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CARN-AP practice questions

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Question 1Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The SBIRT model used in primary care and addiction settings consists of which three components?

  1. Screening, Brief Intervention, and Referral to Treatment Correct answer.
  2. Substance Brief Interview and Rehabilitation Therapy
  3. Standardized Brief Intake and Relapse Testing
  4. Screening, Behavioral Intervention, and Relapse Training

Explanation

SBIRT is a public health framework: universal screening with a validated instrument, a brief motivational intervention for those who screen positive, and referral to specialty treatment when indicated. The other acronyms do not describe a recognized model.

Question 2Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client completes the CAGE questionnaire and answers "yes" to two of the four items. How should the nurse interpret this result?

  1. A confirmed diagnosis of alcohol use disorder
  2. A positive screen that warrants further assessment Correct answer.
  3. A high risk of complicated withdrawal
  4. A negative screen requiring no follow-up

Explanation

The CAGE is a four-item screen, and a score of two or more is considered positive and should prompt a fuller assessment. The instrument is a screening aid only; it neither establishes a diagnosis nor estimates withdrawal risk.

Question 3Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client meets four of the eleven DSM-5 criteria for stimulant use disorder within the past 12 months. How is the severity of the disorder classified?

  1. Severe
  2. Moderate Correct answer.
  3. In early remission
  4. Mild

Explanation

DSM-5 grades severity by the number of criteria met: two to three is mild, four to five is moderate, and six or more is severe. Four criteria therefore place the disorder in the moderate range.

Question 4Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which instrument is used to quantify the severity of opioid withdrawal and monitor the response to treatment?

  1. COWS Correct answer.
  2. DAST-10
  3. CIWA-Ar
  4. CAGE

Explanation

The Clinical Opiate Withdrawal Scale (COWS) rates eleven signs and symptoms to score opioid withdrawal severity and guide medication dosing. The CIWA-Ar addresses alcohol withdrawal, and the CAGE and DAST-10 are screening questionnaires.

Question 5Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which statement best describes the CIWA-Ar?

  1. It screens for unhealthy alcohol use in primary care settings
  2. It quantifies alcohol withdrawal severity to guide symptom-triggered dosing Correct answer.
  3. It confirms a diagnosis of alcohol use disorder in adults
  4. It measures recent alcohol intake through a laboratory panel

Explanation

The CIWA-Ar is a ten-item rating scale (maximum score 67) that quantifies alcohol withdrawal severity and supports symptom-triggered benzodiazepine dosing. It is a monitoring instrument, not a diagnostic or screening test.

Question 6Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client scores 12 on the PHQ-9. How should the nurse interpret this score?

  1. A positive screen for clinically significant depression Correct answer.
  2. A confirmed diagnosis of major depressive disorder
  3. A score consistent with an acute manic episode
  4. No evidence of a depressive disorder

Explanation

A PHQ-9 total of 10 or more is the standard threshold for a positive screen for clinically significant depression, and scores of 10 to 14 fall in the moderate range. The PHQ-9 is a severity and screening measure, not a diagnostic instrument.

Question 7Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which screening tool is specifically validated for substance use screening in adolescents aged 12 to 21?

  1. MAST
  2. CAGE
  3. CRAFFT Correct answer.
  4. AUDIT

Explanation

The CRAFFT is a six-item screen designed for adolescents and young adults; its name recalls the domains of Car, Relax, Alone, Forget, Family or Friends, and Trouble. The AUDIT, CAGE, and MAST were developed and validated primarily in adult populations.

Question 8Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A 30-year-old woman completes the AUDIT-C and scores 3. How should the nurse interpret this result?

  1. A positive screen, since the threshold for women is 3 Correct answer.
  2. An invalid result because the AUDIT-C is scored 0 to 12
  3. A score indicating alcohol dependence
  4. A negative screen, since the cutoff is 4 for all clients

Explanation

The AUDIT-C is scored 0 to 12, and a positive screen is defined as 4 or more in men and 3 or more in women. A woman scoring 3 therefore screens positive and warrants further assessment.

