NSG 554/ NSG554 Exam 4 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

NSG 554/ NSG554 Exam 4 V1 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A What do you need to do before diagnosing a patient with a mental health disorder? Rule out all other causes of symptoms before diagnosing any mental health disorder. What should you differentiate in a patient who presents frequently with physical complaints? You need to differentiate if they have a psychiatric diagnosis impacting their physical health or if there is an organic or medical cause of the symptoms. When should you refer out for mental health cases? Refer out for complicated mental health cases, suspected schizophrenia, OCD, dual diagnosis, etc. What percentage of the population has anxiety disorders? 10% What is the duration requirement for excessive anxiety and worry in Generalized Anxiety Disorder (GAD) according to DSM-5? More days than not for at least 6 months Part A of DSM-5 criteria for GAD states that the anxiety/worrry must be _____ about a number of events or activities (work, school performance) What is one of the required DSM-5 criteria for GAD? (part B) Difficult to control the worry According to the DSM-5, pts must have 3 or more of the following for a diagnosis of GAD -Restlessness or feeling keyed up or on edge -Easily fatigued -Difficulty concentrating or mind going blank -Irritability -Muscle tension -Sleep disturbances (difficulty falling or staying asleep) Part D of the criteria for GAD requires pts to experince ______ Clinically significant distress/impairment in social, occupational, or other important areas of functioning What must be ruled out for a diagnosis of GAD regarding substance effects? (part E of criteria) Anxiety related to psychological effects of a substance or another medical condition What medical conditions need to be considered when diagnosing GAD? hyperthyroidism, hyponatremia, asthma, SUD, anemia, Cushing sx, hypoglycemia, hypocalcemia, arrhythmia, anti-NMDA receptor, encephalitis, post-concussive sx, brain tumor, partial seizures What medications/substances should be considered when diagnosing GAD? caffeine, cocaine, amphetamines, hallucinogens, anticholinergics, cannabis, narcotics, PCP, withdrawal from ETOH, nicotine, benzos What is one of the excluding criteria for diagnosing GAD? (part F) Disturbance is not better explained by another mental health disorder What screenings should be done for GAD? -GAD-2 or -7: self reporting scale -(PHQ-4 or -9): Provides a very brief screen for both anx. and dep. -screening for depression, SI risk (ASQ) Why do you have to perform any diagnostics to diagnose GAD since it is a mental health disorder? need to R/O underlying causes: endocrine, cardiac (ECG), neuro, SUD, and other MH disorders What diagnostics should be done to rule out other diagnoses during a work up for GAD? Labs (should be normal): Initial tests may include TSH, CBC, BMP, UTox, and ECG. What are the first-line treatments for Generalized Anxiety Disorder (GAD)? SSRIs and SNRIs What are the benefits of using SSRIs and SNRIs for GAD? Effective, well-tolerated, no abuse/dependence, and treat co-morbid depression. What factors should be considered when selecting medication for GAD? Side-effect profile, drug-drug interactions, and patient treatment history/preference. What is a common SSRI for GAD? Escitalopram What is the recommended starting dose for Escitalopram (Lexapro) in GAD? 10 mg/day, may titrate to a maximum of 20 mg/day. What are common SNRI for GAD? duloxetine, venlafaxine What is the recommended starting dose for Duloxetine (Cymbalta) in GAD? 30 mg/day, titrate by 30 mg/day weekly, maximum of 120 mg/day. Even though the max dose of duloxetine for GAD is 120mg/day, are higher doses more effective? no, doses60mg/day are rarely more effective What is the recommended starting dose for Venlafaxine XR (Effexor XR) in GAD? 37.5-75.0 mg, may increase by 75 mg every 4 days, maximum of 225 mg/day. How long should a patient be treated with the highest approved dose of an SSRI/SNRI before it can be deemed ineffective/switching to another agent? At least 4-6 weeks. What should be done when discontinuing an SSRI or SNRI? Taper gradually. What is a potential short-term treatment option while waiting for antidepressants to take effect? Adding a benzodiazepine. How long may it take for remission to occur in GAD treatment? 