PMHNP Case Study: Identifying and Treating Depression and Personality Disorders, Exams of Nursing

Download PMHNP Case Study: Identifying and Treating Depression and Personality Disorders and more Exams Nursing in PDF only on Docsity! 0 6670 MIDTERM EXAM 75 QUESTIONS WITH 100%VERIFIED ANSWERS GRADED A+.(ANSWERS WELL EXPLAINED) 1 ● Question 1 Sally is a 54-year-old female who presents for care at the urging of her employer. She says that she doesn’t think she needs to be there, but the manager of her division at work strongly suggested that she make an appointment. She is the evening shift manager in the accounting department of a major online sales organization. Her role requires meticulous accountability of a complex system of production statistics, and she has done this exceedingly well for years. She has been a valued employee, and her work is above reproach. A few months ago, the company adopted a new software program that required a complete revamping of Sally’s department. She has not adapted well, and her resulting anxiety is almost prohibitive of functioning in her role. During her interview, Sally is very somber and serious, and is clearly having difficulty with this change. She is distraught over the potential of not being able to do her job well and meet her immediate supervisor’s expectations. Recognizing the likely diagnosis, the PMHNP knows that Sally is likely to respond best to: 0 out of 1 points Selecte d Answer : [None Given] Answers: Pharmacotherapy with clonazepam Respon se Feedbac k : Free-association, nondirective therapy Interpersonal therapy Serotonergic agents (b) is the correct answer. These patients often recognize that there is a problem and will do well with this form of therapy, although it is a long and complex process. Clonazepam and serotonergic agents are effective with obsessive-compulsive disorder, but their utility with obsessive-compulsive personality disorder is less clear. Interpersonal therapy is not among the therapeutic modalities with any demonstrated success with this personality disorder. ● Question 2 Becci is a 31-year-old female who presents to the PMHNP for evaluation after being referred by her friend who is a patient of the practice. She describes a relatively acute, recent onset of panic attacks. Becci says that “out of the blue” her heart starts to race, her mouth gets dry, she gets shaky, and feels like she cannot get her breath. She is afraid because her friend has panic disorder and Becci knows that before her friend got treat ment, she basica lly would not 4 sho uld not be per ceived as a purposeful mischaracterization – the patients are not usually trying to misrepresent thing; they are reporting their genuine impression. Finally, recurrent depressions spanning decades will most likely require pharmacotherapy along with some form of nonpharmacologic intervention for best outcomes. ● Question 4 1 out of 1 points 5 Danielle is a 31-year-old female who is having a psychiatric evaluation at the insistence of her husband. They have been married for 4 years, and her husband has finally become so frustrated by her jealous behavior that he threatened to leave her if she didn’t “get help.” Her husband insists that he has never been unfaithful, but Danielle repeatedly accuses him of having an affair. If he is even a few minutes late getting home from work, she demands an explanation and then does not believe anything he says. She does not have any real friends —her sister is her closest social contact, but Danielle has been angry with her for several weeks and won’t answer phone calls. Reportedly she does this often, and according to her husband can “hold a grudge forever.” During the interview, Danielle is calm, responsive, but distant. She says she really doesn’t understand why she is there—there is not a problem. The PMHNP considers the most likely diagnosis and discusses with Danielle that the treatment of choice is: Selected Answer: Psychoth er apy Answers: Diazepa m Pimozid e Respon se Feedbac k : Psychoth er apy Group therap y (c) is the correct answer. Danielle’s symptoms and history are consistent with paranoid personality disorder. Psychotherapy is the treatment of choice for this condition. These patients often do not do well in group therapy as a rule, although for some it can increase social skills. Pharmacotherapy is not a primary mechanism of treatment, but when comorbid agitation and anxiety occur, diazepam may be used. In some patients with quasidelusional thinking, pimozide has been helpful. ● Question 5 A 22-year-old male patient is started on sertraline 50 mg p.o. daily after presenting with a major depressive episode. After tolerating without difficulty for 2 weeks, his dose is increased to 100 mg p.o. daily. Approximately 4 weeks later he reports an unusual set of new symptoms for the last week and a half. He says he feels “amped up” and just very 1 out of 1 points 6 generally agitated and nervous. He was short- tempered at work and home and was snapping at people for no good reason. He also reports difficulty concentrating at work. Last week he expressed disproportionate anger at his work and his boss told him that he was bipolar and should be put on medication. The PMHNP discusses with the patient that: Selected Answer: When symptoms are preceded by antidepressant therapy, a diagnosis of bipolar does not apply Answers: When symptoms are preceded by antidepressant therapy, a 9 include (a) through (c). ● Question 7 1 out of 1 points In documenting a mental status exam (MSE) for Janet, a 54- year-old female, the PMHNP notes that she is bradykinesic, has poverty of speech, is depressed, and appears flat. This includes all the following elements of physical examination except: Selected Answer: Answers: Respon se Feedbac k : Appearan c e Appearan c e Motor activit y Mood Affect (a) is the correct answer. Appearance and behavior refer to a general description, such as apparent age, style of dress, jewelry, grooming and hygiene. None of these are noted here. Janet’s motor activity is bradykinesia, her mood is depressed, and her affect is flat. ● Question 8 When performing a psychiatric assessment of an elderly patient with Alzheimer’s dementia, the PMHNP recognizes that: 1 out of 1 points Selected Answer: All of the above. Answers: An important part of the history will come from the caregiver The patient must also be interviewed alone to preserve privacy of the relationship A sexual history is not necessary in patients who are not sexually active All of the above. 