NURS 6670 Final Exam with Answers (75/75)

NURS 6670 Final Exam 1. Mrs. Johnson is a 79-year-old lady who has been managed for Alzheimer’s dementia with a variety of nonpharmacologic management strategies such as promoting a clear household routine, timed toileting, pet therapy, and other strategies to provide structure. However, she was finally started on donepezil 10 mg daily at bedtime to try and maximize cognitive function and memory. When following up for medication tolerance and adverse effects, the PMHNP recognizes that the most common patient complaints include: 2. Mr. and Mrs. Comstock are both patients of your practice; Mr. Comstock is treated for depression, which is largely secondary to his wife’s progressive dementia. He is trying to take care of her but finds it very emotionally difficult. Previously very active, they have become socially isolated as their friends are not comfortable around Mrs. Comstock’s progressively obvious dementia symptoms. Mr. Comstock’s brother and his wife were visiting yesterday, and it became very uncomfortable. Mr. Comstock said they were having a conversation about a recent election and his wife suddenly became extremely agitated and started acting out inappropriately; she was yelling and broke a figurine from the table; she finally left the room. He said this has not happened before—that usually she participates in conversations, even if sometimes she jokes too much or changes the subject. The PMHNP discusses with Mr. Comstock that it sounds as though his wife: 3. Valerie is a 27-year-old woman who has been referred by her primary care provider. She was initially diagnosed with major depressive episode following a breakup with her boyfriend of 7 years. They moved into a house together 1 year ago, but within a few months the boyfriend moved out. Valerie was unresponsive to medication for depression and was referred to the mental health clinic. During this initial psychiatric evaluation, the PMHNP learns that a primary reason for the breakup was that Valerie had an extensive routine every night of repeatedly checking every door and window in the home to ensure that they were locked. Valerie’s nighttime routine is exhaustive and involves checking every door and window at least four times. She has a remote history of being attacked in her home while alone and states that she is unable to go to bed until she is certain that every door and window is locked. When considering diagnostic criteria for OCD, the PMHNP needs further assessment to ascertain which diagnostic criteria? 4. Camille is a PMHNP student preparing a presentation for a group of primary care providers on common signs and symptoms of psychiatric disorders often first seen in primary care offices. The goal is to increase awareness of early indicators for mental health referral. When discussing obsessive-compulsive disorder, Camille discusses that the most common pattern of obsession is: 5. All of the following strategies are used successfully to manage paradoxical insomnia except: 6. The PMHNP is formulating a diagnosis for Peter, a 24-year-old man who was admitted for management of acute psychoses. He believed that he was the Holy Ghost of the Christian Trinity. According to his mother and father, he did not have any psychiatric symptoms or history throughout childhood and adolescence, but after college, he began to develop “issues” characterized by extremes of mood in which he would be too depressed to attend classes for weeks at a time followed by a rebound in which he would go partying, stay awake for days at a time, and go on ridiculous shopping sprees. When considering a diagnosis of schizoaffective disorder, the PMHNP attempts to establish that: 7. Nava is a 47-year-old female who has been in care for the last 9 months for a major depressive episode. She has struggled with depression intermittently since her 20s, but at this point she is on combination therapy with sertraline and bupropion and has achieved an excellent remission. However, she is asking for some help with her sleep. She says she has always had insomnia to some degree, mostly trouble falling asleep, but she thought that once she felt better from her depression it would improve. A review of Nava’s sleep hygiene habits reveals that there are numerous areas that could benefit from improvement. Nava’s sleep hygiene habits should ultimately be improved to include all the following except: 8. Amnestic disorders have a wide variety of potential causes, including vitamin and mineral deficiencies, infectious diseases, substance-related causes, and structural damage. The shared feature is that many of these causes tend to affect the: 9. Donna is a 41-year-old woman who is being evaluated at the request of her primary care provider for obsessive compulsive disorder. Which of the following aspects of Donna’s family medical history should prompt an immediate referral to a neurologist? 