PMHNP Exam Study Guide: Questions & Answers for Mental Health Professionals, Exams of Nursing

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PMHNP COMPREHENSIVE EXAM QUESTIONS

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Stages of Change (Transtheoretical Model) - ANSWER (Prochaska & DiClemente) ● Precontemplation—little to no awareness of the problem or intent to change ● Contemplation—thinking about making a change in the next 6 months, weigh pros and cons ● Preparation—prepare to make change within the next month, start to make small changes ● Action—enacted the change for 1 day-6 months ● Maintenance—maintained behavior/change for 6 months or longer Maslow's Hierarchy of Needs - ANSWER ● Physiological (food, water, shelter, warmth) ● Safety (security, stability, freedom from fear) ● Belonging/love (friends, family, spouse, lover) ● Self-esteem (achievement, mastery, recognition, respect) ● Self-actualization (pursue, inner talent, creativity, fulfillment) Benner's Model - ANSWER ● Novice—unconscious incompetence, no experience, governed by rules and regulations ● Advanced beginner—able to analyze and deliberately act ● Competency/proficiency— 2 - 5 yrs experience, able to synthesize info/coordinate

● Expert—flexible, intuitive, efficient MMSE Scoring - ANSWER ○ 23 - 30 normal ○ 19-23 borderline ○ <19 impaired MMSE components - ANSWER ● Orientation ● Registration (repeat 3 words) ● Attention and Calculation (count backwards from 100 by 7, spell words backward) ● Recall (repeat the same 3 words from immediate recall) ● Language (name an object, repeat a phrase, read a sentence, write a sentence, copy intersecting pentagons) Levels of Prevention - ANSWER · Primary prevention—methods to avoid occurrence of disease (most population-based health promotion efforts) · Secondary prevention—methods to diagnose and treat existent disease in early stages before it causes significant morbidity · Tertiary prevention—methods to reduce negative impact of existent disease by restoring function and reducing disease-related complications · Quaternary prevention—methods to mitigate or avoid results of unnecessary or excessive interventions in the health system frontal lobe - ANSWER A region of the cerebral cortex that has specialized areas for movement, abstract thinking, planning, memory, and judgement

• prefrontal, motor strip, EPS, basal ganglia

temporal lobe - ANSWER hearing, language (Wernicke's), memory, emotion parietal lobe - ANSWER sensory processing and input components of the limbic system - ANSWER interpreting significance of sensory input; hippocampus, amygdala, hypothalamus, cingulate gyrus, thalamus anterior cingulate cortex - ANSWER integrating complex external information; empathy, emotion processing posterior cingulate cortex - ANSWER participates in memory and visual processing; day dreaming, values, relevance to self hypothalamus & what NTs does it balance - ANSWER homeostasis (food, water, temperature), controls pituitary release, balance of DA and 5HT posterior pituitary - ANSWER ADH and oxytocin thalamus - ANSWER relay station for incoming sensory information, allowing for processing and interpretation according to other structures' input cerebellum - ANSWER control center for controlling voluntary movement, fine tunes movement

cerebellar lesion symptoms - ANSWER ataxia, awkward, tremor with effort, difficulty with sequential movements, balance brainstem - ANSWER responsible for automatic survival functions; midbrain, pons, medulla where is dopamine produced - ANSWER substantia nigra where is serotonin produced - ANSWER raphe nuclei where is norepinephrine produced - ANSWER locus coeruleus in the pons where is acetylcholine produced - ANSWER Nucleus basalis of Meynert cranial nerves - ANSWER Olfactory—smell Optic—vision Oculomotor—eye movement Trochlear—eye movement Trigeminal—face sensation & chewing Abducens—eye movement Facial—facial movements and taste Vestibulocochlear—hearing Glossopharyngeal—taste, swallowing Vagus—movement, sensation, visceral organs

