NR546 Midterm Exam with accurate verified solutions + rationales ( GUARANTEED SUCCESS )

What should the PMHNP consider when prescribing chemical restraints?

-allergy status

-prior med hx for adverse drug reactions r/t the meds ordered in the chemical restraint

-state regulations regarding chemical restrains must be reviewed

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.

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

-provides information on how a client may break down and metabolize medications based on the cytochrome P450 system.

Tanrıkulu and Erbaş (2020) investigated identical twins to determine the presence of an inherited link for schizophrenia and why one twin may develop schizophrenia when the other does not. When two people have 100% identical DNA, why don't both persons develop the exact illnesses? Studies of identical Danish twins found that if one twin had schizophrenia, the other twin had a 50% lifetime risk of developing schizophrenia (Lemvigh et al., 2020). Why is there only half the risk?

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

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.

central sulcus

separates the frontal lobe from the parietal lobe

frontal lobe

associated with movement, intelligence, abstract thinking

broca's area

speech production

temporal lobe

involves object identification and auditory signals

cerebellum

coordination

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

includes circuits that are associated with pleasure and reward

basal ganglia

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

dorsal striatum

involved in complex motor actions and linkage of cognition to motor actions

-main input area for basal ganglia

*activated when anticipating or engaging in pleasure

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

How does epigenetics impact a person's mental health?

internal or external factors activate portions of the genome that result in the manifestation of mental health symptoms

-activation is often a result of a stressful event, which, when combined with the genetic risk, results in the disease

-genes being on or off

-occurrence of symptoms may be the result of inheritance of an abnormal gene or of normal genes being "on" when they should be "off."

Types of epigenetic changes:

DNA Methylation

Histone modification

Non-coding RNA

The potential legal and ethical issues impacting mental health treatment must also be taken into account, including:

-informed consent

-competence to make healthcare decisions

-off-label prescribing

Informed consent

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

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

-have the right to refuse treatment

-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: clients with schizophrenia or sex offenders

-Guardians can provide consent for clients who have limited cognitive capabilities or are incompetent to make decisions

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

Off-Label Prescribing

Some clients may benefit from the unapproved use of a drug for symptom management.

-Example: many SSRIs used to tx anxiety and OCD but are not FDA approved for use in this disorder.

-potentially raises ethical and legal concerns

-PMHNP must remain up to date with the latest recommendations for off-label prescribing.

Incidence of mental illness-what factors are increasing the incidence

Psychological and sociological factors

Lifestyle factors such as a client's smoking status, diet, exercise, history of medication adherence, or history of addiction should be considered when prescribing psychotropic medications

Adherence

Persistence

-taking med over intended time period

Compliance

-taking med as prescribed

left hemisphere

-speech comprehension

-word recognition

-grammar

-sequential processing

-recognition of detail

-conscious mental processing

right hemisphere

-prosody of speech

-emotional modulation

-visual-spatial skills

-recognition of facial expression

-music

-abstract mathematical skills

-holistic processing

-unconscious mental processing

Pharmacokinetics

the study of what happens to a drug from the time of administration until the parent drug and all metabolites leave the body

CYP450

CYP450 enzymes in the gut wall or liver convert drug substrate into a biotransformed product in the bloodstream, responsible for degradating of a large # of psychotropic drugs

-Not all ind. have same genetic form of CYP450 enzymes, determined with pharmacogenetic testing

*Most individuals have "normal" rates of drug metabolism from the major CYP450 enzymes and are said to be "extensive metabolizers", most drug doses are set for these individuals.

*genetic variants of these enzymes can make poor metabolizers or ultra rapid metabolizers

Five of the most important:

CYP450 1A2, 2B6, 2D6, 2C9, 2C19, and 3A4.

ultra rapid metabolizers

elevated enzyme activity

subtherapeutic drug levels

poor efficacy with standard doses

genotyping

the patient for pharmacogenomic use

-genes for these CYP450 enzymes can now be readily measured and used to predict which patients might need to have dosage adjustments

-measurement of genes for drug metabolism

most common targets of psychotropic drugs

G-protein receptors

-Drug actions at these receptors occur in a spectrum, from full agonist actions, to partial agonist actions, to antagonism, and even to inverse agonism.

