CMN 548 Exam with Questions and Answers Latest 2026/27 Updates Complete
Solution Study Guide – University of South Alabama
Antimanic and Mood stabilizing agents
LITHIUM
1. What are the therapeutic indications for Lithium?
• mania (feeling highly excited, overactive or distracted) hypomania (like mania, but less
severe) bipolar disorder, where your mood changes between feeling very high (mania)
and very low (depression)
2. When treating acute mania, how long would it take for lithium to exert antimanic effects?
• 1-3 weeks of treatment
3. What treatment options/medications may be used as adjunct for acute mania while lithium
levels are reaching therapeutic?
• Effective combination therapies for acute mania include lithium or valproic acid with
quetiapine (Seroquel) or risperidone (Risperdal). Quetiapine and cariprazine (Vraylar)
are effective single agents for the treatment of acute bipolar depression
• Benzo's, DRA's, SDA's, or valproic acid
4. What types of patients respond less well to lithium during acute mania than those with
classic mania?
• Mixed mania, secondary mania, and mania associated with substance abuse--as well as
rapid cycling --generally respond poorly to lithium therapy
• Txtbk: less success when patients with mixed or dysphoric mania, rapid cycling,
comorbid substance abuse, or organic brain disorders are included.
5. What differential diagnoses would the clinician include for an individual who is taking lithium
as maintenance for bipolar disorder and a depressive episode occurs? 7891
• The differential diagnosis of bipolar I disorder should always include major depressive
disorder, other bipolar disorders, anxiety disorders, attention-deficit/hyperactivity
disorders (ADHD), and personality disorders
6. What are the treatment options for a patient experiencing a depressive episode who is
currently on lithium maintenance for bipolar disorder? 7891
• A generally recommended approach for patients with bipolar depression who are
already taking lithium is to increase dosage to the maximum tolerated level up to 1
mM/L either alone or, for more severe depressions, in combination with an
antidepressant.
• Treating bipolar depression with a conventional antidepressant alone does not protect
against mania and may even precipitate mania or rapid cycling.
CMN 548 Exam Guide
,7. What four reasons is initiating maintenance therapy with lithium after the first manic episode
a wise choice for clinicians?
• 1.Each episode of mania increases the risk of subsequent episodes
2. Among people responsive to lithium, relapses are 28 times more likely after
lithium d/c
3. Ppl who initially respond to lithium, d/c it and then had a relapse no longer
responded to lithium
4. It increases efficacy and reduces mortality
8. Review Table 29.19-3 – Adverse Effects of Lithium
Adverse Effects of Lithium-neurological
benign, nontoxic: dysphoria, lack of spontaneity, slowed reaction time, memory
difficulties.
Tremor: postural, occasional extrapyramidal
Toxic: coarse tremor, dysarthria, ataxia, neuromuscular irritability, seizures, coma, death
Miscellaneous: peripheral neuropathy, benign intracranial HTN, myasthenia gravis-like
syndrome, altered creativity, lowered seizure threshold.
Adverse Effects of Lithium-Endocrine
Thyroid: goiter, hypothyroidism, exophthalmos, hyperthyroidism (rare)
Parathyroid: hyperparathyroidism, adenoma
Adverse Effects of Lithium-Cardiovascular
benign T-wave changes, sinus node dysfunction
Adverse Effects of Lithium-renal effects
concentrating defect, morphologic changes, polyuria (nephrogenic diabetes insipidus),
reduced GFR, nephrotic syndrome, renal tubular acidosis
Adverse effect of Lithium-dermatological effect
Acne, hair loss, psoriasis, rash
Adverse effects of Li-GI effect
appetite loss, nausea, vomiting, diarrhea
Miscellaneous adverse effects of Li
altered carbohydrate metabolism, weight gain, fluid retention
CMN 548 Exam Guide
,9. What patient education regarding sodium intake and excretion should be included when
prescribing lithium?
• Clients under lithium therapy don't need to limit their sodium intake, instead it is
recommended to keep salt intake the same as before prescription of the lithium
medication. Increasing the dose of lithium without evaluating the client's lab works can
cause lithium toxicity, overdose, and renal failure.