10 Respon se Feedbac k : (d.) is the correct answer. Even in clearly impaired patients, in which a big part of the history may come from a caregiver, the patient should be interviewed alone to preserve the privacy of the relationship and allow the patient the opportunity to discuss things that he or she would not discuss in front of others, such as suicidal or paranoid ideation. While some of the history may come from a caregiver, all elements are equally important, and the demented patient’s contribution may easily 11 be more important to the chief complaint. A sexual history is important as history and fantasies may contribute to the current issue. ● Question 9 When differentiating a major depressive episode from dysthymic disorder, the PMHNP considers that: Selected Answer: Dysthymia is more subjective in its presentation than depression Answers: The cognitive theory of depression does not apply to dysthymia Hospitalization is typically indicated early in the course of dysthymia 1 out of 1 points Respon s e Feedbac k : Dysthymia is more subjective in its presentation than depression Insight-oriented therapy is the most effective treatment for dysthymia (c) is the correct answer. While dysthymia overlaps with depression, it is different in that symptoms tend to be more prevalent than physical findings; disturbances in appetite, libido, and psychomotor function rarely occur. The cognitive theory of depression also applies to dysthymia; hospitalization is rarely indicated in dysthymia, and while insight-oriented therapy has been historically utilized, objective evidence supports cognitive, behavioral, or pharmacotherapy. ● Question 10 During the interview of Kevin, a 42-year-old male who presents for treatment because of marital problems, the PMHNP responds to his tears by gently moving a box of tissues toward him. This is a facilitating intervention of interview known as: Selected Answer: 1 out of 1 points Answers: Acknowledge m ent Reinforceme nt 14 : Respon se Feedbac (b) is the correct answer. Treatment of this disorder is very difficult as patients must acknowledge and eschew their narcissism before any real therapeutic progress can be made; 1 out of 1 points k however, these patients are prone to both depression and mood swings for which both serotonergic drugs and lithium have been successful. Psychoanalytic therapy has been advocated, but there is no validating research. Group therapy has 15 been advocated for by some clinicians, although more research is needed. There is no evidence that immobilized patients do better—this concept is true of antisocial personality disorder. ● Question 13 0 out of 1 points Fletcher is a 29-year-old male referred for court-ordered counseling. He has a long history of repeated offenses including DUI, domestic violence, battery, and other violent acts that fortunately have not yet caused any serious injury or death to the recipients. An interview with his wife reveals that he has lied about almost everything for the last few years; he is able to get hired for jobs because he is very engaging and likeable, and then invariably he gets fired because he misses work and doesn’t do his job properly when he is there. According to the wife, they have known each other since high school, where Fletcher was very happy and well-adjusted. He was on the soccer team, liked by teachers, and never demonstrated the tendencies he does now. Apparently in college he got involved with a fraternity that was notorious for alcohol and drug abuse, and he started drinking heavily; it was “all downhill from there.” The PMHNP considers that: Selected Answer: History and symptoms are most consistent with antisocial personality disorder Answers: History and symptoms are most consistent with antisocial personality disorder Fletcher needs a neurological workup to include an EEG and assessment for neurological soft signs Consistent with his symptoms, Fletcher will likely respond well to a stress interview Respon se Feedbac k : It is likely that substance abuse is the underlying cause of symptoms and should be explored further (d) is the correct answer. Typical antisocial personality disorder history extends into adolescence. Fletcher’s behavior appears to have changed following his substance-abuse behaviors, consistent with a diagnosis of substance-abuse disorder— when this is the case, a diagnosis of antisocial personality disorder is not warranted. Abnormal EEG and neurological soft signs are more common in antisocial personality disorder. A stress interview is a technique in which the patient is confronted aggressively with the inconsistencies in his own history and is a therapeutic technique in antisocial personality disorder —again, not appropriate in Fletcher’s case. ● Question 14 1 out of 1 points Anne is a 32-year-old female who presented to care after a random drug screening at work was positive for cocaine. She was initially resistant to 16 therapy, maintaining that her use is not a problem and she could stop at any time. Upon further discussion in session, it appears that she uses cocaine every day at work, sometimes 2–3 times, other days more. She also uses it occasionally at home and most weekends. During her third session, she admitted that it is a financial burden, and she basically cannot afford any other form of recreation. She 19 0 out of 1 points Alexa is a 27-year-old female who has come to group therapy while she is in the city jail. She was arrested for vagrancy because she was sleeping in her car in a parking lot at a local shopping center. She could not post bail, so she is sentenced to 14 days in jail. During group, she contributes that none of this is her fault. Her mother is totally evil because she would not let Alexa stay in the family home. She has some other family. but they are all jerks because they won’t help her. Alexa’s friend Melanie is the absolute best person in the world, but she can’t help because her boss fired her for no reason. Alexa has a history of arrests for buying illegal drugs and prostitution. The last time she was in jail, her sentence was extended for 30 days because she got into a fight with another inmate and beat her up so badly she had to be admitted to the hospital for 6 days. The PMHNP considers which of the following personality disorders? Selected Answer: Narcissis Answers: tic Histrion i c Narcissi s tic Respon se Feedbac k : Borderli n e Schizoid (c) These behaviors are most consistent with borderline personality disorder. Histrionic personalities are often extreme, flamboyant, and sexually aggressive, but do not typically have this pattern of law breaking or incarceration. Narcissistic personalities are not characterized by splitting behaviors—the grandiose sense of self- importance is the dominant feature. Schizoid personalities are much more aloof and withdrawn, not prone to these extremes of emotion. ● Question 17 Answer: D The professional relationship between therapist and patient with e schizoid personality disorder is a challenge because these patients do s not typically seek care independently. However, once a trusting c relationship develops, this type of patient may: r i b Selected e 20 an active fantasy life with imaginary friends Answers: Reveal a very strong desire for an intimate relationship Become very engaged in group therapy Describe an active fantasy life with imaginary friends Demonstrate psychotic or delusional features 1 out of 1 points 21 Respon se Feedbac k : (c) is the correct answers. If a trusting relationship develops, patients may eventually discuss an active fantasy life. They genuinely do not have much, if any, interest in sex or intimacy. Schizoid patients may become involved in group therapy settings, although they remain very quiet and appear disengaged. These patients do not have psychotic of delusional episodes; that would constitute a different diagnosis. ● Question 18 1 out of 1 points The major defensive mechanisms employed by patients with histrionic personality disorder include: Selected Answer: Repression and dissociation Answers: Respons e Feedbac k: ● Question Repression and dissociation Projective identification Fantasy and isolation Splitting (a) is the correct answer. These are most commonly used by histrionic personalities. Projective identification and splitting are more commonly used by borderline personalities, whereas fantasy and isolation. 