CU NR 546 PSYCHOPHARMACOLOGY COMPREHENSIVE EXAM 2025 | 86 VERIFIED Q&A WITH STEP-BY-STEP CLINICAL EXPLANATIONS | COMPLETE COVERAGE OF ANTIDEPRESSANTS, ANTIPSYCHOTICS, MOOD STABILIZERS & ANXIOLYTICS

How does reviewing the genetic makeup of a client help guide the PMHNP in selecting medication for clients?

Genetic testing can assist by providing more information on how clients may respond to certain psychotropic medications, as well as providing information on how a client may break down and metabolize medications based on the cytochrome P450 system.

There may be an environmental exposure that turned a gene "on" that should have been "off" for one twin to develop schizophrenia and not the other

. Both environmental and psychosocial stressors can impact mental health. Although twins may have identical genes, their gene expression may be different.

Neuroscience

is the study of the structure and function of the brain and is a field which is making great advancements (Pliszka, 2016). A strong foundational understanding of neuroscience and how the structure and function of the brain can result in mental health symptoms is necessary to treat mental illnesses.

Some mental disorders such as Alzheimer's disease, schizophrenia, and major depressive disorder are thought to be a result of malformations or malfunctions within the brain.

The psychiatric mental health nurse practitioner (PMHNP) must comprehend how medications impact the brain in order to safely and effectively prescribe psychotropic medications.

Brain tissue

is composed of gray and white matter.

gray matter

The cerebellum, cerebrum, brain stem, and the butterfly-shaped portion of the central spinal cord are comprised of gray matter which contains neural cell bodies, axon terminals, dendrites, and all nerve synapses.

It is the working area of the brain and the focus of psychiatry and neurology.

Gray matter

associated with learning.

Changes in the gray matter are linked to psychiatric diagnoses including Alzheimer's disease, schizophrenia, and major depressive disorder.

White Matter

contains nerve fibers that connect neurons from different regions into functional circuits.

The myelin that coats neuronal axons is necessary for electrical impulse transmission.

Think of the white matter as a transit system. If there are breaks in the system, then people cannot get to their destinations.

Within the brain, these breaks affect neural communication, affecting behavior.

Damage to the myelin can impair transmission which can impact not only sensory and motor function, but also cognition.

White matter abnormalities are associated with autism and vascular dementia.

The central sulcus separates which lobes?

frontal lobe from parietal lobe

Frontal lobe

Associated with movement, intelligence, abstract thinking. etc.

Broca's area

Speech

Temporal lobe

Involves object identification and auditory signals

Cerebellum

coordination and balance

Wernicke's area

Speech comprehension

occipital lobe

Primary visual area

parietal lobe

Keeps us alert to what is going on around us

Sensory Cortex

Pain, heat, and other sensations

motor cortex

Movement

Hippocampus

Involved in both memory and anxiety

Nucleus accumbens

Involved in the reward process.

Thalamus

Involved in sensory organ and motor command processing

Striatum

Involved in complex motor actions, also links cognition to motor actions

Limbic System

This includes circuits that are associated with pleasure and reward, emotion and learning

Basal ganglia

A group of structures involved in voluntary motor movements

Amygdala

Involved in emotional regulation and perception of odors

Corpus callosum

Controls the communication between the two brain hemispheres

white matter

Contains nerve fibers that connect neurons from different regions into functional circuits

Grey matter

Contains nerve cells and dendrites

Brain tissue

Made up of grey matter and white matter

What is the global burden of disease of mental health, neurological, and substance use disorders?

30%

How many children and adolescents are impacted by mental health disorders worldwide?

20%

How much does lost productivity related to anxiety and depression cost the global economy each

$1 trillion USD

The development of mental health conditions are linked to causes

such as genetics, biochemical processes, environment, and lifestyle. Mental illness is common, and treatment often includes the use of psychotropic medications.

When prescribing medications, the psychiatric mental health nurse practitioner (PMHNP) must consider each client's unique circumstances including, but not limited to their:

symptoms

age

physical health

previous response to treatment

lifestyle

Treatment for mental health conditions requires

individualized care that incorporates the client's desires and goals.

Which is the priority data used to determine a treatment plan for mental health disorders?

client symptoms

Adherence

can be defined as persistence or compliance.

Persistence is taking the medication over the intended time period.

