Nurs Midterm Exam

NURS MIDTERM Which of the following is not a core competency of APRNs? A. Technology and information literacy B. Health delivery system C. Ethics D. Delegated practice - ANS delegated practice 7. A patient has been prescribed sertraline 50 mg daily for the past year without adverse effects and remission of symptoms. The patient has missed the last two appointments but leaves a message that he feels "fantastic!" The wife called to reschedule a follow-up appointment, saying he has been giddy lately, emotionally labile, and spending money so frivolously that their account has been overdrawn. During the appointment the patient becomes hostile and tells the PMHNP that he is a phony, and not even a real doctor, and is having an affair with his wife. The patient is uninterruptible, with pressured speech. What pharmacological change is indicated? A. Start lithium, increase sertraline B. Start valproic acid, stop sertraline C. Start valproic acid D. Stop sertraline - ANS 7. Answer B. Start valproic acid and stop sertraline. Antidepressants can precipitate or exacerbate mania in patients with bipolar disorder who are frequently misdiagnosed initially with unipolar disorder. Increasing the sertraline while starting lithium will continue to exacerbate mania symptoms. Starting valproic acid without stopping the selective serotonin reuptake inhibitor (SSRI) will delay the treatment of mania. Stopping the sertraline without starting a mood stabilizer will delay the resolution of the manic symptoms. Which of the following is characteristic of the leadership competency for APRNs? A. Participating in a community-focused program that promotes mental health and reduces the risk of mental health problems B. Evaluating the appropriate use of seclusion and restraints in caring for a mentally ill patient C. Developing an age-appropriate treatment plan D. Modifying the treatment plan based on the patient's needs - ANS Answer A. Participating in a community-focused program that promotes mental health exemplifies a leadership competency. Evaluating the appropriate use of seclusion and restraints, developing an age-appropriate treatment plan, and modifying the treatment plan based on clients' needs are clinical competencies. All of the following are characteristic of the independent practice competency except: A. Insulin during differential diagnoses B. Conducting individual and group psychotherapy C. Taking opportunities to influence health policy to reduce the stigma of mental health services D. Implementing plans to minimize complications and to promote function - ANS Answer C. Taking opportunities to influence health policy and reduce the stigma of mental health services exemplifies health policy competency. Considering differential diagnoses, conducting psychotherapy, and implementing plans to minimize comorbidity are 35 examples of practicing with full practice authority at the top of the professional license. A state's Nurse Practice Act specifies all of the following except A. Who may use the title nurse practitioner B. What a nurse practitioner can do C. Restriction of the nurse practitioner's practice D. Provide oversight for service and benefits provided to patients - ANS Answer D. The state Nurse Practice Act does not provide for oversight of services and benefits provided to patients. It does define who may use the title and the work of the nurse practitioner as well as restrict the practice of the professional. Which of the following may govern the profession of the PMHNP? A. Statutory law B. The U.S. Constitution C. Certification D. City ordinances - ANS Answer A. Statutory laws govern the practice of a profession. The U.S. Constitution, certifications, and city ordinances do not address professional practice. Which of the following factors are facilitating the growth of the PMHNP? A. Increased competition in the job market B. Overlapping scope of practice with other types of nurse practitioners C. Decreasing stigmatization D. Collaborative practice relationships with physicians - ANS Answer C. Decreasing stigmatization regarding mental health enhances the growth of the profession. Increased competition, overlapping scope of practice, and mandated collaborative practice relationships restrict the growth of the profession. Why is it necessary for insurance companies to credential PMHNPs? A. To protect the public by ensuring a minimum level of professional competence B. To define the scope of practice and practice requirements C. To ensure a professional organization certifies the person is licensed to practice D. To define the role of the nurse practitioner - ANS Answer A. The purpose of credentialing is to ensure public safety and a minimum level of professional competence; this helps reduce vicarious liability on the insurance company. Insurance companies do not define the scope of practice; they have nothing to do with professional organizations who grant certification. State governing bodies define the role of the nurse practitioner. Which of the following allows the PMHNP to practice in a state? A. Certification B. Licensure C. Credentialing D. Graduation - ANS Answer B. LICENSURE Certification allows a professional to practice their profession in a state. Certification designates successful completion of a course of study. Credentialing is a process that verifies minimum levels of professional competence to ensure public safety. Graduation is a ceremony offered by an educational institution in accordance with established criteria of completion. All of the following statements are true regarding scope of practice except: A. The scope of practice defines the nurse practitioner role and actions B. The scope of practice identifies competencies assumed to be held by all nurse practitioners in a specific role C. The scope of practice provides a way to judge the nature of the care provided D. The scope of practice varies broadly from state to state - ANS Answer C. The scope of practice defines the nurse practitioner role and actions, identifies minimal competencies held by all nurse practitioners, and varies broadly from state to state. It does not provide a way to judge the nature of care provided. All the following statements are true regarding standards of practice except: A. Standards of practice reflect professional agreement focusing on the minimum levels of acceptable performance B. Standards of practice provide a way to judge the nature of care provided C. Standards of practice identify competencies assumed to be held by all nurse practitioners (NPs) who function in a similar role D. Standards of practice can be used legally to describe a standard of care that must be met by a provider - ANS Answer C. Standards of practice reflect the professional agreement that focuses on the minimum levels of acceptable performance, a means of judging the nature of care provided, and can be used legally to describe the standard of care that must be met by a provider. It does not identify competencies held by all nurse practitioners as that is provided in the scope of practice. 