Which of the following patients is not appropriate for management in the primary care setting?
- A 27-year-old female with new onset depressive symptoms and a scheduled psychiatric intake in 6 weeks
- A 27-year-old male with new onset inattentive symptoms and no history of psychiatric evaluation
- A 32-year-old female who is acutely manic and suicidal and currently has no psychiatric provider
- A 32-year-old male who has been psychiatrically stable on lithium for a year
2. A 27-year-old male with new onset inattentive symptoms and no history of psychiatric evaluation
Patients with newly identified symptoms who do not present imminent risk should be referred for a mental health evaluation.
By 2020, the World Health Organization estimates which of the following illnesses will be the number two cause of "lost years of healthy life" worldwide?
- Bipolar Disorder
- Major Depressive Disorder
- Generalized Anxiety Disorder
3. Major Depressive Disorder
Major Depressive Disorder will soon be the second worldwide cause of disability-adjust life years lost due to ill-health, disability, or early death.
According to the National Institute of Mental Health, half of all mental illness begins by which age?
- 8 years old
- 14 years old
- 24 years old
- 32 years old
2. 14 years old
Fifty percent of all mental illness begins by age 14.
A 70-year-old male patient comes to see his family nurse practitioner complaining of vague aches and pains and forgetfulness over the past 3 months. His wife shares with the nurse practitioner that he is snapping at family members, no longer likes to go out for weekly family dinners, and is not interested in sex. He has a history of diabetes but his labs are normal. He scores a 28/30 on his Folstein Mini Mental Status Exam (MMSE). What does the family nurse practitioner suspect?
- Major Depressive Disorder
- Alzheimer’s disease
- Major Neurocognitive Disorder
- Complications of diabetes
1. Major Depressive Disorder
In older adults, symptoms of depression often include physical aches and pains not caused by a medical condition, memory difficulties or personality changes, and social withdrawal. Dementia would be considered if the patient showed signs of cognitive decline, such as a low score on the MMSE. A score of 23 or lower indicates cognitive impairment.
A 37-year-old female patient requests a prescription for antidepressant medication. She reports low energy, poor self-esteem, overeating behaviors, difficulty making decisions, and feeling hopeless. When asked how long her symptoms have been occurring, she states, "I’ve always been this way." The nurse practitioner suspects which of the following?
- Borderline Personality Disorder
- Major Depressive Disorder
- Persistent Depressive Disorder
- Bipolar Disorder
3. Persistent Depressive Disorder
The symptoms of persistent depressive disorder occur for at least two years, with no more than 2 months without symptoms.
A family nurse practitioner is seeing a 33-year-old patient for a follow-up visit for her depression. The patient began sertraline (Zoloft) 50 mg four weeks ago and reports a partial response. The nurse practitioner does which of the following?
- Increases the dosage
- Advises switching to a different medication
- Considers augmenting with another agent
- Refers to a psychiatric provider
1. Increases the dosage
The next step would be to increase the dosage until full response.
A 55-year-old male patient returns for follow-up after starting an antidepressant after one week. He reports occasional headaches and worries it is not working. The family nurse practitioner advises all but which of the following?
- "Side effects are common but often go away in a couple of weeks."
- "Successful treatment often involves a dose adjustment."
- "Patients typically show improvement in the first week, so it is time to consider a switch."
- "Do not stop taking the medication without calling me."
3. "Patients typically show improvement in the first week, so it is time to consider a switch."
It generally takes at least 2 weeks to show a response, though for many patients it takes at least 4–6 weeks.
A 61-year-old male patient is following up 6 months after discharge from the hospital after having a heart attack. The family nurse practitioner would like to begin an SSRI for his symptoms of depression. He is also taking clopidogrel (Plavix). The nurse practitioner proceeds cautiously recognizing which of the following risks?
- Sleep disturbance
- Serotonin Syndrome
- Increased risk of bleeding
3. Increased risk of bleeding
Patients taking an SSRI along with an antiplatelet agent are at increased risk of bleeding. While they are not absolute contraindications to be taken together, the nurse should weigh the risks of bleeding and untreated depression, monitor INR, and ask the patient to report signs of bleeding promptly.