Compliance is taking the medication as prescribed. According to Dell'Osso et al. (2020), client, clinician, and structural factors all contribute to non-adherence.

Client factors that contribute to nonadherence include

concern about

side effects,

fear of addiction to medications,

misunderstanding of expected outcomes.

Clinician factors that contribute to nonadherence include

lack of shared-decision making with the client, providing inadequate education about medications, and lack of follow up.

Structural factors that contribute to nonadherence include

medication access, medication cost, and stigma associated with mental illness.

Informed Consent

Clients have the right to receive enough information to make decisions about treatment.

They must also be informed about potential risks associated with medications.

Clients have the right to refuse treatment and cannot be forcibly medicated in non-emergencies.

However, clients can be forcibly medicated if they are violent toward themselves or others and when less restrictive methods have failed.

Compliance

A court order may be issued for a client to receive treatment against their wishes if they are considered a danger to themselves or others.

Examples include clients with schizophrenia or sex offenders. Guardians can also provide consent for clients who have limited cognitive capabilities or are incompetent to make decisions.

Ultimately, PMHNPs are responsible for being knowledgeable about their state laws and abiding by them.

Off-Label Perscribing

Some clients may benefit from the unapproved use of a drug for symptom management. For example, many selective serotonin reuptake inhibitors (SSRIs) are used to treat anxiety and obsessive-compulsive disorder but are not FDA approved for use in this disorder.

Off-label prescribing potentially raises ethical and legal concerns; the PMHNP must remain up to date with the latest recommendations for off-label prescribing.

What should the PMHNP consider when prescribing chemical restraints for this client?

Prescribing considerations include carefully reviewing the client's allergy status and prior medication history for adverse drug reactions related to the medications ordered in the chemical restraint.

If the client has a known allergy and was given the medication, the prescriber and staff could be held liable for harm to the client. Also, state regulations regarding chemical restraints must be reviewed, as some states do not allow court-ordered treatment against a client's wishes.

Are the PMHNP and other staff liable if the client has an allergic reaction or adverse side effects to the drugs used for chemical restraint?

No. The client has been court-ordered to take the prescribed medications and the standing order for chemical restraints is approved. The PMHNP and other staff are not liable if the patient has an allergic reaction or adverse side effects.

Normal and abnormal genes both contribute to

disease and drug efficacy.

Epigenetics

can contribute to the risk of any disorder or disease. Psychiatric disorders can also be due to normal genes that are "on" that should be "off."

Mental health diagnoses contribute significantly

to the global burden of disease.

to appropriately prescribe psychotropic medications.

A strong understanding of the functions of the brain and neurotransmitter roles in illness and treatment is needed

Psychiatric prescribing decisions are based

on neuroscience and symptom presentation.

The field of epigenetics

is rapidly growing and can help explain how gene expression is influenced by environmental factors and how epigenetics contributes to the manifestation of mental illness.

when prescribing medications including

Consideration must also be given to each client's unique their symptoms, age, physical health, and lifestyle.

The potential legal and ethical issues impacting mental health treatment must

also be taken into account, including informed consent, competence to make healthcare decisions, and off-label prescribing.

Which of the following is a prominent CYP enzyme in the body and what is it responsible for?

CYP3A4 - responsible for metabolism of a number of medications

Dosing adjustments may be required.

What is the direct role of transcription factor?

influence gene expression

antagonist effect

antagonist effect - drug binds to receptor, but does not activate a response

Partial agonist

drug does not fully activate receptors

Inverse agonist -

drug causes opposite effect of the agonist.

Which is a first messenger?

neurotransmitter- G protein linked systems and ion channel linked cascades are triggered by neurotransmitters.

Which action explains an agonists effect on ligand-gated ion channels?

Agonists cause ligand-gated ion channels to open more frequently.

When prescribing psychotropic medications, the PMHNP knows that these medications work within which specific areas?

mood

dorsolateral prefrontal cortex (DLPFC)

is concerned with higher level functioning

VLPFC (ventrolateral prefrontal cortex)

involved with motor inhibition the IFG contains Broca's area which is associated with speech production understanding grammar.

Basal ganglia

are a group of structures involved in voluntary motor movements. Basal ganglia are also involved in cognition and emotion.

Psychosis

can be an overwhelming experience for clients, making them feel out of control and out of touch with reality.

Antipsychotic medications

can be effective in reducing the symptoms of psychosis.