10. Shireen is a 21-year-old transgender female who has been through an exhaustive counseling program and is ready to start hormone therapy with estrogen, progesterone, and testosterone-blocking agents. When counseling her specifically about the risks, benefits, and required monitoring of hormonal therapy, the PMHNP advises Shireen that: 11. John is a 19-year-old male who is self-referred for care after being prematurely discharged from the military. He is vague as to the details of his discharge, but it appears he had difficulty with performance evaluations and was apparently arrested for several incidences of illegal substance abuse. Comprehensive evaluation of John reveals that he thinks he “is really a woman,” but he cannot accept this and joined the Army to try and “be a real man.” John indicates that he has always felt like he was really a girl, and he says that he “hates that he has a penis.” When considering a diagnosis of gender dysphoria, the PMHNP knows that which of the following would be most consistent with John’s history? 12. Dual-sex therapy is a therapeutic approach to sexual dysfunction in a marital dyad or relationship that is believed to result from disharmony or misunderstanding in the relationship. This is most effective in couples when: 13. The PMHNP is preparing a community-based presentation for both the staff and residents of a local life-care facility. The facility offers a continuum of care from independent apartment living to assisted living to nursing home care. In an effort to increase awareness of signs and symptoms of dementia as compared to pseudodementia, the management has contracted with the PMHNP to prepare these informative educational programs. When comparing and contrasting these two conditions, the PMHNP emphasizes that in pseudodementia the patient is usually: 14. The PMHNP student is working on a community outreach project as part of a larger primary prevention program designed to protect children from pedophiles. When considering target audiences and program design, the PMHNP student recognizes that most pedophile offenders report: 15. The PMHNP is asked to prepare a presentation for non-nursing health care workers in a local long-term care facility on the various causes of cognitive impairment in the elderly. A case presentation approach is used to reinforce principles of identifying delirium, which needs to be reported to the patient’s attending provider right away. The case should emphasize which of the following features as being closely correlated with delirium? 16. Hypersomnia has a variety of etiologies, and treatments are varied based upon underlying cause. Which of the following types of hypersomnolence disorder is best managed with wake-promoting substances or psychostimulants? 17. Jeremy is a 21-year-old male who is referred by his primary care provider. He has persistent erythema of both hands, which was initially thought to be eczema but eventually was diagnosed as a result of chronic, excessive handwashing. Further evaluation of Jeremy revealed findings consistent with obsessive compulsive disorder. The PMHNP considers that the most appropriate initial therapy for Jeremy would be: 18. Recurrent isolated sleep paralysis is characterized by the awareness of normal REM-mediated paralysis in the partially conscious state. It is a feature of normal REM sleep, and lifetime occurrence is estimated to be as high as 50%. While counseling patients about this condition, the PMHNP correctly states all the following except: 19. Coryn has been referred to the PMHNP because she has a significant sleep disorder that has not been responsive to typical primary care strategies. She has tried sedative hypnotics, improving sleep hygiene, avoiding daytime naps, melatonin, and almost anything else suggested. She has always had trouble sleeping “like normal people,” but she is newly married and her sporadic sleep patterns are beginning to cause stress in the marriage. Her history suggests a circadian rhythm sleep disorder. When counseling Coryn, the PMHNP advises her that all the following strategies have demonstrated success except: 20. R.M. is an 81-year-old male who was evaluated at his own request because of his failing memory. He is an active older adult and has enjoyed a comfortable retirement lifestyle, but over the last year he has become increasingly troubled by his forgetfulness. His wife agrees that it has extended beyond the occasional memory lapse; he forgets names of things he should know and has forgotten commitments to friends and family. After a thorough evaluation, the PMHNP diagnoses mild cognitive impairment (MCI). R.M. asks if this is really Alzheimer’s disease, if it is going to get worse, and what can he do about it? The most appropriate response would be to tell R.M. that: 21. The PMHNP is asked to evaluate the elderly father of one of her patients. The father is a 72-year-old male who is demonstrating some difficult personality changes. His memory and ability to function ADLs seem intact, but the daughter reports that he seems very impulsive, and he doesn’t seem to appreciate that some actions or behaviors are inappropriate. He has been making inappropriate sexual remarks to some of her daughter’s friends and doesn’t understand that it is a problem. When considering various causes of dementia, the PMHNP evaluates for additional symptoms including: 22. The clinical evaluation of neurocognitive disease includes a detailed assessment of cognition. Which of the following aspects of cognitive testing may result in false positives due to poor education or low intelligence? 