Midterm Exam 2024-2025 for NR 547 Course, Exams of Nursing

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DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) differential diagnosis - correct answer- The provider's initial hypothesis

• a working list of potential problems that can be associated with the initial or chief complaint
• Diagnostic and Statistical Manual of Mental Disorders (DSM- 5 - TR)
• provides guidance for identifying psychiatric diagnoses Psychiatric assessment: History taking - correct answer- - History of Present Illness
• How long have you been feeling this way?
• Did something happen in your life that may have triggered these emotions?
• How is this current situation impacting your life? The Psychiatric History
• Have you ever been hospitalized for any mental health issues?
• Have you ever had counseling or psychotherapy?
• Have you ever taken medications for your mental health in the past?
• Are you currently on any medications for mental health or sleep? Medical History/Screening for General Medical Conditions
• Do you have a primary care provider?
• Do you have any medical illnesses?
• Are you currently taking any medications or herbal supplements?
• Do you have any allergies to medications?
• Have you ever been hospitalized for any reason?
• Have you ever had surgery? Family Psychiatric History
• Has any relative of yours ever been hospitalized for a mental health issue?
• Has any blood relative of yours ever been diagnosed with a mental health issue?
• Has any blood relative of yours had a history of seizures or dementia/Alzheimer's?

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Social and Developmental History

• Tell me a little bit about your childhood and how you grew up.
• How was your experience in school when you were younger? Did you enjoy school?
• How do you support yourself with your finances?
• Do you have a good support system? Are you currently in a relationship? Where do you live? Who do you live with?
• What do you do in your free time? What activities do you enjoy? Screening and Psychiatric Rating Scales - correct answer- Evidence-based screening tools and psychiatric rating scales
• can help the provider identify symptoms and assess their severity and can assist with the evaluation of response to treatment A 52-year-old client presents to the emergency department following a car accident. The emergency department (ED) physician is concerned that the client may have intentionally crashed her car and requests a stat PMHNP consult. In speaking with the PMHNP, the client describes persistent feelings of sadness and hopelessness. She states that she often wonders if her husband would be happier if she wasn't around anymore since she's never happy and sometimes thinks about what it would be like to just take a handful of sleeping pills and go to sleep forever. The client reports a previous suicide attempt when she was 16 but denies that she is considering killing herself right now. Based on the client's ASQ score, what is the most appropriate response? No action is necessary as the client is not currently considering suicide. Provide a brief suicide safety assessment. Alert the client's primary care physician. Provide a ST - correct answer- Provide a brief suicide safety assessment. Rationale: While the client's responses do not indicate a need for a stat full safety and mental health evaluation, the client requires a brief suicide safety assessment to determine whether a full mental health evaluation in necessary. It is also important to notify the client's physician or the clinician responsible for the client's care.

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Platelets: 150,000-300,000/microliter Basic Laboratory Interpretation: Comprehensive Metabolic Panel (CMP) - correct answer- common blood test used to determine general health status

• fluid and electrolyte balance, status of the body's metabolism, liver function, and kidney function
• used to monitor the effects of medications, such as antipsychotics, on liver function and glucose levels
• rule out medical conditions that could cause symptoms
• Ex: changes in mood or cognition Sodium (Na+): 136-145 mEq/L Postassium (K+): 3.5-5.0 mEq/L Chloride (Cl-): 95-105 mEq/L Bicarbonate (HCO3-): 22-28 mEq/L Calcium, serum (Ca 2+) 8.4-10.2 mg/dl Glucose, serum Fasting: 70-110 mg/dl; 2-h postprandial: <120mg/dl Cholesterol, serum: REC<200 mg/dl Total Protein 6.0-7.8 g/dl Albumin 3.5-5.5 g/dl
• Kidney Tests
• Creatinine, serum 0.6-1.2mg/dl
• Urea nitrogen, serum (BUN) 7-18mg/dl
• Liver Tests
• Alanine aminotransferase (ALT), serum: 8-20 U/L
• Aspartate aminotransferase (AST), serum: 8-20 U/L
• Bilirubin, serum (adult) Total//Direct: 0.1-1.0 mg/dl // 0.0-0.3 mg/dl
• Phosphatase (alkaline), serum: 20-70 U/L