A 27-year-old female patient follows up with her family nurse practitioner after having her first baby. Her nurse midwife began escitalopram (Lexapro) during pregnancy for symptoms of depression and the patient is concerned about the risks to the baby of continuing this medication while breast-feeding. Which of the following is the best advice the nurse practitioner can give?
- The patient should stop this medication because it can cause withdrawal symptoms in the baby.
- The patient should switch to a tricyclic antidepressant that has lower risk to the baby.
- This medication is relatively safe and the amount of the drug to the nursing infant is low.
- The patient should stop the medication and begin psychotherapy instead.
3. This medication is relatively safe and the amount of the drug to the nursing infant is low.
When clinically warranted, antidepressants in breast-feeding are considered relatively safe for use. SSRIs are the best studied. While they are secreted in breast milk, there is no evidence that they pose a significant risk to the nursing infant. Tricyclic antidepressants are also considered relatively safe during breast-feeding. However, there is no known benefit of one antidepressant over another, and switching may put the mother at risk of relapse.
A patient who is being treated with lithium 600 mg twice daily has a trough lithium level of 0.9 mEq/L. The patient is currently euthymic. The nurse practitioner does which of the following?
- Decreases the medication to prevent toxicity
- Discontinues the medication to prevent toxicity
- Maintains the current dosage because the plasma level is within range
- Maintains the current dosage because the benefit outweighs the risk
3. Maintains the current dosage because the plasma level is within range
The recommended therapeutic range of lithium is between 0.5–1.2 mEq/L.
The family nurse practitioner orders all but the following lab work for an annual follow-up visit of her patient on lithium treatment.
- Thyroid function tests
- Urine creatinine
- Urine specific gravity
- Lipid panel
4. Lipid panel
Lithium alters sodium transport across cell membranes and increases risk for acute and chronic kidney disease. Urine creatinine and urine specific gravity should be checked on initiation, at least annually, and if symptomatic. Furthermore, lithium increases the secretion of intrathyroidal iodine, inhibiting the release of T3 and T4 and increasing the risk for hypothyroidism. A thyroid function panel should be checked upon initiation, at least annually, and if symptomatic. A lipid panel is not indicated for lithium initiation or maintenance. However, lithium is associated with weight gain and it is prudent to screen for dyslipidemia in overweight or obese patients.
A 28-year-old new mom returns four weeks after being prescribed escitalopram for postpartum depression by her family nurse practitioner. She reports that she feels better than she has ever felt, does not feel tired after several sleepless nights up with the baby, and has re-connected with previous friends to chat in her free time. She notes that her husband thinks she’s doing well, too, because she has been so sensual. The family nurse practitioner does which of the following?
- Continues the current dosage of escitalopram
- Decreases the dosage of escitalopram
- Advises the new mom that she is responding to oxytocin and should pace herself as hormone levels readjust
- Suspects Bipolar Disorder and discontinues the medication
4. Suspects Bipolar Disorder and discontinues the medication
Symptoms of mania include increased energy, decreased need for sleep, more talkative than usual, and excessive interest in pleasurable activities. Antidepressants may trigger symptoms of mania when underlying mood disorders are present. While oxytocin increases in the immediate postpartum period, as it drops off, new moms are more likely to experience symptoms of depression.
A 19-year-old male college student expresses concerns about being unable to talk to others, avoidance of joining activities he likes, fear of speaking in class, and avoiding approaching professors. His grades are poor due to concentration and lack of participation. His diagnosis is which of the following?
- Generalized Anxiety Disorder
- Social Anxiety Disorder
- Attention Deficit Hyperactivity Disorder
- Antisocial Personality Disorder
2. Social Anxiety Disorder
Social Anxiety Disorder is characterized by intense anxiety and distress around the fear situation, recognition that the fear is unreasonable or excessive, and social, academic, or occupational impairment related to avoidance of activities associated with the fear.
