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NR 546: EXAM, 2025/2026 WITH
CORRECT/ACCURATE ANSWERS
Lifespan Considerations in ADHD - CORRECT ANSWERS- Pregnancy · Stimulants may cause fetal harm including increases in low birth weight and pregnancy. Breastfeeding · Stimulants are not recommended while breastfeeding. Children · ADHD medications are not approved for children under 6. Consider short-acting medications for children who have significant appetite loss or are underweight; this may improve appetite for lunch and dinner. Neurotransmitters and Sleep - CORRECT ANSWERS- Sun: · acetylcholine · norepinephrine · histamine · serotonin · orexin
· dopamine · TMN-Tuberomammillary nucleus turns on when its time to wake up Moon: · Gamma aminobutyric acid (GABA) · Melatonin · VLPO-VENTROLATERAL PREOPTIC AREA-turns on when its time to go to sleep Insomnia causes - CORRECT ANSWERS- Insomnia is frequently triggered by acute stress and resolves when the stress resolves. Many coexisting medical conditions, such as pain, thyroid abnormalities, asthma, and gastroesophageal reflux, and medications such as selective serotonin reuptake inhibitors (SSRIs), steroids, stimulants, and β-agonists, can cause insomnia SLEEP MEDICATIONS-Over-the-Counter Sleep Aids - CORRECT ANSWERS- Antihistamines such as diphenhydramine (Benadryl) are commonly used for short-term difficulty sleeping. Diphenhydramine is FDA-approved for the treatment of insomnia and can be effective at reducing sleep latency and increasing sleep time. However, diphenhydramine has undesirable anticholinergic effects and carryover sedation which limits its use, especially in older adults.
SLEEP MEDICATIONS-Orexin Receptor Antagonists - CORRECT ANSWERS- Suvorexant (Belsomra): improves sleep maintenance. Mild adverse effects are similar to those of z-drugs (zolpidem, eszopiclone, and zaleplon). Studies indicated suvorexant is well-tolerated in older adult. The suvorexant dose should be decreased when given with drugs that inhibit CYP3A4, such as diltiazem, erythromycin, and ketoconazole. Lemborexant (Dayvigo) is FDA approved for the treatment of adults with insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Adverse effects include daytime somnolence. Avoid the use of lemborexant with strong or moderate CYP3A inhibitors and inducers. SLEEP MEDICATIONS-Sedating Antidepressants - CORRECT ANSWERS- Medications · trazodone (Desyrel) · amitriptyline (Elavil) · mirtazapine (Remeron) Sleep Medications-Z-Drugs - CORRECT ANSWERS- Sedative/hypnotic drugs, or z-drugs, act on the brain to produce a calming effect. These agents may be prescribed to help clients who are unable to fall asleep as well as those who have difficulty maintaining sleep or returning to
sleep once awake. Z-drugs bind to benzodiazepine sites on GABA receptors Sleep Medications-Z-Drugs - CORRECT ANSWERS- zolpidem (Ambien) zaleplon (Sonata) eszopiclone (Lunesta) Prescribe for PRN use. · These are a schedule IV controlled substance. · There is some potential for abuse/dependence. · The safety of use longer than 4-6 weeks is unclear. Sleep Medications-Benzos - CORRECT ANSWERS- Although benzodiazepines have been approved for use with insomnia, they are not considered a first-line treatment due to the potential for misuse; however, when first-line agents fail, benzodiazepines may be used with caution for insomnia Lifespan Considerations with Sleep meds - CORRECT ANSWERS- Pregnancy · Consider the risk-benefit ratio. · Avoid z-drugs when possible; use them for the shortest duration possible.
· severe or painful RLS Jessica is a 28-year-old client with a diagnosis of generalized anxiety disorder. Her anxiety is well-controlled with escitalopram and therapy. She presents with new complaints of insomnia and states, "I have constant itching and need to move my legs while I am in bed." - CORRECT ANSWERS- Which of the following diagnostic tests should be completed next? Select all that apply. · caffeine intake · ferritin level · pregnancy test Rationale: Caffeine, alcohol, and nicotine may all increase the risk for RLS. Pregnancy and iron deficiency anemia may cause RLS. Foods high in tyrosine are not associated with RLS. A CT scan is not indicated for this client. Jessica's lab work is within normal limits, and her pregnancy test is negative. She reports drinking two cups of coffee each morning and denies alcohol or nicotine use. Based on her assessment and diagnostic data, which of the following is the best medication choice to treat Jessica's RLS? - CORRECT ANSWERS- · ropinirole Rationale: Ropinirole is a first-line agent for RLS. Iron is not appropriate in a client unless serum ferritin indicates deficiency. Gabapentin is appropriate for RLS but is a second-line medication. Diazepam is not appropriate for this client.