• Excessive sodium (dramatic diet changes) intake lowers lithium concentrations
• Too little sodium (fad diets) can lead to potentially toxic concentrations of
lithium
• Decrease in body fluids (excessive perspiration) can lead to dehydration &
lithium toxicity
10. What cardiovascular assessment should be done prior to initiating lithium therapy?
• Before starting treatment with lithium, it is essential to get kidney function tests and
thyroid function tests. In patients above 50 years of age, an electrocardiogram is also
necessary.
• Low-salt diets, certain diuretics, ACE inhibitors, angiotensin II receptor type-1
antagonists, fluid-electrolyte imbalances, and impaired renal function all predispose to
lithium toxicity.
• Lithium can cause diffuse slowing, widening of frequency spectrum, and
potentiation & disorganization of background rhythm on ECG
oBradycardia & arrhythmias may occur (particularly in pts with cardiovascular
disease)
oCan reveal Brugada's syndrome which is potentially life threatening
• Before starting lithium ask about heart conditions, unexplained fainting, & family
hx of problems or sudden unexplained death before age 45
11. Weight gain during lithium therapy is caused by what mechanisms/actions?
• drug’s complex effects on carbohydrate metabolism. Other possible causes include
lithium-induced hypothyroidism, fluid retention, and increased caloric intake from
thirst-quenching beverages.
• •Poorly understood effects of lithium on carbohydrate metabolism
• Can also result from lithium-induced hypothyroidism, lithium-induced edema, or
excessive consumption of soft drinks & juices to quench lithium-induced thirst
12. How is lithium-induced postural tremor treated? 7909
• postural tremor in the arms and hands. Because the tremor worsens during activities
requiring fine motor control, it can be socially embarrassing and occupationally
troublesome. Tremor sometimes improves spontaneously, but if it does not, benefit
CMN 548 Exam Guide
, may be obtained from dose reduction, use of a slow-release lithium preparation,
elimination of dietary caffeine, discontinuation of other medications, and treatment of
associated anxiety. Medications useful in treating lithium tremor include β-adrenergic
receptor antagonists such as propranolol (Inderal), as well as primidone (Mysoline), and
possibly gabapentin (Neurontin). With long-term lithium therapy, a tremor with
parkinsonian characteristics may occur occasionally. Worsening of tremor at any time
during the course of lithium therapy may be an indication of impending lithium
intoxication, and severe tremor should be considered due to lithium toxicity until
proven otherwise.
• Tremor: most notable in outstretched hands, especially in finger tips & during
tasks involving fine manipulations
• Tx: divide the daily dosage, using a SR formulation, reducing caffeine intake,
reassessing the concomitant use of other medicines, & treating comorbid anxiety
oPropranolol & primidone can reduce the tremor
ow/ hypokalemia- K+ may reduce the tremor
• If tremor is SEVERE- suspect toxicity
13. Discuss the cause of polyuria, the most common renal effect of lithium, and its treatment.
7911
• Lithium increases urine volume primarily by inhibiting the effect of antidiuretic hormone
on the kidneys, although additional renal (including disruption of the aquaporin-2
shuttle) and CNS mechanisms have been identified
• Treatment considerations include (1) adequate fluid replacement, (2) use of the lowest
effective dosage, and (3) counteractive medications such as thiazides or potassium
sparing diuretics, or indomethacin (Indocin). Amiloride (Midamor) or an amiloride-
hydrochlorothiazide combination (Moduretic) is preferred to minimize the risk of
hypokalemia
• •Cause: lithium antagonism to the effects of antidiuretic hormone which thus
causes diuresis
• Tx: fluid replacement, use of lowest effective dose of lithium, single daily dose of
lithium
oThiazide diuretic can be used: HOWEVER, when a diuretic, lithium dosage should
be halved & diuretic shouldn't be started for 5 days because the diuretic is likely to
increase lithium concentrations
14. Along with laboratory monitoring of serum concentrations, what other laboratory studies is
considered prudent to monitor for serious renal adverse effects?
