NR 546 Midterm Exam
What should the PMHNP consider when prescribing chemical restraints? - ANSWER
-allergy status
-prior med hx for adverse drug reactions r/t the meds ordered in the chemical
restraint
-state regulations regarding chemical restrains must be reviewed
Are the PMHNP and other staff liable if the client has an allergic reaction or adverse
side effects to the drugs used for chemical restraint? - ANSWER No.
The client has been court-ordered to take the prescribed medications and the
standing order for chemical restraints is approved. The PMHNP and other staff are
not liable if the patient has an allergic reaction or adverse side effects.
How does reviewing the genetic makeup of a client help guide the PMHNP in
selecting medication for clients? - ANSWER -Genetic testing can assist by
providing more information on how clients may respond to certain psychotropic
medications
-provides information on how a client may break down and metabolize medications
based on the cytochrome P450 system.
Tanrıkulu and Erbaş (2020) investigated identical twins to determine the presence of
an inherited link for schizophrenia and why one twin may develop schizophrenia
when the other does not. When two people have 100% identical DNA, why don't both
persons develop the exact illnesses? Studies of identical Danish twins found that if
one twin had schizophrenia, the other twin had a 50% lifetime risk of developing
schizophrenia (Lemvigh et al., 2020). Why is there only half the risk? - ANSWER
Both environmental and psychosocial stressors can impact mental health. Although
twins may have identical genes, their gene expression may be different.
There may be an environmental exposure that turned a gene "on" that should have
been "off" for one twin to develop schizophrenia and not the other.
central sulcus - ANSWER separates the frontal lobe from the parietal lobe
frontal lobe - ANSWER associated with movement, intelligence, abstract thinking
broca's area - ANSWER speech production
temporal lobe - ANSWER involves object identification and auditory signals
cerebellum - ANSWER coordination
wernicke's area - ANSWER speech comprehension
occipital lobe - ANSWER primary visual area
parietal lobe - ANSWER keeps us alert to what is going on around us
,sensory cortex - ANSWER pain, heat, and other sensations
motor cortex - ANSWER movement
hippocampus - ANSWER involved in both memory and anxiety
nucleus accumbens - ANSWER involved in the reward process
thalamus - ANSWER involved in sensory organ and motor command processing
striatum - ANSWER involved in complex motor actions, also links cognition to motor
actions
limbic system - ANSWER includes circuits that are associated with pleasure and
reward
basal ganglia - ANSWER group of structures involved in voluntary motor
movements
amygdala - ANSWER involved in emotional regulation and perception of odors
corpus callosum - ANSWER controls the communication between the two brain
hemispheres
white matter - ANSWER contains nerve fibers that connect neurons from different
regions into functional circuits
grey matter - ANSWER contains nerve cells and dendrites
brain tissue - ANSWER made up of grey matter and white matter
dorsal striatum - ANSWER involved in complex motor actions and linkage of
cognition to motor actions
-main input area for basal ganglia
*activated when anticipating or engaging in pleasure
The field of epigenetics is rapidly growing and can help explain how gene expression
is: - ANSWER influenced by environmental factors and how epigenetics contributes
to the manifestation of mental illness
How does epigenetics impact a person's mental health? - ANSWER internal or
external factors activate portions of the genome that result in the manifestation of
mental health symptoms
-activation is often a result of a stressful event, which, when combined with the
genetic risk, results in the disease
-genes being on or off
-occurrence of symptoms may be the result of inheritance of an abnormal gene or of
normal genes being "on" when they should be "off."
,Types of epigenetic changes: - ANSWER DNA Methylation
Histone modification
Non-coding RNA
The potential legal and ethical issues impacting mental health treatment must also
be taken into account, including: - ANSWER -informed consent
-competence to make healthcare decisions
-off-label prescribing
Informed consent - ANSWER Clients have the right to receive enough information
to make decisions about treatment.
-must also be informed about potential risks associated with medications.
-have the right to refuse treatment
-cannot be forcibly medicated in non-emergencies. However, clients can be forcibly
medicated if they are violent toward themselves or others and when less restrictive
methods have failed
Compliance - ANSWER A court order may be issued for a client to receive
treatment against their wishes if they are considered a danger to themselves or
others.
-Examples: clients with schizophrenia or sex offenders
-Guardians can provide consent for clients who have limited cognitive capabilities or
are incompetent to make decisions
-PMHNPs are responsible for being knowledgeable about their state laws and
abiding by them.
Off-Label Prescribing - ANSWER Some clients may benefit from the unapproved
use of a drug for symptom management.
