CHAPTER 19- Mental Health in Primary Care

Question 1

Which of the following patients is not appropriate for management in the primary care setting?

1. A 27-year-old female with new onset depressive symptoms and a scheduled psychiatric intake in 6 weeks
2. A 27-year-old male with new onset inattentive symptoms and no history of psychiatric evaluation
3. A 32-year-old female who is acutely manic and suicidal and currently has no psychiatric provider
4. A 32-year-old male who has been psychiatrically stable on lithium for a year

Answer 1

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.

Question 2

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?

1. Bipolar Disorder
2. Schizophrenia
3. Major Depressive Disorder
4. Generalized Anxiety Disorder

Answer 2

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.

Question 3

According to the National Institute of Mental Health, half of all mental illness begins by which age?

1. 8 years old
2. 14 years old
3. 24 years old
4. 32 years old

Answer 3

2. 14 years old

Fifty percent of all mental illness begins by age 14.

Question 4

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?

1. Major Depressive Disorder
2. Alzheimer’s disease
3. Major Neurocognitive Disorder
4. Complications of diabetes

Answer 4

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.

Question 5

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?

1. Borderline Personality Disorder
2. Major Depressive Disorder
3. Persistent Depressive Disorder
4. Bipolar Disorder

Answer 5

3. Persistent Depressive Disorder

The symptoms of persistent depressive disorder occur for at least two years, with no more than 2 months without symptoms.

Question 6

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?

1. Increases the dosage
2. Advises switching to a different medication
3. Considers augmenting with another agent
4. Refers to a psychiatric provider

Answer 6

1. Increases the dosage

The next step would be to increase the dosage until full response.

Question 7

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?

1. “Side effects are common but often go away in a couple of weeks.”
2. “Successful treatment often involves a dose adjustment.”
3. “Patients typically show improvement in the first week, so it is time to consider a switch.”
4. “Do not stop taking the medication without calling me.”

Answer 7

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.

Question 8

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?

1. Sleep disturbance
2. Serotonin Syndrome
3. Increased risk of bleeding
4. Akathesia

Answer 8

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.

Question 9

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?

1. The patient should stop this medication because it can cause withdrawal symptoms in the baby.
2. The patient should switch to a tricyclic antidepressant that has lower risk to the baby.
3. This medication is relatively safe and the amount of the drug to the nursing infant is low.
4. The patient should stop the medication and begin psychotherapy instead.

Answer 9

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.

Question 10

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?

1. Decreases the medication to prevent toxicity
2. Discontinues the medication to prevent toxicity
3. Maintains the current dosage because the plasma level is within range
4. Maintains the current dosage because the benefit outweighs the risk

Answer 10

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.

Question 11

The family nurse practitioner orders all but the following lab work for an annual follow-up visit of her patient on lithium treatment.

1. Thyroid function tests
2. Urine creatinine
3. Urine specific gravity
4. Lipid panel

Answer 11

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.

Question 12

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?

1. Continues the current dosage of escitalopram
2. Decreases the dosage of escitalopram
3. Advises the new mom that she is responding to oxytocin and should pace herself as hormone levels readjust
4. Suspects Bipolar Disorder and discontinues the medication

Answer 12

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.

Question 13

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?

1. Generalized Anxiety Disorder
2. Social Anxiety Disorder
3. Attention Deficit Hyperactivity Disorder
4. Antisocial Personality Disorder

Answer 13

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.

Question 14

Which nonpharmacologic modality is most recommended for the treatment of Generalized Anxiety Disorder?

1. Psychoanalytic Therapy
2. Prolonged Exposure Therapy
3. Cognitive Behavioral Therapy
4. Social Rhythm Therapy

Answer 14

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.

Question 15

Which of the following stress-relieving activities would be difficult for a patient with agoraphobia?

1. Listening to relaxing music
2. Going to a friend’s house
3. Deep breathing
4. Caring for a pet

Answer 15

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.

Question 16

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?

1. “Ativan is a safe and effective treatment for your panic attacks.”
2. “SSRIs are a better option for the long-term management of your panic disorder.”
3. “Psychotherapy can help you cope with feelings of panic.”
4. “Marijuana may be causing your anxiety or making it worse. Let’s talk more about your use.”

Answer 16

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.

Question 17

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?

1. Schedules regular, noninvasive visits
2. Schedules the patient with a specialist for further evaluation
3. Begins antidepressant medication
4. Encourages the patient to limit stressful daily activities

Answer 17

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.

Question 18

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:

1. Suspects a panic attack and advises the patient to continue her medications.
2. Suspects Serotonin Syndrome and discontinues the Imitrex.
3. Suspects Serotonin Syndrome and discontinues the Cymbalta.
4. Advises the patient to go to the emergency department for cardiovascular assessment.

