Which of the following patients is most appropriate for treatment with sertraline?
- A pregnant female who was treated several years ago with an SSRI for depression
- A woman breast-feeding her infant who is reporting sleeplessness and difficulty finding time to socialize since the birth of her baby
- A woman with a history of depression who reports poor attachment to the infant and feeling overwhelmed and helpless most of the time
- A woman presenting with severe mood lability that has increased since the birth of her baby
3. A woman with a history of depression who reports poor attachment to the infant and feeling overwhelmed and helpless most of the time
The risk of depression is high in this scenario and the consequences of untreated depression in this context carry serious risks for both mother and child. "A woman presenting with severe mood lability that has increased since the birth of her baby" is incorrect because "mood lability" warrants a more comprehensive investigation into the symptoms, and an antidepressant might not be the appropriate medication. Sleep disruption and changes in sociality are typical for mothers with newborns.
The NP is working with a 45-year-old patient with a 3-year history of heroin and cocaine dependence who expresses readiness to begin opioid substation therapy. He has an extensive legal history involving drug trafficking. The patient asks for advice on which opioid substitution therapy "is better." Which is the most appropriate response?
- "Buprenorphine is more dangerous during the induction phase, so methadone is a better choice."
- "Methadone is administered at the clinic daily and is more effective when someone is experiencing dependence to both heroin and cocaine."
- "Each has its own risks and benefits. Methadone is more stigmatized, so buprenorphine is a better choice."
- "Either way, because of your history of trafficking, you will have to be monitored closely with weekly urine drug screens."
2. "Methadone is administered at the clinic daily and is more effective when someone is experiencing dependence to both heroin and cocaine."
This answer empowers the patient with knowledge to make the best choice for her/himself. A patient with a legal history might be required to comply with a urine drug screen, but this would not be a therapeutic response.
A patient treated with clozapine would need to be aware of which fact?
- Clozapine requires laboratory monitoring in the beginning of treatment because of the potential risk of agranulocytosis.
- Clozapine requires blood work monthly for the potential risk of agranulocytosis.
- Clozapine requires blood monitoring if the patient has a family history significant for heart disease due to the potential risk of myocarditis.
- Clozapine requires blood monitoring weekly during the first 6 months of treatment, biweekly for the following 6 months, and then once a month for the entire duration of therapy.
4. Clozapine requires blood monitoring weekly during the first 6 months of treatment, biweekly for the following 6 months, and then once a month for the entire duration of therapy.
This is the FDA requirement for patients prescribed clozapine.
The NP has a 30-year-old patient with elevated prolactin levels who is receiving risperidone for schizophrenia. What action should the NP take?
- Continue therapy if patient is tolerating medication with no reported side effects and continue to monitor both prolactin levels and potential adverse effects.
- Discontinue therapy given the potential risks for hyperprolactinemia.
- Immediately lower the dose of risperidone.
- Risperidone is the only atypical antipsychotic that does not require monitoring prolactin levels.
1. Continue therapy if patient is tolerating medication with no reported side effects and continue to monitor both prolactin levels and potential adverse effects.
Elevated prolactin levels are common with risperidone. Monitoring for side effects is important, but elevated levels alone do not necessarily require discontinuing.
Which of the following patients presenting with psychosis would warrant further screening for schizophrenia?
- A 19-year-old male presenting with grossly disorganized speech, flat affect, and who appears suddenly suspicious of family and friends.
- A 20-year-old male with a history of severe mood disturbances, presenting with rapid speech and grandiosity, telling the office personnel that he has been appointed to solve the country’s immigration problem.
- A 44-year-old female who is suspicious that her coworkers are trying to sabotage her employment after discovering a hand-written note in her employer’s office.
- A 35-year-old male with treatment-resistant depression who has begun to experience auditory hallucinations.
1. A 19-year-old male presenting with grossly disorganized speech, flat affect, and who appears suddenly suspicious of family and friends.
This patient is presenting with both positive and negative symptoms typical of schizophrenia. The 20 year old male with rapid speech and grandiosity more accurately reflects a patient experiencing a manic episode of bipolar. A 44-year-old female who is suspicious that her coworkers are trying to sabotage her requires further investigation but does not necessarily reflect paranoid ideation. A 35-year-old male with treatment-resistant depression requires further follow-up, but because psychosis is a symptom of severe depression, depression with psychotic features is more likely.
Which information is accurate regarding screening for intimate personal violence (IPV)?
- Typically, IPV occurs in heterosexual relationships.
- Poverty is stressful, so providers should monitor for IPV more carefully when working with low-income families.
- IPV occurs in all ages and ethnicities, without regard to socioeconomic status.
- IPV is particularly problematic in same-sex relationships.