23. Trayvon is a 28-year-old male who was recently discharged from the military as a result of some behavioral issues leading to early termination. He was never in a combat situation, and his behavior and anger seem to predate his military enlistment. He is only in care because the military offers this as a transitional service, and Trayvon thinks it will help him be successful with future job applications. During a comprehensive evaluation of Trayvon, the PMHNP realizes that, among other things, he is experiencing postcoital dysphoria. Predictably this is causing some problems with his girlfriend, and he asks if there is anything he can take to help. The PMHNP advises that: 24. Joyce is a 30-year-old female patient who was recently diagnosed with schizophrenia after being referred for mental health evaluation by the police. She demonstrated paranoid delusions that ultimately led to such disruptive behavior at her place of work that the police were called. Her husband was able to provide a history consistent with prodromal symptoms, and in retrospect her disorganized thought and poor insight were evident over the last few months. She was initially stabilized on IM Zyprexa (olanzapine) and has been maintained on oral Zyprexa for the last 2 weeks, and has been on 10 mg daily for 1 week. Today at follow-up she demonstrates mild improvement. Her hygiene and appearance are much improved. She is still hearing voices and has delusions that communists are trying to infiltrate the company for which she works. She is open to the idea that these are delusions but still seems hesitant to accept that premise. At this point her medication management should include: 25. A wide variety of sleep-wake disorders are referred to the PMHNP for assessment and management. A contemporary approach to managing insomnia centers around: 26. Jack is a 19-year-old male who is being treated for obsessive-compulsive behavior. He has just begun his mission as a member of the Church of Jesus Christ of Latter Day Saints, and his partner has encouraged him to come to care due to his compulsive cleaning behaviors. Jack has had a very difficult time with treatment; after several sessions, it is apparent that he is having obsessive sexual thoughts with which he is not comfortable. Jack would like to avoid pharmacotherapy if he can, and is interested in exploring psychotherapeutic interventions. The PMHNP refers Jack to therapy and discusses with him that the psychodynamic theories of OCD include: 27. Danny is a 19-year-old male who presents to the college mental health center at the insistence of his roommate. Danny has developed what his roommate calls an obsession with cleanliness. He showers several times a day and changes his clothes easily four or five times. He also brushes his teeth every couple of hours, convinced that he has bad breath. During the interview, it does not appear that these are anxiety-reducing rituals but rather he is certain that he has unpleasant body odors and needs to keep showering and brushing his teeth to get rid of them. While considering a diagnosis of obsessive-compulsive disorder, the PMHNP considers that differential diagnoses for Danny include all the following except: 28. Jenna is 21-year-old female who is referred to college behavioral health services by her academic advisor following an advising session that made the advisor very uncomfortable. Jenna indicated that she wanted to change her major to religious studies. Jenna says that she was surfing the Internet trying to find an affordable used car, but every website she saw contained hidden messages just for her. These messages told her that she needed to find the religious meaning in her life and that she should start by redirecting her college pathway. The PMHNP recognizes that this represents: 29. Physiologic assessment of patients with paraphilias has demonstrated that most them have: 30. Steve is a 31-year-old male who presents for care on his own initiative. He has a new girlfriend for whom he really cares, but he is concerned that his lack of sex drive may be a problem as the relationship progresses. He says he just is not interested in sex. He doesn’t think about it, and while he really enjoys the company of this lady and doing things with her, he is not interested in sexual relations. When considering a diagnosis of male hypoactive sexual desire disorder, the PMHNP must consider all of the following except: 31. A secondary prevention strategy to reduce the incidence of pedophilia includes: 32. The primary differentiating feature between mild cognitive impairment (MCI) and Alzheimer’s dementia is: 33. With respect to the negative symptoms of schizophrenia, all of the following statements are true except: 34. Mr. Vasquez is a 76-year-old man who is presented to care by his daughter for management of his Parkinson’s dementia. He was initially diagnosed with Parkinson’s disease 5 years ago and has been managed with good results on carbidopa-levodopa (Sinemet). Approximately 18 months ago he began to develop symptoms of dementia that led to a diagnosis Parkinson’s dementia. Today the daughter reports that he has been acting “different” for over a week. He suddenly seems to be hallucinating and trouble sleeping, and has overall been acting acutely confused. There have been a few spells where he was hard to rouse. She took him to the primary care provider, but they could not identify any acute cause of his symptoms; they even lowered his Parkinson’s medication, but it didn’t help. After ensuring that the appropriate metabolic causes of delirium have been rule out, the PMHNP considers: 35. Which of the following is a true statement with respect to psychoanalytic therapy for patients with paraphilias? 