Pharmacology - An Illustrated Review

Questions & Answers

Review Questions

1. The major 5-hydroxytryptamine (5-HT)–containing nuclei in the brain are located in the

A.   interomediolateral column of the spinal cord.

B.   thalamus.

C.   red nucleus.

D.   locus caeruleus.

E.   raphe nuclei.

2. Which of the following changes will increase the rate of induction of surgical anesthesia with an inhalation agent if all other factors remain unchanged?

A.   Increased patient respiration

B.   Increased tissue solubility of anesthetic

C.   Increased weight of patient

D.   Increased blood: gas solubility

3. A patient has just undergone a procedure that required general anesthesia. In the recovery room, the patient's respiration rate and heart rate are noted to be gradually increasing. His blood pressure is 155/90 mm Hg, and his temperature, which was normal before the surgery, is 38°C (100.4°F). These symptoms could be indicative of a reaction to which drug combination?

A.   Morphine/diazepam

B.   Halothane/succinylcholine

C.   Halothane/nitrous oxide

D.   Nitrous oxide/succinylcholine

E.   Morphine/atropine

4. Oxygen is administered to the patient in question 3, and measures are taken to reduce the patient's core temperature. In addition, intravenous administration of a drug is ordered. What is the purpose of this drug?

A.   To dilate peripheral vessels by a direct action on smooth muscle

B.   To decrease respiration via an action in the brainstem

C.   To block muscarinic cholinergic receptors

D.   To provide sedation via depression of the central nervous system

E.   To decrease Ca2+ release from the sarcoplastic reticulum of skeletal muscle

5. Local anesthetic agents block nerve conduction by

A.   altering metabolism.

B.   interfering with Na+-K+-ATPase.

C.   increasing the resting membrane potential.

D.   blocking Na+ channels in the nerve membrane.

E.   blocking γ-aminobutyric acid type B (GABAB) receptors.

6. Which is usually lost first after the injection of a local anesthetic?

A.   sense of touch.

B.   sense of pressure.

C.   sense of proprioception.

D.   motor control.

E.   sense of pain.

7. A 7-year-old boy who fell off his bike has a laceration on his right knee that requires sutures. Lidocaine hydrochloride as a 2% solution with epinephrine 1:100,000 is used for local infiltration anesthesia. What is the purpose of the inclusion of epinephrine?

A.   To produce vasoconstriction and increase the duration of action of the local anesthetic

B.   To produce vasodilation and increase absorption of the local anesthetic into the circulation

C.   To decrease the sensitivity of C fibers to the local anesthetic

D.   To decrease the sensitivity of sympathetic nerve endings to the local anesthetic

E.   To produce a higher degree of anesthesia in tissues supplied by end-organs

For questions 8 to 13, the following are the answer choices:

A.   Voltage-dependent ion channels

B.   Ligand-gated ion channels

C.   Presynaptic synthetic pathways

D.   Transmitter reuptake mechanisms

E.   Extracellular and glial degradative enzymes

F.    G-protein coupled membrane receptors

8. Which is the site of action for lidocaine?

9. Which is the site of action for gamma-aminobutyric acid (GABA) at GABAA receptors?

10. Which is the site of action for fluoxetine?

11. Which is the site of action for morphine?

12. Which is the site of action for levodopa?

13. Which is the site of action for galantamine?

14. Phenelzine and isocarboxazid are termed “suicide” inhibitors because they

A.   are effective in preventing suicidal behavior.

B.   are apparently irreversible inhibitors of monoamine oxidase.

C.   prevent hallucinations.

D.   decrease monamine levels in the brain.

15. A patient who is unconscious is admitted to the emergency room. She has ingested a combination of ethanol and diazepam. Which of the following might be appropriate therapy?

A.   Naloxone

B.   Naltrexone

C.   Fluphenazine

D.   Flumazenil

E.   Amphetamine

16. An 18-year-old female patient has been experiencing severe abdominal pain for several days. This has been accompanied by occasional vomiting. The patient is anxious and appears confused. Blood pressure and heart rate are increased. Her urine is red in color. Porphobilinogen, δ-aminolevulinic acid, and porphyrins in urine are increased. How could administering a barbiturate to this patient exacerbate these symptoms?