-Example: many SSRIs used to tx anxiety and OCD but are not FDA approved for
use in this disorder.
-potentially raises ethical and legal concerns
-PMHNP must remain up to date with the latest recommendations for off-label
prescribing.
Incidence of mental illness-what factors are increasing the incidence - ANSWER
Psychological and sociological factors
Lifestyle factors such as a client's smoking status, diet, exercise, history of
medication adherence, or history of addiction should be considered when prescribing
psychotropic medications
Adherence - ANSWER Persistence
-taking med over intended time period
Compliance
-taking med as prescribed
left hemisphere - ANSWER -speech comprehension
-word recognition
-grammar
-sequential processing
, -recognition of detail
-conscious mental processing
right hemisphere - ANSWER -prosody of speech
-emotional modulation
-visual-spatial skills
-recognition of facial expression
-music
-abstract mathematical skills
-holistic processing
-unconscious mental processing
Pharmacokinetics - ANSWER the study of what happens to a drug from the time of
administration until the parent drug and all metabolites leave the body
CYP450 - ANSWER CYP450 enzymes in the gut wall or liver convert drug
substrate into a biotransformed product in the bloodstream, responsible for
degradating of a large # of psychotropic drugs
-Not all ind. have same genetic form of CYP450 enzymes, determined with
pharmacogenetic testing
*Most individuals have "normal" rates of drug metabolism from the major CYP450
enzymes and are said to be "extensive metabolizers", most drug doses are set for
these individuals.
*genetic variants of these enzymes can make poor metabolizers or ultra rapid
metabolizers
Five of the most important:
CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4.
ultra rapid metabolizers - ANSWER elevated enzyme activity
subtherapeutic drug levels
poor efficacy with standard doses
genotyping - ANSWER the patient for pharmacogenomic use
-genes for these CYP450 enzymes can now be readily measured and used to
predict which patients might need to have dosage adjustments
-measurement of genes for drug metabolism
most common targets of psychotropic drugs - ANSWER G-protein receptors
-Drug actions at these receptors occur in a spectrum, from full agonist actions, to
partial agonist actions, to antagonism, and even to inverse agonism.
Pharmacokinetics concepts - ANSWER absorption
distribution
metabolism
excretion
Flockhart Table - ANSWER drug interactions that are mediated by cytochrome
P450 enzymes
What should the PMHNP consider when prescribing chemical restraints? - ANSWER
-allergy status
-prior med hx for adverse drug reactions r/t the meds ordered in the chemical
restraint
-state regulations regarding chemical restrains must be reviewed
Are the PMHNP and other staff liable if the client has an allergic reaction or adverse
side effects to the drugs used for chemical restraint? - ANSWER No.
The client has been court-ordered to take the prescribed medications and the
standing order for chemical restraints is approved. The PMHNP and other staff are
not liable if the patient has an allergic reaction or adverse side effects.
How does reviewing the genetic makeup of a client help guide the PMHNP in
selecting medication for clients? - ANSWER -Genetic testing can assist by
providing more information on how clients may respond to certain psychotropic
medications
-provides information on how a client may break down and metabolize medications
based on the cytochrome P450 system.
Tanrıkulu and Erbaş (2020) investigated identical twins to determine the presence of
an inherited link for schizophrenia and why one twin may develop schizophrenia
when the other does not. When two people have 100% identical DNA, why don't both
persons develop the exact illnesses? Studies of identical Danish twins found that if
one twin had schizophrenia, the other twin had a 50% lifetime risk of developing
schizophrenia (Lemvigh et al., 2020). Why is there only half the risk? - ANSWER
Both environmental and psychosocial stressors can impact mental health. Although
twins may have identical genes, their gene expression may be different.
There may be an environmental exposure that turned a gene "on" that should have
been "off" for one twin to develop schizophrenia and not the other.