3. IPV occurs in all ages and ethnicities, without regard to socioeconomic status.
IPV occurs in all ages and ethnicities, without regard to socioeconomic status. IPV is present in all ages, sexual orientation, and ethnicities.
The NP is seeing a 23-year-old female with Borderline Personality Disorder who reports that she wishes she were dead because her boyfriend just ended a short but intense relationship with her. What is the most appropriate response?
- Perform a careful risk assessment even if it appears that she is trying to gain attention and has no plan or intention to harm herself.
- Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder. Validate her feelings and screen her carefully for intention, plan, and other self-injurious behavior.
- Acknowledge her feelings but give little attention to her "acting out" and suicidal threats.
- Inform her family of her threats so she can be monitored at home. Give emergency numbers in case suicidality increases.
2. Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder. Validate her feelings and screen her carefully for intention, plan, and other self-injurious behavior.
Recognize that suicidal ideation and impulsivity are very common in patients diagnosed with Borderline Personality Disorder is the most appropriate therapeutic response. It is important to validate the patient’s feelings while also screening for suicidality. The choices that assume that the patient is not at risk is a potentially false assumption. Informing her family is important, but only after responding therapeutically to the patient and then assessing for risk.
Which of the following laboratory tests is NOT required when a patient is receiving therapy with an atypical antipsychotic?
- Oral glucose tolerance test
- Hepatic panel
2. Oral glucose tolerance test
Monitoring glucose is required, but an oral glucose tolerance test is not specifically indicated.
A 30-year-old female reports that she enjoys a "couple of drinks" when she goes out with friends. This occurs 3 or 4 times a week. She states that she has missed work a few times due to hangovers and her girlfriend ended their relationship because she didn’t like her "partying so much." What is the most appropriate action by the nurse practitioner?
- Explain to her that this behavior is considered at-risk drinking because she is above the recommended limit for alcohol intake for females.
- Realize that she has to recognize harmful drinking on her own.
- Ask her whether she believes the drinking is getting in the way of her job and relationships. Explain to her what harmful drinking means. Perform the CRAFFT and CAGE questionnaire. Screen for other potential substance abuse.
- Refer her for substance abuse treatment.
3. Ask her whether she believes the drinking is getting in the way of her job and relationships. Explain to her what harmful drinking means. Perform the CRAFFT and CAGE questionnaire. Screen for other potential substance abuse.
Assessing where the patient is regarding at-risk substance abuse behavior is important. The first step should be an honest, non-threatening conversation, and then an assessment to determine the risk of substance abuse or misuse.
A patient presents for his follow-up appointment. He has a stable job as a software programmer and is well groomed with proper hygiene with no symptoms of psychosis. The patient reports that he is suspicious that the office staff has been reading his medical chart. You ask him why he believes this and he responds with, "The HIPAA Confidentiality stuff is just a smoke screen for the government to know our business." When the nurse practitioner attempts to refute this, he becomes angry and hostile. The nurse practitioner would screen for which of the following personality disorders?
- Paranoid Personality Disorder
- Social Anxiety Disorder
- Schizoid Personality Disorder
1. Paranoid Personality Disorder
This patient is presenting with signs of paranoid personality disorder, including suspicion, anger, and hostility.
The "SAL" for suicide risk assessment screens for which three important domains?
- Safety, Access, and Lethality
- Security, Accessibility, and Lethality
- Specificity, Accessibility, and Legitimacy
- Specificity, Availability, and Lethality
4. Specificity, Availability, and Lethality
This is the only correct choice for utilizing the SAL acronym for suicide risk assessment.
Which of the following is the most appropriate action to take for a 21-year-old female with a history of overdoses?
- Do not prescribe any medication until safety is established.
- Refer to visiting nurse services so medication can be administered directly by home health care staff.
- Prescribe only a 7-day supply of medication.
- Avoid medication that is the most lethal in overdose.
3. Prescribe only a 7-day supply of medication.
A 7-day supply and asking the patient to return in one week is safer than prescribing an entire month’s supply of medication. Not prescribing any medication is incorrect because medication may be indicated, and discontinuing prescriptions is potentially harmful. Refering to home health care staff is possible but not always feasible. Avoiding medication that is the most lethal in an overdose is an important guideline to guide prescription management, but not always possible given the individual complexities of a patient’s treatment needs.
The NP at the VA is treating a 24-year-old male recently deployed to the Middle East who returned home last month. Which of the following should the nurse practitioner prioritize?
- Validating patient’s feelings and experiences
- Sleep quality and content and startle response
- Risk of hypertension and DM Type II
- Infectious disease
2. Sleep quality and content and startle response
Poor sleep, nightmares, and an exaggerated startle response are common symptoms of PTSD. Although it is always important to validate patients’ feelings and experiences, this is patient is at high risk for PTSD and should be screened appropriately.