A.   By producing incoordination

B.   By producing insomnia

C.   By inducing liver enzymes

D.   By inducing vomiting

E.   By interacting with ethanol

17. A 45-year-old man with a history of alcoholism reports feeling constantly anxious. He says he is always on edge, is irritable, and has difficulty concentrating. Although he finds this tiring, he has not been sleeping well. Because of this patient's history, what would be the most desirable agent to use to treat anxiety?

A.   Buspirone

B.   Phenobarbital

C.   Fluphenazine

D.   Diazepam

E.   Amphetamine

18. The selective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine) differ from the tricyclic antidepressants (e.g., amitriptyline) in that they

A.   have an immediate onset of antidepressant action.

B.   inhibit monoamine oxidase (MAO).

C.   have no effect on 5-hydroxytryptamine (5-HT), or serotonin, pathways in the central nervous system.

D.   are less likely to produce weight gain.

19. A 32-year-old man developed a decreased need for sleep, increased energy, elevated mood, and hyperactivity. He was diagnosed with a manic disorder, and treatment with an antimanic drug was initiated. After 2 weeks of treatment, the patient developed a mild hand tremor. What does the tremor indicate?

A.   Lithium toxicity

B.   Lack of sleep

C.   Fluoxetine toxicity

D.   Chlorpromazine toxicity

E.   Fatigue as a result of hyperactivity

20. The therapeutic effects of lithium

A.   are observed following the first dose.

B.   are antagonized by the administration of chlorpromazine.

C.   are observed in normal, nonmanic patients.

D.   occur in 70 to 80% of manic patients.

21. You see an adolescent female patient in your office who is being treated for epilepsy. She has hirsutism, her lips are thickened, the mass of skin around her cheekbones is increased, and she has gingival hyperplasia. Which drug would be most likely to cause these effects?

A.   Phenytoin

B.   Carbamazepine

C.   Phenobarbital

D.   Ethosuximide

E.   Valproic acid

22. Which of the following is very effective for the control of absence (petit mal) seizures?

A.   Phenobarbital

B.   Phenytoin

C.   Valproic acid

D.   Carbamazepine

23. Useful therapy for generalized tonic-clonic (grand mal) epilepsy includes

A.   phenytoin.

B.   ethosuximide.

C.   pentazocine.

D.   chlorpromazine.

24. A patient who has recently begun treatment for generalized tonic-clonic seizures complains of red, itchy skin. He also says he has been feeling as if he has the flu. His body temperature is 38°C (100.4°F). Upon examination, a multiforme erythematous maculopapular rash is observed on his arms and chest. Which of the following would be the most appropriate therapy?

A.   Discontinue the drug treatment immediately.

B.   Discontinue the drug treatment immediately, and initiate treatment with valproic acid.

C.   Discontinue the drug treatment immediately, and initiate treatment with ethosuximide.

D.   Prescribe hydrocortisone cream for the skin lesions.

E.   No action is needed, as the rash is common with anticonvulsant therapy.

25. A patient taking thioridazine has xerostomia (dry mouth), tachycardia, dry skin, and urinary hesitancy. In what capacity is thioridazine acting that brings about these effects?

A.   As an agonist at muscarinic receptors

B.   As an antagonist at muscarinic receptors

C.   As an agonist at dopamine receptors

D.   As an antagonist at dopamine receptors

E.   As a mixed agonist-antagonist at opioid receptors

26. The therapeutic actions of an antipsychotic drug such as chlorpromazine are most likely due to its action as an

A.   antagonist at dopamine receptors on cells receiving mesolimbic innervation.

B.   antagonist at dopamine receptors on cells receiving nigrostriatal innervation.

C.   antagonist of muscarinic receptors.

D.   agonist at opioid receptors.

E.   antagonist at adenosine receptors.

27. A 20-year-old male college student is brought to the clinic by his parents. He has recently stopped attending classes and has refused to answer his cell phone. When questioned, he says that he is afraid that he is being watched and that his classmates are out to get him. He doesn't want them to track him through his phone, but they can call him without using the phone. He has not been showering or eating regularly. Organic and substance abuse disorders are ruled out, and a diagnosis of schizophrenia is made. You must decide whether to treat him with haloperidol or thioridazine. Which statement correctly compares the effectiveness of the drugs and their propensity for producing acute extrapyramidal neurotoxicities?