Answer 18

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.

Question 19

Elderly adults are at increased risk from impaired cognition and falls due to which of the following medications?

1. Fluoxetine
2. Duloxetine
3. Lorazepam
4. Buspirone

Answer 19

3. Lorazepam

Elder adults are at increased risk of adverse effects, including cognitive impairment, from benzodiazepines.

Question 20

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?

1. Assures the mother that this is typical for a child of her age
2. Administers the M-CHAT
3. Administers the ASQ
4. Schedules a visit in 6 months to see if the child has improved communication

Answer 20

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.

Question 21

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?

1. He has started hitting his classmates.
2. He refuses to go to class.
3. He feels hopeless about his ability to complete his assignments.
4. He believes his teachers are out to get him.

Answer 21

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.

Question 22

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?

1. Risperdal 0.5 mg
2. Prozac 40 mg
3. Clonzepam 1 mg
4. Haldol 5 mg

Answer 22

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.

Question 23

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?

1. Observes and documents how the child interacts in the exam room
2. Sends a validated rating scale to the teacher to obtain collateral information
3. Prescribes a stimulant medication
4. Refers the child to a psychiatrist for additional evaluation

Answer 23

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.

Question 24

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?

1. Sends a Vanderbilt ADHD Rating Scale to his teacher for collaborative information
2. Provides guidance to his mother on positive and negative reinforcement of behaviors
3. Refers the child and family to a behavioral therapist
4. Initiates treatment with Concerta 18 mg

Answer 24

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.

Question 25

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:

1. Suspects depression and requests the student complete a PHQ-9.
2. Suspects depression and prescribes an antidepressant.
3. Suspects malingering and calls his mother.
4. Suspects malingering and orders a random urine drug screen.

Answer 25

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.

Question 26

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?

1. Sense of foreshortened future
2. Unwillingness to speak about the traumatic event
3. Nightmares
4. Increased startle response

Answer 26

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.

Question 27

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?

1. This is a chronic disorder that you will likely experience throughout your lifetime.
2. Tics typically wax and wane so you are likely to experience tics throughout your lifetime during stressful periods.
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.
4. Tics will improve considerably with medication that is both safe and effective.

Answer 27

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.

Question 28

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?

1. 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.
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.
3. Discontinue the medication and offer her an alternative therapy without abuse potential.
4. Complete the CRAFFT questionnaire.

Answer 28

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.

Question 29

Which of the following patients most urgently requires a follow-up suicide risk screening?

1. A 30-year-old female who is grieving the loss of her father. She is diagnosed with major depressive disorder.
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.
3. 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.
4. A 20-year-old male with a history of substance abuse who reports sleep disturbances after beginning sobriety 30 days ago.

Answer 29

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.

Question 30

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?

1. “I would like to recommend sertraline for your symptoms. Sleep should improve as your symptoms improve.”
2. “I would like to recommend Ativan for sleep since it is a fast-acting medication.”
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.”
4. “Cognitive Behavioral Therapy (CBT) is the best treatment for the symptoms you are describing. I would like to refer you to a therapist.”

Answer 30

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.

Question 31

Which of the following patients is most appropriate for treatment with sertraline?

1. A pregnant female who was treated several years ago with an SSRI for depression
2. A woman breast-feeding her infant who is reporting sleeplessness and difficulty finding time to socialize 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
4. A woman presenting with severe mood lability that has increased since the birth of her baby

Answer 31

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.

Question 32

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?

1. “Buprenorphine is more dangerous during the induction phase, so methadone is a better choice.”
2. “Methadone is administered at the clinic daily and is more effective when someone is experiencing dependence to both heroin and cocaine.”
3. “Each has its own risks and benefits. Methadone is more stigmatized, so buprenorphine is a better choice.”
4. “Either way, because of your history of trafficking, you will have to be monitored closely with weekly urine drug screens.”

Answer 32

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.

Question 33

A patient treated with clozapine would need to be aware of which fact?

1. Clozapine requires laboratory monitoring in the beginning of treatment because of the potential risk of agranulocytosis.
2. Clozapine requires blood work monthly for the potential risk of agranulocytosis.
3. Clozapine requires blood monitoring if the patient has a family history significant for heart disease due to the potential risk of myocarditis.
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.

Answer 33

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.

Question 34

The NP has a 30-year-old patient with elevated prolactin levels who is receiving risperidone for schizophrenia. What action should the NP take?

1. Continue therapy if patient is tolerating medication with no reported side effects and continue to monitor both prolactin levels and potential adverse effects.
2. Discontinue therapy given the potential risks for hyperprolactinemia.
3. Immediately lower the dose of risperidone.
4. Risperidone is the only atypical antipsychotic that does not require monitoring prolactin levels.