19 0 out of 1 points Jen is a 31-year-old female who presents for care complaining of depressed mood. During the interview, it becomes apparent that she has a long history of depressive symptoms, as well as a long history of being socially isolated and feeling generally inadequate. When considering a diagnosis of dysthymia, the PMHNP considers that the core concept of dysthymia refers to sub-affective or subclinical depressive disorder with all of the following except: Selected Answer: Strong family history of depression and bipolar disorder Answers: Low-grade chronicity for at least 2 years Insidious onset, usually in 24 Selected Answer: Suicidal or homicidal ideation Answers: Mood-congruent delusions of grandeur Suicidal or homicidal ideation 25 Respons e Feedbac k: ● Question Impaired judgment with no insight Unrestrained flow of ideas (b) is the correct answer. While most manic patients are assaultive or threatening, the incidence of suicidal and homicidal ideation is unknown. Conversely, the other answer choices are all classic in the manic patient and are present most of the time. 22 1 out of 1 points From a biological perspective, all of the following neurotransmitters are implicit in the anxiety response except: Selected Answer: Dopamine Answers: Gamma-aminobutyric acid Norepinephri ne Serotonin Respons e Feedbac k: Dopamine (d) is the correct answer. While dopamine is clearly implicit in other mental health disorders, such as schizophrenia, it is not among the neurotransmitters linked to the anxiety response. ● Question 23 The International Study of Expert Judgment on Therapeutic Use of Benzodiazepines and Other Psychotherapeutic Medications was designed to gather systematic data on the opinions of leading clinicians concerning the 0 out of 1 points benefits and risks of benzodiazepines and alternative anxiety treatments. Which of the following best characterizes the majority opinion of this group? Selected Answer: The panel supports increased federal and/or state restrictions on benzodiazepine prescribing Answers: Patients who require long-term benzodiazepine management should be maintained on long-acting agents The use of benzodiazepines long term for anxiety does not pose a high risk of dependence and abuse 26 Respo ns e The panel supports increased federal and/or state restrictions on benzodiazepine prescribing When detoxifying from therapeutic dosages, daily intake should be decreased by 10–25% (b) is the correct answer. Most of the panel members opine that the benefit of benzodiazepines in long-term anxiety management 29 Respon se Feedbac k : Self-esteem Interpersonal relationships (c) is the correct answer. Patients with narcissistic personality disorder have an extremely fragile sense of self-esteem, which makes them vulnerable to depression when it is assaulted. They have an inflated sense of self-importance, a central feature of this disorder. Their defense mechanisms are intact; this is part of the pathophysiology of this disorder. They do have difficulties with interpersonal relationships because of their self-aggrandizing nature—not due to fragility. ● Question 26 Cory J. is a 23-year-old male being seen by the PMHNP today for an initial evaluation. He says that he does not think anything is wrong, but his family, including his mother, grandmother, and aunt, have all told him that he must be 1 out of 1 points “mentally ill.” He has been unable to hold a job and has worked as a cook at more than five chain restaurants in the last 6 months. He has no real friends—he says his “friends” only call him when they need something but never help him. He is currently staying with his grandmother but reportedly will soon be homeless “unless things change.” While he is telling his story, the PMHNP appreciates that Cory repeatedly includes details that make it hard to understand his point. When asked why he thinks he will be homeless, he responds by talking about how many hours he has worked and how everything was going well but then his car broke down and he couldn’t afford to fix it because his tax return was held by the IRS. The PMHNP recognizes that this represents an abnormal: Selected Answer: Thought process Answers: Affect Cognitio n Respon s e Feedbac k : Thought process Abstract reasonin g (c) is the correct answer. Overinclusion of trivial or irrelevant details that make it difficult to get to the point is indicative of circumstantiality, which is an abnormal thought process. Affect is an expression of mood and may be described as happy, 30 irri tab le, tea rful, etc. Cognition describes the patient’s level of consciousness, orientation, memory, and attention..Abstract reasoning is the ability to expand a concrete or specific concept to a general idea or application. ● Question 27 1 out of 1 points 31 A variety of pharmacologic agents have demonstrated effectiveness in the treatment of post-traumatic stress disorder. Which of the following does not have any evidenced-based support in the literature? Selected Answer: Antipsycho ti cs Answers: SSRI s TCA s Antiadren er gics Respon se Feedbac k : Antipsycho ti cs (d) is the correct answer. There are no data to support the efficacy of antipsychotics, and these are only indicated acutely for severe agitation or aggression. Conversely, SSRIs; TCAs; antiadrenergics, such as clonidine propranolol; as well as MAOIs and mood stabilizers all have demonstrated utility. ● Question 28 The PMHNP is on call at the local county correctional facility. He is asked to evaluate M.S., a 21-year-old male who was just arrested following an altercation at a local bar. M.S. has never been incarcerated before and apparently has no psychiatric or medical history available. His toxicology screen was negative for alcohol or any drugs of abuse. His mother says 1 out of 1 points that he has in the past had some occasions when he got kind of agitated, but this is the first time it’s been a problem. Reportedly some people from his office were at the bar celebrating a birthday, and before anyone knew what happened an argument escalated into M.S. getting very loud, yelling, and acting “crazy” before he punched a coworker and started breaking bottles. When considering a manic or hypomanic episode, the PMHNP expects that his speech would most likely be: Selected Answer: Increas ed 34 The PMHNP is evaluating Jared, a 47-year-old male who is brought to care by his wife because “he’s not the man I married 20 years ago.” According to his wife, she and Jared have been married for 20 years, have two children, and have lived a “normal” life. Jared owns a local construction company 0 out of 1 points and their marriage has been a solid one, characterized by the typical day- to-day issues that occur in most