4-6 months. For how long should GAD be treated? At least 12 months. What meds for GAD should be avoided in older adults? benzos and TCAs Why should benzos and TCAs be avoided in older adults? increase risk for fall and adverse reactions When to refer to specialist for GAD? -if no improvement with initial treatment -need for therapy -possible dual diagnosis, active SI What are the general screening recommendations for depression by the U.S. Preventive Services Task Force? Universal screening for depression in all adult patients in the primary care setting. Should pregnant and postpartum women be screened for depression? Yes, they should be included in universal screening for depression. MDD DSM-5 criteria 5+ of the following symptoms for 2 weeks: - depressed mood - subjective or observed by other - dec interest/pleasure - weight loss/gain - insomnia or hypersomnia - psychomotor agitation/slowing - fatigue or loss of energy - feelings of worthlessness or guilt - dec concentration/indecisiveness - recurrent thoughts of death/SI with at least 1 of the 5 symptoms is either depressed mood or loss of interest/pleasure (anhedonia) Dysphoria Subjective or observation by others of depressive mood most of the day anhedonia decrease in interest/pleasure in previously enjoyable activities most of day What does Criterion B of the DSM for Major Depressive Disorder state? Symptoms cause social, occupational, or functional distress. What does Criterion C of the DSM for Major Depressive Disorder specify? Symptoms are not attributable to substance effects or other medical conditions. What is stated in Criterion D of the DSM for Major Depressive Disorder? At least one major depressive episode is not better explained by schizoaffective disorder, superimposed schizophrenia, delusional disorder, etc. What does Criterion E of the DSM for Major Depressive Disorder indicate? There has never been a manic episode or hypomanic episode. Minor depression criteria 2 to 4 of the following symptoms of Criteria A + B & C as above and: -Persistent depressive disorder (dysthymia) and cyclothymic disorder are not present -The mood disturbance does not occur exclusively during a psychotic disorder MDD diagnostics -Diagnostics for underlying cause: can be a secondary/reactive depression -CBC, electrolytes, kidney/LFTs, TSH -rapid plasma reagin, HIV test -toxicology screen, vitamin levels (D, B12, folate) -Consider a pregnancy test in all reproductive-age women - CT/ MRI of the brain: should be considered for organic brain syndrome or hypopituitarism Screening/diagnostic tools for MDD PHQ-2 or PHQ-9, ASQ SIGECAPS + depressed mood -Sleep: changes in sleep habits from baseline excessive sleep, early waking, or inability to fall asleep -Interest: loss of interest in previously enjoyable activities -Guilt: excessive or inappropriate guilt may or may not be related to a specific problem or circumstance -Energy: perceived lack of energy -Concentration: inability to concentrate on specific tasks -Appetite: an increase or decrease in appetite -Psychomotor: restlessness and agitation or the perception that everyday activities are too strenuous to manage. -Suicidality: the desire to end one's life or hurt oneself, harmful thoughts directed internally, or recurrent thoughts of death or homicide When to screen for suicide risk? JACHO rec. that all patients seen in medical settings be screened What is the ASQ screening tool used for? Assessing suicide risk Who needs immediate referral or treatment for suicide risk? Individuals with active or imminent-risk suicidal ideation (SI) or homicidal ideation (HI) What should be done if a patient answers 'yes' to any of the first four ASQ questions? Ask if they are currently having active thoughts of killing themselves What is the next step if a patient confirms current suicidal thoughts? Conduct a STAT safety/full mental health evaluation in ED/emergent psych What precautions should be taken for a patient with confirmed suicidal thoughts? Keep the patient in sight and implement suicide precautions, and ensure the patient cannot leave until evaluated with a full STAT/safety mental health by emergency psychaitric services What should be done if a patient answers yes to previous questions but 'no' to the current suicidal thoughts question? Conduct a brief suicide safety assessment (BSSA) to determine if a full evaluation is needed What does the BSSA assess? Frequency of thoughts, plan, past behavior, symptoms, social support, and stressors What should be done if a patient refuses to answer questions or leaves during the assessment? It is considered Against Medical Advice (AMA) What is the follow-up procedure if a patient is deemed at risk but not imminent? Review the safety plan and send the patient home with a mental health referral within 72 hours When should follow-up contact occur after sending a patient home? Within 48 hours via phone call First line medications for MDD SSRIs and SNRIs What is the starting dose of Citalopram (Celexa)? 