Psychiatric-Mental Health Nurse Practitioner Exam Medications 2 — Questions and Answers
Question 1: A patient on clozapine develops a WBC of 2,800/mm³. What is the most appropriate action?
- Reduce the clozapine dose by 50%
- Discontinue clozapine immediately and do not rechallenge (Correct answer)
- Continue clozapine and recheck WBC in 1 week
- Add prophylactic G-CSF and continue clozapine
Correct answer: Discontinue clozapine immediately and do not rechallenge
A WBC below 3,000/mm³ indicates agranulocytosis risk; clozapine must be stopped immediately and is permanently contraindicated for that patient.
Question 2: Which antidepressant is most appropriate for a patient with major depressive disorder who also has significant insomnia but cannot tolerate anticholinergic side effects?
- Amitriptyline
- Mirtazapine (Correct answer)
- Paroxetine
- Doxepin
Correct answer: Mirtazapine
Mirtazapine is highly sedating via H1 antagonism and has minimal anticholinergic activity, making it suitable for patients needing sleep aid without anticholinergic burden.
Question 3: A patient prescribed lithium develops nausea, vomiting, coarse tremor, and confusion. Serum lithium level is 2.1 mEq/L. What is the priority intervention?
- Administer activated charcoal
- Initiate hemodialysis (Correct answer)
- Hold one dose and recheck in 6 hours
- Reduce the lithium dose and add an antiemetic
Correct answer: Initiate hemodialysis
A lithium level above 2.0 mEq/L with severe neurological symptoms requires hemodialysis to rapidly remove lithium, as lithium is not bound to activated charcoal.
Question 4: Which of the following is the mechanism of action of aripiprazole that differentiates it from most other second-generation antipsychotics?
- Full D2 receptor antagonism
- D2 receptor partial agonism (Correct answer)
- D1 receptor full agonism
- Selective serotonin reuptake inhibition
Correct answer: D2 receptor partial agonism
Aripiprazole acts as a partial agonist at D2 and D3 receptors, stabilizing dopamine activity rather than fully blocking it, which reduces EPS risk.
Question 5: A woman of childbearing potential is being started on valproate for bipolar disorder. What is the most critical counseling point?
- Valproate is safe during the first trimester only
- Valproate carries a high risk of neural tube defects and requires reliable contraception (Correct answer)
- Folate supplementation eliminates valproate's teratogenic risk
- Valproate is preferred over lithium in pregnancy
Correct answer: Valproate carries a high risk of neural tube defects and requires reliable contraception
Valproate is a major teratogen associated with neural tube defects (spina bifida), cognitive impairment in offspring, and requires a REMS program with mandatory contraception.
Question 6: Which medication requires monitoring of fasting glucose and HbA1c due to its high risk of causing metabolic syndrome?
- Ziprasidone
- Aripiprazole
- Olanzapine (Correct answer)
- Haloperidol
Correct answer: Olanzapine
Olanzapine has the highest metabolic risk among antipsychotics, causing significant weight gain, hyperglycemia, and dyslipidemia requiring routine metabolic monitoring.
Question 7: A patient taking phenelzine eats a meal containing aged cheese and develops a severe hypertensive crisis. What is the pharmacological explanation?
- Phenelzine inhibits dopamine beta-hydroxylase, concentrating dopamine
- MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release (Correct answer)
- Phenelzine blocks alpha-2 receptors, enhancing norepinephrine release
- Cheese directly inhibits MAO-B, potentiating phenelzine's effects
Correct answer: MAO inhibition prevents tyramine breakdown, causing massive norepinephrine release
MAO normally degrades tyramine in the gut and liver; when MAO is inhibited, tyramine enters circulation and triggers massive norepinephrine release causing hypertensive crisis.
Psychiatric-Mental Health Nurse Practitioner Exam Medications 2
A patient on clozapine develops a WBC of 2,800/mm³.
What is the most appropriate action?