marriages, but otherwise happy. For the last 2–3 months, she says Jared has completely changed. He will get angry for no apparent reason and even broke a 35 lamp once. He tells stupid and offensive jokes that no one else thinks are funny, and even had someone call the police when he continued to make inappropriate remarks to a woman in a restaurant. Jared seems unsure what to say, but his wife is adamant that this is a totally different man from the one she has known. The PMHNP knows that Jared should be evaluated for: Selected Answer: Substance abuse disorder Answers: Borderline personality disorder Respon se Feedbac k : Structural brain damage Substance abuse disorder Cognitive impairment (b) is the correct answer. Personality changes that occur later in the lifespan, have rapid onset, and include impaired control of behaviors and emotions are most likely due to structural damage related to head injury; neoplasms and cerebral vascular disease are also considerations. Personality disorders are usually evident well before the 5th decade. Substance abuse will be assessed in the history, but there is no report of that here. Cognitive impairment is usually not an early feature of personality disorder due to general medical condition. ● Question 31 1 out of 1 points Tim is a 20-year-old male who has been referred for care by his college counselor. The counselor has noted that Tim engages in virtually no social activities in college, and for that matter avoids day-to-day activities that require social interaction. By his own admission, Tim never participates in class discussions, even in online discussion boards. Tim is so afraid of rejection that he confines himself to his room and his studies. When differentiating schizoid personality from avoidant personality, the PMHNP knows that a primary difference is that: Selected Answer: Avoidant personalities have a strong desire for personal relationships Answers: Avoidant personalities have a strong desire for personal relationships Avoidant personalities may have an active fantasy life Schizoid personalities are perceived as distant and aloof Schizoid personalities may be very attached to animals Respon se Feedback 36 : (a) is the correct answer. Avoidant personalities do have a desire for interpersonal relationships; schizoid personalities do not. Both types of personalities may have an active fantasy life, be perceived as distant and aloof, and be attached to animals; none of these things differentiate one type from the other. ● Question 32 0 out of 1 points 39 Patients on lithium carbonate for management of bipolar disorder should be subject to routine assessment of: Selected Answer: TSH and serum Na+ Answers: CBC and BMP Respon se Feedbac k : TSH and serum Na+ CMP and ECG LFTs and EEG (b) is the correct answer. Lithium, as an iodine-containing medication, presents a risk of both hypothyroidism and hyponatremia. Patients on lithium should have routine monitoring of these labs as well as lithium levels. CBC is not routinely indicated; this is appropriate for drugs that can cause pancytopenia, such as valproic acid. ECG, LFT, and EEG are not routinely indicated. ● Question 35 Mr. Henderson is a 69-year-old man who presents for evaluation and care for depression. His wife died 6 months ago following a difficult 2 years with breast cancer. His primary complaint is that he just does not look forward to anything anymore. He cannot get interested in his children and grandchildren, he 0 out of 1 points no longer enjoys any of his hobbies because he and his wife used to do them together. He does not sleep well, and wakes up frequently during the night. He also admits to thinking more and more about dying himself, although he expressly denies suicidal ideation. His medical history is significant for coronary artery disease, osteoarthritis, hypothyroidism, hypertension, and dyslipidemia. He also has atrial fibrillation and is on warfarin for emboli prophylaxis, but he does not remember the names of all of his other medications. When considering pharmacotherapy for Mr. Henderson, the PMHNP considers that which of the following SSRIs is safest with respect for potential drug interactions? Selected Answer: Fluoxetine Answers: Fluoxetin e Paroxetin e 40 Respon se Feedbac k : Escitalop r am Sertralin e (c) is the correct answer. Escitalopram is the only medication of those listed that has no inhibitory impact on any CYP450 isoenzymes. Since Mr. Henderson does not know the names of his other drugs, it is best to avoid CYP450 inhibitors. All of the other choices have some degree of inhibition on several isoenzymes, including the 2C9 isoenzyme, which metabolizes warfarin. 41 ● Question 36 The PMHNP is asked to evaluate the parent of one of her existing patients, a 49- year-old woman named Sheri. Sheri reports that her father, a 78-year-old man who lives alone, has always been in good health. However, when Sheri went to have breakfast with him this past Sunday, she found her 1 out of 1 points father overtly confused and he did not even seem to recognize her at first. Sheri is concerned that he has Alzheimer’s disease, and she is amazed because two days prior he was “completely fine.” The PMHNP knows that the most likely cause of this presentation is: Selected Answer: Urinary tract infection Answers: Respon se Feedbac k : Urinary tract infection Mild cognitive impairment Normal pressure hydrocephalus Depression (a) is the correct answer. The acute nature of this mental status change without any preexisting conditions or deficits is consistent with infection, most likely of the urinary tract. This is not mild cognitive impairment as his current symptoms clearly interfere with ADLs. Normal pressure hydrocephalus is remotely possible but much less likely. Depression may mimic dementia, but the acute and global nature of this presentation is more consistent with delirium. ● Question 37 Differentiating post-traumatic stress disorder (PTSD) from panic disorder and generalized anxiety disorder can be challenging. Which of the following provides the strongest support for PTSD vs the other two differential diagnoses? Selected Answer: Reexperiencing the event Answers: The time course of symptoms Presence of physiologic arousal Reexperiencing the event Response to pharmacotherapy 1 out of 1 points 44 Answer: 12-lead ECG Answers: Urine drug screen Hepatic function test Pulmonary function test 12-lead ECG 45 Respon se Feedbac k : (d) is the correct answer. In patients who are at high risk, such as those with cardiomyopathy, a 12-lead ECG should be assessed prior to starting methadone at doses > 100 mg daily as it may prolong the QT interval predisposing to ventricular dysrhythmia. A urine drug screen is typically performed prior to treatment, but this is not related to the dose of methadone. Hepatic function profile is appropriate only if there is concern about liver disease, and pulmonary function test does not have any routine indication. ● Question 40 Karen is a 19-year-old female who has been referred to care after being seen in the emergency department following a violent sexual assault. She was working late one evening at the shopping mall and walked alone to her car after 0 out of 1 