A.   Haloperidol is more likely to be effective, but it is also more likely to produce extrapyramidal neurotoxicities.

B.   Thioridazine is more likely to be effective, but it is also more likely to produce extrapyramidal neurotoxicities.

C.   The likelihood of effective treatment is equal, but haloperidol is more likely to cause extrapyramidal neurotoxicities.

D.   The likelihood of effective treatment is equal, but thioridazine is more likely to cause extrapyramidal neurotoxicities.

E.   The likelihood of effective treatment is equal, and so is the likelihood of extrapyramidal neurotoxicities.

28. A patient undergoing chronic treatment for schizophrenia, first with a typical antipsychotic and then with an atypical agent, continues to experience episodes of paranoia and hallucinations. It is decided to use clozapine as therapy. Patients being treated with clozapine must have a baseline white blood cell count (WBC) and absolute neutrophil count (ANC) before initiation of treatment, as well as regular WBCs and ANCs during treatment and for at least 4 weeks after discontinuation of treatment. Which of the following may be caused by clozapine, thus necessitating these blood tests?

A.   Agranulocytosis

B.   Weight gain

C.   Orthostatic hypotension

D.   Anticholinergic side effects

E.   Neuroleptic malignant syndrome

29. At 2 weeks of treatment with clozapine, the patient in question 28 has blood tests that reveal an elevated creatine kinase (CK) and white blood cell count (WCC). This could be associated with the development of which of the following?

A.   Akathisia

B.   Acute dystonia

C.   Tardive dyskinesia

D.   Extrapyramidal symptoms

E.   Neuroleptic malignant syndrome

30. Drug-induced parkinsonism may occur during treatment with typical antipsychotic agents. The parkinsonian symptoms can be treated with

A.   anticholinergic drugs.

B.   levodopa.

C.   chlorpromazine.

D.   haloperidol.

31. κ (kappa) opiate receptors mediate

A.   supraspinal analgesia.

B.   respiratory depression.

C.   euphoria.

D.   dependence.

E.   spinal analgesia.

32. Which of the following is converted to a metabolite that is capable of inducing stimulation of the central nervous system (CNS), especially in patients with renal failure?

A.   Acetaminophen

B.   Meperidine

C.   Pentazocine

D.   Naloxone

E.   Naltrexone

33. A 23-year-old man fell from a roof and suffered a ruptured spleen. He has been in a methadone maintenance program for several months and is taking a regular large dose of methadone. Physical examination suggests abdominal bleeding. He is rushed to the operating room for an emergency splenectomy. The anesthesiologist uses sodium thiopental to induce anesthesia and halothane during the surgery. After 1 week, the patient is recovering and is now receiving the same daily dose of methadone he was taking before his accident. That night, pain from the incision keeps him awake, and the resident on duty administers a drug. Within a few minutes, the patient is nauseated, sweating, tremoring, and having intestinal cramps. He also has waves of gooseflesh and involuntary kicking movements of the legs. This is an expected result of administering which of the following drugs to this patient?

A.   Methadone

B.   Codeine

C.   Chloral hydrate

D.   Pentazocine

E.   Diazepam

34. Methadone differs from morphine in that methadone

A.   is not an effective analgesic.

B.   produces a shorter and more tolerable abstinence syndrome than morphine.

C.   is metabolized to morphine.

D.   has a longer half-life.

E.   is selective for κ opioid receptors.

35. A 27-year-old pregnant woman who has had no prenatal care was brought to the hospital in the final stages of labor. A healthy, full-term infant was delivered with no apparent complications. However, within 24 hours, the infant became irritable, cried constantly, and would not nurse. The mother admitted to recent heavy use of illegally obtained oxycodone. Given the history, what are the infant's symptoms most likely indicative of?