Which nonpharmacologic modality is most recommended for the treatment of Generalized Anxiety Disorder?
- Psychoanalytic Therapy
- Prolonged Exposure Therapy
- Cognitive Behavioral Therapy
- Social Rhythm Therapy
3. Cognitive Behavioral Therapy
Cognitive Behavioral Therapy (CBT) has been proven effective for a range of anxiety disorders, including Generalized Anxiety Disorder. It is a structured, problem-focused, and goal-oriented approach that helps modify negative thinking and beliefs in order to change behavior.
Which of the following stress-relieving activities would be difficult for a patient with agoraphobia?
- Listening to relaxing music
- Going to a friend’s house
- Deep breathing
- Caring for a pet
2. Going to a friend’s house
People with agoraphobia fear being in situations where escape can be difficult or embarrassing and they often avoid leaving home.
A 42-year-old female presents for follow-up after two emergency room visits for shortness of breath, heart palpitations, sweating, and fear of dying. A comprehensive workup shows no cause of medical illness. A urine drug screen prior to the office visit is positive for marijuana. The patient states, "Ativan really helped in the emergency room. Will you continue it?" What does the FNP advise?
- "Ativan is a safe and effective treatment for your panic attacks."
- "SSRIs are a better option for the long-term management of your panic disorder."
- "Psychotherapy can help you cope with feelings of panic."
- "Marijuana may be causing your anxiety or making it worse. Let’s talk more about your use."
4. "Marijuana may be causing your anxiety or making it worse. Let’s talk more about your use."
Some substances, such as marijuana, may cause symptoms of anxiety and panic. A timeline of psychiatric symptoms and substance use is needed to differentiate psychiatric disorders from substance-induced symptoms.
A 51-year-old newly established female patient has changed providers three times in the past year due to feelings that her medical care is inadequate. She has been in to see the family nurse practitioner twice in the past month. At each visit, she shares that she has spent long hours researching her health concerns and is very anxious about her undiagnosed illness, despite reassurances from the FNP that her medical workup is normal. The FNP does which of the following?
- Schedules regular, noninvasive visits
- Schedules the patient with a specialist for further evaluation
- Begins antidepressant medication
- Encourages the patient to limit stressful daily activities
1. Schedules regular, noninvasive visits
The patient is experiencing Somatic Symptom Disorder, characterized by disproportionate or excessive health anxiety and body vigilance that continues for 6 or more months. Treatment should include regular noninvasive medical assessments, acceptance of physical symptoms rather than a goal of symptom resolution, and encouraging the patient to remain active and limit the effect of the target symptom on daily functioning.
A family nurse practitioner prescribes Imitrex to a 39-year-old female patient with a history of migraines who is also taking Cymbalta 60 mg daily for anxiety. After taking the first dosage of Imitrex, the patient returns for a same-day visit and reports that she is shivering, has diarrhea, and muscle aches. She is afebrile and her heart rate is normal. The nurse practitioner:
- Suspects a panic attack and advises the patient to continue her medications.
- Suspects Serotonin Syndrome and discontinues the Imitrex.
- Suspects Serotonin Syndrome and discontinues the Cymbalta.
- Advises the patient to go to the emergency department for cardiovascular assessment.
2. Suspects Serotonin Syndrome and discontinues the Imitrex.
Serotonin Syndrome is a serious adverse drug reaction caused by medications with direct and indirect serotonergic effects. Mild cases are typically self-limiting and respond to discontinuation of the offending agent. However, in the case of severe symptoms, including fever, irregular heart rate, and/or seizures, the patient may require hospitalization and supportive care to prevent life-threatening complications.
Elderly adults are at increased risk from impaired cognition and falls due to which of the following medications?
Elder adults are at increased risk of adverse effects, including cognitive impairment, from benzodiazepines.
During a well-child visit, the mother of a 17-month-old shares concerns that her daughter is not yet pointing to objects to ask for what she wants and is very difficult to comfort. The family nurse practitioner takes which of the following as the next step?