Question 9Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which DSM-IV substance dependence criterion was eliminated from the DSM-5 substance use disorder criteria?

  1. Continued use despite physical or psychological harm
  2. Withdrawal
  3. Tolerance
  4. Recurrent legal problems related to substance use Correct answer.

Explanation

DSM-5 merged abuse and dependence into a single use disorder and dropped the legal-problems criterion, which performed poorly across cultures and was rarely endorsed. Craving was added as a new criterion.

Question 10Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Within the ASAM Criteria, assessment of a client's recovery environment and relational supports belongs to which dimension?

  1. Dimension 6: recovery environment Correct answer.
  2. Dimension 4: readiness to change
  3. Dimension 3: emotional, behavioral, and cognitive conditions
  4. Dimension 1: intoxication and withdrawal potential

Explanation

The ASAM Criteria organize assessment into six dimensions; Dimension 6 covers the recovery environment, including living situation, family and social supports, and exposure to substances or violence. This dimension informs the least restrictive but safe level of care.

Question 11Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A 45-year-old man scores 16 on the full AUDIT. This score indicates which of the following?

  1. Hazardous use that requires no further evaluation
  2. A negative screen for hazardous drinking
  3. An invalid score that must be readministered
  4. A level of risk warranting further diagnostic assessment Correct answer.

Explanation

An AUDIT total of 8 or more indicates hazardous or harmful drinking, and scores of 16 or higher reflect a high level of risk that calls for diagnostic assessment and possible treatment. The AUDIT is scored 0 to 40, so 16 is a valid result.

Question 12Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A urine ethyl glucuronide (EtG) test is used primarily to do which of the following?

  1. Establish a diagnosis of alcohol use disorder
  2. Document heavy drinking over the past several months
  3. Detect alcohol ingestion within the past several days Correct answer.
  4. Quantify the severity of alcohol withdrawal

Explanation

EtG is a minor alcohol metabolite detectable in urine for roughly three to four days after drinking, making it useful as a marker of recent abstinence. Because incidental exposure such as alcohol-based hand sanitizer can produce low positives, results must be interpreted with a cutoff and clinical context.

Question 13Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Carbohydrate-deficient transferrin (CDT) is most useful for identifying which of the following?

  1. Recent opioid use within the past week
  2. A single episode of binge drinking within 24 hours
  3. Cannabis use within the past month
  4. Sustained heavy alcohol use over the preceding weeks Correct answer.

Explanation

CDT rises with sustained heavy alcohol intake over roughly two to four weeks and normalizes over a similar period after abstinence, giving it high specificity for chronic heavy drinking. It is insensitive to isolated episodes of binge drinking, which is why EtG or breath testing is used for recent use.

Question 14Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client who took diazepam daily for several weeks stops the medication. A urine immunoassay for benzodiazepines is most likely to remain positive for how long?

  1. Up to several weeks Correct answer.
  2. Exactly five days in every client
  3. Less than 12 hours
  4. No more than 24 hours regardless of half-life

Explanation

Detection time depends on the drug's half-life and the duration of use; long-acting agents such as diazepam and its metabolites can remain detectable for several weeks after chronic use. Short-acting benzodiazepines typically clear within about three days.

Question 15Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The Two-Item Conjoint Screen (TICS) is considered positive when which condition is met?

  1. The total score exceeds four
  2. Both items are answered yes
  3. Either item is answered yes Correct answer.
  4. The client reports any alcohol use in the past year

Explanation

The TICS asks whether in the past year the client has drunk or used drugs more than intended and whether the client has wanted or needed to cut down. A yes to either question is a positive screen, chosen for high sensitivity at the cost of lower specificity.

Question 16Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

On the GAD-7, a total score of 15 or higher is typically interpreted as which level of anxiety?

  1. Moderate anxiety
  2. Minimal anxiety
  3. Mild anxiety
  4. Severe anxiety Correct answer.

Explanation

GAD-7 severity bands are 5 to 9 for mild, 10 to 14 for moderate, and 15 or higher for severe anxiety. A score of 10 or more is generally the threshold for clinically significant symptoms warranting further evaluation.

