NR 607 FINAL EXAM - COMPLETE QUESTIONS
AND DETAILED SOLUTIONS LATEST UPDATE THIS YEAR
JUST RELEASED
Question 1: Which of the following are the most appropriate
pharmacologic management strategies for Skylar? Select all that
apply.
A. ontinue risperidone 6 mg daily
B. switch to aripiprazole 10 mg daily
C. iscontinue all antipsychotic medications
D. prescribe valbenazine 40 mg daily
Answer:
continue risperidone 6 mg daily
-prescribe valbenazine 40 mg daily
Rationale: The most appropriate pharmacologic management strategies for Skylar
include continuing risperidone 6 mg daily and prescribing valbenazine 40 mg daily. Skylar
has had good symptom control with risperidone, but is experiencing symptoms of tardive
dyskinesia (TD) as evidenced by their AIMS score of 2; a score of 2 or greater indicates
TD. The APA recommends treating moderate to severe TD symptoms associated with
antipsychotic therapy with a vesicular monoamine transporter 2 (VMAT2) such as
valbenazine
Question 2: select the most appropriate ICD-10-CM codes for
Skylar s diagnosis.
Answer:
F20.9 and G24.09
Rationale:
F20.9 Schizophrenia reflects Skylar's diagnosis that is being treated at today's visit. On
the ICD 10 webpage you will see this synonym for the code: Schizophrenia in remission.
G24.09 Other drug induced dystonia corresponds to the new diagnosis- tardive
,dyskinesia.
Question 3: Which of the following is the appropriate E/M code for
this visit?
A. 99214
B. 99213
C. 99215
D. 99205
E. 99204
Answer:
99215
Rationale: Skylar is an established client with one chronic illness and a newly diagnosed
second chronic illness who needs prescription drug management. The new onset TD
warrants additional decision making. Therefore, Skylar's visit qualifies as 99215:
established client with high level medical decision making.
Question 4: stepwise approach based on the STAR*D study to
manage clients with TRD
Answer:
Treatment Decision Process
-Initial Evaluation and Management
• Not all depressions are equal
• A screening tool is used to assess symptoms and severity
• Rule-out medical diagnosis (hypothyroidism, anemia, etc.)
• Assess for comorbidities
• Substance abuse
• OCD/PTSD/anxiety
• SSRI based on above factors
-Wait/Reassure - minimum of 4 weeks
• Adequate Response - Continue presenting tx
• Inadequate Response - Next steps include:
,➣adherence
➣barriers (cost, cognition)
Question 5: ➣repeat depression screen ➣educate ➣onset of
action/dosing ➣increasing medication dose ➣consider adding
psychotherapy • Adequate Response - Continue presenting tx •
Inadequate/Partial Response: ➣Medication adherence ➣Barriers
➣Repeat depression screen ➣Increase medication (up to max
amount recommended) ➣Psychotherapy adherence • Not
Effective?: ➣Re-evaluate ➣Switch to different SSRI/serotonin and
norepinephrine reuptake inhibitors (SNRI) (remission success of 25
percent) Harry is a 48-year-old who presents to the outpatient
mental health clinic for an initial evaluation of symptoms of
depression. Harry has been prescribed bupropion XL 300 mg daily
by his primary care provider and has been taking it for the past five
years. Harry endorsed that at first, the medication "worked really
well," but states he has been feeling more down lately and is
concerned that the medication is no longer working. He stated that
about eight months ago, he changed to a new position at work that
was "overwhelming." He had no time to participate in his hobbies,
which include reading, racquetball, and golf. He states that since
his promotion, "I have no time to do anything but work, eat, and
sleep, so I tend to eat and sleep a lot more than I used to." Harry
states that his wife of 18 years has become frustrated with him
because he has no energy to participate in raising their children,
but Harry
A. Wait/Reassure - minimum of 2-4 weeks
B. Wait/Reassure - minimum of 4 weeks
Answer:
switch to bupropion 150 mg twice daily
-recommend follow-up with a primary provider
-recommend initiating psychotherapy
, Rationale: The most appropriate initial treatment for Harry is to switch to bupropion 150
mg twice daily, recommend follow-up with the primary provider, and recommend initiating
psychotherapy. Because the client has had gastric bypass surgery, his ability to absorb
extended-release medications may be impaired. Since the medication initially worked to
control his symptoms, it is reasonable to begin by switching to the same medication in an
immediate release format. Harry should follow up with his primary provider to obtain a
complete physical, including lab work for possible deficiency of vitamin D or B12.
Because of the client's recent increase in daily stressors, psychotherapy may also be
appropriate at this time.
Question 6: Bettina is a 24-year-old who presents to the mental
health clinic after a referral from her primary care provider. She
endorses symptoms of depression that began "when I was still in
college," including excessive sleepiness, withdrawal from social
activities, the guilt associated with "leaving my friends hanging,"
and anhedonia. Bettina states that she saw a counselor through the
college health service, which helped her symptoms somewhat, but
she was unable to continue with counseling after graduation two
years ago. She made an appointment with her primary care
provider to discuss medications for depressive symptoms and was
prescribed citalopram 20 mg daily. After six weeks on the
medication, she did not experience relief of symptoms and
returned to the provider at which time her dose was increased to 40
mg daily. She had a follow-up appointment with the provider six
months later, at which time she was prescr
Answer:
continue current medications and add aripiprazole 2 mg daily
Rationale: The most appropriate treatment for Bettina is to continue her current
medications and add aripiprazole 2 mg daily. According to the STAR*D guidelines, the
client may choose to remain on the current medications and add an atypical antipsychotic
medication such as aripiprazole. Alternatively, the client may choose to discontinue
current medications and start a tricyclic or tetracyclic antidepressant. The client may also
choose to begin therapy. Inpatient admission is not indicated for this client.
