The Psychiatric-Mental Health Nurse Practitioner Certification Review Manual Flashcards

1
Q

2-01. Which of the following is not a core competency of APRNs?

A. Technology and information literacy

B. Health delivery system

C. Ethics

D. Delegated practice

A

Answer D. Delegated practice is not a core competency of the APRN. The nurse practitioner may delegate individual tasks but not the practice. The APRN must demonstrate competency in technology and information literacy, health delivery systems, and ethical principles and decision making.

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2
Q

2-02. Which of the following is characteristic of the leadership competency for APRNs?

A. Participating in a community-focused program that promotes mental health and reduces the risk of mental health problems

B. Evaluating the appropriate use of seclusion and restraints in caring for a mentally ill patient

C. Developing an age-appropriate treatment plan

D. Modifying the treatment plan based on the patient’s needs

A

Answer A. Participating in a community-focused program that promotes mental health exemplifies a leadership competency. Evaluating the appropriate use of seclusion and restraints, developing an age-appropriate treatment plan, and modifying the treatment plan based on clients’ needs are clinical competencies

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3
Q

2-03. All of the following are characteristic of the independent practice competency except:

A. Insulin during differential diagnoses

B. Conducting individual and group psychotherapy

C. Taking opportunities to influence health policy to reduce the stigma of mental health services

D. Implementing plans to minimize complications and to promote function

A

Answer C. Taking opportunities to influence health policy and reduce the stigma of mental health services exemplifies health policy competency. Considering differential diagnoses, conducting psychotherapy, and implementing plans to minimize comorbidity are examples of practicing with full practice authority at the top of the professional license.

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4
Q

2-04. A state’s Nurse Practice Act specifies all of the following except:

A. Who may use the title nurse practitioner

B. What a nurse practitioner can do

C. Restriction of the nurse practitioner’s practice

D. Provide oversight for service and benefits provided to patients

A

Answer D. The state Nurse Practice Act does not provide for oversight of services and benefits provided to patients. It does define who may use the title and the work of the nurse practitioner as well as restrict the practice of the professional.

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5
Q

2-05. Which of the following may govern the profession of the PMHNP?

A. Statutory law

B. The U.S. Constitution

C. Certification

D. City ordinances

A

Answer A. Statutory laws govern the practice of a profession. The U.S. Constitution, certifications, and city ordinances do not address professional practice.

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6
Q

2-06. Which of the following factors are facilitating the growth of the PMHNP?

A. Increased competition in the job market

B. Overlapping scope of practice with other types of nurse practitioners

C. Decreasing stigmatization

D. Collaborative practice relationships with physicians

A

Answer C. Decreasing stigmatization regarding mental health enhances the growth of the profession. Increased competition, overlapping scope of practice, and mandated collaborative practice relationships restrict the growth of the profession.

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7
Q

2-07. Why is it necessary for insurance companies to credential PMHNPs?

A. To protect the public by ensuring a minimum level of professional competence

B. To define the scope of practice and practice requirements

C. To ensure a professional organization certifies the person is licensed to practice

D. To define the role of the nurse practitioner

A

Answer A. The purpose of credentialing is to ensure public safety and a minimum level of professional competence; this helps reduce vicarious liability on the insurance company. Insurance 35companies do not define the scope of practice; they have nothing to do with professional organizations who grant certification. State governing bodies define the role of the nurse practitioner.

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8
Q

2-08. Which of the following allows the PMHNP to practice in a state?

A. Certification

B. Licensure

C. Credentialing

D. Graduation

A

Answer B. Certification allows a professional to practice their profession in a state. Certification designates successful completion of a course of study. Credentialing is a process that verifies minimum levels of professional competence to ensure public safety. Graduation is a ceremony offered by an educational institution in accordance with established criteria of completion.

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9
Q

2-09. All of the following statements are true regarding scope of practice except:

A. The scope of practice defines the nurse practitioner role and actions

B. The scope of practice identifies competencies assumed to be held by all nurse practitioners in a specific role

C. The scope of practice provides a way to judge the nature of the care provided

D. The scope of practice varies broadly from state to state

A

Answer C. The scope of practice defines the nurse practitioner role and actions, identifies minimal competencies held by all nurse practitioners, and varies broadly from state to state. It does not provide a way to judge the nature of care provided.

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10
Q

2-10. All the following statements are true regarding standards of practice except:

A. Standards of practice reflect professional agreement focusing on the minimum levels of acceptable performance

B. Standards of practice provide a way to judge the nature of care provided

C. Standards of practice identify competencies assumed to be held by all nurse practitioners (NPs) who function in a similar role

D. Standards of practice can be used legally to describe a standard of care that must be met by a provider

A

Answer C. Standards of practice reflect the professional agreement that focuses on the minimum levels of acceptable performance, a means of judging the nature of care provided, and can be used legally to describe the standard of care that must be met by a provider. It does not identify competencies held by all nurse practitioners as that is provided in the scope of practice.

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11
Q

2-11. All of the following are considered personal health identifiers except:

A. Patient’s name

B. Patient’s diagnosis

C. Address

D. Phone number

A

Answer B. Personal health identifiers include name, address, and phone number. Patient diagnosis is not considered a personal health identifier.

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12
Q

2-12. Unless the patient provides consent for releasing information, the Health Information Portability and Accountability Act (HIPAA) prohibits the disclosure of personal health identifiers to all of the following except:

A. The patient’s next of kin

B. The patient’s health insurance company

C. The patient’s clergy

D. The patient’s attorney

A

Answer B. The patient must consent to release personal health identifiers to next of kin, clergy, and an attorney. Patient consent is not required to release personal health identifiers to a patient’s health insurance company.

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13
Q

2-13. All of the following circumstances would allow the release of medical information without the patient’s consent except:

A. If the client reveals intent to harm self or others

B. Records to the insurance company

C. Responding to court orders, subpoenas, or summons

D. Next of kin wanting to help the patient make decisions

A

Answer D. Medical information may be released to parties needing to know to prevent harm to self and others, arranging for payment from the health insurance company, and in response to court subpoenas or summonses. The patient must consent to release medical information to the next of kin helping to make healthcare decisions.

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14
Q

2-14. A PMHNP is asked to determine if the patient has the capacity for informed consent. All of the following elements are necessary for making this determination except:

A. The patient understands the purpose of the proposed treatment for the procedure

B. The patient understands the risks and discomforts and benefits of the treatment

C. The patient understands alternatives to the intended procedure

D. The patient has a therapeutic alliance with the surgeon

A

Answer D. The following elements must be considered when asked to determine capacity for informed consent: the patient’s understanding of the purpose of the proposed treatment, the risks and discomforts, benefits of the treatment, and alternatives to the intended procedure. The therapeutic alliance with the surgeon is not essential for a capacity decision.

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15
Q

2-15. Which of the following ethical principles deals with promoting the well-being of a patient?

A. Justice

B. Beneficence

C. Nonmaleficence

D. Autonomy

A

Answer B. The principle of beneficence is that of doing good for the patient. Justice is the principle of equity. Nonmaleficence is the principle of first doing no harm. Autonomy is the principle of respecting the individual’s right to self-determination.

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16
Q

2-16. Which of the following ethical principles would conflict if the treatment team wanted to implement a therapeutic deception for the good of the patient?

A. Beneficence

B. Nonmaleficence

C. Justice

D. Veracity

A

Answer D. Veracity is the ethical principle of truthfulness and nondeception neither by omission or commission. Beneficence is the principle of doing good. Nonmaleficence is the principle of first doing no harm. Justice is the principle of equity.

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17
Q

2-17. A patient who is refusing psychiatric treatment has their case adjudicated. The judge orders treatment over objection for the good of the patient. Which ethical principle is trumped?

A. Beneficence

B. Nonmaleficence

C. Justice

D. Autonomy

A

Answer D. Autonomy is the principle of respecting the individual’s right to self-determination. Beneficence is the principle of doing good. Nonmaleficence is the principle of first doing no harm. Justice is the principle of equity.

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18
Q

2-18. Actions judged based on their inherent value regardless of their consequence is based on which ethical decision-making approach?

A. Teleological theory

B. Deontological theory

C. Virtue ethics

D. Justice principle

A

Answer B. Deontological theory considers the inherent value regardless of consequences. The teleological approach allows the ends to justify the means. Virtue ethics is an approach to ethical decision-making that considers the moral character of the individual rather than the action. Justice is the principle of equity.

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19
Q

2-19. An action that is judged good or bad based on the consequence demonstrates which ethical decision-making approach?

A. Teleological theory

B. Deontological theory

C. Virtue ethics

D. Justice principle

A

Answer A. The teleological approach allows the ends to justify the means. Deontological theory considers the inherent value regardless of consequences. Virtue ethics is an approach to ethical decision-making that considers the moral character of the individual rather than the action. Justice is the principle of equity.

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20
Q

2-20. All of the following are necessary criteria for commitment for involuntary evaluation and treatment except:

A. The person has a diagnosed psychiatric disorder

B. The person has potential to harm self or others because of the disorder and is unaware or unwilling to accept the nature and severity of the disorder

C. Treatment is likely to improve function

D. The patient is unable to afford the cost of treatment

A

Answer D. 36Involuntary commitment is intended to protect the patient and society; therefore, the patient’s financial resources are not considered as a criteria for treatment.

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21
Q

2-21. A PMHNP is working with a nonprofit organization to implement a public health campaign aimed at reducing the stigma of mental illness. Which role of the PMHNP best describes this activity?

A. Mentoring

B. Advocacy

C. Policy making

D. Case management

A

Answer B. Advocacy entails promoting a particular cause or policy. Mentoring is a relationship with a more experienced individual for the purpose of guiding the professional development of the less experienced individual. Policy making is the process of developing laws and regulations. Case management is a collaborative process of assessment, planning, facilitation, care coordination, and evaluation of resources needed to meet the patient’s needs in a cost-effective manner.

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22
Q

2-22. The PMHNP is working with an insurance organization to provide oversight and authorization of series and benefits to patients. Which role of the PMHNP best describes this activity?

A. Mentoring

B. Advocacy

C. Policy making

D. Case management

A

Answer D. Case management is a collaborative process of assessment, planning, facilitation, care coordination, and evaluation of resources needed to meet the patient’s needs in a cost-effective manner. Mentoring is a relationship with a more experienced individual for the purpose of guiding the professional development of the less experienced individual. Advocacy entails promoting a particular cause or policy. Policy making is the process of developing laws and regulations.

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23
Q

2-23. Which of the following roles of the PMHNP requires mutual respect and an interactive learning process to facilitate role development, competencies, and skill acquisition?

A. Mentoring

B. Advocacy

C. Policy making

D. Case management

A

Answer A. Mentoring is a relationship with a more experienced individual for the purpose of guiding the professional development of the less experienced individual. Advocacy entails promoting a particular cause or policy. Policy making is the process of developing laws and regulations. Case management is a collaborative process of assessment, planning, facilitation, care coordination, and evaluation of resources needed to meet the patient’s needs in a cost-effective manner.

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24
Q

2-24. All of the following are true regarding living wills except:

A. Legally binding in all 50 states

B. Designates in writing an agent to act on behalf of the person should they become unable to make decisions

C. Prepared while the client is mentally competent to designate preferences for care if the client becomes incompetent

D. Should be considered as an aspect of relapse planning for compliance with chronic psychiatric disorders

A

Answer A. A living will is not legally binding in all 50 states, but does designate agents to act on behalf of the patient in the event of incapacity, is prepared while the patient has capacity, and is considered an aspect of relapse planning for compliance with chronic psychiatric disorders.

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25
Q

2-25. A specific behavior related to a person’s culture and not leading to a psychiatric disorder is classified as:

A. Temporary delusion

B. Brief psychotic episode

C. Adjustment disorder

D. Culture-bound syndrome

A

Answer D. Culture-bound syndrome is specific behavior common to a person’s culture, and is considered a variation of normal and not a psychiatric diagnosis. Delusions are deeply held beliefs despite evidence to the contrary. A brief psychotic episode is an acute onset thought disorder marked by disorganization and at least one of the following symptoms: delusions, hallucinations, bizarre behavior and posture, and disorganized speech. Adjustment disorder is a mood disorder marked by emotional or behavioral symptoms that develop in response to an identifiable stressor within 3 months of onset of the stress and lasting no more than 6 months.

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26
Q

2-26. The learned beliefs and behaviors common among all members of a group defines:

A. Complex delusions

B. Folie a deux

C. Culture

D. Folie a famille

A

Answer C. Culture is the learned belief and behaviors common among all members of a group. Complex delusions are deeply held beliefs despite evidence to the contrary with an elaborate web of interconnected delusions. Folie a deux is a shared delusion between two people. Folie a famille is a delusion held among cohabitating family members.

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27
Q

2-27. All of the following factors put households headed by a single female at risk for homelessness except:

A. Education

B. Underemployment

C. Inadequate benefits

D. Inaccessible housing options

A

Answer A. Education increases the likelihood of gainful employment. Underemployment, inadequate benefits, and inaccessible housing all increase the risk of homelessness.

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28
Q

2-28. Which mental illness accounts for the highest rate of mental illness?

A. Major depressive disorder

B. Bipolar disorder

C. Schizophrenia

D. Oppositional defiant disorder

A

Answer A. The incidence of major depressive disorder in the United States is 12.8%, oppositional defiant disorder is 10.2%, bipolar disorder 2.6%, and schizophrenia 1%.

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29
Q

2-29. During a psychiatric evaluation, the client reveals to the PMHNP a transgender identity. The client indicates a preference for personal pronouns like he and him. What is the biological sex of the client?

A. Male

B. Female

C. Lesbian

D. Asexual

A

Answer B. The biological sex of the client is female, but the gender identity is male. Lesbian and asexual are descriptors of sexual orientation.

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30
Q

2-30. A new graduate PMHNP is considering a job at a psychiatric ED. The medical director informs the prospective hire that they are expected to evaluate and treat children, adolescents, adults, and geriatric patients. What document should be consulted to determine if the PMHNP can legally treat psychiatric patients across the life span?

A. The state Nurse Practice Act

B. The hospital bylaws

C. The PMHNP scope of practice

D. The PMHNP can treat any patient because there is a collaborating physician

A

Answer A. A state Nurse Practice Act describes what is permissible and impermissible for a PMHNP to do. The hospital bylaws govern the local organization and can be more restrictive, but not more lenient than state laws. The scope of practice identifies competencies unique to the subspecialty. The PMHNP is an independently licensed individual who bears liability for errors of omission and commission regardless of the collaborative agreement. The collaborative agreement cannot supersede state law.

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31
Q

2-31. The process of synthesizing, disseminating, and using research-generated knowledge to make a change in practice is known as:

A. Research utilization

B. Evidence-based practice

C. Research

D. Quality improvement

A

Answer A. Research utilization is the process of synthesizing and disseminating research-generated knowledge to make a change in care. Evidence-based practice is a problem-solving approach that uses the best evidence in making decisions about patient care that takes into account client needs, values, and clinical expertise, but may not be generalizable beyond the immediate problem. Research is the systematic empirical inquiry of relationships among variables. Quality improvement is a systematic approach to the analysis of current practice, efficiency, outcomes, and benchmarks.

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32
Q

2-32. The process of integrating the best research evidence with clinical expertise and client needs and values is known as:

A. Research utilization

B. Evidence-based practice

C. Research

D. Quality improvement

A

Answer B. Evidence-based practice is a problem-solving approach that uses the best evidence in making decisions about patient care that takes into account client needs, values, and clinical expertise, but may not be generalizable beyond the immediate problem. Research utilization is the process of synthesizing and disseminating research-generated knowledge to make a change in care. Research is the systematic empirical inquiry of relationships among variables. Quality improvement is a systematic approach to the analysis of current practice, efficiency, outcomes, and benchmarks.

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33
Q

2-33. All of the following are components of research utilization except:

A. Critique of the literature

B. Synthesize findings

C. Applying the findings

D. Randomizing the sample

A

Answer D. Randomizing the sample is a component of certain types of research. Critique and literature synthesis and applying the findings are components of research utilization.

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34
Q

2-34. The first step in implementing an evidence-based practice change is to:

A. Identify the patient, population, and problem

B. Identify key shareholders

C. Obtain institutional review board approval

D. Review the literature

A

Answer A. Identifying the patient, population, and problem is the first step in implementing an evidence-based practice change. Identifying stakeholders, obtaining institutional review board approval, and reviewing the literature are subsequent steps.

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35
Q

2-35. All of the following are methods of dissemination of findings except:

A. Presenting at conferences

B. Publishing in peer-reviewed journals

C. Poster presentation

D. Oral defense to your committee

A

Answer D. Oral defense to your committee is not a method of dissemination, but rather peer review. Presenting at conferences, publishing, and poster presentations are examples of dissemination.

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36
Q

2-36. What concept is defined by a sample that is representative of the population, and where the results can be generalized?

A. Internal validity

B. External validity

C. Prevalence

D. Incidence

A

Answer B. External validity relates to the generalizing of findings beyond the study to the population. Internal validity is the degree of truthfulness about inferences regarding causal relationships. Prevalence is a measure of all individuals affected at a particular time. Incidence is a measure of the number of new occurrences only during a particular period of time.

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37
Q

2-37. What concept is defined by an independent variable causing a change in the dependent variable?

A. Internal validity

B. External validity

C. Prevalence

D. Incidence

A

Answer A. Internal validity is the degree of truthfulness about inferences regarding causal relationships. External validity relates to the generalizing of findings beyond the study to the population. Prevalence is a measure of all individuals affected at a particular time. Incidence is a measure of the number of new occurrences only during a particular period of time.

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38
Q

2-38. What method of analysis describes the basic features of the data and summarizes and organizes observations?

A. Inferential statistics

B. Descriptive statistics

C. Regression analysis

D. Analysis of variance (ANOVA)

A

Answer B. Descriptive statistics define, summarize, and organize data. Inferential statistics use various methods of analysis to deduce properties of probability and distribution that may be reflective of the population. Regression analysis is a statistical method that allows one to examine the relationship between two or more variables. ANOVA is a collection of statistical models and their associated estimation to analyze differences among group means in a sample.

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39
Q

2-39. What method of analysis enables one to reach conclusions that extend beyond the immediate data and is generated by quantitative research designs?

A. Inferential statistics

B. Descriptive statistics

C. Regression analysis

D. Standard deviations

A

Answer A. Inferential statistics use various methods of analysis to deduce properties of probability and distribution that may be reflective of the population. Descriptive statistics define, summarize, and organize data. Regression analysis is a statistical method that allows one to examine the relationship between two or more variables. Standard deviation is a calculated quantity to indicate the degree of spread among data.

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40
Q

2-40. Which statistical test differentiates among three or more groups?

A. t-test

B. Analysis of variance (ANOVA)

C. Pearson’s r correlation

D. Probability

A

Answer B. ANOVA is a collection of statistical models and their associated estimation to analyze differences among group means in a sample. A t-test is a type of inferential statistic used to determine if there is a significant difference in means between two groups assuming normal distribution. Pearson’s r correlation is a number between −1 and 1 that indicates the extent to which two variables are linearly related. Probability is a ratio describing the extent to which something is likely to occur.

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41
Q

2-41. Which statistical test identifies if the means of two groups are statistically different from each other?

A. t-test

B. Analysis of variance (ANOVA)

C. Pearson’s r correlation

D. Probability

A

Answer A. A t-test is a type of inferential statistic used to determine if there is a significant difference in means between two groups assuming normal distribution. ANOVA is a collection of statistical models and their associated estimation to analyze differences among group means in a sample. Pearson’s r correlation is a number between −1 and 1 that indicates the extent to which two variables are linearly related. Probabilityis a ratio describing the extent to which something is likely to occur.

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42
Q

2-42. Which statistical test identifies a relationship between two variables?

A. t-test

B. Analysis of variance (ANOVA)

C. Pearson’s r correlation

D. Probability

A

Answer C. Pearson’s r correlation is a number between −1 and 1 that indicates the extent to which two variables are linearly related. A t-test is a type of inferential statistic used to determine if there is a significant difference in means between two groups assuming normal distribution. ANOVA is a collection of statistical models and their associated estimation to analyze differences among group means in a sample. Probability is a ratio describing the extent to which something is likely to occur.

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43
Q

2-43. The level of significance describing the probability of a particular result occurring by chance alone is represented by which of the following?

A. p-value

B. z-score

C. Odds ratio

D. Confidence interval

A

Answer A. The p value describes the level of significance describing the probability of a particular result occurring by change alone. The z-score is a standardized measure of standard deviations above or below a population mean. The odds ratio is a statistic that attempts to quantify the strength of an association between an exposure and an outcome. The confidence interval describes a range of values indicating the likelihood of the data containing a true value of an unknown population.

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44
Q

2-44. All of the following are governed by the institutional review board except:

A. Ensuring risks to participants are minimized

B. Ensuring equitable selection

C. Evaluating risks and benefits, ensuring reporting of adverse events

D. Regulating funding for the study

A

Answer D. The institutional review board does not govern funding of a study, but does ensure risks to participants are minimized, subjects are equitably selected, and ensures the reporting of adverse events and risk-benefits are reevaluated.

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45
Q

2-45. All patients have the right to all of the following except:

A. Confidential care

B. Care in the least restrictive manner

C. The ability to consent and withdraw consent at any time

D. To be treated by a physician

A

Answer D. Clients have a right to be treated by a qualified provider who may not be a physician. All patients have the right to receive care in the least restrictive manner with the utmost confidence, and may consent or withdraw consent at any time.

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46
Q

3-01. A member of the group states that his problem is not that bad and he can stop anytime he chooses. Using on occasion is just a way to have fun with friends. Which concepts of the Health Belief Model best describes the group member’s readiness to change?

A. Perceived severity and perceived barriers

B. Self-efficacy and perceived benefits

C. Cues to action and perceived susceptibility

D. Self-efficacy and perceived susceptibility

A

Answer A. The member is expressing the belief regarding the seriousness of the condition as minimal, and that the cost of abstaining from the addiction is reducing time with friends. Self-efficacy is an individual’s belief in his or her innate ability to achieve a goal and perceived benefits refer to the individual’s perception of the effectiveness of an action to reduce a threat or illness. Perceived susceptibility is the individual’s perception of acquiring disease or illness, and cues to action are stimuli necessary to trigger a health-promoting behavior.

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47
Q

3-02. A member of the group expresses how difficult it has been to maintain her sobriety and as a result does not feel she will be successful this time. Which concept of the Health Belief Model would be the most significant risk factor for relapse?

A. Low perception of severity

B. Low self-efficacy

C. High perceived benefits

D. Cues to action

A

Answer B. The member is expressing the belief that because she has relapsed in the past, that she is likely to relapse again, which reflects a low confidence in her ability to successfully perform the behavior. Perceived benefits refer to the individual’s perception of the effectiveness of an action to reduce a threat or illness. Perceived susceptibility is the individual’s perception of acquiring disease or illness, and cues to action are stimuli necessary to trigger a health-promoting behavior.

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48
Q

3-03. A member attending the group for the first time expresses gratitude for being court ordered to attend the recovery group instead of serving prison time, and he realizes how out of control he was while using. Which Health Belief Model concept was demonstrated?

A. Perceived severity and perceived barriers

B. Self-efficacy and perceived benefits

C. Cues to action and perceived severity

D. Self-efficacy and perceived susceptibility

A

Answer C. The member describes the trigger that activated the ability to take action, and the seriousness of the condition and sequelae. Perceived barriers are the belief in the tangible and psychological costs associated with the advised behavior. Perceived severity is the individual’s belief of how serious a condition and its consequences are. Self-efficacy is an individual’s belief in his or her innate ability to achieve a goal.

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49
Q

3-04. A 30-year-old man with three past psychiatric hospitalizations for schizoaffective disorder presents for follow-up care with the PMHNP. Before discharge, the patient received court ordered Zyprexa Relprevv 300 mg IM X 1. The patient tells the PMHNP that he is aware that smoking can “make him need more medication.” Which stage of change is the patient in?

A. Precontemplation

B. Contemplation

C. Preparation

D. Action

E. Maintenance

A

Answer B. He is in the contemplation stage: The patient has indicated that a problem exists but has not expressed a desire to change. Precontemplation—In this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). Preparation (determination)—In this stage, people are ready to take action within the next 30 days. Action—In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. Maintenance—In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward.

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50
Q

3-05. The PMHNP is caring for a 20-year-old man with bipolar I disorder. The patient indicates that he does not have a problem because he can accomplish so much during his manic episodes. Which stage of change is the patient in?

A. Precontemplation

B. Contemplation

C. Preparation

D. Action

E. Maintenance

A

Answer A. The patient is in the precontemplation stage; in this stage, people do not intend to take action in the foreseeable future (defined as within the next 6 months). The patient denies the problem and has no intention of making a change. Contemplation—In this stage, people intend to start the healthy behavior in the foreseeable future (defined as within the next 6 months). Preparation (determination)—In this stage, people are ready to take action within the next 30 days. Action—In this stage, people have recently changed their behavior (defined as within the last 6 months) and intend to keep moving forward with that behavior change. Maintenance—In this stage, people have sustained their behavior change for a while (defined as more than 6 months) and intend to maintain the behavior change going forward.

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51
Q

3-06. The PMHNP is explaining the risks and benefits of long-acting injectable antipsychotics to a patient with a history of medication nonadherence. The patient is asking logical questions that demonstrate he can understand the facts. Which process of changing represents the patient’s position?

A. Social liberation

B. Reinforcement management

C. Self-liberation

D. Consciousness raising

A

Answer D. The patient is in the consciousness raising stage; i.e., increasing awareness about healthy behavior and discovering and accepting facts in support of the health behavior change. Social liberation—Environmental opportunities that exist to show society is supportive of healthy behavior. Reinforcement management—Rewarding the positive behavior and reducing the rewards that come from negative behavior. Self-liberation—Commitment to change behavior based on the belief that achievement of the healthy behavior is possible. Consciousness raising—Increasing awareness about healthy behavior.

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52
Q

3-07. The PMHNP has prescribed a patient naltrexone and bupropion for binge eating disorder. The patient has lost 4 lbs. since her last visit 1 month ago. The patient states that sometimes she finds it very difficult to not binge eat when her emotions are intense, and expresses doubt in her ability to make a lasting change. Which of the following is the best response?

A. “I can increase your dose of medication or augment you with another medication.”

B. “On a scale of 1 to 10 how important is this change for you to make?”

C. “Give me an example of something in your life that you are most proud of achieving.”

D. “Would you like a referral to a dietician?”

A

Answer C. The patient is expressing low self-efficacy; by asking about past successes the patient’s self-efficacy may be enhanced. Although augmenting the medication may be possible, the patient is experiencing the positive effects of the medication (weight loss).

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53
Q

3-08. A 35-year-old female with personality disorder not otherwise specified takes quetiapine 50 mg qhs for sleep, and 12.5 mg q6h PRN for anxiety. She tells the PMHNP that no one seems to understand how much stress she is under and would like to change providers. Which of the following would be the best response?

A. “Do you think you need your medication adjusted?”

B. “It sounds to me like you are frustrated and do not feel listened to.”

C. “I can give you a list of three psychiatrists whom you can choose from to give you the care you want.”

D. “It will take some time for the medication to reach full effect before you are feeling better.”

A

Answer B. Express empathy by affirming the client’s feelings, and demonstrating reflective listening by using her words to gain insight into her motivations. Asking if she needs her medication adjusted invalidates her feelings as does giving her an answer about medication efficacy. Offering her a list of referrals communicates a lack of commitment to the therapeutic relationship on the part of the PMHNP if done without exploring underlying motivation.

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54
Q

3-09. Which of the following is a therapeutic technique to facilitate a health behavior change in a 28-year-old male with substance use disorder who is in denial regarding the severity of his habit?

A. Solution-focused therapy

B. Strategic therapy

C. Psychopharmacology with naltrexone 50 mg daily

D. Motivational interviewing

A

Answer D. Motivational interviewing will allow the PMHNP to hear the client’s reasons for maintaining the status quo as well as elicit his reasons for what it would take to trigger a desire to change. Solution-focused therapy is a goal-directed psychotherapy based on direct observation to a series of precisely constructed questions. Strategic (family) therapy does not focus on the individual but the social structure. Psychopharmacology may be appropriate but the naltrexone is not indicated as the substance is not specified.

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55
Q

3-10. A 65-year-old female was discovered in her apartment by police, who called an ambulance for transport to the hospital, after her neighbors had not seen her in several days. The patient received IV hydration, and her labs show microcytic hypochromic anemia. She is admitted to inpatient psychiatry for evaluation and treatment of what is thought to be a hoarding disorder. Which need is of primary concern to the PMHNP?

A. Adequate nutrition, hydration, and safety planning

B. The patient feeling a sense of belonging

C. The patient attends psychosocial rehab groups

D. The patient requires forms for the Family Medical Leave Act

A

Answer A. Physiological needs must take priority over psychological needs. According to Maslow’s hierarchy physiological needs include sex, food, water, warmth, and rest, followed by safety needs, then psychological needs of love and belonging, esteem needs including prestige and feelings of accomplishment, and finally self-actualization defined as achieving one’s full potential and using creative energy.

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56
Q

3-11. A 60-year-old man with alcohol use disorder in remission presents to the psychiatric ED and is very distraught. He tells the PMHNP that he was at his daughter’s wedding and called upon to make a toast. The waiter had handed him the champagne glass, and he took a sip of alcohol for the first time in 10 years. He tells the PMHNP that he is concerned he may relapse and go back to his old ways. What is the best response by the PMHNP?