20 mg/day What is the maximum dose of Citalopram (Celexa) for patients over 60 years old? 20 mg/day What is a concern associated with Citalopram (Celexa) at doses over 40 mg? QTc prolongation What is the starting dose of Escitalopram (Lexapro)? 10 mg/day What is a concern when using Escitalopram (Lexapro)? QTc prolongation What is the starting dose of Fluoxetine (Prozac)? 20 mg/day What is the most commonly prescribed 1st line SSRI for teens that is FDA approved for depression? fluoxetine (prozac) What is the black box warning regarding antidepressant use with adolescnets? increased risk of suicidality in children, adolescents and young adults When should a referral to mental health specialist be made for adolescents? When prescribing medications What is the starting dose of Paroxetine (Paxil)? 20 mg/day What is the starting dose of Sertraline (Zoloft)? 50 mg/day Which SSRI has increased rates of diarrhea? sertraline (zoloft) Adverse effects of SSRIs sexual dysf, GI upset, dizziness, insomnia, headache, weight gain Are the side effects that are present on initiation of SSRI premanent? No, they typically resolve within the 1st week. SNRI Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine XR (Effexor XR) Which SNRI has incrased rates of sexual dysfunction and drowsiness? Venlafaxine (effexor) bupropion (wellbutrin) NDRI serotonin modulators Trazodone (Desyrel) Vilazodone (Viibryd) Vortioxetine (Trintellix) Common adverse effects of serotonin modulators somnolence, dizziness, constipation/diarrhea, sexual dysf. What may occur with abrupt discontinuation of antidepressants, especially SSRIs? Withdrawal symptoms may occur. What percentage of patients may experience withdrawal symptoms when discontinuing antidepressants abruptly? Up to 50% of patients. What are some common withdrawal symptoms from antidepressants? Dizziness, nausea, headache, paresthesia. What does the FINISH mnemonic stand for in relation to antidepressant withdrawal symptoms? Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, Hyperarousal. What are considerations when prescribing antidepressants for older adults? should start at lower doses, check any drug interactions; avoid TCAs, Fluoxetine (Prozac), Paroxetine (Paxil), Paxil CR What is the first step in the American Psychiatric Association (APA) treatment guidelines for the acute phase? Full evaluation, including risk to self and others, with selection of appropriate treatment setting. What is the primary goal of treatment during the acute phase according to the APA guidelines? Symptom remission and recovery of function. What types of treatment does the APA recommend offering during the acute phase? Either psychotherapy or a 2nd-generation antidepressant (SSRI or SNRI). What is recommended for severe cases during the acute phase according to the APA? Combined therapy. How often should follow-up occur after starting medication in the acute phase? Follow-up within 2 to 4 weeks, then every 2 weeks until improvement, and then monthly. How frequently should the dosage be increased during the acute phase? Every 3 to 4 weeks until remission. How long does it typically take to achieve the full effect of treatment in the acute phase? 4 to 6 weeks. What might be necessary if a patient does not respond to the initial medication during the acute phase? A second medication may be needed. How many visits are recommended for monitoring during the acute phase? At least 6 visits. What is the follow-up recommendation for younger patients or those at high suicide risk during the acute phase? See within the first week and follow frequently. Patient education regarding antidepressants -4-6 weeks to take effect -common side effects— usually go away within a week -create a safety plan with the patient When to refer to mental health specialist when considering medication for MDD -not responding to tx, warranted for long-term treatment, medication use, and titration, and therapy -passive SI What are the three components of the SUD triad? 1. Psychological dependence/craving and behavior involved with the procurement of the drug. 2. Physiologic dependence with withdrawal symptoms on discontinuance of the drug. 3. Tolerance with a need to increase the dose to obtain the desired effect. What are some common substances of abuse? ETOH (alcohol), opioids, cocaine, marijuana, methamphetamine, benzodiazepines, hallucinogenics, caffeine. What are some risk factors for substance use disorder? Family history of substance use, family dysfunction, trauma, significant life stressors, availability of substances, genetics, previous history of SUD or gambling, mental health diagnosis. SUD initial assessment -H&P: know what the drug of choice is, and the symptoms that come with it, and the withdrawal -Patients can become addicted to opioids within as little as 3-5 days -little to no indication for opioids as first-line treatment for anything in the outpatient setting -screening tools: AUDIT, CAGE, TAPS, S2BI, BSATD frequency of use, symptoms -nonjudgmental — in a way where they will not want to lie to you -frequency of use, symptoms -withdrawal symptoms present — COWS, CIWA-Ar -ETOH: intoxication, CNS depression, psychomotor dysfunction, withdrawal symptoms, DTs, -men: 4 or more drinks/day or 14 drinks/week -women: 3 or more drinks/day or 7drinks/week -BAC: 80mg/dL (legal limit), n/v=150mg/dL, lethal range=350-900mg/dL SUD initial diagnostics based on the substance used and the effects on the body Utox, breathalyzer, serum toxicology Assessment/screening tools What does SUD treatment vary based on? The substance, treatment for withdrawal symptoms, and specialized treatment needed. What types of referrals may be needed for SUD treatment? Referral for MAT, inpatient treatment, detox, or IOP. What are two support groups for SUD? Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). What medications are commonly used for Opioid Use Disorder (OUD)? Buprenorphine, methadone, opioid agonist therapies, Suboxone, and Sublocade. What is required for providers to prescribe Suboxone? Special prescriptive authority. Treatment considerations for eating disorders Referral is always needed for an interdisciplinary approach with mental health/nutrition -many need inpatient tx What is anorexia nervosa? A severe food restriction leading to significantly low body weight relative to age, sex, and physical health. What are the key features of anorexia nervosa? Intense fear of gaining weight, behaviors that interfere with weight gain, and altered perception of body weight/shape. What are the two types of anorexia nervosa? Restrictive type and binge eating/purging type. What is a common initial assessment finding in anorexia nervosa? Malnourished and cachectic. What is a common psychological characteristic of individuals with anorexia nervosa? Denial of the seriousness of their underweight status. What are some physical exam findings associated with anorexia nervosa? Cold intolerance, constipation, loss of body fat, bradycardia, lanugo, and dry skin. What initial diagnostics should be considered for anorexia nervosa? Rule out other medical/mental health diagnoses that could be contributing. What are some medical conditions to rule out when diagnosing anorexia nervosa? Addison's disease, hyperthyroidism, GI disorders (like Crohn's disease), cancer/lymphoma, hypothalamic tumor, and type 1 diabetes mellitus. What types of medications could contribute to anorexia nervosa? Stimulants, chemotherapy, and others. What is Bulimia Nervosa characterized by? Repeated binge eating followed by inappropriate compensatory behaviors to prevent weight gain. Image: What is Bulimia Nervosa characterized by? What are some examples of compensatory behaviors in Bulimia Nervosa? Self-induced vomiting, misuse of laxatives, diuretics, fasting, and excessive exercise. What defines binge eating in Bulimia Nervosa? Eating an amount of food larger than what most individuals would eat in a similar time period and feeling unable to control the overeating. How often do binge eating and compensatory behaviors occur in Bulimia Nervosa? At least once a week for 3 months. How does self-value relate to Bulimia Nervosa? Self-value is overly influenced by body shape and weight. Do binge eating and compensatory behaviors occur during episodes of Anorexia Nervosa? No, they do not occur exclusively during episodes of Anorexia