NR547 Final Exam Questions And Answers, Exams of Nursing

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NR547 Final Exam

Medications for depression - SSRIs SNRIs SDRIs TCAs MAOIs SSRIs - -Action: inhibit 5-HT reuptake -Examples: citalopram, escitalopram, fluoxetine, paroxetine, sertraline -Adverse effects:

• nausea
• agitation
• diarrhea
• headache
• weight gain
• sexual side effects SNRIs - -inhibit 5-HT reuptake -inhibit NE reuptake (↑ energy, focus) -increase DA in prefrontal cortex (↑ cognition) -Examples: desvenlafaxine, duloxetine, levomilnacipran, venlafaxine -Adverse effects:
• elevated blood pressure
• nausea
• sweating

• tremors
• anxiety
• insomnia
• constipation
• anorexia
• sexual dysfunction SDRIs - -inhibit DA reuptake (↑alertness, motivation) -inhibit NE reuptake (↑energy) -Adverse effects:
• agitation
• headache
• dry mouth
• constipation
• weight loss TCAs - -Action: inhibits the reuptake of serotonin and norepinephrine; blocks norepinephrine, histamine, and acetylcholine receptors -Examples: amitriptyline, clomipramine, desipramine, doxepin -Common Side Effects:
• dry mouth
• constipation
• blurred vision
• urinary retention
• sedation
• weight gain

Prescribing pearls: duloxetine (Cymbalta) - effective for atypical pain at higher doses; appropriate for clients who present with somatic symptoms of depression; effective for atypical pain, such as fibromyalgia and diabetic neuropathy Prescribing pearls: venlafaxine (Effexor) - treats both depression and anxiety disorders, ensure trial of higher dose before switching to a different medication Prescribing pearls: desvenlafaxine (Pristiq) - effective for perimenopausal vasomotor symptoms considered when selecting a medication: - -Client preference -Prior treatment response -Anticipated adverse effects -Comorbidities -Half-life and interactions -Cost if a medication is not achieving efficacy: - -Increase dose gradually -Switch to a different drug within the same class -Switch to drug in a different class -Add a second medication Use to protect against suicide - lithium MDD and BPD genetics - genetic factors contribute 31-42% of the disease risk in MDD and 59-85% in BPD

monoamine hypothesis of depression - -posits that depression occurs as a result of a deficiency of one or all three monoamine transmitters

• serotonin, norepinephrine, and dopamine -while mania may result from an excess *Emphasis is now shifted from the monoamines to their receptors and other downstream events such as the regulation of gene expression, growth factors, environmental factors, and epigenetic changes
  • Three principal neurotransmitters -norepinephrine (NE), dopamine (DA), and serotonin 5HT
• comprise the monoamine neurotransmitter system
• implications for the pathophysiology and treatment of mood disorders
• All known pharmacologic treatments for mood disorders act upon one or more of these three neurotransmitters -Many of the symptoms of mood disorders are hypothesized to involve dysfunction of various combinations of the monoamine neurotransmitters Mood disorders include ____________________ and ___________________ - depressive disorders and bipolar disorders Major depressive disorder (MDD) - one of the most prevalent psychiatric disorders -estimated that more than 300 million people suffer from -leading cause of disability worldwide -7.1% of adults and 13.3% of adolescents in the U.S. had at least one major depressive episode -An imbalance of specific neurotransmitters, including dopamine, serotonin, and norepinephrine, can influence brain activity and result in depression -decreased neurotransmitter activity in the prefrontal cortex (PFC)

Alzheimer's disease coronary artery disease depression in malignancy hypothyroidism hyperthyroidism hyperparathyroidism Cushing's syndrome Addison's disease diabetes mellitus key symptoms of depression: - depressed mood and a loss of interest or pleasure -may also present with physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation -often report difficulty sleeping, lack of motivation, or trouble completing tasks -severe cases, depressed clients may report delusions or hallucinations -may even present as catatonia MDD by severity: mild, moderate, or severe - Mild: The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis. Moderate: The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe: The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis. melancholic features - Symptoms worse in the morning, excessive guilt, significant weight loss

atypical features - Weight gain, hypersomnia, heavy feeling in arms or legs Screening tools for depression severity - -Patient Health Questionnaire (PHQ) -Beck Depression Inventory-II (BDI-II) -Hamilton Depression Rating Scale (HAM-D) -Edinburgh Postnatal Depression Scale (EPDS) in post-partum and pregnant women -Children's Depression Inventory (CDI) -Children's Depression Rating Scale (CDRS) -Geriatric Depression Scale (GDS) in older adults The United States Preventive Services Task Force (USPSTF) recommends depression screening: - for adults 18 years of age or older and adolescents ages 12-18 years old. The American Academy of Family Physicians recommends screening for depression in: - the general adult population, including pregnant and post-partum women. The American Academy of Pediatrics recommends maternal screening for postpartum depression at: - infants' 1, 2, and 4- month visits. The American Academy of Pediatrics' Bright Futures program recommends: (screenin) - annual screening in adolescent clients for emotional and behavioral problems. Medicaid's child health component, the Early and Periodic Screening, Diagnosis and Treatment program recommends: - screening to detect physical and mental conditions at various age intervals. If a risk is identified, the provider should follow up with diagnosis and treatment.

Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Must Not Miss Diagnosis: BD - Clients with bipolar disorder may present during the depressive phase -may not report any symptoms of hypomanic or manic episodes

• provider must obtain a careful history from the client and/or family members to differentiate between bipolar disorder and depression -Bipolar disorder should be ruled out as a cause of depression before prescribing medication as certain antidepressant medications can precipitate a manic episode or induce rapid-cycling bipolar depression *may contribute to the increased incidence of death by suicide in children and adults younger than 25 Ameeta, a 42-year-old female, presents to the primary care clinic with a three-month history of "feeling low and sad" with poor energy, inability to concentrate, and irritability. She indicates that the symptoms were initially present once per week but have increased to 4-5 times per week. She reports making an error last week at the grocery store where she works as a cashier and snapping at the customer when the error was brought to her attention. She is concerned about her loss of interest in her usual social activities and a 20-pound weight gain. She also reports frequent headaches, difficulty getting out of bed in the morning, feeling worthless, and low libido. She acknowledges that she feels guilty daily as she has not visited her son in 6 months and believes that she has "let him down". Thinking about it keeps her "up at night". She has difficulty falling and staying asleep every night. She denies suicidal idea - citalopram 20 mg po daily Rationale: Although all three drugs are appropriate to use when treating unipolar depression, Citalopram is an SSRI and is considered a first-line choice. Bipolar disorder - mental illness that causes extreme shifts in emotions, mood, and energy levels -Shifts in mood usually occur over several days to weeks -classified according to the types of mood episodes exhibited -affects approximately 2.6% of the adult population in the U.S. -sixth leading cause of disability in the world

-most frequently diagnosed in late adolescence or early 20s -lifelong condition cause of bipolar disorder - unknown -Individuals with family members who have bipolar disorder are more likely to develop it -interaction between genetic factors and the environment may be contributory -Brain imaging reveals white matter hyperintensities, reduction in gray matter volume, increased ventricular size, and decreased frontal cortical area volumes Bipolar disorder symptoms - Depressive Symptoms -similar to MDD Manic Symptoms -elevated, expansive, or irritable mood Hypomanic Symptoms -milder form of mania Mixed Symptoms -presence of symptoms of depression and mania simultaneously dx manic - -elevated, expansive, or irritable mood for at least one week, mood present most of the day and nearly every day -severe enough to cause significant impairment in social or occupational functioning, to req hospitalization to prevent harm to the client or others, or symptoms include psychotic features -three or more of the following symptoms (APA, 2022) must be present and represent a significant change from usual behavior:

-symptoms last for at least four days, but fewer than seven and include the same symptoms as mania without causing severe impairment or requiring hospitalization -Psychotic features are not present with bipolar II disorder, although irritability and anger are common. Carlo is a 24-year-old married auto mechanic who works full-time. His wife reports that he began several home repair projects about three weeks ago "out of the blue." He is painting the exterior of the home, remodeling a bathroom, and digging a new garden. He used to sleep 6-7 hours per night, but he is now sleeping about 3 ½ hours per night. Although Carlo has no history of bipolar disorder, his wife is concerned that this may be a manic episode. Her father was diagnosed with bipolar I disorder; she worries that Carlo's symptoms are similar. Based on the DSM-5-TR (APA, 2022), does Carlo meet the diagnostic criteria for bipolar I disorder? yes no unable to determine - unable to determine Rationale: Carlo meets category A criteria (abnormal and persistent increased activity lasting at least one week) and two diagnostic criteria in category B for bipolar I disorder (decreased need for sleep and increase in goal-directed activity). However, three symptoms are required for diagnosis; more information is needed to determine if Carlo is experiencing additional symptoms or if his behaviors are significantly impacting his occupational or social interactions. In addition, the PMHNP should inquire about the use of medications and/or legal and illegal stimulants to determine if they may be impacting Carlo's behavior. Rapid cycling - four or more episodes of depression and mania occur within one year Cyclothymia - numerous episodes of hypomanic symptoms that do not meet the criteria for a hypomanic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode -at least two consecutive years during which clients are symptomatic at least half the time and not symptom-free for more than two consecutive months

Tariq is a 22-year-old who presents with symptoms of racing thoughts and an inability to pay attention in his college classes. He is currently failing most of his courses. He feels like he needs to talk constantly. He calls friends at all hours and tries to engage strangers in conversation. He also reports feeling restless and tense. He has experienced these symptoms continuously for the past two weeks. His toxicology screen is negative, and he takes no medications. What is the appropriate ICD-10 code for Tariq? - F31. Rationale: The ICD-10 code is F31.89 bipolar 1 disorder with anxious distress. Tariq meets diagnostic criteria for Bipolar I, with symptoms including racing thoughts, difficulty paying attention, and constant talking. He is experiencing consequences from his behavior as he is failing classes. He has experienced the symptoms for two weeks. Because he also has symptoms of restlessness and increased tension, he also meets the qualifying diagnostic criteria for anxious distress. Savannah is a 32-year-old who presents with her husband. Her husband states that Savannah has spent thousands of dollars on new clothing and shoes in the past month. The clothing she has purchased is much more revealing than her typical wardrobe. She is sleeping for just a few hours per night. She is spending hours on Twitter and is constantly boasting about how many retweets she receives and how many followers she has. Two days ago, Savannah reported that the drummer of her favorite band began following her; she is planning to skip work for a week to travel out of state and attend the band's concert. She asserts that the drummer has invited her backstage to have sex following the concert. Savannah has never had behaviors like this in the past. Her toxicology screen is negative. What is the appropriate ICD-10 code for Savannah? - F31. Rationale: The ICD-10 code is F31.2 bipolar 1 disorder with mood-congruent psychotic features. Savannah meets diagnostic criteria for bipolar I, with symptoms of grandiosity, decreased sleep, and excessive shopping. She is experiencing impairment in social and occupational functioning. She has experienced these symptoms for a month. Because Savannah is also experiencing delusional thinking consistent with her mood, she also meets the criteria for mood-congruent psychotic features. Vladimir is a 25-year-old who presents with feelings of racing thoughts. His thoughts are centered on feelings of worthlessness. He reports feeling very fatigued and continually paces around the room. He has been irritable and easily distracted for the last two weeks. He endorses an increase in sexual

hallucinogens methamphetamine marijuana Rationale: Medications and substances with effects that mimic mania include levodopa, hallucinogens, antidepressants, methamphetamine, marijuana, or cocaine. Bipolar disorder tx: pharmacological - Antipsychotics Anticonvulsants Benzodiazepines Lithium salts Antidepressants Bipolar disorder tx: _____________Acts as a mood stabilizer, more effective at treating mania than depressive symptoms. - Lithium salts Bipolar disorder tx: _____________SSRIs may trigger manic episodes in individuals who are predisposed to them. - Antidepressants Bipolar disorder tx: _______________Acts on dopamine receptors to reduce levels of excess dopamine, exhibit high affinity for D2, D3, 5-HT1A, and 5-HT2A receptors. - Antipsychotics Bipolar disorder tx: ______________May be combined with other medications to treat bipolar disorder, may improve both mania and depressive symptoms. - Anticonvulsants Bipolar disorder tx: ______________Slows the activity of the brain resulting in a reduction of mania, anxiety, and panic disorder - Benzodiazepines

lab tests required for Lithium: - serum lithium level renal function thyroid function lab tests required for Valproic acid (Depakote): - serum valproate level liver function CBC lab tests required for Carbamazepine: - serum carbamazepine level renal function liver function CBC lab tests required for Atypical antipsychotic medications: - CBC HbA1C Bipolar disorder tx: Nonpharmacological - adjunct nonpharmacological treatment options may help reduce symptom burden -Health Education -Client and family support -Electroconvulsive therapy (ECT) -Psychotherapy Suicide in the U.S. - -Approximately 2/3 of clients with depression contemplate suicide

• 10-15% die by suicide -Suicide is the second leading cause of death between the ages of 10-24 years

-Risk factors:

• Chronic illness
• Disability/ loss of mobility
• Change in living situation
• Role transitions
• Loss of independence
• Bereavement
• Economic hardships Depression Lifespan Considerations: Older Adults, pertinent information for an interview - -socialization, including recent changes or loss -ability to complete activities of daily living (ADLs) -typical physical activity -appetite changes -weight loss or gain -psychotic symptoms -suicidal thoughts or ideations Bipolar Lifespan considerations: older adults - Approximately 10% of bipolar cases are diagnosed after the age of 50 -mania is more likely to be expressed as agitation or irritability rather than euphoria -more likely to experience mixed episodes -Late-onset bipolar disorder may be difficult to distinguish from dementia Geriatric Depression Scale (GDS) - self-reporting tool that may be used to diagnose and treat depression

0-4: No depression No treatment indicated 5-8: Mild depression Pharmacologic or psychotherapeutic treatment may be indicated Base treatment on duration of symptoms and functional impairment 9-11: Moderate depression Pharmacologic, psychotherapeutic, or combination treatment indicated 12-15: Severe depression Pharmacologic, psychotherapeutic, or combination treatment indicated It is important to evaluate _______________ when depression is suspected - cognitive function -Older clients may have associated memory loss, slowed processing, or impaired executive functioning

• Depression is an independent risk factor for dementia
• A Mini-Cog or other cognitive screening tool can provide a baseline assessment for clients In clients who have dementia, self-reporting scales, such as the GDS, may be inappropriate. The __________________________________ may be used as an alternative - Cornell Rating Scale for Depression in Dementia goal of treatment for older adults experiencing depression - achieve symptom remission -Options
• pharmacotherapy
• psychotherapy