A. “Don’t worry; it was only one drink.”

B. “How have you been able to maintain your sobriety for so long?”

C. Tell the patient he will be admitted to inpatient rehab.

D. Start the patient on naltrexone 50 mg daily for alcohol use disorder

A

Answer B. Enhancing the patient’s self-efficacy by having him reflect on the effective strategies that have been previously working for him will reduce his risk of relapse. Telling a patient not to worry is invalidating. It is not appropriate to admit a patient to inpatient rehab as he has not relapsed but lapsed. Starting the patient on naltrexone for daily use may be appropriate as part of enhancing sobriety, but the Sinclair method, in this case, is a more tailored response and does not negate his adaptive coping mechanisms for the last 10 years.

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57
Q

3-12. A 25-year-old female, admitted to an extended observation psychiatric unit, observes that another patient is placed on 1:1 observation status after expressing suicidal ideations to her psychiatrist. During her meeting with the PMHNP, the patient tells him that she would like to have 1:1 observation because she too is feeling suicidal. What is the best response by the PMHNP?

A. “What is your plan to commit suicide?”

B. “I will place you on 1:1 status, your safety is very important to us.”

C. Order Haldol 5 mg, and Ativan 2 mg PO X 1 now.

D. Put the patient in therapeutic seclusion to prevent self-harm.

A

Answer A. Patients may express suicidal ideation, but the PMHNP must assess further to determine lethality, means, coping strategies, and protective factors. Before prescribing a treatment, a complete assessment is necessary.

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58
Q

3-13. A middle-school girl who is timid to take any risks, prefers solitary activities, and does not ask questions of her teachers for fear that she is bothering them likely did not master which developmental stage?

A. Trust versus mistrust

B. Autonomy versus shame and doubt

C. Industry versus inferiority

D. Initiative versus guilt

A

Answer D. Failing to master the stage of initiative versus guilt inhibits the development of purpose and virtue, and children remain followers, lack self-initiative, and can feel like they are a bother to others. Middle-school children are in the stage of development of industry versus inferiority and moving toward identity versus role confusion.

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59
Q

3-14. A 66-year-old registered nurse, who retired from psychiatry 3 years ago, spends much of her time watching television. She is easily irritated by those interrupting her shows and has no desire to engage in any activities or identify with a broader community. Which developmental stage did she fail to master?

A. Generativity versus stagnation

B. Ego integrity versus despair

C. Industry versus inferiority

D. Initiative versus guilt

A

Answer A. Mastering the developmental stage of generativity versus stagnation leads to the development of caring as a virtue and a desire to be a part of a broader community, leave a legacy, and feel useful. Failing to master this stage yields a lack of interest in the broader community, and feelings of leading a disconnected existence with a nothing to contribute.

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60
Q

3-15. A woman who discovers her husband has committed suicide in the middle of the night decides to tell her 4- and 6-year-old children the next morning that the reason daddy is not here today is that he went to work. Based on their developmental stage, what might they assume when mommy says she is going to work?

A. Going to work means you are not coming home

B. Mommy will come home, as has been the case in the past

C. When someone cannot be seen, then they cease to exist

D. Daddy will come home when mommy goes to work

A

Answer A. Children in this stage are considered preoperational and have an organized schema that has helped them understand that when people go to work, they come back. Thinking at this stage is egocentric and magical. Introducing this new accommodation to the children will make them think that when mommy goes to work, she will not be returning home.

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61
Q

3-16. A mother of a teenage boy is unable to acknowledge that her son’s mental illness is perpetuated by his poly substance use disorder and is insisting that his father’s genes are to blame. Which defense mechanism is employed?

A. Reaction formation

B. Regression

C. Denial

D. Dissociation

A

Answer C. Denial is the not acknowledging an ego dystonic reality. Reaction formation is displacing angry feelings with extremely warm feelings. Regression is characterized by the individual abandoning age-appropriate coping strategies in favor of an earlier, more childlike pattern (e.g., high-pitched voice with up speaking). Dissociation is detaching from the immediate stress, in reality, to protect the ego from a complete loss of reality as in psychosis.

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62
Q

3-17. A 36-year-old Korean male who has recently started attending graduate school complains of persistent abdominal pain despite an extensive gastrointestinal work-up including an upper and lower gastroscopy. Which of the following defense mechanisms is employed?

A. Conversion

B. Dissociation

C. Denial

D. Reaction formation

A

Answer A. Conversion disorder is the manifestation of physical symptoms due to psychological stressors or angst. Dissociation is detaching from the immediate stress, in reality, to protect the ego from a complete loss of reality as in psychosis. Denial is not acknowledging an ego dystonic reality. Reaction formation is displacing angry feelings with extremely warm feelings.

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63
Q

3-18. The PMHNP is treating a client for generalized anxiety disorder with depressive symptoms. Treatment has included both psychopharmacology and interpersonal psychotherapy. The patient abruptly reports a reemergence of the symptoms that have been in remission. In what phase of therapy is this an expected finding?

A. Orientation

B. Working/treatment

C. Termination

D. Acclimation

A

Answer C. During the termination phase of a therapeutic relationship, the client may experience reemergence of symptoms previously in remission as a manifestation of regression and resistance to termination. During the orientation phase, the patient may demonstrate symptoms of a reluctance to disclose, avoidance, guardedness, ambivalence, and elation. During the working treatment phase the patient may manifest transference, increased resistance, increased ambivalence, and threaten early termination.

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64
Q

3-19. All of the following are attributes of cultural care that may influence the therapeutic alliance except

A. Religion

B. Gender roles

C. Beliefs

D. Urban setting

A

Answer D. The aspects of cultural care that may influence the therapeutic alliance include the patient’s values, beliefs, generational influences, gender roles, and religion. The current physical location of the episode of care is not an influencing cultural factor.

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65
Q

3-20. Anxiety can arise from intrapsychic conflict among the structures of the mind. Which structure of the mind deals with reality testing and the thinking process?

A. Id

B. Ego

C. Superego

D. Defense mechanisms

A

Answer B. The Ego is the structure of the conscious, rational mind that deals with reality testing and thinking processes. The Id is the primitive, pleasure-driving structure, and the Superego is the mediator between the Id and the Ego and deals with morality.

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66
Q

4-01. The PMHNP is evaluating a 68-year-old man for symptoms of major depression. While assessing the appearance of the patient, an obvious left-sided ptosis is noted. Which cranial nerve is directly linked to this condition?

A. III

B. IV

C. V

D. VI

A

Answer A. Cranial nerve III oculomotor coordinates eye movements including eye lid function and pupillary dilation. Cranial IV (throchlea) allows for the downward medial gaze, V (trigeminal nerve) is associated with the mandible function of mastication, VI (abducens) allows for eye movement in the downward motion.

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67
Q

4-02. A 55-year-old woman has been referred for a psychiatric evaluation for a change in personality, lack of impulse control, and increasingly reckless decision-making. Which area of the brain would be responsible for these symptoms?

A. Parietal lobe

B. Broca’s area

C. Wernicke’s area

D. Frontal lobe

A

Answer D. Frontal lobe controls voluntary movement, ability to project future consequences, governs social cues, reasoning, planning, and parts of speech. The parietal lobe is associated with sensory integration, attentiveness, and spatial awareness. Broca’s area (although located in the frontal lobe of the dominant hemisphere) specifically is associated with speech production (fluency); Wernicke’s area is associated with comprehension.

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68
Q

4-03. A patient was recently started on a dopamine antagonist, and complains of breast tenderness and a milky discharge. What is the most likely explanation for these symptoms?

A. Dopamine transmission in the nigrostriatal pathway

B. Dopamine transmission in the tuberoinfundibular pathway

C. Dopamine transmission in the mesolimbic pathway

D. Dopamine increases throughout the basal ganglia

A

Answer B. The tuberoinfundibular pathway transmits dopamine from the hypothalamus to the pituitary gland and increases the secretion of prolactin releasing hormone, in turn creating hyperprolactinemia. The nigrostriatal pathway transmits dopamine from to the midbrain to the caudate nucleus which can trigger various movement disorders. The mesocorticllimbic pathway transmits dopamine to the prefrontal cortex and midbrain, and disorders in this pathway are associated with thought disorders.

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69
Q

4-04. A patient who was recently started on haloperidol for psychosis begins to manifest hand tremor, and a shuffling gait. What is the most likely explanation for these symptoms?

A. Dopamine transmission in the nigrostriatal pathway

B. Dopamine transmission in the tuberoinfundibular pathway

C. Dopamine transmission in the mesolimbic pathway

D. Dopamine increases throughout the basal ganglia

A

Answer A. The nigrostriatal pathway transmits dopamine from to the midbrain to the caudate nucleus which can trigger various movement disorders. The tuberoinfundibular pathway transmits dopamine from the hypothalamus to the pituitary gland and increases the secretion of prolactin releasing hormone, in turn creating hyperprolactinemia. The mesocorticllimbic pathway transmits dopamine to the prefrontal cortex and midbrain, and disorders in this pathway are associated with thought disorders.

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70
Q

4-05. A 72-year-old man with a comorbid history of uncontrolled hypertension is referred to the PMHNP for dementia secondary to depression. The mental status exam reveals difficulty speaking fluently, inappropriate and confabulated responses, incongruent affect, and poor judgment. A cerebrovascular accident in which region of the brain would better explain these symptoms?

A. Parietal lobe

B. Wernicke’s area

C. Broca’s area

D. Occipital lobe

A

Answer C. Broca’s area, located in the dominant hemisphere of the brain, is associated with speech production and fluency; dysfunctions in this area are associated with incongruent affect, decreased motivation, impaired judgment and attention, and confabulation. Wernicke’s area is associated with comprehension. The parietal lobe is the area of sensory integration, spatial awareness, and conscious awareness of the opposite side of the body. The occipital lobe is associated with the visual cortex and receives signals through the optic tract and interprets color, form, and movement of visually perceived objects.

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71
Q

4-06. Which region of the brain is associated with sensory integration, spatial awareness, and conscious awareness of the opposite side of the body?

A. Occipital lobe

B. Wernicke’s area

C. Broca’s area

D. Parietal lobe

A

Answer D. The parietal lobe is the area of sensory integration, spatial awareness, and conscious awareness of the opposite side of the body. The occipital lobe is associated with the visual cortex signals through the optic tract and interprets color, form, and movement of visually perceived objects. Broca’s area, located in the dominant hemisphere of the brain, is associated with speech production and fluency; dysfunctions in this area are associated with incongruent affect, decreased motivation, impaired judgment and attention, and confabulation. Wernicke’s area is associated with comprehension.

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72
Q

4-07. A patient appears internally preoccupied and responding to auditory hallucination. This patient may have a pathology affecting which lobe of the brain?

A. Temporal lobe

B. Occipital lobe

C. Parietal lobe

D. Cerebellum

A

Answer A. The temporal lobe is the primary auditory area of the brain. The occipital lobe is associated with the visual cortex signals through the optic tract and interprets color, form, and movement of visually perceived objects. The parietal lobe is the area of sensory integration, spatial awareness, and conscious awareness of the opposite side of the body.

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73
Q

4-08. A patient presents with atypical symptoms of psychosis that include inconsistent auditory hallucinations without disorganization. What is the best definition of an EEG and its utility?

A. Radiologic test utilizing magnets and radio waves to provide a detailed image of the structures of the brain

B. Electrophysiologic test that depicts electrical activity on the surface of the brain

C. A serum test to indicate nutritional deficiencies that inhibit the formation of neurotransmitters

D. A neuropsychological test to distinguish psychosis from a psychosomatic illness.

A

Answer B. An EEG is an electrophysiological test that depicts electrical activities as various waveforms from the surface of the brain; these may indicate an ectopic stimulus that may be responsible for neurological symptoms. An MRI is a nonradioactive imaging test that uses magnets and radio waves to provide a detailed image of the structures of the brain. No serum test exists to distinguish nutritional deficiencies responsible for the formation of neurotransmitters. A genetic test exists for methyl-tetrahydrofolate reductase (MTHFR) expression, indicating the ability to convert folic acid to L-methylfolate. Neuropsychological tests are psychometrically sound measurement tools in which the scores are computed to support evidence for a particular diagnosis and focused on the functional correlation associated with an area of the brain.

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74
Q

4-09. Neurons that only travel from the body to the brain are called:

A. Sensory neurons

B. Motor neurons

C. Interneurons

D. Astrocytes

A

Answer A. Sensory neurons are afferent fibers transmitting information from stimuli from the body to the brain. Motor neurons are efferent fibers conducting impulses from the brain to the body. Interneurons are a neuronal circuit allowing for communication between motor and sensory neurons, especially within the reflex arc. Astrocytes are star-shaped cells; they provide nutrients and maintain the extracellular ionic balance involved in growth and repair of nerve cells to maintain the blood-brain barrier.

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75
Q

4-10. The part of the neuron that takes in and receives messages is called:

A. Dendrite

B. Axon

C. Synapse

D. Node of Ranvier

A

Answer A. Dendrites transmit information to the soma. Axons transmit information from the soma. A synapse is the gap between two nerve cells. The node of Ranvier is a gap between the myelin sheaths of Schwann cells and the uninsulated ion channel.

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76
Q

4-11. What is the fatty layer that prevents interference and increases the speed of impulse transmission along the axon?

A. Dendrite

B. Axon

C. Synapse

D. Myelin sheath

A

Answer D. The myelin sheath is the fatty layer that prevents interference and increases the speed of impulse transmission along the axon. Dendrites transmit information to the soma. Axons transmit information from the soma. A synapse is the gap between two nerve cells.

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77
Q

4-12. Which of the following receives messages and conducts impulses to the soma?

A. Dendrite

B. Axon

C. Synapse

D. Myelin sheath

A

Answer A. Dendrites transmit information to the soma. Axons transmit information from the soma. Synapses are the gap between two nerve cells. The myelin sheath is the fatty layer that prevents interference and increases speed of impulse transmission along the axon.

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78
Q

4-13. The junction between two neurons is known as the:

A. Dendrite

B. Node of Ranvier

C. Synapse

D. Soma

A

Answer C. A synapse is the gap between two nerve cells. Dendrites transmit information to the soma. The node of Ranvier is a gap between the myelin sheaths of Schwann cells and the uninsulated ion channels. The soma is the body of the nerve cell containing the nucleus.

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79
Q

4-14. When explaining the means by which neurotransmitters relate to mental illness, a patient ask, “What is a neurotransmitter?” The best answer is:

A. A fatty layer covering the axon

B. A chemical messenger

C. A nerve cell

D. The space between nerve cells

A

Answer B. A neurotransmitter is a chemical messenger, created from dietary substrates, that transmits information between neurons. The myelin sheath is the fatty layer that prevents interference and increases the speed of impulse transmission along the axon. The soma is the body of the nerve cell containing the nucleus. Synapse is the gap between two nerve cells.

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80
Q

4-15. A patient is diagnosed with major depressive disorder with the most prominent feature of apathy, anhedonia, and isolation. Which neurotransmitter is associated with the symptoms?

A. Serotonin

B. Gamma-aminobenzoic acid (GABA)

C. Dopamine

D. Cannabinoids

A

Answer C. Dopamine increases a sense of well-being and satisfaction; it is the primary driver of the reward system. Serotonin reduces pain perception and enhances satiety. Gamma-aminobenzoic acid (GABA) is primarily inhibitory; it increases sleepiness and reduces anxiety, memory, and alertness. Cannabinoids increase hunger and reduce motivation and sex drive.

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81
Q

4-16. The PMHNP prescribes fluoxetine to treat depression. Which neurotransmitter will be made readily available in the synapse?

A. Dopamine

B. Serotonin

C. Gamma-aminobenzoic acid (GABA)

D. Acetylcholine

A

Answer B. Serotonin reduces pain perception and enhances satiety. Gamma-aminobenzoic acid (GABA) is primarily inhibitory; it increases sleepiness and reduces anxiety, memory, and alertness. Dopamine increases a sense of well-being and satisfaction; it is the primary driver of the reward system. Acetylcholine increases heart rate, muscle contractions, salivation, and sweating; it is prescribed to enhance memory.

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82
Q

4-17. The PMHNP in the ED is evaluating a 68-year-old woman who was recently diagnosed with mild cognitive impairment and cannot remember the name of the medication that she has recently started 1 week ago. The patient is complaining of increased heart rate, sweating, and muscle spasms progressively worsening for the last 3 days. Which neurotransmitter is associated with this adverse effect?

A. Serotonin

B. Acetylcholine

C. Gamma-aminobenzoic acid (GABA)

D. Dopamine

A

Answer B. Acetylcholine increases heart rate, muscle contractions, salivation, and sweating; it is prescribed to enhance memory. Serotonin reduces pain perception and enhances satiety. Gamma-aminobenzoic acid (GABA) is primarily inhibitory; it increases sleepiness and reduces anxiety, memory, and alertness. Dopamine increases a sense of well-being and satisfaction; it is the primary driver of the reward system.

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83
Q

4-18. Which of the following neurotransmitters exert inhibition over neuronal function?

A. Acetylcholine

B. Cannabinoids

C. Gamma-aminobenzoic acid (GABA)

D. Dopamine

A

Answer C. Gamma-aminobenzoic acid (GABA) is primarily inhibitory; it increases sleepiness and reduces anxiety, memory, and alertness. Acetylcholine increases heart rate, muscle contractions, salivation, and sweating; it is prescribed to enhance memory. Cannabinoids increase hunger and reduce motivation and sex drive. Dopamine increases a sense of well-being and satisfaction; it is the primary driver of the reward system.

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84
Q

4-19. A patient with alcohol use disorder is admitted for detox in anticipation of admission to an inpatient rehabilitation facility. The patient takes metoprolol for hypertension, which he has forgotten to take today, and his last drink was 72 hours ago. Which tool should the PMHNP use to evaluate for symptoms of withdrawal?

A. Hamilton Rating Scale for Depression

B. Clinical Institute Withdrawal Assessment

C. Vital signs

D. Quick Inventory of Depressive Symptomatology

A

Answer B. Clinical Institute Withdrawal Assessment (CIWA) is a nine-item, clinician-observed rating scale to quantify the severity of alcohol withdrawal. The Hamilton Rating Scale for Depression is a self-report scale to measure depressive symptoms, and is commonly used at baseline and to measure treatment progress. Vital signs are a nonspecific measure of hemodynamic stability. The Quick Inventory of Depressive Symptomatology is a self-report survey assessing the severity of depressive symptoms.

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85
Q

4-20. A 45-year-old man presents for a follow-up visit after starting on an SSRI 2 weeks ago for major depressive disorder. Which assessment tool would be the best indicator of progress?

A. Geriatric Depression Scale

B. The Young Mania Rating Scale

C. Yale-Brown Obsessive Compulsive Scale

D. Quick Inventory of Depressive Symptomatology

A

Answer D. Quick Inventory of Depressive Symptomatology is a self-report survey assessing the severity of depressive symptoms. The Geriatric Depression Scale is a self-report binary questionnaire used to measure depressive symptoms (concentration, self-image, agitation, losses, motivation, obsessive traits) in older adults.

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86
Q

5-01. The PMHNP knows that the study of how the body absorbs, distributes, metabolizes, and excretes a medication is known as:

A. Breakdown

B. Pharmacokinetics

C. Pharmacodynamics

D. First-pass effect

A

Answer B. Pharmacokinetics is the study of what the body does to a drug concerning absorption, distribution, metabolism, and excretion (ADME). The breakdown is one aspect of metabolism in which the drug is prepared for bodily excretion. Pharmacodynamics is the study of the relationship between drug concentration and effect on the body. First-pass effect is the uptake and conversion of the drug in the liver after enteric absorption.

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87
Q

5-02. After a drug is absorbed the substrate binds to protein for transport. Which portion of the drug is available for therapeutic effects?

A. Bound

B. Unbound

C. Metabolized

D. Excreted

A

Answer B. Unbound drug is the portion of the drug available for therapeutic effects. Bound is the part of the drug that binds to protein and fat in preparation for excretion. Metabolization is the process in which a drug is prepared for excretion. Excretion is the process in which a substance leaves the body.

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88
Q

5-03. A 19-year-old male is referred to the PMHNP by the student health office for alcohol use disorder. The patient states that on one occasion he passed out much sooner than he usually would with far less than he would usually drink. Upon further interview, the patient reveals the time he passed out was during a fraternity hazing in which he was butt-chugging (receiving a beer and vodka enema). What pharmacokinetic process was bypassed by this rectal administration route?

A. Excretion

B. Absorption

C. Distribution

D. First-pass effect

A

Answer D. The first-pass effect is the precirculation process of uptake and conversion by which a substrate is significantly reduced through the CYP450 pathway. Nonenteric routes of administration bypass this effect. Excretion is the process by which substances leave the body. Absorption is the movement of the drug into the bloodstream. Distribution is the movement of the drug through the bloodstream to target receptors where protein binding occurs.

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89
Q

5-04. The PMHNP is monitoring a serum drug level for a medication with a 24-hour half-life. How many hours will it take to reach steady state?

A. 48 hours

B. 72 hours

C. 96 hours

D. 120 hours

A

Answer D. 120 hours; steady state is achieved in five half-lives of the medication (5 × 24 = 120).

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90
Q

5-05. A patient with schizophrenia was discharged from the hospital on olanzapine 5 mg twice a day. He immediately resumed smoking cigarettes and escalated to one pack per day. Upon presenting for his 1-week follow-up appointment, the patient reports he is having trouble sleeping and the voices have started to return. Which of the following actions should the PMHNP take?

A. Send the patient to the ED for stabilization

B. Change to another antipsychotic medication, and refer to a psychiatrist

C. Increase his olanzapine, and schedule a follow-up visit in 2 days

D. Tell him to stop smoking and give him a nicotine patch

A

Answer C. Increase his olanzapine and schedule a follow up visit because the patient’s symptoms are no longer controlled and smoking is a known inducer of the CYP450 pathway. The patient has not indicated a threat of harm to self or others; changing to another antipsychotic medication requires retitration and is not indicated. Telling a patient to stop smoking may trigger a psychological paradox and can erode therapeutic alliance.

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91
Q

5-06. A patient who has been stable on quetiapine (Seroquel XR) for 3 months has decided to start to drink grapefruit juice twice daily because she has heard it helps with weight loss. She calls to report that since her new diet she has been feeling fatigue and difficulty waking up in the morning. What is the best response by the PMHNP?

A. “I will put in a new prescription for a lower dose of your medication.”

B. “Stop drinking the grapefruit juice, and schedule an appointment to discuss the matter further.”

C. “I will prescribe you a stimulant, and see you in 2 weeks.”

D. “You should make an appointment with your primary care provider for evaluation.”

A

Answer B. Stop drinking the grapefruit juice and schedule an appointment to discuss weight gain/weight loss. Grapefruit is a known inhibitor of the CYP450 pathway; stopping this will reduce the sedation over time. It is not appropriate to prescribe this patient a stimulant as the cause has not been determined. Deferring the patient to primary care is not suitable as there is a potential psychotropic drug interaction.

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92
Q

5-07. A 79-year-old female with no past psychiatric history is admitted with new onset auditory hallucinations. The patient states her most bothersome symptom is the voices, which have kept her from sleeping through the night for the last 3 weeks, and as a result, she is tired and irritable. Which medication should the PMHNP order for bedtime for sleep?

A. Olanzapine 2.5 mg PO

B. Lorazepam 1 mg PO

C. Chlorpromazine 50 mg PO

D. Sertraline 50 mg PO

A

Answer A. Olanzapine is an atypical antipsychotic that can help the patient sleep. Because of the patient’s age, it is essential to start at a low dose and slowly titrate as tolerated. Benzodiazepines are not preferred in the elderly as they increase risk especially at higher starting doses. 92Chlorpromazine potentiates many anticholinergic effects particularly at high starting doses. Sertraline is not sedating, and the dose should be started lower in the elderly.

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93
Q

5-08. A 16-year-old male with a history of smoking cigarettes and marijuana is being evaluated at the request of the school and parents. The child states that the reason he smokes is it “helps calm me down” as he is anxious all the time. Which of the following medications would be the best choice?

A. Fluoxetine 20 mg PO daily

B. Clonazepam 0.5 mg PO daily

C. Vortioxetine 20 mg daily

D. Citalopram 5 mg PO daily

A

Answer A. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) with a long half-life, approved in children for depression and anxiety. Children’s dosages should be started at the usual (not lower dose) given their faster metabolisms. Clonazepam is a benzodiazepine and should be avoided given the high potential for abuse and addiction in a patient who is demonstrating illegal behavior. Vortioxetine is not approved in children, and citalopram, while approved, is at too low a dose for starting in children.

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94
Q

5-09. A patient has had a pharmacogenomic test, which reveals he is an extensive metabolizer on CYP450, 1A2, 2D6, and 3A4. The PMHNP should prescribe:

A. A lower than usual dose

B. The usual dose

C. A higher than usual dose

D. A different medication

A

Answer B. Extensive metabolizers are normal, and medications should be prescribed according to the prescriber’s information. Poor metabolizers have two defective genes and require lower doses of medicine and a long titration schedule and may not be able to achieve therapeutic effect. Slow metabolizers need lower doses of medicine as well. Ultra-rapid metabolizers need higher doses of drug. Changing the drug would not be appropriate as extensive metabolizers are normal.

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95
Q

5-10. A woman in her 20th week of pregnancy has been resumed on lithium for bipolar disorder. The PMHNP knows that the patient may become subtherapeutic despite taking the medication as prescribed due to:

A. Increased blood volume

B. Increased fetal metabolism

C. Reduced muscle mass

D. Reduced blood volume

A

Answer A. Increased blood volume occurs as pregnancy progresses and patients may need higher doses of medication to maintain concentration effects. Fetal metabolism has no impact on maternal metabolism, but caution is exercised for potential adverse effects to the fetus. Pregnant women do not have decreased muscle mass or reduced blood volume.

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96
Q

5-11. The PMHNP knows the relationship between drug concentration and effect on the body is known as:

A. Pharmacology

B. Pharmacokinetics

C. Pharmacodynamics

D. Physiology

A

Answer C. Pharmacodynamics is the study of the relationship between drug concentration and effect on the body. Pharmacology is the study of medication uses, effects, and modes of action. Pharmacokinetics is concerned with the body’s effect on the drug concerning absorption, distribution, metabolism, and excretion. Physiology is a biological branch concerned with normal functions of an organism.

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97
Q

5-12. A patient who had previously reported feeling much better on her antidepressant suddenly says the “drug seems to have stopped working. This is known as:

A. Tolerance

B. Tachyphylaxis

C. Side effect

D. Adverse effect

A

Answer B. Tachyphylaxis is the rapidly diminishing responsiveness to increasing doses of the medication, also known as the poop-out effect. Tolerance is the process of becoming desensitized and therefore less responsive to a particular dose of medication over time, thereby requiring an increase.

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98
Q

5-13. A medication that works by receptor activation to produce a biological response is an:

A. Agonist

B. Enzyme inhibitor

C. Inverse agonist

D. Antagonist

A

Answer A. An agonist is a medication that works by receptor activation to produce a biological effect. An enzyme inhibitor slows the catalytic action of the enzyme and allows neurotransmitters to remain in circulation. An inverse agonist is a medication that binds to the same receptor as an agonist but induces an opposite biological response. An antagonist is a medication that blocks a receptor and inhibits a biological response, even from endogenous agonists.

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99
Q

5-14. A drug that binds to a receptor but does not fully activate it, producing a muted biological response, is a(n):

A. Agonist

B. Enzyme inhibitor

C. Partial agonist

D. Antagonist

A

Answer C. Partial agonists bind to a receptor but do not fully activate it, and produce a muted biological response. An agonist is a medication that works by receptor activation to produce a biological effect. An enzyme inhibitor slows the catalytic action of the enzyme, and allows neurotransmitters to remain in circulation. An antagonist is a medication that blocks a receptor and inhibits a biological response, even from endogenous agonists.

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100
Q

5-15. A drug that binds to the same receptor as an agonist, but induces an opposite biological response, is a(n):

A. Antagonist

B. Inverse agonist

C. Agonist

D. Partial agonist

A

Answer B. An inverse agonist is a medication that binds to the same receptor as an agonist but induces an opposite biological response. An antagonist is a medication that blocks a receptor and inhibits a biological response, even from endogenous agonists. An agonist is a medication that works by receptor activation to produce a biological effect. Partial agonists bind to a receptor but do not fully activate it, and produce a muted biological response.

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101
Q

5-16. A drug that blocks receptors, inhibiting a biological response, is known as a(n):

A. Partial agonist

B. Inverse agonist

C. Antagonist

D. Agonist

A

Answer C. An antagonist is a medication that blocks a receptor to inhibit a biological response even from endogenous agonists. Partial agonists bind to a receptor but do not fully activate it, and produce a muted biological response. An inverse agonist is a medication that binds to the same receptor as an agonist but induces an opposite biological response. An agonist is a medication that works by receptor activation and produces a biological effect.

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102
Q

5-17. One of the most common electrolyte abnormalities associated with the use of psychotropic medication is:

A. Hyperkalemia

B. Hypercalcemia

C. Hyponatremia

D. Hypernatremia

A

Answer C. Hyponatremia is the most common electrolyte abnormality associated with psychotropic medication; the condition is called drug-induced syndrome of inappropriate 93antidiuretic hormone secretion. Hyperkalemia is related to renal insufficiency, which can be acute or chronic. Hypercalcemia is associated with neoplastic disorders and abnormal bone metabolism and resorption. Hypernatremia is related to a water deficit.