Question 17Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which instrument screens for use of multiple substances, including tobacco, alcohol, cannabis, and stimulants, and produces substance-specific risk scores?

  1. ASSIST Correct answer.
  2. CAGE
  3. AUDIT
  4. CIWA-Ar

Explanation

The WHO ASSIST collects information on multiple substances and yields separate risk scores that are classified as low, moderate, or high, each linked to a recommended intervention. The AUDIT and CAGE focus on alcohol, and the CIWA-Ar measures withdrawal.

Question 18Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The Mood Disorder Questionnaire (MDQ) is used to screen for which condition?

  1. Posttraumatic stress disorder
  2. Major depressive disorder
  3. Generalized anxiety disorder
  4. Bipolar spectrum disorder Correct answer.

Explanation

The MDQ screens for bipolar spectrum illness by asking about a cluster of manic or hypomanic symptoms, their co-occurrence, and resulting functional problems. A positive screen requires all three elements, which reduces false positives in general populations.

Question 19Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which statement best distinguishes screening from comprehensive assessment?

  1. Screening is performed only by physicians; nurses perform assessment
  2. Screening flags probable risk; assessment establishes diagnosis and treatment planning Correct answer.
  3. Screening establishes a diagnosis; assessment estimates future risk
  4. Screening and assessment are interchangeable terms in practice

Explanation

Screening uses brief validated tools to identify clients who probably have a problem and need a closer look, whereas assessment is a comprehensive process that establishes diagnoses, severity, co-occurring conditions, and a treatment plan. Screening results alone do not establish a diagnosis.

Question 20Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A pregnant client is screened with the T-ACE. Which item is scored positive when she reports needing more than two drinks to feel the effect?

  1. Cut down
  2. Annoyance
  3. Tolerance Correct answer.
  4. Eye-opener

Explanation

The T-ACE adapts the CAGE for pregnancy: Tolerance (more than two drinks to feel high, scored 2 points), Annoyed by criticism, Cut down, and Eye-opener. A total of 2 or more is a positive screen.

Question 21Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which set of symptoms is most consistent with DSM-5 cannabis withdrawal?

  1. Irritability, insomnia, decreased appetite, and restlessness after stopping heavy use Correct answer.
  2. Hypersomnia, increased appetite, and euphoria
  3. Generalized seizures and delirium with autonomic instability
  4. Pinpoint pupils, respiratory depression, and bradycardia

Explanation

DSM-5 cannabis withdrawal requires at least three of seven symptoms developing within about a week of stopping prolonged heavy use, including irritability, anxiety, sleep difficulty, decreased appetite, restlessness, depressed mood, and abdominal pain or tremors. It is not medically dangerous but commonly drives relapse.

Question 22Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client has met none of the DSM-5 substance use disorder criteria, apart from craving, for five months. Which specifier applies?

  1. In partial remission
  2. In early remission Correct answer.
  3. In remission on agonist therapy
  4. In sustained remission

Explanation

DSM-5 defines early remission as at least three but fewer than twelve months without meeting any criteria other than craving for alcohol or drugs. Sustained remission requires twelve months or longer.

Question 23Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which feature most strongly favors a substance-induced psychotic disorder over a primary psychotic disorder in a client who uses methamphetamine daily?

  1. Symptoms that persist unchanged for more than six months
  2. Onset during intoxication with remission within a month of abstinence Correct answer.
  3. A first-degree relative with schizophrenia
  4. Gradual social withdrawal over several years

Explanation

In substance-induced psychotic disorder, delusions and hallucinations arise during or soon after intoxication or withdrawal and typically resolve within about one month of sustained abstinence. Family history, premorbid decline, and a chronic unremitting course point instead toward a primary psychotic disorder.

Question 24Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client taking bupropion for smoking cessation has a positive urine immunoassay for amphetamines, but confirmatory gas chromatography–mass spectrometry is negative. What is the most accurate interpretation?

