NR568 Advanced Pharmacology Weeks 5-8 Final Exam
Instructions:
Select the best answer for each question.
Section 1: Psychopharmacology (Questions 1-40)
1. A patient with major depressive disorder (MDD) has failed two SSRIs. You are
considering switching to venlafaxine (SNRI). What is the most significant dose-
dependent adverse effect you must monitor for?
A. Sedation
B. Hyponatremia
C. Hypertension
D. Weight gain
Answer: C. Hypertension
Rationale: Venlafaxine is an SNRI that, at higher doses (typically >150 mg/day), inhibits
norepinephrine reuptake more potently. This can lead to a dose-dependent increase in
blood pressure. The prescriber must monitor blood pressure regularly and consider dose
reduction or discontinuation if hypertension develops. Options A and D are more common
with other antidepressants, and B is a risk but less directly dose-dependent than
hypertension.
2. Which of the following is a unique adverse effect associated with the atypical
antipsychotic clozapine that requires mandatory, periodic monitoring?
A. Tardive dyskinesia
B. QTc prolongation
C. Agranulocytosis
D. Hyperprolactinemia
Answer: C. Agranulocytosis
Rationale: Clozapine carries a black box warning for severe neutropenia and
agranulocytosis. The FDA requires enrollment in a Risk Evaluation and Mitigation Strategy
(REMS) program with mandatory absolute neutrophil count (ANC) monitoring. While the
,other options are also potential side effects of antipsychotics, agranulocytosis is uniquely
and most dangerously associated with clozapine.
3. A patient on lithium for bipolar disorder presents with nausea, vomiting,
diarrhea, and coarse tremors. Their serum lithium level is 2.0 mEq/L. What is the
priority intervention?
A. Administer an antiemetic and continue current dose.
B. Reduce the dose by 50% and recheck level in 3 days.
C. Discontinue lithium and consider hemodialysis.
D. Increase fluid intake to 4 liters/day.
Answer: C. Discontinue lithium and consider hemodialysis.
Rationale: A lithium level of 2.0 mEq/L is in the severe toxicity range (>2.0 mEq/L),
especially with significant GI symptoms and neurological signs (coarse tremor). This is a
medical emergency. The priority is to discontinue the drug immediately. Hemodialysis is
the definitive treatment for severe lithium toxicity to prevent permanent neurological
damage. Reducing the dose or simply increasing fluids is insufficient for this level of
toxicity.
4. Which medication is considered first-line pharmacotherapy for generalized
anxiety disorder (GAD) in an adult patient with no other comorbidities?
A. Alprazolam
B. Buspirone
C. Sertraline
D. Hydroxyzine
Answer: C. Sertraline
Rationale: SSRIs (like sertraline) and SNRIs are considered first-line treatments for GAD
due to their efficacy and favorable safety profile compared to benzodiazepines. Buspirone
is also a first-line option but is often less effective, and SSRIs/SNRIs are generally preferred
due to more robust evidence. Alprazolam is a benzodiazepine with a high potential for
dependence and should not be first-line. Hydroxyzine is typically used for acute,
situational anxiety, not as a first-line chronic treatment.
5. A patient on phenelzine (MAOI) is prescribed a new medication for migraines.
Which of the following would be contraindicated due to a risk of a hypertensive
crisis?
A. Sumatriptan
B. Propranolol
C. Topiramate
D. Naproxen
,Answer: A. Sumatriptan
Rationale: Sumatriptan is a triptan. The combination of an MAOI and a triptan, or within
14 days of discontinuing an MAOI, is contraindicated due to the risk of serotonin
syndrome and hypertensive crisis. This is due to the shared serotonergic pathways. The
other medications (beta-blocker, anticonvulsant, NSAID) do not have this interaction.
6. A 72-year-old patient with dementia and agitation is started on risperidone.
What is the most significant black box warning associated with this medication in
the elderly population?
A. Increased risk of cerebrovascular events (stroke)
B. Extrapyramidal symptoms
C. Hyperglycemia and diabetes
D. Orthostatic hypotension
Answer: A. Increased risk of cerebrovascular events (stroke)
Rationale: All atypical antipsychotics carry an FDA black box warning for an increased risk
of mortality and cerebrovascular adverse events (e.g., stroke) in elderly patients with
dementia-related psychosis. While the other options are valid side effects, the black box
warning specifically highlights these severe cardiovascular risks.
7. Which drug is most effective for treating akathisia, a common side effect of
antipsychotic medications?
A. Diphenhydramine
B. Benztropine
C. Propranolol
D. Amantadine
Answer: C. Propranolol
Rationale: Akathisia is characterized by subjective restlessness and objective fidgety
movements. Beta-blockers, particularly propranolol, are often the most effective
pharmacological treatment for antipsychotic-induced akathisia. Anticholinergics (like
benztropine) and antihistamines (like diphenhydramine) are more effective for dystonia
and parkinsonism. Amantadine is sometimes used for parkinsonism.