AND DETAILED SOLUTIONS LATEST UPDATE THIS YEAR
JUST RELEASED
Question 1: Which of the following are the most appropriate
pharmacologic management strategies for Skylar? Select all that
apply.
A. ontinue risperidone 6 mg daily
B. switch to aripiprazole 10 mg daily
C. iscontinue all antipsychotic medications
D. prescribe valbenazine 40 mg daily
Answer:
continue risperidone 6 mg daily
-prescribe valbenazine 40 mg daily
Rationale: The most appropriate pharmacologic management strategies for Skylar
include continuing risperidone 6 mg daily and prescribing valbenazine 40 mg daily. Skylar
has had good symptom control with risperidone, but is experiencing symptoms of tardive
dyskinesia (TD) as evidenced by their AIMS score of 2; a score of 2 or greater indicates
TD. The APA recommends treating moderate to severe TD symptoms associated with
antipsychotic therapy with a vesicular monoamine transporter 2 (VMAT2) such as
valbenazine
Question 2: select the most appropriate ICD-10-CM codes for
Skylar s diagnosis.
Answer:
F20.9 and G24.09
Rationale:
F20.9 Schizophrenia reflects Skylar's diagnosis that is being treated at today's visit. On
the ICD 10 webpage you will see this synonym for the code: Schizophrenia in remission.
G24.09 Other drug induced dystonia corresponds to the new diagnosis- tardive
,dyskinesia.
Question 3: Which of the following is the appropriate E/M code for
this visit?
A. 99214
B. 99213
C. 99215
D. 99205
E. 99204
Answer:
99215
Rationale: Skylar is an established client with one chronic illness and a newly diagnosed
second chronic illness who needs prescription drug management. The new onset TD
warrants additional decision making. Therefore, Skylar's visit qualifies as 99215:
established client with high level medical decision making.
Question 4: stepwise approach based on the STAR*D study to
manage clients with TRD
Answer:
Treatment Decision Process
-Initial Evaluation and Management
• Not all depressions are equal
• A screening tool is used to assess symptoms and severity
• Rule-out medical diagnosis (hypothyroidism, anemia, etc.)
• Assess for comorbidities
• Substance abuse
• OCD/PTSD/anxiety
• SSRI based on above factors
-Wait/Reassure - minimum of 4 weeks
• Adequate Response - Continue presenting tx
• Inadequate Response - Next steps include:
,➣adherence
➣barriers (cost, cognition)
Question 5: ➣repeat depression screen ➣educate ➣onset of
action/dosing ➣increasing medication dose ➣consider adding
psychotherapy • Adequate Response - Continue presenting tx •
Inadequate/Partial Response: ➣Medication adherence ➣Barriers
➣Repeat depression screen ➣Increase medication (up to max
amount recommended) ➣Psychotherapy adherence • Not
Effective?: ➣Re-evaluate ➣Switch to different SSRI/serotonin and
norepinephrine reuptake inhibitors (SNRI) (remission success of 25
percent) Harry is a 48-year-old who presents to the outpatient
mental health clinic for an initial evaluation of symptoms of
depression. Harry has been prescribed bupropion XL 300 mg daily
by his primary care provider and has been taking it for the past five
years. Harry endorsed that at first, the medication "worked really
well," but states he has been feeling more down lately and is
concerned that the medication is no longer working. He stated that
about eight months ago, he changed to a new position at work that
was "overwhelming." He had no time to participate in his hobbies,
which include reading, racquetball, and golf. He states that since
his promotion, "I have no time to do anything but work, eat, and
sleep, so I tend to eat and sleep a lot more than I used to." Harry
states that his wife of 18 years has become frustrated with him
because he has no energy to participate in raising their children,
but Harry
A. Wait/Reassure - minimum of 2-4 weeks
B. Wait/Reassure - minimum of 4 weeks
Answer:
switch to bupropion 150 mg twice daily
-recommend follow-up with a primary provider
-recommend initiating psychotherapy
, Rationale: The most appropriate initial treatment for Harry is to switch to bupropion 150
mg twice daily, recommend follow-up with the primary provider, and recommend initiating
psychotherapy. Because the client has had gastric bypass surgery, his ability to absorb
extended-release medications may be impaired. Since the medication initially worked to
control his symptoms, it is reasonable to begin by switching to the same medication in an
immediate release format. Harry should follow up with his primary provider to obtain a
complete physical, including lab work for possible deficiency of vitamin D or B12.
Because of the client's recent increase in daily stressors, psychotherapy may also be
appropriate at this time.
Question 6: Bettina is a 24-year-old who presents to the mental
health clinic after a referral from her primary care provider. She
endorses symptoms of depression that began "when I was still in
college," including excessive sleepiness, withdrawal from social
activities, the guilt associated with "leaving my friends hanging,"
and anhedonia. Bettina states that she saw a counselor through the
college health service, which helped her symptoms somewhat, but
she was unable to continue with counseling after graduation two
years ago. She made an appointment with her primary care
provider to discuss medications for depressive symptoms and was
prescribed citalopram 20 mg daily. After six weeks on the
medication, she did not experience relief of symptoms and
returned to the provider at which time her dose was increased to 40
mg daily. She had a follow-up appointment with the provider six
months later, at which time she was prescr
Answer:
continue current medications and add aripiprazole 2 mg daily
Rationale: The most appropriate treatment for Bettina is to continue her current
medications and add aripiprazole 2 mg daily. According to the STAR*D guidelines, the
client may choose to remain on the current medications and add an atypical antipsychotic
medication such as aripiprazole. Alternatively, the client may choose to discontinue
current medications and start a tricyclic or tetracyclic antidepressant. The client may also
choose to begin therapy. Inpatient admission is not indicated for this client.