A 13-year-old female presents to the NP’s office and reports she has been "hearing voices." The NP screens for psychosis. Which of the following descriptions of the "voice" would most concern the treating nurse practitioner?
- "It’s like a voice telling me that I am ugly and stupid."
- "I hear it a lot. It sounds like a whisper, but then it tells me that I should hurt people."
- "I only hear the voice when I’m really sad but it sounds like my mom’s voice trying to cheer me up."
- "It’s the "inner voice" that helps me do the right thing."
2. "I hear it a lot. It sounds like a whisper, but then it tells me that I should hurt people."
Auditory hallucinations that are commanding in nature and involve voices instructing the person to harm oneself or another are most concerning and require further assessment and management.
The NP is seeing a 14-year-old male with recent onset of both motor and vocal tics who is requesting a medication to "make the tics go away." What is the most appropriate response?
- "I can see that the tics are really bothering you. The best thing we can do is start a form of therapy known as "habit reversal therapy." If that doesn’t work, then we can try a medication."
- "I can see that the tics are really bothering you. Let’s try a therapy known as Habit Reversal Therapy and a medication called risperidone, which will help decrease the tics."
- "I know the tics are bothering you, but there is a really good chance they will go away on their own and we won’t need medication."
- "Tics are not really a big problem. You can learn how to control it."
1. "I can see that the tics are really bothering you. The best thing we can do is start a form of therapy known as "habit reversal therapy." If that doesn’t work, then we can try a medication."
Habit Reversal Therapy (HRT) is first-line therapy. If this fails to result in adequate progress, medication can be considered. Concomitant therapy is appropriate only after HRT has failed to produce an adequate response. Saying the tics will go away is innappropriate if the patient finds the tics distressing. Saying the tics are not a big problem is invalidating of the patient’s feelings and therefore not appropriate.
The NP is treating a patient with a diagnosis of ADHD who reports he is doing well in school but is experiencing poor attention in the afternoon. This has become increasingly problematic since his schoolwork consists of several hours of homework each night. He is currently prescribed Concerta 36 mg. Which is the next best step?
- Suggest an increase in Concerta.
- Suggest stopping Concerta and beginning an alternative long-acting stimulant.
- Add methylphenidate 5 mg at 3 pm.
- Add a second dose of Concerta at noon.
3. Add methylphenidate 5 mg at 3 pm.
Add methylphenidate 5 mg at 3 pm is correct because the attention problems are occurring during a time when the Concerta is unlikely to have therapeutic effects. Since many children take their morning stimulant early in the day, rebound inattention can occur at the end of the day when homework assignments pose a challenge. Increasing the Concerta is not necessary since the patient is reportedly doing well in school. Administering a second dose of Concerta at noon is also incorrect.
Which of the following medications should be avoided when treating a patient with a diagnosis of ADHD and a history of opiate abuse?
The potential for abuse with Adderall and other stimulants is high and should be avoided when possible for patients who have a history of substance abuse or misuse. Lorazepam, Percocet, and Lexapro are not medications used to treat ADHD.
The NP initiates Lamictal for a patient. Which of the following is critical information that should be shared with the patient?
- "We have to monitor routine blood levels for this medication."
- "This medication has to be titrated slowly because it can cause agranulocytosis."
- "This medication has to be titrated slowly and you should monitor for signs of a rash."
- "This medication can cause infertility."
3. "This medication has to be titrated slowly and you should monitor for signs of a rash."
Lamotrigine (Lamictal) has been known to cause Stevens–Johnson syndrome, a serious and potentially fatal rash. Lamotrigine does not cause agranulocytosis or infertility. In general, no laboratory monitoring is required.
A patient presents with confusion and is complaining of "muscles feeling weird." Which of the following is the most likely cause?
- Patient recently started on valproic acid.
- Patient recently increased dosage of haloperidol.
- Patient recently discontinued lithium.
- Patient recently began methylphenidate for ADHD.
2. Patient recently increased dosage of haloperidol.
Neuroleptic Malignant Syndrome (NMS) is characterized by confusion, fever, muscle rigidity, and autonomic instability. This is a dangerous potential side effect of haloperidol. Neither valproic acid, lithium, nor adderall are known to cause NMS.
Which of the following classes of medications would the nurse practitioner avoid if a patient makes the following statement: "I’ll take the pills as long as it doesn’t interfere with my life too much. I’m not great at following rules."
- Second-generation antipsychotics
MAOIs require that patients avoid foods high in tyramine. This includes some cheeses, meats, and soy-based products. Failure to avoid these guidelines can result in a hypertensive crisis.