8. A patient is being tapered off a long-term benzodiazepine. Which withdrawal
symptom is of greatest concern due to its potential lethality?
A. Insomnia
B. Rebound anxiety
C. Seizures
D. Muscle twitching
, Answer: C. Seizures
Rationale: Abrupt discontinuation of benzodiazepines after long-term use can precipitate a
withdrawal syndrome that includes anxiety, insomnia, and tremors. However, the most
severe and potentially life-threatening withdrawal symptoms are seizures and delirium.
These require careful, slow tapering and medical supervision.
9. Bupropion is contraindicated in which of the following patient populations?
A. Patients with a history of seizures
B. Patients with post-traumatic stress disorder
C. Patients with hypertension
D. Patients with insomnia
Answer: A. Patients with a history of seizures
Rationale: Bupropion lowers the seizure threshold in a dose-dependent manner and is
contraindicated in patients with a history of seizures or a current seizure disorder (e.g.,
epilepsy). It is also contraindicated in patients with bulimia or anorexia nervosa due to an
increased seizure risk. While it can exacerbate insomnia, it is not an absolute
contraindication, and hypertension is a relative concern but not a strict contraindication.
10. Your patient with ADHD is currently on methylphenidate and reports a "crash"
in the late afternoon. What is the most appropriate pharmacologic strategy to
address this?
A. Increase the morning dose of immediate-release methylphenidate.
B. Switch to an extended-release formulation like OROS methylphenidate (Concerta).
C. Add a small dose of a short-acting stimulant in the afternoon.
D. Discontinue methylphenidate and start atomoxetine.
Answer: C. Add a small dose of a short-acting stimulant in the afternoon.
Rationale: A "crash" at the end of the day from a long-acting formulation can be managed
by adding a small "booster" dose of a short-acting stimulant in the afternoon. Increasing
the morning dose would likely prolong the effect but could also increase side effects.
Switching to an extended-release formulation might help if the issue is a short duration of
action, but the question specifically describes a crash from the current regimen, implying
its duration is insufficient. Atomoxetine is a non-stimulant with a different mechanism and
is not the primary strategy for managing a stimulant crash.
11. A patient with schizophrenia is well-controlled on haloperidol. He now
presents with involuntary, repetitive, worm-like movements of his tongue and
face. This is most likely:
A. Acute dystonia
B. Akathisia
Instructions:
Select the best answer for each question.
Section 1: Psychopharmacology (Questions 1-40)
1. A patient with major depressive disorder (MDD) has failed two SSRIs. You are
considering switching to venlafaxine (SNRI). What is the most significant dose-
dependent adverse effect you must monitor for?
A. Sedation
B. Hyponatremia
C. Hypertension
D. Weight gain
Answer: C. Hypertension
Rationale: Venlafaxine is an SNRI that, at higher doses (typically >150 mg/day), inhibits
norepinephrine reuptake more potently. This can lead to a dose-dependent increase in
blood pressure. The prescriber must monitor blood pressure regularly and consider dose
reduction or discontinuation if hypertension develops. Options A and D are more common
with other antidepressants, and B is a risk but less directly dose-dependent than
hypertension.
2. Which of the following is a unique adverse effect associated with the atypical
antipsychotic clozapine that requires mandatory, periodic monitoring?
A. Tardive dyskinesia
B. QTc prolongation
C. Agranulocytosis
D. Hyperprolactinemia
Answer: C. Agranulocytosis
Rationale: Clozapine carries a black box warning for severe neutropenia and
agranulocytosis. The FDA requires enrollment in a Risk Evaluation and Mitigation Strategy
(REMS) program with mandatory absolute neutrophil count (ANC) monitoring. While the
,other options are also potential side effects of antipsychotics, agranulocytosis is uniquely
and most dangerously associated with clozapine.
3. A patient on lithium for bipolar disorder presents with nausea, vomiting,
diarrhea, and coarse tremors. Their serum lithium level is 2.0 mEq/L. What is the
priority intervention?
A. Administer an antiemetic and continue current dose.
B. Reduce the dose by 50% and recheck level in 3 days.
C. Discontinue lithium and consider hemodialysis.
D. Increase fluid intake to 4 liters/day.
Answer: C. Discontinue lithium and consider hemodialysis.
Rationale: A lithium level of 2.0 mEq/L is in the severe toxicity range (>2.0 mEq/L),
especially with significant GI symptoms and neurological signs (coarse tremor). This is a
medical emergency. The priority is to discontinue the drug immediately. Hemodialysis is
the definitive treatment for severe lithium toxicity to prevent permanent neurological
damage. Reducing the dose or simply increasing fluids is insufficient for this level of
toxicity.
