Questions

Just like the actual exam

Aligned with the American Nurses Credentialing Center format. Authored & peer-reviewed by PMHNPs.

Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.

  • Must address important content
  • Must be well structured

Question

A 21-year-old woman with a history of seasonal allergies and major depressive disorder presents to the emergency department complaining of chills and muscle soreness approximately 3 hours after ingesting MDMA. She is visibly agitated but able to convey her history. She reports taking no other illicit substance, but she notes taking an 11 mg oral extended-release tablet of brompheniramine earlier this morning. She describes ongoing episodes of uncontrollable sneezing but reports no chills or soreness prior to taking MDMA. She attests to continued adherence with a daily regimen of fluoxetine 60 mg oral tablet. Her temperature is 102.1°F with a regular pulse of 110 beats/min. Physical exam reveals dilated pupils, persistent ocular clonus, diaphoresis, and sustained ankle jerking after dorsiflexion of the feet bilaterally. Her lungs are clear. There is no sign of edema in the face or limbs. Which of the following is the most likely diagnosis?

A Anaphylaxis
B Influenza
C Serotonin syndrome
D Somatic symptom disorder

Serotonin syndrome is a life-threatening condition that results from the simultaneous use of multiple serotonergic agents. N-methyl-3,4-methylenedioxyamphetamine (MDMA) and selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine elevate mood by increasing serotonin levels in the brain. However, antihistamines vary in serotonin activity. Some first-generation antihistamines, such as brompheniramine and chlorpheniramine, are 5-HT2A agonists and should be used with caution in patients taking SSRIs, while others such as cyproheptadine display 5-HT2A antagonism. Serotonin syndrome is triggered by high levels of serotonin at synapses in the brainstem and manifests as fever, diaphoresis, dilated pupils, ocular clonus, nausea, vomiting, and myoclonus in the extremities. In addition to the drugs listed above (MDMA, brompheniramine, and fluoxetine), serotonin syndrome can also be triggered when the following drugs are used in combination: monoamine oxidase inhibitors, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, St. John’s wort, bupropion, trazodone, meperidine, tramadol, fentanyl, sumatriptan, cocaine, amphetamines, linezolid, dextromethorphan, lithium, tryptophan, and levodopa.

Anaphylaxis (A) is a life-threatening allergic reaction that leads to respiratory distress and circulatory collapse but is not known to cause elevated temperature. Influenza (B) is a viral infection that may manifest as fever, fatigue, rhinorrhea and muscle soreness. However, influenza usually results from contact with an infected individual and is neither associated with serotonergic drugs nor serotonergic signs such as dilated pupils, ocular clonus, or myoclonus. Somatic symptom disorder (D) is evident when a patient has a debilitating preoccupation with multiple perceived physical ailments. In contrast to the woman from the vignette, people with somatic symptom disorder display inappropriate and exaggerated concern for their symptoms. Displaying grave concern is not inappropriate after the acute onset of flu-like symptoms following MDMA ingestion because such symptoms may herald a potentially life-threatening event.


Explanations

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Understanding why an answer choice is incorrect is just as important as knowing why one is correct. That’s why every Rosh Review question includes detailed explanations for the correct and incorrect answer choices. These comprehensive summaries link the most important components of a topic—from risk factors to diagnostics and treatment—giving you the context to build relationships between them.

  • Created for optimal learning and recall
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  • Focus on the essential information

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Custom illustrations and tables help further clarify the core concepts. When information is presented visually, you can focus on meaning, easily reorganize and group similar ideas, and make better use of your memory.

serotonin syndrome

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One Step Further

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After each explanation is a straightforward question with a simple, memorizable answer that reinforces the corresponding topic.

  • Strengthens your knowledge
  • Stands alone from the main explanation so you’re not rereading content

Q: Which first-generation antihistamine is used to reverse serotonin syndrome?

REVEAL ANSWER

A: Cyproheptadine.

Serotonin Syndrome

  • Patient with a history of taking multiple medications that increase the amount of serotonin
  • PE will show mental status changes, autonomic instability, and neuromuscular abnormalities
  • Treatment is benzodiazepines, cyproheptadine, removing the offending agent(s)

Rapid Review

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These bulleted reviews focus on condensed, high-yield concepts about the main topic, from patient presentation to preferred management.

  • Cover the fundamentals in one list
  • Allow you to quickly scan the must-know information
I’ve been a nurse for 10 years and used Rosh Review for my NP exam and loved it. The content is in-depth and did a great job to help me learn what I needed for the exam.

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