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103
Q

5-18. A patient who has been stable on his long-acting injectable medication tells the PMHNP that he would like to quit smoking. What is the best response?

A. “Good for you, I can prescribe you a nicotine patch to help.”

B. “Let us make an appointment as your medication dose may need to be lowered.”

C. “I will refer you to a smoking cessation support group.”

D. “I am glad you have decided to quit smoking.”

A

Answer B. Making an appointment with the patient for psychoeducation and careful medication adjustment is most appropriate as the patient may become more sedated when the inducing properties of cigarette smoke are less present in the system. Verbal reinforcement and prescribing a medication sight unseen is not the preferred response. Referring the patient to smoking cessation, while helpful, does not address the potential drug–drug interactions. Expressing encouragement for healthy behaviors would be insufficient in this case.

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104
Q

5-19. A patient has been taking valproic acid for mood stabilization from a manic episode but is still not sleeping through the night. His last drug level was 50 mcg/mL. The PMHNP notices the patient seems disoriented to time and is flapping his wrists. What should the PMHNP do next?

A. Give the patient lactulose 20 g PO

B. Draw an ammonia level

C. Increase the dose of valproic acid

D. Augment with an atypical antipsychotic

A

Answer B. Patients can develop encephalopathy due to hyperammonemia when taking valproic acid. It is essential to check the ammonia level before treating the patient. Increasing the dose of medication would worsen the situation, and adding another agent does not address the underlying problem.

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105
Q

5-20. A patient who has been taking paroxetine for 3 years wants to come off due to sexual side effects. He had gradually tried to wean the dose on his own but noticed feelings of dizziness, fatigue, headaches, anxiety, and electric-like shocks in his head. These findings are most consistent with SSRI discontinuation. What would be a reasonable action for the PMHNP to take?

A. Reassure the patient that the symptoms will go away eventually

B. Prescribe the patient fluoxetine for 1 week

C. Have the patient resume the paroxetine and prescribe the patient a PD5-inhibitor

D. Start the patient on an antipsychotic for his somatic delusions

A

Answer B. Prescribing the patient fluoxetine (a long half-life selective serotonin reuptake inhibitors [SSRI]) will reduce the discontinuation syndrome symptoms. Reassuring the patient may provide some psychological comfort, but it does not address the physical distress of the patient. Resuming the medication and prescribing a second agent for sexual dysfunction does not solve the present problem. There is no evidence that the patient is having a somatic delusion as discontinuation syndrome is well documented in the literature associated with paroxetine.

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106
Q

6-01. A systematic inquiry that elaborates on the chief complaint while eliciting pertinent positive and pertinent negative factors from the history is known as:

A. The mental status exam

B. Review of systems

C. Physical exam

D. Diagnostic formulation

A

Answer B. The review of systems describes the systematic inquiry that elaborates on the chief complaint and elicits pertinent positive and pertinent negative factors from the health history. The mental status exam is a neuropsychological test used to classify observations associated with a psychiatric disorder. The physical exam is an organized approach to gather objective data from the patient’s body regions and organ systems. The diagnostic formulation is an articulate summary of biopsychosocial findings that account for the patient’s chief complaint.

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107
Q

6-02. The mental status exam includes all of the following except:

A. Appearance and behavior

B. Mood and affect

C. Cranial nerves and reflexes

D. Insight and judgment

A

Answer C. Cranial nerves and reflexes are complements of the physical exam. The mental status exam includes assessments of appearance, behavior, mood, affect, insight, and judgment.

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108
Q

6-03. A 72-year-old female presents to the emergency department for altered mental status. Her urine analysis is negative, and her labs are normal. She has been referred to psychiatry for dementia. The patient’s husband reports increasing forgetfulness over the last 6 months, walking as if her feet are stuck to the ground, and most recently episodes of urinary incontinence. Based on the signs and symptoms which of the following diagnostic tests should the PMHNP order to rule out an underlying condition?

A. Lumbar puncture

B. Noncontrast head CT scan

C. Arterial blood gas

D. Electroencephalogram

A

Answer B. A noncontrast head CT scan is helpful in excluding the diagnosis of normal pressure hydrocephalus, which presents with an abnormal (magnetic) gait, urinary incontinence, and cognitive decline. Lumbar puncture is used to diagnose infectious, autoimmune issues, and paraneoplastic syndromes associated with the nervous system. Arterial blood gases are used to measure concentrations of atmospheric gases in patients with respiratory distress. An electroencephalogram is used to measure brain wave activity in people with suspected seizure and sleep disorders.

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109
Q

6-04. The condition in which the patient is unable to discriminate between objects based on touching is known as:

A. Agraphesthesia

B. Choreiform

C. Astereognosis

D. Dysdiadochokinesia

A

Answer C. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements.

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110
Q

6-05. The PMHNP is conducting a neurological examination on a patient with altered mental status. The inability to perform rapidly alternating hand movements is known as:

A. Agraphesthesia

B. Choreiform

C. Astereognosis

D. Dysdiadochokinesia

A

Answer D. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching.

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111
Q

6-06. The PMHNP is observing a patient making repetitive and rapid jerking involuntary coordinated movements. In documenting the findings of the mental status exam, which of the following concisely describes this behavior?

A. Agraphesthesia

B. Choreiform

C. Astereognosis

D. Dysdiadochokinesia

A

Answer B. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements.

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112
Q

6-07. The PMHNP is supervising a nurse practitioner student. When presenting the case, the student notes that the patient has an inability to recognize letters or numbers drawn on the palm with a pointed object. This sign is called:

A. Agraphesthesia

B. Choreiform

C. Astereognosis

D. Dysdiadochokinesia

A

Answer A. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements.

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113
Q

6-08. A patient is started on lamotrigine for bipolar depression. The patient complained of a rash comprised of blistering skin and mouth sores after a dose increase. The blood work reveals normal renal and liver function. Which type of drug rash is most likely?

A. DRESS syndrome

B. Stevens–Johnson syndrome

C. Psoriasis

D. Atopic dermatitis

A

Answer B. Stevens–Johnson syndrome is a specific, life-threatening drug rash characterized by blisters giving way to dermis and hives on the lining of any mucous membranes. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is associated with a rise in eosinophils, liver enzymes, renal insufficiency, and positive cardiac enzymes. Psoriasis is characterized by scaly patches and erythema, and can exacerbate with streptococcal and viral infections, and exposure to immunizations and antimalarial drugs. Atopic dermatitis is a common inflammatory skin disease which varies in presentation from dry skin scales to blisters and fissuring.

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114
Q

6-09. In observing the appearance of the patient with depression and a history of systemic lupus erythematosus, the PMHNP notices a lesion on the neck of the patient about the size of a pencil eraser, flush with the skin, uniformly colored, with discrete borders and consistent texture. The PMHNP should:

A. Refer the patient to dermatology

B. Refer the patient to rheumatology

C. Refer the patient to oncology

D. Watch and wait

A

Answer D. Watching and waiting is appropriate in this scenario, as long as moles are <6 mm, flush with the skin, symmetrical in size, shape, texture, and color, and have regular borders. The lesion does not have characteristics consistent with cancerous lesions or autoimmune pathology.

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115
Q

6-10. A 35-year-old man diagnosed with bipolar disorder mentions to his PMHNP that he had felt a lump on his left testicle. He is concerned he has not had a physical exam in 10 years. What is the best action by the PMHNP?

A. Perform a urogenital exam and order an ultrasound

B. Explore the reason for not having had a physical in so long

C. Refer him to his primary care provider

D. Refer him to urology

A

Answer B. Exploring the reasons for not having had a physical exam in 10 years will help provide the necessary information for anticipatory guidance as the patient undergoes diagnostic investigation. Urogenital exams are generally not performed by psychiatric providers. Referring the patient to his primary care provider or urology would be appropriate but without further assessment specific barriers to accessing care remain unknown.

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116
Q

6-11. A 26-year-old female is diagnosed with psychosis not otherwise specified (NOS) and substance use disorder. Which of the following lab tests should be ordered prior to starting antipsychotic medications?

A. Hemoglobin A1C, lipid profile, EKG

B. Urinalysis, urine pregnancy test

C. Amylase, lipase, liver function test

D. Cardiac enzymes, brain naturetic peptide

A

Answer A. Antipsychotic medications are known to accelerate the onset of type 2 diabetes mellitus and dyslipidemia, and prolong the QTc interval; baseline evaluation provides a frame of reference for ongoing treatment and monitoring. Urinalysis and a pregnancy test would not preclude or be affected by antipsychotic medications. Pancreatic and liver function tests are not known to be affected by antipsychotic medications. Cardiac enzymes and brain naturetic peptide are used to evaluate cardiac function, which can be affected by clozapine-induced myocarditis, but require clinical correlation to confirm suspicion, and should not be ordered de novo.

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117
Q

6-12. A 57-year-old man was evaluated in the ED for altered mental status. His head CT scan is negative, white blood cells are 6,000, urinalysis negative for infection with positive ketones, serum glucose is 120 mg/dL, sodium is 148, blood urea nitrogen 22, creatinine 1.8, and cardiac enzymes are negative. Neurology has cleared him for an acute event, and the ED physician has cleared him for psychiatry. The PMHNP evaluating him obtained collateral information that the patient has been in bed for 3 days, and not eating or drinking because the voices tell him the food is bad and the water is contaminated. What should the nurse practitioner do first?

A. Order 1 L normal saline at 100 mL/hr

B. Order Haldol 5 mg PO × 1

C. Order a lumbar puncture

D. Order hemoglobin A1C and lipid profile

A

Answer A. The clinical history and lab findings are suggestive of dehydration, which can account for delirium; this must be excluded prior to diagnosing a psychiatric disorder. Haldol is an antipsychotic medication with sedating effects, which would cloud the diagnostic formulation. Lumbar puncture is ordered to rule out infections, and autoimmune and paraneoplastic syndromes with clinical suspicion. Hemoglobin A1C and lipid profiles are ordered at baseline before starting antipsychotic therapy for continued use.

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118
Q

6-13. A 30-year-old man with history of alcohol use disorder is being evaluated for altered mental status. He has a negative blood alcohol level, aspartate transaminase 100, alanine transaminase 90, hemoglobin 10, hematocrit 30, negative stool for occult blood, negative head CT scan. What further tests should the PMHNP order before diagnosing psychosis not otherwise specified?

A. EKG

B. Lipid profile

C. Hemoglobin A1C

D. Serum ceruloplasmin

A

Answer D. Serum ceruloplasmin (copper-carrying protein) is decreased in most instances of Wilson’s disease in which there is a decreased ability to incorporate copper into apoceruloplasmin, resulting in increased free copper in plasma, liver, and brain tissue. EKG, hemoglobin A1C, and lipid profile do not provide an explanation for the signs and symptoms presented.

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119
Q

6-14. The Consultation Liaison PMHNP is asked to evaluate an 88-year-old woman admitted to medicine with community acquired pneumonia for capacity regarding intubation. On evaluation the patient is inattentive and easily distracted, with waxing and waning sensorium. The patient was recently started on broad spectrum IV antibiotics. What is the most likely diagnosis?

A. Depression

B. Dementia

C. Delirium

D. Psychosis

A

Answer C. Delirium is characterized by an acute onset waxing and waning sensorium, inattentiveness, and distractibility, and can be caused by infection, new environment, and medications. Depression is a psychiatric disorder that must have symptoms present for at least 2 weeks. Dementia is a disorder characterized by chronically impaired cognition and may include changes in personality over time. Psychosis is characterized by disorganized thinking, alterations in perception of reality, and an inability to care for oneself.

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120
Q

6-15. When evaluating a new 40-year-old, 4-week postpartum woman complaining of fatigue, irritability, dry skin, and poor sleep quality for mood disorder, which of the following diagnostic tests should be ordered to aid in formulating a diagnosis?

A. Hemoglobin A1C

B. EKG

C. Thyroid-stimulating hormone (TSH) and free T4

D. Urine pregnancy test

A

Answer C. TSH and free T4 can be affected in the postpartum period and cause signs and symptoms of thyroiditis, which include fatigue and irritability. Mood disorder is a diagnosis of exclusion, which can have similar symptoms to hypothyroidism. Hemoglobin A1C, EKG, and urine pregnancy tests are not indicated as they will not account for the presenting symptoms and clinical scenario.

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121
Q

6-16. A 40-year-old man who has been on olanzapine for schizophrenia has a lipid profile indicating total cholesterol 240 mg/dL, and low-density lipoprotein (LDL) 200 mg/dL. Which of the following is recommended?

A. Lifestyle modification

B. Statin therapy

C. Serial EKGs

D. Transthoracic echocardiogram

A

Answer B. 112Statin therapy is indicated for patients with LDL >70 mg/dL with diabetes, patients with known atherosclerotic heart disease (ASCVD) and high total cholesterol, patients with an LDL >190 mg/dL, and patients with diabetes between the ages of 45 to 75.

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122
Q

6-17. A 24-year-old man has been stable on lithium 1,800 mg daily for 2 years. His most recent serum lithium level is 2.0. The patient has no signs or symptoms of toxicity. Which of the following is the best action by the PMHNP?

A. Tell the patient to stop his medications immediately

B. Encourage the patient to drink more water

C. Repeat the lithium level and ensure it is a trough

D. Send the patient to the ED

A

Answer C. Repeat the lithium level and ensure it is a trough as the patient has not had any dosage changes and has no signs or symptoms of toxicity. Encouraging the patient to drink more water assumes the elevated level is correct. Telling the patient to stop the medication may cause his level to drop below therapeutic range and require retitration. Sending the patient to the ED is viable, but the blood draw may not be at a time when the lithium is at the trough.

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123
Q

6-18. A 19-year-old female is evaluated in the ED for admission to an eating disorders unit and has a history of bulimia nervosa. Which of the following diagnostic tests should be ordered?

A. Electrolytes and renal function

B. Liver and pancreatic function

C. Lipid profile and hemoglobin A1C

D. Urinalysis and urine pregnancy test

A

Answer A. Electrolytes and renal function will help determine if the patient is medically stable to be in an eating disorders unit. Liver and pancreatic function tests are not acutely affected by bulimia nervosa. Lipid profile and hemoglobin A1C is not affected acutely by bulimia nervosa. Regardless of the results of the urinalysis and pregnancy test, the patient may still be treated for the eating disorder.

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124
Q

6-19. A 26-year-old man has been on an antipsychotic. He requires further titration for control of symptoms. Which of the following tests should be repeated?

A. EKG

B. Liver function test

C. Urinalysis

D. Head CT scan

A

Answer A. The EKG test should be repeated, as antipsychotics are known to prolong the QTc (except for aripiprazole). Liver function tests, urinalysis, and head CT scans are not affected by antipsychotic medication titration.

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125
Q

6-20. Which of the following is an indication for monitoring of serum drug levels?

A. Smoking cessation

B. New diagnosis of diabetes

C. Resolution of symptoms

D. New diagnosis of hyperlipidemia

A

Answer A. Smoking cessation is an indication for monitoring serum drug levels because smoking is a known inducer of the CYP450 pathway. The patient may have higher than normal/toxic serum drug levels as a result. The new diagnosis of diabetes or hyperlipidemia or resolution of symptoms are not indications for testing serum drug levels if the medications are prescribed within the recommended timeframe.

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126
Q

7-01. A 61-year-old married woman who has been sober from alcohol use disorder for 25 years relapsed 3 weeks ago. She reports drinking 1.5 L of vodka and half a liter of scotch daily. On exam she is emotionally labile ranging from irritable to crying, slurring her words, and exhibits a bilateral upper extremity fine tremor. Vitals: blood pressure 150/100, heart rate 110, respiratory rate 18, SpO2 98% room air. She reports feeling nauseous, sweating, and moderately anxious. What is the primary concern for this patient?

A. Alcohol use disorder

B. Generalized anxiety disorder

C. Alcohol withdrawal

D. Delirium tremens

A

Answer C. Alcohol withdrawal symptoms include emotional lability, bilateral upper extremity tremor, hypertension, tachycardia, nausea, sweating, and anxiety. Alcohol use disorder is characterized by a pattern of use with significant impairment with two or more Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria over the previous 12-month period. Generalized anxiety disorder is characterized by excessive worrying lasting at least 6 months. Delirium tremens is a severe form of alcohol withdrawal marked by global confusion, audiovisual hallucinations, fever, hypertension, and diaphoresis, which occur within 3 to 10 days of the last alcoholic drink.

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127
Q

7-02. A patient who has required increasing amounts of medication to achieve the desired effect and develops withdrawal symptoms when dosing is delayed is said to be:

A. Dependent

B. Tolerant

C. Addicted

D. In withdrawal

A

Answer A. Dependence is characterized by the repeated use of a substance for physical needs leading to increased tolerance and, when discontinued, results in physical withdrawal symptoms. Tolerance is a condition in which repeated administration of the dosage causes a decreased effect despite increasingly larger doses, which are required to obtain the effect observed in the initial dosage. Addiction is psychological dependence leading to persistent and increased use of the substance or behavior and when discontinued causes distress and urges to resume use 125despite adverse consequences. Withdrawal is a substance-specific cluster of signs and symptoms that occur when reducing or stopping the consistent use of the substance.

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128
Q

7-03. A patient is complaining of chronic back pain and requests a refill of his oxycodone prescription because the pain is so bad he becomes suicidal. As a result, his primary care provider referred him to the PMHNP. The patient states he can tell if he is late taking his next dose by even 1 hour as he becomes very anxious, restless, irritable, and begins sweating. He states that he is so worried about having pain attacks that much of his day is spent waiting to take the next dose. When he runs out of his medication between visits he buys some from his friend. Which of the following best describes the patient’s condition?

A. Dependence

B. Addiction

C. Tolerance

D. Withdrawal

A

Answer B. Addiction is psychological dependence leading to persistent and increased use of the substance or behavior and, when discontinued, causes distress and urges to resume use despite adverse consequences. Dependence is characterized by the repeated use of a substance for physical needs leading to increased tolerance and, when discontinued, results in physical withdrawal symptoms. Tolerance is a condition in which repeated administration of the dosage causes a decreased effect despite increasingly larger doses, which are required to obtain the effect observed in the initial dosage. Withdrawal is a substance-specific cluster of signs and symptoms that occur when reducing or stopping the consistent use of the substance.

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129
Q

7-04. A 30-year-old male who was started on sertraline for generalized anxiety disorder was also started on lorazepam 1 mg for sleep during the first 2 weeks as he was adjusting to the medication. At the 2-week follow-up visit his psychiatrist increased the sertraline, but the dose of lorazepam does not seem to be helping with sleep and the patient is requesting a higher dose. Which of the following best describes the patient’s condition?

A. Dependence

B. Addiction

C. Tolerance

D. Withdrawal

A

Answer C. Tolerance is a condition in which repeated administration of the dosage causes a decreased effect despite increasingly larger doses which are required to obtain the effect observed in the initial dosage. Dependence is characterized by the repeated use of a substance for physical needs leading to increased tolerance and, when discontinued, results in physical withdrawal symptoms. Addiction is psychological dependence leading to persistent and increased use of the substance or behavior and, when discontinued, causes distress and urges to resume use despite adverse consequences. Withdrawal is a substance-specific cluster of signs and symptoms that occur when reducing or stopping the consistent use of the substance.

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130
Q

7-05. A patient who has been drinking a six-pack of beer each night to relax after work has been having trouble staying asleep through the night. When she wakes up at 2 a.m. she takes diphenhydramine 25 mg to help her fall back asleep, but this makes her sleep through the alarm clock and late for work. She also reports having a headache through midmorning until she gets her second cup of coffee. She thinks this is related to her alcohol use and has unsuccessfully tried to cut down several times in the past year. Which of the following disorders best describes this patient’s condition?

A. Alcohol use disorder

B. Withdrawal syndrome

C. Caffeine use disorder

D. Insomnia

A

Answer A. Alcohol use disorder is characterized by a pattern of use with significant impairment with two or more Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria over the previous 12-month period. Withdrawal syndrome is a cluster of symptoms related to significantly reducing or stopping a substance or behavior. Caffeine intoxication requires a dose more than 250 mg in addition to a cluster of central nervous system excitatory symptoms shortly after the consumption. Insomnia is characterized by a persistent pattern of interrupted sleep and may be a primary problem or secondary concern induced by alcohol use.

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131
Q

7-06. The physiological process in which structural changes occur in the brain, increasing the likelihood of addiction over time and increasing the risk of relapse after a period of sobriety, is called:

A. Cognitive restructuring

B. Neuroadaptation

C. Neurogenesis

D. Cerebral ischemia

A

Answer B. Neuroadaptation is the physiologic process caused by a physical change in the body due to repeated exposure to a substance. Cognitive restructuring is a psychotherapeutic process of learning to identify and dispute irrational thoughts. Neurogenesis is the growth and development of neurons. Cerebral ischemia is brain tissue death caused by insufficient blood flow.

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132
Q

7-07. The PMHNP is evaluating a 45-year-old man in the emergency department; he has no past psychiatric history and presents with passive suicidal ideations and emotional lability. Which of the following tests is essential in helping formulate a preliminary diagnosis and treatment plan?

A. 12-lead EKG

B. Urine toxicology

C. Complete blood count

D. Liver profile

A

Answer B. Urine toxicology is essential because various drugs of abuse can induce various psychopathology, and all psychiatric diagnoses are made by exclusion. A 12-lead EKG will not provide insight into the presenting signs and symptoms but may guide medication selection. A complete blood count will not help explain the presenting symptoms, and any findings will require further investigation. The liver profile results will not explain the current symptom presentation but may raise the index of suspicion for further investigation.

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133
Q

7-08. A 43-year-old man is requesting medication-assisted treatment for addiction with Suboxone and wants to begin immediately to “get his life back.” What should the PMHNP do first?

A. Assess his current level and history of use

B. Prescribe Suboxone 2 mg SL daily to start now

C. Provide psychoeducation regarding Suboxone maintenance

D. Refer the patient to an inpatient detox facility

A

Answer A. Evaluating for substance use disorder requires an evaluation of the current level and history of use. Suboxone is not prescribed until the patient is in opioid withdrawal, otherwise a precipitated withdrawal may occur. Psychoeducation should be based on the findings from the evaluation, which must occur first. Before referring a patient for any therapy, it is important to know the extent of the problem.

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134
Q

7-09. Which of the following medications is preferred for a 21-year-old male with a history of polysubstance use disorder and difficulty with medication adherence?

A. Naltrexone 50 mg PO only when planning to use substances

B. Naltrexone 50 mg PO daily

C. Naltrexone 380 mg IM monthly

D. Methadone maintenance

A

Answer C. Naltrexone 380 mg IM offers the best option for medication nonadherence and harm reduction. Oral agents used at the patient’s discretion given his history of nonadherence are less likely to be effective. Beginning someone on methadone maintenance requires a high degree of adherence.

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135
Q

7-10. A patient who has been sober for 20 years is anticipating some major life changes in the next 3 months and is very worried about relapse. Which of the following actions should the PMHNP do first?

A. Refer the patient to Alcoholics Anonymous

B. Asses his coping strategies

C. Offer the patient naltrexone to be used in the Sinclair method

D. Refer the patient to inpatient rehab

A

Answer B. Assess coping strategies before prescribing treatment. The patient should have a thorough assessment that considers the risk factors for relapse before optimal relapse prevention strategies can be prescribed.

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136
Q

7-11. A 34-year-old man is inattentive, dysphoric, disinhibited, with impaired memory and psychomotor retardation. All of the following drugs of abuse may cause these symptoms except:

A. Alcohol

B. Opioids

C. Cannabis

D. Stimulants

A

Answer D. Stimulants of the central nervous system do not cause psychomotor retardation and memory impairment. Alcohol, opioids, and cannabis have central nervous system depressant properties and can cause inattention, dysphoria, disinhibition, cognitive impairment, and psychomotor retardation.

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137
Q

7-12. Which of the following agents could cause a patient to behave restlessly, agitated, grandiose, aggressive, and emotionally labile?

A. Amphetamines

B. Opioids

C. Marijuana

D. Ketamine

A

Answer A. Amphetamines stimulate the central nervous system and can cause restlessness, agitation, grandiosity, aggressive behavior, and emotional lability. Opioids, cannabinoids, and ketamine induce euphoric feelings and blunting of affect.

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138
Q

7-13. A 43-year-old man was involved in a motor vehicle collision in which he was found to have a blood alcohol concentration of 0.200. He was observed wandering around the crash site, slurring his words, and unable to provide a clear history. Emergency Medical Services brought him to the emergency department. The nurse triaged him to psychiatry for acute alcohol intoxication. What is the first priority for the PMHNP?

A. C-spine stabilization and head imaging

B. IV hydration

C. Explore the client’s willingness to enter rehab

D. Ask the patient when he had his last drink

A

Answer A. C-spine stabilization and head imaging are of paramount importance in this intoxicated man who was involved in a motor vehicle collision. Intoxication reduces his reliability as a historian and can impair his pain sensation. Physiological needs and safety take priority over other psychosocial needs.

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139
Q

7-14. In assessing a patient’s withdrawal symptoms from opioids, which evidence-based tool would be most appropriate?

A. Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar)

B. Minnesota Multiphasic Personality Inventory (MMPI)

C. Clinical Opioid Withdrawal Scale (COWS)

D. Hamilton Rating Scale for Depression (HAM-D)

A

Answer C. The Clinical Opioid Withdrawal Scale (COWS) helps quantify the symptoms of opioid withdrawal to guide symptom management or Suboxone induction. The Clinical Institute Withdrawal Assessment of Alcohol Scale-Revised (CIWA-Ar) is used for alcohol withdrawal symptom assessment. The Minnesota Multiphasic Personality Inventory (MMPI) is a personality assessment. The Hamilton Rating Scale for Depression (HAM-D) screens for depression.

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140
Q

7-15. Which of the following immediate determinants related to relapse prevention is the biggest predictor of relapse?

A. Outcome expectancy

B. Negative emotional state

C. Ineffective coping skills

D. Previous history of lapse

A

Answer B. A negative emotional state is the most significant predictor of relapse. Outcome expectancy, ineffective coping skills, and previous history of relapse can also predict relapse but to a lesser degree than a negative emotional state.

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141
Q

7-16. The clinical management of patients differs depending on the substance-related syndrome exhibited. A patient with a history of alcohol use disorder who presents for a monthly injection of naltrexone is disinhibited, emotionally labile, inattentive, and impulsive and is likely in which of the following phases?

A. Acute withdrawal

B. Acute intoxication

C. Sobriety

D. Manic

A

Answer B. Acute intoxication is characterized by disinhibition, emotional lability, inattention, and impulsivity. Withdrawal symptoms include tremor, anxiety, hyperreflexia, diaphoresis, and autonomic hyperactivity. Sobriety is the quality of being congruent in mood and affect with good impulse control, and situationally appropriate responses. Manic is a state of abnormally elevated arousal, affect, and energy often with accompanying mood lability.

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142
Q

7-17. A patient presents for a follow-up visit and has a dual diagnosis of substance use disorder and major depressive disorder. He reports that he has been feeling increasingly anxious, having difficulty sleeping. He continues to attend his Alcoholics Anonymous meetings regularly, but reports he had two beers 3 days ago and feels very guilty. Which of the following best describes this patient’s situation?

A. Relapse

B. Withdrawal

C. Intoxication

D. Lapse

A

Answer D. A lapse is a brief pause in sobriety, which may or may not lead to relapse. Relapse is a reactivation of the disease or return to a behavior consistent with substance use disorder after a prolonged period of sobriety. Withdrawal is a substance-specific cluster of signs and symptoms that occur when reducing or stopping the consistent use of the substance. Intoxication is a state of near poisoning, manifesting signs of inebriation (disinhibition, impaired cognition, delayed neurological response time).

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143
Q

7-18. Which of the following substances would be most likely to cause withdrawal symptoms?

A. Alprazolam

B. Diazepam

C. Clonazepam

D. Chlordiazepoxide

A

Answer A. Alprazolam has an 11-hour half-life; medications with shorter half-lives are more likely to cause withdrawal symptoms if dependence develops. Diazepam, clonazepam, and chlordiazepoxide have half-lives >20 hours and are less likely to manifest withdrawal symptoms.

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144
Q

7-19. A patient with familial fatty liver disease and elevated liver enzymes secondary to alcohol use disorder is admitted for detox. Which of the following benzodiazepines should not be used?

A. Temazepam

B. Lorazepam

C. Oxazepam

D. Chlordiazepoxide

A

Answer D. Chlordiazepoxide is metabolized in the liver by cytochrome P-mediated oxidation. Temazepam, lorazepam, and oxazepam are metabolized by conjugation. They are less dependent on global liver function and are preferred in patients with liver disease.

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145
Q

7-20. A patient who has been sober for 7 days struggles with cravings and is fearful of relapse. He reports taking naltrexone daily. What agent should the PMHNP prescribe to help reduce his cravings?

A. Citalopram

B. Disulfiram

C. Buprenorphine

D. Thiamine

A

Answer A. Citalopram and other SSRIs have been found to decrease desirability, liking, and consumption of alcohol in alcohol-dependent drinkers. Given the patient presentation, prescribing an SSRI will help the patient without doing harm. Disulfiram is an aversive agent. Buprenorphine has been found to reduce cravings and withdrawal symptoms in patients with opioid dependence. Thiamine is indicated to prevent and mitigate Wernicke–Korsakoff syndrome associated with vitamin B1 deficiency, which is commonly found in patients with alcohol dependence.