15-Which of the following ethical principles deals with promoting the wellbeing of a patient? A. Justice B. Beneficence C. Nonmaleficence D. Autonomy - ANS Answer B. The principle of beneficence is that of doing good for the patient. Justice is the principle of equity. Nonmaleficence is the principle of first doing no harm. Autonomy is the principle of respecting the individual's right to self-determination. Which of the following ethical principles would conflict if the treatment team wanted to implement a therapeutic deception for the good of the patient? A. Beneficence B. Nonmaleficence C. Justice 31 D. Veracity - ANS Answer D. Veracity is the ethical principle of truthfulness and nondeception neither by omission or commission. Beneficence is the principle of doing good. Nonmaleficence is the principle of first doing no harm. Justice is the principle of equity. A patient who is refusing psychiatric treatment has their case adjudicated. The judge orders treatment over objection for the good of the patient. Which ethical principle is trumped? A. Beneficence B. Nonmaleficence C. Justice D. Autonomy - ANS Answer D. Autonomy is the principle of respecting the individual's right to self-determination. Beneficence is the principle of doing good. Nonmaleficence is the principle of first doing no harm. Justice is the principle of equity. 21A PMHNP is working with a nonprofit organization to implement a public health campaign aimed at reducing the stigma of mental illness. Which role of the PMHNP best describes this activity? A. Mentoring B. Advocacy C. Policy making D. Case management - ANS ADVOCACY The PMHNP is working with an insurance organization to provide oversight and authorization of series and benefits to patients. Which role of the PMHNP best describes this activity? A. Mentoring B. Advocacy C. Policy making D. Case management - ANS CASE MANAGEMENT 30. A new graduate PMHNP is considering a job at a psychiatric ED. The medical director informs the prospective hire that they are expected to evaluate and treat children, adolescents, adults, and geriatric patients. What document should be consulted to determine if the PMHNP can legally treat psychiatric patients across the life span? A. The state Nurse Practice Act B. The hospital bylaws C. The PMHNP scope of practice D. The PMHNP can treat any patient because there is a collaborating physician - ANS Answer A. A state Nurse Practice Act describes what is permissible and impermissible for a PMHNP to do. The hospital bylaws govern the local organization and can be more restrictive, but not more lenient than state laws. The scope of practice identifies competencies unique to the subspecialty. The PMHNP is an independently licensed individual who bears liability for errors of omission and commission regardless of the collaborative agreement. The collaborative agreement cannot supersede state law. A systematic inquiry that elaborates on the chief complaint while eliciting pertinent positive and pertinent negative factors from the history is known as: A. The mental status exam B. Review of systems C. Physical exam D. Diagnostic formulation - ANS Answer B. The review of systems describes the systematic inquiry that elaborates on the chief complaint and elicits pertinent positive and pertinent negative factors from the health history. The mental status exam is a neuropsychological test used to classify observations associated with a psychiatric disorder. The physical exam is an organized approach to gather objective data from the patient's body regions and organ systems. The diagnostic formulation is an articulate summary of biopsychosocial findings that account for the patient's chief complaint. The mental status exam includes all of the following except: A. Appearance and behavior B. Mood and affect C. Cranial nerves and reflexes D. Insight and judgment - ANS Answer C. Cranial nerves and reflexes are complements of the physical exam. The mental status exam includes assessments of appearance, behavior, mood, affect, insight, and judgment. A 72-year-old female presents to the emergency department for altered mental status. Her urine analysis is negative, and her labs are normal. She has been referred to psychiatry for dementia. The patient's husband reports increasing forgetfulness over the last 6 months, walking as if her feet are stuck to the ground, and most recently episodes of urinary incontinence. Based on the signs and symptoms which of the following diagnostic tests should the PMHNP order to rule out an underlying condition? A. Lumbar puncture B. Noncontrast head CT scan C. Arterial blood gas D. Electroencephalogram - ANS Answer B. A noncontrast head CT scan is helpful in excluding the diagnosis of normal pressure hydrocephalus, which presents with an abnormal (magnetic) gait, urinary incontinence, and cognitive decline. Lumbar puncture is used to diagnose infectious, autoimmune issues, and paraneoplastic syndromes associated with the nervous system. Arterial blood gases are used to measure concentrations of atmospheric gases in patients with respiratory distress. An electroencephalogram is used to measure brain wave activity in people with suspected seizure and sleep disorders The condition in which the patient is unable to discriminate between objects based on touching is known as: A. Agraphesthesia B. Choreiform C. Astereognosis D. Dysdiadochokinesia - ANS Answer C. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Dysdiadochokinesia is the inability to perform rapidly alternating hand The PMHNP is conducting a neurological examination on a patient with altered mental status. The inability to perform rapidly alternating hand movements is known as: A. Agraphesthesia B. Choreiform C. Astereognosis D. Dysdiadochokinesia - ANS Answer D. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. The PMHNP is observing a patient making repetitive and rapid jerking involuntary coordinated movements. In documenting the findings of the mental status exam, which of the following concisely describes this behavior? A. Agraphesthesia B. Choreiform C. Astereognosis D. Dysdiadochokinesia - ANS Answer B. Choreiform movements describe repetitive and rapid jerking and involuntary coordinated movements. Agraphesthesia is the inability to recognize letters or numbers drawn on the palm with a pointed object. Astereognosis is the condition in which the patient is unable to discriminate between objects based on touching. Dysdiadochokinesia is the inability to perform rapidly alternating hand movements. The PMHNP is supervising a nurse practitioner student. When presenting the case, the student notes that the patient has an inability to recognize letters or numbers drawn on the palm with a pointed object. This sign is called: A. Agraphesthesia B. Choreiform C. Astereognosis D. Dysdiadochokinesia - ANS Answer A. Agraphesthesia is the inability to recognize letters or A patient is started on lamotrigine for bipolar depression. The patient complained of a rash comprised of blistering skin and mouth sores after a dose increase. The blood work reveals normal renal and liver function. Which type of drug rash is most likely? A. DRESS syndrome B. Stevens-Johnson syndrome C. Psoriasis D. Atopic dermatitis - ANS Answer B. Stevens-Johnson syndrome is a specific, life-threatening drug rash characterized by blisters giving way to dermis and hives on the lining of any mucous membranes. In observing the