NR 546 FINAL EXAM VERSION 1 AND VERSION 2 NEWEST 2026 ACTUAL EXAM COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+

NR 546 FINAL EXAM VERSION 1 AND VERSION 2 NEWEST 2026 ACTUAL EXAM COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Lithium Anticonvulsants Second generation antipsychotics Pharmacologic Treatment of Bipolar Disorder major depressive disorder (MDD) one of the most common mental disorders -Approximately 7.1% of adults in the U.S. had episode in last year, prevalence highest (13.1%) among individuals aged 18-25 S/S -depressed mood -loss of interest or pleasure in daily activities -irritability -withdrawal -problems with sleep, eating, energy, concentration, or self-worth -severe depression: may experience thoughts of suicide or psychotic symptoms. Unipolar depression Chronic condition characterized by extreme fluctuations in mood, energy, and ability to function -Moods may be manic, hypomanic, or depressed and may include mixed mood or psychotic features -many have only experienced only one manic episode in their lifetime -Mood fluctuations may be separated by periods of high stability or may cycle rapidly -diagnosed when a client has one or more episodes of mania or hypomania with a history of one or more major depressive episodes -high risk for suicide Bipolar disorder (BD) characterized by a persistently elevated, expansive, or irritable mood. Related symptoms may include inflated self-esteem, increased goal-directed activity or energy, including grandiosity, decreased need for sleep, excessive talkativeness, racing thoughts, flight of ideas (FOI), distractibility, psychomotor agitation, and a propensity to be involved in high-risk activities. Mania leads to significant functional impairment and may include psychotic features or necessitate hospitalization mania requires at least one episode of mania for at least one week (or any duration if hospitalization due to symptoms is required) Bipolar Type I: diagnosis requires a current or past hypomanic episode and a current or past major depressive episode. Symptoms last for at least 4 days but fewer than seven. -Hypomanic symptoms are not of sufficient duration or severity to cause significant functional impairment, psychosis, or hospitalization. -Anger and irritability are common. -Clients often enjoy the elevation of mood and are reluctant to report these symptoms, making bipolar more difficult to diagnose if the client presents in the depression phase. Bipolar Type II: involves the chronic presentation of hypomanic and depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Cyclothymia: antidepressant therapy may precipitate a manic episode or induce rapid-cycling bipolar depression -may contribute to the increased incidence of death by suicide in children and adults younger than 25 If bipolar depression is mistaken for MDD: monotherapy -Antidepressants should be combined with a mood stabilizer to prevent the onset of a hypomanic or manic episode Antidepressants are used cautiously in clients with bipolar disorder and never as ________________. Decreased positive affect: depressed mood loss of joy lack of interest loss of energy decreased alertness decreased self-confidence appetite changes DA, NE Dysfunction causes what mood related symptoms Increased negative affect: depressed mood guilt fear/anxiety hostility irritability loneliness appetite changes 5HT, NE Dysfunction causes what mood related symptoms -depression occurs as a result of a deficiency of one or all three monoamine transmitters • serotonin, norepinephrine, and dopamine -while mania may result from an excess monoamine hypothesis of depression • Selective Serotonin Reuptake Inhibitors (SSRIs) • Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) • Norepinephrine Dopamine Reuptake Inhibitors (NDRI) • Serotonin Antagonist and Reuptake Inhibitors (SARIs) Medication Management for Depression, First-Line Treatment: Mechanism of action • inhibit 5-HT reuptake Adverse effects -diarrhea -headache -weight gain -sexual side effects SSRI's Mechanism of action • inhibit 5-HT reuptake • inhibit NE reuptake (increase energy, focus) • increase DA in prefrontal cortex (increase cognition) Adverse effects -elevated blood pressure -anxiety -insomnia -constipation SNRI's Mechanism of action • inhibit DA reuptake (increase alertness, motivation) • inhibit NE reuptake (increase energy) Adverse effects -agitation -headache -dry mouth -constipation -weight loss NDRI's citalopram (Celexa) SSRI Prescribing Pearls: med with mild antihistamine effects escitalopram (Lexapro) SSRI Prescribing Pearls: med with no known drug interactions fluoxetine (Prozac) SSRI Prescribing Pearls: med with longest half-life paroxetine (Paxil) SSRI Prescribing Pearls: med that also treats social anxiety and insomnia fluvoxamine (Luvox) SSRI Prescribing Pearls: med that treats anxious depression; smokers require an increased dose sertraline (Zoloft) SSRI Prescribing Pearls: med that also treats social anxiety and hypersomnolence INDICATION -Depression -GAD -Social anxiety disorder -Panic disorder Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine. TESTS -Check bp before initiating tx & regularly