Psychosis is a syndrome

that can be associated with several different psychiatric disorders.

Symptoms of psychosis include

hallucinations, delusions, disorganized speech, disorganized behavior, and distortions of reality.

This syndrome can affect a person's cognition, affective response, communication, capacity to recognize reality, and ability to relate to others

Psychosis

is a defining feature for some psychotic disorders while other disorders may have a psychotic component.

Psychosis is a defining

feature for some psychotic disorders while other disorders may have a psychotic component.

Diagnoses Requiring the Presence of Psychosis

schizophrenia

substance-induced psychotic disorders

schizophreniform disorder

schizoaffecive disorder

delusional disorder

brief psychotic disorder

psychotic disorder due to a medical condition

Diagnoses with Psychosis as a Feature

mania

depression

cognitive disorders

dementia

Schizophrenia

is one of the most common disorders treated by antipsychotic medications. The prevalence of schizophrenia is difficult to determine due to the complexity of the diagnosis and other factors.

Current estimates place the prevalence of schizophrenia and related psychotic disorders in the U.S. between 0.25% and 0.64% with international estimates of the prevalence of schizophrenia among non-institutionalized persons is 0.33% to 0.75%

Positive symptoms

H allucinations

D elusions

T hought disorder

H ostility

E xcitability

Motor symptoms

Motor delay

Dyscoordination

EPS, e.g.,ParkinsonismDyskinesia

Active symptoms

Depression

Anxiety

Suicidality

Cognition

Attention

Working memory

Verbal memory

Visual memory

Executive functioning

Processing speed

Social conditioning

Negative symptoms

Affective flattening

Alogia

Anhedonia

Amotivation

Asociality

Genetics

Many genes play a role in the likelihood that an individual will develop schizophrenia as do epigenetic factors. Heritability for schizophrenia may be as high as 79% .

Evidence exists that links gene-environment interaction to the diagnosis of schizophrenia

Environmental Triggers

Regular Cannabis Use

Exposure to Early Life

Trauma Sexual

Abuse Emotional

Abuse Emotional

Neglect

Bullying

Neuroanatomy

Several areas of the brain are associated with the symptoms of schizophrenia.

When brain circuitry in the prefrontal cortex malfunctions, patients may experience symptoms.

Mesocortical and ventromedial prefrontal cortex

negative and affective symptoms

Dorsolateral:

cognitive symptoms

Orbitofrontal and connections to the amygdala:

aggressive, impulsive symptoms

Dopamine Role in Psychosis

Many theories exist regarding the causes of psychosis and schizophrenia. A leading hypothesis is that psychosis and schizophrenia are associated with a dysfunction of the neurotransmitter dopamine (DA) (Stahl, 2021).

Dopamine dysfunctions are also involved in other conditions that cause psychosis, such as severe depression, certain medical disorders, and substance abuse.

Traditionally, schizophrenia and psychosis symptoms have been associated with a surplus of dopamine, since medications that block dopamine, specifically D2, have been found to reduce the positive symptoms of schizophrenia. Stahl (2021) suggests that it is more likely that schizophrenia symptoms are related to "out of tune" dopamine

Medications to treat psychosis are classified as either

first generation antipsychotics (FGAs) or second- generation antipsychotics (SGAs).

Antipsychotics are prescribed based on their pharmacological properties, side effect profiles, and adverse effects according to the unique symptoms and needs of individuals across the lifespan.

Within medication management, medications from this and other classes are used across many diagnoses, making the former naming conventions inaccurate.

Selecting medications based on mechanism of action allows for precise, individualized prescribing as specific symptoms are targeted. ​

First generation antipsychotics (FGAs) are also known as

typical antipsychotics and are appropriate for acute and chronic management of schizophrenia and psychosis.

First Generation Antipsychotics

Desirable Effects

Improves Positive Symptoms

Acute & Chronic Schizophrenia & Psychosis

Non-selectively blocks dopamine D2 receptors, specifically in mesolimbic pathway

Undesirable Effects

Risk of Developing

Hyperprolactinemia Desirable Effects

Improves Positive Symptoms

Acute & Chronic Schizophrenia & Psychosis

Non-selectively blocks dopamine D2 receptors, specifically in mesolimbic pathway

Undesirable Effects

Risk of Developing

Hyperprolactinemia

& Extrapyramidal Symptoms

(Negative Symptoms

Unaffected)