points dark. She was assaulted, beaten, and thankfully a passerby saw her lying in some bushes and called 911. Initially she was resistant to mental health care, but now, 2 months later, she feels as though she needs help because she is experiencing a collection of symptoms including flashbacks, dreams of the assault, palpitations, anxiety, and a sense that she is watching the assault happen to her This sense of watching the assault as if she was an observer is characteristic of which diagnostic domain of PTSD? Selected Answer: Intrusion symptoms Answers: Intrusion sympto ms Respon se Feedbac k : Avoiding stimuli Autonomic arousal Clinical significanc e (b) is the correct answer. There are three domains in which patients show symptoms, represented by a–c above. Depersonalization and derealization are characteristic of avoidance. Diagnostic criteria do require clinically significant distress, but this is not among the three domains. ● Question 41 Valida ted and 46 reliable instruments are an important part of assessment for both clinical practice and research in psychiatrics. Which of the following tools is currently considered the standard for assessing clinical outcomes in treatment studies of schizophrenia? Selected Answer: BPRS Answers: SCID 0 out of 1 points 49 Respon se Feedbac k : Hypomanic episodes may occur as a response to antidepressants (d) is the correct answer. Both manic and hypomanic episodes cannot be diagnosed when the change in mood is a response to antidepressant therapy. In both types of episodes, the patient must either not be in treatment for depression or enough time must have passed that treatment is not a factor. The duration of symptoms is shorter, as hypomanic episodes require 4 days for diagnosis and manic episodes 1 week. Full manic episodes cause marked social or occupational impairment; hypomanic episodes are noticeable to others but do not necessarily lead to such dysfunction. Manic episodes may include psychosis, whereas hypomanic episodes do not. ● Question 44 Which among the following neurotransmitters is decreased in depression and increased in mania? Selected Answer: Serotonin Answers: 0 out of 1 points Respon se Feedbac k : Dopamine Norepineph ri ne Serotonin Glutamat e (a) is the correct answer. Norepinephrine and serotonin are clearly implicit in depression, but their relationship or concentration in mania is not established. Although glutamate is being explored as a neurotransmitter implicit in mood disorders, its role is emerging and not well articulated now. ● Question 45 Dependence is a common feature of many psychiatric disorders. One of the primary distinguishing features that differentiates dependent personality disorder from histrionic and borderline personalities is that: Selected Answer: Dependent personalities tend to have long-term relationships with one person Answers: The treatment of dependent personality is rarely 1 out of 1 points 50 successful Occupational dysfunction is rarely impaired Dependent personalities tend to have long-term relationships with one person This disorder tends to be more common in men Response (c) is the correct answer. Unlike other personality disorders, dependent 51 Feedbac k : personalities tend to have long-term relationships with one person rather than a series. Treatment is often successful; insight-oriented therapies enable patients to understand their behavior and become more successful. With dependent personality disorder, occupational functioning tends to be impaired because these patients cannot act independently or without close supervision. This disorder is more common in women. ● Question 46 Trudy L. is a 29-year-old female patient who initiated care because she feels like she has no energy. She just had her annual wellness exam and her primary care provider told her that she is in excellent health. Because she complained about this excessive fatigue, her PCP performed a CBC, CMP, UA and thyroid function tests and was told, along with her physical examination, that everything looks normal. Further discussion reveals that Trudy is having some relationship challenges with her boyfriend of 2 years and this seems to be “spilling over” at work, where she is having persistent conflict with her supervisor. Ultimately the PMHNP diagnoses Trudy with major depressive disorder, mild, single episode. The PMHNP and Trudy discuss treatment options, and Trudy would really like to try nonpharmacologic interventions. Which of the following represents the best approach for Trudy? Selected Answer: Interperson al therapy Answers: Family therapy Behavior therapy Psychoanalytic therapy 1 out of 1 points Respon se Feedbac k : Interpersonal therapy (d) is the best answer. Family therapy is not regarded as a primary therapy choice for major depressive disorder. While some data suggests that it may prevent relapse by lessening stressors, it is not among the best options presented here. There are limited data on the efficacy of behavior therapy. Psychoanalytic therapy may be helpful for depression, although it is typically a very long process and not practical for acute symptom management. Interpersonal therapy has a body of evidence to support its efficacy for major depressive disorder and may simultaneously help Trudy with her current relationship concerns. Interpersonal therapy is a goal-oriented 54 (d) is the corr ect ans wer . These findings are suggestive of hallucinogen intoxication. Alcohol is a CNS depressant and would not cause tremor or tachycardia; that is more likely with alcohol withdrawal. Cannabis intoxication does cause impaired coordination and motor function but not tremor or tachycardia. Opiates are a SNS antagonist and produces pupillary constriction, constipation, and apathy as well as euphoria. ● Question 49 1 out of 1 points 55 Jeffrey T. is a 27-year-old man who has presented for care after being required to do so by the county court. He was involved in a car accident, and while he was not at fault for the accident, routine blood alcohol screening revealed that he was driving while intoxicated. He is a bit resentful at being required to attend therapy; he is very vocal that his driving was not impaired and that he is able to function normally even after drinking what others might consider excess amounts of alcohol. His wife confirms this; they both admit that what began as one or two beers after work a few years ago has evolved to where he now drinks at least a 12 pack of beer nightly. Regardless, they both confirm that he never “seems drunk,” and this does not interfere with his job or fulfilling his family functions. Jeffrey’s ability to function normally despite high blood alcohol is likely a result of: Selected Answer: Adaptatio n Answers: Depend e nce Abuse Respon s e Feedbac k : Adaptati o n Addictio n (c) is the correct answer. Cellular or pharmacodynamic adaptation refers to the ability of the CNS to function despite high blood levels of the substance of abuse. Dependence refers to repeated use of a substance with or without physical dependence, but does not specifically encompass the concept of functioning normally with increased doses. Abuse generally refers to using drugs or alcohol in a manner deviant from