during tx Starting Dose -Initial 37.5 mg daily (extended-release) or 25-50 mg divided into 2-3 doses (immediate-release) Adverse Effects -H/A, nervousness, insomnia, sedation, nausea, diarrhea, decreased appetite, sexual dysfunction, asthenia, sweating, SIADH, hyponatremia, increase BP PEARLS -treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication -preferred treatments for treatment-resistant depression venlafaxine (Effexor) INDICATION -MDD Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine TESTS -Monitor BP before and during treatment. Starting Dose -50 mg/day Adverse Effects -Insomnia, sedation, anxiety, dizziness, nausea, vomiting, constipation, decreased appetite, sexual dysfunction, sweating, SIADH, hyponatremia, increased BP PEARLS -effective for perimenopausal vasomotor symptoms desvenlafaxine (Pristiq) INDICATION -MDD -Diabetic peripheral neuropathic pain -Fibromyalgia -GAD -Chronic musculoskeletal pain Mechanism of Action -SNRI (dual serotonin and norepinephrine reuptake inhibitor), Boosts neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine TESTS -Monitor BP before and during treatment. Starting Dose -Depression initial 40 mg/day in 2 doses. -Anxiety initial 60 mg once daily. Adverse Effects -nausea, diarrhea, decreased appetite, dry mouth, constipation, insomnia, sedation, dizziness, sexual dysfunction, sweating, increased blood pressure, urinary retention. PEARLS -effective for atypical pain at higher doses; fibromyalgia and diabetic neuropathy -appropriate for clients who present with somatic symptoms of depression -Drug interactions: Inhibitors of CYP450 2D6, such as paroxetine, fluoxetine, and quinidine, may increase plasma levels of duloxetine and require a dosage reduction of dulox duloxetine (Cymbalta) GI tract, only 10% *which causes GI side effects 90% of serotonin receptors are in the __________ and _________ are within the brain Most adverse effects will subside after 4-5 days once the body adjusts to increased serotonin levels client education for specific medication classes: SSRI's -Medications should not be abruptly stopped to avoid discontinuation symptoms. -NE effects of the medication may increase anxiety in some clients. Report worsening anxiety to the provider. client education for specific medication classes: SNRI's -Take medication in the morning. -Stop taking medication if seizures occur. -Stop taking medication if anxiety is noted. client education for specific medication classes: NDRI's Serotonin Antagonist and Reuptake Inhibitors -potently block 5-HT2A and 5HT 2C receptors, allow more 5-HT to interact at postsynaptic 5-HT1A sites -Trazodone most common -adverse effects: • sedation • drowsiness • blurred vision • constipation • dry mouth • severe: priapism (Medical emergency) Patient education: side effects, take at HS due to sedation Off-label uses: insomnia, anxiety Other tx options: SARI's INDICATION -MDD Mechanism of Action -Serotonin norepinephrine receptor agonist, alpha2 receptor agonist. Boosts neurotransmitters serotonin and norepinephrine/noradrenaline. TESTS -Monitor weight and BMI during tx Starting Dose -15 mg/day in the evening Adverse Effects -Sedation, weight gain, dry mouth, constipation, abnormal dreams, confusion, hypotension, Changes in urinary function. Flu-like symptoms may indicate low white blood cell or granulocyte count. PEARLS -sedation/drowsiness, useful for clients with insomnia. -increased appetite/weight gain, useful for clients with depression-related weight loss -Precautions: May cause photosensitivity, avoid alcohol (increase sedation) Mirtazapine (Remeron) INDICATION -MDD Mechanism of Action -Dual-acting serotonin reuptake inhibitor plus 5HT1A partial agonist. Boosts neurotransmitter serotonin. TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -Nausea, diarrhea, vomiting, insomnia, dizziness, bruising, sexual dysfunction, SIADH. -Rare: Bleeding, hyponatremia. PEARLS -Appropriate for depression/comorbid anxiety, action similar to combination of SSRI and buspirone. -Precautions: Not approved in children Vilazodone (Viibryd) INDICATION -MDD Mechanism of Action -Multimodal antidepressant, Serotonin multimodal (SMM) -Increases release of serotonin, norepinephrine, dopamine, glutamate, acetylcholine, and histamine and reduces the release of GABA TESTS -None for healthy individuals Starting Dose -10 mg/day Adverse Effects -nausea, vomiting, constipation, sexual dysfuction. PEARLS -Improves depression-related cognition -Long half-life means vortioxetine can generally be abruptly discontinued. -Not approved in children Vortioxetine (Trintellix) INDICATION -Depression Mechanism of Action -SARI (serotonin 2 antagonist/reuptake inhibitor). Blocks serotonin 2A receptors. TESTS -None for healthy individuals Starting Dose -150 mg/day in divided doses Adverse Effects -dizziness, sedation, hypotension, Nausea, vomiting, edema, blurred vision, constipation, dry mouth, headache, incoordination, tremor, hypotension, syncope, occasional sinus bradycardia. -Rare: rash, priapism. Trazodone (Desyrel) SRI and NRI properties, but they also block α1-adrenergic, histamine-1, and muscarinic cholinergic receptors -not used first-line