appearance of the patient with depression and a history of systemic lupus erythematosus, the PMHNP notices a lesion on the neck of the patient about the size of a pencil eraser, flush with the skin, uniformly colored, with discrete borders and consistent texture. The PMHNP should: A. Refer the patient to dermatology B. Refer the patient to rheumatology C. Refer the patient to oncology D. Watch and wait - ANS Answer D. Watching and waiting is appropriate in this scenario, as long as moles are 6 mm, flush with the skin, symmetrical in size, shape, texture, and color, and have regular borders. The lesion does not have characteristics consistent with cancerous lesions or autoimmune pathology. A 35-year-old man diagnosed with bipolar disorder mentions to his PMHNP that he had felt a lump on his left testicle. He is concerned he has not had a physical exam in 10 years. What is the best action by the PMHNP? A. Perform a urogenital exam and order an ultrasound B. Explore the reason for not having had a physical in so long C. Refer him to his primary care provider D. Refer him to urology - ANS Answer B. Exploring the reasons for not having had a physical exam in 10 years will help provide the necessary information for anticipatory guidance as the patient undergoes diagnostic investigation. Urogenital exams are generally not performed by psychiatric providers. Referring the patient to his primary care provider or urology would be appropriate but without further assessment specific barriers to accessing care remain unknown. A 26-year-old female is diagnosed with psychosis not otherwise specified (NOS) and substance use disorder. Which of the following lab tests should be ordered prior to starting antipsychotic medications? A. Hemoglobin A1C, lipid profile, EKG B. Urinalysis, urine pregnancy test C. Amylase, lipase, liver function test D. Cardiac enzymes, brain naturetic peptide - ANS Answer A. Antipsychotic medications are known to accelerate the onset of type 2 diabetes mellitus and dyslipidemia, and prolong the QTc interval; baseline evaluation provides a frame of reference for ongoing treatment and monitoring. Urinalysis and a pregnancy test would not preclude or be affected by antipsychotic medications. Pancreatic and liver function tests are not known to be affected by antipsychotic medications. Cardiac enzymes and brain naturetic peptide are used to evaluate cardiac function, which can be affected by clozapine-induced myocarditis, but require clinical correlation to confirm suspicion, and should not be ordered de novo. A 57-year-old man was evaluated in the ED for altered mental status. His head CT scan is negative, white blood cells are 6,000, urinalysis negative for infection with positive ketones, serum glucose is 120 mg/dL, sodium is 148, blood urea nitrogen 22, creatinine 1.8, and cardiac enzymes are negative. Neurology has cleared him for an acute event, and the ED physician has cleared him for psychiatry. The PMHNP evaluating him obtained collateral information that the patient has been in bed for 3 days, and not eating or drinking because the voices tell him the food is bad and the water is contaminated. What should the nurse practitioner do first? A. Order 1 L normal saline at 100 mL/hr B. Order Haldol 5 mg PO × 1 C. Order a lumbar puncture D. Order hemoglobin A1C and lipid profile - ANS Answer A. The clinical history and lab findings are suggestive of dehydration, which can account for delirium; this must be excluded prior to diagnosing a psychiatric disorder. Haldol is an antipsychotic medication with sedating effects, which would cloud the diagnostic formulation. Lumbar puncture is ordered to rule out infections, and autoimmune and paraneoplastic syndromes with clinical suspicion. Hemoglobin A1C and lipid profiles are ordered at baseline before starting antipsychotic therapy for continued use A 30-year-old man with history of alcohol use disorder is being evaluated for altered mental status. He has a negative blood alcohol level, aspartate transaminase 100, alanine transaminase 90, hemoglobin 10, hematocrit 30, negative stool for occult blood, negative head CT scan. What further tests should the PMHNP order before diagnosing psychosis not otherwise specified? A. EKG B. Lipid profile C. Hemoglobin A1C D. Serum ceruloplasmin - ANS Answer D. Serum ceruloplasmin (copper-carrying protein) is decreased in most instances of Wilson's disease in which there is a decreased ability to incorporate copper into apoceruloplasmin, resulting in increased free copper in plasma, liver, and brain tissue. EKG, hemoglobin A1C, and lipid profile do not provide an explanation for the signs and symptoms presented. The Consultation Liaison PMHNP is asked to evaluate an 88-year-old woman admitted to medicine with community acquired pneumonia for capacity regarding intubation. On evaluation the patient is inattentive and easily distracted, with waxing and waning sensorium. The patient was recently started on broad spectrum IV antibiotics. What is the most likely diagnosis? A. Depression B. Dementia C. Delirium D. Psychosis - ANS Answer C. Delirium is characterized by an acute onset waxing and waning sensorium, inattentiveness, and distractibility, and can be caused by infection, new environment, and medications. Depression is a psychiatric disorder that must have symptoms present for at least 2 weeks. Dementia is a disorder characterized by chronically impaired cognition and may include changes in personality over time. Psychosis is characterized by disorganized thinking, alterations in perception of reality, and an inability to care for oneself. When evaluating a new 40-year-old, 4-week postpartum woman complaining of fatigue, irritability, dry skin, and poor sleep quality for mood disorder, which of the following diagnostic tests should be ordered to aid in formulating a diagnosis? A. Hemoglobin A1C B. EKG C. Thyroid-stimulating hormone (TSH) and free T4 D. Urine pregnancy test - ANS Answer C. TSH and free T4 can be affected in the postpartum period and cause signs and symptoms of thyroiditis, which include fatigue and irritability. Mood disorder is a diagnosis of exclusion, which can have similar symptoms to hypothyroidism. Hemoglobin A1C, EKG, and urine pregnancy tests are not indicated as they will not account for the presenting symptoms and clinical scenario. A 40-year-old man who has been on olanzapine for schizophrenia has a lipid profile indicating total cholesterol 240 mg/dL, and low-density lipoprotein (LDL) 200 mg/dL. Which of the following is recommended? A. Lifestyle modification B. Statin therapy C. Serial EKGs D. Transthoracic echocardiogram - ANS Answer B. Statin therapy is indicated for patients with LDL 70 mg/dL with diabetes, patients with known atherosclerotic heart disease (ASCVD) and high total cholesterol, patients with an LDL 190 mg/dL, and patients with diabetes between the ages of 45 to 75. A 24-year-old man has been stable on lithium 1,800 mg daily for 2 years. His most recent serum lithium level is 2.0. The patient has no signs or symptoms of toxicity. Which of the following is the best action by the PMHNP? A. Tell the patient to stop his medications immediately B. Encourage the patient to drink more water C. Repeat the lithium level and