NR 546 WEEK 2 EXAM (288 QUESTIONS AND ANSWERS) 2024 UPDATED GRADED 100% PASS (ACTUAL EXAM), Exams of Nursing

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NR 546 WEEK 2 EXAM (288 QUESTIONS AND

ANSWERS) 2024 UPDATED GRADED 100% PASS

(ACTUAL EXAM)

Prefrontal Cortex Symptoms of MDD - Exact answer Concentration Mental Fatigue Mood PFC & Amygdala Symptoms of MDD - Exact answer Guilt Suicidality Worthlessness Striatum Symptoms of MDD - Exact answer Physical fatigue Nucleus Accumbens Symptoms of MDD - Exact answer Pleasure interests Hypothalamus Symptoms of MDD - Exact answer Sleep Appetite Thalamus & Hypothalamus Symptoms of Mania - Exact answer Decreased sleep/arousal Striatum Symptoms of Mania - Exact answer Motor/agitation Prefrontal cortex (PFC) Symptoms of Mania - Exact answer Risk-taking Talkative/pressured speech Nucleus Accumbens & PFC Symptoms of Mania - Exact answer Racing thoughts, grandiosity PFC & Amygdala Symptoms of Mania - Exact answer Mood Medication Management - Exact answer SSRI-Selective Serotonin Reuptake Inhibitors *Inhibit 5 HT reuptake

SNRI-Serotonin Norepinephrine Reuptake Inhibitors *inhibit 5-HT reuptake *inhibit NE reuptake (increase energy, focus) *increase DA in prefrontal cortex (increase cognition) NDRI-Norepinephrine Dopamine Reuptake inhibitors *inhibit DA reuptake (increase alertness, motivation) *inhibit NE reuptake (increase energy) SARI-Serotonin Antagonist Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs): Most adverse effects will subside after 4-5 days once the body adjusts to increased serotonin levels.

• Exact answer diarrhea headache weight gain sexual side effects Serotonin Norepinephrine Reuptake Inhibitors (SNRIs): 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. - Exact answer elevated blood pressure anxiety insomnia constipation Norepinephrine Dopamine Reuptake Inhibitors (NDRI): Take medication in the morning. Stop taking medication if seizures occur. Stop taking medication if anxiety is noted. - Exact answer agitation headache dry mouth constipation weight loss escitalopram (Lexapro) SSRI - Exact answer no known drug interactions best tolerated SSRI 27-32 hour half-life good for forgetful prone clients least CYP reactions Substrate for 3A citalopram (Celexa) SSRI - Exact answer mild antihistamine effects; Half- Life: 23-45 hours

Weak Inhibitor of 2D fluoxetine (Prozac) SSRI - Exact answer longest half-life Use caution in patients with comorbid anxiety due to risk for activation and panic attacks Half-Life: 2-3 days parent, 2 week metabolite Inhibits 2D6 and 3A paroxetine (Paxil) SSRI - Exact answer also treats social anxiety and insomnia associated with weight gain will experience withdrawal with missed dose or abrupt stop Half-Life: 24 hours Inhibits 2D fluvoxamine (Luvox) SSRI - Exact answer treats anxious depression smokers require an increased dose Half-Life: 9-28 hours Inhibits 3A4, 2C9, 1A sertraline (Zoloft) SSRI - Exact answer also treats social anxiety and hypersomnolence Half-Life: 22-36 hour parent; 62-104 hour metabolite Inhibits 2D6 and 3A4 weakly at low doses venlafaxine (Effexor) - Exact answer treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication Half-life: Parent drug 3-7 hour; metabolite has 9-13 hour duloxetine (Cymbalta) SNRI - Exact answer effective for atypical pain at higher doses; appropriate for clients who present with somatic symptoms of depression; effective for atypical pain, such as fibromyalgia and diabetic neuropathy Half-Life: 12 hours Inhibitor of 2D bupropion (Wellbutrin) - Exact answer NDRI may improve energy, alertness, and motivation; not first-line treatment for anxiety; contraindicated in clients with a history of seizures