  1. Bupropion cross-reacted with the immunoassay; the negative confirmation should be relied on Correct answer.
  2. The immunoassay should simply be repeated until it is negative
  3. The result proves the client is diverting bupropion
  4. The client used amphetamines and the confirmatory test is unreliable

Explanation

Immunoassays are antibody-based screening tests prone to cross-reactivity, and bupropion is a well-recognized cause of false-positive amphetamine results. A negative definitive method such as GC-MS or LC-MS/MS overrides the screening result.

Question 25Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which statement about assessing a client at risk for alcohol withdrawal is accurate?

  1. Blood alcohol concentration does not predict withdrawal severity Correct answer.
  2. CIWA-Ar scores rise in proportion to blood alcohol concentration
  3. Withdrawal severity can be predicted from the client's age alone
  4. A normal blood alcohol concentration excludes impending withdrawal

Explanation

Withdrawal severity reflects the degree of neuroadaptation from chronic heavy use, so it is assessed with serial clinical rating such as the CIWA-Ar rather than with a blood alcohol level. A client can have a low or zero blood alcohol level and still be hours away from severe withdrawal.

Question 26Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which question is one of the four items on the CAGE screening questionnaire for alcohol use?

  1. Have you ever missed work because of drinking?
  2. Have you ever felt you should cut down? Correct answer.
  3. Have you ever driven after drinking?
  4. Have you ever had a blackout from drinking?

Explanation

The CAGE acronym stands for Cut down, Annoyed, Guilty, and Eye-opener. It is a brief four-item screen for alcohol problems, and each item is answered yes or no. Driving after drinking, blackouts, and missed work are not CAGE items.

Question 27Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The SBIRT model includes which three components?

  1. Stabilization, brief therapy, intensive outpatient
  2. Screening, brief intervention, referral to treatment Correct answer.
  3. Screening, behavioral interview, relapse prevention
  4. Assessment, detoxification, aftercare

Explanation

SBIRT stands for Screening, Brief Intervention, and Referral to Treatment. It is a public health approach for identifying and addressing risky substance use in general settings. The other combinations mix components from treatment or assessment models rather than SBIRT.

Question 28Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is used primarily to do which of the following?

  1. Measure blood alcohol concentration at the time of the assessment
  2. Screen for co-occurring depression in clients with alcohol use disorder
  3. Diagnose alcohol use disorder using the DSM-5 criteria for substance use disorders
  4. Quantify alcohol withdrawal severity and guide symptom-triggered treatment Correct answer.

Explanation

The CIWA-Ar is a structured rating scale for the severity of alcohol withdrawal. Scores are used to guide symptom-triggered dosing of withdrawal medications and to monitor response. It does not diagnose alcohol use disorder or measure blood alcohol concentration.

Question 29Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which assessment finding is most characteristic of opioid intoxication?

  1. Dilated pupils and hypertension
  2. Pinpoint pupils and respiratory depression Correct answer.
  3. Conjunctival injection and increased appetite
  4. Slurred speech and ataxia with normal pupils

Explanation

Opioid intoxication classically produces miosis, respiratory depression, and decreased level of consciousness. These findings reflect central nervous system and respiratory depression. Dilated pupils, conjunctival injection, and ataxia are more typical of other substances.

Question 30Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client meets five DSM-5 criteria for alcohol use disorder. How should the nurse classify the severity?

  1. Moderate Correct answer.
  2. Mild
  3. Severe
  4. Subthreshold

Explanation

DSM-5 substance use disorder severity is based on the number of criteria met: 2 to 3 is mild, 4 to 5 is moderate, and 6 or more is severe. Five criteria therefore indicate a moderate disorder. Subthreshold is not a DSM-5 severity category for substance use disorder.

Question 31Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A 16-year-old completes the CRAFFT screening tool and answers yes to two questions. How should the nurse interpret this score?