A.   Tolerance to oxycodone

B.   Normal response at birth

C.   Opiate withdrawal

D.   Hunger

E.   Bilirubinemia

36. A 65-year-old male retired autoworker complains of tightness in his arms and legs, as well as difficulty walking and going down stairs. He is well nourished and shows no change in facial expressions during the examination. A mild resting tremor of his right hand is noted. Parkinson disease is diagnosed, and treatment is begun with a dopamine receptor agonist. What is the rationale of this therapy?

A.   To increase glucose production in skeletal muscle

B.   To prevent the peripheral decarboxylation of dopamine

C.   To activate dopamine receptors on interneurons in the motor cortex

D.   To mimic the central actions of dopamine in the substantia nigra

E.   To directly stimulate postsynaptic receptors within the striatum

37. An alternative strategy to treat Parkinson disease is to inhibit the metabolism of endogenous dopamine. Which of the following drug combinations inhibit the breakdown of dopamine?

A.   Entacapone and selegiline

B.   Levodopa and carbidopa

C.   Dopa decarboxylase and monoamine oxidase (MAO)

D.   Fluoxetine and sertraline

E.   Bromocriptine and trihexyphenidyl

38. Which of the following is a dopamine receptor agonist?

A.   Levodopa

B.   Bromocriptine

C.   Amantadine

D.   Carbidopa

E.   Benztropine

39. In the treatment of Parkinson disease, which of the following is an alternative approach to increasing dopamine?

A.   Decrease the cholinergic component

B.   Increase the cholinergic component

C.   Decrease the noradrenergic component

D.   Increase the noradrenergic component

E.   Antagonize the serotonergic component

40. For which of the following drugs are miosis, respiratory depression, and lack of bowel sounds the signs of acute intoxication?

A.   Lysergic acid diethylamide (LSD)

B.   Amphetamine

C.   Morphine

D.   Methaqualone

41. Liver damage may result from chronic abuse of

A.   lysergic acid diethylamide (LSD)

B.   ethanol

C.   amphetamine

D.   cocaine

42. Ethanol may have interactions with several other drugs. The interaction of ethanol with other central nervous system (CNS) depressant drugs is characterized by

A.   an enhanced CNS depressant action.

B.   a decreased CNS depressant activity of the other drug.

C.   an increased gastric irritation.

D.   a decreased gastric irritation.

E.   There is no interaction.

43. A patient comes to you complaining of insomnia and nausea. Examination shows a coarse tremor of the extremities, oral temperature of 38.5°C (101.3°F), hyperactive deep tendon reflexes, and orthostatic hypotension. He admits a daily alcohol intake of at least a pint of whiskey and several cans of beer. During the examination, there is a short period of myoclonic jerking of the arms and legs. The patient then volunteers that he had been in jail all night, having been arrested for being drunk and disorderly, though he barely remembers the episode. He has had no drug or alcohol for ~18 hours. Before the patient can be treated, he slumps over, clutching his abdomen. Examination later in the hospital suggests a perforated duodenal ulcer with internal bleeding. The surgeon recommends immediate surgery. During recovery, the patient shows tremor, anxiety, agitation, and muscle twitches. A drug is given that suppresses these signs of alcohol withdrawal. What is the drug?

A.   A vitamin

B.   An opiate receptor blocker

C.   An acetaldehyde dehydrogenase inhibitor

D.   A benzodiazepine receptor agonist

E.   An antimicrobial

44. Upon discharge, the patient in question 43 agrees to seek therapy for his alcohol addiction, including group therapy and a medication. The patient is given a wallet card listing the medication and is warned that, when taking this drug, exposure to alcohol in his diet, in over-the-counter medications, and in toiletries may produce sweating, flushing, headache, nausea, and vomiting. Which drug is prescribed?

A.   A vitamin

B.   An opiate receptor blocker

C.   An aldehyde dehydrogenase inhibitor

D.   A benzodiazepine receptor agonist

E.   An antimicrobial

45. A heavy user of alcohol is in the hospital and scheduled to have his gallbladder removed. He was given pentobarbital to promote sleep the night before the operation. The nurse is surprised to find him still awake after she has doubled the usual dose. What is this an example of?

