NURS 5433 FINAL EXAM – SUMMARIZED COVERAGE
Advanced psychiatric-mental health nursing across the lifespan: neurobiology of mental illness,
pharmacotherapy (antidepressants, antipsychotics, mood stabilizers, anxiolytics, stimulants),
psychotherapeutic modalities (CBT, DBT, MI), assessment of risk (suicide, violence, abuse),
legal/ethical issues (informed consent, restraints, capacity), special populations (perinatal,
geriatric, SUD), and integrated care in primary mental health settings.
1. A 32-year-old with MDD and no prior med trials reports nausea, insomnia, and anxiety
starting 3 days after sertraline 50 mg daily.
• Switch to fluoxetine immediately.
• Add low-dose mirtazapine for sleep.
• Continue sertraline and offer reassurance.
• Reduce dose to 25 mg for one week.
Continue sertraline and offer reassurance.
Early transient side effects typically resolve in 1–2 weeks; do not alter dose unless severe.
2. A 45-year-old on lithium for bipolar I has a new tremor, nausea, and polyuria. Lithium level =
1.8 mEq/L.
• Increase fluids and monitor.
• Hold lithium and check renal function.
• Add propranolol for tremor.
• Reduce dose by 50%.
Hold lithium and check renal function.
*Level >1.5 mEq/L requires holding dose and evaluating toxicity.*
3. A 19-year-old with schizophrenia has been on clozapine 6 weeks. Today, fever 101.5°F, sore
throat, and malaise.
, • Reassure and treat symptomatically.
• Check absolute neutrophil count (ANC) immediately.
• Increase clozapine to therapeutic dose.
• Start broad-spectrum antibiotics.
Check absolute neutrophil count (ANC) immediately.
Fever + sore throat on clozapine raises agranulocytosis concern until ruled out.
4. A 28-year-old with panic disorder reports no improvement after 6 weeks of paroxetine 40 mg
daily.
• Augment with buspirone.
• Switch to phenelzine.
• Increase to 60 mg daily.
• Add alprazolam PRN.
Increase to 60 mg daily.
Max FDA dose for paroxetine in panic disorder is 60 mg; 6 weeks is adequate for partial trial.
5. A 60-year-old with GAD and hypertension is on lisinopril and complains of sexual dysfunction
2 weeks after starting duloxetine.
• Add sildenafil.
• Switch to venlafaxine immediate release.
• Switch to escitalopram.
• Reduce duloxetine to 20 mg daily.
Switch to escitalopram.
Escitalopram has lower incidence of sexual side effects among SSRIs/SNRIs; duloxetine rate is
moderate-high.
6. A pregnant woman (28 weeks) with bipolar I reports a manic relapse off all meds. Which is
safest?
, • Valproate 500 mg BID.
• Lithium carbonate 600 mg BID.
• Carbamazepine 400 mg BID.
• Olanzapine 10 mg daily.
Olanzapine 10 mg daily.
Atypical antipsychotics have more favorable reproductive safety profiles than valproate or
lithium in pregnancy.
7. A 41-year-old with ADHD and past cocaine use disorder requests stimulants. Next step?
• Prescribe methylphenidate LA.
• Recommend behavioral therapy only.
• Urine drug screen and controlled substance agreement.
• Prescribe atomoxetine.
Urine drug screen and controlled substance agreement.
Substance use history requires risk mitigation; non-stimulants may be safer but ruling out active
use is first.
8. A 22-year-old with bulimia nervosa has hypokalemia and tooth erosion. Best initial
pharmacotherapy?
• Fluoxetine 60 mg daily.
• Topiramate 50 mg BID.
• Amitriptyline 100 mg HS.
• Ondansetron PRN.
Fluoxetine 60 mg daily.
Only FDA-approved medication for bulimia; dose higher than for depression.
9. A 55-year-old with MDD and chronic kidney disease (eGFR 30) fails bupropion. Which
antidepressant requires no dose adjustment?
, • Duloxetine.
• Venlafaxine XR.
• Sertraline.
• Desvenlafaxine.
Sertraline.
Minimal renal excretion; others accumulate in CKD and risk toxicity.
10. A 74-year-old with Alzheimer’s disease becomes aggressive, hitting staff. Non-pharmacologic
de-escalation fails. Best initial medication?
• Haloperidol 5 mg IM.
• Quetiapine 25 mg nightly.
• Lorazepam 2 mg IM.
• Citalopram 20 mg daily.
Quetiapine 25 mg nightly.
Low-dose atypical antipsychotic for behavioral disturbance in dementia, after non-
pharmacologic failure.
11. A 30-year-old with bipolar II and current hypomania is on lithium 900 mg (level 0.9). He
develops acne and mild tremor.
• Switch to valproate.
• Add low-dose propranolol.
• Discontinue lithium immediately.
• Reduce lithium to 600 mg.
Add low-dose propranolol.
Propranolol treats lithium-induced tremor without destabilizing mood.
12. A 48-year-old with PTSD, nightmares, and hyperarousal failed paroxetine and sertraline.
Next best evidence-based option?
