• A 27-year-old with bipolar disorder, on lithium for 3 years,
presents to the ED with complaints of dizziness and weakness.
The vital signs show: HR 115, RR 13, BP 115/60, T 37.3° C. The
physical exam reveals dry mucus membranes, and a sinus
tachycardia. The labs reveal a glucose of 86, Na 153, K 3.8, Cl
109, HCO3 30, BUN 30, Cr 1.1, lithium level 1.6. You obtain a
urine analysis. What might you expect the urine specific gravity
to be if the patient's complaints were secondary to a renal
effect caused by the lithium?
A. 1.005
B. 1.015
C. 1.020
D. 1.030
• A 56-year-old woman presents to the ED with
signs and symptoms of Li toxicity. She has been
on a stable dose for many years and states she
has been compliant with her medications and
proper dosing. She does report she was recently
started on a "new medication," but can't
remember what it is. Which of the following
drugs is least likely to increase the risk of Li
A. Hydrochlorothiazide
B. Fluoxetine
C. Ibuprofen
D. Theophylline
E. Captopril
• A 22-year-old male is brought to the ED
after a suicide attempt. He took an
unknown amount of lithium 30 min PTA.
You find him to be lethargic and have
increased motor tone with rigidity and
hyperreflexia. All of the following listed
below are methods by which to decrease
the absorption or increase the clearance of
lithium except:
– A. Isotonic saline boluses followed by
– B. Gastric lavage
– C. Whole-bowel irrigation using polyethylene
glycol electrolyte solution
– D. Sodium polystyrene sulfonate (cationic
exchange resin)
– E. Hemodialysis
• Which statement is
correct concerning
– A. Induced emesis can be
beneficial in acute ingestion.
– B. Activated charcoal is beneficial
in reducing gastric absorption.
– C. Lithium has a prothyroid effect
resulting in hyperthyroidism.
– D. Lithium can precipitate a
serotonin syndrome.
– E. Lithium can cause a central
diabetes insipidus.
• All of the following factors can
contribute to the development of
lithium toxicity EXCEPT:
– A. Volume depletion due to use of
diuretics, febrile illnesses,
gastrointestinal losses, and other
states which may cause sodium
– B. Diabetes
– C. Renal insufficiency and impaired
renal perfusion, such as seen in
cases of congestive heart failure
– D. Concomitant use of nonsteroidal
inflammatory drugs or ACE
• The therapeutic lithium level is __ mEq/L;
toxicity is common with levels above __
– A. 0.2-0.6; 1.0
– B. 0.6-1.2; 2.0
– C. 1.0-2.0; 4.0
– D. 1.6-2.2, 6
“The product, originally named “Bib-Label Lithiated Lemon-Lime
Soda”, was launched two weeks before the Wall Street Crash of 1929.
It contained lithium citrate, a mood-stabilizing drug. It was one of a
number of patent medicine products popular in the late-19th and
early-20th centuries; they made claims similar to today’s health
foods. Specifically it was marketed as a hangover cure. The product’s
name was soon changed to 7 Up.”
• Antibiotics that may interfere with renal
excretion of lithium, causing an increased
lithium level and toxicity include:
– A. penicillin.
– B. tetracycline.
– C. erythromycin.
– D. sulfonamides.
• All of the following clinical effects are
seen with in cases of chronic lithium
toxicity EXCEPT:
– A. Neurological: Muscle weakness, ataxia,
tremor, apathy, dysarthria, confusion,
agitation, seizures, and CNS depression
ranging from drowsiness to coma and
respiratory depression.
– B. Gastrointestinal: nausea, anorexia, and
– C. Cardiovascular: bradycardia,
hypotension, prolonged QTC, and
– D. Genitourinary: Nephrogenic diabetes
insipidus may occur and may lead to
dehydration and hyponatremia.
– E. Nephrogenic diabetes insipidus may
occur and leads to hypernatremia not
• Which combination of
descriptions is correct
about the volume of
distribution, tissue
binding and excretion of
– A. small volume, is tissue
bound, excreted by kidneys
– B. large volume, not tissue
bound, excreted by liver
– C. small volume, not tissue
bound, kidneys
– D. large volume, tissue
bound, liver
• Which statement concerning the side effects of
antipsychotics is true?
A. Agranulocytosis is a frequent side effect of
B. Akathisia should be treated by increasing the
dose of the antipsychotic.
C. Antipsychotics can't be prescribed for
patients with known seizure disorder.
D. Extrapyramidal syndromes are common with
atypical antipsychotics.
E. QT prolongation can occur at therapeutic
Which statement concerning
antipsychotic overdose is true?
A. Agranulocytosis is an effect of clozapine overdose.
B. Blood levels of the antipsychotic drug are helpful in
overdose management.
C. Sedation is the most common finding in antipsychotic
D. The most common cardiac rhythm in antipsychotic
overdose is ST w/ prolonged QRS complex.