ensure it is a trough D. Send the patient to the ED - ANS Answer C. Repeat the lithium level and ensure it is a trough as the patient has not had any dosage changes and has no signs or symptoms of toxicity. Encouraging the patient to drink more water assumes the elevated level is correct. Telling the patient to stop the medication may cause his level to drop below therapeutic range and require retitration. Sending the patient to the ED is viable, but the blood draw may not be at a time when the lithium is at the trough. A 19-year-old female is evaluated in the ED for admission to an eating disorders unit and has a history of bulimia nervosa. Which of the following diagnostic tests should be ordered? A. Electrolytes and renal function B. Liver and pancreatic function C. Lipid profile and hemoglobin A1C D. Urinalysis and urine pregnancy test - ANS Answer A. Electrolytes and renal function will help determine if the patient is medically stable to be in an eating disorders unit. Liver and pancreatic function tests are not acutely affected by bulimia nervosa. Lipid profile and hemoglobin A1C is not affected acutely by bulimia nervosa. Regardless of the results of the urinalysis and pregnancy test, the patient may still be treated for the eating disorder. A 26-year-old man has been on an antipsychotic. He requires further titration for control of symptoms. Which of the following tests should be repeated? A. EKG B. Liver function test C. Urinalysis D. Head CT scan - ANS Answer A. The EKG test should be repeated, as antipsychotics are known to prolong the QTc (except for aripiprazole). Liver function tests, urinalysis, and head CT scans are not affected by antipsychotic medication titration. Which of the following is an indication for monitoring of serum drug levels? A. Smoking cessation B. New diagnosis of diabetes C. Resolution of symptoms D. New diagnosis of hyperlipidemia - ANS Answer A. Smoking cessation is an indication for monitoring serum drug levels because smoking is a known inducer of the CYP450 pathway. The purpose of a professional organization's scope and standards of practice is to: A. Define the roles and actions for that particular profession B. Define the differences between professions C. Establish the legal authority to practice for a profession D. Define the legal statutes that are governing a profession - ANS answer A. The scope and standards dictated by professional organizations define the role and actions of a particular profession. The government appoints professional boards to define the differences between professions, establish criteria for licensure, and define the legal statutes that govern a profession. Which of the following is representative of legal ruling trends over the past 30 years? A. Juries have been encouraged to find defendants not guilty because of insanity B. People with mental illness retain their inalienable rights even when committed to a mental hospital C. Courts place increased trust in the professional judgment of mental healthcare providers to make ethical decisions 236 D. The time in bringing cases before a magistrate for commitment hearings has been reduced - ANS Answer A. The person has a diagnosed mental disorder and poses harm to self or others as a result of the disorder, and treatment is likely to improve functioning. It is not sufficient for the patient to be unwilling or unable to accept the nature and severity of a mental disorder without having been diagnosed, the harm stems from the diagnosed condition, and treatment is likely to improve the condition. The patient's threat and risk level must be as a result of a diagnosed mental disorder. A history of serious mental illness that is currently untreated is insufficient for involuntary admission if they are not a threat as a result of the disorder at the present time. 8. Which of the following elements is reflective of a professional relationship rather than a social relationship? A. In a professional relationship, there is no place for social interactions B. In a professional relationship, the PMHNP is solely responsible for making the relationship work C. In a professional relationship, the primary focus is on the client and their needs D. In a professional relationship, goals are left vague so that the client feels any issue can be discussed - ANS Answer C. Professional relationships are focused exclusively on the client's needs and outcomes. Professional relationships should not include advice based on personal experience. The responsibility for the client's well-being is shared between the patient and the treatment team. The PMHNP should not exploit the therapeutic relationship for personal favors. A 45-year-old White female agreed to hospitalization after presenting to the emergency department with passive suicidal ideations. After 24 hours she states that she wishes to leave because "this place cannot help me." Which of the following actions reflects the legal right of the client? A. The patient should be discharged immediately B. The patient is discharged after she signs forms indicating her actions and acknowledging her actions are against medical advice C. Contact a collaborating physician to convert the patient to an involuntary status D. Explain that the patient cannot leave until further assessments are completed and collateral information is obtained - ANS Answer D. Explain that the patient cannot leave until further assessment and collateral information is obtained with the aim of seeing if she will agree to remain on a voluntary basis. Discharging the patient immediately without further information may increase the risk of suicide. Before the patient signs out against medical advice, further assessment is required for capacity to refuse care. Converting the patient to involuntary status requires further assessment. A 39-year-old woman has been in therapy for the last 3 months. She has shown much improvement in her functioning and has developed much insight into her illness. This week during her session you discuss service determination, and she suddenly begins to demonstrate the first symptoms that brought her into therapy initially. She is now hesitant for discharge and wants to continue services as she is displaying regressed behavior. What is the best explanation for her symptom return? A. Acute stress reaction B. Reaction formation C. A normal resistance seen in the termination time of therapy D. A sign of undiagnosed pathological attachment - ANS Answer C. Regression is a temporary defense mechanism in response to stress in order to avoid circumstances. Projection is a defense mechanism in response to a stressor in which the patient would tell the PMHNP they are ending therapy because they cannot be helped. It is common for patients to relapse with symptoms during the termination phase. 