A.   Addiction

B.   Physical dependence

C.   Psychological dependence

D.   Cross-tolerance

E.   Synergism

46. For which of the following drugs are ataxia and sedation the signs of acute intoxication?

A.   Lysergic acid diethylamide (LSD)

B.   Amphetamine

C.   Morphine

D.   Methaqualone

47. For which of the following drugs are decreased fatigue and increased talkativeness the signs of acute intoxication?

A.   Lysergic acid diethylamide (LSD)

B.   Amphetamine

C.   Morphine

D.   Methaqualone

48. Of the following drugs of abuse, which is most likely to produce the greatest degree of psychological dependence in the largest percentage of users?

A.   Cocaine

B.   Codeine

C.   Heroin

D.   Methadone

E.   Methaqualone

49. For which of the following drugs are anxiety, paranoia, and hallucinations the signs of acute intoxication?

A.   Lysergic acid diethylamide (LSD)

B.   Amphetamine

C.   Morphine

D.   Methaqualone

50. Intoxication with which one of the following agents causes changes in body image, feelings of estrangement, negativism, and hostility?

A.   Barbiturates

B.   Caffeine

C.   Cocaine

D.   Marijuana

E.   Phencyclidine hydrochloride (PCP)

51. A 32-year-old woman has enrolled in a smoking cessation program at work. She has been smoking since she was a teenager. She currently smokes a pack a day but has been unable to quit, despite several tries. Pharmacotherapies she is considering include the nicotine patch, varenicline, and bupropion. How does varenicline differ from the nicotine patch?

A.   Varenicline is a nicotinic receptor antagonist that prevents nicotine from acting at its receptor and blocks the rewarding effects of nicotine.

B.   Varenicline is a partial agonist that stimulates the receptor to relieve cravings and withdrawal while simultaneously blocking nicotine binding.

C.   Varenicline is a nicotine analogue agonist that stimulates the receptor and acts as a replacement for the nicotine found in tobacco.

D.   Varenicline is a selective serotonin reuptake inhibitor that acts as an antidepressant to prevent the negative mood experienced during withdrawal from nicotine.

E.   Varenicline is a dopamine/norepinephrine reuptake inhibitor that acts to increase dopamine in the brain, leading to a decreased craving to smoke.

Answers and Explanations

1. E The cell bodies of the main groups of 5-HT-containing neurons are located in the raphe nuclei of the brainstem (p. 69).

2. A Because anesthetic induction with inhalation agents is via the lungs, increasing respiration will increase the rate of absorption and thus induction of anesthesia (p. 76).

B Increased tissue solubility will decrease the rate of induction.

C The rate of anesthetic induction is generally independent of the patient's weight.

D Increased blood gas solubility will decrease the rate of i nduction.

3. B Malignant hyperthermia is a rare complication of anesthesia with any volatile anesthetic but, most commonly, with halothane, particularly when it is combined with a depolarizing neuromuscular blocking agent such as succinylcholine. During malignant hyperthermia, there is a substantial increase in skeletal muscle oxidative metabolism, which increases body temperature, consumes oxygen, and leads to a buildup of carbon dioxide (p. 76).

4. E Dantrolene is used as a treatment for malignant hyperthermia. This drug acts directly on skeletal muscle to decrease Ca2+ release from the sarcoplasmic reticulum. This in turn decreases muscle contraction, metabolism, and the generation of heat, thereby decreasing hyperthermia (pages 76 and 117).

5. D Local anesthetics prevent action potential propagation by blocking Na+ channels in the nerve membrane from the cytoplasmic side of the channel (p. 79).

A–C, E Local anesthetics do not alter metabolism, interfere with ATPase, increase the resting membrane potential, or block GABAB receptors.

6. E Smaller diameter unmyelinated nerve fibers are most sensitive to block by local anesthetics. Pain fibers are the smallest and so are blocked first (p. 80).

A–D The loss of the sense of pain is followed by the loss of sensations of cold, warmth, touch, and deep pressure. Proprioceptive and motor fibers are least sensitive.