Avoid in patients with comorbid anxiety Half-Life: Parent 10-14 hours; Metabolite 20-27 hours Inhibits 2D Serotonin Antagonist and Reuptake Inhibitors (SARIs) - Exact answer SARIs potently block 5-HT2A and 5HT 2C receptors, which allow more 5- HT to interact at postsynaptic 5-HT1A sites. Serotonin blockade and reuptake inhibition is present at higher doses. Trazodone - Exact answer The most common SARI, also blocks histaminergic and α-adrenergic receptors. Half-Life: 3-6 hours Serotonin Antagonist and Reuptake Inhibitors (SARIs) - Exact answer Common Adverse Effects · sedation · drowsiness · blurred vision · constipation · dry mouth Serious Adverse Effect priapism Serotonin norepinephrine receptor agonist, alpha2 receptor agonist - Exact answer Mirtazapine Serotonin multimodal (SMM)/serotonin partial agonist reuptake inhibitor (SPARI) - Exact answer Vilazodone (Viibryd) · Inhibits serotonin reuptake with partial 5HT1A agonism Appropriate for depression/comorbid anxiety, its action is similar to a combination of SSRI and buspirone Serotonin multimodal (SMM) - Exact answer Vortioxetine (Trintellix) · Acts as SSRI plus 5HT1A partial agonism · Improves depression-related cognition Tricyclic antidepressants (TCAs) - Exact answer Tricyclic antidepressants (TCAs) possess both SRI and NRI properties, but they also block other receptors, including α1-adrenergic, histamine-1, and muscarinic cholinergic receptors. TCAs are not used first-line because of the high incidence of

adverse effects and the risk of potential overdose and death due to overdose Tricyclic antidepressants (TCAs) - Exact answer Drugs: · amitriptyline (Elavil) · desipramine (Norpramin) · doxepin (Sinequan) · imipramine (Tofranil) · nortriptyline (Pamelor) Tricyclic antidepressants (TCAs) - Exact answer Common adverse effects of TCAs Alpha-1 adrenergic effects-Orthostatic hypotension Histamine effects-Sedation Histamine effects-Weight gain Anticholinergic effects-Blurred vision Anticholinergic effects-Urinary retention Anticholinergic effects-Constipation Anticholinergic effects-Dry mouth MAOIs - Exact answer Last choice medication class for depression due to the many potential, serious side effects. MAOIs have specific dietary restrictions that when ignored, may be very uncomfortable or very serious for clients. MAOIs - Exact answer Drugs: · phenelzine (Nardil) · selegiline (Emsam) - MAOI-B · tranylcypromine (Parnate) · isocarboxazid (Marplan) MAOI's Key Points - Exact answer · Clients taking MAOIs are at 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 medication before initiating an MAIO. Foods to Avoid When Taking MAO-A Medications - Exact answer · Red wine (Avoid)

· Sauerkraut (Avoid) · Cheese (Avoid) · Soy (Avoid) · Smoked meats (Avoid) Foods to Avoid When Taking MAO-A Medications - Exact answer Rationale: Limiting the consumption of tyramine is necessary for orally available MAOIs due to inhibition of MAO-A in the gut. Dietary restrictions are not required for the transdermal formulation of selegiline. Tyramine is present in many aged or preserved foods including aged cheeses, tap and non-pasteurized beers, aged or smoked meat or fish, sauerkraut, kimchee, soy products, and tofu. Foods to be avoided when taking MAO-A medications include wine, meats, sauerkraut, cheese, and soy. Newer Treatments for Resistant Depression - Exact answer · The goal of antidepressant treatment is the remission of symptoms; however, the current treatment response of clients with mood disorders varies widely and is often unsatisfactory. · For example, in clients with MDD, the treatment efficacy of selective serotonin reuptake inhibitors (SSRIs), the most used first-line pharmacological agent is between 48 and 64% with reported remission rates as low as 23.5%. · Treatment-resistant depression occurs when depression persists after the client has adequately trialed at least two antidepressant therapies. Newer Treatments for Resistant Depression - Exact answer Esketamine (Spravato)-N-methyl-D-aspartate (NMDA) receptor inhibitor Dextromethorphan/quinidine (Nuedexta)-under investigation for Resistant depression Esketamine (Spravato)-N-methyl-D-aspartate (NMDA) receptor inhibitor - Exact answer Nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior. Esketamine reaches peak onset in the body in between 20-40 minutes. Due to the risk of adverse outcomes due to sedation and dissociation, esketamine must be administered in a supervised healthcare setting Initiating Medication - Exact answer · Start patients on a single drug for 4- 8 weeks to assess efficacy

· Start with the lowest recommended dose to reduce side effects · If not achieving efficacy follow the process below: 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 If not achieving efficacy for MDD follow the process below: - Exact answer -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 Discontinuing Medications - Exact answer · Clients should be advised not to suddenly stop any medication or omit doses due to the risk of discontinuation syndrome. · Paroxetine has the highest risk of discontinuation syndrome 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- months to reduce the risk of relapse. Black Box Warning: Suicide Risk with Antidepressant Drugs - Exact answer · Clients with depression may consider or attempt suicide. · The risk for suicide may increase at the start of treatment with antidepressants. -Antidepressant-induced suicide is more prevalent in children, adolescents, and adults younger than 25 years Serotonin Syndrome - Exact answer Symptoms may include 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).