Answer 34

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.

Question 35

Which of the following patients presenting with psychosis would warrant further screening for schizophrenia?

1. A 19-year-old male presenting with grossly disorganized speech, flat affect, and who appears suddenly suspicious of family and friends.
2. 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.
3. 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.
4. A 35-year-old male with treatment-resistant depression who has begun to experience auditory hallucinations.

Answer 35

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.

Question 36

Which information is accurate regarding screening for intimate personal violence (IPV)?

1. Typically, IPV occurs in heterosexual relationships.
2. Poverty is stressful, so providers should monitor for IPV more carefully when working with low-income families.
3. IPV occurs in all ages and ethnicities, without regard to socioeconomic status.
4. IPV is particularly problematic in same-sex relationships.

Answer 36

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.

Question 37

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?

1. 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.
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.
3. Acknowledge her feelings but give little attention to her “acting out” and suicidal threats.
4. Inform her family of her threats so she can be monitored at home. Give emergency numbers in case suicidality increases.

Answer 37

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.

Question 38

Which of the following laboratory tests is NOT required when a patient is receiving therapy with an atypical antipsychotic?

1. Prolactin
2. Oral glucose tolerance test
3. Hepatic panel
4. Weight

Answer 38

2. Oral glucose tolerance test

Monitoring glucose is required, but an oral glucose tolerance test is not specifically indicated.

Question 39

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?

1. Explain to her that this behavior is considered at-risk drinking because she is above the recommended limit for alcohol intake for females.
2. Realize that she has to recognize harmful drinking on her own.
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.
4. Refer her for substance abuse treatment.

Answer 39

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.

Question 40

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?

1. Paranoid Personality Disorder
2. Social Anxiety Disorder
3. Schizophrenia
4. Schizoid Personality Disorder

Answer 40

1. Paranoid Personality Disorder

This patient is presenting with signs of paranoid personality disorder, including suspicion, anger, and hostility.

Question 41

The “SAL” for suicide risk assessment screens for which three important domains?

1. Safety, Access, and Lethality
2. Security, Accessibility, and Lethality
3. Specificity, Accessibility, and Legitimacy
4. Specificity, Availability, and Lethality

Answer 41

4. Specificity, Availability, and Lethality

This is the only correct choice for utilizing the SAL acronym for suicide risk assessment.

Question 42

Which of the following is the most appropriate action to take for a 21-year-old female with a history of overdoses?

1. Do not prescribe any medication until safety is established.
2. Refer to visiting nurse services so medication can be administered directly by home health care staff.
3. Prescribe only a 7-day supply of medication.
4. Avoid medication that is the most lethal in overdose.

Answer 42

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.

Question 43

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?

1. Validating patient’s feelings and experiences
2. Sleep quality and content and startle response
3. Risk of hypertension and DM Type II
4. Infectious disease

Answer 43

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.

Question 44

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?

1. “It’s like a voice telling me that I am ugly and stupid.”
2. “I hear it a lot. It sounds like a whisper, but then it tells me that I should hurt people.”
3. “I only hear the voice when I’m really sad but it sounds like my mom’s voice trying to cheer me up.”
4. “It’s the “inner voice” that helps me do the right thing.”

Answer 44

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.

Question 45

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?

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.”
2. “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.”
3. “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.”
4. “Tics are not really a big problem. You can learn how to control it.”

Answer 45

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.

Question 46

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?

1. Suggest an increase in Concerta.
2. Suggest stopping Concerta and beginning an alternative long-acting stimulant.
3. Add methylphenidate 5 mg at 3 pm.
4. Add a second dose of Concerta at noon.

Answer 46

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.

Question 47

Which of the following medications should be avoided when treating a patient with a diagnosis of ADHD and a history of opiate abuse?

1. Lorazepam
2. Percocet
3. Adderall
4. Lexapro

Answer 47

3. Adderall

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.

Question 48

The NP initiates Lamictal for a patient. Which of the following is critical information that should be shared with the patient?

1. “We have to monitor routine blood levels for this medication.”
2. “This medication has to be titrated slowly because it can cause agranulocytosis.”
3. “This medication has to be titrated slowly and you should monitor for signs of a rash.”
4. “This medication can cause infertility.”

Answer 48

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.

Question 49

A patient presents with confusion and is complaining of “muscles feeling weird.” Which of the following is the most likely cause?

1. Patient recently started on valproic acid.
2. Patient recently increased dosage of haloperidol.
3. Patient recently discontinued lithium.
4. Patient recently began methylphenidate for ADHD.

Answer 49

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.

Question 50

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.”

1. SNRI
2. SSRI
3. Second-generation antipsychotics
4. MAOI

Answer 50

4. MAOI

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.