CMN 548 Exam Guide
Solution Study Guide – University of South Alabama
Antimanic and Mood stabilizing agents
LITHIUM
1. What are the therapeutic indications for Lithium?
• mania (feeling highly excited, overactive or distracted) hypomania (like mania, but less
severe) bipolar disorder, where your mood changes between feeling very high (mania)
and very low (depression)
2. When treating acute mania, how long would it take for lithium to exert antimanic effects?
• 1-3 weeks of treatment
3. What treatment options/medications may be used as adjunct for acute mania while lithium
levels are reaching therapeutic?
• Effective combination therapies for acute mania include lithium or valproic acid with
quetiapine (Seroquel) or risperidone (Risperdal). Quetiapine and cariprazine (Vraylar)
are effective single agents for the treatment of acute bipolar depression
• Benzo's, DRA's, SDA's, or valproic acid
4. What types of patients respond less well to lithium during acute mania than those with
classic mania?
• Mixed mania, secondary mania, and mania associated with substance abuse--as well as
rapid cycling --generally respond poorly to lithium therapy
• Txtbk: less success when patients with mixed or dysphoric mania, rapid cycling,
comorbid substance abuse, or organic brain disorders are included.
5. What differential diagnoses would the clinician include for an individual who is taking lithium
as maintenance for bipolar disorder and a depressive episode occurs? 7891
• The differential diagnosis of bipolar I disorder should always include major depressive
disorder, other bipolar disorders, anxiety disorders, attention-deficit/hyperactivity
disorders (ADHD), and personality disorders
6. What are the treatment options for a patient experiencing a depressive episode who is
currently on lithium maintenance for bipolar disorder? 7891
• A generally recommended approach for patients with bipolar depression who are
already taking lithium is to increase dosage to the maximum tolerated level up to 1
mM/L either alone or, for more severe depressions, in combination with an
antidepressant.
• Treating bipolar depression with a conventional antidepressant alone does not protect
against mania and may even precipitate mania or rapid cycling.
CMN 548 Exam Guide
,7. What four reasons is initiating maintenance therapy with lithium after the first manic episode
a wise choice for clinicians?
• 1.Each episode of mania increases the risk of subsequent episodes
2. Among people responsive to lithium, relapses are 28 times more likely after
lithium d/c
3. Ppl who initially respond to lithium, d/c it and then had a relapse no longer
responded to lithium
4. It increases efficacy and reduces mortality
8. Review Table 29.19-3 – Adverse Effects of Lithium
Adverse Effects of Lithium-neurological
benign, nontoxic: dysphoria, lack of spontaneity, slowed reaction time, memory
difficulties.
Tremor: postural, occasional extrapyramidal
Toxic: coarse tremor, dysarthria, ataxia, neuromuscular irritability, seizures, coma, death
Miscellaneous: peripheral neuropathy, benign intracranial HTN, myasthenia gravis-like
syndrome, altered creativity, lowered seizure threshold.
Adverse Effects of Lithium-Endocrine
Thyroid: goiter, hypothyroidism, exophthalmos, hyperthyroidism (rare)
Parathyroid: hyperparathyroidism, adenoma
Adverse Effects of Lithium-Cardiovascular
benign T-wave changes, sinus node dysfunction
Adverse Effects of Lithium-renal effects
concentrating defect, morphologic changes, polyuria (nephrogenic diabetes insipidus),
reduced GFR, nephrotic syndrome, renal tubular acidosis
Adverse effect of Lithium-dermatological effect
Acne, hair loss, psoriasis, rash
Adverse effects of Li-GI effect
appetite loss, nausea, vomiting, diarrhea
Miscellaneous adverse effects of Li
altered carbohydrate metabolism, weight gain, fluid retention
CMN 548 Exam Guide
,9. What patient education regarding sodium intake and excretion should be included when
prescribing lithium?
• Clients under lithium therapy don't need to limit their sodium intake, instead it is
recommended to keep salt intake the same as before prescription of the lithium
medication. Increasing the dose of lithium without evaluating the client's lab works can
cause lithium toxicity, overdose, and renal failure.