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Basic Laboratory Interpretation: Thyroid Function Tests (TFTs) - correct answer- used to rule out thyroid disorders as a cause for symptoms

• symptoms related to thyroid disorders include anxiety, restlessness, depression, mood swings, sleeping difficulties, difficulties with concentration, short-term memory lapses, and lack of mental alertness Normal TFT levels TSH: 0.4-4.5 mIU/L T3: 100-200 ng/dL T4: 5-11 ug/dL Basic Laboratory Interpretation: Vitamin B12 Level - correct answer- Deficiency of vitamin B can affect mood and other brain functions
• psychiatric symptoms associated with B12 deficiency include depression, mania, psychotic symptoms, and cognitive impairment normal: 190-950 picograms/mL
• 200-300/mL indicates a borderline level with a possible need for additional testing Basic Laboratory Interpretation: Vitamin D Level - correct answer- affects functions such as neurotransmission, neuroprotection, & neuroimmunomodulation
• high prevalence of vitamin D deficiency in clients with psychiatric disorders such as schizophrenia, depression, seasonal affective disorder, and cognitive impairment
• Symptoms of vitamin D deficiency include depression, irritability, anxiety, psychosis, and poor brain development 25 - hydroxy vitamin D blood test: normal 20-50 ng/mL, less than 12 ng/mL indicates a deficiency Basic Laboratory Interpretation: Toxicology Screen - correct answer- - rule out substance use as a cause for symptoms
• used before starting therapy involving controlled substances
• used to monitor medication adherence
• used in the diagnosis of substance use disorder

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Beth is a 24-year-old who presents with anxiety. Her T3 is 260 ng/dL. - correct answer- Refer Rationale: Clients with hyperthyroidism have elevated T3 levels. Hyperthyroidism is associated with anxiety symptoms. Client can be reevaluated for anxiety once hyperthyroid treatment has been initiated and T3 levels are within normal limits. Treat or Refer: Fred is a 19-year-old who presents with psychosis. His vitamin B12 level is 900 picograms/mL. - correct answer- Begin treatment Rationale: The B12 level is within normal limits. Treatment for symptoms of psychosis should be initiated. Treat or Refer: Ted is a 64-year-old who presents with confusion. His serum creatinine is 7.0 mg/dL and BUN is

32. • correct answer- Refer Rationale: Elevated serum creatinine and BUN indicate a problem with kidney function, which could contribute to confusion. Symptom-Directed Treatment - correct answer- Psychiatric medication is generally prescribed in a transdiagnostic manner in which symptoms rather than diagnoses guide clinical practice Social Determinants of Health (SDOH) - correct answer- the conditions in which individuals are "born, grow, live, work, and age" that contribute to the development of both physical and psychiatric pathology over the course of one's life" SDOH: social and structural factors that impact mental health - correct answer- • Discrimination, racism, social exclusion

• Adverse early life experiences
• Poor education
• Unemployment, underemployment, job insecurity
• Poverty
• Neighborhood deprivation
• Food insecurity

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

• Poor housing quality and housing instability Legal and Ethical Considerations - correct answer- Protecting the privacy and confidentiality of client records is a legal obligation and may help reassure the client The SNAPPS Method - correct answer- Summarize the history and findings Narrow the differential dx to 2-3 possibilities Analyze the differential by comparing & contrasting the possibilities Probe the preceptor by asking questions about alternative approaches or uncertainties Plan the management of the client's health issues Select an issue from the case for self-directed learning Prioritizing Client Complaints and Questions - correct answer- Use client-centered communication techniques
• Strategies
• Acknowledge the client's list of questions and concerns and review the list with the client with a statement such as, "I see you have a list of concerns; let's look at it together."
• Mutually negotiate what to cover during the visit, use of positive language
• Be honest about the time allotted for the visit while planning jointly how to use that time
• Plan for follow-up, Set a mutual agenda and time frame for the next visit, Review which issues have been addressed, and which ones will be addressed at the next visit. Document this plan as a reminder for the next visit Parts of the Initial Psychiatric Interview - correct answer- Identifying data Source and reliability Chief complaint Present illness Past psychiatric history

