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187.  Stephanie is a 36-year-old female who presents to the clinic with a  history of anxiety. Social history is unremarkable. For the last 4  years, she has been well controlled on paroxetine, however she feels “it  just doesn’t work anymore.” You have decided to change her medication  regimen to vortioxetine 5mg, titrating up to a max dose of 20mg per day  based on tolerability. The patient asks, “When can I expect this to  start kicking in?” The best response is:                   a.   3 or 4 days                   b.   1 or 2 weeks                   c.   3 or 4 weeks                   d.   10 weeks             3.75 points                Question 2          Which of the following medications, when given intramuscularly, is most likely to cause severe postural hypotension?                   a.   haloperidol                   b.   lorazepam                   c.   benztropine                   d.   chlorpromazine             3.75 points                Question 3          Sam is a 48-year-old male who presents to the clinic with signs  and symptoms consistent with GAD & MDD. Which of the following  medications would be the LEAST appropriate choice when initiating  pharmacotherapy?                   a.   duloxetine                   b.   sertraline                   c.   mirtazapine                   d.   buproprion             3.75 points                Question 4          Jason is a 6-year-old child whose mother presents to the clinic  with him. The mother says that “he’s not himself lately.” After a  thorough workup, you diagnose the patient as having GAD. Which of the  following medications would be the LEAST appropriate to prescribe to  this child?                   a.   Sertraline                   b.   Paroxetine                   c.   Venlafaxine                   d.   Buspirone             3.75 points                Question 5          Mirza is a 75-year-old patient with a long history of  schizophrenia. During the past 5 years, she has shown significant  cognitive decline consistent with dementia. The patient has been well  controlled on a regimen of risperidone 1mg BID. As the PMHNP, the most  appropriate course of action for this patient is:                   a.   Increase the risperidone to 1mg QAM, 2mg QPM                   b.   Discontinue risperidone and prescribe a long-acting injectable such as Invega Sustenna.                   c.   Discontinue risperidone and initiate therapy with clozapine.                   d.   Augment the patient’s risperidone with brexpiprazole.             3.75 points                Question 6          Amber is a 26-year-old female who presents to the clinic 6 weeks  postpartum. The patient states that she has been “feeling down” since  the birth of her son. She is currently breastfeeding her infant. You  diagnose the patient with Postpartum depression. Which of the following  is the LEAST appropriate option in treating her PPD?                   a.   paroxetine                   b.   escitalopram                   c.   citalopram                   d.   sertraline             3.75 points                Question 7          Jordyn is a 27-year-old patient who presents to the clinic with  GAD. She is 30 weeks pregnant and has been well controlled on a regimen  of sertraline 50mg daily. Jordyn says that “about once or twice a week  my husband really gets on my nerves and I can’t take it.” She is opposed  to having the sertraline dose increased due to the risk of further  weight gain. You have decided to prescribe the patient a short-term  course of benzodiazepines for breakthrough anxiety. Which of the  following is the LEAST appropriate benzodiazepines to prescribe to this  patient?                   a.   diazepam                   b.   alprazolam                   c.   clonazepam                   d.   lorazepam             3.75 points                Question 8          Steve is a 35-year-old male who presents to the primary care  office complaining of anxiety secondary to quitting smoking cold turkey 2  weeks ago. The patient has a 14-year history of smoking two packs per  day. The patient has an unremarkable social history other than a recent  divorce from his wife, Brittany. Which of the following would be the  LEAST effective medication to treat Steve’s anxiety?                   a.   Buproprion                   b.   Sertraline                   c.   Varenicline                   d.   Alprazolam             3.75 points                Question 9          Rebecca is a 32-year-old female who was recently prescribed  escitalopram for MDD. She presents to the clinic today complaining of  diaphoresis, tachycardia, and confusion. The differential diagnosis for  this patient, based on the symptoms presenting, is:                   a.   Panic disorder                   b.   Gastroenteritis                   c.   Abnormal gait                   d.   Serotonin syndrome             3.75 points                Question 10          The patient in the previous question states, “I can’t even last 1  more day without feeling like my insides are going to explode with  anxiety.” The most appropriate course of action would be:                   a.   Inform the patient to try yoga or other natural remedies until the vortioxetine takes effect.                   b.   Prescribe a short-term course of low dose benzodiazepine, such as alprazolam.                   c.   Prescribe an SNRI, such as venlafaxine, in addition to the vortioxetine.                   d.   Recommend in-patient mental health for the foreseeable future.             