Accessory—spinal, neck movement Hypoglossal—tongue movement preganglionic NT of SNS - ANSWER ACh postganglionic NT of SNS - ANSWER NE preganglionic NT of PNS - ANSWER ACh postganglionic NT of PNS - ANSWER ACh origin of SNS - ANSWER thoracolumbar origin of PNS - ANSWER craniosacral pharmacokinetics - ANSWER what the body does to the drug Components of pharmacokinetics - ANSWER absorption, distribution, metabolism, excretion (half-life, steady state by 4 half-lives) pharmacodynamics - ANSWER what the drug does to the body examples of pharmacodynamics - ANSWER upregulation, downregulation, actions at receptors, therapeutic index/margin of safety

dopamine - ANSWER drive, motivation, pleasure, psychosis, attention, motor, energy too much dopamine - ANSWER schizophrenia, nausea, vomiting, addictive behavior, over movement, sexual functioning not enough dopamine - ANSWER EPS, anhedonia, negative sx, inc temp, under movement, parkinsonism serotonin - ANSWER depression, obsession, migraines, anxiety, intestines, nausea, sexual too much serotonin - ANSWER inc mood, inc temp, GI sx, sexual dysfunction not enough serotonin - ANSWER depression, SI, anxiety, panic, aggression, pain, dec temp norepinephrine - ANSWER energy, conc, attention, vigilance, energy too much norepinephrine - ANSWER inc mood, inc HR/BP, attention not enough norepinephrine - ANSWER depression, vasodilation, orthostasis, dec HR

acetylcholine - ANSWER PNS at muscarinic receptors, muscle contraction and cognition at nicotinic receptors too much ACh - ANSWER lower HR, inc GI motility, inc sweating, inc salivation, inc cognition not enough ACh - ANSWER inc HR, dec cognition, can't see, can't pee, can't stool, can't drool monoamine oxidase - ANSWER deactivates NE, DA, 5HT MAOIs - ANSWER inhibit enzymatic destruction of monoamines, risking the sudden release of stored up monoamines; food interactions w/ tyramine and drug interactions w/ anything that promotes the release of stored up NA and DA can cause hypertensive crisis MDD - ANSWER depressed mood or anhedonia PLUS 4 of the following: sleep disturbance, weight/appetite change, fatigue/dec energy, psychomotor agitation or retardation, difficulty conc, guilt/worthlessness, SI TCAs - ANSWER inhibit reuptake of serotonin and norepinephrine, cause anticholinergic and anti adrenergic ASE SSRI common adverse effects - ANSWER - nausea

• dry mouth
• insomnia
• somnolence

• headache
• nervousness
• anxiety
• gastrointestinal (GI) disturbances
• anorexia
• sexual dysfunction
• agitation
• dizziness
• fatigue
• jittery
• emotional flattening SSRI discontinuation syndrome - ANSWER Flu-like symptoms, fatigue, myalgia, decreased concentration, N/V, impaired memory, paresthesia, shock like sensations, irritability, anxiety, insomnia, crying without provocation, dizziness, vertigo, agitation serotonin syndrome sx & tx - ANSWER autonomic instability, hyperthermia, confusion/altered sensorium, myoclonus, cardiovascular instability, flushing, diarrhea, cramps, seizures, restlessness, ataxia, headache, insomnia, HYPERREFLEXIA, diaphoresis
• Treatment: cyproheptadine (5-HT2 receptor antagonist) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) - ANSWER inc available NE and 5HT

• effexor, pristiq, cymbalta, fetzima bupropion (what do you know about it) - ANSWER Norepinephrine and dopamine reuptake inhibitor contraindicated w/ seizure history and eating disorders good for low energy depression smoking cessation and off label ADHD mirtazapine MOA - ANSWER remeron alpha 2 blocker, inc release of 5HT and NE highly sedating, potential for weight gain bipolar disorder I/ criteria for manic episode - ANSWER abnormal, persistently elevated euphoric OR irritable mood, plus 3 of the following or 4 if only irritable mood, for at least 1 wk or requiring hospitalization: distractibly, indiscretion, grandiose, flight of ideas, activity inc, sleep disturbance, talkative

bipolar disorder II/criteria for hypomanic episode - ANSWER duration is 4 days and does not cause significant impairment or hospitalization Depakote range & toxicity levels - ANSWER 50 - 125 mcg/mL is therapeutic level <450 limited toxicity 450 - 850 moderate-severity toxicity