because of the high incidence of adverse effects and the risk of potential overdose and death • amitriptyline (Elavil) • desipramine (Norpramin) • doxepin (Sinequan) • imipramine (Tofranil) • nortriptyline (Pamelor) Tricyclic antidepressants Orthostatic hypotension Alpha-1 adrenergic effects Dry mouth Blurred vision Urinary retention Constipation Anticholinergic effects Weight gain Sedation Histamine effects first developed, LAST CHOICE medication class for depression due to the many potential, serious side effects -specific dietary restrictions, Foods that contain tyramine should be avoided (Red wine, Sauerkraut, Cheese, Soy, Smoked meats) -block enzymes responsible for the breakdown of 5-HT, NE, and DA • two primary forms of the MAO enzyme: MAO-A and MAO-B • both located in the brain, MAO-A also in gut Drugs: -phenelzine (Nardil) - duration 14 days -selegiline (Emsam) - MAOI-B - duration 14 days -tranylcypromine (Parnate) -duration 14-30 days -isocarboxazid (Marplan) - duration 14 days Side effects: -Confusion -Dizziness -Insomnia -Sedation -Vivid dreams Pearls: -high risk for hypertensive crisis if tyramine is ingested -Do not prescribe any serotonergic agents within 2 weeks of MAOI discontinuation due to an increased risk of serotonin syndrome -Wait at least 5 half-lives after discontinuing a serotonergic medicati MAOIs breaks down 5-HT, DA, NE, and tyramine -used to treat depression and anxiety "A" is for antidepressant or anxiolytic MAO-A responsible for the breakdown of dopamine, phenylethylamine, and tyramine -used to treat Parkinson's disease; however, high-dose selegiline (Emsam) may be used to treat anxiety or depression MAO-B Tyramine is present in many aged or preserved foods including aged cheeses, tap and nonpasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu. Foods to avoid when taking MAOIs Antipsychotic medications are sometimes prescribed at low doses as adjunctive medications for severe depression Adjunct treatment for depression nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior -reaches peak onset in the body in between 20-40 minutes -risk of adverse outcomes due to sedation and dissociation *must be administered in a supervised healthcare setting Newer tx for resistant depression: esketamine (Spravato) Ketamine is an N-methyl-D-aspartate (NMDA) receptor inhibitor, results in the downstream release of glutamate -high doses, ketamine may cause psychotic symptoms, in low doses, it has a rapid effect on depression -Ketamine clinics have provided intravenous ketamine for treatment-resistant unipolar and bipolar depression *required frequent dosing, inconvenient, expensive Newer tx for resistant depression: Ketamine clinics Researchers are investigating, related to NMDA -currently approved by the FDA for the treatment of pseudobulbar affect *combines dextromethorphan and quinidine as an oral treatment Newer tx for resistant depression: dextromethorphan/quinidine (Nuedexta) Client preference Prior treatment response Anticipated adverse effects Comorbidities Half-life and interactions Cost considered when selecting an antidepressant medication Start clients on a single drug for 4-8 weeks to assess efficacy. Start with the lowest recommended dose to reduce side effects. If a medication is not achieving efficacy: -Increase the dose gradually to the efficacious dose range. -Switch to a different drug within the same class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial. -Switch to a drug in a different class after an adequate trial which includes higher dosing and a minimum of eight weeks of trial. -Add a second medication as an adjunct. Antidepressants: Initiating Medication Don't suddenly stop or omit doses due to risk of discontinuation syndrome -Paroxetine highest risk due to serotonin transporter inhibition and anticholinergic rebound -If a treatment course has lasted 8 weeks, discontinuation over 1-2 weeks is safe. Once symptoms are in remission, continue treatment for 4-9 months to reduce the risk of relapse Antidepressants: Discontinuing Medications Suicide Risk with Antidepressant Drugs -Clients with depression may consider or attempt suicide -risk for suicide may increase at the start of treatment -Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years. Antidepressants Important Prescribing Considerations: Black Box Warning Most antidepressant medications have serious drug-drug interactions. Carefully review the client's history and current prescriptions before selecting a medication. Antidepressants Important Prescribing Considerations: Drug-Drug Interactions potentially life-threatening condition reported with the use of serotonergic antidepressants -especially when they are used concomitantly with other serotonergic drugs (such as triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John's Wort), and with drugs that impair serotonin metabolism (particularly MAOIs) S/S -mental status changes (e.g., agitation, hallucinations, delirium, and coma) -autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia) -neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination) -seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea) If such symptoms