- Assures the mother that this is typical for a child of her age
- Administers the M-CHAT
- Administers the ASQ
- Schedules a visit in 6 months to see if the child has improved communication
2. Administers the M-CHAT
Early signs of Autistic Disorder may include deficits and social and communication skills, including not being comforted by others and not pointing or responding to pointing. The M-CHAT may be utilized for toddlers aged 16–30 months. While the FNP may call the child back in 6 months, early intervention is of primary importance and a referral is indicated if a child scores high on developmental screening.
A 12-year-old male who has been diagnosed with Autistic Spectrum Disorder comes to see the family nurse practitioner because he is experiencing increased anxiety since beginning middle school. Previously, he liked school and was earning average grades. He is in a general education classroom with a good support system for social skills and transitions. The FNP finds that his heightened anxiety impacts his functioning in which of the following ways?
- He has started hitting his classmates.
- He refuses to go to class.
- He feels hopeless about his ability to complete his assignments.
- He believes his teachers are out to get him.
2. He refuses to go to class.
Anxiety in a child with Autistic Disorder may lead to school avoidance, a drop in grades, or increased social isolation.
A 42-year-old nonverbal male with Autism Spectrum Disorder who lives in adult foster care presents with symptoms of increased aggression following recent changes in staffing at the home. Despite modifications to his behavior plan, for the past two months he has been hitting other residents and staff members. He is at risk of losing his placement. The family nurse practitioner initiates which of the following?
- Risperdal 0.5 mg
- Prozac 40 mg
- Clonzepam 1 mg
- Haldol 5 mg
1. Risperdal 0.5 mg
Risperdal is FDA-approved for the treatment of irritability, including aggression, self-injurious behavior, and temper tantrums, in both adults and children with Autistic Disorder.
A 7-year-old female comes in to see the family nurse practitioner because she is having problems in school. Her father is concerned that she has Attention Deficit Hyperactivity Disorder because she has trouble concentrating and sitting still in class. The family nurse practitioner does what as an initial step?
- Observes and documents how the child interacts in the exam room
- Sends a validated rating scale to the teacher to obtain collateral information
- Prescribes a stimulant medication
- Refers the child to a psychiatrist for additional evaluation
1. Observes and documents how the child interacts in the exam room
A physical exam noting behavioral observations is the initial step in diagnosing ADHD. However, symptoms may not be present in a brief office visit. Further steps include a caregiver interview and obtaining caregiver and teacher rating scales, such as the Conners or Vanderbilt Rating Scales.
A 12-year-old male was recently suspended from school for having a bad attitude and deliberately annoying other students in the hallway between classes. His mother schedules an appointment to request stimulant medication so he can go back to class. The family nurse practitioner does which of the following?
- Sends a Vanderbilt ADHD Rating Scale to his teacher for collaborative information
- Provides guidance to his mother on positive and negative reinforcement of behaviors
- Refers the child and family to a behavioral therapist
- Initiates treatment with Concerta 18 mg
3. Refers the child and family to a behavioral therapist
Behavioral therapy is indicated for this child, given the degree of functional impairment related to school performance. Medication is generally not indicated for managing oppositional behaviors.
A 20-year-old college student is home for the summer and schedules an appointment to see his family nurse practitioner because he is concerned about ADHD. He was previously an A student in high school but notices that lately he is unmotivated, has trouble concentrating, and has experienced a decline in grades. The family nurse practitioner:
- Suspects depression and requests the student complete a PHQ-9.
- Suspects depression and prescribes an antidepressant.
- Suspects malingering and calls his mother.
- Suspects malingering and orders a random urine drug screen.
1. Suspects depression and requests the student complete a PHQ-9.
While a person with ADHD may have difficulty initiating work and completing tasks, a person with depression is more likely to experience decreased motivation and related functional impairment.
You are interviewing a 10-year-old female with a recent history of physical abuse. Which of the following symptoms is seen primarily in adults with PTSD but not with children?