850 coma, metabolic acidosis, resp dep Depakote Toxicity - ANSWER coma, confusion, somnolence, seizures, dizziness, hallucinations, irritability, headache, hepatotoxicity, CEREBRAL EDEMA, tachycardia, hypotension, N/V, abdominal pain, PANCREATITIS Depakote baseline labs - ANSWER LFT, CBC, platelets, pregnancy test Depakote side effects - ANSWER - hepatotoxicity

• weight gain
• sedation
• n/v
• hair loss
• thrombocytopenia (notify MD if these occur)
• abdominal pain, dark urine, yellow tinged eyes

Depakote indications - ANSWER seizures, bipolar disorder (mixed episodes/irritability or aggression), migraine prevention Lithium indication - ANSWER manic and depressive episodes of bipolar disorder Lithium baseline labs - ANSWER BUN/ Cr thyroid/TSH CBC ECG over 50 ********* pregnancy test GFR lithium birth defect - ANSWER Ebstein's anomaly (a right ventricular outflow tract obstruction defect d/t compromised tricuspid valve) lithium therapeutic level - ANSWER 0.6-1.2 mEq/L DC if level is 1.5 or above Lithium signs of toxicity - ANSWER N/V, fine tremor, fatigue, tachycardia, ataxia, confusion, agitation, delirium, hypertonia, hypothermia, hypotension, seizures, renal failure, coma, death lithium level of 1.5 to 2.0 - ANSWER mental confusion, poor coordination, coarse tremors, GI distress, dizzy

lithium level 2- 3 - ANSWER tinnitus, nystagmus, ataxia ataxia - ANSWER the loss of full control of bodily movements lithium level > 3 - ANSWER seizures, coma, death lithium and sodium - ANSWER Lithium decreases sodium reabsorption in the kidneys which can lead to sodium deficiency. Decreased - sodium can lead to lithium retention and toxicity. Be aware of anything that can lead to dehydration or loss of sodium diarrhea, vomiting, sweating) as lithium levels may then rise to toxic levels. lithium is the gold standard for - ANSWER manic episodes lamotrigine - ANSWER lamictal; anticonvulsant lamictal indications - ANSWER seizures & bipolar depression lamictal adverse effects - ANSWER 1. Dizziness

2. Ataxia
3. Somnolence
4. Headaches.
5. Blurred vision
6. Nausea

7. **Rash common and occasionally severe, should be d/c's if develops. Can manifest to Steven Johnsons syndrome, toxic epidermal necrolysis. watch for malaise, joint pain, purple bruised blotchy patches **Concurrent Valproic acid can double the Lamictal concentration examples of SGAs - ANSWER Zyprexa, Clozaril, Seroquel, Abilify/aripiprazole, Risperdal, Invega/paliperidone, Latuda/lurisadone, Vraylar/cariprazine, Geodon/ziprasidone, Fanapt/iloperidone, Saphris/asenapine Seroquel adverse effects - ANSWER sedation, weight gain, anticholinergic & antihistaminic effects zyprexa adverse effects - ANSWER metabolic syndrome, sedation abilify adverse effects - ANSWER akathisia, less sedation latuda administration - ANSWER must take with 350 cal meal Latuda indication - ANSWER bipolar depression, schizophrenia Vraylar (cariprazine) - ANSWER atypical antipsychotic, indicated for manic episodes and schizophrenia CYP3A4 inhibitors - ANSWER increase the concentration of drugs that are metabolized by the CYP system

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sodium valproate isoniazid cimetidine ketoconazole alcohol and grapefruit juice chloramphenicol erythromycin sulfonamides ciprofloxacin omeprazole metronidazole CYP3A4 inducers - ANSWER decrease the concentration of drugs that are metabolized by the CYP system CRAP GPs carbemazepines rifampicin alcohol phenytoin griseofulvin phenobarbitone sulphonylureas