occur, clients should discontinue serotonergic agents and initiate treatment of symptoms. Clients should be educated about the signs and symptoms of serotonin syndrome and monitored -part Antidepressants Important Prescribing Considerations: Serotonin Syndrome Bupropion -has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI. match the specific complaint to the best antidepressant medication: Eric, 49, is concerned about sexual side effects of antidepressant medications Mirtazapine -may be used to increase appetite/weight gain in older clients. match the specific complaint to the best antidepressant medication: Terry, 76, has lost several pounds in the past few months. She has little appetite. Vortioxetine -can improve the speed of processing and cognitive function due to its unique mechanism of action. match the specific complaint to the best antidepressant medication: Karl, 35, complains of "brain fog" as a part of his depression symptoms. Suboptimal folate levels in depressed patients (adjunct to antidepressant) • L-Methylfolate is a bioavailable form of folate • L-methylfolate, or 6-(S)-5-methyl-tetrahydrofolate, is derived from folate and is the form that enters the brain and works directly as a methyl donor and monoamine synthesis modulator Role of L-Methylfolate in depression tx Treatment with l-methylfolate seems to be safe, has few if any side effects, and is generally less expensive than augmenting with a second branded antidepressant or atypical antipsychotic Why is L-Methylfolate recommended as an adjunct in depression? Fluoxetine -has a 2-3 days half-life, an excellent option for forgetful people. match the specific complaint to the best antidepressant medication: Lauren, 19, reports she sometimes forgets to take her pills on time. Fluvoxamine Not approved for depression in US, only OCD Fluoxetine -5HT2C antagonism may contribute to its efficacy in this disorder Only SSRI approve for eating disorders Trazodone -The sedative effects of trazodone can assist with sleep disturbances when given at bedtime. This medication is most appropriate for sleep concerns. Trazadone is not first line for depression due to the significant sedation side effect. match the specific complaint to the best antidepressant medication: Edna, 62, has difficulty falling asleep most nights. Paroxetine is contraindicated in pregnancy due to the risk of congenital defects, including atrial septal defects. Antidepressants Lifespan Considerations: Pregnancy Infant irritability should be monitored when SNRIs are prescribed. Antidepressants Lifespan Considerations: Breastfeeding -Older adults may not respond to antidepressants as robustly as younger people if the first episode of depression occurs after age 65. -Citalopram and escitalopram should be dosed at 1/2 dose due to the risk of QTc prolongation. -2019 American Geriatric Society (AGS) Beers Criteria include the following recommendations: • Avoid paroxetine in clients with a history of falls/fractures. • Avoid tricyclic antidepressants prescribed with other central nervous system (CNS) depressants. Antidepressants Lifespan Considerations: Older Adult Antidepressants increase the risk of death by suicide in children and adults younger than 25. Antidepressants Lifespan Considerations: Children Escitalopram best-tolerated SSRI fewest drug-drug interactions 27-32-hour half-life which is less prone to side effects if a dose is late or forgotten Christina is a 34-year-old who presents to the office with complaints of loss of energy, anxiety, and excessive sleeping. She has no past medical history. She is diagnosed with depression. She is concerned about starting on antidepressants because she has heard they cause weight gain, and she isn't great at remembering to take pills "unless I can take them in the morning." Using the prescription pad below, write a prescription for Christina to treat her depression. What medication? The medication will take several weeks to achieve full effect. A dosage increase is indicated. -Antidepressant medications generally take 4-6 weeks to achieve symptom relief. This client was started on the lowest dose to decrease side effects. Increasing the dose is the most appropriate next step. Starting doses may not be efficacious. When a medication is tolerated but not efficacious at the starting dose, a dose increase can often achieve efficacy. -Although an additional medication may need to be added or a different medication may need to be prescribed if no improvement is seen, the PMHNP should first increase the dose and ensure a 6-8 week trial of medication is completed prior to any medication changes Christina returns to the office after 2 weeks and complains that she feels "the same" and wants to know if she can change to a different prescription to treat her depression. Which of the following statements is an appropriate response to Christina? mood stabilizers anticonvulsants atypical antipsychotics Medications for Bipolar Disorder -lithium -lamotrigine (Lamictal) -valproic acid (Depakene) -Second generation antipsychotics • aripiprazole (Abilify) • cariprazine (Vraylar) • lurasidone (Latuda) • quetiapine (Seroquel) • asenapine (Saphris)