- Sense of foreshortened future
- Unwillingness to speak about the traumatic event
- Increased startle response
1. Sense of foreshortened future
Children often do not present with a sense of foreshortened future. The developmental context of the perspective of the child is important to consider. Symptoms listed in the other choices are typical of children presenting with PTSD.
The parents of a 14-year-old child with a history of Tourette’s syndrome are asking about his prognosis? Which is the most appropriate response?
- This is a chronic disorder that you will likely experience throughout your lifetime.
- Tics typically wax and wane so you are likely to experience tics throughout your lifetime during stressful periods.
- Most commonly, tics begin to decrease in adolescence. Most people are symptom-free in adulthood, although other people will experience tics throughout their lifetime.
- Tics will improve considerably with medication that is both safe and effective.
3. Most commonly, tics begin to decrease in adolescence. Most people are symptom-free in adulthood, although other people will experience tics throughout their lifetime.
Tics typically begin to decrease in adolescence. This is important to inform both children and parents of the prognosis and that there is a chance the child will not experience tics in adulthood.
The FNP is seeing a 24-year-old patient who is requesting another prescription for hydrocodone since she lost the previous one. The FNP is concerned about potential abuse. Which of the following is an important first step in the intervention?
- Request that the patient complete a urine drug screen to test levels of opioid in the urine. Inform her that she cannot receive another prescription today.
- Explain to the patient that this is a highly addictive drug and ask if she believes she is beginning to struggle with a dependence on hydrocodone.
- Discontinue the medication and offer her an alternative therapy without abuse potential.
- Complete the CRAFFT questionnaire.
2. Explain to the patient that this is a highly addictive drug and ask if she believes she is beginning to struggle with a dependence on hydrocodone.
The therapeutic alliance is important, and exploring the issue in an honest, non-threatening context is the most effective approach. While a urine toxicology screen and follow-up regarding other potential problems with substance abuse or misuse is important, the first step is exploring the situational context with the patient.
Which of the following patients most urgently requires a follow-up suicide risk screening?
- A 30-year-old female who is grieving the loss of her father. She is diagnosed with major depressive disorder.
- A 30-year-old male who has a history of multiple psychiatric hospitalizations and who reports he has not attended work for 2 weeks and has avoided friends and family.
- A 54-year-old woman who is in the middle of a divorce and involved in an intense custody battle. She is experiencing intense rage at her children’s father.
- A 20-year-old male with a history of substance abuse who reports sleep disturbances after beginning sobriety 30 days ago.
2. A 30-year-old male who has a history of multiple psychiatric hospitalizations and who reports he has not attended work for 2 weeks and has avoided friends and family.
Both social isolation and past psychiatric hospitalization is a warning sign of suicide risk. While the other patients warrant additional assessment in the context of safety and suicide risk, the clinical scenario of choice B is most worrisome.
The nurse practitioner who is employed at the VA hospital is seeing a 24-year-old male returning from overseas who reports intense nightmares. He is afraid to sleep at night and feels he is functioning poorly both at home and at work. Which of the following is the most appropriate response by the nurse practitioner?
- "I would like to recommend sertraline for your symptoms. Sleep should improve as your symptoms improve."
- "I would like to recommend Ativan for sleep since it is a fast-acting medication."
- "I would like to refer you to a therapist to help you with your symptoms. In the meantime, I would like to start prazosin to improve sleep and decrease nightmares."
- "Cognitive Behavioral Therapy (CBT) is the best treatment for the symptoms you are describing. I would like to refer you to a therapist."
3. "I would like to refer you to a therapist to help you with your symptoms. In the meantime, I would like to start prazosin to improve sleep and decrease nightmares."
Referring to a therapist is important given that the patient will need ongoing follow-up care. However, initiating prazosin is the best choice given the patient’s report of debilitating nightmares. Sertraline is prescribed for PTSD, but a thorough assessment of PTSD symptoms is warranted before sertraline should be initiated. Ativan is highly addictive and not the best choice for this clinical situation.