E. Outcomes of overdose are improved using airway
control, IV crystalloid, EKG and activated charcoal.
• Which statement concerning neuroleptic
malignant syndrome (NMS) is true?
A. All patients with NMS should be admitted to a critical
care unit.
B. Concomitant use of lithium is protective against NMS.
C. Dantrolene is preferred treatment for the muscle
rigidity of NMS.
D. NMS has an abrupt onset that usually occurs w/in the
1st 2 wks of antipsychotic tx
E. The clinical features of hyperthermia and muscle
rigidity must be present to diagnose NMS.
• A 25yo presents to the ED c/o of a facial tic for 2d.
He started haloperidol tx 2 wks ago. He has nl vital
signs and is found to have an involuntary motor tic
of his face as well as neck muscle spasm on
physical exam. What is the appropriate ED
A. Admit for IV diphenhydramine tx & obs.
B. Emergent psychiatry consult
C. Start on oral diphenhydramine & have him f/u w/ his
D. Stop the haloperidol, IV diphenhydramine, and
discharge home on oral diphenhydramine if the
symptoms improve.
E. Stopping his haloperidol is sufficient to treat his
dystonia. Have him follow up with his psychiatrist for a
medication change.
• Treatment of neuroleptic overdose include all of
the following EXCEPT:
A. Determination of fingerstick glucose in patients
presenting with altered mental status
B. Management of hypotension with crystalloids, or if
this initial management is unsuccessful, initiation of a
potent alpha-agonists such as norepinephrine
C. Lidocaine, cardioversion/defibrillation, sodium
bicarbonate for management of ventricular arrhythmias
D. Administration of procainamide if torsade de pointes
• Phenothiazines are metabolized primarily by the
liver. They are highly protein-bound with a volume
of distribution of about __ L/kg, so dialysis is __ in
the treatment of phenothiazine toxicity.
A. 1; effective
B. 5; ineffective
C. 10; effective
D. 20; ineffective
• Phenothiazine overdoses may present with
cardiovascular, central nervous system, and
___ toxicity.
A. sympathomimetic
B. anticholinergic
C. serotonergic
D. gastrointestinal
• Pts on chronic phenothiazine tx may develop
Neuroleptic Malignant Syndrome. All of the
following statements about NMS are true
A. Marked by hyperthermia, rigidity, ams, autonomic
instability, met. acidosis, & rhabdo.
B. Onset of NMS can begin within days to weeks of
initiation of medication, or increasing dose.
C. Management includes supportive care with IV
crystalloids, cooling measures, benzodiazepines, and
neuromuscular blockade with nonpolarizing paralytics
D. Bromocriptine, amantadine, and dantrolene have
been proven to be extremely effective in the
management of hyperthermia.
• Hydrocarbons (HCs) can affect many organ
systems, but derangements in which organ
system most commonly lead to death after HC
A. Cardiac
B. Gastrointestinal
C. Nervous System
D. Pulmonary
E. Renal
• A healthy 20 yo male presents after accidentally
ingesting furniture polish that was stored in a plastic
container that he mistook for a beverage. The
ingestion occurred approximately 1 hour ago. He has
no complaints. His VS and PE are normal. Which is
the most appropriate course of action?
A. Careful gastric decontamination using NG tube
B. Serum electrolytes
C. Drug Screen
D. Carbon monoxide level
E. Observe for 6 hours & discharge if condition does
not change
• A 4 yo boy with a history of asthma is brought to the ED
following an accidental hydrocarbon ingestion 2 hours ago. He
initially was noted to be coughing but now has no complaints.
His VS are normal. His physical examination reveals mild
bilateral wheezing but with good air movement. His oxygen
saturation is 99% on room air. A chest radiograph is normal.
The child is placed on a cardiac monitor and IV access is
obtained . What is the most appropriate treatment plan?
A. Endotracheal intubation
B. Intravenous sodium bicarbonate
C. Nebulized albuterol
D. Observation and supportive care only
E. Oral activated charcoal
• A 16 year old male is brought to the ED by his
friends. They were huffing in the park and the
patient began to have a seizure. He has no
known history of seizures. His blood glucose is
110. What is the likely additive to the
hydrocarbon that he was huffing?
Diesel oil
Mineral seed oil
Pine oil
• A 24 yo male presents to the ED with a fever. He is
well known to the staff as a “huffer”. He has been
there on multiple occasions with intoxication. His
CBC returns with a WBC 1.7, Hgb 7.2, and platelet
count of 45,000. What is the likely type of
hydrocarbon that he has been using recently that can
cause this abnormality?
A. Aromatic hydrocarbon such as lighter fluid
B. Embalming fluid which contains camphor
C. Halogenated hydrocarbon such as Scotchguard
D. Gasoline which contains lead
Which of the following characteristics of a
hydrocarbon increases its ability to be
A. High viscosity
B. High volatility
C. Low viscosity
D. Low volatility
E. Presence of a arsenic side chain
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