generalized anxiety disorder DSM-V criteria - ANSWER excessive anxiety and worry more days than not for at least 6 months about a variety of things, difficult to control the worry, with 3 or more of the following: restlessness/edginess, fatigue/dec energy, difficulty conc, irritability, tension, sleep problems children GAD sx - ANSWER somatic sx, avoiding school, poor performance, seek excessive reassurance, perfectionistic attitude antidepressants approved for GAD - ANSWER paroxetine, venlafaxine XR (watch BP), citalopram, escitalopram, duloxetine panic attack criteria - ANSWER 4+ of these that develop abruptly & peak within 10 min: palpitations, sweating, trembling, shortness of breath, choking feeling, chest pain, nausea, dizziness, derealization/depersonalization, fear of losing control, fear of dying, paresthesias, chills or hot flashes followed by one month of worry it will happen again, for panic disorder medications for panic disorder - ANSWER • SSRIs are treatment of choice: paroxetine (Paxil), sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa), fluvoxamine (Luvox)

• If patients do not respond to SSRIs, short-term treatment with a benzodiazepine may be used:

diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), chlordiazepoxide (Librium), clorazepate (Tranxene)

• Or patients may switch to another type of antidepressant such as a SNRI: venlafaxine XR (Effexor)
• Or TCA's: clomipramine (Anafranil), amytriptyline (Elavil), imipramine (Tofranil) agoraphobia dsm-5 criteria - ANSWER Anxious about two or more:
• Using public transportation
• Being in open spaces
• Being in enclosed places (e.g., shops, cinema)
• Standing in line or being in a crowd
• Being outside of the home alone The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic- like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). The agoraphobic situations almost always provoke fear or anxiety. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

• Other criteria note functional impairment, at least 6 months, not explained by... etc treatment for OCD - ANSWER clomipramine, fluoxetine, sertraline, fluvoxamine, paroxetine Behavioral therapy (exposure and response prevention, cognitive behavior family therapy) PANDAS - ANSWER Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections separation anxiety disorder dsm-5 criteria - ANSWER A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. social anxiety disorder dsm-5 criteria - ANSWER Marked fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others Ex: social interactions, being observed, performing Fears he/she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. humiliating or embarrassing, will lead to rejection or offend others) The social situations are avoided or endured with intense fear or anxiety The fear is out of proportion The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more Impairs functioning Specify: Performance only medications for social anxiety disorder - ANSWER paroxetine, sertraline, buspirone, alprazolam, clonazepam, propranolol, atenolol

benzodiazepines mechanism of action - ANSWER Enhance the affinity of the GABAA receptors for GABA benzodiazepine withdrawal symptoms - ANSWER Insomnia, restlessness, anxiety, panic, paranoia, abdominal pain, nausea, sensitivity to light and sound, headache, fatigue, muscle twitches benzodiazepine contraindications - ANSWER - Known drug allergy

• Narrow-angle glaucoma
• Pregnancy
• TBI Benzodiazepine antidote - ANSWER Flumazenil buspirone - ANSWER BuSpar Anxiolytic, anti anxiety 5HT receptor partial agonist metabolized by the liver Buspirone MOA - ANSWER Stimulates 5-HT1A receptors, partial agonist Buspirone adverse effects - ANSWER paradoxical anxiety, dizziness, blurred vision, headache, nausea

substance use d/o dsm-5 criteria - ANSWER maladaptive pattern of substance use leading to impairment or distress w/ 2 or more of the following: using despite failure to fulfill obligations using despite interpersonal problems tolerance, WD, inc amounts, inc time unsuccessful attempts to reduce use cravings blood alcohol levels & symptoms - ANSWER 0.05 disinhibition 0.1 noticeable motor interference 0.2 significant motor and emotional disinhibition 0.3 confusion, stupor 0.4-0.5 coma, brainstem inhibition, death labs affected by alcohol use - ANSWER inc AST/ALT, inc bilirubin, dec MCV, dec B12, dec folate, dec thiamine Wernicke's encephalopathy triad - ANSWER thiamine deficiency fluctuating attention, ataxia, nystagmus Korsakoff's syndrome - ANSWER deficient thiamine and B memory damage

alcohol withdrawal symptoms & timing - ANSWER autonomic hyperactivity (sweating, flushing, tachycardia, hypertension, hyperreflexia) anxiety & tremors > 8 hrs seizures > 12-24 hrs delirium tremens > 72 hrs alcohol withdrawal treatment - ANSWER Long-acting benzodiazepines, fluids, thiamine, folic acid CIWA scoring - ANSWER 0 - 9 absent to minimal 10 - 19 mild to moderate Over 20 severe WD and possible DTs 15 or higher tx sched + PRNs ICU if > 35 or resp dep CIWA - ANSWER Clinical Institute Withdrawal Assessment for Alcohol COWS - ANSWER Clinical Opiate Withdrawal Scale COWS scoring - ANSWER 5 - 12 mild