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Psychosis

• Hallucinations: Auditory, visual, olfactory, tactile.
• Paranoia.
• Delusions: TV, radio, thought broadcasting, mind control, referential thinking.
• Patient's perception: Spiritual or cultural context of symptoms, reality testing. Other
• Attention-deficit/hyperactivity disorder symptoms.
• Eating disorder symptoms: Binging, purging, excessive exercising process of DSM-5 differential diagnosis - correct answer- 1) ruling out Malingering and Factitious Disorder

2. ruling out a substance etiology
3. ruling out an etiological medical condition
4. determining the specific primary disorder(s)
5. differentiating Adjustment Disorder from the residual Other Specified and Unspecified conditions
6. establishing the boundary with no mental disorder most common mental illness in the United States - correct answer- Anxiety disorders

• Anxiety impacts approximately 18% of the adult population and 25% of children ages 13- 17 each year Obsessive-compulsive disorder (OCD) - correct answer- characterized by persistent, uncontrollable thoughts or actions that occur over an hour or more per day
• one of the top 20 illness-related disabilities worldwide first line medication treatment: Generalized anxiety disorder - correct answer- - SSRIs
• SNRIs
• Buspirone
• Drug Therapy at least 12 months

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) first line medication treatment: Panic disorder - correct answer- - Paroxetine

• Sertraline
• Fluoxetine
• Drug therapy 6-9 months first line medication treatment: Obsessive compulsive disorder - correct answer- - Fluoxetine
• Fluvoxamine
• Sertraline
• Paroxetine
• Clomipramine (TCA)
• Drug therapy for at least 1 year first line medication treatment: Social anxiety disorder - correct answer- - Sertraline
• Paroxetine
• Drug therapy takes 4 weeks to see effects first line medication treatment: Post-traumatic stress disorder - correct answer- - Paroxetine
• Sertraline Anxiety is often comorbid with _________________ as well as medical conditions such as ____________, ___________, and ___________ - correct answer- major depression, COPD, asthma, diabetes Generalized anxiety disorder (anxiety) - correct answer- neurological condition
• characterized by persistent, uncontrollable worrying that causes emotional distress
• show symptoms on most days, for a period of at least six months
• common symptoms of anxiety include restlessness, irritability, muscle tension, fatigue, and sleep disturbances
• GAD is twice as common in women as in men Patients with anxiety disorders often show increased activity in the ______________ and _______________ - correct answer- amygdala and prefrontal cortex Positron emission tomography (PET) scans have shown reduced ___________________ in patients with anxiety - correct answer- serotonin binding

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Rationale: Harold meets the following diagnostic criteria for generalized anxiety disorder: He has three symptoms associated with worry, including fatigue, difficulty concentrating, and sleep difficulties. He has experienced anxiety more days than not for over 6 months, and his worries are impacting his relationship. Social Anxiety Disorder - correct answer- AKA social phobia

• condition in which typical, everyday social interactions cause significant anxiety, self- consciousness, fear of embarrassment, or a feeling of being judged negatively by others
• may worry about the presence of physical symptoms that others may notice such as trembling or blushing
• derealization, or a feeling of "spacing out," may occur
• Causes likely include a combination of genetic and environmental factors
• past year: 7% of adults and 9% of adolescents
• DSM- 5 - TR defines social anxiety disorder as an individual's fear of acting in a way that might cause judgment by others
• anxiety is persistent, lasting greater than six months Usually, social anxiety disorder causes distress and anxiety in specific social situations such as: - correct answer- - making small talk with others
• meeting new people
• performing in front of others (called performance anxiety) Panic attack - correct answer- brief episode of acute anxiety during which an individual develops an intense fear of negative outcomes accompanied by a feeling of imminent danger
• can be unpredictable
• feelings are often accompanied by physiological symptoms
• symptoms typically peak within ten to twenty minutes, some may last for hours Symptoms of Panic Attacks: - correct answer- - Palpitations, pounding heart, or accelerated heart rate
• Trembling or shaking
• Paresthesias (numbness or tingling sensations)
• Sensation of shortness of breath or smothering
• Derealization (feelings of unreality) or depersonalization (feeling detached from oneself)