societal norms, and while Jefferey may be doing that, adaptation is the phenomenon described in this scenario. Addiction refers to a situation in which deprivation of the substance produces distress and mental or physical deterioration—something not described in this scenario. While these may be present for Jeffrey, the phenomenon specifically described here is adaptation. ● Question 50 1 out of 1 points Sarah is a 23-year-old patient who presents for a follow-up of her major depressive episode. She was titrated up to maximal dose fluoxetine 6 56 weeks ago after demonstrating tolerance without side effects at lower doses. Today in follow-up, she reports that she still has no sides effects but no therapeutic effect either. There does not appear to be any measurable improvement of her initial presenting symptoms. The PMHNP knows that the most appropriate approach at this point is to: Selected Answer: Change to another antidepressant medication Answers: Reconsider the diagnosis of major 59 Feedbac k : episode of depression, and one theory suggests that the physiologic changes that accompany this episode place patients at higher risk for subsequent episodes. There is no evidence that pharmacotherapy increases this risk. The most compelling data for life events suggests that losing a parent before age 11 is the greatest life event risk factor for major depressive disorder. While response to pharmacotherapy does take up to 8 weeks, this is not an etiology. ● Question 52 Marcus is an 18-year-old male presented for care by his parents. It is time for Marcus to begin exploring colleges and he flat out refuses to do so. Both Marcus and his parents admit that he has had a rather solitary lifestyle. He has been home-schooled since the eighth grade. According to his parents, he is extremely intelligent and in junior high it became very difficult for him to be in school. He was very uncomfortable in the school setting and it was counterproductive to learning, so the parents were amenable to home schooling. However, now they want him to go to college, but he will not discuss it. When considering differential diagnosis, the PMHNP considers all of the following except: Selected Answer: Social anxiety Answers: 0 out of 1 points Respon se Feedbac k : Schizophreni a Social anxiety Schizoid personality Agoraphobia (a) is the correct answer. There is no report of positive symptoms of schizophrenia, which would be required for this differential. However, social anxiety, schizoid personality, agoraphobia, as well as avoidant personality and depression, should all be considered here. A more detailed psychiatric interview is necessary to differentiate among them. ● Question 53 Mrs. Maxwell is a 75-year-old patient with moderate Alzheimer’s dementia. She lives with her son and his wife and generally does very well with her day to day activities. The family understands the importance of routine and Mrs. Maxwell maintains a regular schedule of activities including her meals, timed toileting, and recreational activities. Which of the following behaviors should prompt and immediate depression screening for Mrs. Maxwell? 0 out of 1 points 60 Selected Answer: An unplanned weight loss despite consistent oral intake Answers: An acute change in mental status Angry verbal outbursts that seem 61 Respon se Feedbac k : unwarranted Death of her best friend An unplanned weight loss despite consistent oral intake (b) is the correct answer. Mood disorders in demented patients often present as seemingly disproportionate anger. When a patient with a dementing disorder develops increasing irritability or anger, a depression screening should be among the first assessments. An acute mental status change is delirium and urinary tract infection is the first thing to rule out. Death of a best friend may trigger a depressive episode but, absent symptoms, a screening is not indicated. Unplanned weight loss, in the absence of decreased intake, warrants evaluation for organic disease. Conversely, decreased intake with concomitant weight loss may be symptomatic of a mood disorder. ● Question 54 1 out of 1 points Anthony is a 41-year-old male patient who presents for evaluation. His wife made the appointment because she is worried about him and he would not seek care on his own. Anthony has become progressively withdrawn over the last few months and is in danger of losing his job because he misses so many days. He has been evaluated by his primary care provider and has no apparent medical conditions. His wife reports that he has been diagnosed with depression in the past, and has even taken medication that seemed to help. This time he just refused to pursue care. After a comprehensive assessment, the PMHNP diagnoses the patient with major depressive episode with psychotic features. Consistent with the Texas Algorithm Medication Project (TAMP), the appropriate choice of initial medication therapy would be: Selected Answer: Fluoxetine and olanzapine Answers: Venlafaxine and clozapine Fluoxetine and olanzapine Amitriptyline and haloperidol Paroxetine and buspirone Respon : se Feedbac k 64 months; medication must not be stopped abruptly or without provider supervision. This is because the physiologic consequence of abrupt cessation is likely to result in: Selected 0 out of 1 points 65 Answer: Rebound depressive symptoms Answers: Respon se Feedbac k : Antidepressant discontinuation syndrome Rebound depressive symptoms A manic or hypomanic episode Unresponsiveness to medication with future episodes (a) is the correct answer. Antidepressant discontinuation syndrome is a collection of symptoms represented by the mnemonic FINISH (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal). These are most abrupt when the patient has been on medication for > 6 weeks. While depressive symptoms may occur, (a) is the best answer as this is the most likely concern. Manic symptoms are not any more likely to occur with discontinuation of an antidepressant—antidepressants may precipitate a manic or hypomanic episode if the patient has undiagnosed bipolar disorder. While subsequent episodes of major depression are more challenging to treat than initial episodes for a variety of reasons, there is no direct correlation to abrupt cessation of medication. ● Question 57 Chantel is a 19-year-old female who presents for care because she thinks she is bipolar. During her initial interview, she admits that she has a long history of feeling like she was the person in the family of whom there were always high expectations, and she was never able to express concerns or feelings of inadequacy. When asked why she thinks she is bipolar, she says she gets very 0 out of 1 points moody. She was at the grocery store last week and slipped and fell. While waiting for help, she could not control her anger and reached up to swipe all the food off of the shelves. She has been fired from jobs because of her uncontrollable temper; she sometimes “just can’t be around certain people.” Chantel also reports that at times she will go two full days and nights being unable to sleep, and that her mind keeps racing and she can’t “shut it down.” When this happens, she just gets up and does things around the