Concerns for Sexual Side Effects - Exact answer Bupropion has fewer sexual side effects than other first-line treatments. Bupropion can also be prescribed as an adjunct to a SSRI. Complaining of Brain Fog as part of Depression Symptoms - Exact answer Vortioxetine can improve the speed of processing and cognitive function due to its unique mechanism of action. Patient often forgets to take pills - Exact answer Fluoxetine has a 2-3 days half-life, an excellent option for forgetful people Pregnancy Considerations for Depression - Exact answer Paroxetine is contraindicated in pregnancy due to the risk of congenital defects, including atrial septal defects. Prescribing for older adults with depression - Exact answer Citalopram and escitalopram should be dosed at 1/2 dose due to the risk of QTc prolongation -Avoid paroxetine in clients with a history of falls/fractures. -Avoid tricyclic antidepressants prescribed with other central nervous system (CNS) depressants. MEDICATION MANAGEMENT FOR BIPOLAR DISORDER - Exact answer · Treatment of bipolar disorder (BD) varies depending on the presenting symptoms. · Some medications are more appropriate for symptoms of mania, while others are better for symptoms of depression. · Medication classes used include mood stabilizers, anticonvulsants, and atypical antipsychotics. Lithium - Exact answer ACTION: alters cation transport in the nerve and muscle (downstream signal transduction cascades) Lithium may work by affecting signal transduction, perhaps through its inhibition of second messenger enzymes such as inositol monophosphatase, by modulation of G proteins, or by interaction at various sites within downstream signal transduction cascades, including glycogen synthetase kinase 3 (GSK3). Lithium - Exact answer INDICATIONS: -euphoric mania

-rapid cycling -maintenance therapy HALF-LIFE: 18-30 hours Lithium Therapeutic Levels - Exact answer Therapeutic levels: 1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment) Lamotrigine (Lamictal) - Exact answer ACTION: affects sodium channel ion transport and enhances the activity of y- aminobutyric acid (GABA) Lamotrigine (Lamictal) - Exact answer INDICATION: -maintenance therapy -monotherapy for bipolar disorder HALF LIFE: 33 hours Lamotrigine (Lamictal) - Exact answer PRESCRIBING PEARLS: This drug is equal in efficacy to lithium. Educate clients and assess for rash at each visit. Ten percent of rashes are benign. There is a risk for rare Stevens-Johnson Syndrome rash and multi-organ failure. Take at bedtime due to sedation side effect. Lamotrigine (Lamictal) - Exact answer Therapeutic levels: Not monitored Valproic acid (Depakene) - Exact answer ACTION: affects ion transport and enhances the activity of y-aminobutyric acid (GABA) Valproic acid (Depakene) - Exact answer INDICATION: acute mania mixed mood comorbid substance use multiple prior episodes HALF LIFE: 9-16 hours Valproic acid (Depakene) - Exact answer Therapeutic levels:

50-100mcg/mL; Toxic Levels: >175 mcg/mL Valproic acid (Depakene) - Exact answer If using with Lamitrogine decrease dose by 50% Second generation antipsychotics - Exact answer aripiprazole (Abilify) cariprazine (Vraylar) lurasidone (Latuda) quetiapine (Seroquel) asenapine (Saphris) risperidone (Risperdal) olanzapine (Zyprexa) ziprazadone (Geodon) Second generation antipsychotics - Exact answer ACTION: DA, NE, and 5-HT receptor antagonists Second generation antipsychotics - Exact answer INDICATION: acute bipolar depression acute manic or mixed episodes bipolar maintenance/adjunct Second generation antipsychotics - Exact answer ADVERSE EFFECTS: weight gain sedation GI effects Second generation antipsychotics - Exact answer PRESCRIBING PEARLS: Indications vary with each medication. Check for monotherapy vs. adjunct indication. Monitor for extrapyramidal effects. XR form may improve adherence. Monthly injection may improve adherence. Select second generation antipsychotics first to decrease risk of side effects and long-term adverse effects. Carbamazepine (Tegretol) - Exact answer ACTION: glutamate voltage gated sodium and calcium channel blocker (Glu-CB)