Hyperactivity is modulated by the prefrontal cortex - CORRECT ANSWERS- TRUE Impulsivity is modulated by the orbitofrontal cortex - CORRECT ANSWERS- TRUE-dACC is associated with impulsivity Alzheimer's Association has identified a list of 10 early warning signs and symptoms which include - CORRECT ANSWERS- · memory loss · challenges in planning or solving problems · trouble understanding visual and spatial relationships · difficulty completing familiar tasks · disorientation · problems with word finding · misplacing things · impaired judgment · social withdrawal · changes in mood The etiology of AD - CORRECT ANSWERS- Genes appear to play a strong role, with late-onset AD showing heritability of 58-79% and early-onset AD showing over 90%
Neural Signaling in AD - CORRECT ANSWERS- Acetylcholine (ACh) is a neurotransmitter necessary for processing memory and learning. AD leads to decreased acetylcholinesterase activity and a permanent loss of cholinergic neurons. Neural Signaling in AD - CORRECT ANSWERS- Decreased cholinergic function is linked to memory dysfunction, particularly short-term memory. Neuronal damage may also occur due to abnormal activation of N-methyl-d-aspartate (NMDA) receptors by glutamate Diagnosis of AD - CORRECT ANSWERS- AD is currently diagnosed through the exclusion of other causes of dementia, such as vascular disease, Lewy body dementia, Parkinson's disease, and Creutzfeldt- Jacob disease. Early symptoms of AD - CORRECT ANSWERS- Early AD may include anxiety, irritability, and sleep disruption, which could be the presenting symptoms that bring clients to providers for treatment. Stages of AD - CORRECT ANSWERS- Preclinical (asymptomatic but brain amyloid is increased) Mild cognitive impairment (neurodegeneration due to elevated tau and brain volume loss) Severe cognitive deficits-(dementia)
Treatment of dementia begins in what stage? - CORRECT ANSWERS- Mild stage. Pharmacologic treatment focusing on helping the client manage symptoms and behavioral issues that may present. Medications for Alzheimer's Disease - CORRECT ANSWERS- Treatment for AD includes cholinesterase inhibitors (ChEIs) and memantine. First-line treatment of AD - CORRECT ANSWERS- Use of a cholinesterase inhibitor, which increases the availability of acetylcholine, and may help maintain functional ability, and slow cognitive decline. First-line treatment of AD - CORRECT ANSWERS- ChEIs are likely to be most effective in the early stages of AD when postsynaptic cholinergic receptors are still available; however, once neurons are destroyed by the disease, ChEIs are no longer effective Cholinesterase Inhibitors (ChEIs) function - CORRECT ANSWERS- ChEIs increase levels of the neurotransmitter acetylcholine ChEIs do not change the progression of AD; they provide some alleviation of symptoms
effects, and inducers of CYP2D6 and CYP3A4 may increase the rate of elimination Rivastigmine (Exelon) Mechanism of Action - CORRECT ANSWERS- · rivastigmine (Exelon) acts centrally for both acetylcholinesterase and butyrylcholinesterase, thereby potentially increasing its efficacy. Rivastigmine (Exelon) Common Side Effects - CORRECT ANSWERS- · gastrointestinal symptoms (anorexia, nausea, vomiting, or diarrhea) · weakness · dizziness · tremor Rivastigmine (Exelon) Precautions - CORRECT ANSWERS- · asthma or chronic obstructive pulmonary disorder (COPD) · sick sinus syndrome · gastrointestinal (GI) Bleeding · weight < 50 kg · asthma or chronic obstructive pulmonary disorder (COPD) · sick sinus syndrome · gastrointestinal (GI) Bleeding · weight < 50 kg
· Cholinesterase inhibitors are not recommended in pregnancy and lactation. Rivastigmine (Exelon) Prescribing Pearls - CORRECT ANSWERS- · rivastigmine (Exelon) is administered orally or topically (transdermal patch). · The transdermal patch is used for dementia associated with Parkinson's disease. Rivastigmine (Exelon) Metabolism - CORRECT ANSWERS- Medications that induce or inhibit CYP450 metabolism will not modify rivastigmine (Exelon) metabolism Galantamine (Razadyne, Razadyne ER) Mechanism of Action - CORRECT ANSWERS- galantamine (Razadyne, Razadyne ER) acts by elevating acetylcholine (Ach) in the cerebral cortex, modulating the nicotinic Ach receptors to increase Ach release from existing presynaptic nerve terminals. It also increases glutamate and serotonin levels; however, the benefits of this action are unknown Galantamine (Razadyne, Razadyne ER) Side Effects - CORRECT ANSWERS- · gastrointestinal symptoms (nausea, vomiting, diarrhea, anorexia, and weight loss) · headache