  1. Positive screen; further substance use assessment is indicated Correct answer.
  2. Positive only if one of the yes answers concerns alcohol
  3. Negative screen; no further action is needed
  4. Invalid because the CRAFFT requires a total score of 4 or higher to be meaningful

Explanation

The CRAFFT is a brief adolescent substance use screen, and a score of 2 or more yes answers is considered positive. A positive screen indicates the need for further assessment, not a diagnosis. Alcohol-only answers are not required for a positive screen.

Question 32Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The Clinical Opiate Withdrawal Scale (COWS) is best used to do which of the following?

  1. Diagnose opioid use disorder during the initial admission assessment
  2. Predict the risk of opioid overdose
  3. Rate opioid withdrawal severity and monitor treatment response Correct answer.
  4. Screen for benzodiazepine co-use

Explanation

The COWS is an observer-rated scale that quantifies the severity of opioid withdrawal. It helps clinicians monitor withdrawal and response to treatment. It is not a diagnostic instrument for opioid use disorder and does not predict overdose risk.

Question 33Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The DAST-10 is designed to screen for which of the following?

  1. Problematic use of drugs other than alcohol Correct answer.
  2. Co-occurring psychotic symptoms and related disorders
  3. Alcohol use disorder only
  4. Tobacco dependence

Explanation

The Drug Abuse Screening Test, 10-item version, screens for problematic drug use other than alcohol. It asks about consequences and patterns of drug use over the past year. Alcohol-specific screening is done with tools such as the AUDIT or CAGE.

Question 34Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

The Timeline Followback (TLFB) method is used during assessment to do which of the following?

  1. Confirm a diagnosis with a structured personality inventory
  2. Measure current intoxication using a breath or saliva sample
  3. Estimate past daily substance use with a calendar and anchor dates Correct answer.
  4. Determine the half-life of a substance from serial blood levels

Explanation

The TLFB is a retrospective self-report method that uses a calendar and personally meaningful anchor dates to estimate daily substance use. It improves recall of frequency and quantity over a defined period. It is not a biological test or a personality inventory.

Question 35Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Within the ASAM Criteria, assessment of a client's medical conditions and complications, such as liver disease or hypertension, belongs to which dimension?

  1. Dimension 2: biomedical conditions and complications Correct answer.
  2. Dimension 3: emotional, behavioral, or cognitive conditions
  3. Dimension 6: recovery environment
  4. Dimension 1: intoxication and withdrawal

Explanation

ASAM Dimension 2 addresses biomedical conditions and complications that may affect treatment planning. Examples include liver disease, hypertension, and other medical problems. Withdrawal risk is primarily Dimension 1, while psychiatric symptoms are Dimension 3.

Question 36Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

An elevated gamma-glutamyl transferase (GGT) level is most useful in assessment for which purpose?

  1. Establishing a diagnosis of opioid use disorder
  2. Supporting suspicion of heavy sustained alcohol use Correct answer.
  3. Measuring acute alcohol intoxication
  4. Confirming recent cocaine use within 24 hours

Explanation

GGT is a liver enzyme that can be elevated with sustained heavy alcohol use. It is not specific to alcohol and can rise with liver disease or certain medications, so it supports rather than confirms a suspicion. It does not measure acute intoxication or diagnose opioid use disorder.

Question 37Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client with alcohol use disorder has met no DSM-5 criteria for 5 months except craving. Which specifier applies?

  1. In sustained remission
  2. On maintenance therapy
  3. In early remission Correct answer.
  4. In a controlled environment

Explanation

In DSM-5, early remission means that the criteria for substance use disorder have not been met for at least 3 months but for less than 12 months, with the possible exception of craving. Sustained remission requires 12 months or longer. Maintenance therapy and controlled environment are separate specifiers.

Question 38Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A hair drug test is being considered for a client who denies use beyond the past week. Which statement about hair testing is most accurate?

  1. It is the preferred test for determining acute intoxication
  2. It can detect chronic use over a longer window than urine Correct answer.
  3. It is unaffected by environmental contamination or cosmetic treatments
  4. It detects only substances used within the previous 24 to 72 hours

Explanation

Hair testing can reflect repeated substance use over weeks to months, giving a longer detection window than urine for chronic use. It cannot establish the exact time of last use, and results may be affected by environmental contamination or hair treatments. It is not used to determine acute intoxication.