7. A Epinephrine is added to local anesthetic solutions to produce vasoconstriction at the site of injection. Termination of the action of a local anesthetic depends on its diffusion from the site of injection. Vasoconstriction decreases systemic absorption and prolongs the duration of action (p. 79).

8. A Lidocaine blocks voltage-dependent Na+ channels from the cytoplasmic side of the channel (p. 79).

9. B Gamma-aminobutyric acid (GABA) acts at GABAA receptors, which are ligand-gated ion channels. Activation leads to opening of the Cl channel and synaptic inhibition (pages 68 and 72).

10. D Fluoxetine is a serotonin-specific reuptake inhibitor (SSRI) (p. 89).

11. F Morphine acts at opioid receptors (highest affinity for μ receptors), which are G-protein coupled receptors (p. 102).

12. C Levodopa is a precursor of dopamine synthesis. It is transformed to dopamine by aromatic amino acid decarboxylase (p. 111).

13. E Galantamine is a competitive cholinesterase inhibitor. By inhibiting cholinesterase it increases the concentration of acetylcholine (ACh) in the brain. It is used to treat the symptoms of Alzheimer disease (p. 115).

14. B “Suicide” inhibitors are so named because they bind irreversibly to the enzyme, in this case monoamine oxidase, inactivating it. Restoration of enzymatic activity requires synthesis of new enzyme (p. 88).

A, C The term does not refer to prevention of suicidal behavior or hallucinations.

D Phenelzine and isocarboxazid increase monoamine levels in the brain by inhibiting their breakdown by monoamine oxidase.

15. D Flumazenil is a relatively specific competitive benzodiazepine receptor antagonist useful in overdose or poisoning. Even in the presence of ethanol, blocking the effect of the benzodiazepine, diazepam may be sufficient to restore consciousness (p. 83).

16. C The symptoms are consistent with acute intermittent porphyria, a disorder of porphyrin metabolism. Barbiturates are potent inducers of liver enzymes and will further increase porphyrin synthesis and worsen the disease. Barbiturates are contraindicated in patients with acute intermittent porphyria, porphyria variegata, or a positive family history of these porphyrias (p. 83).

17. A Benzodiazepines and ethanol produce similar depressant effects on the central nervous system (CNS). Benzodiazepines are more likely to be abused by patients with a history of CNS depressant abuse. For this patient, an anxiolytic like buspirone that produces less sedation and has a lower propensity for mimicking or enhancing the effects of ethanol is preferable (p. 85).

B Phenobarbital is a barbiturate used for anesthetic induction, insomnia, and as an anticonvulsant. It is not used for anxiety and is prone to abuse.

C Fluphenazine is an antipsychotic and an antiemetic drug. It is not used to treat anxiety.

E Amphetamine is a stimulant drug that would keep the patient awake. Chronic use will lead to anxiety.

18. D The SSRIs are less likely than the tricyclic antidepressants to produce weight gain (p. 89).

A None of the antidepressant drugs have an immediate onset of antidepressant action.

B, C The SSRIs do not inhibit MAO, but they do inhibit 5-HT reuptake.

19. A Lithium is an antimanic drug with a narrow therapeutic index. Tremor is an indicator of mild toxicity (pages 89 and 90).

B–E Under these circumstances, tremor does not indicate a lack of sleep, fluoxetine or chlorpromazine toxicity, or fatigue as a result of hyperactivity.

20. D Lithium is effective in treating mania in 70 to 80% of patients (p. 89).

A The effects of lithium take 1 to 2 weeks to fully develop; they are not seen immediately following the first dose.

B The effects of lithium are not antagonized by the antipsychotic drug chlorpromazine. On the contrary, antipsychotic drugs may be used to treat severe acute mania.

C Lithium has no effects on nonmanic patients, unless toxic doses are ingested.

21. A These are side effects of phenytoin (p. 92).

B Carbamazepine side effects include GI upset, hematological disorders, hypersensitivity, vertigo, diplopia, and blurred vision.

C Phenobarbital side effects include sedation and rashe s. Ataxia and nystagmus may also occur at excessive doses.