4. Which medication is considered first-line pharmacotherapy for generalized
anxiety disorder (GAD) in an adult patient with no other comorbidities?
A. Alprazolam
B. Buspirone
C. Sertraline
D. Hydroxyzine
Answer: C. Sertraline
Rationale: SSRIs (like sertraline) and SNRIs are considered first-line treatments for GAD
due to their efficacy and favorable safety profile compared to benzodiazepines. Buspirone
is also a first-line option but is often less effective, and SSRIs/SNRIs are generally preferred
due to more robust evidence. Alprazolam is a benzodiazepine with a high potential for
dependence and should not be first-line. Hydroxyzine is typically used for acute,
situational anxiety, not as a first-line chronic treatment.
5. A patient on phenelzine (MAOI) is prescribed a new medication for migraines.
Which of the following would be contraindicated due to a risk of a hypertensive
crisis?
A. Sumatriptan
B. Propranolol
C. Topiramate
D. Naproxen
,Answer: A. Sumatriptan
Rationale: Sumatriptan is a triptan. The combination of an MAOI and a triptan, or within
14 days of discontinuing an MAOI, is contraindicated due to the risk of serotonin
syndrome and hypertensive crisis. This is due to the shared serotonergic pathways. The
other medications (beta-blocker, anticonvulsant, NSAID) do not have this interaction.
6. A 72-year-old patient with dementia and agitation is started on risperidone.
What is the most significant black box warning associated with this medication in
the elderly population?
A. Increased risk of cerebrovascular events (stroke)
B. Extrapyramidal symptoms
C. Hyperglycemia and diabetes
D. Orthostatic hypotension
Answer: A. Increased risk of cerebrovascular events (stroke)
Rationale: All atypical antipsychotics carry an FDA black box warning for an increased risk
of mortality and cerebrovascular adverse events (e.g., stroke) in elderly patients with
dementia-related psychosis. While the other options are valid side effects, the black box
warning specifically highlights these severe cardiovascular risks.
7. Which drug is most effective for treating akathisia, a common side effect of
antipsychotic medications?
A. Diphenhydramine
B. Benztropine
C. Propranolol
D. Amantadine
Answer: C. Propranolol
Rationale: Akathisia is characterized by subjective restlessness and objective fidgety
movements. Beta-blockers, particularly propranolol, are often the most effective
pharmacological treatment for antipsychotic-induced akathisia. Anticholinergics (like
benztropine) and antihistamines (like diphenhydramine) are more effective for dystonia
and parkinsonism. Amantadine is sometimes used for parkinsonism.
8. A patient is being tapered off a long-term benzodiazepine. Which withdrawal
symptom is of greatest concern due to its potential lethality?
A. Insomnia
B. Rebound anxiety
C. Seizures
D. Muscle twitching
, Answer: C. Seizures
Rationale: Abrupt discontinuation of benzodiazepines after long-term use can precipitate a
withdrawal syndrome that includes anxiety, insomnia, and tremors. However, the most
severe and potentially life-threatening withdrawal symptoms are seizures and delirium.
These require careful, slow tapering and medical supervision.
9. Bupropion is contraindicated in which of the following patient populations?
A. Patients with a history of seizures
B. Patients with post-traumatic stress disorder
C. Patients with hypertension
D. Patients with insomnia
Answer: A. Patients with a history of seizures
Rationale: Bupropion lowers the seizure threshold in a dose-dependent manner and is
contraindicated in patients with a history of seizures or a current seizure disorder (e.g.,
epilepsy). It is also contraindicated in patients with bulimia or anorexia nervosa due to an
increased seizure risk. While it can exacerbate insomnia, it is not an absolute
contraindication, and hypertension is a relative concern but not a strict contraindication.
10. Your patient with ADHD is currently on methylphenidate and reports a "crash"
in the late afternoon. What is the most appropriate pharmacologic strategy to
address this?
A. Increase the morning dose of immediate-release methylphenidate.
B. Switch to an extended-release formulation like OROS methylphenidate (Concerta).
C. Add a small dose of a short-acting stimulant in the afternoon.
D. Discontinue methylphenidate and start atomoxetine.
Answer: C. Add a small dose of a short-acting stimulant in the afternoon.
Rationale: A "crash" at the end of the day from a long-acting formulation can be managed
by adding a small "booster" dose of a short-acting stimulant in the afternoon. Increasing
the morning dose would likely prolong the effect but could also increase side effects.
Switching to an extended-release formulation might help if the issue is a short duration of
action, but the question specifically describes a crash from the current regimen, implying
its duration is insufficient. Atomoxetine is a non-stimulant with a different mechanism and
is not the primary strategy for managing a stimulant crash.
11. A patient with schizophrenia is well-controlled on haloperidol. He now
presents with involuntary, repetitive, worm-like movements of his tongue and
face. This is most likely:
A. Acute dystonia
B. Akathisia
