NR 547 MIDTERM STUDY GUIDE
The NR547 exam questions are taken from the Course Activities, lectures, linked resources and required readings.
Mid-Term Exam: The Mid-Term has 75 questions worth two points each. You will have one attempt to complete the
exam with a time limit of 75 minutes.
Week 1: Foundations in Differential Diagnosis Formulation
1. The differential diagnosis:
1. Importance of the differential diagnosis: critical step in providing safe, quality care. It helps
discern an accurate diagnosis; helps PMHNP gather useful responses to formulate and narrow the
list of potential diagnoses based on client’s presenting symptoms.
2. Analysis of:
a) presenting symptoms: identify symptoms; ask length of time and any fluctuations in
severity; determine presence of stressors included; identify factors that alleviate or
exacerbate symptoms;
b) clinical data such as physical exam: must decide if medical, surgical, or neurological
condition is the cause of mental disorder; once determined that no disease process can be held
accountable, then the diagnosis of a mental health disorder can be made; knowledge and
understanding of physical signs and symptoms enables providers to recognize signs and
symptoms that may indicate possible medical or surgical illness.
c) laboratory analysis: vital in achieving goals of arriving at accurate diagnoses, identifying
medical comorbidities, implementing appropriate treatment, and delivering cost effective
care; CBC, CMP (serum electrolytes, LFTs, BUN, Cr), thyroid function tests, serum B12,
vitamin D, toxicology screen, and urinalysis.
d) Medical history including medications: includes treatments both past and present; past
surgeries should also be reviewed; essential to understand patient’s reaction to illnesses and
coping skills employed; important when determining potential causes of mental illness as well
as comorbid or confounding factors and may dictate possible treatment options or limitations;
Medical illness can precipitate a psychiatric disorder (ex. Anxiety in an individual recently
diagnosed with cancer); Medical illnesses can mimic a psychiatric disorder (ex.
Hyperthyroidism resembling an anxiety disorder); Medical illness can be precipitated by a
psychiatric disorder or its treatment (ex. a metabolic syndrome in a patient on a second-
generation antipsychotic medication); Medical illnesses can influence the choice of treatment
of a psychiatric disorder (ex. renal disorder and the use of lithium carbonate); pay special
attention to neurologic issues (seizures, head injury, pain disorder); know any hx of prenatal
or birthing problems or issues with developmental milestones; reproductive and mensgtrual
history is essential as well as a careful assessment of the potential for current or future
pregnancy.
Medications: include all current psych meds and how long they have been used, compliance, effects,
and any side effects; non-psych meds, OTC meds, sleep aids, herbal, and alternative meds should also
be reviewed; it is wise to advise patient should be asked to bring all medications to interview; Allergies
to medications should also be assessed (including which medication and the nature of the extent of and
the treatment of the allergic response)
3. Evidence-based screening tools and psychiatric rating scales
a) Scoring
b) Advantages and disadvantages: key role is to standardize the info collected across time and
by various observers; This standardization ensures a consistent, comprehensive evaluation
that may aid treatment planning by establishing a diagnosis, ensuring a thorough description
of symptoms, identifying comorbid conditions, and characterizing other factors affecting
treatment response. Also, the use of a rating scale can establish a baseline for follow-up of the
progression of an illness over time or in response to specific interventions. helps to monitor
patients over time or for providing information that is more comprehensive that what is
, generally obtained in a routine clinical interview; helps providers identify symptoms and assess
their severity and can assist with the evaluation of response to treatment; healthcare
administrators and payors are increasingly requiring standardized assessments to justify the
need for services or to assess the quality of care; also used in research that informs the practice
of psychiatry; most rating scales also offer the user the advantages of a formal evaluation of the
measure’s performance characteristics. This allows the clinician to know to what extent a given
scale produces reproducible results (reliability) and how it compares to more definitive or
established ways of measuring the same thing (validity).
c) Components:
- WHO disability Assessment schedule (WHODAS 2.0): self-administered; measures
disability along cognition, interpersonal relations, work, and social impairments; Can
be taken at intervals along the course of a person’s illness; reliable in tracking
changes that indicate a positive or negative response to therapeutic interventions or
course of illness; recommended for general use.