• Excessive sodium (dramatic diet changes) intake lowers lithium concentrations
• Too little sodium (fad diets) can lead to potentially toxic concentrations of
lithium
• Decrease in body fluids (excessive perspiration) can lead to dehydration &
lithium toxicity
10. What cardiovascular assessment should be done prior to initiating lithium therapy?
• Before starting treatment with lithium, it is essential to get kidney function tests and
thyroid function tests. In patients above 50 years of age, an electrocardiogram is also
necessary.
• Low-salt diets, certain diuretics, ACE inhibitors, angiotensin II receptor type-1
antagonists, fluid-electrolyte imbalances, and impaired renal function all predispose to
lithium toxicity.
• Lithium can cause diffuse slowing, widening of frequency spectrum, and
potentiation & disorganization of background rhythm on ECG
oBradycardia & arrhythmias may occur (particularly in pts with cardiovascular
disease)
oCan reveal Brugada's syndrome which is potentially life threatening
• Before starting lithium ask about heart conditions, unexplained fainting, & family
hx of problems or sudden unexplained death before age 45
11. Weight gain during lithium therapy is caused by what mechanisms/actions?
• drug’s complex effects on carbohydrate metabolism. Other possible causes include
lithium-induced hypothyroidism, fluid retention, and increased caloric intake from
thirst-quenching beverages.
• •Poorly understood effects of lithium on carbohydrate metabolism
• Can also result from lithium-induced hypothyroidism, lithium-induced edema, or
excessive consumption of soft drinks & juices to quench lithium-induced thirst
12. How is lithium-induced postural tremor treated? 7909
• postural tremor in the arms and hands. Because the tremor worsens during activities
requiring fine motor control, it can be socially embarrassing and occupationally
troublesome. Tremor sometimes improves spontaneously, but if it does not, benefit
CMN 548 Exam Guide
, may be obtained from dose reduction, use of a slow-release lithium preparation,
elimination of dietary caffeine, discontinuation of other medications, and treatment of
associated anxiety. Medications useful in treating lithium tremor include β-adrenergic
receptor antagonists such as propranolol (Inderal), as well as primidone (Mysoline), and
possibly gabapentin (Neurontin). With long-term lithium therapy, a tremor with
parkinsonian characteristics may occur occasionally. Worsening of tremor at any time
during the course of lithium therapy may be an indication of impending lithium
intoxication, and severe tremor should be considered due to lithium toxicity until
proven otherwise.
• Tremor: most notable in outstretched hands, especially in finger tips & during
tasks involving fine manipulations
• Tx: divide the daily dosage, using a SR formulation, reducing caffeine intake,
reassessing the concomitant use of other medicines, & treating comorbid anxiety
oPropranolol & primidone can reduce the tremor
ow/ hypokalemia- K+ may reduce the tremor
• If tremor is SEVERE- suspect toxicity
13. Discuss the cause of polyuria, the most common renal effect of lithium, and its treatment.
7911
• Lithium increases urine volume primarily by inhibiting the effect of antidiuretic hormone
on the kidneys, although additional renal (including disruption of the aquaporin-2
shuttle) and CNS mechanisms have been identified
• Treatment considerations include (1) adequate fluid replacement, (2) use of the lowest
effective dosage, and (3) counteractive medications such as thiazides or potassium
sparing diuretics, or indomethacin (Indocin). Amiloride (Midamor) or an amiloride-
hydrochlorothiazide combination (Moduretic) is preferred to minimize the risk of
hypokalemia
• •Cause: lithium antagonism to the effects of antidiuretic hormone which thus
causes diuresis
• Tx: fluid replacement, use of lowest effective dose of lithium, single daily dose of
lithium
oThiazide diuretic can be used: HOWEVER, when a diuretic, lithium dosage should
be halved & diuretic shouldn't be started for 5 days because the diuretic is likely to
increase lithium concentrations
14. Along with laboratory monitoring of serum concentrations, what other laboratory studies is
considered prudent to monitor for serious renal adverse effects?
CMN 548 Exam Guide