13 - 24 moderate 25 - 36 MODERATELY SEVERE 36+ SEVERE WITHDRAWAL AUDIT-C - ANSWER Shorter version of AUDIT for acute and critical care units

• screening test for heavy drinking and/or active abuse Score: 4-13 at risk, > 14 high risk CRAFFT - ANSWER 6 - item screen for alcohol or drugs in adolescents, 14- 18 (C=car, R=relax, A=alone, F=forget, F= family or friends, T= trouble) score 2+ indicates problem SBIRT - ANSWER Screening, Brief Intervention, and Referral to Treatment AUDIT scoring - ANSWER < 8 low risk 8 - 14 hazardous use pattern 15+ moderate/severe use d/o and dependence CAGE - ANSWER cut down, annoyed, guilty, eye opener Acamprosate (Campral) - ANSWER Reduces withdrawal in abstinent alcoholics

Disulfiram (Antabuse) - ANSWER Used for alcohol aversion therapy. Clients started on Disulfiram must avoid any form of alcohol or they would develop a severe reaction. Teach pt to avoid some over-the-counter cough preparations, mouthwash etc. Naltrexone (ReVia) - ANSWER Reduces or eliminates alcohol craving medications to abstain from opioids - ANSWER methadone, buprenorphine schizophrenia dsm-5 criteria - ANSWER Two or more of the following, each present for a significant amount of time during a 1-month period (one has to be from first three) --Delusions --Hallucinations -- Disorganized speech -- Disorganized behavior -- Negative symptoms (alogia, avolition, affective flattening, dec attn, dec memory, dec language, anxiety, hostility, substance abuse) positive symptoms of schizophrenia - ANSWER delusions and hallucinations negative symptoms of schizophrenia - ANSWER disturbance of affect, blunting (severe reduction in the intensity of affect expression), flat affect, inappropriate affect (might laugh hysterically while describing someones death), absence of appropriate behaviors

schizophreniform disorder - ANSWER Psychotic disorder involving the symptoms of schizophrenia but lasting b/w 1-6 months brief psychotic disorder - ANSWER Psychotic disturbance involving delusions, hallucinations, or disorganized speech or behavior but lasting less than 1 month; often occurs in reaction to a stressor. delusional disorder - ANSWER a psychotic disorder in which the primary symptom is one or more delusions, duration 1 month or longer schizoaffective disorder - ANSWER Psychotic disorder featuring symptoms of both schizophrenia and major mood disorder. must have hallucinations or delusions for 2 wks in absence of a major mood episode specify bipolar or depressed type first generation antipsychotics and dopamine pathways - ANSWER - block D2 in mesolimbic pathway= reduced positive sx

• block D2 in mesocortical pathway= worsens negative sx
• block D2 in nigrostriatal pathway= EPS (akathisia, dystonia, parkinsonism--rigid, tremor, bradykinesia, posture), TD (writhing, facial twitching, irreversible)

• block D2 in tuberofundibular pathway= hyperprolactinemia (DA is prolactin inhibiting factor) FGAs Adverse Effects - ANSWER CV: orthostatic hypotension, syncope (conscious to unconscious very quickly), ECG changes Dermatologic: photosensitivity Hematologic: agranulocytosis (monitor CBC) metabolic: weight gain sexual dysfunction: decreased libido antihistaminic, anticholinergic, antiadrenergic effects Neuroleptic Malignant Syndrome - ANSWER Adverse reaction to antipsychotics with severe muscle rigidity, hyperthermia, autonomic instability (hypotension, tachycardia, diaphoresis, tachypnea), confusion/altered LOC, mutism, coma, death, elevated WBC and CPK NMS treatment - ANSWER dantrolene--D2 agonist bromocriptine--muscle relaxant