Pharmacokinetics concepts

absorption

distribution

metabolism

excretion

Flockhart Table

drug interactions that are mediated by cytochrome P450 enzymes

comprehensive list of drugs and the interactions related to the cytochrome P450 system

Neurotransmitters

chemicals released by neurons to send communication across synaptic clefts to other neurons

-impact human emotion and behavior

Neurotransmission:

the chemical transmission of information between neurons and their target cells

-the chemicals, or neurotransmitters, are released from their transport vesicles to bind with receptor sites to perform their duties, which are excitatory or inhibitory

-neurotransmitter then either returned and stored for future use (reuptake) or inactivated and dissolved by enzymes

-Types: Classic, Retrograde, Volume

Classic neurotransmission

neurons send electrical impulses from one part of the cell to another part of the same cell via their axons

-one neuron hurling a chemical messenger, or neurotransmitter, at the receptors of a second neuron

-electrical impulse converted chemical signal at the synapse in a process known as excitation-secretion coupling, the first stage of chemical neurotransmission, then back into electrical impulse in second neuron

-chemical information from the first neuron triggering a cascade of further chemical messages within the second neuron to change that neuron's molecular and genetic functioning

Retrograde neurotransmission

postsynaptic neurons "talk back" to their presynaptic neurons

-second neuron to the first at the synapse between them

-Chemicals produced specifically as retrograde neurotransmitters at some synapses include: endocannabinoids, gaseous neurotransmitter nitric oxide (NO), nerve growth factor (NGF).

Volume neurotransmission

Neurotransmission without a synapse or nonsynaptic diffusion neurotransmission

-Chemical messengers sent by one neuron to another can spill over to sites distant to the synapse by diffusion

-neurotransmission can occur at any compatible receptor within the diffusion radius of the neurotransmitter

-neurotransmission occurs in chemical "puffs"

-sophisticated "chemical soup."

-example: dopamine action in the prefrontal cortex, at the sites of autoreceptors on monoamine neurons

Excitatory neurotransmitters:

increase the likelihood that the neuron will fire an action potential

inhibitory neurotransmitters:

decrease the likelihood that a neuron will fire an action

neurotransmitters that most impact mental health can be classified into four major categories:

cholinergics

-acetylcholine

monoamines

-norepinephrine, dopamine, serotonin, histamine

amino acids

-gamma- amino-butyric acid and glutamate

neuropeptides

Inhibitors: VISA CKGQ

Valproate

Isoniazid

Sulfonamides

Amiodarone

Chloramphenicol

Ketoconazole

Grapefruit Juice

Quinidine

-decrease medication metabolism

Inducers: CRAP GPS

Carbamazepine

Rifampin

Alcohol

Phenytoin

Griseofulvin

Phenobarbital

Sulfonylureas

-increase medication metabolism

neurotransmitters that may be responsible for a client's symptoms of depression

Imbalanced levels of acetylcholine, norepinephrine, serotonin, histamine, or glutamate can contribute to symptoms of depression

client who is a poor metabolizer:

has a lower concentration of the necessary enzyme to metabolize a drug, which results in higher blood concentrations of the drug.

-increase the risk of side effects and adverse reactions

Why is trazodone not used as a front-line antidepressant

Its antidepressant that has a secondary effect of blocking histamine and adrenergic receptors

-causes sedation and somnolence and as a result

*often used as an adjunct in therapy when a depressed patient has difficulty sleeping

effect on neurotransmitters and side effects: Selective Serotonin Reuptake Inhibitors (SSRIs)

Inhibits the reuptake of serotonin, which can cause nausea, agitation, headache, and sexual dysfunction

effect on neurotransmitters and side effects: Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

Inhibits the reuptake of serotonin and norepinephrine, which can cause nausea, sweating, insomnia, tremors, sexual dysfunction

effect on neurotransmitters and side effects: Tricyclic Antidepressants

-Inhibits the reuptake of serotonin and norepinephrine, which can cause sexual dysfunction

-Blocks norepinephrine receptors, which can cause hypotension and tachycardia

-Blocks histamine receptors, which can cause sedation and weight gain

-Blocks acetylcholine receptors, which can cause dry mouth, constipation, blurred vision, and urinary retention

effect on neurotransmitters and side effects: Monoamine Oxidase Inhibitors (MAOIs)

Increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it, which can cause sedation, dizziness, sexual dysfunction, and hypertensive crisis

effect on neurotransmitters and side effects: Benzodiazepines

Increases the receptor affinity for GABA, which can cause dependence and confusion

effect on neurotransmitters and side effects: Bupropion

Inhibits the reuptake of norepinephrine and dopamine, which can cause insomnia, dry mouth, tremors, and seizures

antagonist

causes a conformational change that stabilizes the receptor in the baseline state and thus is "silent."

-blocks the action of a neurotransmitter

agonists

fully stimulate G-protein-linked receptors

partial agonists

stimulate receptors to a lesser degree than an agonist or natural neurotransmitter

SSRIs, SNRIs, and tricyclic antidepressants increase ________ levels.