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

• Feeling of choking
• Feeling of chest pain or discomfort
• Nausea or abdominal stress
• Feeling dizzy, unsteady, light-headed or faint
• Chills or heat sensations Panic disorder - correct answer- occurs when a person experiences repeated panic attacks
• Anxiety about future attacks may lead to behavioral changes
• avoid situations that might trigger attacks Fabrizia is a 27-year-old graphic designer who presents to the clinic two months after an emergency department visit for complaints of chest pain, palpitations, nausea, and dizziness. Her electrocardiogram (ECG) and cardiac enzyme panels showed no abnormalities. She states that the symptoms began while she was watching a movie with her boyfriend and lasted about 15 minutes. She has never experienced anything like this in the past, but since the episode, she has worried occasionally about the symptoms recurring, as her father died of a heart attack at age 45. Based on the DSM- 5 - TR, does Fabrizia meet diagnostic criteria for panic disorder? - correct answer- No Rationale: Fabrizia meets diagnostic criteria for a panic attack, but not for panic disorder. During her panic attack, she reported having four cardinal symptoms associated with a panic attack. She has only had one panic attack, and although she has expressed worry about symptoms recurring, it is not persistent concern or worry. phobia - correct answer- an intense fear of a specific situation or object
• The fear associated with a phobia is not in proportion to the actual danger associated with the situation or object
• often occur after experiencing or witnessing a traumatic event
• typically develop in childhood
• Types of phobias:
• natural or environmental (lightning, water, tornado)

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) Based on the DSM- 5 - TR, does Sigourney meet diagnostic criteria for agoraphobia? - correct answer- Yes Rationale: Sigourney meets the following diagnostic criteria for agoraphobia: she has marked anxiety about using public transportation and being in enclosed spaces and crowds. She fears a situation because she worries about her ability to escape. She has changed her behaviors to avoid situations that cause her anxiety, and she has caused social impairment in her life. Adjustment Disorder with Anxiety - correct answer- DSM-5 classifies adjustment disorder as a trauma- and stressor-related disorder

• presents with nervousness, worry, or jitteriness
• Adjustment disorder occurs in the presence of a specific and identifiable stressor
• common stressors include loss of employment, getting married, a new disability, or a natural disaster
• Symptoms begin within three months of the stressor and typically last no more than six months Callie is an 18-year-old college student who reports to the healthcare provider that she feels anxious "about everything." Her restlessness and irritability have impacted her relationship with her significant other. She reports no significant past medical or mental health history. She states that her anxiety started about 8 months ago when she decided to transfer from her local community college to a large state university to pursue a law degree. During the law program's orientation attended by 300 students, she learned that only 100 students would be selected out of 300 applications for the fall admission. She began feeling inferior that she would not be one of the students accepted. She also started thinking about "plan B," assuming that her grades are not "good enough" to get her selected for the program. She told the PMHNP that she was preparing for the rejection because she does not measure-up to the other appli - correct answer- generalized anxiety disorder Rationale: Callie has persistent symptoms of anxiety accompanied by restlessness and irritability. The thoughts are unrealistic since she has pre-determined that she is not good enough for the law program without evidence to support that feeling. She also compares herself to strangers where she automatically assumes that they are better prepared for the program than she is. She decides not to apply to the law program based on these unsubstantiated thoughts. Jeremy is a 44-year-old male who works as a department head for a local grocery store chain that is down-sizing due to economic reasons. Top level management has announced that there