Question 39Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

A client with heavy stimulant use develops depressed mood and anhedonia only during intoxication and within days of cessation, with full resolution after 3 weeks of abstinence. Which diagnosis is most likely?

  1. Bipolar I disorder, current depressive episode
  2. Major depressive disorder, recurrent
  3. Persistent depressive disorder
  4. Substance-induced depressive disorder Correct answer.

Explanation

A mood disturbance that arises during or soon after substance intoxication or withdrawal and resolves with sustained abstinence is most consistent with a substance-induced depressive disorder. The close temporal relationship is the key distinguishing feature. Primary mood disorders would not be expected to resolve fully simply with 3 weeks of abstinence.

Question 40Assessment, Screening, and Diagnosis of Substance Use and Co-occurring Disorders

Which tool is commonly used to assess the severity of neonatal abstinence syndrome in an infant exposed to opioids in utero?

  1. CRAFFT adolescent substance use screen
  2. Clinical Institute Withdrawal Assessment for Alcohol
  3. Clinical Opiate Withdrawal Scale for adults
  4. Finnegan Neonatal Abstinence Scoring System Correct answer.

Explanation

The Finnegan Neonatal Abstinence Scoring System is a standardized tool for rating signs of neonatal abstinence syndrome and guiding treatment decisions. The COWS and CIWA-Ar are adult withdrawal scales. The CRAFFT is an adolescent substance use screen.

Question 41Psychopharmacology and Medication Management

Naltrexone's therapeutic effect in alcohol use disorder is best described by which mechanism?

  1. Positive allosteric modulation of GABA-A receptors
  2. Partial agonism at mu-opioid receptors with a ceiling effect on respiratory depression
  3. Competitive mu-opioid receptor antagonism that blunts alcohol reward Correct answer.
  4. Irreversible inhibition of aldehyde dehydrogenase

Explanation

Naltrexone is a competitive antagonist at mu-opioid receptors; blocking opioid-mediated reinforcement reduces the rewarding effects of alcohol and heavy drinking. It does not alter alcohol metabolism and has no GABAergic activity.

Question 42Psychopharmacology and Medication Management

Which statement about acamprosate is accurate?

  1. It requires a loading dose and undergoes extensive hepatic metabolism by CYP3A4
  2. It produces a disulfiram-like reaction when combined with alcohol
  3. It blocks mu-opioid receptors and thereby reduces alcohol craving
  4. It is renally excreted unchanged and modulates glutamate and GABA transmission Correct answer.

Explanation

Acamprosate is eliminated renally as unchanged drug, so dosing must be reduced in moderate renal impairment and it is contraindicated in severe renal impairment. Its action is thought to involve dampening glutamatergic (NMDA) activity and restoring the GABA/glutamate balance during abstinence.

Question 43Psychopharmacology and Medication Management

A patient taking disulfiram drinks alcohol and develops flushing, throbbing headache, nausea, and hypotension. Which enzyme is inhibited?

  1. Aldehyde dehydrogenase, causing acetaldehyde build-up Correct answer.
  2. Monoamine oxidase, causing tyramine accumulation
  3. Alcohol dehydrogenase, causing acetate accumulation
  4. CYP2E1, causing fatty acid oxidation

Explanation

Disulfiram blocks aldehyde dehydrogenase, so acetaldehyde accumulates after alcohol ingestion and produces the flushing, headache, nausea, tachycardia, and hypotension of the disulfiram-ethanol reaction. The reaction can be severe and even life-threatening.

Question 44Psychopharmacology and Medication Management

Buprenorphine's receptor activity is best characterized as which of the following?

  1. A full mu-opioid agonist with dose-dependent respiratory depression
  2. A kappa-opioid agonist with no activity at mu receptors
  3. A pure mu-opioid antagonist used only for overdose reversal
  4. A partial mu-opioid agonist with high receptor affinity Correct answer.