___________ do not impact serotonin levels.

increase serotonin levels.

Benzodiazepines do not impact serotonin levels.

Is nicotine an inducer or an inhibitor of the CYP 1A2 enzyme?

inducer

Nicotine is an inducer of the CYP 1A2 enzyme. Does the PMHNP anticipate Joshua may need a higher or lower dose of olanzapine to achieve a therapeutic response?​

Higher

-Nicotine is an inducer of the CYP 1A2 enzyme, so it lowers the concentration of drugs. Therefore, a higher dose of olanzapine may be needed to control his symptoms.

Ernesto, a 60-year-old, presents to the PMHNP with report of having anxiety, frequent occurrences of feeling frozen in place and like his heart is pounding out of his chest, as well as having difficulty sleeping. ​

The PMHNP suspects the client has an elevated level of which neurotransmitter?

Norepinephrine

-responsible for the regulation of fight or flight responses and can impact mood and sleep.

Which of the following is the best medication class for the PMHNP to prescribe for Ernesto to address his elevated norepinephrine levels?​

selective serotonin reuptake inhibitor would block the reuptake of serotonin, leaving a larger amount of serotonin available. Increasing the amount of serotonin would help regulate the feelings of fear and anxiety. Reducing the occurrence of fear would help reduce the release of norepinephrine. ​

A serotonin and norepinephrine reuptake inhibitor would prevent the reuptake of norepinephrine, which would not reduce the level of norepinephrine as needed. Benzodiazepines increase the levels of GABA and do not impact norepinephrine. A monoamine oxidase inhibitor would increase levels of norepinephrine. ​

During a follow up appointment after 4 weeks, the PMHNP should assess for the need to add which medication to Ernesto's treatment plan?

The nurse should assess for sexual dysfunction and anticipate the potential need for a phosphodiesterase inhibitor such as sildenafil (Viagra).

-After 4 to 6 weeks, the client should be experiencing full effects of the SSRI, so the need for a short-term medication like a benzodiazepine or a beta blocker are not anticipated. St. John's Wort is contraindicated with an SSRI and can cause serotonin syndrome.

Glu

Glutamate

-amino acid

-excitatory neurotransmitter

-"workhorse" of the brain-can affect almost every neuron in the brain

-affects: energy, memory, learning, neural plasticity

-relay sensory info. and regulate spinal and motor reflexes

-too much: schizophrenia, epilepsy, mania

-receptors: NMDA, AMPA

GABA

inhibitory neurotransmitter

-decrease neuroexcitability across the brain

-"chill", take the edge off stress, help people calm down, relax, destress, sleep

-to little: may experience anxiety or schizophrenia

-slows down everything, even breathing

-affect executive function and motor coordination, increase risk for accidents

-Increased levels of gamma-aminobutyric acid have a calming effect.

5HT

Serotonin

-help regulate mood

-makes relaxed, comfortable, decreases stress, regulate sleep, arousal, libido, aggression, pain perception

NE

norepinephrine

-monoamine neurotransmitter

-focus and productivity

-too much due to stress, meds, caffein, stimulants can cause: nervous, antsy, affect focus

DA

dopamine

-monoamine neurotransmitter

-regulate mood

-associated with executive function, ability to perform well, be organized, emotional intelligence

-movement and coordination

-to little: lose pleasure, interest, alertness, self-confidence, parkinson's disease

-to much: schizophrenia and psychosis

-reward center: can lead to addiction

-has own pathways

Ach

acetylcholine

-in CNS: affects arousal, motivation, attention, learning, REM sleep, impacts sleep, pain perception, memory

-in PNS: makes you sweat and salivate

-link between brain and muscles

-not enough: Alzheimer's, Parkinson's, Schizophrenia

-too much: Depression

-Role in addiction

-Receptors: nicotinic & muscarinic

Histamine (Neurotransmitter)

Histamine impacts alertness, pain sensation, and inflammatory responses; increased levels result in depression.

Melatonin (neurotransmitter)

Act at MT1-3 G-protein coupled receptors

Sleep/wake cycle

insomnia: melatonin agonists

Psychotropic drug metabolism may be impacted by factors such as:

-age

-smoking

-caffeine intake

-other medications

-Some drugs or foods may inhibit or induce the rate of drug metabolism.

One-third of psychotropic drugs bind to a ______________, and one-third bind to ___________________.

neurotransmitter, G-protein-linked receptors.