- Structured clinical interview for DSM (SCID): starts with a section on demographic
information and clinical background; 7 diagnostic groups: mood, psychotic, substance
abuse, anxiety, somatic, eating, and adjustment disorders; available information
(hospital records, informants, and patient observation) should be used to rate the
SCID; administered by experienced clinicians; formal training in the SCID is required;
Reliability data suggests that SCID performs better on more severe disorders (ex.
bipolar disorder, alcohol dependence) than on milder ones (ex. dysthymia); validity is
limited; used as the gold standard ; considered standard interview to verify the
diagnosis in clinical trials; useful to ensure a systematic evaluation in psychiatric
patients (ex. on admission to an inpatient unit or at intake into an outpatient clinic);
also used in forensic practice to ensure a formal or reproducible examination.
- Brief Psychiatric Rating scale (BPRS): short scale measuring the severity of
psychiatric symptomatology; assess change in psychotic inpatients and covers thought
disturbance, emotional withdrawal and retardation, anxiety and depression, and
hostility and suspiciousness; Reliability is good to excellent when raters are
experienced but is difficult to achieve without substantial training; Validity is also
good; been used extensively for decades as an outcome measure in treatment studies
of schizophrenia; given its focus on psychosis and associated symptoms, it is only
suitable for patients with fairly significant impairment.
- Positive and Negative Syndrome Scale (PANSS): used to remedy perceived deficits
in the BPRS in the assessment of positive and negative symptoms of schizophrenia
and other psych disorders; requires a clinician because it requires considerable probing
and clinical judgment; a semi structured interview guide is available; reliability for
each scale is reasonably high with excellent internal consistency and interrater
reliability; Validity is good; standard tool for assessing clinical outcome in treatment
studies of schizophrenia and other psychotic disorders; east to administer and sensitive
to change with treatment; useful for tracking severity in clinical practice
- Scale for the assessment of positive symptoms (SAPS) and scale for the
assessment of negative symptoms (SANS): designed to provide a detailed
assessment of positive and negative symptoms of schizophrenia and may be used
separately or in tandem; SAPS assesses hallucinations, delusions, bizarre behavior,
and thought disorder; SANS assesses affective flattening, poverty of speech, apathy
(lack of interest), anhedonia (inability to experience pleasure from activities usually
found enjoyable), and inattentiveness; both are used to monitor treatment effects in
clinical research
- Hamilton Rating scale for depression (HAM-D): monitors severity of major
depression with a focus on somatic symptomatology; commonly used version
consists
The NR547 exam questions are taken from the Course Activities, lectures, linked resources and required readings.
Mid-Term Exam: The Mid-Term has 75 questions worth two points each. You will have one attempt to complete the
exam with a time limit of 75 minutes.
Week 1: Foundations in Differential Diagnosis Formulation
1. The differential diagnosis:
1. Importance of the differential diagnosis: critical step in providing safe, quality care. It helps
discern an accurate diagnosis; helps PMHNP gather useful responses to formulate and narrow the
list of potential diagnoses based on client’s presenting symptoms.
2. Analysis of:
a) presenting symptoms: identify symptoms; ask length of time and any fluctuations in
severity; determine presence of stressors included; identify factors that alleviate or
exacerbate symptoms;
b) clinical data such as physical exam: must decide if medical, surgical, or neurological
condition is the cause of mental disorder; once determined that no disease process can be held
accountable, then the diagnosis of a mental health disorder can be made; knowledge and
understanding of physical signs and symptoms enables providers to recognize signs and
symptoms that may indicate possible medical or surgical illness.
c) laboratory analysis: vital in achieving goals of arriving at accurate diagnoses, identifying
medical comorbidities, implementing appropriate treatment, and delivering cost effective
care; CBC, CMP (serum electrolytes, LFTs, BUN, Cr), thyroid function tests, serum B12,
vitamin D, toxicology screen, and urinalysis.
d) Medical history including medications: includes treatments both past and present; past
surgeries should also be reviewed; essential to understand patient’s reaction to illnesses and
coping skills employed; important when determining potential causes of mental illness as well
as comorbid or confounding factors and may dictate possible treatment options or limitations;
Medical illness can precipitate a psychiatric disorder (ex. Anxiety in an individual recently
diagnosed with cancer); Medical illnesses can mimic a psychiatric disorder (ex.
Hyperthyroidism resembling an anxiety disorder); Medical illness can be precipitated by a
psychiatric disorder or its treatment (ex. a metabolic syndrome in a patient on a second-
generation antipsychotic medication); Medical illnesses can influence the choice of treatment
of a psychiatric disorder (ex. renal disorder and the use of lithium carbonate); pay special
attention to neurologic issues (seizures, head injury, pain disorder); know any hx of prenatal
or birthing problems or issues with developmental milestones; reproductive and mensgtrual
history is essential as well as a careful assessment of the potential for current or future
pregnancy.