15. Which of the following is an example of a mature defense mechanism? A. Projection B. Repression C. Altruism D. Regression - ANS 5. Answer C. An example of altruism is a client who states the well-being of others is equally important as his own, and perhaps even more important in certain situations. An example of projection is a husband who has an anger problem attributing his anger to his wife, and saying she has an anger problem. An example of repression is a client who has suffered abuse and neglect as a child but has no recollection and has trouble forming relationships. An example of regression is a 22-year-old female who is chewing on a pen cap while waiting for the results of a pregnancy test. 16. A Black man in the fifth decade of life has been seen for several weeks of psychotherapy to discuss his current stressors. He proceeds to curl up in the fetal position and lie on the floor. Which defense mechanism is he manifesting? A. Repression B. Projection C. Denial D. Regression - ANS 16. Answer D. Regression is a defense mechanism where the person moves back to a previous phase of psychological development and task mastery. 18. For which of the following reasons are selective serotonin reuptake inhibitors (SSRIs) considered the first-line drug of choice for depression without psychotic features? A. Ease of dosing for step-wise titration B. Promote sleep C. Difficulty in overdosing for suicidal patients D. Drug level monitoring capabilities - ANS 8. Answer C. SSRI medications are difficult to overdose on and are among the safest psychotropic medications. SSRIs may be activating and impair sleep during periods of titration. SSRI dosing and titration are based on the therapeutic response and tolerability of side effects. SSRI drug levels are not correlated with therapeutic efficacy. 20. The following statement is reflective of which type of therapy: "If a miracle were to happen and all of your symptoms that brought you into therapy no longer existed, what would be different?" A. Cognitive behavioral therapy B. Dialectical behavioral therapy 238 C. Solution-focused therapy D. Psychoanalysis - ANS 20. Answer C. Solution focused therapy is a goal-directed collaborative approach to motivate psychotherapeutic change and is conducted through direct observation to a series of precisely constructed questions. Cognitive behavioral therapy focuses on challenging and changing cognitive distortions, behaviors, and feelings with personal coping strategies targeting a current problem. Dialectical behavioral therapy is a skill-based approach that focuses on four main areas: emotional regulation, improving distress tolerance, mindfulness, and interpersonal effectiveness. Psychoanalysis is a therapeutic approach that focuses on the interaction of the conscious and unconscious mind that is presumed to be motivating present behavior. 38. Psychotropic medications are used to treat A. Psychiatric disorders B. Psychiatric symptoms C. Neurological conditions D. Endocrine disorders - ANS 38. Answer B. Psychiatric symptoms are treated with psychotropic medications; these medications are not used to treat disorders but rather specific symptoms that are characteristic of a mental illness. Neurological conditions are discretely defined disorders that may present with psychiatric symptoms, which are sometimes managed with psychotropic agents. Endocrine disorders are discretely characterized disorders that may present with psychiatric symptoms that are treated with psychotropic medications. 45. A patient who was able to escape the World Trade Center during 9/11 is dysphoric several months after the event and tells the PMHNP that she does not want to talk about her coworkers who were lost because it hurts so much. Which defense mechanism is being utilized? A. Denial B. Suppression C. Undoing D. Projection - ANS 45. Answer B. Suppression is a mature defense mechanism characterized by a conscious decision to delay paying attention to a thought or emotion to cope with the present reality. Denial is a pathological defense mechanism characterized by a refusal to accept a fact because it is perceived as too threatening. Undoing a neurotic defense mechanism occurs is when a person tries to cancel out a threatening thought or emotion by engaging in a contrary behavior. Projection, an immature defense mechanism, occurs when ego-dystonic thoughts and desires are attributed to another person. 46. A patient who is not willing to discuss his involvement in a psychological trauma is using which of the following defense mechanisms? A. Denial B. Suppression C. Projection D. Undoing - ANS 46. Answer A. Denial is a pathological defense mechanism characterized by refusal to accept reality because it is perceived as too threatening. 47. A sole survivor from a house fire tells the PMHNP that she does not remember anything about how she got out. Which defense mechanism is being used? A. Suppression B. Denial C. Repression D. Sublimation - ANS 47. Answer C. Repression is a neurotic defense mechanism in which the person consciously expresses pleasurable emotions accompanied by unexplainable amnesia or lack of awareness of an ego-dystonic event. 48. A man finds his coworkers exceptionally difficult to work with, and he finds them generally incompetent. He does not share his thoughts with his coworkers or his boss out of fear of hurting their feelings. He suddenly has the urge to bring baked goods several times a week. Which defense mechanism is the best explanation for this behavior? A. Denial B. Suppression C. Repression D. Undoing - ANS 48. Answer D. Undoing a neurotic defense mechanism is when a person tries to cancel out a threatening thought or emotion by engaging in a contrary behavior. 49. Which of the following is a defense mechanism purpose? A. Alert to danger B. Protect the Id C. Resolve conflicts D. Suppress intuition - ANS 49. Answer C. The purpose of defense mechanisms is to resolve conflicts associated with Ego-dystonic stimuli. 50. Which of the following is the best intervention for a client experiencing ataque de nervios? A. Benzodiazepines B. Using a family member to interpret C. Involuntary admission D. Referral to supportive psychotherapy by a therapist who speaks the language - ANS 0. Answer D. Culturally competent psychotherapy is most appropriate to build a therapeutic alliance and to understand the etiology of the problem. Medications are not preferred first-line interventions. Using a family member to interpret violates the patient's confidentiality and may not provide the best insight. Involuntary admission is for patients who have a diagnosed mental illness and pose potential harm to self or others as a result of the mental illness. 51. A 15-year-old boy is being treated for attention deficit hyperactivity disorder (ADHD). He has a family history of bipolar disorder. Which of the following ADHD symptoms overlap with bipolar disorder in children and adolescents? A. Talkativeness, hyperactivity, and distractibility B. Insomnia, mood lability, distractibility C. Irritability, talkativeness, insomnia D. Sleep problems, irritability, mood swings - ANS 51. Answer A. Talkativeness, hyperactivity, and distractibility are overlapping symptoms of ADHD and bipolar disorder in children and adolescents. Avoidance behaviors, mood lability, irritability, recklessness, hypervigilance, and aggressiveness are symptoms consistent with PTSD. Disorganization, interrupting, and carelessness are primarily symptoms of ADHD. 55. Many psychotropic medications come with a black box warning, particularly for use in children and young adults. What specific education must you provide to a 22-year-old male as the PMHNP to the patient? A. Risk of increased impulsive behavior B. Risk of increased suicidal thoughts C. Risk of sexual side effects D. Risk of teratogenic sperm production - ANS 55. Answer B. Increased risk of suicidal thoughts or behaviors should be mentioned explicitly to people under 25 years of age when prescribing psychotropic medications with black box warnings. Increased impulsive behavior, sexual side effects, and dysuria are not included in black box warnings. 