D Ethosuximide side effects include GI upset, CNS depression, rashes (rarely Stevens-Johnson syndrome) and blood dyscrasias (rarely).

E Valproic acid side effects include alopecia, GI upset, ataxia, tremor, and mild behavioral effects.

22. C Of the drugs listed, valproic acid is the only one that is effective in absence seizures (p. 94).

A Phenobarbital is a barbiturate used to treat generalized tonic-clonic seizures, partial seizure and febrile convulsions.

B Phenytoin is effective for all types of seizures except absence and atonic seizures. It is also used for trigeminal neuralgia.

D Carbamazepine is used to treat generalized tonic-clonic seizures, complex partial seizures and trigeminal neuralgia.

23. A Of the agents listed, phenytoin is the only one used for generalized tonic-clonic seizures (p. 91).

B Ethosuximide is the drug of choice for absence seizures.

C Pentazocine is an opioid drug used to treat pain.

D Chlorpromazine is an antipsychotic agent.

24. B The patient is experiencing an allergic reaction to the drug, which may progress to Stevens-Johnson syndrome if the drug is not withdrawn. Of the drugs indicated for use in generalized tonic-clonic seizures, valproic acid is the least likely to lead to Stevens-Johnson syndrome (p. 94).

25. B The side effects are characteristic anticholinergic effects (p. 99).

26. A The therapeutic efficacy of typical antipsychotics is correlated with their ability to block the D2 subtype of dopamine receptors. The mesolimbic pathway is the dopaminergic pathway involved in the modulation of behaviors related to schizophrenia (p. 98).

B The nigrostriatal dopaminergic pathway is involved in the control of movements and in therapy for Parkinson disease.

27. C In general, the antipsychotic agents are similarly effective in treating schizophrenia. The likelihood of extrapyramidal side effects is greater with haloperidol than thioridazine (p. 100).

28. A WBC and ANC are measured prior to and during clozapine therapy to detect for bone marrow suppression by the drug and to prevent agranulocytosis (p. 101).

29. E Neuroleptic malignant syndrome is an idiosyncratic reaction to antipsychotic drugs that tends to occur more frequently with typical antipsychotics, but it can occur with atypical agents, such as clozapine. It presents with fever, muscular rigidity, altered mental status, and autonomic dysfunction (e.g., arrhythmias and fluctuating blood pressure), leading to elevated CK and WBCs (p. 99).

30. A Anticholinergic drugs such as benztropine can be used to treat drug-induced parkinsonism. Benztropine is a muscarinic receptor antagonist that blocks acetylcholine in the striatum and so counteracts excessive cholinergic activity that results from dopamine deficiency (p. 115).

B It would not make sense to treat drug-induced parkinsonism with levodopa to increase dopamine levels because the typical antipsychotics are dopamine antagonists and because this could worsen the symptoms of schizophrenia.

C, D Chlorpromazine and haloperidol are typical antipsychotics that may induce Parkinson-like symptoms.

31. E κ (kappa) opiate receptors are found mainly in the spinal cord where they modulate pain sensations (p. 102).

A-D The other choices are mediated by µ receptors.

32. B Meperidine is a synthetic opiate agonist, especially at μ receptors. Of the drugs listed, it can induce CNS simulation (p. 106).

A Acetominophen is an analgesic and antipyretic drug.

C Pentazocine is a mixed opiate agonist-antagonist that is used as an analgesic.

D, E Naloxone and naltrexone are opiate antagonists.

33. D The patient's responses are typical signs of opiate withdrawal. Pentazocine is a mixed agonist-antagonist at opiate receptors that may precipitate opiate withdrawal in dependent individuals (p. 107).

34. D The half-life of methadone is ~24 hours compared with 4 hours for morphine. This allows once-daily dosing of methadone to prevent opiate withdrawal (p. 107).

A Methadone is an effective analgesic agent (equally as potent as morphine).

B The methadone abstinence syndrome is longer and may not be more tolerable than withdrawal from morphine.

C Methadone is not metabolized to morphine.

E Methadone is not selective for the κ receptor but acts at all three subtypes of opiate receptor.