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) will be restructuring of the company where many of the employees are no longer deemed essential. Because of the automatic self-check-out systems, there is no longer the need to employ as many cashiers as possible. Jeremy has been given the task of notifying his employees of this major change in staffing. He plans to share these decisions at next week's staff meeting. From the moment Jeremy received this directive, he started to feel fearful of the possibility of announcing the decision to downsize as well as deciding on who would be eliminated. On the day of the staff meeting, his employees were present. As he started the staff meeting, he began to feel nausea. He even noticed his heart pounding. When he was questioned by an employee on - correct answer- panic attack Rationale: Jeremy's anxiety is associated with a stressful situation (delivering the bad news) and a fear that something bad will happen (staff's reaction to the announcement). He experiences physical symptoms of heart pounding, nausea, dizziness, and inability to formulate an organized answer to the question. The setting is also in a familiar place among colleagues where no real threat exists. Sari is a 34-year-old female who is engaged to be married in one month. This will be her second marriage. She has been divorced for three years. Her fiancé, who is also divorced, has arranged for Sari to meet his three teenagers. Sari learns through a mutual friend of hers and the fiancé, that his teenagers, although hesitant, are willing to meet her. On the day of the arranged meeting, Sari is asked to arrive to the restaurant to meet the teens prior to the fiancé's arrival because he has been held up at a meeting. Sari agrees but starts to feel uneasy about it. She is concerned that they will not accept her because of her previous divorce and the fact that she is not their mother although they were willing to meet her. The closer she got to the restaurant, the more uneasy she felt to the point of disorientation. Just before entering the restaurant, she turned around and called her fiancé to inform him that her - correct answer- generalized anxiety disorder panic disorder panic attack social anxiety Rationale: Sari feels like she will be judged by the teens because she is not their mother. She avoids the situation by creating an excuse for not meeting them at the restaurant. The feelings are unwarranted since the teens agreed to meet with Sari. Anxiety rating scale: GAD- 7 - correct answer- General Anxiety Disorder- 7

• answer question with several days (+1), more than half days (+2), nearly every day (+3)

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

• Behavior at interview 0 - 17: Mild anxiety 18 - 24: Mild to moderate anxiety 25 - 30: Moderate to severe anxiety 31 - 56: Severe anxiety HAMILTON ANXIETY RATING SCALE (HAM-A) - correct answer- developed in the late 1950s to assess anxiety symptoms, both somatic and cognitive.
• provides limited coverage of the "worry" required for a diagnosis of generalized anxiety disorder and does not include the episodic anxiety found in panic disorder.
• score of 14 has been suggested as the threshold for clinically significant anxiety
• scores of 5 or less are typical in individuals in the community
• Reliability is fairly good based on internal consistency, interrater, and test-retest studies.
• Validity appears good based on correlation with other anxiety scales but is limited
• used extensively to monitor treatment response in clinical trials of generalized anxiety disorder and may also be useful for this purpose in clinical settings. Medical Diagnoses that Mimic Anxiety - correct answer- - Certain medications and substances may cause symptoms of anxiety
• Anxiety symptoms may also present as part of another primary mental disorder
• Depression, substance abuse, and schizophrenia can all have anxiety components
• Baseline labs help rule out a medical diagnosis or other condition
• CMP, TFT, toxicology screen Which of the following medical conditions is likely to present with symptoms that mimic anxiety? hypothyroidism hyperthyroidism dysrhythmias irritable bowel syndrome

DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) anemia diabetes type 2 migraine headache covid- 19 rheumatoid arthritis menopause - correct answer- hyperthyroidism dysrhythmias irritable bowel syndrome migraine headache rheumatoid arthritis menopause Rationale: Medical conditions that commonly present with symptoms that mimic anxiety include endocrine disorders including hyperthyroidism and adrenal dysfunction cardiac disorders including angina and dysrhythmias, GI conditions including irritable bowel syndrome and GERD, inflammatory conditions including lupus and rheumatoid arthritis, neurological disorders including migraine headaches and seizures, and respiratory conditions including asthma and COPD. Changes in the menstrual cycle, including PMS and menopause, may also cause symptoms that mimic anxiety. Which of the following medications or substances commonly cause symptoms that mimic anxiety? bupropion nasal decongestants metoprolol levothyroxine Insulin albuterol cocaine