Carbamazepine (Tegretol) - Exact answer INDICATION: acute mania mixed mood HALF LIFE: 26-65 hours Carbamazepine (Tegretol) - Exact answer ADVERSE EFFECTS: GI effects Sedation Hyponatremia Neutropenia rash (Stevens-Johnson Syndrome)-Consider genotyping clients with Asian ancestry; the HLA-B 2501 allele increases risk of Steven-Johnson Syndrome Carbamazepine (Tegretol) - Exact answer Therapeutic levels: 4-12 mcg/mL; Toxic levels: >12mcg/mL FIRST LINE COMBINATION THERAPY FOR BPI D/O, Current manic episode, with depressive features - Exact answer Lithium + Lamotrigine Lithium + Aripiprazole Lithium + Risperdal OR Valproic Acid + Lamotrigine Valproic Acid + Aripiprazole Valproic Acid + Risperdal MANAGEMENT OF ACUTE AGITATION (pacing or fidgeting in mild cases or uncooperative threatening and aggressive behaviors in severe cases) - Exact answer -In the inpatient setting, the use of rapid-acting oral antimanic medications is preferred. -When agitation persists, additional rapidly acting pharmacologic therapies may be needed. -A loading dose of divalproex, oral formulations of atypical antipsychotics, conventional antipsychotics such as haloperidol or loxapine, and/or benzodiazepines such as lorazepam may be appropriate -If oral medications are ineffective or if the agitation is severe, the client is refusing oral medications, or when oral therapy cannot be safely or reliably administered, an IM or inhaled formulation should be considered.

-IM options include olanzapine, aripiprazole, or haloperidol. Inhaled loxapine may also be given INITIAL TREATMENT SELECTION for a client with bipolar disorder should follow a stepwise approach beginning with a thorough assessment - Exact answer Assess · client safety · comorbidities · treatment adherence Initiate/optimize therapy · choose monotherapy or combination · optimize dose · check for adherence Add-on or switch therapy · use an alternative first-line agent or add on an additional first-line agent · if first-line agents are not effective, may switch to second-line agents NONADHERENCE RISK FACTORS - Exact answer Medication factors · adverse effects · low treatment doses Manifestation of BD · mixed episodes · rapid cycling · hallucinations · BD I Comorbidities · substance use · obsessive-compulsive disorder Demographics · male · younger · lower education level · single Other · poor insight · negative attitude · low self-esteem PRESCRIBING PEARLS - Exact answer · Lurasidone (Latuda) should be taken with food, at least 350 calories, for maximum absorption.

· Lithium carbonate (Lithobid) starting dose is reduced by at least 50% in clients with renal impairment. · Lithium levels can be increased by nonsteroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting enzyme (ACE) inhibitors and decreased by caffeine and mania. Lithium Lab Monitoring - Exact answer · serum lithium level · renal function · thyroid function Rationale: Lithium has a narrow therapeutic index and should be monitored carefully. Serum levels should be evaluated 5 days after any dosage change and regularly at 6-month intervals. Lithium can cause renal and thyroid toxicity. Renal and thyroid function should be evaluated every 6 months. Valproic Acid Lab Monitoring - Exact answer · serum valproate level · liver function · CBC Rationale: Valproic acid and its derivatives can cause leukopenia, thrombocytopenia, and hepatotoxicity. Monitor CBC and liver function tests (LFTs) every 3 months for 1 year and then annually Carbamazepine Lab Monitoring - Exact answer · serum carbamazepine level · renal function · liver function · CBC Rationale: Carbamazepine can cause blood dyscrasias, hepatotoxicity, and renal failure. Order a CBC, LFT, and renal function every 3 months for 1 year and then annually. Atypical antipsychotic medications Lab Monitoring - Exact answer · CBC · HbA1C Rationale: Atypical antipsychotics can cause increased blood glucose and an increased risk of developing diabetes mellitus (DM) II. Measure HbA1C every 3 months for 1 year and then annually. Certain medications, such as Clozapine, may cause blood dyscrasias and CBC should be monitored closely.