The six main neurotransmitters are:

serotonin (5HT)

norepinephrine (NE)

dopamine (DA)

acetylcholine (Ach)

glutamate (Glu)

gamma-aminobutyric acid (GABA)

Signal transduction cascades can produce:

downstream (delayed) and/or long-lasting effects

-explains why some psychopharmacological drugs do not provide an immediate response but require time to see the drug effects

Signal transduction cascades

communication from the genome of the presynaptic neuron to the genome of the postsynaptic neuron, and then back from the genome of the postsynaptic neuron to the genome of the presynaptic neuron via retrograde neurotransmission

-process involves long strings of chemical messages within both presynaptic and postsynaptic neurons

-initial events occur in less than a second, but the long-term consequences are mediated by downstream messengers that take hours to days to activate, yet can last for many days or even for the lifetime of a synapse or neuron

-somewhat akin to a molecular "pony express"

Signal transduction cascades: Each molecular site within the cascade of transduction of chemical and electrical messages is a potential location for:

a malfunction associated with a mental illness

-also a potential target for a psychotropic drug

Retrograde

transcription factor

A regulatory protein that binds to DNA and affects transcription of specific genes.

antipsychotic meds

primarily used for schizophrenia & psychotic disorders

-also used as adjunctive meds for management of tx-resistant depression & other conditions

-not curative

-decrease/control symptoms/improve quality of life

Schizophrenia

a disturbance that must last for 6 months or longer, including at least one month of positive symptoms or negative symptoms

-neurodevelopmental, brain disorder

-psychological condition involving chronic or repeated episodes of psychosis

cause: combination of genetics and environmental factors

DX: based on clinical interview

psychosis

set of symptoms in which a person's mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others is impaired

Symptoms of psychosis:

-delusions & hallucinations (Hallmarks)

-disorganized speech

-disorganized behavior

-distortions of reality

-inappropriate or very strong emotions or apathy

-negative symptoms: diminished emotional expression and decreased motivation

area of the brain thought to be responsible for the positive symptoms of schizophrenia is the ____________. one of the neuronal pathways known to be affected here is the ___________ from the _____________ and the _____________.

limbic system, mesolimbic pathway, ventral tegmental area (VTA), nucleus accumbens

schizophrenia: the dopamine theory

suggests that in the mesolimbic pathway, neurons from the VTA (ventral tegmental area) release higher than normal levels of dopamine into the synaptic cleft at the NAC (nucleus accumbens).

-More dopamine binds to the D2 dopamine receptors in the NAC. This is thought to be the cause of positive symptoms

Schizophrenia: dopamine and mesocortical system

area of the brain thought to be responsible for negative symptoms of schizophrenia, prefrontal cortex

-mesocortical pathway goes from the VTA (ventral tegmental area) to the PFC (prefrontal cortex)

-dysregulation of dopamine between these two areas of the brain results in the negative and cognitive symptoms

Dopamine pathway: mesolimbic

location: Ventral tegmental area (VTA) within midbreain to the nucleus accumbens (NA) in the limbic system

function: regulates emotional behaviors & associated with reward, motivation, pleasure

symptoms: overactivation causes (+) symptoms and may be a downstream consequence of prefrontal cortex dysfunction & glutamate activity in the hippocampus

Dopamine pathway: mesocortical

location: ventral tegmental area (VTA) to the prefrontal cortex (PFC). Specifically affecting dorsolateral prefrontal cortex (DLPFC) & ventromedial prefrontal cortex (VMPFC)

function: regulates cognition, executive function, emotions, affect.

DLPFC-cognitive, (-) symptoms

VMPFC-affective & (-) symptoms

symptoms: hypoactivation of pathway may cause (-), cognitive, & affective symptoms

dopamine pathway: nigrostriatal

location: projects from substantia nigra (in midbrain) to basal ganglia (striatum & globus pallidus)

function: part of extrapyramidal nervous system, controls posture & voluntary motor movements

symptoms: imbalance of pathways causes movement disorders. Common disorders-parkinson's and tremor.

Low dopamine in basal ganglia-akathisia & dystonia.

Hyperactivation of pathway-tics, dyskinesias, chorea.

Chronic blockade of D2 pathway-tardive dyskinesia.

dopamine pathway: tuberinfundibular

location: projects from hypothalamus to anterior pituitary gland

function: dopamine inhibits prolactin release from pituitary

symptoms: disruption of pathway causes prolactin level to rise resulting in gynecomastia & galactorrhea.

Females-amenorrhea

Both may get sexual dysfunction

neurobiological factors that contribute to psychosis and schizophrnia

-genetics

-neuroanatomy

-neural networks

-neural signaling