36. Jaime is a 19-year-old woman who is in psychiatric care as a condition of probation. She first came to the attention of the juvenile detention system when she was 15 years old. She was babysitting for a neighbor, and the parents came home early and found that she was exposing her breasts to the 9-year-old child in her care. Since then she has had several similar episodes, and since turning 18, she has been arrested several times for exposing herself to children and teenagers. During her evaluation, she admits that the only way she can experience arousal and orgasm is to engage in this behavior and then masturbate afterward. She has had more conventional sexual experiences but does not enjoy them. When considering a diagnosis of paraphilic disorder, the PMHNP recognizes that which of the following features is inconsistent with the typical paraphilic disorder patient? 37. What is the primary difference between sexual interest and arousal disorders in men and women? 38. In addition to the diagnostic criteria observed in patients with schizophrenia, physical examination of these patients is frequently characterized by: 39. The PMHNP is preparing a presentation for a primary care conference. The topic is “Recognizing Schizophrenia: Common Signs and Symptoms Encountered by the Primary Care Provider.” A critical point to stress to primary care clinicians is that: 40. Mr. T. is a 24-year-old man who presented himself to care for management of compulsions that have become so consuming that it is interfering with his job. He is a truck driver for a local branch of a ational delivery company. Several months ago, he rather abruptly developed a very strong compulsion to ensure that every door in the vehicle was in the unlocked position before he could drive. At this point he is unable to drive unless he checks every door seven times, and as he frequently gets in and out of the vehicle during the day, this has become prohibitive of making his stops on time. He has been on sertraline 200 mg daily for 4 weeks now without any meaningful improvement. The PMHP considers that the next step in his care might reasonably include all of the following except: 41. Stephen is a 19-year-old male who is having a court-mandated psychiatric assessment after causing a car accident that resulted in a serious, nonfatal injury to a passenger in his car. Stephen is adamant that he just “fell asleep” and he was not doing anything wrong. A review of his sleep history does not suggest a sleep deficit, although his mother says that he always “stays up late.” A careful history suggests that Stephen might be subject to narcolepsy attacks. Which of the following confirms a diagnosis of narcolepsy? 42. Sarah is a 52-year-old female who is referred to psychiatric care by her primary care provider. Sarah clearly does not feel that the evaluation is necessary and indicates that she has essentially been “blackmailed” by her long-time primary care provider who says he will no longer see Sarah until she has a mental health assessment. The referring PCP reports that Sarah is convinced that she has a cancer that he cannot diagnose. Sarah’s mother, brother, and sister all died from various cancers, and Sarah has become convinced that she has one too, although no one can find it. A genetic evaluation indicates no genetic or familial risk. Sarah has had a thorough physical examination; been screened for colorectal, breast, and cervical cancer; and has also had CT scans of the head and chest; the last two at her request as her mother and brother had brain and lung cancer, respectively. Sarah has no specific symptoms but is fixed in the belief that she has cancer that no one can find. When considering a diagnosis of delusional disorder, the PMHNP would expect Sarah’s evaluation to reveal: 43. Several medical disorders can produce symptoms of obsessive-compulsive disorder (OCD). Which of the following findings in a patient with new onset OCD should prompt an evaluation for a neurologic cause of symptoms? 