SPECIAL CONSIDERATIONS: Pregnancy - Exact answer · Lithium, valproic acid, and carbamazepine are teratogenic and are contraindicated during pregnancy. · Lurasidone has been used in pregnancy without teratogenic effects. SPECIAL CONSIDERATIONS: Breast Feeding - Exact answer Breast Feeding Avoid breastfeeding for clients prescribed carbamazepine, lithium, and lamotrigine SPECIAL CONSIDERATIONS: Older Adult - Exact answer Use caution. Reduced renal and hepatic function may impact metabolism and elimination. Reduce dose as necessary. · Avoid carbamazepine (may cause syndrome of inappropriate antidiuretic hormone secretion [SIADH]). · Use caution with antipsychotic medications (may increase the risk of falls). · Antipsychotic medications may increase the risk of stroke, cognitive decline, and death in dementia clients. Avoid lithium in clients taking ACE inhibitors or loop diuretics SPECIAL CONSIDERATIONS: Children - Exact answer Age 10 +: · lurasidone (bipolar depression) · aripiprazole (acute and mixed mania) · quetiapine (monotherapy and adjunct for acute mania) · asenapine (acute and mixed mania) · risperidone (monotherapy and adjunct for acute and mixed mania) Age 13 +: · olanzapine (acute and mixed mania) BIPOLAR 1 - Exact answer · The diagnosis of bipolar I disorder requires at least one episode of mania for at least one week (or any duration if hospitalization due to symptoms is required). · Mania is 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 BIPOLAR 1 - Exact answer Mania diagnosed by having (1) of either Elevated/expansive mood OR Irritable mood AND (3) or more of: 1.) Inflated self-esteem/grandiosity 2.) Increased goal-directed activity or agitation 3.) Risk Taking 4.) Decreased need for sleep 5.) Distractible/Concentration 6.) More talkative pressured speech 7.) Flight of ideas/racing thoughts. *If mood is only irritable, must have 4 symptoms present above. BP TYPE II - Exact answer · A diagnosis of bipolar II disorder 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 Cyclothymia - Exact answer · Cyclothymia involves the chronic presentation of hypomanic and depressive symptoms that do not meet the diagnostic criteria for a major depressive or manic/hypomanic episode. Decreased positive affect: DA, NE Dysfunction - Exact answer · depressed mood · loss of joy · lack of interest · loss of energy · decreased alertness · decreased self-confidence · appetite changes

Increased negative affect: 5HT, NE Dysfunction - Exact answer · depressed mood · guilt · fear/anxiety · hostility · irritability · loneliness · appetite changes Neural Networks - Exact answer The classic monoamine hypothesis of depression posits that 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; however, this hypothesis has limitations. Neural Signaling - Exact answer Three principal neurotransmitters, norepinephrine (NE), dopamine (DA), and serotonin 5HT, have implications for the pathophysiology and treatment of mood disorders. Norepinephrine, dopamine, and serotonin are monoamines. Monoamines work in concert and comprise the monoamine neurotransmitter system Monoamine transmitters - Exact answer serotonin, norepinephrine, and dopamine Lithium - Exact answer Levels can be increased by NSAIDs and ACE inhibitors Decreased by caffeine and mania Unchanged by amiloride, furosemide, and sulindac Lithium - Exact answer Well established to help prevent suicide in clients with mood disorders MAOI's Duration of action - Exact answer Drugs: · phenelzine (Nardil)-Clinical Duration of action up to 14 days · selegiline (Emsam) - MAOI-B-Clinical Duration of action up to 14 days · tranylcypromine (Parnate)-Clinical Duration of action 14- 30 days · isocarboxazid (Marplan)-Clinical Duration of action up to 14 days L-Methylfolate in Depression - Exact answer Enhances antidepressant response. Methylfolate crosses the blood brain barrier and is a cofactor

required for the complete synthesis of serotonin, norepinephrine, and dopamine in the brain. Supplementation with L-methylfolate in addition to SSRIs or SNRIs shows symptom reduction in MDD, and may be an effective monotherapy in MDD. Morphine-Prototype opioid agonist - Exact answer Morphine binds to opioid receptors in the central nervous system (CNS), inhibiting ascending pain pathways, and altering the perception and response to pain Morphine - Exact answer The onset of action of immediate release formulation is patient-dependent, with variable absorption. The onset of action intravenously is 5-10 minutes, with a duration 3-5 hours. Also available in controlled release formulation (MS Contin) and extended- release morphine (Avinza) Fentanyl - Exact answer Almost immediate onset of action when given IV, with a duration of 0.5-1 hour Fentanyl - Exact answer More potent than morphine, but short duration of action. This medication is the preferred opioid for those unable to tolerate morphine or hydromorphone and in those with severe hepatic and renal disease Hydromorphone - Exact answer Similar opioid agonist as morphine but more potent. Oral and parenteral doses are not equivalent (parenteral doses up to 5 times more potent) Methadone - Exact answer In addition to its opioid receptor activity, it is also an antagonist of the N-methyl-D-aspartate (NMDA) receptor Methadone - Exact answer Utilized in detoxification and maintenance treatment of opioid addiction and heroin addiction, with high variability among patients Methadone - Exact answer This is a long acting opioid that binds to and occupies mu-opioid receptors, reducing craving for opioids and prevents withdrawal symptoms for 24 hours Half-life: 8-59 hours