Explanation

Buprenorphine is a partial agonist at mu receptors with very high affinity, which produces a ceiling effect on respiratory depression and allows it to displace full agonists. Its high affinity explains both its safety profile and the risk of precipitated withdrawal.

Question 45Psychopharmacology and Medication Management

Which medication is a partial agonist at the alpha4beta2 nicotinic acetylcholine receptor and is approved for smoking cessation?

  1. Varenicline Correct answer.
  2. Clonidine
  3. Nortriptyline
  4. Bupropion SR

Explanation

Varenicline binds as a partial agonist at alpha4beta2 nicotinic receptors, providing modest dopamine release while blocking nicotine binding. Bupropion, nortriptyline, and clonidine are used for cessation but do not act at nicotinic receptors.

Question 46Psychopharmacology and Medication Management

Naloxone reverses opioid overdose by which action?

  1. Acting as a partial agonist at mu receptors to stabilize respiration
  2. Blocking opioid reuptake at presynaptic terminals
  3. Accelerating hepatic glucuronidation of opioids
  4. Competitively displacing opioids at mu receptors Correct answer.

Explanation

Naloxone is a competitive mu-opioid antagonist that displaces opioid agonists from receptors, rapidly reversing respiratory depression. Its short duration relative to many opioids means repeat dosing or infusion may be required.

Question 47Psychopharmacology and Medication Management

A patient with chronic heavy alcohol use is admitted with hypoglycemia and receives intravenous glucose. Which intervention should accompany the glucose to reduce the risk of Wernicke encephalopathy?

  1. Intravenous magnesium sulfate with a banana bag
  2. Oral naltrexone before the first meal and again at bedtime
  3. Oral folic acid 1 mg daily with a multivitamin
  4. Parenteral thiamine given before or with glucose-containing fluids Correct answer.

Explanation

Thiamine is a cofactor for glucose metabolism, so administering glucose without thiamine can precipitate or worsen Wernicke encephalopathy in thiamine-deficient patients. Parenteral thiamine should be given before or alongside glucose-containing fluids.

Question 48Psychopharmacology and Medication Management

Which strategy is preferred when discontinuing long-term benzodiazepine therapy in a patient with sedative-hypnotic use disorder?

  1. Abrupt discontinuation of the benzodiazepine to avoid prolonged dependence
  2. Gradual dose reduction, often using a long-acting benzodiazepine Correct answer.
  3. A fixed rapid taper completed within three days
  4. Substitution with an atypical antipsychotic and no taper

Explanation

Abrupt cessation after long-term use risks severe withdrawal including seizures and delirium, so a gradual taper is standard. Switching to a long-acting agent such as diazepam can smooth the taper in patients who tolerate it.

Question 49Psychopharmacology and Medication Management

Which electrocardiographic finding is of greatest concern during methadone maintenance therapy?

  1. Sinus tachycardia at 105 beats per minute
  2. Peaked T waves suggesting hyperkalemia
  3. QTc prolongation, particularly above 500 ms Correct answer.
  4. Shortening of the PR interval below 120 ms

Explanation

Methadone prolongs the QT interval in a dose-dependent manner, and a QTc above 500 ms raises the risk of torsades de pointes. Risk is increased by high doses, electrolyte abnormalities, and interacting drugs that inhibit methadone metabolism.

Question 50Psychopharmacology and Medication Management

A patient taking oxycodone regularly receives a first dose of buprenorphine four hours after the last oxycodone dose. Which outcome is most likely?

  1. Delirium tremens requiring benzodiazepines
  2. A disulfiram-like reaction with flushing and hypotension
  3. Precipitated opioid withdrawal from displacement at mu receptors Correct answer.
  4. Serotonin syndrome from opioid cross-reactivity

Explanation

Buprenorphine's high mu affinity lets it displace full agonists while providing only partial activation, abruptly lowering net opioid effect and precipitating withdrawal. Induction is therefore timed for clinical withdrawal, typically when COWS scores indicate adequate withdrawal.