Medications: include all current psych meds and how long they have been used, compliance, effects,
and any side effects; non-psych meds, OTC meds, sleep aids, herbal, and alternative meds should also
be reviewed; it is wise to advise patient should be asked to bring all medications to interview; Allergies
to medications should also be assessed (including which medication and the nature of the extent of and
the treatment of the allergic response)
3. Evidence-based screening tools and psychiatric rating scales
a) Scoring
b) Advantages and disadvantages: key role is to standardize the info collected across time and
by various observers; This standardization ensures a consistent, comprehensive evaluation
that may aid treatment planning by establishing a diagnosis, ensuring a thorough description
of symptoms, identifying comorbid conditions, and characterizing other factors affecting
treatment response. Also, the use of a rating scale can establish a baseline for follow-up of the
progression of an illness over time or in response to specific interventions. helps to monitor
patients over time or for providing information that is more comprehensive that what is
, generally obtained in a routine clinical interview; helps providers identify symptoms and assess
their severity and can assist with the evaluation of response to treatment; healthcare
administrators and payors are increasingly requiring standardized assessments to justify the
need for services or to assess the quality of care; also used in research that informs the practice
of psychiatry; most rating scales also offer the user the advantages of a formal evaluation of the
measure’s performance characteristics. This allows the clinician to know to what extent a given
scale produces reproducible results (reliability) and how it compares to more definitive or
established ways of measuring the same thing (validity).
c) Components:
- WHO disability Assessment schedule (WHODAS 2.0): self-administered; measures
disability along cognition, interpersonal relations, work, and social impairments; Can
be taken at intervals along the course of a person’s illness; reliable in tracking
changes that indicate a positive or negative response to therapeutic interventions or
course of illness; recommended for general use.
- Structured clinical interview for DSM (SCID): starts with a section on demographic
information and clinical background; 7 diagnostic groups: mood, psychotic, substance
abuse, anxiety, somatic, eating, and adjustment disorders; available information
(hospital records, informants, and patient observation) should be used to rate the
SCID; administered by experienced clinicians; formal training in the SCID is required;
Reliability data suggests that SCID performs better on more severe disorders (ex.
bipolar disorder, alcohol dependence) than on milder ones (ex. dysthymia); validity is
limited; used as the gold standard ; considered standard interview to verify the
diagnosis in clinical trials; useful to ensure a systematic evaluation in psychiatric
patients (ex. on admission to an inpatient unit or at intake into an outpatient clinic);
also used in forensic practice to ensure a formal or reproducible examination.
- Brief Psychiatric Rating scale (BPRS): short scale measuring the severity of
psychiatric symptomatology; assess change in psychotic inpatients and covers thought
disturbance, emotional withdrawal and retardation, anxiety and depression, and
hostility and suspiciousness; Reliability is good to excellent when raters are
experienced but is difficult to achieve without substantial training; Validity is also
good; been used extensively for decades as an outcome measure in treatment studies
of schizophrenia; given its focus on psychosis and associated symptoms, it is only
suitable for patients with fairly significant impairment.
- Positive and Negative Syndrome Scale (PANSS): used to remedy perceived deficits
in the BPRS in the assessment of positive and negative symptoms of schizophrenia
and other psych disorders; requires a clinician because it requires considerable probing
and clinical judgment; a semi structured interview guide is available; reliability for
each scale is reasonably high with excellent internal consistency and interrater
reliability; Validity is good; standard tool for assessing clinical outcome in treatment
studies of schizophrenia and other psychotic disorders; east to administer and sensitive
to change with treatment; useful for tracking severity in clinical practice
- Scale for the assessment of positive symptoms (SAPS) and scale for the
assessment of negative symptoms (SANS): designed to provide a detailed
assessment of positive and negative symptoms of schizophrenia and may be used
separately or in tandem; SAPS assesses hallucinations, delusions, bizarre behavior,
and thought disorder; SANS assesses affective flattening, poverty of speech, apathy
(lack of interest), anhedonia (inability to experience pleasure from activities usually
found enjoyable), and inattentiveness; both are used to monitor treatment effects in
clinical research
- Hamilton Rating scale for depression (HAM-D): monitors severity of major
depression with a focus on somatic symptomatology; commonly used version
consists
