NR547 FINAL EXAM QUESTIONS WITH COMPLETE SOLUTIONS, Exams of Nursing

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NR547 FINAL EXAM QUESTIONS WITH COMPLETE SOLUTIONS 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, lev milnacipran, 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 • hypotension • tachycardia • sexual dysfunction MAOIs -Action: increases norepinephrine and serotonin by inhibiting the enzyme that inactivates it -Examples: isocarboxazid, phenelzine, tranylcypromine -Common Side Effects: • sedation • dizziness • sexual dysfunction • hypertensive crisis Prescribing pearls: citalopram (Celexa) mild antihistamine effects Prescribing pearls: escitalopram (Lexapro) no known drug interactions Prescribing pearls: fluoxetine (Prozac) longest half-life Prescribing pearls: paroxetine (Paxil) also treats social anxiety and insomnia Prescribing pearls: fluvoxamine (Luvox) treats anxious depression smokers require increased dose Prescribing pearls: sertraline (Zoloft) Certain conditions are associated with depression, including: epilepsy post-stroke Parkinson's disease multiple sclerosis degenerative brain disease 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. Immuno-Psychiatry (neuroimmunology) explores how the immune system interacts with the brain and the mind -This interaction can affect both physical and mental health -The immune system protects the body from infection • Macrophages are the centurions of the immune system. Macrophages warn the immune system of a potential threat by secreting cytokines alerting more macrophages to come to the injured site • Cytokines (inflammatory proteins in the blood) can send signals across the blood-brain barrier. • Nerve cells exposed to cytokines are more likely to die than regenerate • In rat studies, rats injected with cytokines exhibited social withdrawal, less movement, and altered sleeping and eating patterns. • Inflamed nerve cells cannot effectively transmit 5-hydroxytryptamine (5HT) or serotonin receptors. • Persons with inflammatory conditions are significantly more depressed than the general population. *People who frequently eat foods known to cause inflammation (carbs) are more likely to exhibit depressive symptoms • People tend to feel better when they eat clean, possibly due to the decreased inflammation Medical Diagnoses that Mimic Depressive Disorders hypothyroidism vitamin D deficiency anemia chronic fatigue syndrome Medications with side effects mimicking depression include: cannabis, alcohol, clonidine, antidepressants, anticonvulsants, antimigraine agents, corticosteroids, contraceptives, and varenicline (Chantix) Depression treatment: pharmacological Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) 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. at least one major depressive episode and at least one current or past hypomanic episode, but no full mixed or manic episode -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? F31.89 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? F31.2 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 behavior, including several recent episodes of unprotected sex with multiple partners. He admits to having suicidal ideations. What is the appropriate ICD-10 code for Vladimir? F31.12 Rationale: The ICD-10 code is F31.12 bipolar 1 disorder manic episode with mixed features. Vladimir meets diagnostic criteria for bipolar I disorder, with symptoms including racing thoughts, psychomotor agitation, distraction, risky behaviors, and irritability for the past two weeks. Because he also endorses fatigue, feelings of worthlessness, and suicidal ideation, he meets the criteria for a manic episode with mixed features. Screening tools for bipolar disorders: Mood disorder questionnaire -a non-diagnostic, self-rated instrument that provides information to clients who may need additional assessment. Bipolar spectrum diagnostic scale -a self-rated instrument presented in story format that is sensitive to subtle symptoms of bipolar disorder Medical Diagnoses that Mimic Bipolar Disorder -hyperthyroidism -hyperaldosteronism -brain tumor -neurocognitive disorder -delirium Rationale: Medical conditions that commonly present with symptoms that mimic mania include hyperthyroidism, hypercortisolemia, hyperaldosteronism, brain tumor, neurocognitive disorder, acromegaly, delirium, lupus, HIV, or syphilis. medications or substances commonly cause symptoms that mimic mania? steroid medications hallucinogens methamphetamine marijuana • 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 • psychosocial interventions Depression tx for older adult: Pharmacologic SSRIs & SNRIs -Escitalopram, citalopram, and sertraline have fewer drug-drug interactions than other medications and are appropriate choices for initial therapy in older adults taking multiple medications Depression tx for older adult: Nonpharmacologic Engagement Social support Exercise Relaxation DIGFAST mnemonic that may be helpful to assess for bipolar disorder in the clinical setting: Distractibility Impulsivity Grandiosity Flight of ideas Activity level Sleep Talkativeness Neurocognitive disorders delirium and dementia Dementia -a group of symptoms that mainly affects memory, cognition and social interactions, and the ability to do everyday tasks. -Symptoms start gradually often with no clear beginning, and are usually permanent. -Most dementias are caused by neurodegenerative diseases, most commonly Alzheimer's disease, Lewy body dementia and frontotemporal dementia • clumps of abnormal proteins to build up inside neurons, damaging them, and causing them to slowly degenerate and die -vascular dementia is another common cause of progressive dementia • brain damage occurs when the blood supply to the neurons is reduced or blocked, again causing them to malfunction or die -Cognitive Symptoms: Difficulty with complex tasks, Difficulty planning and organizing, Loss of coordination -Psychological symptoms: Personality changes, Inappropriate behaviour, Paranoia, Fear, anxiety, anger or depression. Delirium ACUTE SUDDEN CHANGE IN MENTAL STATE -typically begins suddenly with a noticeable start point. -mainly affects attention, and often resolves after a few days or weeks, although it can last longer. -acute, transient, and usually reversible brain malfunction -thought to be brought on by multiple neurotransmitter imbalances Delirium symptoms -Cognitive Symptoms: Rambling or nonsense speech, Difficulty reading and writing, Wandering attention, Becoming easily distracted, Becoming withdrawn, -Psychological symptoms: Inability to focus, Reduced awareness of the environment, Disturbed sleep -May have hallucinations -symptoms can fluctuate throughout the day causes of delirium -lack of oxygen -drugs • anticholinergics • psychoactive • opioids -withdrawal • delirium tremens -stressful situations -dehydration & electrolyte imbalance