worsen anxiety or tremor in some. Clinical pearl: In Parkinson's disease, prefer sertraline,
mirtazapine, or moclobemide; avoid anticholinergic antidepressants.
Q4: A patient on phenelzine (MAOI) for treatment-resistant depression presents to the
emergency department with severe headache, hypertension (210/120 mmHg),
diaphoresis, and neck stiffness after eating at a restaurant. Which dietary component is
most likely responsible?
A. Fresh garden salad with vinegar dressing