61. Which of the following personality disorders are classified as Cluster A? A. Paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder B. Antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder C. Avoidant personality disorder, dependent personality disorder, obsessive compulsive personality disorder D. Paranoid personality disorder, antisocial personality disorder, obsessive compulsive personality disorder, histrionic personality disorder - ANS 61. Answer A. Cluster A personality disorders are considered the odd, eccentric type and include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Cluster B personality disorders are considered the dramatic type and include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Cluster C personality disorders are considered the anxious avoidant type and include avoidant personality disorder, dependent personality disorder, and obsessive compulsive personality disorder. 67. When asking an adolescent male about his cannabis use disorder, which of the following signs or symptoms would you expect him to report? A. Enhanced motor skills B. Accelerated time passage C. Heightened sensitivity to external stimuli D. Lower heart rate - ANS 67. Answer C. Heightened sensitivity, including paradoxical anxiety, is an adverse effect associated with the use of tetrahydrocannabinol (THC). 264 Cannabis use also impairs motor skills and cognition, and decreases motivation. 74. A PMHNP is contracted to a student health clinic to work with incoming freshman and transfer students for several weeks. The PMHNP encounters a student who describes himself as shy and uncomfortable in social situations. He reports having few friends in high school and has realized that he needs a few drinks to loosen up before going out to party. Upon further questioning, it is revealed he consistently drinks two to three beers on the weekend to enhance his socialization. According to the DSM-5, does this student have a mental illness? A. Yes, mild alcohol use disorder B. No, the student does not meet the criteria for mental illness, This is a normal college kid C. Yes, adjustment disorder with mixed features D. Yes, social anxiety disorder - ANS 74. Answer B. No, the student does not meet the criteria for mental illness. Alcohol use disorder requires a maladaptive use pattern leading to significant impairment or distress associated with two other consequence criteria. Adjustment disorder requires clinically significant emotional or behavioral symptoms, not qualifying for a mood disorder. Social anxiety disorder is characterized by considerable fear or anxiety about social situations in which the individual fears scrutiny by others. 77. David is a 43-year-old veteran of Operation Iraqi Freedom. A PMHNP is currently treating him for generalized anxiety disorder and major depressive disorder. During their last visit the PMHNP learned that David had a blast injury and sustained head trauma during his tour in Iraq. At the time he was diagnosed with a traumatic brain injury. His current regimen includes fluoxetine 40 mg daily and clonazepam 1 mg twice daily. In light of this new information what are some potential adverse effects? A. Benzodiazepines cause memory problems and confusion in clients with a history of traumatic brain injury B. Benzodiazepines increase the risk of a subsequent traumatic brain injury C. Benzodiazepines are addictive, and therefore banned from the VA formulary D. Benzodiazepines lower the seizure threshold particularly in clients with traumatic brain injury - ANS 77. Answer A. Benzodiazepines cause cognitive impairment and confusion in patients with a history of traumatic brain injury and should not be used long term. Benzodiazepines do not increase the risk of subsequent traumatic brain injury, and they raise the seizure threshold 78. A 23-year-old male with schizoaffective disorder and a history of four past hospitalizations for manic episodes has been started on clozapine. During the weekly complete blood count with differential, which of the following results would necessitate discontinuing treatment? A. Absolute neutrophil count (ANC) less than 2,000 B. Leukocytes less than 5,000 C. ANC less than 1,000 D. Leukocytes less than 2,000 and ANC less than 1,200 - ANS 78. Answer C. Clozapine should be stopped in a patient with an ANC less than 1,000. Clozapine can continue as long as the ANC is greater than 1,000; prior to starting the ANC should be greater than 1,500. 82. A 59-year-old man has been seeing the PMHNP for schizophrenia. He was first diagnosed when he was 21 years old. He remains medication compliant. In getting to know the patient, it is revealed that he has very few social interactions, prefers to be alone, and has never had a romantic interest or desire to pursue one. Which type of symptoms is pervasive in this clinical presentation? A. Affective disorder B. Positive symptoms C. Negative symptoms D. Self-care deficit - ANS 82. Answer C. Negative symptoms are characterized by a pervasive loss of function and manifest as apathy, anhedonia, alogia (impoverished speech), and affect flattening. Positive signs are characterized by perceptual disturbances as a result of psychosis; they include hallucinations, delusions, and paranoid thoughts. Psychosis is defined as the inability to test reality and manifests as gross disorganization, including delusions and hallucinations. Self-care deficit is characterized by a failure to meet one's basic needs according to the first two levels of Maslow's hierarchy of needs (physiological needs and safety). 86. The PMHNP is asked to review a medical malpractice case for merit. Which elements must be present to substantiate a claim of negligence? A. Deceit, breach of standards of care, and intent to harm B. Breach of care, violation of ethics, patient abandonment C. Beneficence, nonmaleficence, veracity, breach of standards D. Duty to care, breach of a standard of care, injury related to the breach of the standard of care - ANS 86. Answer D. Negligence requires that the professional had a duty to care, there was a breech in the standard of care, and the injury was sustained due to the breech in the standard of care. Deceit and intent to harm are not elements of the negligence tort. Violation of ethics and patient abandonment are not sufficient elements to claim negligence. Ethical principles and breech of standards without duty and harm are not adequate to claim negligence. 