44. Korsakoff’s syndrome is an amnestic disorder frequently associated with a long history of alcohol abuse, although it may occur in the setting of gastric carcinoma, prolonged total parenteral administration therapy, and hyperemesis gravidarum. Treatment centers around: 45. Michael is an 18-year-old male who is presented to care at the urging of his parents. He has never had any significant medical or psychiatric problems in the past, but during his first semester at college he has developed a very alarming pattern of excess sleep. He is missing classes and is in danger of losing a scholarship. He is sleeping normally at night but apparently is having these very long episodes of napping and sleeping during the day. When he is awake, he tends to be rather withdrawn. His parents have taken him to their family practitioner as they thought he might be using drugs. A full exam, laboratory assessment, and toxicology screen are all normal, and there is no apparent cause for this sleepiness. While very rare, the PMHNP considers Kleine-Levin syndrome and further assesses for coincident onset of: 46. Mrs. Swenson is a 71-year-old patient who has been referred to mental health services for evaluation and management of dementia. She recognized her own cognitive deficits and discussed them with her primary care provider, who advised that she seek specialty care. After performing a comprehensive assessment, the PMHNP diagnoses the patient with vascular dementia. While reviewing her medication list from the PCP, the PMHNP recognizes that which of the following medications may be contributing to Mrs. Swenson’s cognitive impairment? 47. Schizophrenia, schizoaffective disorder, and schizophreniform disorder are all among the continuum of psychiatric illnesses characterized by psychotic episodes. Which of the following clusters of features best distinguishes schizophreniform disorder? 48. Alex J. is a 31-year-old male who is being seen in the emergency room after having a car accident. There were no serious injuries. Alex insists that he was following the speed limit and traffic signs, that he was not doing any drugs or alcohol, but he just fell asleep at the wheel. A head CT and toxicology screen are negative, and other screening laboratory studies do not support any organic cause of sudden sleepiness. The PMHNP considers hypersomnolence disorder vs. narcolepsy. When reviewing his sleep history questionnaire, which of the following historical findings would support a diagnosis of hypersomnolence? 49. Luz is a 24-year-old female who is being evaluated at the strong urging or her mother and the family primary care provider. According to the mother, Luz has been progressively demonstrating obsessive thoughts and compulsive behaviors centering on religion. She is preoccupied with the concept of heaven and hell, and she often becomes very distressed that she is going to go to hell when she dies. The mother also reports that Luz appears to be compulsive about reading her Bible and performing prayers and other rituals several times a day. The PMHNP must perform a detailed history and examination to differentiate obsessive-compulsive disorder (OCD) from: 50. Which of the following infectious diseases associated with psychiatric symptoms is most likely to present with olfactory and gustatory hallucinations, psychosis, personality changes, and partial seizures? 51. Ron D. is a 67-year-old man who has been referred by his primary care provider for management of sleep disorder. He has seen his PCP many times complaining of insomnia. He reports that he lays in bed for “hours” every night before falling asleep and then often wakes up every 90 minutes, sometimes staying awake for more than an hour before he goes back to sleep. He has been trialed on both zolpidem (Ambien) and zaleplon (Sonata) without improvement. Polysomnography did not support the pattern of sleep described by Ron D. During his sleep study, he reported the same complaints, while the objective test results indicated that he fell asleep in < 15 minutes with a total sleep time > 7 hours and 93% sleep efficiency. This is known as: 52. John is a 20-year-old male who is referred to treatment by his father. The two of them live together following the murder of John’s mother 6 weeks ago. It was a tragic occurrence; John’s mother was a nurse at an inner-city hospital and was killed as an innocent bystander in a drive-by shooting. John was very close to his mother, and in the last 3 weeks he has been increasingly distraught. His dad says he did not cope well from the beginning, but for the last 2 weeks he has been agitated, combative, and is hearing voices telling him that he could have saved his mother. He has become so agitated that his father brought him to the emergency room. The PMHNP knows that immediate treatment for John should include: 53. The primary difference between sleepwalking and rapid eye movement behavior disorder (RBD) is that: 54. Due to the adverse effect profile of second generation antipsychotics, patients taking them should have all the following monitored regularly except: 55. Collette is a 23-year-old female who presented for emergency care with her mother because her behavior has become increasingly erratic and caused her to lose her job. Her mother reports that she had never done anything like this in the past, but about 3 months ago, her boyfriend of 3 years broke up with her, and Collette began to express unrealistic beliefs that her boyfriend wanted to drive her crazy and hurt her. A gentleman trying to hail a taxi accidentally bumped into her this morning, and she started screaming that her ex-boyfriend had hired the man to throw her into the street under a car. Collette is on a 2-week suspension from her job as a restaurant server because she was combative to a customer—she accused him of colluding with her ex-boyfriend to