Ketamine - Exact answer Medication useful in general anesthesia and procedural sedation, but also off label usage as infusions for acute pain, as both a stand-alone treatment, as an adjunctive option with opioids, as well as an intranasal formulation Tramadol - Exact answer Opioid agonist, with similar indications and side effect profile as other opioids, but that also blocks reuptake of serotonin and norepinephrine. Indicated for acute pain management, with added benefit for patients with neuropathic pain and nociceptive pain. Has a lower risk of constipation and dependence than other opioids, but does have risk of serotonin syndrome Naloxone - Exact answer -This is a pure antagonist, with clinical indication for treatment of acute opioid overdose. -IV naloxone can dramatically reverse opioids, even in comatose states, with recent widespread community availability of intramuscular and intranasal administration options available given the prescription and recreational opiate crisis, and related deaths. -Given the short duration of action, patients can relapse into coma or previous overdose state, and may need continued monitoring and potentially further doses or constant infusion. Clonidine - Exact answer Antihypertensive agent, and Alpha2-Adrenergic Agonist Thought to produce analgesia at presynaptic and post junction alpha- adrenoceptors in the spinal cord, with pain transmission to the brain prevented. Clonidine - Exact answer Off-label adjunctive treatment for medically supervised opioid withdrawal. Initial treatment is 0.1mg-0.2mg, with ability to repeat up to 4 doses until symptoms resolve Maintenance would be determined by severity of symptoms, with treatment every 6-8 hours. Mesolimbic dopamine pathway - Exact answer -Identified as the key pathway that mediates reward -Connects the ventral tegmental area of the midbrain to the ventral striatum of the basal ganglia

-Begins in the ventral tegmental area (VTA) and connects to the ventral striatum/nucleus accumbens, amygdala, hippocampus, and prefrontal cortex (PFC) Ventral tegmental area (VTA) - Exact answer One of the major dopamine- producing areas of the brain Nucleus accumbens - Exact answer Area found within the ventral striatum and has a strong association with motivation and reward Prefrontal cortex/striatal circuitry - Exact answer Conditions that involve impulsive or compulsive behaviors, such as substance use disorder, obsessive-compulsive disorder (OCD), and obesity may relate to inefficient processing in the prefrontal cortex/striatal circuitry. Mesolimbic dopamine pathway - Exact answer Drugs and alcohol act directly on brain receptors leading to a release of dopamine, the neurotransmitter associated with reward. As substance use increases, brain circuits adapt by reducing sensitivity to dopamine, leading to tolerance and the need to increase the use of a substance to achieve the same high Dopamine Effects on Addictive Drugs - Exact answer Addictive drugs cause a surge of dopamine in the ventral striatum or nucleus accumbens. Repeated use can lead to changes in brain circuitry, leading to craving, addiction, dependence, and withdrawal. Medications which treat addiction target dopamine. Tolerance - Exact answer With repeated ingestion of a drug, the drug shows decreased effect. Increasing doses are required to achieve the effects noted with the original administration. Dependence - Exact answer State of adaptation produced with repeated administration of certain drugs so that physical symptoms occur when the drug is discontinued abruptly. Addiction - Exact answer A change in behavior caused by biochemical changes in the brain after continued substance use characterized by preoccupation with and repeated use of a substance despite negative outcomes