house. Finally, Chantel reports that she cannot hold onto money at all. Whenever she gets a paycheck, she immediately spends it on things that she acknowledges she doesn’t even need. When considering a diagnosis of bipolar disorder, the PMHNP specifically assesses for: Selected Answer: Manic symptoms that are sustained most of the day for at least 2 weeks Answers: Any history of suicidal attempts or serious ideation History and current patterns of substance abuse Concomitant psychotic features such as hallucination or delusion 66 Respon se Feedbac k : Manic symptoms that are sustained most of the day for at least 2 weeks (b) is the correct answer. DSM-5 criteria for bipolar disorder require a single or multiple manic episode that meets four criteria. Chantel meets the first three; (1) a distinct period of abnormal and persistently 69 : association between chronic alcohol use and uremia. When patients with alcohol use disorder have uremia, another etiology should be pursued. ● Question 60 Kevin is a 24-year-old male who seeks treatment for anxiety. He thinks he has an anxiety disorder because he has a lot of the same symptoms that his mother 1 out of 1 points does, and she takes medications for anxiety. He reports being “constantly wired,” irritable, and not sleeping well. Kevin says he always has energy, but it’s not a good kind of energy. He does not have isolated panic attacks; he is always just “amped up.” He denies any substance abuse, and he does not smoke cigarettes. When considering organic causes of his symptoms, the PMHNP must evaluate his: Selected Answer: Caffeine intake Answers: Respon se Feedbac k : Caffeine intake Use of dietary supplements Testosterone level Liver function tests (a) is the correct answer. These symptoms, which sound like anxiety disorder, may all be caused by excess use of caffeine; his daily caffeine intake should be evaluated. Dietary supplements can cause organic problems, but not typically anxiety symptoms. A low testosterone level would not cause anxiety levels but rather symptoms of fatigue, malaise, and weight gain. Elevated liver functions tests may cause nausea and feelings of generally being unwell, but anxiety symptoms are less likely. ● Question 61 Among the various types of therapeutic intervention for patients with borderline personality disorder, which of the following is characterized as polymodal, including group skills training, individual therapy, telephone consultation, and a consultation team with a goal of improving interpersonal skills and decreasing self- destructive behavior? Selected Answer: Dialectical behavioral therapy (DBT) Answers: Mentalization-based treatment (MBT) Transference-focused psychotherapy (TFP) Countertransference-focused 1 out of 1 points 70 psychotherapy (CTFP) Respon se Feedbac k Dialectical behavioral therapy (DBT) (d) is the correct answer. DBT is the form of therapy that has the most empiric support. It is characterized by the stated four modes of 71 : treatment and five essential functions of treatment. MBT is another form of therapy that fosters patient awareness of mental state of self and others. TFP is a form of psychodynamic psychotherapy that is also used. CTFP is not a defined therapeutic approach. ● Question 62 1 out of 1 points Maurice is a 22-year-old male who is being treated for major depressive episode. He presents today for a follow up visit. He was started on sertraline 50 mg daily 4 weeks ago, and 2 weeks ago, his dose was increased to 150 mg daily. Today he is concerned because he doesn’t really feel much symptom improvement, and he thinks he needs something else. The best response to Maurice is to tell him that: Selected Answer: He needs to be increased to 200 mg today and follow up in 4 weeks Answers: Respon se Feedbac k : He needs to be increased to 200 mg today and follow up in 4 weeks He should maintain this dose for 4 weeks and reassess He should change his therapy to an SNRI Addition of cognitive behavioral therapy would likely improve response (a) is the correct answer. Absent adverse events, his medication should be maintained at maximal doses for 4–5 weeks before considering the drug trial ineffective; 50–200 mg is the typical dose range of his medication for major depressive disorder. It is not appropriate to change drug class yet, and while CBT may improve response overall, the best answer in this scenario is to maximize his medication dose. ● Question 63 Melissa is a family nurse practitioner who is enrolled in a PMHNP program and is beginning her first clinical rotation. After being oriented to the practice processes and procedures, she is preparing for her first solo interview of a patient who is presenting to the practice to establish care. Melissa knows that, unlike her experience as a primary care nurse practitioner, the first office visit with a psychiatric patient should be: Selected Answer: Comprehensive m i n u t e s Person- centere Compre ensive Insight- Answers: At least oriented 90 74 t. Her 10-year-old son is having some behavioral issues in school and has been referred for evaluation. While interviewing Janel, the PMHNP appreciates that she appears very emotional. She expresses extreme distress at her son’s behavior and says she will do anything to help him; 1 out of 1 points they are “best friends.” She is very demonstrative during the assessment and seems unhappy when she is not the center of attention during the evaluation process. She repeatedly talks about her own medical problems, such as recurrent headache and abdominal pain, which her doctors cannot diagnose. Her appearance is very flamboyant, and her dress is more appropriate to a nightclub than a family assessment. In addition to 75 managing her son’s needs, Janel would likely benefit from: Selected Answer: Psychoanalytic psychotherapy Answers: Pharmacotherapy Respon se Feedbac k : Psychoanalytic psychotherapy Transference-focused psychotherapy A stress interview (b) is the correct answer. Patients with histrionic personality disorder are typically not aware of their own feelings and will benefit from clarifying their own true feelings. Pharmacotherapy may be helpful if there are additional symptoms such as depression or anxiety, but it is not primary therapy for histrionic personality disorder. Transference- focused psychotherapy is an approach used for borderline personality disorder, and stress interview is among the techniques for antisocial personality disorder. ● Question 66 Hugo is a 39-year-old male who has encouraged his wife to come to counseling because he is worried about her wine drinking. Hugo says that he and his wife have shared a bottle of wine with dinner most nights for the last couple of years, but in the last few months he has become worried that she drinks too much. They both agree that she never really becomes intoxicated, but he does not like the fact that evening wine has become the most important 0 out of 1 points part of her meal. If he wants to go out, she will only go to a place that has a wine she likes. Last month they went on a week-long vacation, and she insisted on packing enough of her wine to last the whole time. If they go to a restaurant that does not have a wine she likes, she will take her