get her fired. After this morning’s incident, her mother was so worried she brought her to the emergency room. Her appearance is disheveled, she is clearly hyperalert and is crying that her boyfriend must have converted her mother to work against her. Heaimaging, screening lab, and a toxicology screen are negative. A leading differential for Collette is: 56. Jake and Laurie are a young married couple who have been referred to mental health counseling because Jake is having disturbing sleep events. Laurie reports that on more than one occasion she has awakened to find Jake having what appears to be a panic attack, but he doesn’t seem to realize it. When he finally wakes up, he is confused and doesn’t really understand what happened, although he does have a sense of intense fear. This has happened twice in the last 2 weeks, and the last time Laurie heard him screaming. Jake is now a bit afraid to go to sleep and as a result does not feel well the next day. The PMHNP recognizes that sleep terrors in adults: 57. R.J. is a 77-year-old man who has been referred for care for refractory depression. His wife died of cancer 2 years ago, and through the course of her illness and death, his family recognized that he seemed depressed. After his wife’s death, his primary care provider tried two different antidepressant medications, and while his mood has improved a bit, his family says he is increasingly “forgetful.” It started out as relatively innocuous things like forgetting where his keys are or forgetting to return a phone call or mail in his monthly bills. His daughter became worried when she went to visit him last weekend and found that he had forgotten how to write a check. He considers himself an otherwise healthy man with a medical history significant only for hypertension, dyslipidemia, and type 2 diabetes. He takes medications for these and feels physically fine. The PMHNP recognizes that R.J. is exhibiting signs and symptoms consistent with: 58. When considering biological issues in gender dysphoria, the PMHNP recognizes that: 59. With respect to the treatment of obsessive compulsive disorder, which of the following statements best characterizes the role of psychotherapy? 60. Gerry is a 24-year-old male who is being evaluated for obsessive-compulsive disorder (OCD). He has a long history of both obsessive thoughts and compulsive behaviors going back into mid-adolescence. When evaluating his history, the PMHNP knows that all of the following are more common in patients with OCD except: 61. A couple in their late thirties presents for care. They have been married for eight years, and the wife is becoming increasingly frustrated by their sex life. As their marriage has progressed she has become increasingly disturbed by the fact that her husband cannot ejaculate during intercourse. It is more of an issue lately because she really wants to have a baby. She admits that their sex life has never been “ideal,” but that she has been able to reach orgasm, often using a sex toy during sex with her husband. Her husband has ejaculated with manual stimulation, but never during intercourse. The husband is rather quiet during the whole evaluation, but he says he does not ejaculate during intercourse and he is “OK with that.” The PMHNP considers that: 62. Jamal is a 31-year-old male who is being evaluated by the PMHNP as part of required care following a suicide attempt. He has never had mental health care before, but his history reveals a significant history of substance abuse. Upon further assessment, Jamal reveals that the reason he uses drugs and alcohol is that he becomes most aroused sexually when he dresses in women’s clothing. He is distressed by this. He says he is attracted to women, he is not gay, but he is just most aroused in this way. He admits that even when he was little, he was always drawn to his mother’s and sister’s clothing and underwear. Jamal’s condition is best characterized as: 63. Which of the following is a true statement with respect to obsessive-compulsive disorder? 64. Trudy is a 49-year-old woman recently diagnosed with schizophrenia. While she has a strong family history of mood disorders, and has herself evidenced some depressive symptoms by history, her delusions and diagnosis of schizophrenia were a big surprise to herself and her family. She has been married for 25 years and by all accounts has had a successful marriage and family life until the last few months when she became increasingly concerned that her best friend was trying to seduce her husband. Further history suggests that she has paranoid delusions and that her memos from work carried messages that her coworkers were trying to destroy her family. Trudy was finally referred for care when she tried to attack a coworker. There is no apparent precipitating factor, and her family cannot understand why she is just now demonstrating symptoms of schizophrenia. Now that she is in treatment, which elements of her history support a good prognosis? 