central sulcus - ANSWER separates the frontal lobe from the parietal lobe
frontal lobe - ANSWER associated with movement, intelligence, abstract thinking
broca's area - ANSWER speech production
temporal lobe - ANSWER involves object identification and auditory signals
cerebellum - ANSWER coordination
wernicke's area - ANSWER speech comprehension
occipital lobe - ANSWER primary visual area
parietal lobe - ANSWER keeps us alert to what is going on around us
,sensory cortex - ANSWER pain, heat, and other sensations
motor cortex - ANSWER movement
hippocampus - ANSWER involved in both memory and anxiety
nucleus accumbens - ANSWER involved in the reward process
thalamus - ANSWER involved in sensory organ and motor command processing
striatum - ANSWER involved in complex motor actions, also links cognition to motor
actions
limbic system - ANSWER includes circuits that are associated with pleasure and
reward
basal ganglia - ANSWER group of structures involved in voluntary motor
movements
amygdala - ANSWER involved in emotional regulation and perception of odors
corpus callosum - ANSWER controls the communication between the two brain
hemispheres
white matter - ANSWER contains nerve fibers that connect neurons from different
regions into functional circuits
grey matter - ANSWER contains nerve cells and dendrites
brain tissue - ANSWER made up of grey matter and white matter
dorsal striatum - ANSWER involved in complex motor actions and linkage of
cognition to motor actions
-main input area for basal ganglia
*activated when anticipating or engaging in pleasure
The field of epigenetics is rapidly growing and can help explain how gene expression
is: - ANSWER influenced by environmental factors and how epigenetics contributes
to the manifestation of mental illness
How does epigenetics impact a person's mental health? - ANSWER internal or
external factors activate portions of the genome that result in the manifestation of
mental health symptoms
-activation is often a result of a stressful event, which, when combined with the
genetic risk, results in the disease
-genes being on or off
-occurrence of symptoms may be the result of inheritance of an abnormal gene or of
normal genes being "on" when they should be "off."
,Types of epigenetic changes: - ANSWER DNA Methylation
Histone modification
Non-coding RNA
The potential legal and ethical issues impacting mental health treatment must also
be taken into account, including: - ANSWER -informed consent
-competence to make healthcare decisions
-off-label prescribing
Informed consent - ANSWER Clients have the right to receive enough information
to make decisions about treatment.
-must also be informed about potential risks associated with medications.
-have the right to refuse treatment
-cannot be forcibly medicated in non-emergencies. However, clients can be forcibly
medicated if they are violent toward themselves or others and when less restrictive
methods have failed
Compliance - ANSWER A court order may be issued for a client to receive
treatment against their wishes if they are considered a danger to themselves or
others.
-Examples: clients with schizophrenia or sex offenders
-Guardians can provide consent for clients who have limited cognitive capabilities or
are incompetent to make decisions
-PMHNPs are responsible for being knowledgeable about their state laws and
abiding by them.
Off-Label Prescribing - ANSWER Some clients may benefit from the unapproved
use of a drug for symptom management.
-Example: many SSRIs used to tx anxiety and OCD but are not FDA approved for
use in this disorder.
-potentially raises ethical and legal concerns
-PMHNP must remain up to date with the latest recommendations for off-label
prescribing.
Incidence of mental illness-what factors are increasing the incidence - ANSWER
Psychological and sociological factors
Lifestyle factors such as a client's smoking status, diet, exercise, history of
medication adherence, or history of addiction should be considered when prescribing
psychotropic medications
Adherence - ANSWER Persistence
-taking med over intended time period
Compliance
-taking med as prescribed
left hemisphere - ANSWER -speech comprehension
-word recognition
-grammar
-sequential processing
, -recognition of detail
-conscious mental processing
right hemisphere - ANSWER -prosody of speech
-emotional modulation
-visual-spatial skills
-recognition of facial expression
-music
-abstract mathematical skills
-holistic processing
-unconscious mental processing
Pharmacokinetics - ANSWER the study of what happens to a drug from the time of
administration until the parent drug and all metabolites leave the body
CYP450 - ANSWER CYP450 enzymes in the gut wall or liver convert drug
substrate into a biotransformed product in the bloodstream, responsible for
degradating of a large # of psychotropic drugs
-Not all ind. have same genetic form of CYP450 enzymes, determined with
pharmacogenetic testing
*Most individuals have "normal" rates of drug metabolism from the major CYP450
enzymes and are said to be "extensive metabolizers", most drug doses are set for
these individuals.
*genetic variants of these enzymes can make poor metabolizers or ultra rapid
metabolizers
Five of the most important:
CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4.
ultra rapid metabolizers - ANSWER elevated enzyme activity
subtherapeutic drug levels
poor efficacy with standard doses
genotyping - ANSWER the patient for pharmacogenomic use
-genes for these CYP450 enzymes can now be readily measured and used to
predict which patients might need to have dosage adjustments
-measurement of genes for drug metabolism
most common targets of psychotropic drugs - ANSWER G-protein receptors
-Drug actions at these receptors occur in a spectrum, from full agonist actions, to
partial agonist actions, to antagonism, and even to inverse agonism.
Pharmacokinetics concepts - ANSWER absorption
distribution
metabolism
excretion
Flockhart Table - ANSWER drug interactions that are mediated by cytochrome
P450 enzymes