35. C Morphine-like opiate agonist ligands readily cross the placenta and will affect the fetus. In this case, the infant is most likely experiencing opiate withdrawal (p. 119).

36. E Parkinson disease results from a degeneration of the dopaminergic neurons in the substantia nigra that project to the striatum. One of the primary therapeutic approaches to Parkinson disease is to restore dopaminergic function, in this case with a dopamine agonist. While the cell bodies of dopamine neurons are in the substanita nigra, these neurons project to the striatum where dopamine is released (p. 111).

37. A Entacapone is a catechol-0-methyltransferase inhibitor, and selegiline is an MAO type B inhibitor (p. 113).

38. B Of the agents listed, the only one that is a dopamine receptor agonist is bromocriptine (p. 113).

A Levodopa is a precursor of dopamine synthesis. Levodopa is pharmacologically inert, its effects are a result of decarboxylation to dopamine.

C Amantadine probably enhances dopamine release in the CNS.

D Carbidopa inhibits the peripheral production of dopamine from L-dopa by inhibiting dopa decarboxylase.

E Benztropine is a muscarinic receptor antagonist that blocks a cetylcholine in the striatum and so counteracts excessive cholinergic activity that results from dopamine deficiency.

39. A An alternative approach to restoring dopaminergic function in Parkinson disease is to decrease the cholinergic activity (p. 111).

40. C Miosis, respiratory depression, and lack of bowel sounds are the signs of acute intoxication with morphine (p. 105).

41. B Chronic use of ethanol, but not the other drugs listed, leads to progressive liver damage that increases with increased ethanol doses and duration of ethanol use (p. 120Fig. 15.1).

A Chronic abuse of LSD include flashbacks and other psychological problems.

C, D Chronic abuse of amphetamine causes anxiety and confusion, leading to paranoia and psychosis which is indistinguishable from schizophrenia.

42. A Ethanol potentiates the sedative and motor incoordinating effects of other drugs that cause CNS depression.

43. D Benzodiazepines are cross-tolerant with alcohol and will alleviate withdrawal symptoms, but they do not have the same stimulating effects on the central nervous system as alcohol (p. 120).

A, B, C, E The other drugs do not suppress alcohol withdrawal.

44. C Disulfiram, the drug prescribed in this case, is an inhibitor of aldehyde dehydrogenase. Ethanol is metabolized to acetaldehyde by alcohol dehydrogenase. Acetaldehyde is then metabolized to acetate by aldehyde dehydrogenase. Disulfiram inhibits aldehyde dehydrogenase, blocking the conversion of ethanol-derived acetaldehyde to acetate. In the presence of disulfiram, acetaldehyde will accumulate and produce flushing, dyspnea, nausea, thirst, chest pain, and palpitation. The effects are intended to be unpleasant so as to discourage alcohol ingestion; however, they can be serious and even life-threatening (p. 121).

45. D Users of ethanol develop tolerance to ethanol and cross-tolerance to other sedative hypnotic agents, such as benzodiazepines and barbiturates, such as pentobarbital (p. 120).

46. D Ataxia and sedation are the signs of acute intoxication with methaqualone (p. 123).

47. B Decreased fatigue and increased talkativeness are the signs of acute intoxication with amphetamines (p. 123).

48. A Psychological dependence consisting of craving and a desire to acquire more of the drug may occur with any of the agents listed, but cocaine has the greatest potential for producing such an effect (p. 123).

49. A Anxiety, paranoia, and hallucinations are the signs of acute intoxication with lysergic diethyl amide (LSD) (p. 124).

50. E The first two symptoms are characteristic following ingestion of PCP, with the latter two occurring in some individuals and more likely following ingestion of larger doses of the drug (p. 124). A–D These symptoms are not typically associated with barbiturate, caffeine, cocaine, or marijuana use.

51. B Varenicline is a partial agonist at the α2β4 subtype of nicotinic acetylcholine receptors. It stimulates the receptor to relieve the cravings and withdrawal from nicotine while simultaneously blocking nicotine binding, thus reducing the rewarding effect if the patient does relapse to smoking (p. 125).