Advanced psychiatric-mental health nursing across the lifespan: neurobiology of mental illness,
pharmacotherapy (antidepressants, antipsychotics, mood stabilizers, anxiolytics, stimulants),
psychotherapeutic modalities (CBT, DBT, MI), assessment of risk (suicide, violence, abuse),
legal/ethical issues (informed consent, restraints, capacity), special populations (perinatal,
geriatric, SUD), and integrated care in primary mental health settings.
1. A 32-year-old with MDD and no prior med trials reports nausea, insomnia, and anxiety
starting 3 days after sertraline 50 mg daily.
• Switch to fluoxetine immediately.
• Add low-dose mirtazapine for sleep.
• Continue sertraline and offer reassurance.
• Reduce dose to 25 mg for one week.
Continue sertraline and offer reassurance.
Early transient side effects typically resolve in 1–2 weeks; do not alter dose unless severe.
2. A 45-year-old on lithium for bipolar I has a new tremor, nausea, and polyuria. Lithium level =
1.8 mEq/L.
• Increase fluids and monitor.
• Hold lithium and check renal function.
• Add propranolol for tremor.
• Reduce dose by 50%.
Hold lithium and check renal function.
*Level >1.5 mEq/L requires holding dose and evaluating toxicity.*
3. A 19-year-old with schizophrenia has been on clozapine 6 weeks. Today, fever 101.5°F, sore
throat, and malaise.
, • Reassure and treat symptomatically.
• Check absolute neutrophil count (ANC) immediately.
• Increase clozapine to therapeutic dose.
• Start broad-spectrum antibiotics.
Check absolute neutrophil count (ANC) immediately.
Fever + sore throat on clozapine raises agranulocytosis concern until ruled out.
4. A 28-year-old with panic disorder reports no improvement after 6 weeks of paroxetine 40 mg
daily.
• Augment with buspirone.
• Switch to phenelzine.
• Increase to 60 mg daily.
• Add alprazolam PRN.
Increase to 60 mg daily.
Max FDA dose for paroxetine in panic disorder is 60 mg; 6 weeks is adequate for partial trial.
5. A 60-year-old with GAD and hypertension is on lisinopril and complains of sexual dysfunction
2 weeks after starting duloxetine.
• Add sildenafil.
• Switch to venlafaxine immediate release.
• Switch to escitalopram.
• Reduce duloxetine to 20 mg daily.
Switch to escitalopram.
Escitalopram has lower incidence of sexual side effects among SSRIs/SNRIs; duloxetine rate is
moderate-high.
6. A pregnant woman (28 weeks) with bipolar I reports a manic relapse off all meds. Which is
safest?
, • Valproate 500 mg BID.
• Lithium carbonate 600 mg BID.
• Carbamazepine 400 mg BID.
• Olanzapine 10 mg daily.
Olanzapine 10 mg daily.
Atypical antipsychotics have more favorable reproductive safety profiles than valproate or
lithium in pregnancy.
7. A 41-year-old with ADHD and past cocaine use disorder requests stimulants. Next step?
• Prescribe methylphenidate LA.
• Recommend behavioral therapy only.
• Urine drug screen and controlled substance agreement.
• Prescribe atomoxetine.
Urine drug screen and controlled substance agreement.
Substance use history requires risk mitigation; non-stimulants may be safer but ruling out active
use is first.
8. A 22-year-old with bulimia nervosa has hypokalemia and tooth erosion. Best initial
pharmacotherapy?
• Fluoxetine 60 mg daily.
• Topiramate 50 mg BID.
• Amitriptyline 100 mg HS.
• Ondansetron PRN.
Fluoxetine 60 mg daily.
Only FDA-approved medication for bulimia; dose higher than for depression.
9. A 55-year-old with MDD and chronic kidney disease (eGFR 30) fails bupropion. Which
antidepressant requires no dose adjustment?
, • Duloxetine.
• Venlafaxine XR.
• Sertraline.
• Desvenlafaxine.
Sertraline.
Minimal renal excretion; others accumulate in CKD and risk toxicity.
10. A 74-year-old with Alzheimer’s disease becomes aggressive, hitting staff. Non-pharmacologic
de-escalation fails. Best initial medication?
• Haloperidol 5 mg IM.
• Quetiapine 25 mg nightly.
• Lorazepam 2 mg IM.
• Citalopram 20 mg daily.
Quetiapine 25 mg nightly.
Low-dose atypical antipsychotic for behavioral disturbance in dementia, after non-
pharmacologic failure.
11. A 30-year-old with bipolar II and current hypomania is on lithium 900 mg (level 0.9). He
develops acne and mild tremor.
• Switch to valproate.
• Add low-dose propranolol.
• Discontinue lithium immediately.
• Reduce lithium to 600 mg.
Add low-dose propranolol.
Propranolol treats lithium-induced tremor without destabilizing mood.
12. A 48-year-old with PTSD, nightmares, and hyperarousal failed paroxetine and sertraline.
Next best evidence-based option?