87. According to the American Nurses Association position statement, which of the following is aimed at reducing human error and creating an open and fair environment for interprofessional equality and collaboration to promote patient safety? A. Just culture B. Personnel policies and HIV in the workplace C. Standardization of health information technology D. Civil disobedience - ANS 87. Answer A. Just culture is the American Nurses Association's (ANA) statement on promoting open and fair interprofessional collaborative relationships aimed at reducing human error. Personnel policies are institution-specific operating procedures. Standardization of health 266 information technology is a recommendation of the Department of Health and Human Services. Civil disobedience is the refusal to comply with particular laws as a peaceful form of political protest. 90. A middle-aged married man was referred to you for management of his depression. His symptoms include fatigue throughout the day, leading him to drink five to six cups of coffee daily to stay awake; this leads to him feeling too wired to sleep at night. He drinks one to two drinks every night. He has no trouble falling asleep. However, his wife kicks him due to his snoring and describes him as a restless sleeper, and he also sweats profusely every night. Which of the following is the most likely cause of his middle insomnia? A. Attention deficit disorder which he is medicating with caffeine B. Alcohol withdrawal syndrome C. Caffeine use disorder D. Obstructive sleep apnea - ANS 90. Answer D. Obstructive sleep apnea best describes these symptoms. Attention deficit hyperactivity disorder cannot be diagnosed from the symptoms presented. He does not meet the criteria for caffeine use disorder and does not have symptoms consistent with an alcohol withdrawal syndrome. 92. You are a board certified PMHNP working in a rural critical access hospital-based clinic, and you are doing medication management for a patient with bipolar 2 disorder, who has comorbid hypertension. When checking his blood pressure, you note that the client is hypertensive, and upon further questioning, the client states he has not seen his primary care provider for 9 months because he finds the cost of the visit and the medication prohibitive. The patient would like you to refill his antihypertensive medication. What is the most appropriate action? A. Call the pharmacy to confirm the medication and dosage and order a refill for 1 month until the patient can see his primary care provider B. Advise the patient to go to the emergency department if any signs and symptoms develop C. Send the patient to urgent care for evaluation and refill of the antihypertensive medication D. Call the patient's primary care provide - ANS 92. Answer D. Collaborating with the patient's primary care provider ensures that the PMHNP is not practicing outside the scope of practice. Calling in a refill for medication without providing proper care and follow-up exposes the PMHNP to negligence claims. Advising the patient to go to the ED for signs and symptoms is acceptable but does not make provision for the pressing problem. Sending the patient to urgent care contributes to the added expense, and further fragments care. 94. A physician is admitted to the hospital and requires an appendectomy. He is medically stable and would like to try conservative management with IV antibiotics. The surgeon consults psychiatry to see if the patient is competent to refuse care. Which of the following is the best response given the scope of practice of the PMHNP? A. Refer the case to a psychiatrist because this is outside the scope of practice for PMHNPs B. Complete the assessment and write an attestation to the patient's competence C. Call the consulting physician and explain that competence is a legal designation, and assess the patient for the capacity to refuse care D. Refer the case to the hospital general counsel so that the patient can have a competency designation - ANS 94. Answer C. Call the consulting physician and explain that competence is a legal designation made by a magistrate, and assess the patient for the capacity to refuse care, which is a clinical determination within the scope of practice of the PMHNP. 95. A nonprofit organization would like to develop a vaccination program, but the grant that will provide the funding requires the project leader to have a doctoral degree, and they have selected a PMHNP on the faculty at a local university to lead this project. Which prevention category are vaccination programs? A. Preventive care B. Primary prevention C. Secondary prevention D. Tertiary prevention - ANS 95. Answer B. Primary prevention focuses on preventing new disease. Secondary prevention focuses on early detection of existing illness. Tertiary prevention focuses on improving function, chronic symptoms/disease management, and reducing morbidity and mortality after the disease has occurred. Preventive care is a comprehensive approach and includes all elements of prevention. 96. A PMHNP is opening a private practice and decided to offer free screening for depression in her local church during their annual health fair. Which prevention category is testing for disease? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Preventive care - ANS 96. Answer B. Secondary prevention focuses on early detection of existing disease. Tertiary prevention focuses on improving function, chronic symptoms/disease management, and reducing morbidity and mortality after the illness has occurred. Preventive care is a comprehensive approach and includes all elements of prevention. Primary prevention focuses on preventing new disease. 97. A PMHNP would like to expand her revenue streams for her private practice. She decides to start a concierge model specifically targeting those who are recently discharged from the hospital after their first manic episode or with a diagnosis of bipolar disorder with the goal of reducing recidivism through medication compliance and administering long-acting injectable medications. This service is an example of which kind of prevention strategy? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Acute treatment - ANS 97. Answer C. Tertiary prevention focuses on improving function, chronic symptoms/disease management, and reducing morbidity and mortality after the disease has occurred. Primary prevention focuses on preventing new disease. Secondary prevention focuses on early detection of existing illness. Preventive care is a comprehensive approach and includes all elements of prevention. Primary prevention focuses on preventing new disease. 102. The PMHNP is evaluating a man who reveals that his girlfriend screams at him and has repeatedly slapped, kicked, and tripped him down the stairs. He states that she has also thrown things at him including a plate, a glass of wine, and once even hitting their 3-yearold son inadvertently. What duty does the PMHNP have concerning reporting this to child protective services? A. No duty, the child is not the patient B. Yes, the PMHNP must report C. Nothing to report because the assault on the child was inadvertent D. Safer not to notify child protective services because the violence may escalate - ANS 102. Answer B. The PMHNP is a mandated reporter. If the PMHNP believes the child is in potential harm or danger, whether due to deliberate or inadvertent reasons, the welfare of the minor must be protected. 