Withdrawal - Exact answer Physiological and psychological reactions that occur when the use of a substance is stopped abruptly Intoxication - Exact answer Condition following the ingestion of a substance resulting in changes in level of consciousness, cognition, perception, judgment, and behavior. SAMHSA (2022a) identified the goals of MAT to include - Exact answer · improved survival · improved treatment retention · decreased illegal activity · increased quality of life · improved birth outcomes in people who use substances while pregnant · reduced HIV and Hepatitis B & C infections OCD/Impulsive Control Disorders - Exact answer Studies indicate dopaminergic activity in the activation of the right ventral striatum in response to images of food in individuals with binge-eating disorders. OCD/Impulsive Control Disorders - Exact answer Pharmacologic management is often used in combination with psychotherapy to address eating disorders Obesity - Exact answer -Phentermine or phentermine/topiramate -Bupropion or bupropion/naltrexone -Lorcaserin -Zonisamide Anorexia - Exact answer -Olanzapine -Avoid bupropion in individuals with anorexia nervosa and bulimia nervosa as bupropion lowers the seizure threshold in these individuals putting them at significantly increased risk for new-onset seizures Bulimia - Exact answer -High Dose Fluoxetine -Avoid bupropion in individuals with anorexia nervosa and bulimia nervosa as bupropion lowers the seizure threshold in these individuals putting them at significantly increased risk for new-onset seizures Binge Eating Disorder - Exact answer -Topiramate

-Bupropion -Lisdexamfetamine SCENARIO: Bernita is a 64-year-old who has been using heroin for 6 years. She is currently unemployed and lives with her daughter in the city center. She does not have health insurance - Exact answer MAT: Methadone SCENARIO: Antoine is a 34-year-old who has been abusing prescription oxycodone. He is employed but is on probation at work for increased absenteeism. He desires MAT but is concerned about his roommates stealing his medication to get high - Exact answer MAT: Buprenorphine plus naloxone (Suboxone) -Suboxone is a good option for a client who may not be able to leave work for medication dosing, as it does not need to be taken under direct observation. -If one tries to administer the buprenorphine/naloxone formulation intravenously, naloxone will prevent any rewarding effects from buprenorphine, making this drug a less desirable street drug Lisa is a 29-year-old who admits to using "pills, heroin, and booze" regularly. She lives in a rural area and is employed part-time. She has a history of poor compliance with past treatments. - Exact answer MAT: Naltrexone RATIONALE:Naltrexone blocks mu-opioid receptors, preventing exogenous opioids from binding there and thus preventing the pleasurable effects of opioid consumption. This medication also reduces alcohol consumption through the modulation of opioid systems, thereby reducing the reinforcing effects of alcohol. For those clients with alcohol use disorder, who have poor adherence to a regimen, and are unable to maintain abstinence, a long-acting injection of naltrexone (Vivitrol) administered monthly can be efficacious Miranda is a 20-year-old who is 18 weeks pregnant and uses heroin. She wants to get clean "for her baby." - Exact answer MAT: Buprenorphine RATIONALE:Buprenorphine is a partial opioid agonist which binds with a strong affinity to the mu-opioid receptor, preventing exogenous opioids from binding at the receptor site, and preventing the pleasurable effects of opioid consumption. While either methadone or buprenorphine may be prescribed in pregnancy, buprenorphine does not require daily visits to an

opioid treatment program and requires less need for dosage adjustments during pregnancy SCENARIO: John is a 56-year-old with a history of seizure disorder who has smoked 1 pack-per-day (PPD) for 30 years. He has tried to quit using nicotine gum without success. He is committed to quitting smoking but feels he would benefit from medication to help. - Exact answer MAT: varenicline RATIONALE: Varenicline is an appropriate medication option for clients who want to quit using tobacco products. Bupropion is contraindicated in clients with seizure disorder. SCENARIO: Ellen is a 35-year-old who has a history of drinking 4-5 alcoholic beverages per day. She was admitted to the hospital for a respiratory infection and was treated with benzodiazepines using the CIWA-Ar scale. She has abstained from alcohol for 8 days and is committed to maintaining abstinence but would like to take a medication to help her stay away from alcohol - Exact answer MAT: disulfiram RATIONALE: Disulfiram creates unpleasant physical symptoms when taken with alcohol. This mild negative stimulus can help reinforce the client's abstinence from drinking alcohol. SCENARIO: Nori is a 24-year-old who has a history of abusing opioid medications and binge drinking. She is not committed to abstain from using at this time. - Exact answer MAT: naloxone RATIONALE: Since Nori is not committed to abstaining at this time, it is important to provide naloxone along with education to help her remain safe from overdose. SCENARIO: Juan is a 19-year-old who has a history of using oxycodone that he has taken from his grandfather and drinking occasional alcohol. He wants to stop using both substances. - Exact answer MAT: naltrexone RATIONALE:Naltrexone is a good option for clients who use opioids and alcohol and are committed to abstinence Pregnancy with Buprenorphine - Exact answer Buprenorphine is an acceptable treatment during pregnancy; however, there is an increased risk of a neonatal withdrawal syndrome in newborns. Pregnancy with Suboxone (buprenorphine/naloxone) - Exact answer Suboxone (buprenorphine/naloxone) cannot be used in pregnancy