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146
Q

8-01. A 66-year-old woman employed as a federal appeals lawyer is being seen by the PMHNP accompanied by her son, who has been concerned about progressive memory problems. Which of the following would be most helpful in distinguishing between common forgetfulness and cognitive impairment?

A. Brain MRI with and without contrast

B. Montreal Cognitive Assessment (MoCA)

C. Family history

D. Hamilton Depression Scale (HAM-D)

A

Answer B. The Montreal Cognitive Assessment is a psychometrically validated screening tool for mild cognitive impairment including visuospatial abilities, short-term recall, trail making, attention, concentration, language, and orientation. A brain MRI is helpful in identifying structural changes that may account for behavior if the affected brain region correlates with the impairment. Family history is important for stratifying risk factors and genetic predisposition but does not confirm a current diagnosis. The Hamilton Depression Scale is used to screen for major depressive disorder which can affect cognition, but the chief complaint was related to cognition.

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147
Q

8-02. A 62-year-old woman formerly employed as a receptionist reports progressive word-finding difficulty over the past 6 months that caused her so much anxiety she quit her job. Her daughter has become increasingly impatient waiting for her to finish her sentences but she has now become depressed due to the relational strain. She denies any other behavioral problems. Which of the following diagnostic tests would be most appropriate?

A. EEG

B. Brain MRI with and without contrast

C. Bilateral carotid Doppler study

D. Transthoracic echocardiogram

A

Answer B. A brain MRI is helpful in identifying structural changes which may account for behavior if the affected brain region correlates with the impairment such as chronic 137cerebrovascular accident affecting Wernicke’s or Broca’s area. An EEG identifies seizure-like activity while it is occurring. A bilateral carotid Doppler study may help stratify the risk for developing a cerebral vascular accident. A transthoracic echo may help stratify the risk for developing a cerebral vascular accident.

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148
Q

8-03. A 70-year-old retired male with a history of hypertension controlled with amlodipine, metoprolol, valsartan, and furosemide has been referred from his primary care provider for depression. Formerly an avid reader, the patient has lost interest in reading and has become increasingly isolative as he has been spilling things during his lunch club meetings and finds this embarrassing, which makes him feel self-conscious and anxious. In which portion of the mental status exam would the PMHNP expect to find a deficit?

A. Orientation to person, time, and place

B. Delayed recall

C. Abstract thinking

D. Intersecting pentagon

A

Answer D. Intersecting pentagons are used to assess visuospatial impairment, which reflects the function of the right parietal lobe, basal ganglia, and prefrontal cortex. Orientation to person, place, and time reflects the temporal lobe, frontal lobe, and cingulate cortex and is impaired in late phases of dementia. Delayed recall reflects the function of the hippocampus and the medial temporal lobe and is more common in Alzheimer’s dementia than frontotemporal dementia. Abstract thinking reflects the function of the frontal and prefrontal regions of the brain.

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149
Q

8-04. A 53-year-old man presents to the emergency department with complaint of sore throat progressively worsening for 3 days with intermittent fever. In triage he tells the RN that he has taken ibuprofen 400 mg 4 hours ago for the pain, and currently his vital signs are blood pressure 120/80, heart rate 88, respiratory rate 12, SPO2 96% on room air. While waiting for the results of the rapid strep test the patient becomes agitated, restless, confused, and increasingly difficult to redirect. He is transferred to the psychiatric emergency department because it is a locked unit. Which of the following is the most likely diagnosis?

A. Presenile dementia

B. Personality disorder

C. Mixed delirium

D. Mood disorder

A

Answer C. Mixed delirium is characterized by a cyclical manifestation of psychomotor retardation and agitation with a disturbance in consciousness; risk factors include infectious process, fever, and relocation. Dementia is a slowly progressive process that impairs cognition with the preservation of level of consciousness. Personality disorder is characterized by a historical pattern of rigid maladaptive coping mechanisms that cause distress. Mood disorder is a diagnosis of exclusion in which there are an insufficient number of symptoms to meet full criteria for major depressive disorder, bipolar disorder, or generalized anxiety disorder.

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150
Q

8-05. The PMHNP is consulted to see a 70-year-old female who was admitted to the skilled nursing facility 3 days ago from the hospital, where she was treated for urinary tract infection, pneumonia, and dehydration. The staff reports that the patient is restless and agitated, awake most of the night, intermittently sleeping during the day, and has poor PO intake. What should the PPMHNP do first?

A. Prescribe quetiapine 12.5 mg PO at bedtime and every 6 hours as needed for agitation

B. Physical exam and diagnostic tests (complete blood count, basic metabolic profile, and urinalysis)

C. Transfer the patient to the ED

D. Call family members for collateral information on her baseline functioning

A

Answer B. Physical exam and diagnostic tests are used to rule out delirium given the patient’s history, age, and clinical presentation. Prescribing medication can worsen delirium and mask symptoms of an underlying cause. Transferring the patient to the ED may worsen or trigger delirium. Obtaining collateral information is helpful in helping to establish a baseline pattern of function, but the acute problem of delirium must be addressed and ruled out first.

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151
Q

8-06. A 55-year-old woman reports to the PMHNP that since she accepted early retirement last year she finds that her memory has gotten worse and she has trouble sleeping at night. She denies any medical problems. What should the PMHNP do first?

A. Perform a Mini-Mental State Exam and Confusion Assessment Methods Instrument

B. Prescribe mirtazapine 15 mg PO at bedtime to help her sleep

C. Encourage her to volunteer with something she feels passionate about

D. Refer her to her primary care provider for a physical exam

A

Answer A. A formalized assessment such as the Mini-Mental State Exam and Confusion Assessment Methods Instrument provides a reproducible means of establishing baseline function and distinguishing delirium from reversible cognitive impairment. Mirtazapine is indicated for major depressive disorder and anxiety but both are a diagnosis of exclusion and are lower priority than delirium. Encouraging volunteer activity may be a good way to develop psychological activation in a patient with a mood disorder, but there is no evidence to support this diagnosis. Referring the patient to her primary care provider for a physical exam does negates the PMHNP’s responsibility to evaluate for neurocognitive disorders.

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152
Q

8-07. Karen is a 68-year-old former legal secretary who enjoys an active social life with her husband. She feels she has something wrong with her medically and has seen many specialists over the year who have found nothing wrong with her. Her husband reports that she continually repeats the same five stories over and over again as if she is telling them for the first time. On two occasions in the last year she has gotten lost coming home from the supermarket and was found by the police a half-mile from her former place of employment. What is the most likely diagnosis?

A. Vascular dementia

B. Huntington’s disease

C. Creutzfeldt–Jakob disease

D. Mixed delirium

A

Answer A. Vascular dementia is the second most common dementia, and is caused by progressive cardio-/cerebrovascular disease and manifests in cognitive decline and plateau phases in which previously lost function is not regained. Huntington’s dementia is a subcortical disease characterized by motor abnormalities including psychomotor slowing, choreoathetoid movements, and executive dysfunction complicated by impaired language, memory, and insight later in the disease process. Pick’s disease is also known as frontotemporal dementia, and is characterized by a change in personality and cognitive decline; a subtype is Kulver-Bucey syndrome, which is manifested by uninhibited cheerfulness, hypersexuality, and hyperorality. Creutzfeldt–Jakob disease is a precipitous onset cognitive decline that rapidly progress to death; symptoms include fatigue and cognitive impairment and eventually aphasia, apraxia, emotional lability, and psychosis. Mixed delirium is characterized by a cyclical manifestation of psychomotor retardation and agitation with a disturbance in consciousness; risk factors include infectious process, fever, and relocation.

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153
Q

8-08. Which type of dementia is characterized by a gradual onset and progressive decline without focal neurological deficits?

A. Alzheimer’s disease

B. Pick’s disease

C. Vascular dementia

D. Huntington’s disease

A

Answer A. Alzheimer’s disease is the most prevalent type of dementia, and is characterized by a gradual onset and progressive decline without focal neurological deficits. Pick’s disease is also known as frontotemporal dementia, and is characterized by a change in personality and cognitive decline; a subtype is Kulver-Bucey syndrome, which is manifested by uninhibited cheerfulness, hypersexuality, and hyperorality. Vascular dementia is the second most common dementia, and is caused by progressive cardio-/cerebrovascular disease and manifests in cognitive decline and plateau phases in which previously lost function is not regained. Huntington’s dementia is a subcortical disease characterized by motor 138abnormalities including psychomotor slowing, choreoathetoid movements, and executive dysfunction complicated by impaired language, memory, and insight later in the disease process.

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154
Q

8-09. A 72-year-old man with a history of hypertension, and type 2 diabetes mellitus has become increasingly disinhibited and flirts with his home health aide. He demands she kiss him or he will pee on himself. She is sometimes able to distract him with cookies but his children often object because it will worsen his blood sugar control. Which of the following is the most likely diagnosis?

A. Alzheimer’s disease

B. Frontotemporal dementia

C. Vascular dementia

D. Creutzfeldt–Jakob disease

A

Answer B. Pick’s disease is also known as frontotemporal dementia, and is characterized by a change in personality and cognitive decline; a subtype is Kulver-Bucey syndrome, which is manifested by uninhibited cheerfulness, hypersexuality, and hyperorality. Alzheimer’s disease is the most prevalent type of dementia, and is characterized by a gradual onset and progressive decline without focal neurological deficits. Vascular dementia is the second most common dementia, and is caused by progressive cardio-/cerebrovascular disease and manifests in cognitive decline and plateau phases in which previously lost function is not regained. Creutzfeldt–Jakob disease is a precipitous onset cognitive decline that rapidly progress to death; symptoms include fatigue and cognitive impairment and eventually aphasia, apraxia, emotional lability, and psychosis.

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155
Q

8-10. A 50-year-old man with a diagnosis of Parkinson’s disease is admitted to the hospital after tripping and falling and breaking his hip while on a business trip, where he was inspecting a slaughterhouse. The third day after surgery the patient is having tremors, intermittent slurred speech, dysarthria, and dysgraphia. The orthopedist is attributing his symptoms to slow postoperative progression complicated by having not taken his antiparkinsonian medications for 2 days and the effects of narcotics. Psychiatry was asked to see the patient for mood disorder and possible delirium to aid in planning discharge to subacute rehab. On exam the patient is unable to name the day, month, or year; has poor three-object registration and recall, scoring 12 of 30 on a mental state exam; his speech fluency and attention span are incongruent with his baseline; and he has no decline in his level of consciousness. Which of the following is among the primary differential diagnoses?

A. Major depressive disorder

B. Presenile dementia

C. Delirium

D. Creutzfeldt–Jakob disease

A

Answer D. Creutzfeldt–Jakob disease is a precipitous onset cognitive decline that rapidly progress to death; symptoms include fatigue and cognitive impairment and eventually aphasia, apraxia, emotional lability, and psychosis. Major depressive disorder is a syndrome identified by five of nine symptoms lasting for 2 weeks, with more than one of the nine symptoms being either depressed mood or anhedonia. Other symptoms can include a change in appetite with weight gain or weight loss, impaired cognition, fatigue, feelings of low self-worth, inattention, and recurrent thoughts of death. Dementia is a constellation of signs and symptoms characterized by a gradual onset of multiple impairments in executive function, intellect, problem-solving, and alteration in memory with the preservation of level of consciousness. Delirium is a constellation of symptoms marked by an acute onset (hours to days) causing short-term decline in cognition with a disturbance in consciousness and inattention.

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156
Q

8-11. A 68-year-old man with no past psychiatric history but with a history of poly substance use disorder is admitted for psychosis (disorganized thoughts, rapid pressured speech, persistent rumination, paranoid delusions, and apathy). Which of the following tests would be most important in determining the etiology of his new onset symptoms?

A. Urine toxicology screening

B. HIV testing

C. Mental state exam

D. Urine culture

A

Answer B. HIV-associated dementia, a neurocognitive disorder with parenchymal abnormalities visualized on MRI, manifests a progressive decline with associated symptoms including obsessive-compulsive disorder, generalized anxiety disorder, depression, and mania. Urine toxicology, while essential in the initial evaluation of a person with altered mental status, is of low yield in this case as polysubstance use disorder is known. A mental state exam has at least partially been completed given the clinical findings identified in the question. Urine culture is important in the evaluation of delirium but given the high-risk lifestyle factors HIV must be ruled out as the treatment requires antiretroviral therapy.

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157
Q

8-12. When evaluating a 78-year-old man, the PMHNP notices the patient frequently leans in with the right side of his head and frequently asks for things to be repeated. His daughter is very worried that he has dementia or depression because he has also become increasingly isolated, as well as increasingly irritable as he believes people are yelling at him out of frustration of not being heard. The daughter is tearful, anxious, and frustrated. What should the PMHNP do first?

A. Separate the patient from the daughter and interview him alone

B. Examine the patient’s ear canals

C. Order a CT scan of the head

D. Provide anticipatory guidance regarding aging parents to the daughter

A

Answer B. The patient is leaning in to hear and asking for things to be repeated but there are no signs and symptoms to indicate dementia or depression. Separating the patient from his daughter may be appropriate but physical needs need to be evaluated first. Head CT scan is not indicated based on the presenting symptoms and increases the risk of incidental findings. Anticipatory guidance should be based on actual problems to help provide for future care needs.

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158
Q

8-13. When providing anticipatory guidance to the loved ones of a 68-year-old woman who has been diagnosed with dementia, what is the most important information to convey?

A. The importance of taking medications exactly as prescribed

B. Safety planning regarding wandering, driving, and fire and fall risk

C. Implementing advance directives for end of life care

D. Encouraging the patient’s autonomy in expressing their wishes

A

Answer B. Safety planning regarding wandering, driving, and fire and fall risk is warranted. Medication adherence is important but a lesser priority in this case. Advance directives for end of life care is an important discussion but less priority than attending to immediate safety needs. Helping the patient retain autonomy is an important ethical principle to govern care, but the current healthcare system puts priority on safety planning.

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159
Q

8-14. Which of the following conditions frequently occurs in patients with dementia but may improve as the condition declines?

A. Psychosis

B. Personality disorders

C. Depression

D. Delirium

A

Answer C. Depression commonly occurs in patients with dementia but the symptoms are reduced as the patient loses self-awareness. Psychosis is more common in patients with HIV-associated dementia and can worsen as dementia progresses. Personality disorder is characterized by a historical pattern of rigid maladaptive coping mechanisms that cause distress. Delirium is characterized by a cyclical manifestation of psychomotor retardation and agitation with a disturbance in consciousness; risk factors include infectious process, fever, and relocation. Psychosis is characterized by the onset of delusions, hallucinations, or disorganized thinking and speech, or grossly disorganized or catatonic behavior.

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160
Q

8-15. Jose is a 48-year-old veteran of Operation Iraqi Freedom, during which he sustained a traumatic brain injury that left him unconscious for 7 days. He has progressively regained function and is able to perform his instrumental activities of daily living most days. His wife is worried because he has periods where she does not recognize him as he becomes irritable, fails to remember important dates and events, and gets headaches so bad that he says he wishes he had died in the war. What is the priority action for the PMHNP to take during this office visit?

A. Provide anticipatory guidance and coping mechanisms to the patient and his wife

B. Refer the patient to the ED for suicidal ideation

C. Prescribe antipsychotic medications to be used when the patient becomes irritable

D. Refer the patient to a neurologist

A

Answer A. 139Providing anticipatory guidance and coping mechanisms to the patient and his wife regarding traumatic brain injuries can help mitigate the impact of some of the symptoms. Referring the patient to the emergency department for suicidal ideations is inappropriate as the patient is not acutely suicidal. Prescribing antipsychotic medication to be used when the patient becomes irritable may be appropriate but nonpharmacological measures as first line are preferred. Referring the patient to a neurologist is not warranted as the primary problem is the sequelae of a traumatic brain injury and family system involvement for ongoing care.

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161
Q

8-16. The husband of a 68-year-old woman with major depressive episodes is concerned about cognitive decline in his wife. Which of the following statements best addresses his concern regarding this symptom?

A. The cognitive decline is reversible once the depression is treated

B. It will be important to plan for her long-term care needs

C. I can prescribe a medication to enhance her memory

D. It is normal for you to be worried about your wife

A

Answer A. The cognitive decline associated with depression is reversible once the depression is treated. Long-term care planning for cognitive impairment secondary to a mood disorder is not eminently indicated. Prescribing medication to enhance memory is not indicated in a patient with a primary mood disorder that is insufficiently treated. Placating the family member without sufficient psychoeducation is not the best answer.

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162
Q

8-17. The primary distinguishing feature between dementia and delirium is:

A. Onset of symptoms and duration

B. Disturbance in consciousness

C. Age of the patient

D. Comorbid conditions

A

Answer B. A disturbance in consciousness is the primary distinguishing feature between dementia and delirium. All delirium is traditionally acute onset and dementia is chronic onset; certain dementias can be more precipitous. Patients of any age can have either delirium or dementia. Patients with both dementia and delirium can have comorbid conditions.

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163
Q

8-18. The primary treatment for delirium is:

A. Antipsychotic medications

B. Mood stabilizing medications

C. Identifying and treating the underlying cause

D. Anticipatory guidance and psychoeducation

A

Answer C. Identifying and treating the underlying cause is the primary treatment for dementia. Adding medications to a patient with delirium with an unknown underlying cause may worsen or compound the delirium as polypharmacy is another causative factor. Anticipatory guidance and psychoeducation is appropriate when tailored to a specific condition.

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164
Q

8-19. Delirium characterized by periods of agitation and restlessness is known as:

A. Hypoactive delirium

B. Hyperactive delirium

C. Mixed delirium

D. Hypomania

A

Answer C. Mixed delirium is characterized by cycling through psychomotor agitation and retardation ranging from apathy to hypervigilance. Hypoactive delirium is characterized by psychomotor retardation and apathy. Hyperactive delirium is characterized by psychomotor agitation, restlessness, and hypervigilance. Mania is characterized by grandiosity, a reduced need for sleep, being more talkative than usual, flight of ideas and racing thoughts, distractibility, and psychomotor agitation with an increase in goal-directed, pleasure-seeking behaviors.

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165
Q

8-20. Delirium characterized by apathy, psychomotor retardation, and inattentiveness is known as:

A. Hypoactive delirium

B. Hyperactive delirium

C. Mixed delirium

D. Mania

A

Answer A. Hypoactive delirium is characterized by psychomotor retardation and apathy. Hyperactive delirium is characterized by psychomotor agitation, restlessness, and hypervigilance. Mixed delirium is characterized by cycling through psychomotor agitation and retardation ranging from apathy to hypervigilance. Mania is characterized by grandiosity, reduced need for sleep, more talkative than usual, flight of ideas and racing thoughts, distractibility, and psychomotor agitation with an increase in goal-directed, pleasure-seeking behaviors.

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166
Q

9-01. A 19-year-old male is attending his post hospital discharge appointment where he was diagnosed with psychosis. He has been taking risperidone 4 mg by mouth twice daily. Which of the following is the top priority during this first encounter with the PMHNP?

A. Baseline EKG, weight, hemoglobin A1C

B. Establish therapeutic alliance

C. Draw a prolactin level

D. Administer a long-acting injectable

A

Answer B. Establishing a therapeutic alliance is the top priority in order to proceed with any further care for this patient. Baseline EKG, weight, and hemoglobin A1C while essential may not be completed unless the patient therapeutic alliance is established. Prolactin level is expected to be elevated in a patient taking risperidone and other long-acting injectables and may provide insight into compliance, but other factors can cause this level to rise. Administering a long-acting injectable is preferred in patients who are medication nonadherent.

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167
Q

9-02. The PMHNP is evaluating a 30-year-old female who reports intermittent auditory hallucinations in which a familiar female voice is commenting on her as she eats. In an effort to deal with the voices she has been using headphones and listens to podcasts and music all the time, but it is interfering with her ability to do her work. Which of the following questions would help in formulating a diagnosis?

A. “How long have you been experiencing the voices?”

B. “Do the voices bother you?”

C. “Are you able to ignore the voices?”

D. “What has helped you deal with the voices?”

A

Answer A. Asking how long the patient has been experiencing the voices allows the PMHNP to determine a more accurate diagnosis and can inform long-term care options. Asking if the voices are bothersome may further inform the assessment. Asking if the patient is able to ignore the voices informs what specific coping strategies have been successful or unhelpful in the past. Inquiring of past helpful coping strategies is beneficial in empowering patients to problem solve.

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168
Q

9-03. A couple presents with their 18-year-old son who was referred by his primary care provider for evaluation of symptoms related to perceptual disturbances, oddly related interpersonal communication, neglect of basic hygiene, and increasing isolative behaviors. These symptoms are most consistent with:

A. Active psychosis

B. Schizophrenia prodrome

C. Residual psychosis

D. Schizophrenia

A

Answer B. Schizophrenia prodrome is characterized by odd beliefs, ideas of reference, unusual perceptual experience, negative symptoms, and deterioration of function prior to the onset of active psychosis. Active psychosis is characterized by delusions, hallucinations, disorganized speech, disorganized behavior, and/or pervasive negative symptoms. Residual phase psychosis is characterized by persistent functional impairment, abnormalities of affect, impaired cognition, and impaired communication.

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169
Q

9-04. A 28-year-old female is referred from her employee assistance program from a tech company for poor hygiene and erratic behaviors interfering with her work. The patient states her company is spying on her and setting her up to fail for the last 9 months. While speaking she stops herself and begins to talk back to someone who is not present. These symptoms are most consistent with:

A. Psychosis

B. Delusions

C. Hallucinations

D. Depression

A

Answer A. 150Psychosis is characterized by paranoid delusions, poor self-care, erratic behavior, and auditory hallucinations persisting for >6 months. Delusions are deeply held beliefs despite evidence to the contrary. Hallucinations are perceptual disturbances involving one of the five senses. Depression is a mood disorder that can cause psychotic symptoms including hallucinations, delusions, and cognitive impairment but there is no mention of a primary mood disorder in this question.

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170
Q

9-05. A 55-year-old female recently accepted a severance package for early retirement from her job as a fashion buyer for a major retail store. Over the past 6 months she has increasingly become isolated, neglecting her self-care, and collecting various things of no real value. Her appearance is unkempt, and her affect is flat. Before being called back to the consultation room the PMHNP notices that the patient seems to be talking to herself audibly. During the consultation the patient makes poor eye contact and wants frequent reassurance that no one is listening in. Which of the following would be the best action for the PMHNP to take?

A. Send the patient to the psychiatric emergency department

B. Speak in a calm reassuring voice and evaluate for comorbid conditions

C. Prescribe an antipsychotic medication for atypical psychosis

D. Order an MRI of the brain to rule out a mass

A

Answer B. Speaking in a calm, reassuring voice and evaluating for comorbid conditions can help the PMHNP build a therapeutic alliance and gather essential information to formulate an accurate diagnosis. Sending the patient to the emergency department may rupture the therapeutic alliance, and in this case, there is no indication of imminent threat to self or others. Prescribing an antipsychotic may be appropriate but the diagnosis of atypical psychosis is not definitive. Head imaging studies are often low yield and should be reserved for atypical presentations that require further assessment.

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171
Q

9-06. When providing anticipatory guidance for the parents of a 23-year-old male with schizophrenia, which of the following statements is most accurate?

A. Medications are most effective for the anhedonia, apathy, and lack of motivation

B. Medications are most effective for hallucinations, disorganization, and delusions

C. Schizophrenia is caused by the use of marijuana

D. Most patients with schizophrenia can live a normal life without medication

A

Answer B. Medications are most effective for positive symptoms. Medications are least effective for negative symptoms. Schizophrenia is not caused by marijuana, but marijuana can induce psychosis, paranoia, and disorganized behavior, which should resolve when the substance is cleared from the body. Most patients with schizophrenia are on lifelong medication and life is often difficult despite the best treatment.

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172
Q

9-07. A 61-year-old female is referred to the psychiatric emergency department with complaints of abdominal pain, nausea, and bloody stools. Despite an extensive evaluation, no underlying cause for her symptoms can be identified and her hemoglobin is normal. The patient insists there is something physically wrong with her. Which of the following best describes her condition?

A. Persecutory delusion

B. Grandiose delusion

C. Jealous delusion

D. Somatic delusion

A

Answer D. With somatic delusion, content is focused on bodily functions and perceived ailments despite evidence to the contrary or absence of evidence for the physical complaint. With persecutory delusions, content is focused on feeling targeted, victimized, and/or singled out by authority figures. Grandiose delusions are focused on the patient’s great talent, status, skills, or knowledge. Jealous delusions are focused on infidelity with attempts to control the behavior of others they believe are being unfaithful.

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173
Q

9-08. A 22-year-old man is referred to the psychiatric emergency department for suicidal ideation. Upon interview the patient states that he is not trying to kill himself, and he really can fly if only people would let him. The patient is emphatic that he is not manic because he is “the best sleeper in the world.” The patient has a bright reactive affect and is pressured at times. Which of the following best describes his condition?

A. Grandiose delusion

B. Hallucinations

C. Erotomaniac delusions

D. Persecutory delusions

A

Answer A. Grandiose delusions are focused on the patient’s great talent, status, skills, or knowledge. Hallucinations are a perceptual disturbance involving one of the five senses. Erotomania is a delusion that someone is in love with the patient or the patient feels infatuated with a person and trys to get them to reciprocate their passionate feelings, becoming enraged when they perceive rejection. During persecutory delusions, content is focused on feeling targeted, victimized, and/or singled out by authority figures.

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174
Q

9-09. A 32-year-old man presents to the emergency department with acute onset disorganization, paranoid delusions, and visual hallucinations of flying bugs, which he tries to crush because he thinks they contain listening devices. The patient is accompanied by the police, who were called because the man was smashing things in a store. Which of the following can the PMHNP diagnose during the initial encounter?

A. Schizophrenia

B. Schizophreniform disorder

C. Brief psychotic disorder

D. Schizoaffective disorder

A

Answer C. Brief psychotic disorder is characterized as disorganization accompanied by either delusions, hallucinations, or disorganized speech (marked with frequent derailment, incoherence, or world salad) lasting <30 days. Schizophrenia includes the symptoms of psychosis (disorganized speech, delusions, hallucinations) lasting >6 months. Schizophreniform disorder is characterized by psychotic symptoms lasting more than 30 days, but <6 months. Schizoaffective disorder includes psychotic symptoms with mutually exclusive manic symptoms.

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175
Q

9-10. A 33-year-old female with history of schizoaffective disorder was brought to the emergency department by police for disruptive behavior, auditory hallucinations, and self-neglect. The patient screams that she had stopped taking her medication. The PMHNP orders Haldol 5 mg PO, which the patient willingly accepts. An hour later the patient demonstrates an involuntary upward deviation of the eyes, and hiccoughs. Which of the following should the PMHNP do first?

A. Draw stat labs for complete blood count, creatinine phosphokinase

B. Stat EKG

C. Haldol 5 mg IM stat

D. Benadryl 25 mg IV push

A

Answer D. Benadryl 25 mg IV push is an antihistamine used for anticholinergic effect, indicated for use in acute extrapyramidal symptoms such as dystonia, oculogyric crisis, and diaphragm spasm. Stat labs are not the priority in this patient with an oculogyric crisis as it will not change the management or solve the problem. Stat EKG does not address the presenting problem. Haldol may worsen the problem and is likely the cause of the problem.

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176
Q

9-11. A 45-year-old man who takes olanzapine 5 mg twice daily for psychosis reports a perpetual sense of restlessness and an inability to sit still. He says, “sometimes it gets so bad I want to jump out of my own skin.” Which of the following is the most likely explanation?

A. Dystonia

B. Akinesia

C. Akathisia

D. Tardive dyskinesia

A

Answer C. Akathisia is the inability to remain still, includes motor restlessness, and is often mistaken for anxiety but described in similar terms. Dystonia is an involuntary muscle spasm due to dopamine blocking agents such as antipsychotic medication. Akinesia is the absence of movement or the difficulty in starting movements with associated flat affect and apathy, and is related to dopamine-blocking agents such as antipsychotic medications. Tardive dyskinesia is a constellation of involuntary movements in a rhythmic pattern that is potentially irreversible due to dopamine blocking agents.

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177
Q

9-12. The PMHNP is evaluating a 37-year-old man who takes a long-acting injectable paliperidone palmitate, who reports that he is glad to not have to take a pill every day. He reports that often, for the first few days after he gets his injection, he notices that he walks slower than usual and with a shuffling gait, feels stiffness in his joints, and people think he is depressed but the symptoms dissipate as the month progresses. Which of the following best describes this condition?

A. Dystonia

B. Akinesia

C. Akathisia

D. Pseudo-Parkinson’s

A

Answer D. Pseudo-Parkinson’s is a movement disorder exhibited by a shuffling gait, motor slowing (bradykinesia), masked faces, and low frequency tremor at rest. Akathisia is characterized by the inability to remain still and motor restlessness, and is often mistaken for anxiety but described in similar terms. Dystonia is an involuntary muscle spasm due to dopamine blocking agents such as antipsychotic medication. Akinesia is the absence of movement or the difficulty in starting movements with associated flat affect and apathy, and is related to dopamine-blocking agents such as antipsychotic medications.

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178
Q

9-13. A condition characterized by abnormal involuntary movements in a rhythmic pattern often affecting the mouth, tongue, and jaw that is potentially irreversible is known as?

A. Tardive dyskinesia

B. Neuroleptic malignant syndrome

C. Pseudo-Parkinson’s

D. Dystonia

A

Answer A. Tardive dyskinesia is a constellation of involuntary movements in a rhythmic pattern that is potentially irreversible due to dopamine-blocking agents. Neuroleptic malignant syndrome is a rare life-threatening reaction to neuroleptic antipsychotic medication, and is associated with high fever, delirium, muscle rigidity, autonomic instability, and diaphoresis. Pseudo-Parkinson’s is a movement disorder exhibited by a shuffling gait, motor slowing (bradykinesia), masked faces, and low frequency tremor at rest. Akathisia is charcterized by the inability to remain still and motor restlessness, and is often mistaken for anxiety but described in similar terms. Dystonia is an involuntary muscle spasm due to dopamine blocking agents such as antipsychotic medication.

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179
Q

9-14. An uninsured patient was who discharged from the hospital on haloperidol 10 mg twice daily presents to the PMHNP for a 2-week follow-up medication check visit. On exam the patient has tachypnea, tachycardia, and tremors, the skin is hot to the touch, and is overall very rigid. What should the PMHNP do first?

A. Prescribe Benadryl 25 mg PO stat

B. Call 911 for transfer to the emergency department

C. Discontinue the Haldol

D. Attempt to establish peripheral IV access

A

Answer B. Call 911; the patient is in acute physiological distress with a high index of suspicion for neuroleptic malignant syndrome and is in need of acute medical attention. Prescribing medication should not take priority over advanced life support. Stopping Haldol is correct but does not take priority over getting the patient to the hospital. Attempting to establish IV access can occur after 911 has been called.

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180
Q

9-15. When providing psychoeducation to the parents of a 20-year-old male with psychosis, which of the following is considered a good prognostic indicator?

A. Early onset

B. Substance induced

C. First degree family member with schizophrenia

D. Delayed treatment with antipsychotics

A

Answer B. Substance-induced psychosis offers the best prognosis because often, when the substance is stopped and cleared from the body, the patient can return to baseline. Early onset, first-degree relative, and delayed treatment of psychotic symptoms are all poor prognostic indicators.

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181
Q

9-16. A 36-year-old man has been readmitted five times in the past year for medication nonadherence despite the use of a long-acting injectable antipsychotic for schizophrenia. The patient is often brought in by police when bystanders report reckless behavior. Which of the following would provide him with the best chance of reduced morbidity and autonomous living?

A. State hospitalization

B. Supportive housing

C. Court ordered assertive community treatment

D. Psychosocial clubhouse

A

Answer C. Court-ordered assertive community treatment allows the patient to live in the community and have multidisciplinary care delivered if the patient fails to come to appointments including long-acting injectables. State hospitalization inhibits autonomy. Supportive housing is insufficient for medication-nonadherent patients. A psychosocial clubhouse relies on the patient’s own initiative to present and does not administer medications.

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182
Q

9-17. A 30-year-old woman is convinced her neighbor is hypnotizing her into performing sexual acts in her sleep because he is turned on by her doing yoga for the last 3 months. She presented to the emergency department requesting a sexual assault forensic exam to prove her claim. The examiner finds her story bizarre and requests a psychiatric evaluation for capacity to consent to forensic examination. When obtaining collateral information, the police reveal that the patient has a restraining order against her from her neighbor for harassment. Which of the following best describes the patient’s condition?

A. Psychosis

B. Erotomanic delusion

C. Somatic delusion

D. Posttraumatic stress disorder

A

Answer B. Erotomanic delusion content is focused on the belief that someone is in love with the patient, the love is idealized and may contain sexual content without evidence to support this, and the objectified lover may not even be aware of the patient. Psychosis is characterized by paranoid delusions, poor self-care, erratic behavior, hallucinations, and disorganization. Somatic delusion content is focused on perceived debilitated body functions or ailments despite any evidence to support the belief. Posttraumatic stress disorder is characterized by flashbacks, nightmares, severe anxiety, and persistent ruminations of a traumatic event.

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183
Q

9-18. A patient is requesting the PMHNP to complete his disability application for schizophrenia because he got fired for disruptive behavior. He states the constant voices ask him questions and interfere with his sleep, so he has started smoking marijuana to help him relax. Which of the following statements is true regarding auditory hallucinations?

A. Auditory hallucinations coincide with a delusion

B. Auditory hallucinations are contrary to delusions

C. Auditory hallucinations are constant in nature

D. Auditory hallucinations usually ask the patient questions

A

Answer A. Auditory hallucinations often coincide with a delusional system. Auditory hallucinations contradicting a delusion are indicative of malingering. They are usually intermittent in nature but can be frequently occurring; it is important to distinguish frequent from constant. Auditory hallucinations usually comment on the person’s behavior or chastise them; 30% of the time the voice asks questions.

184
Q

9-19. A 24-year-old male with three past psychiatric hospitalizations for psychosis inquires if he will have to be on medication for the rest of his life as he is worried about developing diabetes. Which of the following circumstances reduces the likelihood of lifetime medication?

A. Substance-induced psychosis

B. De novo psychosis

C. Parent with history of schizophrenia

D. Completing high school

A

Answer A. Substance-induced psychosis is least likely to require lifelong antipsychotic medications. De novo psychosis, family history of psychosis, and low educational attainment are poor prognostic indicators and increase the likelihood of lifelong antipsychotic medications.

185
Q

9-20. Which of the following is considered a protective factor for suicide in a patient with schizophrenia?

A. Previous attempted suicide

B. Sense of purpose

C. Frequent hospitalizations

D. Presence of medication side effects

A

Answer B. A sense of purpose is a protective factor for suicidal ideation as it may indicate future-oriented thinking to achieve the purpose. Previous suicide attempts are the biggest predictor of completed suicide. The post-discharge rate of suicide is 100 times the global suicide rate for the first 3 months after hospitalization (Chung et al., 2017). Medication side effects may increase stress and anxiety and increase the risk of suicide.

186
Q

10-01. A 38-year-old male reports excessive daytime sleepiness for the last 2 weeks in the setting of restructuring at his job. He is unable to tell if he is having more trouble falling asleep or staying asleep. Sometimes he wakes up at 4 a.m. and is unable to fall back asleep. What should the PMHNP do first?

A. Prescribe zolpidem 10 mg at bedtime as needed

B. Prescribe a mirtazapine 15 mg at bedtime

C. Request the patient complete a sleep log

D. Add an extra blanket to his bed covers

A

Answer C. Request the patient complete a sleep log to gather more information regarding sleep latency, sleep efficiency, and sleep maintenance in order to make appropriate recommendations. Zolpidem as a sedative hypnotic is primarily used for patients who have trouble falling asleep. Mirtazapine is an antidepressant that is sometimes used off label in insomnia and for difficulty staying asleep. Environmental factors conducive to sleep include reducing the temperature of the environment and adding a blanket warmer.

187
Q

10-02. A 45-year-old female reports that she has difficulty falling back asleep after she wakes up at 4 a.m. for the last month. She understands that it is better to get out of bed rather than lay in bed awake. She uses this time to catch up on her reading but as a result is very sleepy during the day. What should the PMHNP recommend?

A. Intermezzo 1.75 mg when she awakes at 4 a.m.

B. Mop the kitchen floor as soon as she wakes up at 4 a.m.

C. Diphenhydramine 25 mg at bedtime

D. Sleep diary for 2 weeks

A

Answer B. Recommending a paradoxical intervention to address the sleep maintenance problem helps the patient realize a sense of control over her insomnia. Nonpharmacological interventions are preferred to pharmacological interventions. A sleep diary is used to gather information and to help clearly identify the type of insomnia.

188
Q

10-03. A 44-year-old male with type 2 diabetes is becoming increasingly irritable, inattentive, and forgetful, and frequently falls asleep in front of his computer at work. He is worried he will get fired and lose his benefits, which he needs to cover his diabetic supplies. He says, “I am so worried that my blood sugars are as high as 300 and on occasion have wet the bed.” What should the PMHNP do during this visit?

A. Provigil 100 mg daily

B. Order a sleep study

C. Mirtazapine 15 mg at bedtime

D. Refer him back to primary care for glycemic control

A

Answer B. A sleep study would help to diagnose if the underlying cause is obstructive sleep apnea (OSA), which is known to have symptoms of irritability, cognitive impairment, and excessive daytime sleepiness. Provigil is indicated for OSA, but a diagnosis has yet to be made. Mirtazapine 162is indicated for depression and anxiety, but an underlying medical condition must be ruled out first. OSA is known to worsen glycemic control.

189
Q

10-04. A 25-year-old woman reports frequently falling asleep during the day for the last 6 months. This has been affecting her work as a computer help desk agent, noting she sometimes nods off during calls but also during times of high volume. When her head hits the back of the chair she wakes up and realizes what has happened. She insists she consistently sleeps 8 hours each night. This is most consistent with which of the following?

A. Narcolepsy

B. Circadian rhythm sleep disorder

C. Hypersomnia

D. Night terrors

A

Answer A. Narcolepsy is characterized by two or more episodes of sleep latency lasting less than 8 minutes and/or two or more episodes of rapid eye movement (REM) sleep; it commonly occurs in the late teens and 20s. Circadian rhythm sleep disorder is often caused by changes in scheduling (shift work, jet lag) and requires a period of acclimation. Primary hypersomnia is excessive daytime drowsiness not due to an environmental sleep disturbance, underlying medical condition, substance induced disorder, or mood disorder, and is not associated with sleep paralysis (cataplexy). Night terrors are episodes of screaming or intense fear and flailing 2 to 3 hours after falling asleep and is often paired with sleepwalking, unlike nightmares, which are not remembered, and are most common in children between the ages of 2 to 12.

190
Q

10-05. John is a 22-year-old RN who has started his first job in the cardiothoracic ICU. After his orientation he began his full-time position working three 12-hour night shifts per week. On his days off he reports excessive fatigue during the day with periods of falling asleep while driving. He also reports difficulty staying awake at work during his first night back to work. Which of the following is the most likely diagnosis?

A. Narcolepsy

B. Circadian rhythm sleep disorder

C. Hypersomnia

D. Night terrors

A

Answer B. Circadian rhythm sleep disorder is often caused by changes in scheduling (shift work, jet lag) and requires a period of acclimation. Primary hypersomnia is excessive daytime drowsiness not due to an environmental sleep disturbance, underlying medical condition, substance induced disorder, or mood disorder, and is not associated with sleep paralysis (cataplexy). Night terrors are episodes of screaming or intense fear and flailing 2 to 3 hours after falling asleep and is often paired with sleepwalking, unlike nightmares, which are not remembered, and are most common in children between the ages of 2 to 12. Narcolepsy is characterized by two or more episodes of sleep latency lasting less than 8 minutes and/or two or more episodes of rapid eye movement (REM) sleep; it commonly occurs in the late teens and 20s.

191
Q

10-06. Ella is trying to help her 3-year-old son sleep through the night but reports recently he has had three episodes of waking up within 3 hours of falling asleep with inconsolable screaming and crying. He then falls back asleep on his own and has no memory of what happened. What would be the best intervention?

A. Recommend diphenhydramine 12.5 mg at bedtime

B. Create and maintain bedtime routine and reduce stimuli

C. Order polysomnography and EEG

D. Prescribe desmopressin nasal spray

A

Answer B. Creating and maintaining a bedtime routine, reducing stress, preventing the child from becoming over tired, and avoiding staying up too late are all appropriate interventions for night terrors. Prescribing diphenhydramine is not indicated for night terrors and can have paradoxical effects. Polysomnography and EEG are indicated for diagnosing obstructive sleep apnea, narcolepsy, and seizure disorders and are not indicated in this case. Desmopressin is indicated for nocturnal enuresis in children older than 6 years old.

192
Q

10-07. A 45-year-old man reports difficulty falling asleep and early morning awakening. He reports excessive daytime sleepiness as a result of his unrestful sleep. What should the PMHNP do first?

A. Prescribe trazadone 100 mg at bedtime

B. Administer Patient Health Questionnaire (PHQ)-9

C. Order a sleep study

D. Have the patient complete a sleep diary

A

Answer B. Administering the Patient Health Questionnaire (PHQ)-9 will help rule out an underlying mood disorder; abnormal sleep patterns such as difficulty falling asleep (increased sleep latency) and early morning awakening are common in depression (that is the main priority). Prescribing medication without knowing the underlying cause should be avoided. Ordering a sleep study would be appropriate for patients with symptoms of obstructive sleep apnea. The purpose of the sleep diary is to capture sleep patterns.

193
Q

10-08. A 22-year-old male has been referred by the employee assistance program at his job for poor work performance. The patient reports that no matter how much coffee he drinks he remains sleepy throughout the day and will doze off at meetings. He notes that he will often awake when his head hits the back of his chair when at a meeting. On occasion he has dropped his cup of coffee in front of everyone and now he feels he is under constant scrutiny and thinks people are speculating he is using drugs. What is the most likely diagnosis?

A. Primary hypersomnia

B. Hypnagogic hallucinations

C. Hypnopompic hallucinations

D. Narcolepsy

A

Answer D. Narcolepsy is characterized by the tetrad of hypersomnia (excessive daytime sleepiness), cataplexy (transient loss of motor tone in the presence of strong emotions, e.g., embarrassment, laughter, fear), and sleep paralysis (partial or total loss of muscle function during sleep-wake transition). Primary hypersomnia is excessive daytime drowsiness not due to an environmental sleep disturbance, underlying medical condition, substance induced disorder, or mood disorder, and is not associated with sleep paralysis (cataplexy). Hypnagogic hallucinations are vivid dreamlike visions that occur while falling asleep. Hypnopompic hallucinations are vivid dreamlike visions that occur when the person is transitioning from sleep to an awake state (often associated with narcolepsy).

194
Q

10-09. A 48-year-old obese woman experiences excessive daytime sleepiness, fatigue, anhedonia, and apathy. Her husband reports that she snores loudly when sleeping, and often will wake up drenched in sweat. The patient has no prior psychiatric history and denies substance abuse. Which of the following is the most likely cause of her symptoms?

A. Airway obstruction

B. Major depression

C. Perimenopause

D. Narcolepsy

A

Answer A. Obstructive sleep apnea is characterized by upper airway obstruction associated with snoring, morning headache, restless sleep, diaphoresis, excessive daytime sleepiness, cognitive impairment, fatigue, and apathy. Major depression is a diagnosis of exclusion (underlying medical conditions must be ruled out first) and includes symptoms such as sleep disturbance, anhedonia, persistent guilt or worry, fatigue, appetite change, psychomotor agitation or retardation, and suicidal ideations. Perimenopause occurs at the fourth to fifth decade of life and is characterized by vasomotor phenomena, breast tenderness, decreased libido, fatigue, and urinary incontinence. Narcolepsy is characterized by the tetrad of hypersomnia (excessive daytime sleepiness), cataplexy (transient loss of motor tone in the presence of strong emotions, e.g., embarrassment, laughter, fear), and sleep paralysis (partial or total loss of muscle function during sleep-wake transition).

195
Q

10-10. A 52-year-old obese man with type 2 diabetes reports dozing off while driving, watching TV, or reading, with increased apathy and fatigue. The PMHNP ordered a sleep study, which revealed 10 episodes of apnea lasting 15 to 20 seconds each per hour of sleep. Based on these findings, what should the PMHNP prescribe for his condition?

A. Antidepressant medications

B. Referral to otolaryngology for uvuloplasty

C. Referral to otolaryngology for rhinoplasty

D. Continuous positive airway pressure

A

Answer D. Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnea. Antidepressant medications are not known to normalize the sleep pattern in patients with obstructive sleep apnea. Referral for surgery is reserved for CPAP treatment failure.

196
Q

10-11. A father brings his 6-year-old son to you because he is worried about him. He states that the son sits up in bed shortly after falling asleep and screams. He says he is inconsolable and unable to be awakened during these episodes but eventually he falls back asleep. The father states he is not able to fall back asleep after those episodes and is exhausted and falling asleep at work during the day. The child is energetic and playful during the day and has no memory of the episodes. What is the most appropriate response?

A. “Are you worried you are doing something wrong?”

B. “I can see you’re upset, but really you are overreacting.”

C. “I can see this is upsetting for you.”

D. “Tell me why you can’t fall back asleep after your son does?”

A

Answer C. “I can see this is upsetting for you” is a simple nonjudgmental statement that communicates empathy and serves as an open-ended prompt to efficiently elicit the most important information. The father may be troubled by something other than the son’s night terrors and his own excessive daytime sleepiness. Specifically directed statements such as “Why can’t you fall back asleep?” or “Are you worried you are doing something wrong?” are less likely to garner complete essential information. Avoid using statements that contain a “but” in your initial response to a patient as it may be construed as a minimizing of their problems and feelings and will inhibit a therapeutic alliance.

197
Q

10-12. The PMHNP is providing psychoeducation and anticipatory guidance to the concerned parent regarding night terrors. At which stage of sleep is this most likely to occur?

A. Any stage of sleep

B. Stage 1

C. Stage 2

D. Stage 3 to 4

A

Answer D. Stage 3 to 4 is when night terrors and parasomnia occur (usually within 3 hours of falling asleep). Sleep terrors do not occur in stage 1, 2, or rapid eye movement (REM) sleep.

198
Q

10-13. Sam is 11 years old without past psychiatric history. He was born by normal spontaneous vaginal delivery with normal APGAR scores. He has met all of his developmental milestones. He began sixth grade this year and has had increased trouble falling asleep. He has always had bedtime rituals but lately they are extending in complexity and length. Most of his time in the evening is spent checking that the lights are turned off and that the windows are locked. As a result, he is only getting 5 hours of sleep at night and now has excessive daytime sleepiness with decreased interest in socialization and failing grades. Which of the following infectious diseases may contribute to this clinical presentation?

A. Treponema

B. Human immunodeficiency virus

C. Streptococcus

D. Congenital herpes simplex virus

A

Answer C. Streptococcus infection has been associated with severe obsessive compulsive disorder and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS). Treponema, human immunodeficiency virus and congenital herpes simplex virus are all associated with psychiatric symptoms in late stages of infection but are the least likely contributors in this case.

199
Q

10-14. The PMHNP is covering for the vacationing psychiatrist and is conducting a follow-up visit for a 24-year-old man diagnosed with major depressive disorder. Which type of sleep disturbance is most consistent with this diagnosis?

A. Early morning awakening

B. Sleeping too deeply

C. Easily awakened/sleeping too lightly

D. Decreased effect of trazadone

A

Answer A. Early morning awakening is most consistently associated with major depression; sleeping too deeply is associated with oversedation. Easily awakened/sleeping too lightly can be associated with hypervigilance in the setting of posttraumatic stress disorder (PTSD). The decreased effect of trazadone is not associated with a diagnosis of major depression and may indicate a need for titration.

200
Q

10-15. A patient with major depression and early morning awakening is likely to have which of the following hormonal states accounting for his symptoms?

A. Elevated testosterone

B. Elevated cortisol

C. Elevated catecholamine

D. Decreased cortisol

A

Answer B. An elevated cortisol level is observed in patients with depression and early morning awakening. Catecholamine and testosterone are decreased in patients with major depression.

201
Q

10-16. A 30-year-old man has been started on sertraline 50 mg daily for major depression 1 week ago. He presents for follow-up. Which of the following sleep patterns is he expected to report?

A. No change in sleep pattern

B. Increased sleep latency

C. Decreased sleep latency

D. Increased sleepiness earlier in the evening

A

Answer B. Increased sleep latency (difficulty falling asleep) is a common adverse effect associated with selective serotonin reuptake inhibitors (SSRIs) and is especially pronounced during initiation and titration of dosage. No change in sleep pattern. SSRIs are clinically activating, and the patient may perceive less need for sleep initially.

202
Q

10-17. A 56-year-old woman with depressed mood reports a decrease in weight, libido, and ability to sleep. In addition, she reports intermittent episodes of constipation. Which neurovegetative symptom should be targeted first when prescribing a psychopharmacological agent?

A. Constipation

B. Sleep

C. Weight loss

D. Depressed mood

A

Answer B. Sleep should be the first symptom targeted and a primary sleep disorder should be ruled out as it can account for many of the symptoms associated with major depression. Many psychotropic medications can make constipation worse, as can a disrupted sleep cycle.

203
Q

10-18. The PMHNP is consulting on a 79-year-old female in a long-term care facility with history of hypertension, coronary artery disease, and atrial fibrillation. The patient is having difficulty sleeping and was started on lorazepam 2 mg at bedtime. The patient has become increasingly agitated and wandering and has been further prescribed lorazepam 2 mg every 6 hours. The patient is also prescribed hydrochlorothiazide 25 mg daily, digoxin 0.125 mg every other day, diltiazem sustained release 360 mg daily, and isosorbide 30 mg daily. What should the PMHNP do first?

A. Begin lorazepam taper

B. Delirium workup

C. Start the patient on mirtazapine 15 mg at bedtime

D. Change lorazepam to alprazolam 1 mg every 4 hours as needed

A

Answer B. A delirium workup is indicated and should include orthostatic vital signs, electrolytes, infectious disease, digoxin level, and EKG as the patient is demonstrating signs of agitated delirium. Delirium can alter sleep pattern. Adding other medications may make delirium worse. Once an underlying cause is considered, weaning the lorazepam would be appropriate as the dose is quite high (8 mg/24 hours). Alprazolam is not preferred for consistent daily use in the elderly.

204
Q

10-19. A 68-year-old man presents with his wife for evaluation of sleep disorder. The wife reports he does not sleep well at night and wanders around the house. He then sleeps much of the day. Which of the following medications is preferred to control this behavior?

A. Chlorpromazine

B. Haloperidol

C. Trazodone

D. Lorazepam

A

Answer C. Trazodone is a serotonergic agent commonly used to help with sleep latency and maintenance, which can reduce wandering at night. It is also associated with increased bleeding and orthostatic changes so starting low is preferred. Benzodiazepines should be avoided in the elderly as they can disinhibit and make behaviors worse and trigger delirium. Antipsychotics should be avoided in the elderly as they are associated with increased extrapyramidal symptoms and tardive dyskinesia. These medications are also anticholinergic and can lead to urinary retention and confusion.

205
Q

10-20. A 55-year-old man with poorly controlled type 2 diabetes was referred for evaluation of medication noncompliance. Upon evaluation you realize that the patient has increased sleep latency, anhedonia, poor appetite, and persistent depressed mood. In addition, he reports chronic neuropathic pain in the feet unrelieved by analgesics. Which of the following medications may address the patient’s symptoms of poor sleep, depressed mood, poor appetite, and neuropathic pain?

A. Lorazepam

B. Escitalopram

C. Trazodone

D. Amitriptyline

A

Answer D. Tricyclic antidepressants have been used to treat chronic neuropathic pain in addition to major depressive disorder, specifically targeting symptoms of poor appetite, disturbed sleep, and depressed mood. Benzodiazepines should be avoided for the long-term and are highly addictive. Selective serotonin reuptake inhibitorss (SSRIs) and serotonin modulators do not have indications for neuropathic pain. Escitalopram may further worsen sleep latency.

206
Q

11-01. A 68-year-old man with no past psychiatric history reports that for the last 2 weeks he believes his internal organs have been removed, and that he has no mouth and therefore does not need to eat or drink. Which of the following best describes the patient’s condition?

A. Schizophrenia

B. Capgras syndrome

C. Cotard’s syndrome

D. Folie a deux

A

Answer C. Cotard’s syndrome is a nihilistic delusion (things, including the self, do not exist) associated with psychotic depression in this case. Folie a deux is a shared delusion of one person influenced by another in which the treatment is to separate the two parties. Capgras syndrome is a delusional belief that people have been replaced by impostors, and is associated with psychosis. Schizophrenia is a chronic and severe thought disorder affecting perceptions and is manifested by gross disorganization.

207
Q
  1. A 50-year-old woman with no past psychiatric history is evaluated for anhedonia, fatigue, apathy, and psychomotor agitation. She tells you that she has been refusing care from her husband because he has been replaced by an alien from outer space and only appears like her husband. Which of the following describes this psychotic depression?

A. Capgras syndrome

B. Cotard’s syndrome

C. Folie a deux

D. Schizophrenia

A

Answer A. Capgras syndrome is a delusional belief that people have been replaced by impostors, and is associated with psychosis. Cotard’s syndrome is a nihilistic delusion associated with psychotic depression and schizophrenia. Folie a deux is a shared delusion of one person influenced by another in which the treatment is to separate the two parties. Schizophrenia is a chronic and severe thought disorder affecting perceptions and is manifested by gross disorganization.

208
Q
  1. A 35-year-old woman 7 days postpartum is brought by the mobile crisis team to the ED at the request of the husband. The patient has no past psychiatric history and takes only prenatal vitamins. He reports that his wife has not been sleeping and has noticed her walking around their apartment in the middle of the night crying and talking to nobody. In addition, she has been ignoring the baby, but last night she told him that it was “Lucifer’s seed and it must be destroyed.” Which of the following is the most likely diagnosis?

A. Delusional disorder

B. Depression with psychosis

C. Schizoaffective disorder

D. Schizophrenia

A

Answer B. Depression with psychosis in the postpartum period (because it has occurred within 4 weeks of delivery) is characterized by depression, mood lability, delusions, and hallucinations. Very psychotic disorders such as schizophrenia or schizoaffective disorder are less common in this clinical presentation and require a longer duration of time to qualify for the diagnosis.

209
Q
  1. A 48-year-old divorced Black woman is admitted to the inpatient psychiatric unit after a serious suicide attempt by overdosing on acetaminophen. She has been admitted seven times with similar presentations after failing multiple treatments with antidepressants. She has been unable to work and has lost interest in all activities she once enjoyed. For the last 2 weeks she has had increased sleep latency, early morning awakening, difficulty concentrating, fatigue, hopelessness, and poor appetite. Which of the following factors would make the PMHNP recommend electroconvulsive therapy (ECT) in lieu of other medication trials?

A. Poor compliance with medications

B. History of bipolar illness

C. Melancholic depression with a history of poor response to medications

D. Persistent depression with psychotic symptoms

A

Answer C. Melancholic depression with a history of poor response to medications and the need for a quick antidepressant response are the universally accepted criteria that encourage ECT over medication and in major depression. Poor compliance with medication would not make a clinician choose ECT over medications as failure has not been demonstrated (treatment over objection and long-acting injectables are often preferred). A history of bipolar illness alone is not sufficient to recommend ECT over medication (lithium and valproic acid must often be stopped when ECT is begun because they alter the seizure threshold). Persistent depression with psychotic symptoms in the absence of failed medication trials would not sufficiently tip the balance in favor of ECT.

210
Q
  1. A patient meeting criteria for major depressive disorder is prescribed fluoxetine 20 mg daily. The PMHNP is reviewing the chart for a meritorious negligence claim. Which of the following conditions should have been documented and excluded from the differentials before prescribing a selective serotonin reuptake inhibitor (SSRI)?

A. Panic disorder

B. Obsessive-compulsive disorder

C. Bipolar disorder

D. Generalized anxiety disorder

A

Answer C. Bipolar disorder must be ruled out prior to prescribing antidepressant medications because they are known to induce mania in susceptible patients. Antidepressants may be carefully administered to patients with bipolar disorder with predominantly depressed features (often must have a mood stabilizing agent on board). Assess if compulsive disorder, generalized anxiety disorder, and panic disorder will all be well treated with SSRI medication.

211
Q
  1. The mother of a 19-year-old male is convinced his bipolar condition was caused by his drinking and drug use. Which of the following statements is true regarding bipolar disorder?

A. Patients with bipolar disorder have a better prognosis than patients with unipolar depression.

B. Patients with bipolar disorder usually do not require lifelong treatment compared to patients with major depression if they abstain from drugs and alcohol.

C. Bipolar disorder has a stronger genetic etiology than major depression.

D. Bipolar disorder is more common than depression in the United States.

A

Answer C. Bipolar disorder has a stronger genetic etiology than major depression. Bipolar patients do not have a better prognosis than unipolar patients; patients with bipolar disorder usually require lifelong treatment compared to patients with depression. Bipolar disorder has no gender or geographic predilection.

212
Q
  1. A patient has been prescribed sertraline 50 mg daily for the past year without adverse effects and remission of symptoms. The patient has missed the last two appointments but leaves a message that he feels “fantastic!” The wife called to reschedule a follow-up appointment, saying he has been giddy lately, emotionally labile, and spending money so frivolously that their account has been overdrawn. During the appointment the patient becomes hostile and tells the PMHNP that he is a phony, and not even a real doctor, and is having an affair with his wife. The patient is uninterruptible, with pressured speech. What pharmacological change is indicated?

A. Start lithium, increase sertraline

B. Start valproic acid, stop sertraline

C. Start valproic acid

D. Stop sertraline

A

Answer B. Start valproic acid and stop sertraline. Antidepressants can precipitate or exacerbate mania in patients with bipolar disorder who are frequently misdiagnosed initially with unipolar disorder. Increasing the sertraline while starting lithium will continue to exacerbate mania symptoms. Starting valproic acid without stopping the selective serotonin reuptake inhibitor (SSRI) will delay the treatment of mania. Stopping the sertraline without starting a mood stabilizer will delay the resolution of the manic symptoms.

213
Q
  1. A 21-year-old man had his first drink at his birthday party with friends last night. He presented the following morning to the emergency department with psychomotor agitation, cognitive impairment, depressed mood, flat affect, and anhedonia. His heart rate is 110, his blood pressure is 90/60, and he complains of abdominal pain. He received 2 L of normal saline IV and is referred to psychiatry for evaluation of mood disorder. Which of the following tests should the consulting PMHNP order given these symptoms?

A. Blood alcohol level

B. Urinalysis

C. Urinary porphobilinogen

D. Acetaminophen level

A

Answer C. Urinary porphobilinogen is used to screen for acute intermittent porphyria, which often manifests through manic or psychotic symptoms and is typically associated with abdominal pain, nausea, vomiting, muscle pain, numbness, tingling, hallucinations, paranoia (commonly occurring after excessive heme demand-triggered alcohol consumption), recreational drug use, stress, and fasting. The patient was naïve to alcohol consumption and many hours have passed since his consumption of alcohol. His acute onset of psychiatric symptoms and abnormal vital signs in the setting of abdominal pain calls for the reiteration of the necessary diagnostic mantra “all psychiatric diagnoses are diagnoses of exclusion.” The PMHNP must rule out an underlying medical cause, substance-induced cause, malingering, and factitious disorder before diagnosing a psychiatric disorder.

214
Q
  1. The certified nurse midwife is evaluating a 29-year-old woman 2 weeks postpartum and finds her neglecting her self-care and minimally attentive to the baby and will not allow anyone else to care for the baby. During the visit a PMHNP is able to provide webcam consultation and liaison services. Based on the information provided, what is the priority in the management of this patient?

A. Electronically prescribe an antipsychotic

B. Electronically prescribe a mood stabilizer

C. Admit the patient to the hospital

D. Electronically prescribe an antidepressant

A

Answer C. 176Admit the patient to the hospital because, in her present condition of postpartum psychosis, the mother is an immediate danger to the infant. Prescribing medications in this instance does not take into account the well-being of the child in the immediate aftermath.

215
Q
  1. A 40-year-old senior associate in a law firm presents for care complaining of fatigue and poor motivation to the degree that he has been avoiding work. His boss has encouraged him to take some time off. The patient also reports that his wife recently kicked him out of the house after discovering his third extramarital affair. For the last 2 weeks he has been sleeping 16 hours a day, poor appetite, and has overdrawn his account. He says that this is most unlike him in that he used to be able to get by on 5 hours of sleep a night, party hard, and work harder. What is the most likely diagnosis for this patient?

A. Bipolar 1

B. Bipolar 2

C. Major depressive disorder

D. Narcissistic personality disorder

A

.Answer B. Bipolar disorder type 2; the patient is demonstrating symptoms of hypomania, which have not required psychiatric treatment or caused occupational dysfunction and currently he is in a depressed state. Hypomania with major depression defines bipolar 2 disorder. Bipolar 1 disorder requires one manic episode that is so severe it causes occupational dysfunction. The patient is not demonstrating grandiose symptoms of entitlement or other narcissistic personality traits.

216
Q
  1. A 60-year-old man has been treated for depression for the last 2 years with a medication he cannot remember. He reports that he has had increasing urinary hesitancy, xerostomia, and intermittent lightheadedness. Which of the following medications is this patient most likely prescribed?

A. Doxepin

B. Fluoxetine

C. Lithium

D. Lamictal

A

Answer A. Doxepin is a tricyclic antidepressant known for its anticholinergic properties including dry mouth, orthostasis, urinary hesitancy, and retention leading to dysuria. Fluoxetine is a selective serotonin reuptake inhibitor mostly associated with GI upset and sexual dysfunction. Lithium is most often associated with nephrogenic diabetes insipidus and symptoms include polyuria, polydipsia, altered mental status, and tremor. Lamictal is an antiepileptic drug commonly used for mood stabilization associated with GI upset and, during periods of titration, Stevens-Johnson syndrome.

217
Q
  1. When providing psychoeducation to a patient with treatment-resistant depression about electroconvulsive therapy (ECT), you tell the patient that the most common adverse effect of treatment is which of the following?

A. Arrhythmia

B. Amnesia

C. Respiratory depression

D. Psychosis

A

Answer B. Amnesia is the most common adverse effect associated with ECT. Anesthesia-induced arrhythmia and respiratory depression are very rare side effects and often do not occur unless the patient is predisposed. Psychosis can often be improved rather than worsened after ECT. ECT is often preferred in cases of psychotic depression.

218
Q
  1. A patient who is considering electroconvulsive therapy (ECT) for resistant depression inquires as to the number of sessions she would likely require. Based on the best evidence currently available what is the best response?

A. 40

B. 20

C. 10

D. 4

A

Answer C. Major depression treated with ECT usually requires between six and 12 sessions. Patients receiving ECT for catatonia can be treated with as little as two to four sessions. Patients with psychosis or mania may require 20 to 40 treatments for a positive therapeutic response.

219
Q
  1. A 35-year-old woman is being evaluated 7 months postpartum for recurrent thoughts about wanting to harm her baby by stabbing with a knife. She continues to breastfeed and care for the baby. Since having these thoughts, she has removed all sharp objects from the home and has started ordering take out food to feed her family. She is reluctant to share these thoughts with her husband. Which of the following medications would be most appropriate to prescribe?

A. Sertraline

B. Lorazepam

C. Benztropine

D. Doxepine

A

Answer A. Sertraline particularly in high doses is preferred for obsessive compulsive symptoms as well as antidepressant and anxiolytic effects. Lorazepam and other benzodiazepines are indicated for short-term use in anxiety but are highly addictive and may have a sedating effect on the baby if breastfeeding continues. Benztropine is used to reduce abnormal involuntary movements (extrapyramidal side effects and tardive dyskinesia) associated with antipsychotic (neuroleptic) medication. Doxepine and other tricyclic antidepressant (TCA) medications are not believed to be as efficacious in obsessive compulsive disorders.

220
Q
  1. A 38-year-old investment banker reveals that on weekends he visits the Delightful Dungeon and pays a dominatrix to tie him up, humiliate him, and whip him. He finds these sessions painful but very sexually arousing. He is able to become aroused and climax without this experience but finds this activity novel and has no desire to stop. Which of the following diagnosis is most likely?

A. Atypical depression

B. Sexual sadism

C. No diagnosis

D. Sexual masochism

A

Answer C. No diagnosis meeting DSM-5 criteria for paraphilia is most likely for this patient. The patient does not have an occupational or social dysfunction, nor does he express any distress caused by his activities. If the patient was distressed by his behavior, he may meet criteria for sexual masochism characterized as the arousal caused by psychological or physical punishment. Sexual sadism requires arousal caused by giving punishment. Fetishism requires the involvement of nonliving objects to cause arousal. The patient does not demonstrate symptoms of atypical depression (mood temporarily lifts in response to positive events, weight gain, excessive daytime sleepiness despite adequate sleep, hypersensitivity to criticism).

221
Q
  1. A 30-year-old G1P0,1 has become increasingly oddly related, neglecting self-care, sleeping much of the day, eating minimally, crying easily, and despite reassurance that her pregnancy is progressing normally, worries that she will lose the pregnancy. Which of the following medications is considered least harmful in pregnancy?

A. Lithium

B. Divalproex

C. Sertraline

D. Haloperidol

A

Answer C. Sertraline (a selective serotonin reuptake inhibitor) is commonly used in antepartum patients because the benefit is thought to outweigh the risk of untreated mental disorder despite a lack of definitive studies. Lithium, divalproex, and haloperidol are all associated with teratogenic effects in the fetus.

222
Q
  1. A pregnant woman with depression is reluctant to take medication for fear of causing her baby neonatal abstinence syndrome due to selective serotonin reuptake inhibitor (SSRI) medication. Her husband states they would like to use a faith healer instead. Which of the following is most accurate regarding the prognosis of depression during pregnancy?

A. The actual course of depression cannot be predicted

B. If the patient does not take medication she will continue to deteriorate

C. There is no risk of adverse effect associated with SSRIs

D. The patient will likely require involuntary commitment to a mental institution

A

Answer A. The prognosis of depression cannot be predicted. It is not a foregone certainty that if the patient does not take medication she will continue to deteriorate. There is risk of neonatal abstinence syndrome associated with SSRIs, and it is not certain that the patient will require involuntary commitment if she does not take this medication.

223
Q
  1. A 25-year-old female is referred by her women’s health nurse practitioner for evaluation. The patient reports that the week before her period every month she feels angrier and is increasingly irritable, and has difficulty concentrating, low energy, and a desire to sleep more and eat more ice cream. These symptoms all seem to stop the week after her period. What is the most likely diagnosis?

A. Cyclothymic

B. No diagnosis; normal female behavior

C. Dysthymia

D. Premenstrual dysphoric disorder

A

Answer D. The patient meets criteria for premenstrual dysphoric disorder; duration is not sufficiently long to qualify for major depressive disorder. Dysthymia requires the persistence of symptoms for at least 2 years. Cyclothymic disorder requires alternating between symptoms of depression and hypomania without meeting full criteria most of the time for at least 2 years and a symptom-free period cannot exceed 2 months.

224
Q
  1. A 30-year-old man was recently terminated from his job for impulsive corporate spending. He was brought to the ED by the police for public nudity. The urine toxicology is negative, and all labs are normal. The patient is pressured and difficult to interrupt. He is demanding to leave and wants to speak to his lawyer, and he states that “the founding fathers declare that all men are created with the inalienable right to life and liberty, and President Trump has caused the Federal Bureau of Investigation (FBI) to trample my rights, which is a high crime and he should be impeached.” Which of the following is the most likely diagnosis?

A. Adjustment disorder

B. Bipolar disorder

C. Major depression

D. Posttraumatic stress disorder (PTSD)

A

Answer B. The most likely diagnosis for this patient is bipolar disorder, currently meeting criteria for a manic episode including psychomotor agitation, grandiose thinking, pressured speech, flight of ideas, impulsive behavior, uncharacteristic excessive spending stated with premorbid euthymia, and high functioning behavior. There is no precipitating identifiable stressor as the primary driver of this manic behavior. Because the patient is in a manic episode he should never be diagnosed with major depressive disorder even if he presents as depressed at some time in the future (lest he be treated with antidepressant monotherapy). He does not have symptoms consistent with PTSD including hypervigilance or avoidance behaviors.

225
Q
  1. A 70-year-old man with a history of hypertension is being evaluated for late effects of a cerebrovascular accident. Which of the following conditions is most associated with microvascular ischemia?

A. Anxiety

B. Obsessive compulsive disorder

C. Depression

D. Posttraumatic stress disorder (PTSD)

A

Answer C. Depression is a common comorbid condition associated with microvascular ischemia such as cerebrovascular accident (CVA) and myocardial infarction. Anxiety and PTSD are not associated with late effects of CVA, but the patient may have hypervigilance regarding self-care and adopt obsessive compulsive behaviors regarding self-care measures.

226
Q

12-01. A 25-year-old female presents to the emergency department, having just witnessed an accident. Her speech is pressured. She states, “There were a lot of people in need of care at the scene, and I should know because I have traveled to many Third World countries. I know how bad needs can get. The people were injured, and she was hit by a car before but did not suffer any injuries. There were a lot of police cars and ambulances.” The patient was triaged to psychiatry. The PMHNP describes her thought process as:

A. Circumstantial

B. Tangential

C. Flight of ideas

D. Loose associations

A

Answer A. Circumstantial describes a speech pattern that is overly inclusive and includes, a lot of unnecessary details and digressions but eventually reaches the point. Tangential describes a thought pattern that uses a lot of unnecessary details and digressions but never returns to the main point. Flight of ideas describes a thought pattern with erratic direction changes with an identifiable connection between thoughts. Loosening of association is characterized by an illogical connection between thoughts digressing in multiple directions, but sentence structure remains intact.

227
Q

12-02. A 45-year-old man is reporting chest pressure, difficulty breathing, numbness, and tingling in his hands and lips. He has been seen in the emergency department in which he underwent a negative cardiac workup. He was subsequently triaged to psychiatry for evaluation. The PMHNP asks how he came to the hospital. He states, “I felt awful, my heart was pounding, I was sweating so much, I thought I was going to die. My father had a similar problem, but he died 10 years ago.” Which of the following best describes the thought pattern?

A. Circumstantial

B. Tangential

C. Flight of ideas

D. Loose associations

A

Answer B. Tangential describes a thought pattern that uses a lot of unnecessary details and digressions but never returns to the main point. Circumstantial describes a speech pattern that is overly inclusive and includes a lot of unnecessary details and digressions but eventually reaches the point. Flight of ideas describes a thought pattern with erratic direction changes with an identifiable connection between thoughts. Loosening of association is characterized by an illogical connection between thoughts digressing in multiple directions, but sentence structure remains intact.

228
Q

12-03. A 29-year-old man presents to the emergency department stating he is very anxious and feels his heart is going to beat out of his chest. He is diaphoretic, with pressured speech and unable to be calmed. A psychiatric consult was called because the patient seems uncooperative and a proper history cannot be obtained. Which of the following conditions must be excluded first?

A. Hypochondriasis

B. Phobia

C. Cocaine-induced mood disorder

D. Panic attack

A

Answer C. Cocaine-induced mood disorder must be ruled out first as it can trigger myocardial infraction and would prohibit the use of beta-blockers in the management of vasospasm and 192anxiety due to the unopposed effects of the alpha blockade on the heart worsening ischemia. Phobia and hypochondriasis are not life threatening conditions, and panic attacks spontaneously resolve within 20 minutes.

229
Q

12-04. A 22-year-old medical student has had several episodes of impending doom over the last 4 months. The events last 10 to 20 minutes and are associated with tremor, sweating, dizziness, and being unable to concentrate. He is now perpetually worried that these attacks will happen when doing his clerkship. The PMHNP in the student health center diagnoses him with panic disorder without agoraphobia. Which medication is the first choice for this condition?

A. Klonopin

B. Fluoxetine

C. Chlordiazepoxide

D. Lithium

A

Answer B. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is the first-line psychopharmacological agent for panic disorders and anxiety disorder. Benzodiazepines like Klonopin, while useful in the short-term, are highly addictive and lead to tolerance. Lithium is not indicated for panic or anxiety disorders.

230
Q

12-05. An 18-year-old girl was visiting colleges with her family and was involved in a fatal car accident 2 weeks ago. Since that time, she continually has flashbacks, difficulty sleeping, persistent ruminations, and is afraid to drive. She has become apprehensive about her family members driving as well. What is the most appropriate diagnosis?

A. Posttraumatic stress disorder

B. Generalized anxiety disorder

C. Adjustment disorder

D. Acute stress disorder

A

Answer D. Acute stress disorder best describes her symptoms of intrusive memory, rumination, hypervigilance, apprehensiveness, and avoidance because the incident was less than 4 weeks ago. Posttraumatic stress disorder would have the same symptoms but they must persist longer than 4 weeks. Generalized anxiety disorder is not associated with a specific traumatic event and the symptoms must persist a majority of the time and include irritability lasting at least 6 months. Adjustment disorder is characterized by the development of mood and anxiety symptoms, not precipitated by a traumatic event.

231
Q

12-06. A 34-year-old woman comes to an appointment because she is bothered by disturbing and recurrent thoughts of harming her 7-month-old infant. She reports that her thoughts are distressing enough that she has removed all sharp objects from the kitchen so that she cannot stab her baby with a knife. She has not shared these thoughts with her husband for fear of how he may react to her. Which of the following is the most likely diagnosis?

A. Obsessive compulsive disorder

B. Generalized anxiety disorder

C. Bipolar disorder with peripartum onset

D. Acute stress disorder

A

Answer A. Obsessive compulsive disorder; the patient’s recurrent thoughts are ego dystonic, and she is attempting to ignore and suppress them and does not discuss them with her husband. She tries to mitigate the risk by getting rid of all the knives. Bipolar disorder with peripartum onset usually occurs within 2 weeks of childbirth and has accompanying mood disorders, hallucinations, and delusions. It is often associated with severe insomnia, rapid mood changes, anxiety, irritability, and psychomotor agitation. Generalized anxiety disorder is not associated with a specific traumatic event and the symptoms must persist a majority of the time and include irritability lasting at least 6 months. Acute stress disorder best describes her symptoms of intrusive memory, rumination, hypervigilance, apprehensiveness, and avoidance because the incident was less than 4 weeks ago.

232
Q

12-07. A 38-year-old Middle Eastern male veteran of Operation Iraqi Freedom is evaluated at the mental health clinic. He reports that he saw many of his battle buddies get killed in action. He has been stateside for 2 years, but since that time he has had trouble sleeping and as such he is very irritable to be around. He reports ongoing nightmares and flashbacks to an explosion and he feels on edge most of the time. He avoids large crowds and loud noises. He finds that having a few beers helps calm him and makes him more pleasant to be around and allows him to socialize rather than isolate himself. Which of the following medications should the PMHNP prescribe?

A. Risperdal

B. Lorazepam

C. Sertraline

D. Imipramine

A

Answer C. Sertraline and other selective serotonin reuptake inhibitors (SSRIs) are indicated for symptoms of posttraumatic stress disorder (PTSD) as indicated by his symptoms. The patient does not demonstrate any psychotic symptoms so there is no need for antipsychotic medication given the risk of metabolic syndrome and limited efficacy for monotherapy and PTSD. Benzodiazepines are highly addictive and should be avoided in this population. Tricyclic antidepressants have a host of anticholinergic adverse effects and should be reserved for chronic pain conditions and failure of first- and second-line therapies.

233
Q

12-08. A 32-year-old man presents on referral from his primary care provider. He reports a 6-month history of recurrent bouts of anxiety associated with chest pain, tachycardia, tremors, nausea, diaphoresis, and an impending sense of doom. The episodes last approximately 20 minutes and he is unable to identify a precipitating event. The patient has become increasingly isolated for fear of not wanting to have this sort of episode in public. The primary care provider started him on a selective serotonin reuptake inhibitor (SSRI) 6 months ago but he continues to have the symptoms. Which adjunctive psychotherapy would be most appropriate for this patient?

A. Eye movement desensitization and reprocessing (EMDR) therapy

B. Interpersonal therapy

C. Supportive psychotherapy

D. Cognitive behavioral therapy

A

Answer D. Cognitive behavioral therapy is an evidence-based psychotherapeutic approach indicated for anxiety disorders and mood disorders. EMDR is specifically developed for the treatment of posttraumatic stress disorder (PTSD). Interpersonal therapy looks at the relationships contributing to depression. Supportive psychotherapy aims to strengthen the patient’s defense mechanisms to restore function and is typically reserved for patients with more primitive coping mechanisms.

234
Q

12-09. The PMHNP is rounding on the inpatient psychiatric unit. During the meeting with a 32-year-old patient with a history of substance use disorder, she informs the patient that her rehabilitation bed is ready, and she will be discharged today. Nursing staff reports that the patient has a heart rate of 120 and a blood pressure of 150/80. In evaluating the patient, the mental health worker informs you that the patient was running in place vigorously before having her vital signs checked. What is the most likely diagnosis to account for this patient’s behavior?

A. Hypochondriasis

B. Malingering

C. Factitious disorder

D. Somatoform disorder

A

Answer C. Factitious disorder is characterized by feigning a sick role to produce symptoms of an illness for personal gratification. Malingering is characterized by pretending to be ill for financial or material gain. Hypochondriasis is a delusion that the patient has a particular medical diagnosis and worries that this illness is causing distressing symptoms. Somatoform disorder is characterized by the patient experiencing numerous physical symptoms that are unrelated to any specific disease state or organ system; usually, symptoms are unrelated, multiple, and difficult to measure.

235
Q

12-10. A 32-year-old male was referred from the urologist for erectile dysfunction. He has been prescribed a phosphodiesterase-5 inhibitor (PD5-I) with variable success despite a negative physiological workup. Which form of therapy is indicated for this sexual dysfunction?

A. Cognitive behavioral therapy

B. Interpersonal therapy

C. Supportive psychotherapy

D. Eye movement desensitization reprocessing (EMDR) therapy

A

Answer A. Cognitive behavioral therapy is an evidence-based psychotherapeutic approach indicated for anxiety disorders and the primary treatment for sexual dysfunction. EMDR is specially developed for the treatment of posttraumatic stress disorder (PTSD). Interpersonal therapy looks at the relationships contributing to depression. Supportive psychotherapy aims to 193strengthen the patient’s defense mechanisms to restore function and is typically reserved for patients with more primitive coping mechanisms.

236
Q

12-11. A 29-year-old woman with a history of panic disorder requests a psychiatric home visit because she continues to experience feelings that her environment is not real. She states that this is very unsettling and, as a result, has stopped going out of her home. In formulating her case, the PMHNP would describe this symptom as the persistence of:

A. Depersonalization

B. Derealization

C. Psychosis

D. Depressive symptoms

A

Answer B. Derealization is common in anxiety disorders, and it is characterized by the sense of one’s surroundings being strange or unfamiliar and not real. Depersonalization is the feeling that one’s identity has been lost as if they are outside their own body. Psychosis is characterized by disordered thought patterns and gross disorganization accompanied by hallucinations or delusions. Depressive symptoms commonly include sleep disruption, anhedonia, apathy, guilt, fatigue, and hopelessness.

237
Q

12-12. A 34-year-old Korean male pediatric dentist is referred to psychiatry for persistent anxiety. Upon further assessment, he reveals that his penis is shrinking into his abdomen. Despite the reassurance he has received from numerous health care providers in the past he remains convinced of this belief. This culture-bound delusion is known as:

A. Zar

B. Taijin kyofusho

C. Koro

D. Kuru

A

Answer C. Koro is the delusion that the penis is shrinking into the abdomen, found in South and East Asian cultures. Zar is a culture-bound syndrome delusion of being spirit possessed, found in North and East African cultures and Middle Eastern cultures. Taijin kyofusho is a Japanese culture-bound syndrome in which one perceives their body to be offensive to others. Kuru is a neurodegenerative prion disease that leads to death, found in New Guinea and transmitted through the cannibalistic funeral ritual of eating the brains of the dead.

238
Q

12-13. A 25-year-old female presents with symptoms of nausea, headache, and backache. Despite consultation with her primary care provider, gastroenterologist, neurologist, and ED visit no identifiable cause has been found for her symptoms. She has been referred to psychiatry but insists she should go to rheumatology. What should the PMHNP do?

A. Refer the patient to rheumatology

B. Inquire as to the most bothersome symptom and when it occurs

C. Order a whole body CT scan

D. Prescribe a selective serotonin reuptake inhibitor (SSRI)

A

Answer B. Somatoform disorder is characterized by the patient experiencing numerous physical symptoms that are unrelated to any specific disease state or organ system; usually, symptoms are unrelated, multiple, and difficult to measure. Inquiring as to the most bothersome symptom and, when it occurs, building a therapeutic alliance helps provide necessary information to begin cognitive behavioral therapy (CBT). Giving the patient a referral to rheumatology may be useful eventually, but the patient lacks any insight into the cause of her symptoms. A whole body CT scan without a specific indication is not evidence based, possesses potential harm from excessive radiation exposure, and risks incidental findings, which may worsen the delusion and anxiety. Prescribing medication without a therapeutic alliance risks alienating the patient.

239
Q

12-14. A patient presents to the emergency department reporting sudden onset blindness. Her physical exam is unremarkable. The patient is referred to psychiatry for disposition because the patient insists she cannot care for herself. What is the most likely diagnosis?

A. Somatoform disorder

B. Conversion disorder

C. Hypochondriasis

D. Factitious disorder

A

Answer B. Conversion disorder is characterized as the sudden onset of a singular neurological defect, often in the setting of acute stress. Factitious disorder is characterized by feigning a sick role to produce symptoms of an illness for personal gratification. Hypochondriasis is a delusion that the patient has a particular medical diagnosis and worries that this illness is causing distressing symptoms. Somatoform disorder is characterized by the patient experiencing numerous physical symptoms that are unrelated to any specific disease state or organ system; usually, symptoms are unrelated, multiple, and difficult to measure.

240
Q

12-15. A 32-year-old White male was formerly employed as a corporate lawyer and has recently started his own business. He has started experiencing symptoms of intense anxiety when taking the subway to work. The symptoms include feeling short of breath, chest pressure, sweaty, irritable, and an impending sense of doom. The symptoms have persisted and worsened over time to where he has everything delivered and cannot leave the house. What is the most likely diagnosis?

A. Malingering

B. Delusional disorder

C. Agoraphobia

D. Hypochondriasis

A

Answer C. Agoraphobia is characterized by a fear of open spaces and/or crowded spaces, and often is comorbid with panic disorder. Hypochondriasis is the misinterpretation of signs and symptoms, leading to a delusion of illness. Malingering is the faking of symptoms for secondary gain or the avoidance of consequences. Delusional disorder is a deeply held belief despite evidence to the contrary.

241
Q

12-16. A 62-year-old billionaire was recently arrested on charges of pedophilia and child pornography. He was denied bail at his hearing and is waiting in jail pending his trial. The next morning the patient was found passed out on the ground and transferred to the emergency department. He was evaluated, and the work up was negative. Upon discharge, he tells the emergency department attending he is suicidal and wants to hang himself. The patient is referred to psychiatry for evaluation of suicidal ideation. Which of the following conditions must be considered in the differential diagnosis?

A. Malingering

B. Delusional disorder

C. Agoraphobia

D. Hypochondriasis

A

Answer A. Malingering is the faking of symptoms for secondary gain or the avoidance of consequences. Delusional disorder is a deeply held belief despite evidence to the contrary. Agoraphobia is characterized by a fear of open spaces and/or crowded spaces, and often is comorbid with panic disorder. Hypochondriasis is the misinterpretation of signs and symptoms, leading to a delusion of illness.

242
Q

12-17. A 28-year-old woman is admitted with sepsis. Her condition responds to antibiotics but then nearing the end of the course of her treatment, she seems to spike a fever again and requires further antibiotics. The patient tells her team that she is very depressed, and they order a psychiatric consultation. The PMHNP evaluates the patient in the semiprivate room and upon leaving the roommate passes a note to the PMHNP, informing her that she observed the patient roommate injecting her IV with tap water. What is the most likely diagnosis?

A. Factitious disorder

B. Malingering

C. Conversion disorder

D. Delusional disorder

A

Answer A. Factitious disorder, also known as Munchausen’s syndrome, is when the patient induces her own illness and symptoms to maintain the sick role for personal gratification. Malingering is the faking of symptoms for secondary gain or the avoidance of consequences. Delusional disorder is a deeply held belief despite evidence to the contrary. Conversion disorder is characterized as the sudden onset of a singular neurological defect often in the setting of acute stress.

243
Q

12-18. A 50-year-old woman referred from the surgical service is described as a “frequent flyer.” She reports vague complaints that have no apparent cause or objective clinical findings. Most recently, she complains of vaginal pain, headache, and stomachache. Upon interview she is tearful, guarded, and withdrawn. What is the most likely psychiatric diagnosis?

A. Malingering

B. Conversion disorder

C. Somatization disorder

D. Factitious disorder

A

Answer C. Somatization disorder is characterized by the patient experiencing numerous physical symptoms that are unrelated to any specific disease state or organ system; usually, symptoms are unrelated, multiple, and difficult to measure. Factitious disorder, also known as Munchausen’s 194syndrome, is when the patient induces her own illness and symptoms to maintain the sick role for personal gratification. Malingering is the faking of symptoms for secondary gain or the avoidance of consequences. Conversion disorder is characterized as the sudden onset of a singular neurological deficit often in the setting of acute stress.

244
Q

12-19. A 30-year-old female is referred by her women’s health nurse practitioner for vaginismus. The woman is distraught and embarrassed because she has not been able to consummate her marriage. Which therapeutic technique would be most helpful?

A. Systematic desensitization

B. Exposure therapy

C. Distraction

D. Group therapy

A

Answer A. Systematic desensitization is a modality of cognitive behavioral therapy in which the patient controls the stressful impetus until a more muted response is produced. Exposure therapy prematurely provided may worsen and entrench the anxiety-provoking occurrence. Distraction can be included in systematic desensitization but is not a first-line treatment. Group therapy may be helpful eventually, but it is essential to build a therapeutic alliance before making a referral.

245
Q

12-20. A 15-year-old boy has refused to go to school for the past month. Every morning he has a new symptom or develops one and has to be picked up from school. When he is home, the symptoms disappear. On weekends the symptoms never present. What is the most likely diagnosis?

A. Separation anxiety

B. Social anxiety

C. Agoraphobia

D. Panic disorder

A

Answer A. Separation anxiety is characterized by developmentally inappropriate, excessive apprehensiveness and worry related to separating from significant attachment figures or a source of comfort. Social anxiety is characterized by marked fear or anxiety about social situations in which the individual is exposed to possible scrutiny by others. There is not sufficient information in the presentation to suggest social anxiety to be this patient’s diagnosis. Agoraphobia is characterized by the fear and avoidance of multiple situations due to thoughts that it may be difficult to escape should a panic attack occur. Panic disorder is a discrete episode of heightened arousal characterized by intense apprehension, fear, terror, or the impending sense of doom.

246
Q

13-01. A 16-year-old male is being evaluated in a partial hospital program for adolescents for major depressive disorder. In addressing safety planning with the boy and his parents, they raised the question of possible suicidality with the use of selective serotonin reuptake inhibitors (SSRIs). What question should the PMHNP ask regarding the most common means of suicide and adolescence?

A. Does the home contain ligature risks?

B. Is the medicine cabinet locked?

C. Are there firearms in the home?

D. Can all the knives be secured?

A
247
Q

13-02. A 16-year-old girl with no past medical history was referred by her primary care provider who saw her for a sports physical because she said she was depressed. During the interview the girl revealed that she has been feeling tired, sad, is crying easily, and has difficulty falling asleep. She reports that she has also been eating a lot more and to keep from gaining weight she has been taking laxatives and on occasion makes herself vomit. She has dropped out of the yearbook committee and she is not sure she wants to go to college anymore. Which nonpharmacologic intervention is most appropriate?

A. Group therapy

B. Psychoanalysis

C. Family therapy

D. Cognitive behavioral therapy

A

Answer D. Cognitive behavioral therapy is the preferred psychotherapeutic intervention for major depressive disorder and bulimia nervosa. Group therapy, psychoanalysis, and family therapy may also be effective long term, but the evidence supports cognitive behavioral therapy above these other modalities.

248
Q

13-03. A 17-year-old girl with major depressive disorder single episode and bulimia nervosa is unable to actively participate in psychotherapy because she says she feels too sleepy during the day because she is unable to sleep at night. In addition, she is inattentive, irritable, finds it difficult to concentrate, and has no desire to do anything. Which pharmacological agent is preferred for monotherapy?

A. Atypical antipsychotic

B. Selective serotonin reuptake inhibitor

C. Tricyclic antidepressant

D. Mood stabilizer

A

Answer B. Selective serotonin reuptake inhibitors (SSRIs) are the first-line agent for major depressive disorder in children and adolescents and are very difficult to overdose. Tricyclic antidepressants (TCAs) are associated with numerous adverse effects and are much easier to overdose. Stabilizers are primarily used for bipolar disorder and only as augmentation for major depression. Antipsychotics are associated with weight gain and are not indicated for major depression in children or adolescents.

249
Q

13-04. A 6-year-old boy is referred by the child study team for speech difficulty. On examination the boy is friendly and cooperative, his speech is clear, and he uses simple sentences with a limited vocabulary. Most notably he confuses verb tenses consistently. The parents report he met most of his developmental milestones except speech, which was delayed. His clinical presentation is most consistent with which of the following?

A. Stuttering disorder

B. Expressive language disorder

C. Reading disorder

D. Writing disorder

A

Answer B. Expressive language disorder is characterized by limited vocabulary with consistent errors in verb tense, and word finding difficulties with appropriately complex sentence structure. Symptoms are presented that are consistent with reading or writing disorders; the clear speech excludes stuttering disorder.

250
Q

13-05. When evaluating a 7-year-old girl diagnosed with expressive language disorder, which of the following assessments would be most helpful in confirming the diagnosis?

A. Diagnostic interview scheduled for children

B. Diagnostic interview for children and adolescents

C. Children’s assessment scale

D. IQ test

A

Answer D. An IQ test would be most helpful in confirming the diagnosis of expressive language disorder because the diagnosis of intellectual disability must be ruled out. The other assessments are semistructured interviews used primarily in the assessment of mood disorder, anxiety disorder, and oppositional defiant behavior.

251
Q

13-06. A mother 4 months postpartum is referred to infant psychiatry as the baby has failed to gain weight over the last 2 months. He has dropped from the 75th percentile to the 50th percentile. The mother states that up until 8 weeks of age he was gaining weight and growing just fine. The baby is generally happy and continues to meet his developmental milestones. Of note, the mother has returned to work after her postpartum leave 2 months ago and the baby is in daycare 5 days a week. The mother notes that he has been increasingly spitting up for the last month soon after receiving breast milk via the bottle. She has also started to supplement with formula out of concern for his poor weight gain. This clinical description is most consistent with which type of disorder?

A. Bulimia nervosa

B. Pica

C. Rumination disorder

D. Anorexia

A

Answer C. Rumination disorder is a feeding disorder of infancy and early childhood characterized by regurgitation shortly after eating without swallowing the spit up food, lasting at least 1 month following a period of normal function. Rumination disorder is common in infants who have a variety of caretakers or are maintained in an unstable environment. There is no indication of deliberate food avoidance consistent with anorexia nervosa, the infant does not have episodes of binge eating followed by purging, and is not self-inducing vomiting or afraid of becoming fat. There is no report of eating nonnutritive substances, elevated lead level, or anemia.

252
Q

13-07. A 10-year-old boy is referred by the school nurse because of persistent stomachache every morning in school. In evaluating the boy, the PMHNP learned that he does not like to go to school and insists on coming home immediately, and that he sleeps in his parent’s bed at night. His clinical description is most characteristic of which of the following conditions?

A. Social phobia

B. Separation anxiety

C. Reactive attachment disorder

D. Posttraumatic stress disorder (PTSD)

A

Answer B. Separation anxiety best describes this clinical presentation characterized by developmentally inappropriate and excessively anxious disposition regarding separation from the home or other sources of comfort. Social phobia would require persistent fear of social or performance situations in which exposure triggers near panic attack or temper tantrums. PTSD would require hypervigilance and avoidance behaviors at least 4 weeks after a trauma. Reactive attachment disorder requires severely disturbed social relationships, in most contexts beginning before 5 years of age.

253
Q

13-08. A 4-year-old boy is brought to the pediatric emergency department kicking and screaming while trying to run away from the sharks he fears are going to eat him. Which of the following diagnostic tests would be most appropriate?

A. Complete blood count

B. Comprehensive metabolic profile

C. Urine toxicology

D. EKG

A

Answer C. Urine toxicology is the most likely diagnosis; it is a substance-induced psychotic disorder and is the most common etiology for florid visual hallucinations in children. It is essential to rule out potential ingestion of prescription drugs, illicit drugs, over-the-counter medications, or other household agents. A complete blood count, a comprehensive metabolic profile, and an EKG may be helpful in providing supportive care.

254
Q

13-09. The PMHNP is performing primary prevention in the high school regarding mental illness. The most common psychiatric emergency in children and adolescents is:

A. Sexually inappropriate behavior

B. Homicidal behavior

C. Suicidal behavior

D. Psychotic behavior

A

Answer C. Suicidal behavior is the most common psychiatric emergency in the child adolescent population. Psychotic behavior, homicidal behavior, and sexually inappropriate behavior are far less common.

255
Q

13-10. A 10-year-old boy who had been prescribed fluoxetine for major depressive disorder presents to the psychiatric emergency department for running into the street in front of a car on the way home from school. In the emergency department, he has been selectively mute, but the nurse practitioner student was able to elicit his desire to be dead. He has been medically cleared pending a psychiatric evaluation. What is the most common sign of major depressive disorder in children?

A. Weight change

B. Hypersomnia

C. Psychomotor agitation

D. Hopelessness

A

Answer C. Psychomotor agitation is more commonly observed in children than adolescents with major depressive disorder. They may also appear more anxious, irritable, dysphoric, and selectively mute, with a flat affect. Hypersomnia, changes in weight, and hopelessness are more common in adolescents with major depressive disorder.

256
Q

13-11. A 16-year-old boy with a history of substance use disorder reports fatigue, apathy, and anhedonia almost every day and his mother reports increasing irritability and raging behavior. The boy says he smokes marijuana daily just to feel good and is unwilling to give it up. The mother wants some sort of medication to help him feel better so that he stops smoking marijuana. The PMHNP agrees to prescribe fluoxetine 20 mg daily. What is the most common side effect associated with this medication?

A. Hypotension

B. Nausea

C. Weight gain

D. Sedation

A

Answer B. The most common adverse effect associated with selective serotonin reuptake inhibitors (SSRIs) is nausea. Other adverse effects include insomnia, agitation, and headache. Weight gain and sedation are not associated with SSRIs in children.

257
Q

13-12. A 24-month-old girl is referred to psychiatry for an expressive language disorder. The mother reports that the child has not yet spoken a clear word, inconsistently follows commands, and does not play with her older brother of 4 years. In addition, the mother reports that the child has started making repetitive motions with her hands and seems to be clumsy with increasing difficulty walking. These clinical findings are suggestive of a pervasive developmental disorder, most likely:

A. Autism spectrum disorder

B. Rett syndrome

C. Cerebral palsy

D. Intellectual disability

A

Answer B. Rett syndrome is characterized by normal prenatal and perinatal development through the first 6 months of life, at which time the loss of previously acquired skills may develop along with stereotypic hand movements and impaired coordination with loss of social interaction. Autism spectrum disorder and cerebral palsy do not account for the progression and regression of this clinical course. Intellectual disability may be a comorbid condition but does not account for the psychomotor findings.

258
Q

13-13. Child protective services is requested for an evaluation of a 9-month-old girl in foster care whose mother was on a methadone maintenance program and using cocaine while pregnant. The child is HIV negative and during the assessment you learn of a 3-year-old brother who is HIV positive. You are asked to recommend placement for both these children. Which of the following is best?

A. A hospital

B. A group home

C. A nursing home

D. A foster home

A

Answer D. A foster home is the optimal place for young children, especially those with HIV, so that they may benefit from psychological belonging and adequate individual emotional support rather than in a group setting. The risk of opportunistic and nosocomial infection is greater in group homes, nursing homes, and hospitals.

259
Q

13-14. An 8-year-old boy is referred to you for evaluation for disruptive behavior in school. The teachers report that without warning the boy will make disruptive sounds or shout out in class. Other than these instances the boy is described as polite and well kempt, but restless. This clinical presentation is most consistent with which of the following disorders?

A. Oppositional defiant disorder

B. Conduct disorder

C. Tourette’s syndrome

D. Separation anxiety disorder

A

Answer C. Tourette’s syndrome is the most likely diagnosis as the outbursts are consistent with vocal tics and motor tics are often incorrectly identified as restless behavior. He does not meet criteria for oppositional defiant disorder or conduct disorder as he is described as polite and well kempt without hostility, destructive tendencies, or angry behaviors. There are no signs or symptoms consistent with anxious behaviors in the setting of separation from a comforting figure or object.

260
Q

13-15. An 8-year-old boy diagnosed with leukemia is referred to child psychiatry because he is consistently displaying a flat affect, irritability, angry acting out, and occasional physical aggression toward his 6-year-old brother. What approach should the PMHNP take when interviewing this child?

A. Ask the child direct questions about how he feels about his disease

B. Provide toys and allow the child to play

C. Encourage the child to talk about whatever is on his mind

D. Sit quietly and allow the child to talk

A

Answer B. A play interview in which the child is provided with toys and allowed to play is an effective and efficient way to interview children. Even with encouragement and direct questions children are unlikely to produce sufficient spontaneous dialogue in an uncomfortable setting with a stranger. It is unlikely that the child will spontaneously express his thoughts and feelings to a stranger who sits by quietly.

261
Q

13-16. A 10-year-old girl is referred for evaluation of behavioral difficulties. Her teachers report that she is easily distracted and fails to complete any class work, and often stares off into space or tries to chat with her neighbor. Her mother reports that mornings are the most difficult because of her general disorganization and forgetfulness. Otherwise she is socially engaged and enjoys many activities. Which of the following is the most likely diagnosis?

A. Conduct disorder

B. Oppositional defiant disorder

C. Disruptive behavior

D. Attention deficit disorder

A

Answer D. Attention deficit disorder inattentive type; she is very distractible and forgetful in school as well as at home with impaired ability to function. There are no displays of aggression, destruction of property, deceitfulness, theft, or serious violations of rules that are associated with conduct disorders and oppositional defiant disorder. Disruptive behavior disorder is reserved for conduct disorders not meeting full Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria.

262
Q

13-17. The school psychologist refers a 7-year-old girl with difficulty reading, distractibility, and writing avoidance behaviors. The child has no diagnosed conditions, takes no medications, and met all of her developmental milestones. She loves arts and crafts and physical education. Prior to diagnosing a learning disorder, which of the following screening tests must be performed?

A. Vision and hearing

B. Complete history and physical exam

C. Neurological evaluation

D. Family history

A

Answer A. Vision and hearing exam must be performed to rule out visual and auditory deficits. Neurological evaluation should be guided by the evidence of focal neural deficits or physical exam findings. Family history is also helpful in identifying any issues of heritability.

263
Q

13-18. An 8-year-old boy presents with nocturnal enuresis, which persists despite behavioral interventions including eliminating fluid intake in the evening, scheduled awakening at night to use the bathroom, and a urine alarm. Which of the following medications is most appropriate?

A. Trazodone

B. Imipramine

C. Fluoxetine

D. Methylphenidate

A

Answer B. Imipramine, a tricyclic antidepressant, is the standard agent used in the treatment of nocturnal enuresis (most likely for its anticholinergic effects). Trazodone is commonly used for insomnia associated with major depression and not indicated in children. Fluoxetine is commonly indicated for major depressive disorder and anxiety. Methylphenidate is commonly prescribed for attention deficit hyperactivity disorder.

264
Q

13-19. The PMHNP is evaluating a 22-month-old girl whose mother is concerned about aggressive behavior toward her 4-month-old brother. The mother states that her daughter is often angry and irritable with directed hostility toward the baby. Which of the following responses is best?

A. You should ignore your daughter’s behavior and it will pass

B. Your daughter’s behavior is normal for her age

C. Each day, schedule some time for you and your daughter to spend together without the baby

D. Explain to your daughter that the baby needs more attention than she does right now

A

Answer C. Each day schedule alone time with the daughter without the baby as she may be feeling rejected, jealous, or angry. She needs to know that she is still loved and wanted. Ignoring the behavior may cause it to escalate or entrench the message that her needs are not important. While normal behavior it must be addressed.

265
Q

13-20. Which of the following developmental milestones should a 2-year-old child be able to accomplish?

A. Ride a tricycle

B. Copy a circle

C. Identify age and gender

D. Copy a square

A

Answer B. Copying a circle is developmentally appropriate for a 24-month-old child. At 3 years old they can identify age, gender, and ride a tricycle. At 5 years old they can draw a square.

266
Q

14-01. A 56-year-old widow has deeply held beliefs about various conspiracy theories where the government is spying on her and her sister is trying to control her money. She attends writing classes, sings in the choir, and works as a mailroom clerk in a law firm. Which of the following is the most likely diagnosis of this patient?

A. Paranoid personality disorder

B. Schizotypal personality disorder

C. Schizoid personality disorder

D. Schizophrenia

A

Answer A. The most likely diagnosis for this patient is paranoid personality disorder due to the pervasive paranoia and delusional thinking. Schizotypal personality disorder includes magical thinking, unusual perceptual disturbance, and odd speech or behavior. Schizoid personality is not characterized by paranoid ideations. Schizophrenia requires a period of persistent psychotic symptoms for at least 6 months with impaired functioning including hallucinations congruent with delusions, disorganized speech, impaired cognition, and agitation.

267
Q

14-02. A 35-year-old man is found to have a flat affect, very few current social contacts, and prefers to be alone. He was referred by the employee assistance program for evaluation after someone reported him for odd behavior. His boss reports that in 20 years he has never called out sick, does not attend company outings, and has never spoken of a significant other. Which of the following is the most likely diagnosis?

A. Paranoid personality disorder

B. Schizotypal personality disorder

C. Schizoid personality disorder

D. Schizophrenia

A

Answer C. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and restricted range of expressions. Paranoid personality disorder is characterized by a consistent and persistent thought pattern without perceptual disturbance. Schizotypal personality disorder is characterized by a consistent and persistent pattern of social deficits associated with acute discomfort in social settings with associated cognitive and perceptual distortions and eccentric behaviors. Schizophrenia requires a period of persistent psychotic symptoms for at least 6 months with impaired functioning including hallucinations congruent with delusions, disorganized speech, impaired cognition, and agitation.

268
Q

14-03. A 68-year-old woman who has been self-employed as a copyeditor avoids social gatherings and would rather stay home and read. She has a few distant friends who check in on her occasionally and who report her entire home is covered in bed sheets. She attends church weekly but quickly leaves after the service. She is known to never be without her feather boa. Which of the following best describes this patient?

A. Paranoid personality disorder

B. Schizotypal personality disorder

C. Schizoid personality disorder

D. Schizophrenia

A

Answer B. Schizotypal personality disorder is characterized by a consistent and persistent pattern of social deficits associated with acute discomfort in social settings with associated cognitive and perceptual distortions and eccentric behaviors. Paranoid personality disorder is characterized by a consistent and persistent thought pattern without perceptual disturbance. Schizoid personality disorder is characterized by a pervasive pattern of detachment from social relationships and restricted range of expressions. Schizophrenia requires a period of persistent psychotic symptoms for at least 6 months with impaired functioning including hallucinations congruent with delusions, disorganized speech, impaired cognition, and agitation.

269
Q

14-04. A 40-year-old man with a past history of oppositional defiant behavior as a child has recently been released on parole for possession of marijuana and theft. He tells the probation officer to “send me to the psychiatrist so I can get some disability.” Which of the following describes these personality traits?

A. Cluster C personality

B. Cluster B personality

C. Cluster A personality

D. Malingering

A

Answer D. Malingering is the faking of symptoms for financial or material gain, commonly comorbid in people with antisocial personality disorder. Cluster B traits are characterized by persistent and consistent relationship disruptions in a variety of contexts with transient episodes of psychosis in acute stress states; symptoms include dramatic expressions of emotion and fluctuating emotional state with low frustration tolerance. Cluster A personality disorders are characterized by a pattern of consistent and persistent distrust and suspiciousness with odd behaviors in various contexts. Cluster C disorders are characterized by a consistent and persistent pattern of fear and anxiety in a variety of contexts across multiple domains in which the person expresses avoidance coping behaviors.

270
Q

14-05. A 27-year-old woman with a history of substance use disorder and unstable employment brags to her mandated group therapy peers of her shoplifting exploits. These traits are most consistent with which of the following personality disorder?

A. Antisocial personality disorder

B. Borderline personality disorder

C. Histrionic personality disorder

D. Narcissistic personality disorder

A

Answer A. Antisocial personality disorder is characterized by a pervasive lack of empathy, impulsivity, aggression, and manipulation of others for personal gain. Borderline personality disorder is characterized by an unstable sense of self, intense interpersonal relationships, and emotional volatility. Histrionic personality disorder is characterized by a consistent and pervasive pattern of excessive emotionality and other attention seeking behaviors. Narcissistic personality disorder is characterized by a persistent and consistent inferiority complex overcompensated by an inflated sense of self-importance and need to be admired and perceived as special.

271
Q

14-06. A 30-year-old female is admitted to the emergency department with her teddy bear after slashing her arms when her boyfriend left for a weeklong business trip. She states she did not want to kill herself but rather wanted him to come back home. These character traits are most consistent with which of the following personality disorders?

A. Antisocial personality disorder

B. Borderline personality disorder

C. Histrionic personality disorder

D. Narcissistic personality disorder

A

Answer B. Borderline personality disorder is characterized by an unstable sense of self, intense interpersonal relationships, and emotional volatility. Histrionic personality disorder is characterized by a consistent and pervasive pattern of excessive emotionality and other attention seeking behaviors. Narcissistic personality disorder is characterized by a persistent and consistent inferiority complex overcompensated by an inflated sense of self-importance and need to be admired and perceived as special. Antisocial personality disorder is characterized by a pervasive lack of empathy, impulsivity, aggression, and manipulation of others for personal gain.

272
Q

14-07. A 28-year-old female enters the room with wide gestures and declares, “I have arrived; let the fun begin.” She struts her way through the room, bumping her way through the crowd and stepping on a few toes. These behaviors are most consistent with which personality disorder?

A. Antisocial personality disorder

B. Borderline personality disorder

C. Histrionic personality disorder

D. Narcissistic personality disorder

A

Answer C. Histrionic personality disorder is characterized by a consistent and pervasive pattern of excessive emotionality and other attention seeking behaviors. Narcissistic personality disorder is characterized by a persistent and consistent inferiority complex overcompensated by an inflated sense of self-importance and need to be admired and perceived as special. Antisocial personality disorder is characterized by a pervasive lack of empathy, impulsivity, aggression, and manipulation of others for personal gain. Borderline personality disorder is characterized by an unstable sense of self, intense interpersonal relationships, and emotional volatility.

273
Q

14-08. Mr. B was recently promoted to the position of vice president at his company. He is charming, articulate, well dressed, and admired from afar. On one occasion a new subordinate challenged his decision. Mr. B responded with anger and passive aggressive tactics, leading the subordinate to cancel weekend plans to implement Mr. B’s idea. These personality traits are most consistent with which of the following disorders?

A. Antisocial personality disorder

B. Borderline personality disorder

C. Histrionic Personality disorder

D. Narcissistic personality disorder

A

Answer D. Narcissistic personality disorder is characterized by a persistent and consistent inferiority complex overcompensated by an inflated sense of self-importance and need to be admired and perceived as special. Antisocial personality disorder is characterized by a pervasive lack of empathy, impulsivity, aggression, and manipulation of others for personal gain. Borderline personality disorder is characterized by an unstable sense of self, intense interpersonal relationships, and emotional volatility. Histrionic personality disorder is characterized by a consistent and pervasive pattern of excessive emotionality and other attention seeking behaviors.

274
Q

14-09. A 24-year-old man who has been diagnosed with substance-induced mood disorder is doing well maintaining his sobriety for the last 5 years. He complains of being lonely but is afraid of going to any social events lest he come into contact with alcohol. He requires much reassurance that he is okay, he will be fine, and that he is good enough to be around others whom he perceives to be better adjusted to life. These characteristics are most consistent with which of the following?

A. Avoidant personality disorder

B. Dependent personality disorder

C. Obsessive compulsive personality disorder

D. Paranoid personality disorder

A

Answer A. Avoidant personality disorder is characterized by a consistent and persistent pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to real or perceived critique. Dependent personality disorder is characterized by a consistent and persistent pervasive pattern of maladaptive behaviors arising from an excessive need to be cared for leading to submissive, clingy behaviors with the goal of reducing the chance of separation. Obsessive compulsive personality disorder is characterized by a consistent and persistent pervasive pattern of obsessions of perfectionism, order, and inter- and intra-personal control at the expense of openness, flexibility, and efficiency coupled with an excessive devotion to work. Paranoid personality disorder manifests as the reluctance to confide in others, and is motivated by fear that the personal information will be used for malevolent intent rather than for fear of embarrassment.

275
Q

14-10. Mr. Smith is complaining about another failed romantic relationship. He says his girlfriend described him as needy all the time, avoidant of confrontation at all costs, agreeable to all her requests, and never disagreeable with her. She told him she was done with his passive ways and was going to find a real man. These traits are most consistent with which of the following disorders?

A. Avoidant personality disorder

B. Dependent personality disorder

C. Obsessive compulsive personality disorder

D. Paranoid personality disorder

A

Answer B. Dependent personality disorder is characterized by a consistent and persistent pervasive pattern of maladaptive behaviors arising from an excessive need to be cared for leading to submissive, clingy behaviors with the goal of reducing the chance of separation. Avoidant personality disorder is characterized by a consistent and persistent pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to real or perceived critique. Obsessive compulsive personality disorder is characterized by a consistent and persistent pervasive pattern of obsessions of perfectionism, order, and inter- and intra-personal control at the expense of openness, flexibility, and efficiency coupled with an excessive devotion to work. Paranoid personality disorder manifests as the reluctance to confide in others, and is motivated by fear that the personal information will be used for malevolent intent rather than for fear of embarrassment.

276
Q

14-11. In a movie, Jack Nicholson played a meticulous writer who was highly productive, very concerned about germ contamination, and very ritualistic about walking on sidewalk cracks. In addition, he would turn lights on and off repeatedly and use a brand new bar of soap to wash his hands with exceedingly hot water. These traits are characteristic of which personality disorder?

A. Avoidant personality disorder

B. Dependent personality disorder

C. Obsessive compulsive personality disorder

D. Paranoid personality disorder

A

Answer C. Obsessive compulsive personality disorder is characterized by a consistent and persistent pervasive pattern of obsessions of perfectionism, order, and inter- and intra-personal control at the expense of openness, flexibility, and efficiency coupled with an excessive devotion to work. Dependent personality disorder is characterized by a consistent and persistent pervasive pattern of maladaptive behaviors arising from an excessive need to be cared for leading to submissive, clingy behaviors with the goal of reducing the chance of separation. Avoidant personality disorder is characterized by a consistent and persistent pervasive pattern of social inhibition, feelings of inadequacy, and a hypersensitivity to real or perceived critique. Paranoid personality disorder manifests as the reluctance to confide in others, and is motivated by fear that the personal information will be used for malevolent intent rather than for fear of embarrassment.

277
Q

14-12. In treating personality disorders the role of psychopharmacology is to:

A. Alleviate comorbid mood symptoms

B. Undo the antecedents leading to the disorder

C. Modify behaviors

D. Prevent comorbid conditions from developing

A

Answer A. Primary treatment for personality disorders is psychotherapy. Medication is only used to alleviate comorbid symptoms associated with the distress caused by the personality disorder. Medications cannot undo past events or prevent disorders from developing or modifying behavior.

278
Q

14-13. Which of the following personality disorders can be diagnosed in a single visit?

A. Narcissistic personality disorder

B. Borderline personality disorder

C. Antisocial personality disorder

D. Histrionic personality disorder

A

Answer C. Antisocial personality disorder can be diagnosed in a single visit if there is a past history of conduct disorder before age 15 and current signs and symptoms of the pervasive disregard for the rights of others. Narcissistic personality disorder, borderline personality disorder, and histrionic personality disorder require several visits as the novelty of a new situation and situational anxiety can trigger compensatory behaviors that are not consistent or persistent. No diagnosis should ever be made of someone whom has not been personally evaluated.

279
Q

14-14. Which of the following characteristics distinguishes schizotypal personality disorder from autism spectrum disorder?

A. Severity of social impairment and stereotyped behaviors and interests

B. Severe disturbance in expressive ability with compensatory efforts to communicate in another way

C. Cognitive perceptual disturbances

D. Active desire for relationships but fear of rejection

A

Answer A. Autism spectrum behaviors are associated with more severe social impairment and stereotyped behaviors and interests. A severe disturbance in expressive ability with compensatory efforts is associated with language disorders. Cognitive and perceptual disturbances are associated with paranoid and schizoid personality disturbances. A desire for relationships limited by fear of rejection is associated with avoidant personality disorder.

280
Q

14-15. Which of the following characteristics distinguishes narcissistic personality disorder from antisocial personality disorder?

A. The need for attention is related to the need for approval rather than admiration

B. The lack of empathy manifested in impulsivity and aggression rather than the need for admiration

C. The need for attention is triggered by instability of the self-image and fear of abandonment

D. The grandiosity only occurs during times of elevated mood

A

Answer B. Narcissistic personality disorder is driven by a need for admiration rather than a lack of empathy, as in antisocial personality disorder. When the need for attention is driven by a desire for approval rather than admiration, this is consistent with histrionic personality disorder. If the need for attention is triggered by unstable self-image and fear of abandonment, this is consistent with borderline personality disorder. If the grandiosity is only in the context of elevated mood, this is consistent with mania.

281
Q

14-16. Which of the following characteristics distinguishes borderline personality disorder from histrionic personality disorder?

A. The self-destructive reactions and angry disruptions in close relationships due to identity diffusion and fear of abandonment

B. The manipulation aspect is for personal gain, profit, or power rather than for approval

C. The desire for attention is for the purpose of being superior

D. The lack of dramatic emotions with an excessive dependence on others for praise and guidance

A

Answer A. Borderline personality disorder is associated with self-destructive reactions to real or imagined abandonment. If the dramatic behavior is done for the purpose of manipulation and personal gain, this is consistent with antisocial personality disorder. If the dramatic behavior is done in order that others may perceive one as superior, this is consistent with narcissistic personality disorder. If the approval is sought without drama, this is consistent with dependent personality disorder.

282
Q

14-17. Which of the following characteristics distinguishes schizoid personality disorder from schizophrenia?

A. Cognitive and perceptual disturbance in addition to social isolation

B. Paranoia and suspiciousness

C. Severely impaired social interaction with stereotyped behaviors and interests

D. Persistent psychosis, diminished emotional expression, social withdrawal, disorganized speech, perceptual disturbance

A

Answer D. Schizophrenia is characterized by persistent psychosis, persistent diminished emotional expression, social withdrawal, disorganized speech, and perceptual disturbance, whereas schizoid personality disorder has a restricted range of affect in interpersonal settings and does not have the characteristic speech, organization, and degree of impairment. Paranoia and suspiciousness are characteristic of paranoid personality. Schizotypal personality is characterized by cognitive and perceptual disturbance in addition to social isolation. Autism spectrum disorder is associated with severely impaired social interactions with stereotyped behaviors and interests.

283
Q

14-18. A 26-year-old woman presents with a history since her teen years of dramatic mood swings and quickly becoming depressed for hours to days in response to a separation from a loved one. She also reports rage attacks where she breaks things and screams or superficially scratches herself. Sometimes she binge drinks 1 L of hard liquor and has as many as 10 sexual partners without using condoms. Which defense mechanism is used primarily with this patient?

A. Altruism

B. Intellectualization

C. Splitting

D. Sublimation

A

Answer C. Splitting is a primitive defense mechanism in which individuals are divided up into all good or all bad categories, characteristic with borderline personality disorder. Intellectualization is considered a neurotic defense mechanism in which the individual separates all emotion from reality. Altruism and sublimation are mature defense mechanisms, which are incongruent with the self-destructive tendencies of borderline personality disorder.

284
Q

14-19. A 40-year old male nurse who works the night shift reports an uneventful childhood and college experience. He spends most of the time alone when he is not at work and does not venture out of the house and limits his social contacts to work colleagues during his shift. He is an avid cook and spends much of his free time indoors attending to very complicated recipes with esoteric ingredients. He reports that he is quite content with his life. This patient meets criteria for which of the following conditions?

A. Agoraphobia

B. Avoidant personality disorder

C. Schizoid personality disorder

D. Schizotypal personality disorder

A

Answer C. People with schizoid personality disorder are not distressed by the lack of social interaction and rather prefer it that way. Agoraphobia is characterized by a fear of panic symptoms in public. People with schizotypal disorder may have similar features to schizoid personality disorder but also have bizarre thought patterns. People with avoidant personality disorder are distressed by the lack of social interaction but fear rejection.

285
Q

14-20. A 31-year-old woman has been admitted to the psychiatric hospital after a failed suicide attempt by medication overdose. She has become attached to her PMHNP, who will be off for the next 7 days. The patient reports that she is having urges to cut her wrists upon hearing the news. Which diagnosis best characterizes this clinical presentation?

A. Psychosis

B. Major depressive disorder

C. Borderline personality disorder

D. Histrionic personality disorder

A

Answer C. Borderline personality disorder best classifies this patient’s symptoms, which are triggered by fear of loss and abandonment with intense interpersonal relationships and with a pattern of self-destructive behaviors, threats, mood instability, and emotional regulation and distress tolerance. The patient may meet criteria for major depressive disorder as a comorbid condition and her symptoms appear to be situationally induced and short lived. Psychosis requires disorganization and perceptual disturbance. Histrionic personality disorder makes grand gestures for the purpose of garnering approval and their emotional expressions are more theatrical and seductive.

286
Q

15-01. The PMHNP is evaluating a 32-year-old male who reports social anxiety and depression over his dating prospects. The mental state exam reveals a flat affect, avoidant individual with poor eye contact, and psychomotor agitation. He describes his last relationship in college as one where he just tried to keep the peace. Which of the following areas should the interview focus on to address his concerns?

A. Past substance use

B. Past medical history

C. Past psychiatric hospitalizations

D. Past history of abuse

A

Answer D. The interview for this individual should focus on any past history of abuse. The mental state exam is consistent with findings of posttraumatic stress disorder including avoidance, poor eye contact, and psychomotor agitation within the context of his chief complaint. While it is important to obtain a complete history that includes substance use disorder, past psychiatric hospitalizations, and medical history, the assessment should focus on the patient’s concerns.

287
Q

15-02. A 19-year-old female is being seen at a crisis pregnancy center for an unplanned pregnancy. She feels compelled by her boyfriend to get an abortion, but it goes against her deeply held religious beliefs. Which of the following reduces her risk of being the victim of domestic violence?

A. Pregnancy

B. Financial independence

C. Poor social support

D. Fear of isolation

A

Answer B. Financial independence reduces the risk of becoming a victim of domestic violence. Pregnancy, poor social support, and fear of isolation are all risk factors that increase the likelihood of domestic violence.

288
Q

15-03. A 32-year-old woman who is 6-months postpartum requests a psychiatric house call while her husband is at work. Upon entering the home, the PMHNP notices a well-cared for infant playing in a crib, and the patient sitting in her breakfast nook overlooking the nearby park. She is requesting a medication to help her relax because she feels as if she is walking on eggshells around her husband for fear of him “getting physical with me” if the baby cries too much. Which of the following best describes this woman’s circumstance?

A. Honeymoon phase

B. Abusive incident phase

C. Tension building phase

D. Postpartum depression

A

Answer C. When in the tension-building phase, characterized by emotional instability lasting from hours to months, the victim engages in appeasement and avoidance behaviors in an effort to garner sympathy and positive regard, to prevent the abusive incident. The abusive incident phase is characterized by overt aggressive behavior and can involve hitting, raping, depriving of basic needs, and humiliation. The honeymoon phase is characterized by a manifestation of the defense mechanism of undoing, denial, reaction formation, suppression, and regression (apologizing, gifts, and resolutions of change). Postpartum depression is a primary mood disorder whose onset is during pregnancy or up to 4 weeks after delivery.

289
Q

15-04. The PMHNP is facilitating a closed support group for victims of domestic violence and a member shares she is ready to leave her abuser. What would be the best response?

A. “What plans have you implemented?”

B. “I am glad you are able to stand up for yourself.”

C. “Abusers escalate their aggression when the victim tries to leave.”

D. “Where will you go?”

A

Answer A. By inquiring as to her plans for leaving her abuser, the group can gain an understanding of her insight and can allow an opportunity for psychoeducation about associated risks and benefits. Telling her you are glad she has finally stood up for herself fails to appreciate the insight of her previous actions and circumstances and lacks empathy. Providing information regarding potential escalation without assessing her needs may be construed as trying to talk her out of her decision. Eliciting specific details in a group setting may compromise the safety of the individual.

290
Q

15-05. When conducting a community outreach educational session regarding domestic violence, which of the following points should the PMHNP emphasize?

A. The most dangerous time for victims is when they try to leave the abuser.

B. Depression is a common comorbidity in victims of domestic violence.

C. Victims of domestic violence may tolerate their situation out of fear of the unknown.

D. Healthcare providers should insist on leaving the abuser immediately.

A

Answer A. Escalation in violence and murder most commonly occurs when the victim tries to leave the abuser. Depression may be a common comorbidity of domestic violence, but it is not the most important information as it does not readily change the situation. Victims may tolerate violence out of fear of the unknown and it can be an expression of empathy. Insisting on a particular behavior may cause more harm to the victim.

291
Q

15-06. In the wake of school shootings, administrators have requested education for early warning signs of potential school violence. Which of the following risk factors are specific to increased threats of violence?

A. Increased sense of self worth

B. Bullying or being bullied

C. Serious mental illness

D. Generalized anxiety disorder

A

Answer B. Being bullied or bullying are factors that increase the likelihood of school violence. Having increased self-worth reduces this risk. Serious mental illness and generalized anxiety disorder are not indicative of potential violence.

292
Q

15-07. A patient admitted to a psychiatric inpatient unit was brought in by police for making threats against a cellular phone store because he insists they were spying on him. He became argumentative and smashed the glass counter. While on the unit he has been pacing but keeping to himself. Which of the following behaviors would be most concerning for the safety of the patients on the unit?

A. The patient begins making verbal threats and gestures at copatients.

B. The patient isolates himself in his room and refuses to come out.

C. The patient becomes emotionally labile from crying to laughing.

D. The patient refuses to take medications and argues with the nurse.

A

Answer A. Making threats in words and actions often precedes violent acting out. Isolating can be a sign of maladaptive coping but does not pose imminent risk to other patients. Emotional lability is commonly associated with mood disorders and does not indicate imminent harm to patients. Agents may remain in behavioral control while verbally disagreeing with the nurse and refusing to take medications.

293
Q

15-08. A 40-year-old veteran is being evaluated in the mental health clinic and states that he has had trouble sleeping, feels on edge, and, whenever he is in a crowd, has flashbacks to a time when he had to drive his Humvee through a crowd of civilians to escape enemy fire. He feels guilty for possibly having killed innocent people. Which of the following questions should the PMHNP ask him?

A. Are you hearing any voices?

B. Do you see things that other people do not see?

C. Do you have access to firearms?

D. Is your family worried about you?

A

Answer C. Inquiring about access to firearms is an essential factor in assessing risk for self-harm and homicide. Inquiring about auditory and visual hallucinations may indicate severe psychosis and depression; however, his symptoms are more consistent with posttraumatic stress disorder (PTSD). Inquiring about the concern of family members is helpful in assessing insight, but potential harm to self or others is the priority.

294
Q

15-09. The PMHNP is facilitating a support group for perpetrators of domestic violence. Which of the following is an example of a cognitive distortion expressed by a group member?

A. She just will not listen to me.

B. Sometimes I just get so angry.

C. What I did was wrong.

D. I am sorry I acted that way.

A

Answer A. This is an example of an irrational thought pattern to justify one’s actions. “Sometimes I just get so angry” demonstrates insight into personal feelings. “What I did was wrong” demonstrates insight and remorse and responsibility for actions. “I am sorry I acted that way” demonstrates remorse for wrongdoing.

295
Q

15-10. Mr. Peters is a 45-year-old man who has been married for 12 years when his wife tells him she cannot take it anymore and wants a divorce. He has sought therapy to deal with his new circumstance and reports feeling bewildered and fearful, is having difficulty sleeping and concentrating, and states, “I thought I did everything right. I even told her I forgive her for the affair, and that I was proud of her for going to Alcoholics Anonymous for the last 6 months.” Which of the following questions should the PMHNP ask?

A. Has she ever gotten so angry that she hit you?

B. Have you contacted a lawyer?

C. Where will you go after the divorce?

D. Have you talked about child custody?

A

Answer A. Directly asking about physical violence allows the PMHNP to offer specific help and helps stoke insight. The civic inquiry about divorce plans and custody issues after the fact do not address the present concern of the patient or the dangerousness of the situation.

296
Q

15-11. A 50-year-old woman reports that she is tired of her abusive husband of 20 years and today was the day she is going to do something about it. Which of the following questions should the PMHNP ask?

A. What is your plan to leave?

B. Are you planning to harm or kill your husband?

C. Do you have guns in the home?

D. What changed?

A

Answer B. Inquiring directly about potential homicidal ideation is essential in providing appropriate care for the patient and the community. Subsequently asking about firearms may provide insight into the lethality and accessibility of implementing a plan for violence. Simply inquiring about her plan to leave may allow the patient to avoid the details of homicidal ideation. Inquiring about the final straw does not inform regarding the lethality of the situation.

297
Q

15-12. Which of the following expressed suicidal ideations has the highest lethality?

A. “It would be better if I were not here.”

B. “I am going to kill myself.”

C. “I am planning to take all of my medications at once, I just want this pain to stop.”

D. “I would not be upset if I did not wake up tomorrow.”

A

Answer C. The lethality of a suicidal ideation is heightened when a specific plan regarding means and access to the means is possible. Stating the phrase “I’m going to kill myself” may be hyperbole and requires further inquiry. Passive suicidal ideations, particularly in the elderly and chronically ill, do not indicate an active plan for self-harm and requires further inquiry.

298
Q

15-13. Mrs. Kelly says her daughter-in-law has been very caring and attentive to her. She states that “she makes sure I don’t eat and drink too much, and she does not make me go to all those doctor’s appointments.” Depriving someone of their basic needs, and preventing them from receiving healthcare is an example of:

A. Physical abuse

B. Neglect

C. Sexual abuse

D. Emotional abuse

A

Answer B. Neglect is defined as failing to provide for the essential needs of the dependent person including the prevention of healthcare visits, nutrition, hygiene, and rest. Abuse is defined as an act of violence that causes pain, injury, impairment, or worsens function. Sexual abuse is defined as the nonconsensual intimate touching or exposure to sexually provocative material against one’s will. Emotional abuse is intentionally inflicting emotional distress and anguish through threats of isolation or humiliation.

299
Q

15-14. A 16-year-old boy is being evaluated for emotional lability, hypervigilance, difficulty sleeping, and irritability. During the interview he reports that his first sexual encounter was with his teacher 1 year ago and he continues to have sex with her on occasion. He states that his relationship is consensual. What should the PMHNP do with this information?

A. Prescribe a selective serotonin reuptake inhibitor (SSRI) for posttraumatic stress disorder (PTSD)

B. Report the incident to child protective services

C. Instruct the boy in the proper use of condoms

D. Screen for neurosyphilis

A

Answer B. The PMHNP should report the incident to child protective services for sexual abuse. Minors are deemed to lack capacity to consent to sexual activity with adults; nurse practitioners are mandated reporters of child abuse. Prescribing medication does not address the issue of the ongoing sexual abuse. Instructing the boy in proper condom use implies condoning the ongoing abuse in this situation. Screening for sexually transmitted infections would be appropriate but the priority is stopping the abuse.

300
Q

15-15. Kyle is a 33-year-old wheelchair-bound man with a history of spina bifida and is being seen in a follow-up visit for depression and anxiety. He reports that he is tired of feeling like he is a burden and is very grateful to have the home health aide, who helps with his grooming, hygiene, and meal prep. During his bed bath, the aide will make comments about his disability and his inability to become aroused and have children. This is an example of which of the following?

A. Physical abuse

B. Emotional abuse

C. Sexual abuse

D. Neglect

A

Answer B. Emotional abuse is intentionally inflicting emotional distress and anguish through threats, isolation, or humiliation. Neglect is defined as failing to provide for the essential needs of the dependent person including the prevention of healthcare services, nutrition, hygiene, and rest. Physical abuse is defined as an act of violence that causes pain, injury, impairment, or worsens function. Sexual abuse is defined as the nonconsensual intimate touching or exposure to sexually provocative material against one’s will.

301
Q

15-16. Luanne is a 19-year-old single mother of a 3-year-old boy. She works during the day and attends classes for her high school equivalency exam several evenings per week. Her son is in daycare and an after-school program from 8 a.m. to 7 p.m. 5 days per week. She reports feeling so tired that she sometimes loses her patience with her son and gives him Benadryl to help calm him down and sleep through the night. Which of the following actions should the PMHNP take?

A. Report the mother to child protective services

B. Provide psychoeducation for her son’s challenges

C. Provide dosing instructions to prevent accidental overdose

D. Commend the mother on her efforts of handling work and school

A

Answer A. The PMHNP should report the mother to child protective services for physical abuse, defined as an act of violence that causes pain, injury, or impairment or worsens the function of the individual. PMHNPs are mandated reporters. Protective services can deploy community resources and provide oversight for the well-being of the child in the community. Providing psychoeducation for toddler development is appropriate but does not provide the necessary support and oversight to stop the physical abuse. Providing instructions on proper dosing, while helpful in harm reduction, also provides tacit assent to physical abuse. Commending the mother on her efforts at work and school conveys empathy but does not mitigate the harm to the child.

302
Q

15-17. Mr. Yoon is a 46-year-old male who was referred from the employee assistance program for interpersonal difficulties in the workplace. His boss states that he is very committed to his job, often working late, but he is unable to tolerate any criticism of his work and becomes argumentative and frequently irritable with his coworkers. He never seems to socialize at company events and seems to not speak of any family or friends outside of work. He has become so difficult to work with that termination is possible, but fear persists of a homicidal threat. What should the PMHNP do when seeing this patient?

A. Inquire about access to weapons

B. Prescribe the patient a selective serotonin reuptake inhibitor (SSRI) to reduce anxiety

C. Encourage the patient to find another job

D. Call 911 and transfer the patient to the hospital

A

Answer A. Inquiring about access to weapons is an essential step in assessing the lethality of homicide risk. Prescribing medication does not address the consultation question of threat assessment. Encouraging the patient to find a new job may cause paranoid feelings and emotionally escalate the situation. In the information presented, there is no imminent emergency requiring hospitalization.

303
Q

15-18. A 35-year-old female victim of sexual assault is fearful of getting into any more relationships but expresses dissatisfaction at the prospect of being alone forever. What therapeutic technique would be most appropriate for this patient?

A. Psychopharmacology

B. Cognitive behavioral therapy

C. Dialectical behavioral therapy

D. Psychoanalysis

A

Answer B. Cognitive behavioral therapy addresses cognitive distortions and behavioral responses with concrete strategies to achieve a goal. Psychopharmacology will not address her specific fear related to not finding a relationship. Dialectical behavioral therapy will target more primitive self-sabotaging behavior such as nonsuicidal self-injurious behaviors. Psychoanalysis is best suited for people in late adolescence and early adulthood to examine the unconscious motivations of past and present situations, which takes place over the course of several years.

304
Q

15-19. An elderly woman with dementia engages in a romantic relationship with an elderly man in her assisted living facility. She reports that their sex is consensual but she is sometimes sore afterward. Her daughter has discovered this relationship and insists something be done because she believes her mother is being sexually assaulted. What should the PMHNP do?

A. Report the incident to adult protective services

B. Evaluate the patient for capacity to consent to sex

C. Refer the patient to the emergency department for a sexual assault forensic exam

D. Screen the patient for sexually transmitted infections

A

Answer B. Evaluate the patient for capacity to consent to sexual activity because the diagnosis of dementia does not negate all decision-making capacity. Reporting the incident to protective services would only be appropriate if the patient is deemed to lack capacity and the institution is unable to provide for the safety of the incapacitated individual. The patient with decisional capacity can refuse to go to the emergency department, and sexual assault forensic examination requires that the patient have capacity to consent to the examination. Screening for sexually transmitted infections may require patient consent depending on local laws.

305
Q

15-20. A 36-year-old victim of domestic violence has three young children at home. She presents to the PMHNP for depression, and requests something to calm her nerves because she is not sure how much more she can tolerate. What should the PMHNP do next?

A. Admit the patient for suicidal ideation

B. Admit the patient for homicidal ideation

C. Prescribe a sedative to calm her nerves

D. Provide information about support resources

A

Answer D. Provide the patient with information for community support services. The patient has not expressed suicidal or homicidal ideations and is requesting pharmacological help. Pharmacological aids can be provided but will not address the underlying problem of domestic violence.

306
Q

16-01. A 42-year-old male with alcohol use disorder for 5 years is referred to the PMHNP from his primary care provider for addiction treatment. Which of the following laboratory findings would be consistent with his diagnosis?

A. Increased urine and serum creatinine levels

B. Increased mean corpuscular volume and triglycerides

C. Increased potassium and chloride levels

D. Decreased mean corpuscular volume and normal triglyceride level

A

Answer B. Elevated mean corpuscular volume (MCV) and triglycerides are conventional biomarkers of heavy drinking. Elevated urine and serum creatinine levels are an incongruent finding and suggestive of renal disease. Elevated potassium and chloride are not consistent with impaired renal function. Decreased MCV and normal triglycerides are nonspecific findings consistent with microcytic anemia.

307
Q

16-02. A 9-year-old girl with a history of generalized anxiety disorder has been stable on fluoxetine 10 mg for 6 months and presents for follow-up complaining of bilateral leg pain. The physical exam, complete blood count, and metabolic profile are normal except for an elevated alkaline phosphatase. The PMHNP understands that this finding is:

A. Consistent with liver disease

B. Abnormal and should be repeated immediately

C. Abnormal and requires further evaluation of autoimmune hepatitis

D. A commonly occurring pre-puberty finding known as growing pains

A

Answer D. Growing pains is a diagnosis of exclusion occurring in pre- and early puberty, specifically associated with osteoclastic and osteoblastic activity. Liver disease that causes leg pain is a very late sign and will have associated systemic signs and symptoms. Alkaline phosphatase is a nonspecific indicator of hepatic disease and does not rise in isolation. Elevated alkaline phosphatase is an abnormal but nonspecific indicator of liver and bone health requiring clinical correlation. Alkaline phosphatase in the setting of autoimmune hepatitis should present with associated signs and symptoms and elevated liver enzymes (aspartate transaminase [AST]/alanine aminotransferase [ALT]).

308
Q

16-03. A 50-year-old physician presents with complaints of fatigue, headache, abdominal distress, and weight loss. His husband reports increasing irritability, inattentiveness, and low libido over the last month. He was seen by his primary care provider, who just notified him he had pre-diabetes, hypercholesterolemia, and hypertension despite weight loss. These findings are most consistent with

A. Dysthymia

B. Major depression

C. Generalized anxiety disorder

D. Seasonal affective disorder

A

Answer B. Major depressive symptoms include sleep changes, interest loss, guilt, energy deficit, cognitive impairment, appetite change, psychomotor agitation/retardation, and somatic complaints often comorbid with type 2 diabetes. Dysthymia is associated with anhedonia, hopelessness, lack of productivity, and low self-esteem with feelings of inadequacy lasting for at least 2 years. Generalized anxiety disorder symptoms include persistent worrying, catastrophic thinking, persistent ambivalence, restlessness, persistent fatigue, and muscle tension. Seasonal affective disorder symptoms include a change in sleep, loss of interest, anhedonia, and cognitive impairment occurring in the fall or winter and remitting in the spring and summer.

309
Q

16-04. The purpose of a professional organization’s scope and standards of practice is to:

A. Define the roles and actions for that particular profession

B. Define the differences between professions

C. Establish the legal authority to practice for a profession

D. Define the legal statutes that are governing a profession

A

Answer A. The scope and standards dictated by professional organizations define the role and actions of a particular profession. The government appoints professional boards to define the differences between professions, establish criteria for licensure, and define the legal statutes that govern a profession.

310
Q

16-05. An APRN recognizes the essential nature of primary prevention strategies for a community. Which of the following is an example of a primary prevention strategy?

A. A skills class for at risk adolescents

B. A suicide hotline

C. Mandated treatment

D. A psychosocial clubhouse for the mentally ill

A

Answer A. A skills class for at-risk individuals is an example of primary prevention. The suicide hotline is an example of secondary prevention because a specific condition with specific interventions is aimed at reducing a specific risk outcome. Mandated treatment and a psychosocial clubhouse are tertiary prevention strategies because they are aimed at improving outcomes and reducing symptoms of a condition that has already occurred.

311
Q

16-06. Which of the following is representative of legal ruling trends over the past 30 years?

A. Juries have been encouraged to find defendants not guilty because of insanity

B. People with mental illness retain their inalienable rights even when committed to a mental hospital

C. Courts place increased trust in the professional judgment of mental healthcare providers to make ethical decisions

D. The time in bringing cases before a magistrate for commitment hearings has been reduced

A

Answer A. The person has a diagnosed mental disorder and poses harm to self or others as a result of the disorder, and treatment is likely to improve functioning. It is not sufficient for the patient to be unwilling or unable to accept the nature and severity of a mental disorder without having been diagnosed, the harm stems from the diagnosed condition, and treatment is likely to improve the condition. The patient’s threat and risk level must be as a result of a diagnosed mental disorder. A history of serious mental illness that is currently untreated is insufficient for involuntary admission if they are not a threat as a result of the disorder at the present time.

312
Q

16-07. A patient who has been voluntarily committed is experiencing symptoms of psychosis; he declares he has the right to refuse his medications despite the court order because God told him he would be healed by his faith alone. Based on your knowledge of court-ordered treatment, which of the following statements is true?

A. Psychiatric clients cannot refuse treatment

B. Psychiatric clients can refuse treatment unless it is court ordered

C. Psychiatric clients cannot act in their own best judgment

D. The professional judgment of the PMHNP supersedes the client’s right to refuse medication

A

Answer B. The court order trumps the patient’s right to exercise self-determination and the patient cannot refuse treatment. Until the court orders treatment over objection, the psychiatric client may refuse treatment unless the condition imminently threatens life or limb. The professional judgment of two physicians does not allow for treatment unless there is an imminent threat, in which case one opinion is sufficient.

313
Q

16-08. Which of the following elements is reflective of a professional relationship rather than a social relationship?

A. In a professional relationship, there is no place for social interactions

B. In a professional relationship, the PMHNP is solely responsible for making the relationship work

C. In a professional relationship, the primary focus is on the client and their needs

D. In a professional relationship, goals are left vague so that the client feels any issue can be discussed

A

Answer C. Professional relationships are focused exclusively on the client’s needs and outcomes. Professional relationships should not include advice based on personal experience. The responsibility for the client’s well-being is shared between the patient and the treatment team. The PMHNP should not exploit the therapeutic relationship for personal favors.

314
Q

16-09. In light of the recent school shootings, the local high schools have noticed an unusually high incidence of depressive symptoms and illicit drug use among their students. The PMHNP formulates a plan to address the problem. The goal of the program is to enhance the capabilities of families and teachers to identify antecedents of depression and drug use and to prevent new cases from developing. What level of prevention is this strategy?

A. Tertiary prevention

B. Secondary prevention

C. Solution-focused prevention

D. Primary prevention

A

Answer D. Primary prevention aims to reduce the incidence of a disease or condition. Secondary prevention aims to detect the presence of a condition early and prevent it from getting worse. Tertiary prevention aims to enhance the quality of life after the disease or condition has occurred. Solution focused therapy is a counseling approach that assumes the individual has the capacity to articulate a problem and offer solutions.

315
Q

16-10. A 45-year-old White female agreed to hospitalization after presenting to the emergency department with passive suicidal ideations. After 24 hours she states that she wishes to leave because “this place cannot help me.” Which of the following actions reflects the legal right of the client?

A. The patient should be discharged immediately

B. The patient is discharged after she signs forms indicating her actions and acknowledging her actions are against medical advice

C. Contact a collaborating physician to convert the patient to an involuntary status

D. Explain that the patient cannot leave until further assessments are completed and collateral information is obtained

A

Answer D. Explain that the patient cannot leave until further assessment and collateral information is obtained with the aim of seeing if she will agree to remain on a voluntary basis. Discharging the patient immediately without further information may increase the risk of suicide. Before the patient signs out against medical advice, further assessment is required for capacity to refuse care. Converting the patient to involuntary status requires further assessment.

316
Q

16-11. The PMHNP is aware that the essentials of the therapeutic alliance include all of the following except:

A. Formulating a differential diagnosis

B. Genuineness

C. Acceptance

D. Authenticity

A

Answer A. Formulating a differential diagnosis is not an essential component for the therapeutic alliance. The therapeutic alliance requires genuineness, acceptance, and authenticity.

317
Q

16-12. A 39-year-old woman has been in therapy for the last 3 months. She has shown much improvement in her functioning and has developed much insight into her illness. This week during her session you discuss service determination, and she suddenly begins to demonstrate the first symptoms that brought her into therapy initially. She is now hesitant for discharge and wants to continue services as she is displaying regressed behavior. What is the best explanation for her symptom return?

A. Acute stress reaction

B. Reaction formation

C. A normal resistance seen in the termination time of therapy

D. A sign of undiagnosed pathological attachment

A

Answer C. Regression is a temporary defense mechanism in response to stress in order to avoid circumstances. Projection is a defense mechanism in response to a stressor in which the patient would tell the PMHNP they are ending therapy because they cannot be helped. It is common for patients to relapse with symptoms during the termination phase.

318
Q

16-13. A 30-year-old man reports low self-esteem, demonstrates poor self-control, exhibits much self-doubt, and requires a high degree of reassurance. What developmental task has he failed to master?

A. Trust versus mistrust

B. Industry versus inferiority

C. Generativity versus stagnation

D. Integrity versus despair

A

Answer B. Industry versus inferiority is the stage of development when children learn skills, take pride in their accomplishments, and develop self-esteem from being valued by peers for their competencies. Trust versus mistrust is the first stage of development; if needs are not met in this phase the person demonstrates suspiciousness and anxiety over their ability to effect change in their life. Generativity versus stagnation is an adult phase of development in which the individual is concerned with leaving a good lasting impression; success in this stage yields a sense of accomplishment and failure leads to a feeling of low self-worth and apathy. Integrity versus despair is the final stage of development in which the individual contemplates accomplishments; a failure in this phase leads to feelings of guilt and hopelessness.

319
Q

16-14. A 25-year-old male has been seeing his psychoanalyst four times a week for the last year and is bothered by recent episodes of forgetfulness including misplacing everyday items and missing appointments. Which Freudian psychodynamic principle assumes all behavior conveys purpose?

A. The Ego development principle

B. Psychic determinism principle

C. The Id principle

D. The Superego mediation principle

A

Answer B. Psychic determinism is the psychodynamic principle that assumes all behavior has a purpose. The Ego development principle states that one understands that others have needs and that impulsive actions can cause self-harm. The Id principle seeks pleasure and gratification immediately. The Superego imposes a moral framework and ethical restraint learned from the environment.

320
Q

16-15. Which of the following is an example of a mature defense mechanism?

A. Projection

B. Repression

C. Altruism

D. Regression

A

Answer C. An example of altruism is a client who states the well-being of others is equally important as his own, and perhaps even more important in certain situations. An example of projection is a husband who has an anger problem attributing his anger to his wife, and saying she has an anger problem. An example of repression is a client who has suffered abuse and neglect as a child but has no recollection and has trouble forming relationships. An example of regression is a 22-year-old female who is chewing on a pen cap while waiting for the results of a pregnancy test.

321
Q

16-16. A Black man in the fifth decade of life has been seen for several weeks of psychotherapy to discuss his current stressors. He proceeds to curl up in the fetal position and lie on the floor. Which defense mechanism is he manifesting?

A. Repression

B. Projection

C. Denial

D. Regression

A

Answer D. Regression is a defense mechanism where the person moves back to a previous phase of psychological development and task mastery. Repression is a defense mechanism in which disturbing thoughts are kept from consciousness. Denial is a defense mechanism that involves blocking external events from awareness. Projection is a defense mechanism involving the attribution of one’s own unacceptable thoughts, feelings, and motives to another person.

322
Q

16-17. An ambulance brings a 26-year-old female to the emergency department after a suicide attempt by self-mutilation. Which of the following is the most critical factor to consider when conducting your assessment?

A. Past medical and psychiatric history

B. Hemodynamic stability

C. The current level of suicidality

D. Effective coping mechanisms

A

Answer B. Hemodynamic stability is the priority in any patient assessment. The current level of suicidality and effective coping mechanisms is the next priority, followed by past medical and psychiatric history.

323
Q

16-18. For which of the following reasons are selective serotonin reuptake inhibitors (SSRIs) considered the first-line drug of choice for depression without psychotic features?

A. Ease of do