moderate to severe AD. Based on clinical trials, improvement is modest Memantine (Namenda) Mechanism of Action - CORRECT ANSWERS- This drug prevents glutamate, an excitatory neurotransmitter, from binding at the receptor site. NMDA receptors control activity throughout the brain by regulating how much calcium enters the nerve cell Memantine (Namenda) Mechanism of Action - CORRECT ANSWERS- An overproduction of the NMDA receptor and excess glutamate can lead to excessive calcium entering the cell and disrupting information processing. Blocking NMDA receptors protects neurons from the effects of too much glutamate without affecting normal neurotransmission Memantine (Namenda) Common Side Effects - CORRECT ANSWERS- · gastrointestinal symptoms (constipation, diarrhea, and weight gain) · urinary frequency · confusion · dizziness · headache · cough
Memantine (Namenda) Precautions - CORRECT ANSWERS- · concurrent use with (amantadine, rimantadine, ketamine, or dextromethorphan) · severe hepatic impairment · severe renal impairment · medications or conditions that increase the pH of the urine Memantine (Namenda) Prescribing Pearls - CORRECT ANSWERS- · This is used as monotherapy or in conjunction with ChEIs; when given with ChEIs, fall precautions are required and driving is forbidden due to delayed reactions. Memantine (Namenda) Metabolism - CORRECT ANSWERS- · Minimal inhibition of CYP450 enzymes CYP1A2, CYP2A6, CYP2C9, CYP2D6, CYP2E1, and CYP3A4 occurs, which means there are no pharmacokinetic interactions with medications metabolized by these enzymes Memantine (Namenda) Efficacy - CORRECT ANSWERS- Memantine is associated with an increased life expectancy when compared to donepezil. If treatment failure occurs, 50% of individuals respond to a different agent.
Aricept - CORRECT ANSWERS- Treats psychological symptoms of AD such as anxiety, depression, apathy, delusions, and pacing Rivastigmine - CORRECT ANSWERS- Should be avoided in clients with COPD Rivastigmine - CORRECT ANSWERS- Nicotine can also increase the clearance of the medication. Galantamine - CORRECT ANSWERS- FDA-indicated for mild to moderate dementia but will not address anxiety. A client diagnosed with Alzheimer's disease has decided to stop treatment. The nurse practitioner (NP) has educated the client that medication discontinuation will result in the return of cognitive symptoms and the medication may not work as well if restarted. The client would still like to stop the medication due to the gastrointestinal side effects. Which of the following medications requires tapering? - CORRECT ANSWERS- · rivastigmine · donepezil (Correct answer) · galantamine Rationale: Donepezil requires tapering. Rivastigmine and galantamine do not require tapering.
Starting doses for AD - CORRECT ANSWERS- Donepezil-5mg may increase to 10mg after 4-6 weeks Namenda-5mg, increase by 5mg each week, max 10mg BID Galantimine-IR-4mg BID after 4 weeks may increase to 8mg BID, after 4 more weeks may increase to 12mg BID; ER same titration schedule but dosed once daily, 8, 16, 24mg Rivastigimine-1.5mg BID, increase by 3mg every 2 weeks, titrate to tolerability max 6mg BID; transdermal 4.6/24hours, after 4 weeks increase to 9.5/24 hours max dose 13.3mg Lifespan Considerations in ADHD - CORRECT ANSWERS- Pregnancy · Stimulants may cause fetal harm including increases in low birth weight and pregnancy. Breastfeeding · Stimulants are not recommended while breastfeeding. Children · ADHD medications are not approved for children under 6. Consider short-acting medications for children who have significant appetite loss or are underweight; this may improve appetite for lunch and dinner. Neurotransmitters and Sleep - CORRECT ANSWERS- Sun: · acetylcholine