3.75 points                Question 11          John is a 41-year old-patient who presents to the clinic with  diarrhea, fatigue, and recently has been having tremors. He was  diagnosed 19 years ago with bipolar disorder and is currently managed on  Lithium 300mg BID. As the PMHNP, you decide to order a lithium level  that comes back at 2.3mmol/l. What is the most appropriate course of  action?                   a.   Investigate other differential diagnoses for his symptoms.                   b.   Tell John to skip his next four Lithium doses and resume therapy.                   c.   Tell John he needs to go to the hospital and call an ambulance to bring him.                   d.   Prescribe loperamide to treat the diarrhea and ropinirole to treat the tremors             3.75 points                Question 12          Mark is a 46-year-old male with treatment-resistant depression. He  has tried various medications, including SSRIs, SNRI, and TCAs. You  have decided to initiate therapy with phenelzine. Which of the following  must the PMHNP take into consideration when initiating therapy with  phenelzine?                   a.   There is a minimum 7-day washout period when switching from another antidepressant to phenelzine.                   b.   Patient must be counseled on dietary restrictions.                   c.   MAOIs may be given as an adjunctive therapy with SSRIs.                   d.   A & B                   e.   All of the above             3.75 points                Question 13          Thomas is a 28-year-old male who presents to the clinic with signs  and symptoms consistent with MDD. He is concerned about starting  antidepressant therapy, however, because one of his friends recently  experienced erectile dysfunction when he was put on an antidepressant.  Which of the following would be the most appropriate antidepressant to  start Thomas on?                   a.   Vilazodone                   b.   Sertraline                   c.   Paroxetine                   d.   Citalopram             3.75 points                Question 14          Melvin is an 89-year-old male who presents to the clinic with  signs/symptoms consistent with MDD. Which of the following would be the  LEAST appropriate medication to prescribe to this elderly patient?                   a.   nortriptyline                   b.   amitriptyline                   c.   desipramine                   d.   trazodone             3.75 points                Question 15          Jane is a 17-year-old patient who presents to the office with  signs consistent with schizophrenia. She states multiple times that she  is concerned about gaining weight, as she has the perfect prom dress  picked out and she finally got a date. Which of the following is the  least appropriate choice to prescribe Jane?                   a.   Aripiprazole                   b.   Olanzapine                   c.   Haloperidol                   d.   Brexpiprazole             3.75 points                Question 16          Richard is a 54-year-old male who suffers from schizophrenia.  After exhausting various medication options, you have decided to start  him on Clozapine. Which of the statements below is true regarding  Clozapine?                   a.   Regular blood monitoring must be performed to monitor for neutropenia.                   b.   Clozapine can only be filled by a pharmacy that participates in the REMS program.                   c.   Bradycardia is a common side effect of Clozapine.                   d.   A & B                   e.   All of the above             3.75 points                Question 17          Cindy is a 55-year-old patient who presents with symptoms  consistent with Generalized anxiety disorder. The patient has an  unremarkable social history other than she consumes two or three glasses  of wine per night. Which of the following would be an appropriate  therapy to start this patient on?                   a.   Xanax 0.25mg BID PRN Anxiety                   b.   Escitalopram 10mg daily                   c.   Buspirone 10mg BID                   d.   Aripiprazole 10mg daily             3.75 points                Question 18          Martin is a 92-year-old male who presents to the clinic with  signs/symptoms consistent with MDD. The patient suffers from glaucoma  and just recently underwent surgery for a cataract. Which of the  following is the LEAST appropriate course of therapy when treating the  MDD?                   a.   sertraline                   b.   amitriptyline                   c.   duloxetine                   d.   vilazodone             3.75 points                Question 19          Which of the following statements are true?                   a.   First-generation (typical) antipsychotics are associated with a higher incidence of EPS.                   b.   Second-generation (atypical) antipsychotics are associated with a higher risk of metabolic side effects.                   c.   There is evidence that atypical  antipsychotics are significantly more effective than typical  antipsychotics in the treatment of cognitive symptoms associated with  schizophrenia.                   d.   A & B                   e.   A, B, and C             3.75 points                Question 20          Earle is an 86-year-old patient who presents to the hospital with a  Community Acquired Pneumonia. During stay, you notice that the patient  often seems agitated. He suffers from cognitive decline and currently  takes no mental health medications. Treatment for the CAP include  ceftriaxone and azithromycin. The LEAST appropriate medication to treat  Earle’s anxiety is:                   a.   sertraline                   b.   duloxetine                   c.   citalopram                   d.   venlafaxine            

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