Pregnancy with Naloxone - Exact answer Naloxone increases the risk of neonatal abstinence syndrome. Pregnant clients must be switched to buprenorphine (Subutex) monotherapy. Pregnancy with Methadone - Exact answer Methadone is approved in pregnancy for heroin-addicted women. Dosing requires adjustment. Pregnancy in MAT - Exact answer Short-term newborn withdrawal effects may be seen and may require neonatal intensive care unit (NICU) admission for treatment. Breast Feeding with Naltrexone and Buprenorphine - Exact answer Not recommended Breast Feeding with Methadone - Exact answer Can be prescribed with special consideration given to feeding intervals (breastfeed prior to or 2-6 hours after dose). Older Adult with Buprenorphine - Exact answer Use in the elderly may lead to confusion and drowsiness Older Adult with Methadone - Exact answer Methadone has a high potential for drug interactions, associated with QT prolongation. It is difficult to titrate in the elderly and has a risk for accumulation due to the long half-life MAT for Chronic Alcohol Use Disorder - Exact answer Medication selections for MAT should be based on clinical presentation, history of alcohol use/abuse with comorbid liver disease or renal impairment, concurrent opioid use disorder, and other unique client characteristics Naltrexone (Revia, Vivitrol): - Exact answer Initial treatment for alcohol use disorder -Start while still drinking -Can treat concurrent opioid use disorder -Contraindicated in liver disease -May be given in monthly long-acting injections (Vivitrol)

Acamprosate (Campral) - Exact answer · Modulates glutamine transmission, and resembles gamma-aminobutyric acid (GABA) · Good option for clients who must take opioids for chronic pain · Treats withdrawal symptoms · Abstain prior to beginning treatment No affect on Opioids Disulfiram (Antabuse): - Exact answer -Blocks oxidation of alcohol -Creates unpleasant symptoms when the client drinks while taking medication -Palpitations -Headache -Nausea/vomiting -Flushing ·-Abstain from alcohol for at least 12 hours prior to treatment to avoid a reaction -a disulfiram reaction can occur for up to 14 days after alcohol is consumed Topiramate (Topamax) - Exact answer · An anticonvulsant that blocks sodium channels and enhances GABA-A · Reduces cravings for alcohol Chlorpromazine (Librium) - Exact answer · Benzodiazepine for acute and chronic alcohol use · Can cause benzodiazepine (BZO) withdrawal symptoms when stopped abruptly · Avoid in older adults Alcohol Withdrawal- Mild - Exact answer Mild · Anxiety · Irritability · Headache · Insomnia · Tremors · Nausea/vomiting Alcohol Withdrawal-Moderate - Exact answer Moderate · Increased blood pressure (BP) · Increased heart rate (HR) · Confusion

· Mild hyperthermia · Rapid breathing Alcohol Withdrawal- Severe - Exact answer Severe · Hallucinations · Seizures · Disorientation · Impaired attention · Delirium tremens · Death Alcohol Withdrawal Moderate to Severe - Exact answer The use of pharmacologic interventions should be considered for individuals with withdrawal symptoms due to the risk of increased morbidity and mortality during withdrawal. Alcohol Withdrawal Symptom-Triggered Regimen - Exact answer · Administer benzodiazepine when CIWA-Ar score is 8 or above. · PO lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide (Librium) for symptom-triggered therapy · Reassess CIWA-Ar every hour. Administer CIWA-Ar · every 4-8 hours until score is lower than 8-10 for 24 hours You are discharging this client from the hospital following admission for alcohol withdrawal syndrome. He has no further withdrawal symptoms and he would like to abstain from alcohol use. He informs you that has abused opioids in the past, but he has not used them in the last several months. He is concerned that he is at risk of abusing opioids again. Which of the following is the best pharmaceutical option for this client? - Exact answer - naltrexone (ReVia) common initial treatment for alcohol use disorder. -Can be initiated while the client is still drinking. -Can also be utilized in those with opioid use disorder, as the drug can treat both conditions should be opioid-free for at least 7-10 days to avoid withdrawal Alcohol Treatment in Pregnancy - Exact answer · Teratogenic effects of alcohol on the developing fetus are well known; however, there is limited data on the safety of withdrawal medications in pregnancy.