103. When reviewing the results of the mini mental status exam of a 70- year-old woman you note that the score is 18. How should this test be interpreted? A. Severe dementia B. Mild cognitive impairment C. Moderate cognitive impairment D. Normal exam - ANS 103. Answer C. A mini mental status exam score between 10 and 18 indicates moderate cognitive impairment; a score of 9 or less indicates severe cognitive impairment a score between 19 and 23 indicates mild cognitive impairment a score above 24 indicates a normal exam. 105. What is the process by which the PMHNP identifies signs and symptoms of mental illness and develops an appropriate treatment plan? A. Psychiatric interview B. Physical examination C. Interdisciplinary treatment planning D. Neurological examination - ANS 105. Answer A. The psychiatric interview is the process by which the nurse practitioner identify signs and symptoms of mental illness. The physical exam is the process by which underlying medical conditions are excluded. Interdisciplinary treatment planning discusses the various therapy modalities for a particular condition. The neurological examination is a focused physical exam. 108. The PMHNP understands that elements of cognitive behavioral therapy (CBT) inform dialectical behavioral therapy (DBT). Which of the following are characteristic of DBT? A. Mindfulness, meditation, and emotional regulation B. Systematic desensitization, reintegration, attachment C. Harm reduction, systematic desensitization, aversion therapy D. Aversion therapy, mindfulness, systematic desensitization - ANS 108. Answer A. Mindfulness, meditation, and emotional regulation are all elements of dialectical behavioral therapy. Systematic desensitization is an element of cognitive behavioral therapy. Attachment and reintegration are elements of trauma focused therapy. Aversion therapy is an element of a relapse prevention strategy. 117. A 40-year-old man who is HIV positive has a 10-mm induration from his Mantoux test. What should the PMHNP include in her admission orders? A. Chest x-ray to rule out latent tuberculosis B. The test is negative C. Put the patient on airborne precautions D. Transfer the patient to the medical service - ANS 117. Answer A. A chest x-ray is indicated to rule out active tuberculosis in this immunocompromised patient. The 10-mm induration is considered positive in immunocompromised patients. If the patient is not actively coughing, there is no need for airborne precautions. Latent tuberculosis does not require hospitalization 120. When starting the patient on lithium for bipolar disorder, which of the following tests should be done at baseline? A. Cardiac enzymes B. Renal function C. Liver function D. Complete blood count - ANS 120. Answer B. Impaired renal function is a contraindication. Cardiac enzymes, liver function, and complete blood count are not explicitly indicated for lithium therapy. 125. Who of the following is at the lowest risk for suicide? A. A 60-year-old White man who was recently laid off B. A 25-year-old male with bipolar disorder and substance use disorder C. A 45-year-old woman with major depressive disorder whose mother committed suicide D. A 16-year-old boy with only one close friend with whom he likes to hunt - ANS 125. Answer D. The 16-year-old boy engaging in recreational and social activities is the lowest risk for suicide. Elderly White men with a recent major life stressor, people with substance use disorders, and people with first-degree relatives who have committed suicide are all at high risk. 127. A 62-year-old female is recently diagnosed with obsessive compulsive disorder. Which of the following symptoms are characteristic of the obsession? A. Handwashing B. Checking the gas C. Anxiety D. Rumination - ANS 127. Answer C. Anxiety is the symptom consistent with the obsession. Behaviors such as handwashing, checking the gas, and ruminating are all examples of compulsions. 128. What class of medication is commonly used to treat obsessive compulsive disorder in high doses of monotherapy? A. Tricyclic antidepressants B. Benzodiazepines C. Antipsychotics D. Selective serotonin reuptake inhibitors - ANS 128. Answer D. Selective serotonin reuptake inhibitors are the most commonly prescribed medication in high doses to treat obsessive compulsive disorder as monotherapy. Tricyclic antidepressants, benzodiazepines, and antipsychotics are sometimes used to augment treatment for obsessive compulsive disorder (off label). 129. A 70-year-old woman is suspected of having dementia. What is the best initial method for assessing this condition? A. MRI of the brain B. Comprehensive psychiatric evaluation with collateral information C. PET scan of the brain D. EEG - ANS 129. Answer B. Comprehensive psychiatric evaluation with collateral information is the best way to assess for dementia. An MRI of the brain and PET scan of the brain can suggest microvascular changes and hypometabolic activity consistent with dementia, but the clinical correlation is essential to make the diagnosis. An EEG is used to diagnose a seizure disorder. 131. APRN practice is regulated by the A. State Nurse Practice Act B. Medicare regulations C. Collaborating physician D. Institution in which they practice - ANS 131. Answer A. The state Nurse Practice Act regulates the practice of the APRN. Medicare regulations determine the necessary conditions for reimbursement. The collaborating physician does not make the regulations. The institution can determine practice only in the institution (and must not be broader in scope than state law), but the practice of the APRN is governed by the state. 139. The purpose of licensure for the PMHNP is to: A. Ensure a minimum level of competency B. To restrict access to care C. To preserve the reimbursement structure D. To encourage litigation E. To make sure PMHNPs are hot. - ANS 139. Answer A. Licensure is intended to assure the public of a minimum level of competency. Licensure is not intended to restrict access to care, preserve the reimbursement structure, or encourage litigation. 140. A patient with PTSD reports middle insomnia secondary to nightmares. Which pharmacological class is used specifically to treat this symptom? A. Selective serotonin reuptake inhibitors (SSRIs) B. Alpha blockers C. Beta blockers D. Benzodiazepines - ANS 140. Answer B. Alpha blockers are commonly used to treat nightmares associated with PTSD. SSRIs are often used in PTSD to treat depression and anxiety symptoms. Beta blockers are sometimes used for performance anxiety. Benzodiazepines should not be used long term for anxiety as they are highly addictive. 141. A 36-year-old investment banker has been experiencing chest tightness, palpitations, and diaphoresis. He has had these symptoms three times in the last 3 months. Each time he calls 911 and gets admitted to rule out myocardial infarction findings are unremarkable. What is the most likely diagnosis? A. Generalized anxiety disorder B. Panic disorder C. Facticious disorder D. Malingering - ANS 141. Answer B. Panic disorder can also mimic symptoms of acute myocardial infarction. Generalized anxiety disorder is characterized by consistent and persistent worry and rumination over real or imagined events. Factitious disorder is characterized by an unconscious manifestation of symptoms for secondary gain. Malingering disorder is characterized by a conscious manifestation of symptoms for secondary gain.