65. Johanne is a 22-year-old female who is being treated for narcolepsy. She is attempting to implement a regimen of forced daytime naps in an effort to manage her condition without pharmacotherapy as she is generally averse to taking medications. While following Johanne, the PMHNP should be alert to signs and symptoms of: 66. Maryanne is a 26-year-old female who is in therapy for obsessive compulsive disorder. She was trialed on SSRI therapy without remission and was changed to clomipramine, 25 mg q.h.s. titrated up to 100 mg q.h.s. 2 weeks ago. She presents today for follow up. The PMHNP assesses for which of the following adverse effects? 67. Successful management of narcolepsy often involves combination treatment with both pharmacotherapy and a lifestyle regimen of regularly scheduled forced daytime naps. Which class of medications is used for its REM-suppressant properties in order to reduce cataplexy? 68. Maureen is a 23-year-old female who self-refers to mental health because she is struggling with a recent diagnosis. She recently had appendicitis, but during the diagnostic CT scan she learned that she had cryptorchid testes, and now she is distressed over not knowing if she “is a man or a woman.” She says that she has always been a bit of a tomboy, but that she has never thought of herself as a man, or as wanting to be a man. She has had a boyfriend for 2 years, and she is terrified that if he finds out he will break up with her. She admits that she has never menstruated, but her mother took her to the doctor when she was 16 and “no one seemed worried about it.” The PMHNP recognizes that Maureen’s diagnosis is likely: 69. Catatonia is an uncommon finding most often related to: 70. When evaluating the patient with dementia, the PMHNP recognizes that one of the clinical differences between cortical and subcortical dementias is that in subcortical dementia an early finding will typically not include which of the following? 71. Obsessive compulsive disorder is characterized by variable success to treatment, presenting on a bell-curve continuum. Twenty to 30% of patients have significant improvement, 40–50% have moderate improvement, and 20–40% remain ill or even develop worsening symptoms. Which of the following is best correlated with the most optimistic treatment outcomes? 72. Mr. Levinson is a 41-year-old man who is under care of the PMHNP for mood disorder and insomnia. His mood disorder is currently well managed, but he continues to complain about trouble sleeping. He says the primary issue is that he cannot seem to get comfortable because he has a recurrent sensation of ants or bugs crawling all over his legs. He cannot relax and sleep because he is constantly moving his legs trying to get comfortable. The PMHNP recognizes that: 73. D.M. is a 21-year-old male who presents for admission with his mother. He reports that he “cannot get himself together.” He is disoriented x 3 and his thought processes are chaotic. His speech is disorganized, he is easily distracted, and he appears to be rather agitated. He admits to both visual and auditory hallucinations over the last few weeks, and says he can “hear through the walls.” He was unable to sit still during the evaluation, often getting up and pacing the room, looking out of the windows, and then appearing to listen to something no one else could hear. According to his mother, his behavior has been bizarre for weeks; he has been wandering the neighborhood aimlessly, and reports that he was raped by a male neighbor. His mother finally brought him to the hospital. He appears unaware of his circumstances. D.M. is a poor historian, but does admit to drug and alcohol use on and off for several years. According to his mother, he had a scholarship to college, but it was withdrawn last semester when he stopped going to classes. A screening laboratory assessment is within normal limits, and the PMHNP considers a diagnosis of schizophrenia. D.M.’s presentation is most consistent with which type? 74. Kasey is a 26-year-old male who is referred for emergency psychiatric evaluation in the local community emergency room. His girlfriend came home from work unexpectedly and found him in the bathtub with multiple longitudinal cuts on both wrists. She called 911 and he was stabilized in the ED; the injuries were not serious, and now he is pending psychiatric evaluation. When the PMHNP came into the room, he noticed that Kasey unbuttoned and rebuttoned his shirt four times before settling down to the interview. He presented as depressed and tearful, and admitted to feelings of hopelessness and worthlessness. He admits that he doesn’t really feel connected to anyone; he has always been a loner, and last night he tried to kill himself because life just was not worth living. In addition to his suicidal ideation, the PMHNP recognizes that he needs to be further evaluated for: 75. Jack is a 27-year-old male who has a history of paranoid schizophrenia that first became apparent approximately 10 years ago. He developed paranoid delusions and eventually decompensated to the point that he required inpatient stabilization. At the time, he was started on conventional antipsychotics, but due to intolerable adverse effects he was switched to haloperidol. It worked well, but whenever he stopped taking it, symptoms would recur. After several hospitalizations, he was stabilized. The neurophysiologic theory of schizophrenia suggests that Jack’s symptoms were a result of: