Download Georgette Review PMHNP Exam 388 QUESTIONS and ANSWERS (GRADED A) 100% VERIFIED ANSWERS and more Exams Nursing in PDF only on Docsity! When many answers are remarkably similar, they are usually wrong Interprofessional collaboration is encouraged. Collaborate is usually right. Delegate is usually wrong. ADPIER Assessment, diagnosis, Plan, intervention, evaluate, refer out last. Lithium Normal 0.6-1.2 Lithium toxicity occurs at levels > 1.5 Signs of Lithium toxicity severe nausea, diarrhea, vomiting, confusion, drowsiness, muscle weakness, heart palpitation, coarse hand tremors, unsteady gait Georgette Review PMHNP Exam 388 QUESTIONS and ANSWERS (GRADED A) 100% VERIFIED ANSWERS Lithium is gold standard for MANIA Lithium has evidence shown to reduce suicidal ideation What does lithium cause in neonate, especially 1st trimester Ebstein anomaly (congenital heart defect) dehydration and hyponatremia cause lithium levels to rise Baseline labs before initiation of lithium TSH creatinine (0.6-1.2) BUN (10-20) HCG (all psychotropics females 12-51) EKG 50+ Urinalysis (check for proteins, 4+ may indicate kidney disease) Side Effects of Lithium hypothyroidism coase hand tremors with toxicity maculopapular rash decongestants TCAs atypicals St. John's wart L-tryptophan asthma meds Treatment for hypertensive crisis DC offending agent Administer PHENTOLAMINE Teratogenic effects of benzos floppy baby, cleft palate Teratogenic effects of tegratol neural tube defect teratogenic effects of lithium ebstein anomaly (heart defect) (avoid, especially 1st trimester) teratogenic effects of depakote neural tube defects/spina bifida Adverse reaction to Lamictal Steven Johnson's Syndrome Signs of SJS FEVER --high yield sore throat facial swelling tongue swelling red rash skin sloughing body aches prodromal headache malaise arthralgia painful mucus membranes Lamotrigine is least likely to cause sedation or weight gain Carbamazepine (tegretol) black box warning agranulocytosis (decrease WBCs) aplastic anemia (pallor, fatigue, HA, fever, nosebleeds, bleeding gums, skin rash, SOA) Carbamazepine and asians Screen for HLAB-1502 allele before initiating, due to high incidence of SJS if positive for allele. Child-bearing aged women check for pregnancy before starting mood stabilizer start on folic acid to support neural tube development during the first month that a woman is pregnant Clozaril/clozapine can cause agranulocytosis and neutropenia For monitoring neutropenia in Clozaril, monitor ANC DC clozarli if ANC less than 1000 DC clozaril if WBC 2000-3000, risk of agranulocytosis When on clozaril monitor for signs and symptoms of infection: sudden fever, chills, sore throat, weakness Clozaril only known antipsychotic to decrease risk of suicide in patients with schizophrenia. Emaciation Bradycardua Hypotension Pharm treatment for anorexia there is none therapy Which of the following physical exam findings would help the PMHNP differentiate anorexia nervosa from bulimia nervosa? A. Russell sign B. Low BMI C. Erosion of dental enamel D. Hypertrophy of salivary glands Low BMI If a patient is depression, low energy, fatigued, you would prescribe Wellbutrin Wellbutrin is contraindicated in patients with seizure disorder or conditions that increase risk of seizures such as eating disorder. Which of the following medications has a unique mechanism that is both a norepinephrine and dopamine reuptake inhibitor? A. Bupropion (Wellbutrin) B. Sertraline (Zoloft) C. Clomipramine (Anafranil) D. Duloxetine (Cymbalta) bupropion CLozaril is metabolized by cytochrome P450 enzyme CYP1A2 INducers induce metabolism and therefore decrease serum levels of other drugs that are substrates Smoking will do what to drug levels decrease therapeutic levels of the drug Bull Shit CRAP GPS Induces my rage Barbituates St. Johns Wart Carbamazepine Rifampicin Alcohol Phenytoin Griseofulvin Phenobarbital Sulphonylureas If your patient is a smoker you will need doses of their medication. higher Inhibitors inhibit metabolism and therefore increase levels of the drug. SICKFACES.com for Inhibitors Sodium valproate Isoniazid Cimetidine Ketoconazole Alcohol Chloramphenicol Erythromycin Sulfonamine Cipro Omeprazole Metronidazole Which cytochrome enzyme is implicated as a tobacco inducer when an individual is treated with clozapine a. 2D6 b. 1A2 c. 2C19 benzos Fred flinstone needs a Zanny, Gabba dabba do. Most excitatory neutransmitter glutamate Increased level of corticotropin releasing hormone in the amygdala, hippocampus and locus coeruleus increases symptoms of anxiety. Autism deficits in social communication and social interaction across multiple settings Parents of kids with autism may report No response when called by name Little or no eye contact Children with autism often like to line up, stack, or organize objects and toys. Screenings for autism ADOS M-CHAT ASQ Pharm management for autism antipsychotics are effective for symptoms such as tantrums, aggressive behaviors, self-injurious behaviors Serotonin is a neurotransmitter that is implicated in sleep and mood. What area of the brain has a large majority of serotonin neurons? A. raphe nuclei B. Nucleus acumbuns C. Locus coeruleus D. Amygdala raphe nuclei Executive functioning, thinking, planning, organizing, and problem solving, emotions, and behavioral control, personality frontal lobe memory, understanding, language temporal lobe Both hemispheres of the brain are connected by the corpus callosum Area of sensorimotor information exchange between two hemispheres corpus callosum When there is disturbances in clock drawing test, which hemisphere is compromised right hemisphere/right parietal lobe Area for expressive speech frontal lobe Broca's Area Problems in the frontal lobe can lead to personality changes, emotional changes, and intellectual changes, social skills problems, and behavior changes Area for receptive speech and language comprehension Temporal lobe Wernicke's area Problems in the temporal lobe can lead to auditory hallucinations, aphasia, and amnesia Occipital lobe primary visual area problems in the occipital lobe can lead to Visual field deficits, blindness and visual hallucinations. substantia nigra motor movements amygdala= emotional memory Which of these brain structures puts emotional meaning on a stimulus, forms, emotional memories and is involved with rage and fear amygdala A client presents with complaints of changes in appetite, feeling fatigued, problems with sleep-rest cycle, and changes in libido. What is the neuroanatomical areas off the brain that is responsible for the regulation of these functions? Hypothalamus Which serotonin receptor antagonism makes an antipsychotic "atypical" 5HT2A Excess dopamine in this area causes positive schizophrenic symptoms meoslimbic pathway decreased dopamine leads to negative symptoms of schizophrenia mesocortical pathway Increased blockade of dopamine here leads to EPS nigrostriatal pathway Blockade of dopamine in this pathway can lead to increased prolactin levels tuberoinfundibular pathway Muscle spasms ninth face, neck, tongue, back/neck muscles acute dystonia Oculogyric crisis, which can lead to permanent injury. Patients have prolonged involuntary upwards deviation of the eyes bilaterally. Rare presentation of acute dystonia. Pharm treatment for dystonia cogentin (IM first then oral) Restlessness, inability to sit still. Pacing. Mistaken for anxiety. Akathisia Commonly used rating scale for akathisia is Barnes Akathisia rating scale and extrapyramidal symptom rating scale. Treatment for akathisis 1st line 2nd line 3rd line 1st: beta blocker 2nd: Cogentin 3rd: bnzodiazepine Absence of movement or difficulty initiating movement akinesia Treatment: cogentin Presence of symptoms of Parkinson's produced by D2 blockade in the nigrostriatal pathway Pseudo-Parkinsonism Signs of Parkinsons muscle rigidity shuffling gait mask like facial expression pill rolling tremors cogwheel rigidity Pharmacokinetics What the drug does to the body pharmacodynamics The drug binds to the receptors and activates a biological response (opens the ion channel) agonist effect drug causes the opposite effect of the agonist. Binds to the same receptor but closes the channel inverse agonist drug does not fully activate the receptor partial agonist drug binds to the receptor but foes not activate a biological response antagonist The study of what the drug does to the body. Pharmacodynamics When studying pharmacodynamics involving receptor, you know that an agonist produces the following effect? A. Does not fully activate the receptor B. Blocks the agonist from opening the channel C. Causes the opposite effect D. Activates a biological response and opens the ion channel. Activates a biological response and opens the channel. Medications that can cause mania (very high yield) Steroids Antabuse Isoniazid Antidepressants in persons with bipolar Flonase Medications causing depression steroids beta blockers interferon accutate some retroviral drugs antineoplastic drugs benzos progesterone Fragile X syndrome all their facial structures are larger. Severe adverse effect caused by antipsychotics neuroleptic malignant syndrome Extreme muscle regidity Mutism elevated CPK Myoglobinura (cherry colored urine) Elevated WBCs Elevated LFts signs of NMS Treatment for NMS DC Offending agent Bromcriptine (parlodel) Dantrolene (muscle relaxant Serious effect of SSRIs serotonin syndrome hyperreflexia, myoclonic jerks, sweating serotonin syndromeq Treatment for serotonin syndrome Folstein/mini mental status registration/ability to learn new material repeat after me, bed, bat, ball Suiciidal risk factors previous attempt Male 45+ Female 55+ Divorced, single, separated white living alone psychiatric disorder physical illness substance abuse family history recent loss male gender Characteristics of therapeutic relationship Genuineness Acceptance Nonjudgment Authenticity Empathy Respect Professional boundaries displacement of feelings for significant people int he client's past onto the PMHNP transference Nurses's emotional reaction to the client based on past experiences. Countertransference Sarah presents for her initial intake appointment with complaints of depression. She is being treated for hypertension and asthma by her primary care provider. Knowing that certain medications can cause or exacerbate depression, you obtain a complete medication history. Which of the following medications is known to exacerbate or cause depression? A. Omeprazole B. Propranolol C. Levothyroxine D. Clarithromycin Propranolol A patient with a known diagnosis of bipolar I disorder presents to your clinic complaining of manic symptoms and insomnia. Your patient has been stable on lithium for the past six months To determine if a medication change or increase is warranted, it is important to gather more information. You suspect a possible medication-induced manic episode when the patient endorses what? A. She was recently placed on a beta blocker for anxiety. B. She was recently prescribed a benzo C. She recently had a flare up of her rheumatoid arthritis and received treatment for one week (aka a steroid) D. She recently began a new retroviral agent for hepatitis recently treated for RA Scale to test for alcohol withdrawal CIWA Score on CIWA that warrants PRN greater than 8 Medication that will make patient physically ill if combined with alcohol disulfiram (Antabuse) Antabuse shouldn't be taken for at leas after drinking 12 hours. Signs and symptoms of alcohol withdrawal N/V/D tremors sweats anxiety agitation tactile disturbances auditory disturbances visual disturbances headache altered sensorium agitation Treatment of choice for delirium haloperidol Avoid which class in delirium as it tends to prolong it benzos impaired executive functioning, impaired problem solving, impaired organizational skills, altered memory. slow onset dementia John is a 58 year old male patient with Bipolar 1 disorder and has been stable for 5 years on valproate and Seroquel. He was recently started on Flonase by his primary care. As the PMHNP, you are concerned that the addition of the Flonase may cause A. A hypertensive crisis B. SJS C. NMS D. a manic episode a manic episode A 16-year off boy presents with a long head, large ears, and hyper extensible joints, is very shy, and starts rocking and flapping his hands when he is upset. Which of the following is your most likely diagnosis? A. Tourette disorder B. Autism C. Fragile X D. Rett disorder Fragile X What muscle relaxant is recommended to be used in treatment of NMS? A. Bromocriptine B. Trihexyphenidyl C. Dantrolene D. Benztropine Dantrolene A week after raising the dose of clomipramine, a patient treated for depression presents to the clinic with reports of change in mental status, fever, and hyperreflexxia. As the treating PMHNP, you know these symptoms are consistent with which of the following? A. NMS B. EPS C. Hypertensive crisis D. Serotonin syndrome serotonin syndrome A 24 year olf female attempts suicide by overdose on an MAOI phenelzine. She is stabilized in the hospital. Ten days later she is started on venlafaxine and becomes tachycardia and diaphoretic, and develops myoclonic jerks. What condition is this? A. NMS B. Opisthotonos C. Akathisia D. Serotonin syndrome serotonin syndrome a 17 year old arrives at the emergency department with nonspecific complaints The patient's temperature is 100.8, pulse rate and blood pressure are elevated, and pupils are dilated with decreased reaction to light. Two days ago, the patient began taking sertraline for the treatment of depression. the patient has a history of substance use and smoked marijuana one week ago. The diagnosis is serotonin syndrome Patient being treated for psychosis for 2 weeks develops symptoms of NMS. The following factors help the pMHNP to differentiate NMS from serotonin syndrome. A. autonomic instability, diaphoresis, tremors B. Hyperthermia, leukopenia, tachycardia C. Rigidity, hyperrefelexia, orthostatic hypotension D. Mutism, leukocytosis, myoglobinuria mutism, leukocytosis, myoglobinuria Appraisal of the patient's SI plan, intent and access to implement plan would be documented in which part of standard psychiatric evaluation A Review of symptoms. B. Diagnosis C. Mental status exam D. History of presenting illness C mental status exam a 48 year off Caucasian male presents for his therapy appointment. He is sad about losing his wife recently to covid 19. He reports feeling thoughts of hurting himself. He has a past history of overdosing on propranolol several years ago. Which of the following places him at higher risk of suicide? A. Previous attempt 14-18 Moderate level on the PHQ-9 10-14 Moderate level on the Beck 10-29 Moderate on GAD 7 10-14 Moderate on COWS 13-24 Moderate on CIWA 15 Dementia is characterized by onset. gradual Alzheimers is cortical or subcortical dementia cortical Cortical dementia causes language and memory problems. Examples of subcortical dementia Huntington's disease Parkinson's disease AIDS dementia complex Which type of dementia can cause depression, motor symptoms, and apathy subcortical Cognitive decline (concentration, attention), motor abnormalities(lack of coordination, ataxia, tremors, dystonia, muscle rigidity) and behavioral abnormalities (HIGH YIELD) dementia r/t HIV Recurrent visual hallucinations Parkinson features Adversely reacts to antipsychotics Lewy body dementia---recurrent visual hallucinations. caused by cardiovascular disease. Common in hypertension and CVD vascular dementia Hallmark signs of vascular dementia carotid bruits, fundoscopic abnormalities, and enlarged cardiac chambers Personality, language (slurred) and behavioral changes Picks disease --frontal lobe changes Huntington's disease subcortical, think motor symptoms High incidence of depression nd psychosis First line agent for psychotic symptoms of dementia antipsychotics avoid benzos A 69 year old man with diagnosis of delirium has symptoms of psychosis which include frightening auditory and visual hallucinations and paranoid delusions. Which of the following medications should be chosen first for this man's symptoms? A. Haloperidol B. Quetiapine C. Valium D. Olanzapine haloperidol. Hallmarks of ADHD persistent pattern of inattention or hyperactivity, impulsivity, or both. What to check prior to prescribing a stimulant? cardiac history, family history of CVD and get an EKG prior to starting Amphetamines are approved in children as young as 3 Signs of stimulant abuse insomnia tremors heart palpiations increased BP and HR Rating scale for ADHD Connors and Vanderbilt Must monitor in two settings Hallmarks of borderline personality disorder impulsivity with self-damaging behavior Recurrent suicidal behavior Treatment for Borderline DBT Hallmarks of antisocial personality reckless disregard for welfare of others lack of remorse indifference to the feelings of others INCREASED HOMICIDAL IDEATION --HIGH YIELD Primarily in girls normal development then decline loss of purposeful hand movements stereotypic hand movements --flapping of hands deceleration of head growth Rett syndrome Chronically moody, sad irritable for no reason Disruptive mood dysregulation disorder patient reacts grossly out of proportion to situation sudden rage/anger outbursts Intermittent explosive disorder Mnemonic for depression SIGECAPS Sleep disturbance interest reduced guilt and self-blame energy loss and fatigue concentration problems appetite changes psychomotor changes suicidial thoughts Neurotransmitters involved in depression DNS dopamine, norepinephrine, serotonin cognition and memory symptoms of MDD in older adults is often confused with dementia related symptoms and is called pseudo dementia = depression Clients with pseudodementia/depression, have a of symptoms. acute onset. Dementia patients will have Pseudodementia/depression will have dementia: lack of answers or confabulate answers B. Assess her current level of suicidality C. Take her vital signs D. Asess her health history take her vital signs Bipolar Mnemonic (DIG FAST) Distractibility impulsivity grandiosity flight of ideas agitation, psychomotor sleep need decreased talkativeness, pressured speech What is the gold standard treatment for mania lithium What is neuroprotective treatment for bipolar I lithium Normal Free T4 0.8-2.8 Normal TSH 0.5-5.0 When T4 and T3 are high, and TSH is low hyperthyroidism When T4 and T3 are low, and TSH is high hypothyroidism Hypothyroidism mimics depression hyperthyroidism mimics mania sensitive to cold, cold intolerant hypothyroid heat intolerant hyperthyroid Normal AST and ALT AST 5-40 ALT 5-35 with liver damage ALT rises to 50x normal Argues with authority oppositional defiant disorder defiant but not aggressive oppositional defiant disorder treatment for ODD therapy Person is aggressive, lack of remorse, destruction of property, deceit or theft conduct disorder treatment for conduct disorder target mood and aggression. person has sudden: blindness, mutism, paralysis, paresthesia, neurological symptoms conversion disorder excessive worry more than 6 months GAD Age of onset of schizophrenia in males 18-25 Age of onset of schizophrenia in females 25-35 Cause of schizophrenia intrauterine insults prenatal exposure to toxins, including viral agents Problem in the brain in schizophrenia enlarged ventricles, everything else decreases Things to monitor and labs while on antispychotic serum glucose, serum lipid panel, weight, BMI, waist to hip ratio. liver and kidney function CBC non-harm treatment for schizophrenia ACT (assertive community treatment) Person has psychotic symptoms similar to schizophrenia as well as mood symptoms seen in depression and bipolar schizoaffective trust vs mistrust birth to one year virtue in trust vs mistrust hope autonomy vs shame and doubt early childhood 1-3 years virtue for autonomy vs shame and doubt will (they seek will power, independence) Inititiative vs. guilt late childhood 3-6 years virtue of initiative vs guilt purpose Ability to be a self-starter, to initiate one's own activities. Industry vs inferiority (VERY HIGH YIELD) school age 6-12 years Industry vs inferiority virtue competence Identity vs role confusion Adolescence 12-20 identity vs role confusion virtue fidelity personal identity unfavorable: they're confused over who they are. Initimacy vs isolation Early adulthood 20-35 Freud Anal Stage 1-3 years Erogenous zone: anus Freud Phallic Stage 3-6 years Erogenous zone is genitals Freud latent stage 6 to puberty Representation of sexual feelings Freud Genital stage •puberty-adulthood •sexual urges reawaken & are directed to an individual outside the family circle •unresolved conflicts from previous stages arise •if conflict is resolved, capable of having a mature adult sexual relationship individuals are able to distinguish between self and non self ego boundaries way of coping with anxiety in which an object or person of ambivalence is viewed as perfect or has having exaggerated positive qualities idealization person attributes themselves, an object or another person as completely flawed, worthless, or having exaggerated negative qualities devaluation motivational interviewing based on trans theoretical model of change nonconfrontational ask open ended questions empatheic patient centered affirmations of the positive traits reflective listening Transtheoretical Model of Change Precontemplation Contemplation Preparation Action Maintenance Relapse person has no intention of change and lack of insight precontemplation action in precontemplation give information to raise awareness of the problem, but do not try to tell the person what to do. person is thinking about change, is aware there is a problem, but is not committed to changing contemplation action in contemplation help the person find a change strategy that is realistic, acceptable, accessible, and effective. Person has made the decision to change and is ready for action preparation action step in preparation help the person find the change strategy that is realistic, acceptable, appropriate, and effective. person is engaging in specific, overt actions to change action action step in action support and advocate help accomplish steps for change. Family systems therapy (VERY HIGH YIELD) triangles, triangulation, self-differentiation triangles are not good for the family Structural family therapy boundaries, hierarchies Strategic therapy paradoxical intervention--tell the family member that they can worry for one hour of the day. Solution focused therapy miracle question patient attributes their own unacceptable thoughts feelings, and motives onto another person projection redirection of an impulse (usually aggression) onto a powerless substitute target displacement displace our unacceptable emotions onto behaviors which are constructive and socially acceptable, rather than destructive healthy defense mechanism sublimation concentrating on intellectual aspects to avoid emotional aspects of a difficult situation. Ex, cancer patient reading up on their disease Intellectualization Justification for an uncceptable behavior rationalization Yalom's Curative Factors - Altruism: giving of oneself to help others - Catharsis: relieving of emotions by expressing one's feelings - Universality: recognizing shared feelings and that one's problems are not unique - Existential factors: address accepting the fact that respons. for change comes from w/in oneself - Self-understanding: discovering and accepting unknown parts of oneself - Family reenactment: understanding what is was like growing up in one's family through group exp. - Guidance: accepting advice from other members - Identification: benefiting from imitation of the positive behaviors of other group members - Instillation of hope: experiencing optimism through observing improvement of other members - Interpersonal learning: occurs when receiving feedback from grp members re: one's bx (input), learning successful ways of relating to group members (output) study of long term sequel of adverse childhood events found positive relationship between heart disease, obesity, DM, unintended pregnancy, depression, anxiety, cancer, COPD, sleep disorders, dissociative disorders, and substance use disorder. Dialectical behavioral therapy (DBT) draws on cognitive theory and behavioral theory, along with other theories. Elements of behavioral therapy in DBT include which of the following? A. Skills training and exposure B. Examination of feelings and relating feelings to visceral sensations C. Working through the transference with the therapist D. Cognitive interpretation of past traumatic events. A skills training and exposure treatment approach that does not focus on full symptom resolution but emphasizes resilience and control over problems and life. Recovery isn't about getting rid of the problem, but recognizing and fostering their abilities, interests, and dreams. Recovery Model Goals of Assertive COMMUNITY Treatment help people become more independent and integrate into the community reduce reliance on hospitals providing around the clock care. NP Core Competencies Scientific Foundations Leadership being respectful, competent and professional fidelity telling the truth veracity doing for self autonomy Rennie v Klein Court Case involuntary patient not found incompetent, has a right to refuse psychotropic medications, goal of case management promote quality and cost-effective outcomes. Stark Law you can't refer to family members for treatment of your patients. PICOT Patient or problem intervention comparison outcome time evidence from systematic review or meta analysis of many RCTs level 1 evidence evidence from at least one RCT level 2 evidence Before implementing/creating change of policy assess/address/identify potential organizational barriers and facilitators meet with stakeholders patient advocacy reduce stigma of mental illness through education help patients receive available services Seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix system issues just culture of safety Process for quality improvement plan, do, study, act reflective practice debriefing strategies goal: to improve practice Highest rate of suicide in US native Americans True or false A culturally expected response to a stressor does not always mean a mental illness true grasp palmar reflex disappear by 5-6 months moro startle reflex disappear by 5-6 months babinski reflex normal until age 2 shrill cry in baby