Nervosa. What are some physical examination findings in Bulimia Nervosa? Anemia, electrolyte abnormalities, and changes in the mouth due to vomiting. What dental issues can arise from Bulimia Nervosa? Deterioration of the back of the teeth and enamel due to vomiting. What is a common weight characteristic of individuals with Bulimia Nervosa? They are often normal weight or slightly overweight. What initial diagnostics are performed for Bulimia Nervosa? Ruling out endocrine, metabolic, GI issues, infections, and cancer. What laboratory findings are often associated with Bulimia Nervosa? Anemia, electrolyte abnormalities, and increases in BUN and creatinine. What is a concussion? A type of mild traumatic brain injury (mTBI) characterized by a transient alteration in brain function following an external force. What are common causes of concussions? Falls, motor vehicle accidents, sports injuries, and physical assaults. What is a key component of the assessment guidelines for concussion? Thorough clinical assessment, including detailed history and neurological examination. What standardized assessment tool is used for concussion assessment? Sport Concussion Assessment Tool (SCAT5). What should be implemented for concussion management? Individualized management plans tailored to the patient's symptoms and recovery trajectory. What are common symptoms of a concussion? Headache, confusion, dizziness, nausea, and cognitive impairment. Can loss of consciousness occur with a concussion? No, loss of consciousness is not required for a concussion to be present. What signs should be assessed for potential skull fracture in concussion cases? Battle sign, raccoon sign, and leakage of CSF from ears or nose. Which cranial nerves should be tested during a concussion assessment? Cranial nerves 1, 2, 3, 4, 5, 7, and 8. When should the Glasgow Coma Scale (GCS) be assessed after a concussion? 30 minutes after the injury. Image: When should the Glasgow Coma Scale (GCS) be assessed after a concussion? What GCS score indicates a mild traumatic brain injury (TBI)? GCS 13-15. Image: What GCS score indicates a mild traumatic brain injury (TBI)? What GCS score indicates a severe traumatic brain injury (TBI)? GCS 8. Image: What GCS score indicates a severe traumatic brain injury (TBI)? Can concussion symptoms evolve over time? Yes, symptoms may present immediately or evolve over time. Initial doagnostics for concussion Head/neck CT (based on GCS), may need C-spine precautions/x-ray/CT if neck pain or unconscious Indications for heat CT in head trauma/TBI/concussion -GCS 15 -focal deficit -seizure -coagulopathy -age 60 -persistent h/a -vomiting -retrograde amnesia 30 min. -intoxication -soft tissue injury of head or neck -dangerous mechanism (struck by a car, severe injury) Determining disposition for patient after head trauma Patients needing imaging should be admitted unless head CT is normal, GCS 15, seizure-free, no risk for bleeding, & can be monitored at home hourly by a responsible adult What is the treatment approach for concussion/TBI based on severity? Careful monitoring of symptoms. What should be done if a patient does not meet criteria for imaging after a concussion? They can be sent home with someone capable of performing hourly checks on the patient for 24 hours. What is the recommended return to sports protocol after a concussion? Slow return to sports with an initial period of rest; the patient needs to be asymptomatic. How long do most symptoms of a concussion last? Most symptoms resolve by 1 month, almost all by 3 months, and some may last over 1 year (10 15%). What is the approach for returning to daily activities after a concussion? Gradual return to daily activities, including cognitive and physical exertion. What is the treatment for concussions with no loss of consciousness and negative head CT but persistent symptoms? Resting the eyes (no TV, tablet, computer for long periods) and avoiding activities that can increase the risk of further head injury. What type of clinics can be utilized for concussion management? Concussion clinics for repeat testing and training. When should a referral be made for a concussion patient? For focal neurological deficits, altered consciousness, skull fractures, or late complications of head injury. What are the emergency department criteria for a concussion patient? GCS 15, predisposition for bleeds, seizure, no responsible caregiver, or abnormal head CT.