own in a disposable coffee cup. It seems like for the last few months, she has been drinking more and more, occasionally finishing the bottle alone when he doesn’t want any. Both partners agree that there is no interference with work or any activities or responsibilities, but it is causing some tension in their marriage. When considering a diagnosis of substance use disorder, the PMHNP considers that: Selected Answer: The family history should be assessed for genetic tendency Answers: Hugo’s wife meets diagnostic criteria for this disorder A trial period with no wine ingestion is necessary to assess for withdrawal symptoms The family history should be assessed for genetic tendency Hugo may have unreasonable 76 Respon se Feedbac k : expectations (a) is the correct answer. Diagnostic criteria for substance use disorder includes a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 2 of 11 circumstances that include (1) a great deal of time is spent in activities 79 Respon se Feedbac k : (b) is the correct answer. Physical illness predisposes to DTs, and people in good physical health rarely experience it. Since Margo’s current alcohol pattern is approximately 1 year and she is in good physical health, her risk of DTs is low and she can be safely managed as an outpatient. Beta adrenergic antagonists can be used for sympathetic nervous system hyperactivity but they do not treat or prevent delirium. There is not gender predisposition for DTs. ● Question 69 Laura T. is a 27-year-old female who has been referred for psychiatric evaluation. She has no significant psychiatric or medical history and denies any history of substance abuse, but she is here because she is persistently having olfactory hallucinations. For the last 3 months, she has been having this progressive sense of smelling particularly foul odors—feces, rotting food, trash— with no obvious cause. She made the appointment because she had an uncle who had schizophrenia and he used to have hallucinations too, although he was mostly hearing voices. The PMHNP knows that a priority of assessment includes a: 0 out of 1 points Selecte d Answer : [None Given] Answers: BPRS Toxicolo gy screen Respon se Feedbac k : Head imaging Family history (c) is the correct answer. In North American culture, nonauditory hallucinations are a clue that there is a medical or substance abuse etiology; as the patient denies substance abuse, a priority of assessment is head imaging. The BPRS (brief psychiatric rating scale) measures psychiatric symptomatology and may be appropriate if a physical cause of symptoms is ruled out. A family history is also helpful, but the priority here—and best answer—is imaging to help rule out an organic cause. ● Question 70 Among the various psychotherapeutic techniques available for treating post- 0 out of 1 points traumatic stress disorder, which mechanism achieves its effect by having patients work through the traumatic event while in a deep state of 80 relaxation? Selecte d Answer: Answer s: [None Given] Eye movement desensitization and reprocessing therapy Implosive therapy Systematic desensitization Relaxation and cognitive techniques 81 Respon se Feedbac k : (a) is the correct answer. EMDR is a technique in which the patient focuses on the lateral movement of the clinician’s finger while maintaining a mental image of the trauma. Implosive therapy is an intense desensitization program, while systematic desensitization is graded exposure via video or other methods of simulation. Relaxation and cognitive techniques teach coping mechanisms as well as thought- altering approaches. ● Question 71 0 out of 1 points While preparing a class on personality disorders for a class of PMHNP students, the instructor is presenting case studies of patients with cluster A personalities. One of these cases is Clark M., a 41-year-old man who is described as a life-long “loner.” In high school and college, he kept to himself, excelling in his studies in the sciences. Currently described as a brilliant computer programmer, he clearly prefers solitary pursuits and the company of his cat over people. He knows he is socially isolated, but he is just more comfortable this way. This description is most consistent with: Selecte d Answer: Answer s: Respon se Feedbac k : [None Given] Schizoid personality disorder Schizotypal personality disorder Paranoid personality disorder Delusional disorder (a) is the correct answer. Schizotypal personalities are more likely to be characterized by disordered thinking and communication, and less of a capacity for reality. Paranoid personalities tend to be more socially engaged, and delusional disorders are characterized by delusions with no basis in reality. ● Question 72 0 out of 1 points The PMHNP is preparing a presentation for a primary care conference on geriatric health care. The topic is geriatric depression, and this presentation is designed to increase recognition of community-dwelling elders at risk. An important talking point in this presentation will include all of the following about geriatric depression except: Answer: Selecte d 84 apparently been considered odd all his life, has never married or even dated as far as Megan knows, but she had no idea how odd he was. When his mother died, he seemed disconnected from reality and had episodes of talking to people who weren’t present. Megan says that sometimes she does not even understand what he is talking about. He seems to think he has psychic powers, and that he doesn’t need to move because he knows the house will not be sold. When considering a diagnosis of schizotypal disorder, 85 the PMHNP expects which of the following to be present in the history? Selecte d Answer: Answer s: Respon se Feedbac k : [None Given] A history of schizophrenia of a first-degree relative Sustained psychosis predating his mother’s death Comorbid Asperger’s syndrome Apparent frank thought disorder (c) is the correct answers. If a trusting relationship develops, patients may eventually discuss an active fantasy life. They genuinely do not have much, if any, interest in sex or intimacy. Schizoid patients may become involved in group therapy settings, although they remain very quiet and appear disengaged. These patients do not have psychotic of delusional episodes; that would constitute a different diagnosis. ● Question 75 0 out of 1 points Depressive personality disorder exists along the spectrum of dysthymia and major depressive disorder, but it is different from these two in that: Selecte d Answer : [None Given] Answers: Pharmacologic treatment is not indicated The etiology is different Respon s e Feedbac k : Perfectionism is common Physical symptoms are lacking (c) is the correct answer. Unlike patients with dysthymia or MDD who may lack the drive or ability to attend to personal or work- related details, patients with depressive personality are often meticulous, over- conscientious, and preoccupied with work. While the etiology is unknown, it is generally regarded to include the same psychosocial and physiologic causes. Patients may benefit from low-dose SSRIs or psychostimulants. Physical symptoms, such as psychomotor retardation, may be present. Tuesday, October 10, 2017 11:11:17 PM EDT